Epidemiology of Type 1 Diabetes Mellitus in Korea through an Investigation of the National Registration Project of Type 1 Diabetes for the Reimbursement of Glucometer Strips with Additional Analyses Using Claims Data

Glycemic status, insulin resistance, and mortality from lung cancer among individuals with and without diabetes

BACKGROUND

The effects of glycemic status and insulin resistance on lung cancer remain unclear. We investigated the associations between both glycemic status and insulin resistance, and lung cancer mortality, in a young and middle-aged population with and without diabetes.

METHODS

This cohort study involved individuals who participated in routine health examinations. Lung cancer mortality was identified using national death records. Cox proportional hazards models were used to calculate hazard ratios (HRs) with 95% CIs for lung cancer mortality risk.

RESULTS

Among 666,888 individuals (mean age 39.9 ± 10.9 years) followed for 8.3 years (interquartile range, 4.6-12.7), 602 lung cancer deaths occurred. Among individuals without diabetes, the multivariable-adjusted HRs (95% CI) for lung cancer mortality comparing hemoglobin A1c categories (5.7-5.9, 6.0-6.4, and ≥ 6.5% or 39-41, 42-46, and ≥ 48 mmol/mol, respectively) with the reference (< 5.7% or < 39 mmol/mol) were 1.39 (1.13-1.71), 1.72 (1.33-2.20), and 2.22 (1.56-3.17), respectively. Lung cancer mortality was associated with fasting blood glucose categories in a dose-response manner (P for trend = 0.001) and with previously diagnosed diabetes. Insulin resistance (HOMA-IR ≥ 2.5) in individuals without diabetes was also associated with lung cancer mortality (multivariable-adjusted HR, 1.41; 95% CI, 1.13-1.75). These associations remained after adjusting for changing status in glucose, hemoglobin A1c, insulin resistance, smoking status, and other confounders during follow-up as time-varying covariates.

CONCLUSIONS

Glycemic status within both diabetes and prediabetes ranges and insulin resistance were independently associated with an increased risk of lung cancer mortality.

Distinct changes to pancreatic volume rather than pancreatic autoantibody positivity: insights into immune checkpoint inhibitors induced diabetes mellitus

BACKGROUND

Immune checkpoint inhibitors (ICI) are promising treatment options for various cancers. However, their use is associated with immune-related adverse events (irAEs), including ICI-induced diabetes mellitus (ICI-DM). This study aimed to investigate the clinical features of ICI-DM, with a particular focus on alterations to pancreatic volume.

METHODS

We conducted a retrospective review of 2829 patients who received ICI treatment at the Chang Gung Memorial Hospital, Linkou, between January 2014 and December 2021. New-onset diabetes or diabetic ketoacidosis (DKA) was identified in ten patients receiving ICI therapy. Pancreatic volumes were assessed by manual segmentation of computed tomography (CT) images before and after ICI-DM diagnosis.

RESULTS

Among these ten patients, nivolumab was the most commonly used ICI (50.0%), followed by pembrolizumab (30.0%) and atezolizumab (20.0%). One patient received combination therapy with nivolumab and ipilimumab. The median age was 63.01 years (range: 40.1 - 87.8). ICI-DM developed after a median of 13.5 cycles (range: 2 - 42) of ICI treatment or 9.85 months (range:1.5 - 21.3) since ICI initiation. The initial presentation was DKA in 60.0% of patients. All patients had low or undetectable C-peptide levels (range: <0.033 - 0.133 nmol/L) and were negative for most type 1 diabetes mellitus (T1DM)-related autoantibodies; only one patient tested positive for glutamic acid decarboxylase antibodies. CT imaging revealed significant pancreatic atrophy, with a median pancreatic volume decrease of 19.92% (P = 0.038) from baseline and sustained significant decline at last follow-up (median - 37.14%, P = 0.012).

CONCLUSIONS

ICI-DM is often accompanied by pancreatic atrophy and approximately two-thirds of patients initially present with DKA. Although the majority of ICI-DM patients lack T1DM-related autoantibodies, identifying diminished pancreatic volumes through CT imaging provides valuable clues into the subclinical aspects of ICI-DM development, aiding in the prevention of diabetic emergencies.

TRIAL REGISTRATION

Not applicable.

Impact of statin treatment on cardiovascular risk in patients with type 1 diabetes: a population-based cohort study

BACKGROUND

Cardiovascular disease (CVD) is a major complication in type 1 diabetes mellitus (T1D) patients. Previous studies have suggested that statins may be helpful for prevention of CVD in T1D, but there are limited data on the role of statins in T1D. We investigated the relationship between statin treatment and cardiovascular risk in T1D patients using a population-based cohort.

METHODS

We conducted a retrospective cohort study using the Korean nationwide health insurance database from January 2007 to December 2017. This study included 11,009 T1D patients aged ≥ 20 years without a prior history of CVD. The primary outcome was a composite development of stroke or myocardial infarction. Statin use during follow-up was treated as a time-varying variable. We performed a multivariable time-dependent Cox regression analysis adjusting for sex, age, type of insurance, hypertension, renal disease, and use of antiplatelets and renin-angiotensin-aldosterone system inhibitors.

RESULTS

During the mean follow-up of 9.9 ± 3.7 years of follow-up, 931 T1D patients (8.5%) suffered primary outcome. Statin treatment was associated with a reduced risk of the primary outcome (adjusted hazard ratio, 0.76; 95% confidence interval 0.66-0.88; p < 0.001). Statin use led to decreased risks of ischemic stroke and myocardial infarction, but was not related to hemorrhagic stroke. We also found that the risk of cardiovascular events decreased as the cumulative exposure duration of statins increased.

CONCLUSIONS

Statin use was associated with a lower risk of cardiovascular events in T1D patients. Further prospective studies are needed to confirm the potential role of statins in prevention of CVD in patients with T1D.

Exercise Frequency Reduction Is Associated With Higher Risk of Infection in Newly Diagnosed Diabetes: A Nationally Representative Cohort Study

BACKGROUND

Exercise is an important method to control the progression of diabetes. Since diabetes compromises immune function and increases the risk of infectious diseases, we hypothesized that exercise may affect the risk of infection by its immunoprotective effects. However, population-based cohort studies regarding the association between exercise and the risk of infection are limited, especially regarding changes in exercise frequency. The aim of this study was to determine the association between the change in exercise frequency and the risk of infection among patients with newly diagnosed diabetes.

METHODS

Data of 10,023 patients with newly diagnosed diabetes were extracted from the Korean National Health Insurance Service-Health Screening Cohort. Self-reported questionnaires for moderate-to-vigorous physical activity (MVPA) were used to classify changes in exercise frequency between two consecutive two-year periods of health screenings (2009-2010 and 2011-2012). The association between changes in exercise frequency and the risk of infection was evaluated using multivariable Cox proportional-hazards regression.

RESULTS

Compared with engaging in ≥ 5 times of MVPA/week during both periods, a radical decrease in MVPA (from ≥ 5 times of MVPA/week to physical inactivity) was associated with a higher risk of pneumonia (adjusted hazard ratio [aHR], 1.60; 95% confidence interval [CI], 1.03-2.48) and upper respiratory tract infection (aHR, 1.15; 95% CI, 1.01-1.31). In addition, a reduction of MVPA from ≥ 5 to < 5 times of MVPA/week was associated with a higher risk of pneumonia (aHR, 1.52; 95% CI, 1.02-2.27), whereas the risk of upper respiratory tract infection was not higher.

CONCLUSION

Among patients with newly diagnosed diabetes, a reduction in exercise frequency was related to an increase in the risk of pneumonia. For patients with diabetes, a modest level of physical activity may need to be maintained to reduce the risk of pneumonia.

Association between long-term air pollution exposure and development of diabetes among community-dwelling adults: Modification of the associations by dietary nutrients

BACKGROUND

Studies on the modifying effects of dietary factors on the association between air pollution and diabetes-related outcomes are limited. We examined whether dietary nutrients could modify the association between long-term air pollution exposure and the development of diabetes.

METHODS

We used data from the Cardiovascular Disease Association Study, which enrolled adults aged 40-69 years in Korea between 2005 and 2011 and followed them up until 2016 (n = 14,667). Annual concentrations of fine particulate matter (PM_2.5) and nitrogen dioxide (NO₂) at each participant's residence(s) were estimated using community multiscale air quality models. Intake of 22 dietary nutrients was assessed using a validated food frequency questionnaire during the baseline survey. We examined the product terms between air pollution levels (continuous) and each dietary nutrient (quartile) using Cox regression models, adjusted for potential confounders.

RESULTS

PM_2.5 [hazard ratio (HR) = 1.49, 95 % confidence interval (CI): 1.11, 2.00] and NO₂ (HR = 1.29, 95 % CI: 1.12, 1.49) concentrations were found to be associated with incident diabetes. NO₂ levels interacted with dietary intake of retinol, vitamin A, and cholesterol (p-values for interaction < 0.05). Stronger associations were observed between NO₂ levels and the occurrence of diabetes among individuals with a lower intake of these nutrients compared to those with a higher intake. No interaction was found between PM_2.5 and the 22 investigated dietary nutrients.

CONCLUSIONS

Adequate intake of dietary nutrients, such as retinol, vitamin A, and cholesterol, from various food items in a balanced diet may prevent the occurrence of diabetes in a setting wherein reduction of air pollution levels cannot be achieved in a short time frame.

Insulin Fact Sheet in Type 1 and 2 Diabetes Mellitus and Trends of Antidiabetic Medication Use in Insulin Users with Type 2 Diabetes Mellitus: 2002 to 2019

BACKGROUND

This study investigated the trends of insulin use among Korean patients with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). Changes in prescription of antidiabetic medications in T2DM patients taking insulin therapy were evaluated.

METHODS

We analyzed data from the National Health Insurance Service database in Korea to evaluate the prevalence of insulin users and trends of insulin use in T1DM and T2DM patients from January 2002 to December 2019. We also investigated numbers and types of antidiabetic medications in insulin users with T2DM.

RESULTS

The overall total number of insulin users increased from 2002 to 2019, reaching 348,254 for T2DM and 20,287 for T1DM in 2019 compared with 109,974 for T2DM and 34,972 for T1DM in 2002. The proportion of patients using basal analogs and short acting analogs have increased and those using human insulin, premixed insulin, or biphasic human insulin have decreased (rapid acting analogs: 71.85% and 24.12% in T1DM and T2DM, respectively, in 2019; basal analogs: 76.75% and 75.09% in T1DM and T2DM, respectively, in 2019). The use of other antidiabetic medication in addition to insulin increased for T2DM, especially in dual therapy, reaching up to 52.35% in 2019 compared with 16.72% in 2002.

CONCLUSION

The proportion of the patients using basal or rapid acting analogs increased among all insulin users in both T1DM and T2DM patients. Among patients with T2DM, the proportion of patients using antidiabetic medications in addition to insulin was significantly increased compared to those who used insulin alone.

Association of Body Mass Index and Fracture Risk Varied by Affected Bones in Patients with Diabetes: A Nationwide Cohort Study

BACKGROUND

Body mass index (BMI) is a risk factor for the type 2 diabetes (T2DM), and T2DM accompanies various complications, such as fractures. We investigated the effects of BMI and T2DM on fracture risk and analyzed whether the association varied with fracture locations.

METHODS

This study is a nationwide population-based cohort study that included all people with T2DM (n=2,746,078) who received the National Screening Program during 2009-2012. According to the anatomical location of the fracture, the incidence rate and hazard ratio (HR) were analyzed by dividing it into four categories: vertebra, hip, limbs, and total fracture.

RESULTS

The total fracture had higher HR in the underweight group (HR, 1.268; 95% CI, 1.228 to 1.309) and lower HR in the obese group (HR, 0.891; 95% CI, 0.882 to 0.901) and the morbidly obese group (HR, 0.873; 95% CI, 0.857 to 0.89), compared to reference (normal BMI group). Similar trends were observed for HR of vertebra fracture. The risk of hip fracture was most prominent, the risk of hip fracture increased in the underweight group (HR, 1.896; 95% CI, 1.178 to 2.021) and decreased in the obesity (HR, 0.643; 95% CI, 0.624 to 0.663) and morbidly obesity group (HR, 0.627; 95% CI, 0.591 to 0.665). Lastly, fracture risk was least affected by BMI for limbs.

CONCLUSION

In T2DM patients, underweight tends to increase fracture risk, and overweight tends to lower fracture risk, but association between BMI and fracture risk varied depending on the affected bone lesions.

Identification of genetic variants associated with diabetic kidney disease in multiple Korean cohorts via a genome-wide association study mega-analysis

BACKGROUND

The pathogenesis of diabetic kidney disease (DKD) is complex, involving metabolic and hemodynamic factors. Although DKD has been established as a heritable disorder and several genetic studies have been conducted, the identification of unique genetic variants for DKD is limited by its multiplex classification based on the phenotypes of diabetes mellitus (DM) and chronic kidney disease (CKD). Thus, we aimed to identify the genetic variants related to DKD that differentiate it from type 2 DM and CKD.

METHODS

We conducted a large-scale genome-wide association study mega-analysis, combining Korean multi-cohorts using multinomial logistic regression. A total of 33,879 patients were classified into four groups-normal, DM without CKD, CKD without DM, and DKD-and were further analyzed to identify novel single-nucleotide polymorphisms (SNPs) associated with DKD. Additionally, fine-mapping analysis was conducted to investigate whether the variants of interest contribute to a trait. Conditional analyses adjusting for the effect of type 1 DM (T1D)-associated HLA variants were also performed to remove confounding factors of genetic association with T1D. Moreover, analysis of expression quantitative trait loci (eQTL) was performed using the Genotype-Tissue Expression project. Differentially expressed genes (DEGs) were analyzed using the Gene Expression Omnibus database (GSE30529). The significant eQTL DEGs were used to explore the predicted interaction networks using search tools for the retrieval of interacting genes and proteins.

RESULTS

We identified three novel SNPs [rs3128852 (P = 8.21×10^-25), rs117744700 (P = 8.28×10^-10), and rs28366355 (P = 2.04×10^-8)] associated with DKD. Moreover, the fine-mapping study validated the causal relationship between rs3128852 and DKD. rs3128852 is an eQTL for TRIM27 in whole blood tissues and HLA-A in adipose-subcutaneous tissues. rs28366355 is an eQTL for HLA-group genes present in most tissues.

CONCLUSIONS

We successfully identified SNPs (rs3128852, rs117744700, and rs28366355) associated with DKD and verified the causal association between rs3128852 and DKD. According to the in silico analysis, TRIM27 and HLA-A can define DKD pathophysiology and are associated with immune response and autophagy. However, further research is necessary to understand the mechanism of immunity and autophagy in the pathophysiology of DKD and to prevent and treat DKD.

Influenza vaccination trend and related factors among patients with diabetes in Korea: Analysis using a nationwide database

BACKGROUND

Subjects with diabetes are at higher risk of serious influenza-related complications. We aimed to investigate the yearly trend of influenza vaccination and factors associated with being unvaccinated for influenza in subjects with diabetes using a nationwide observational study performed within the recent decade.

METHODS

Among 105,732 subjects from the Korea National Health and Nutrition Examination Survey between 2007 and 2019, 8,632 with diabetes were included. We investigated the yearly trend of influenza vaccination and factors associated with being unvaccinated for influenza.

RESULTS

During the study period, the prevalence of influenza vaccination in subjects with diabetes showed a tendency to increase every year, reaching almost 60% in 2019, which was higher than the rate in subjects without diabetes. Younger age (adjusted hazard ratio (aHR) [95% CI] 11.29 [8.63-14.75] for < 50 years; 6.16 [5.21-7.29] for 50-65 years), male (aHR 1.67 [1.52-1.87]), current smoker (aHR 1.31 [1.00-1.72], lower-income status (aHR 1.46 [1.17, 1.84]), and high education level (aHR 1.30 [1.01-1.67]) were associated with being unvaccinated. Also, a poorer glycemic control with HbA1c ≥ 9% was found to be correlated with unvaccinated status (aHR 1.48 [1.15-1.90]).

CONCLUSION

The influenza vaccination rate is still unsatisfactory in subjects with diabetes. Young age, males, low-income level, high education level, and poor glycemic control were associated with unvaccinated status. Considering the risk-benefits of influenza vaccination in patients with diabetes, physicians should make an effort to increase vaccination rates, especially in low vaccination rate groups.

Incidence and risk factors of diabetes mellitus in the Chinese population: a dynamic cohort study

OBJECTIVE

Diabetes mellitus is a common condition often associated with an ageing population. However, only few longitudinal studies in China have investigated the incidence of diabetes and identified its risk factors. Therefore, this study aimed to investigate the incidence and risk factors of diabetes in Chinese people aged ≥45 years using the harmonised China Health and Retirement Longitudinal Study (CHARLS) data.

DESIGN

A dynamic cohort study.

SETTING

The harmonised CHARLS 2011-2018.

PARTICIPANTS

19 988 adults aged ≥45 years.

PRIMARY OUTCOME MEASURE

Incident diabetes from 2011 to 2018.

RESULTS

The harmonised CHARLS is a representative longitudinal survey of people aged ≥45 years. Using data extracted from the harmonised CHARLS, we calculated the incidence of diabetes and used a competing risk model to determine risk factors of diabetes. In 2011-2013, 2013-2015, 2015-2018, the crude incidence of diabetes among middle-aged and older people in China was 1403.21 (1227.09 to 1604.19), 1673.22 (1485.73 to 1883.92) and 3919.83 (3646.01 to 4213.30) per 100 000 person-years, respectively, with a significant increasing trend. There were no geographical variations in the incidence of diabetes. Age, obesity and alcohol consumption were associated with an increased risk of incident diabetes.

CONCLUSION

The incidence of diabetes increased annually, without any geographical differences. Age, obesity and alcohol consumption were found to be risk factors for incident diabetes.

Low relative hand grip strength is associated with a higher risk for diabetes and impaired fasting glucose among the Korean population

OBJECTIVE

This study investigated the association between relative hand grip strength (HGS) and glycemic status, such as impaired fasting glucose (IFG) and diabetes, using data from the Korea National Health and Nutrition Examination Survey (KNHANES).

METHODS

We performed a cross-sectional study using the data from the KNHANES of 27,894 individuals from 2014 to 2019. Relative HGS was defined as the absolute HGS divided by body mass index and divided into quartiles in men and women. Odds ratios (OR) for diabetes and IFG were calculated using multivariate logistic regression analysis. All analyses were stratified by sex, and subgroup analysis was age-stratified.

RESULTS

The lowest relative HGS quartile had a significant increase in the risk for diabetes (men: OR 2.72, 95% confidence interval [CI] 2.12-3.50; women: OR 3.38, 95% CI 2.70-4.24) and IFG (men: OR 1.35, 95% CI 1.15-1.59; women: OR 1.60, 95% CI 1.40-1.84). The ORs for diabetes and IFG according to the decreasing quartiles of relative HGS gradually increased in both sexes (P for trend <0.001). ORs and 95% CI of the lowest relative HGS quartile for diabetes were higher in the younger age group than that of the older age group (men: 4.47 and 2.80-7.14 for young adults; 2.41 and 1.37-4.25 for older adults; women: 5.91 and 3.06-9.38 for young adults; 1.47 and 0.92-2.33 for older adults). ORs and 95% CI for IFG was similar with the trend of ORs for diabetes (men: 1.80 and 1.43-2.26 for young adults; 1.17 and 0.75-1.84 for older adults; women: 2.20 and 1.77-2.72 for young adults; 1.33 and 0.86-2.07 for older adults).

CONCLUSION

Lower relative HGS was associated with a higher risk of not only diabetes but also IFG in both sexes. These trends were stronger in younger adults than in older adults.

Weight change and the risk of hip fractures in patients with type 2 diabetes: a nationwide cohort study

Both weight gain and weight loss in type 2 diabetic population were associated with increased risk of hip fracture, while maintaining weight lowered the risk of hip fracture. Regarding the risk of hip fracture, we can propose active monitoring to maintain the weight of type 2 diabetes patients.

INTRODUCTION

In type 2 diabetes, patients are often asked to control their weight in order to reduce their diabetic morbidity. The American Diabetes Association recommends that diabetic patients conduct high-intensity interventions for regulating diet, physical activity, and behavior to reduce weight, followed by long-term comprehensive weight maintenance programs. Although such weight control attempts are required in diabetic patients, there are few studies on the effect of weight change on hip fracture in this population. We aim to investigate the association between body weight change and the incidence of hip fracture in subjects with type 2 diabetes using large-scale, nationwide cohort data on the Korean population.

MATERIALS AND METHODS

A total of 1,447,579 subjects (894,204 men and 553,375 women) > 40 years of age, who were diagnosed with type 2 diabetes, were enrolled in this study. Weight change within 2 years was divided into five categories: from weight loss ≥ 10% to weight gain ≥ 10%. The hazard ratios (HRs) and 95% confidence intervals for the incidence of hip fracture were analyzed, compared with the reference of the stable weight group (weight change < 5%).

RESULTS

Among 5 weight change groups, more than 10% weight loss showed the highest HR (HR, 1.605; 95% CI, 1.493 to 1.725), followed by more than 10% weight gain (HR, 1.457; 95% CI, 1.318 to 1.612). The effect of weight change on hip fracture risk was greater in males than in females, and those under 65 years of age were greater than those over 65 years of age. Baseline BMI did not play a role of weight change affecting the risk of hip fracture. The HR for hip fracture of subjects with regular exercise was lower than those without regular exercise.

CONCLUSIONS

In the type 2 diabetes population, both weight gain and weight loss were significantly associated with a higher risk of hip fracture, whereas maintaining body weight reduced the risk of hip fracture the most.

Epidemiology and phenotypes of diabetes in children and adolescents in non-European-origin populations in or from Western Pacific region

BACKGROUND

Type 1 diabetes (T1D) incidence varies substantially between countries/ territories, with most studies indicating increasing incidence. In Western Pacific region (WPR), reported rates are much lower than European-origin populations. In contrast, there are reports of substantial numbers of young people with type 2 diabetes (T2D). A deeper understanding of T1D and T2D in the WPR may illuminate factors important in pathogenesis of these conditions. Furthermore, with varying resources and funding for diabetes treatment in this region, there is a need to more clearly determine the current burden of disease and also any gaps in knowledge.

AIM

To compile and summarise published epidemiologic and phenotypic data on childhood diabetes in non-European populations in and from WPR.

METHODS

Research articles were systematically searched from PubMed (MEDLINE), Embase, Cochrane library, and gray literature. Primary outcome measures were incidence and prevalence, with secondary measures including phenotypic descriptions of diabetes, including diabetes type categorization, presence of diabetic ketoacidosis (DKA) at onset, autoantibody positivity, C-peptide levels, and human leucocyte antigen phenotype. Extracted data were collected using a customized template. Three hundred and thirty relevant records were identified from 16 countries/territories, with analysis conducted on 265 (80.3%) records published from the year 2000.

RESULTS

T1D incidence ranged from < 1-7.3/100000 individuals/year, rates were highest in emigrant/ mixed populations and lowest in South-East Asia, with most countries/territories (71.4%) having no data since 1999. Incidence was increasing in all six countries/territories with data (annual increases 0.5%-14.2%, highest in China). Peak age-of-onset was 10-14 years, with a female case excess. Rate of DKA at onset varied from 19.3%-70%. Pancreatic autoantibodies at diagnosis were similar to European-origin populations, with glutamic acid decarboxylase-65 autoantibody frequency of 44.1%-64.5%, insulinoma-associated 2 autoantibody 43.5%-70.7%, and zinc transporter-8 autoantibody frequency 54.3% (one study). Fulminant T1D also occurs. T2D was not uncommon, with incidence in Japan and one Chinese study exceeding T1D rates. Monogenic forms also occurred in a number of countries.

CONCLUSION

T1D is less common, but generally has a classic phenotype. Some countries/ territories have rapidly increasing incidence. T2D is relatively common. Registries and studies are needed to fill many information gaps.

Illness Experiences of Adolescents with Type 1 Diabetes

OBJECTIVE

This study is aimed at exploring the illness experiences of adolescents with type 1 diabetes (T1D).

METHODS

Using semistructured questions, 12 adolescents with T1D in Korea were interviewed regarding their illness experiences. Data were analyzed using grounded theory methodology.

RESULTS

Participants described their experiences in the core category, "becoming myself again," which resulted in 130 concepts, 36 subcategories, 13 categories, and five themes. The themes included tied, overwhelmed, running away, struggling, and conciliating. Tied, the first process, entailed three categories: "confined to blood sugar control," "feeling constrained," and "supervised by parents." The overwhelmed process included "self-banished" and "surrounded by stigma." Running away included three categories-"growing up," "folding," and "withdrawal." Struggling entailed "seeking for solution to overcome," "developing response skills," and "accepting help." The last process, conciliating, included "redefining my perspective" and "reconciling with myself."

CONCLUSIONS

The findings indicate that the illness experience of adolescents with T1D should be understood in terms of both physical and psychosocial dimensions, considering the sociocultural and developmental context. The results of this study provide valuable information on diabetes education. Moreover, these findings encourage nurses to develop intervention programs and strategies to help adolescents with T1D.

Prevalence and clinical characteristics of fulminant type 1 diabetes mellitus in Korean adults: A multi-institutional joint research

AIMS/INTRODUCTION

We aimed to determine the hospital-based prevalence and clinical features of fulminant type 1 diabetes mellitus in Korea.

MATERIALS AND METHODS

We identified all patients with diabetes who regularly visited the Endocrinology outpatient clinics at eight centers for a period >1 year between January 2012 and June 2017. We investigated their medical records retrospectively.

RESULTS

During this period, 76,309 patients with diabetes had been regularly followed up. Among them, 913 (1.2%) patients had type 1 diabetes mellitus . There were 462 patients with type 1 diabetes mellitus whose data at the time of the first diagnosis could be identified (359 and 103 with non-ketosis and ketosis onset, respectively). Of these, 15 (3.2% of type 1 diabetes mellitus, 14.6% of ketosis onset diabetes) patients had fulminant type 1 diabetes mellitus. The median ages at diagnosis were 40 and 27 years in the fulminant type 1 diabetes mellitus and non-fulminant type 1 diabetes mellitus groups, respectively. The patients with fulminant type 1 diabetes mellitus had higher body mass index, lower glycated hemoglobin and fasting/peak C-peptide, and lower frequent glutamic acid decarboxylase antibody-positive rate (P =0.0010) at diagnosis. Furthermore, they had lower glycated hemoglobin at the last follow-up examination than those with non-fulminant type 1 diabetes mellitus.

CONCLUSIONS

In this study, the prevalence of type 1 diabetes mellitus was 1.2% among all patients with diabetes, and that of fulminant type 1 diabetes mellitus was 3.2% among those newly diagnosed with type 1 diabetes mellitus. The glycated hemoglobin levels were lower in patients with fulminant type 1 diabetes mellitus than in those with non-fulminant type 1 diabetes mellitus at diagnosis and at the last follow-up examination.

Prestroke Glucose Control and Functional Outcome in Patients With Acute Large Vessel Occlusive Stroke and Diabetes After Thrombectomy

OBJECTIVE

To evaluate whether prestroke glucose control is associated with functional outcomes in patients with acute large vessel occlusive stroke and diabetes who underwent intra-arterial thrombectomy (IAT).

RESEARCH DESIGN AND METHODS

From the Clinical Research Center for Stroke-Korea registry, we included patients with emergent large vessel occlusive stroke with diabetes who underwent IAT between January 2009 and March 2020. The association between the HbA_1c level at admission and functional outcomes (modified Rankin Scale at 3 months after the index stroke) was assessed.

RESULTS

A total of 1,351 patients were analyzed. Early neurological deterioration was more common in patients with higher levels of HbA_1c at admission (P = 0.02 according to HbA_1c quintiles, P = 0.003 according to an HbA_1c cutoff value of 7.0%) than in those with lower HbA_1c levels. Higher HbA_1c levels at admission were significantly associated with decreased odds of favorable functional outcomes at a threshold of 7.0-7.1%. The association was consistently observed in subgroups divided according to age, sex, stroke subtype, occlusion site, degree of recanalization, thrombolysis modalities, time from symptom onset to groin puncture, and treatment period.

CONCLUSIONS

Prestroke glucose control with a target HbA_1c of ≤7.0% may be beneficial for neurological recovery in patients with diabetes undergoing IAT for large vessel occlusive stroke, regardless of stroke subtype, bridging intravenous thrombolysis, occlusion site, degree of recanalization, and treatment period.

Association between domain-specific physical activity and diabetes in Korean adults

This study aimed to investigate the association between domain-specific physical activity (PA) and diabetes in Korean adults. We analyzed 26,653 men and women (aged > 18 years) from the Korea National Health and Nutrition Examination Survey (2014–2018). PA was measured using a validated Global PA Questionnaire. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) after adjustment for various confounders. Transport PA accounted for the majority of total PA (46%, men; 58%, women), followed by leisure-time PA (30%; 22%) and work PA (24%; 20%). In men, ORs (95% CI) of diabetes comparing ≥ 600 metabolic task of equivalent (MET)-min/week vs. no activity were 0.82 (0.71–0.95) for leisure-time PA, 0.85 (0.75–0.96) for transport PA, and 0.88 (0.78–0.99) for leisure-time + transport PA. In women, ORs (95% CI) of diabetes comparing the same groups were 0.73 (0.60–0.89) for leisure-time PA, 0.97 (0.85–1.10) for transport PA, and 0.88 (0.78–1.00) for leisure-time + transport PA. However, work PA showed no association with diabetes. In conclusion, leisure-time PA was inversely associated with diabetes in both men and women, while transport PA was inversely associated only in men. But work PA was not associated with diabetes in Korean adults.

Trends of Diabetes and Prediabetes Prevalence among Korean Adolescents From 2007 to 2018

BACKGROUND

To provide updated prevalence data and to estimate changes in the prevalence of diabetes among Korean adolescents by sex and age between 2007 and 2018.

METHODS

We used the data of children and adolescents (8,718 subjects aged 10 to 18 years) from the Korea National Health and Nutrition Examination Survey IV-VII (KNHANES 2007-2018). The recent prevalence of diabetes and pre-diabetes was estimated by using the latest KNHANES VII. The linear trends were estimated by comparing 3-year KNHANES cycles according to sex and by using logistic regression.

RESULTS

The prevalence of diabetes and pre-diabetes was 0.298% (95% confidence interval [CI], 0.289-0.308) and 7.914% (95% CI, 0.43-0.49). The prevalence of diabetes significantly increased from 0.189 to 0.430 during KNHANE IV and VII. A positive linear trend is significant for diabetes (P trends = 0.006) in only male subjects. The prevalence of pre-diabetes significantly increased from 5.86 to 12.08 in both sexes. During KNHANES IV and VII, the prevalence of obesity increased significantly.

CONCLUSION

Between 2007 and 2018, the prevalence of diabetes among Korean adolescents increased. Further studies are required to determine the causes of these increases.

Risk Factors of Undiagnosed Diabetes Mellitus among Korean Adults: A National Cross-Sectional Study Using the KNHANES Data

In this cross-sectional study, we investigated the baseline risk factors of diabetes mellitus (DM) in patients with undiagnosed DM (UDM). We utilized the Korean National Health and Nutrition Examination Survey (KNHANES) 2010–2017 data. Data regarding the participants’ demographic characteristics, health status, health determinants, healthcare accessibility, and laboratory tests were gathered to explore the differences between the DM, UDM, and without-DM groups. Among the 64,759 individuals who participated in the KNHANES 2010–2017, 32,611 individuals aged ≥20 years with fasting plasma glucose levels of <100 or ≥126 mg/dL were selected. The odds ratios (ORs) regarding family history of diabetes and the performance of national health and cancer screening tests were lower in the UDM group than in the DM group (adjusted OR: 0.54; 95% confidence interval (CI): 0.43, 0.66; adjusted OR: 0.74; 95% CI: 0.62, 0.89; adjusted OR: 0.71; 95% CI: 0.60, 0.85). The ORs of hypertension and obesity were higher in the UDM group than in the DM group (adjusted OR: 1.32; 95% CI: 1.06, 1.64; adjusted OR: 1.80; 95% CI: 1.37, 2.36, respectively). Patients with UDM were more likely to be exposed to DM-related risk factors than those with and without DM. Public health interventions to prevent UDM development are necessary.

Increased Incidence of Pediatric Diabetic Ketoacidosis After COVID-19: A Two-Center Retrospective Study in Korea

PURPOSE

We evaluated the clinical characteristics and severity of diabetic ketoacidosis (DKA) in children before and after the coronavirus disease 2019 (COVID-19) outbreak to identify its indirect effects on DKA incidence.

PATIENTS AND METHODS

This retrospective study included 19 children with DKA admitted to the emergency room (ER) in two centers in Jeonbuk province, Korea during the first 6 months of the year from 2017 to 2020. Data were collected on age, height, body weight, clinical symptoms, diabetic mellitus (DM) type, and laboratory findings. DKA severity was based on the presence of acute kidney injury, cerebrovascular accident, and altered mental status. The ratio of patients with DKA in all pediatric patients who visited the study ERs and in the Jeonbuk population was also determined.

RESULTS

There were no differences in anthropometric characteristics and complication rates between the pre-COVID-19 and COVID-19 periods; however, the rate of polydipsia was significantly higher in the COVID-19 period. All seven patients admitted during the COVID-19 pandemic (100%) had polydipsia and polyuria and were newly diagnosed with DM. The rate of pediatric patients with DKA admitted to the ER in 2020 (0.459%) was more than twice the mean rate of 0.206% for the four-year period. The incidence of DKA in the Jeonbuk population (0.00141%) also exceeded the mean rate (0.0009%).

CONCLUSION

The incidence of pediatric DKA might be higher due to the indirect effect of COVID-19 pandemic. Physicians should be aware of nonspecific symptoms related to DKA in children admitted to the ER.

The risk of hip fractures in individuals over 50 years old with prediabetes and type 2 diabetes - A longitudinal nationwide population-based study

BACKGROUND

The present study aimed to investigate the association between type 2 diabetes mellitus (T2DM) and hip fractures using a large-scale nationwide population-based cohort that is representative of the Republic of Korea. We determined the risks of hip fractures in individuals with prediabetes and T2DM with different diabetes durations, and compared them with the risks of hip fractures in individuals without T2DM.

METHODS

A total of 5,761,785 subjects over 50 years old who underwent the National Health Insurance Service medical checkup in 2009-2010 were included. Subjects were classified into 5 groups based on the diabetes status; Normal, Prediabetes, Newly-diagnosed T2DM, T2DM less than 5 years, and T2DM more than 5 years. They were followed from the date of the medical checkup to the end of 2016. The endpoint was a new development of hip fracture during follow-up. The hazard ratios (HRs) and 95% confidence intervals (CIs) of hip fractures for each group were analyzed using Cox proportional hazard regression models after adjusting for age, sex, smoking, alcohol drinking, regular exercise, body mass index, hypertension, dyslipidemia, and chronic kidney disease.

RESULTS

The HRs of hip fractures were 1 in the Normal group, 1.032 (95% CI: 1.009, 1.056) in the Prediabetes group, 1.168 (95% CI: 1.113, 1.225) in the Newly-diagnosed T2DM2, 1.543 (95% CI: 1.495, 1.592) in the T2DM less than 5 years and 2.105 (95% CI: 2.054, 2.157) in the T2DM more than 5 years. The secular trend of the HRs of hip fractures according to the duration of T2DM was statistically significant (P < .001). Subgroup analyses also showed the same increasing pattern of the HRs of hip fractures according to the duration of T2DM in both sexes and all age groups (50-64 years, 65-74 years, over 75 years).

CONCLUSIONS

In summary, this large-scale, retrospective, longitudinal, nationwide population-based cohort study of 5,761,785 subjects demonstrated that the risks of hip fractures started to increase in prediabetes and was associated linearly with the duration of T2DM. The secular trend of risks of hip fractures according to the duration of T2DM was consistent in both sexes and all age groups.

Association between secondhand smoke exposure and diabetes mellitus in 131 724 Korean never smokers using self-reported questionnaires and cotinine levels: Gender differences

OBJECTIVE

The aim of this study is to compare the gender-different associations between secondhand smoke (SHS) exposure and diabetes in self-reported never smokers verified by cotinine.

METHODS

Self-reported never smokers verified by cotinine levels (<50 ng/mL) enrolled in the Kangbuk Samsung Health Study between April 2011 and December 2016 were included for this study. SHS exposure was defined as current exposure to passive smoke indoors at home or workplace. The gender-specific association between SHS exposure and diabetes was assessed using multivariable regression analyses.

RESULTS

Of the total 131 724 individuals (mean age 35 years, SD 7.1 years), 66.8% were female, and the prevalence of SHS exposure in the entire population was 22.9%. The prevalence of diabetes in the group exposed to SHS was higher than that in the group unexposed to SHS only in females (1.8% vs 1.2%, P < .001 for females; 2.2% vs 2.2%, P = .956 for males). A significant gender interaction existed for the relationships between SHS exposure and diabetes (P for interaction <.001). The multivariate regression model showed that SHS exposure was significantly associated with diabetes only in females (odds ratio [95% CI], 1.40 [1.20, 1.65] for females; 1.00 [0.85, 1.19] for males). In particular, females with SHS exposure ≥1 hour/day, ≥3 times/week, and ≥10 years showed an increased risk of diabetes by more than 50% compared to those without SHS exposure.

CONCLUSIONS

SHS exposure was significantly associated with diabetes in female never smokers with dose-dependent relationship. However, further longitudinal studies are needed to elucidate the gender difference in the incidence of diabetes associated with SHS exposure.

Synthesis of NiCo2O4 Nanostructures and Their Electrochemial Properties for Glucose Detection

In this work, we prepared spinel-type NiCo2O4 (NCO) nanopowders as a low-cost and sensitive electrochemical sensor for nonenzymatic glucose detection. A facile and simple chemical bath method to synthesize the NCO nanopowders is demonstrated. The effect of pH and annealing temperature on the formation mechanism of NCO nanoparticles was systematically investigated. Our studies show that different pHs of the precursor solution during synthesis result in different intermediate phases and relating chemical reactions for the formation of NCO nanoparticles. Different morphologies of the NCO depending on pHs are also discussed based on the mechanism of growth. Electrochemical performance of the prepared NCO was characterized towards glucose, which reveals that sensitivity and selectivity of the NCO are significantly related with the final microstructure combined with constituent species with multiple oxidation states in the spinel structure.

Does Diabetes Increase the Risk of Contracting COVID-19? A Population-Based Study in Korea

BACKGROUND

This study aimed to determine the infection risk of coronavirus disease 2019 (COVID-19) in patients with diabetes (according to treatment method).

METHODS

Claimed subjects to the Korean National Health Insurance claims database diagnosed with COVID-19 were included. Ten thousand sixty-nine patients with COVID-19 between January 28 and April 5, 2020, were included. Stratified random sampling of 1:5 was used to select the control group of COVID-19 patients. In total 50,587 subjects were selected as the control group. After deleting the missing values, 60,656 subjects were included.

RESULTS

Adjusted odds ratio (OR) indicated that diabetic insulin users had a higher risk of COVID-19 than subjects without diabetes (OR, 1.25; 95% confidence interval [CI], 1.03 to 1.53; P=0.0278). In the subgroup analysis, infection risk was higher among diabetes male insulin users (OR, 1.42; 95% CI, 1.07 to 1.89), those between 40 and 59 years (OR, 1.66; 95% CI, 1.13 to 2.44). The infection risk was higher in diabetic insulin users with 2 to 4 years of morbidity (OR, 1.744; 95% CI, 1.003 to 3.044).

CONCLUSION

Some diabetic patients with certain conditions would be associated with a higher risk of acquiring COVID-19, highlighting their need for special attention. Efforts are warranted to ensure that diabetic patients have minimal exposure to the virus. It is important to establish proactive care and screening tests for diabetic patients suspected with COVID-19 for timely disease diagnosis and management.

Clinical Outcomes of COVID-19 Patients with Type 2 Diabetes: A Population-Based Study in Korea

BACKGROUND

The aim of this study was to evaluate clinical outcomes in coronavirus disease 2019 (COVID-19) positive patients with type 2 diabetes compared to those without diabetes in Korea.

METHODS

We extracted claims data for patients diagnosed with COVID-19 from the National Health Insurance Service database in Korea from January 20, 2020 to March 31, 2020. We followed up this cohort until death from COVID-19 or discharge from hospital.

RESULTS

A total of 5,473 patients diagnosed with COVID-19 were analyzed, including 495 with type 2 diabetes and 4,978 without diabetes. Patients with type 2 diabetes were more likely to be treated in the intensive care unit (ICU) (P<0.0001). The incidence of inhospital mortality was higher in patients with type 2 diabetes (P<0.0001). After adjustment for age, sex, insurance status, and comorbidities, odds of ICU admission (adjusted odds ratio [OR], 1.59; 95% confidence interval [CI], 1.02 to 2.49; P=0.0416) and in-hospital mortality (adjusted OR, 1.90; 95% CI, 1.13 to 3.21; P=0.0161) among patients with COVID-19 infection were significantly higher in those with type 2 diabetes. However, there was no significant difference between patients with and without type 2 diabetes in ventilator, oxygen therapy, antibiotics, antiviral drugs, antipyretics, and the incidence of pneumonia after adjustment.

CONCLUSION

COVID-19 positive patients with type 2 diabetes had poorer clinical outcomes with higher risk of ICU admission and in-hospital mortality than those without diabetes. Therefore, medical providers need to consider this more serious clinical course when planning and delivering care to type 2 diabetes patients with COVID-19 infection.

The Combined Impact of Chronic Kidney Disease and Diabetes on the Risk of Colorectal Cancer Depends on Sex: A Nationwide Population-Based Study

PURPOSE

Although both chronic kidney disease (CKD) and diabetes mellitus (DM) are considered factors increasing the risk of colorectal cancer (CRC), their impact on CRC is not fully understood. This study was aimed to investigate the impact of CKD, DM, or both diseases on the risk of CRC and to evaluate sex differences therein.

MATERIALS AND METHODS

Using data from the National Health Insurance Service-Health Examination Cohort in Korea, we conducted a 1:2 matched case-control study. The disease groups consisted of CKD-/DM+ (n=17700), CKD+/DM- (n=22643), and CKD+/DM+ groups (n=8506). After 1:2 matching by age, sex, and health examination year and month, the healthy control group consisted of 97698 individuals.

RESULTS

Multivariate Cox regression analysis showed that the CKD-/DM+, CKD+/DM-, and CKD+/DM+ groups were independently associated with an increased incidence of CRC, compared with controls [hazard ratio (HR), 1.34, 1.31, and 1.63, respectively; all p<0.001]. Compared to the controls, adjusted HRs for the cumulative incidence of CRC in the CKD-/DM+, CKD+/DM-, and CKD+/DM+ groups were, respectively, 1.32, 1.26, and 1.43 in male and 1.38, 1.39, and 2.00 in female. The HR for CRC incidence was significantly higher for the CKD+/DM+ group than for the CKD-/DM+ or CKD+/DM- group in female; however, this significant difference was not observed in male.

CONCLUSION

In female, having both CKD and DM significantly increases the risk of CRC, compared with having CKD or DM alone. This study suggests a significant difference in the effect of CKD or DM on the risk of CRC according to sex.

Diabetes diagnosis from administrative claims and estimation of the true prevalence of diabetes among 4.2 million individuals of the Veneto region (North East Italy)

BACKGROUND AND AIMS

Diabetes can often remain undiagnosed or unregistered in administrative databases long after its onset, even when laboratory test results meet diagnostic criteria. In the present work, we analyse healthcare data of the Veneto Region, North East Italy, with the aims of: (i) developing an algorithm for the identification of diabetes from administrative claims (4,236,007 citizens), (ii) assessing its reliability by comparing its performance with the gold standard clinical diagnosis from a clinical database (7525 patients), (iii) combining the algorithm and the laboratory data of the regional Health Information Exchange (rHIE) system (543,520 subjects) to identify undiagnosed diabetes, and (iv) providing a credible estimate of the true prevalence of diabetes in Veneto.

METHODS AND RESULTS

The proposed algorithm for the identification of diabetes was fed by administrative data related to drug dispensations, outpatient visits, and hospitalisations. Evaluated against a clinical database, the algorithm achieved 95.7% sensitivity, 87.9% specificity, and 97.6% precision. To identify possible cases of undiagnosed diabetes, we applied standard diagnostic criteria to the laboratory test results of the subjects who, according to the algorithm, had no diabetes-related claims. Using a simplified probabilistic model, we corrected our claims-based estimate of known diabetes (6.17% prevalence; 261,303 cases) to account for undiagnosed cases, yielding an estimated total prevalence of 7.50%.

CONCLUSION

We herein validated an algorithm for the diagnosis of diabetes using administrative claims against the clinical diagnosis. Together with rHIE laboratory data, this allowed to identify possibly undiagnosed diabetes and estimate the true prevalence of diabetes in Veneto.

Diabetes and the Risk of Infection: A National Cohort Study

BACKGROUND

Several studies have shown that people with diabetes are vulnerable to infection. This study compared the risk of infection-related hospitalizations, intensive care unit (ICU) admission, and deaths between the person with diabetes and the general population in South Korea.

METHODS

We conducted a cohort study of 66,426 diabetes and 132,852 age-sex-region-matched non-diabetes controls from the general population using a sample of data from the National Health Insurance Service-National Sample Cohort. The cohort was followed up for 9 years. Infections were classified into 17 separate categories. We used Poisson regression, with adjustment for household income and other comorbidities, to estimate incidence rate ratios (IRRs) in order to compare of infection-related hospitalizations, ICU admissions, and deaths.

RESULTS

Compared to non-diabetes controls, diabetes group had a greater risk of almost all the types of infections considered, with the adjusted IRRs (aIRRs) for infection-related hospitalizations being the highest for hepatic abscess (aIRR, 10.17; 95% confidence interval [CI], 7.04 to 14.67), central nervous system (CNS) infections (aIRR, 8.72; 95% CI, 6.64 to 11.45), and skin and soft tissue infections other than cellulitis (SSTIs) (aIRR, 3.52; 95% CI, 3.20 to 3.88). Diabetes group also had a greater risk of ICU admission and death due to SSTIs (aIRR, 11.75; 95% CI, 7.32 to 18.86), CNS infections (aIRR, 5.25; 95% CI, 3.53 to 7.79), and bone and joint infections (aIRR, 4.78; 95% CI, 3.09 to 7.39).

CONCLUSION

In South Korea, people with diabetes has a considerably higher incidence of infection-related hospitalizations and deaths than the general population.

HDL-Cholesterol, Its Variability, and the Risk of Diabetes: A Nationwide Population-Based Study

CONTEXT

The bidirectional relationship between low high-density lipoprotein cholesterol (HDL-C) and glucose intolerance is well established. Recent studies suggested an association of lipid variability with various health outcomes.

OBJECTIVE

To investigate the combined effect of HDL-C levels and their variability on the risk of diabetes.

DESIGN

A population-based cohort study.

SETTING AND PARTICIPANTS

In all, 5,114,735 adults without known diabetes in the Korean National Health Insurance System cohort who underwent three or more health examinations from 2009 to 2013 were included. Visit-to-visit HDL-C variability was calculated using variability independent of the mean (VIM) and the coefficient of variation (CV). Low mean and high variability groups were defined as the lowest and highest quartiles of HDL-C mean and variability, respectively.

MAIN OUTCOME MEASURES

Newly developed diabetes.

RESULTS

There were 122,192 cases (2.4%) of incident diabetes during the median follow-up of 5.1 years. Lower mean or higher variability of HDL-C was associated with higher risk of diabetes in a stepwise manner, and an additive effect of the two measures was noted. In the multivariable-adjusted model, the hazard ratios and 95% CIs for incident diabetes were 1.20 (1.18 to 1.22) in the high mean/high VIM group, 1.35 (1.33 to 1.37) in the low mean/low VIM group, and 1.40 (1.38 to 1.42) in the low mean/high VIM group compared with the high mean/low VIM group. Similar results were observed when modeling the variability using CV and in various subgroup analyses.

CONCLUSIONS

Low mean and high variability in HDL-C were independent predictors of diabetes with an additive effect. Both elevating and stabilizing HDL-C may be important goals for reducing diabetes risk.

Trends in incidence of total or type 2 diabetes: systematic review

OBJECTIVE

To assess what proportions of studies reported increasing, stable, or declining trends in the incidence of diagnosed diabetes.

DESIGN

Systematic review of studies reporting trends of diabetes incidence in adults from 1980 to 2017 according to PRISMA guidelines.

DATA SOURCES

Medline, Embase, CINAHL, and reference lists of relevant publications.

ELIGIBILITY CRITERIA

Studies of open population based cohorts, diabetes registries, and administrative and health insurance databases on secular trends in the incidence of total diabetes or type 2 diabetes in adults were included. Poisson regression was used to model data by age group and year.

RESULTS

Among the 22 833 screened abstracts, 47 studies were included, providing data on 121 separate sex specific or ethnicity specific populations; 42 (89%) of the included studies reported on diagnosed diabetes. In 1960-89, 36% (8/22) of the populations studied had increasing trends in incidence of diabetes, 55% (12/22) had stable trends, and 9% (2/22) had decreasing trends. In 1990-2005, diabetes incidence increased in 66% (33/50) of populations, was stable in 32% (16/50), and decreased in 2% (1/50). In 2006-14, increasing trends were reported in only 33% (11/33) of populations, whereas 30% (10/33) and 36% (12/33) had stable or declining incidence, respectively.

CONCLUSIONS

The incidence of clinically diagnosed diabetes has continued to rise in only a minority of populations studied since 2006, with over a third of populations having a fall in incidence in this time period. Preventive strategies could have contributed to the fall in diabetes incidence in recent years. Data are limited in low and middle income countries, where trends in diabetes incidence could be different.

SYSTEMATIC REVIEW REGISTRATION

Prospero CRD42018092287.

Longitudinal changes in left ventricular structure and function in patients with type 2 diabetes: Normal weight versus overweight/obesity

OBJECTIVE

Although reported to be independent of obesity, the longitudinal changes of left ventricular structure and function have not been well characterized in normal-weight individuals with type 2 diabetes compared with overweight/obese individuals with type 2 diabetes.

METHODS

A total of 558 participants in the Korean Genome and Epidemiology Study who underwent tissue Doppler echocardiography at baseline (cycle 4) and after 8 years (cycle 8) were classified into three groups based on body mass index and diabetes status: (1) normal-weight individuals without type 2 diabetes, (2) normal-weight individuals with type 2 diabetes and (3) overweight/obese individuals with type 2 diabetes.

RESULTS

Only overweight/obese individuals with type 2 diabetes group had higher adjusted left ventricular mass index and lower tissue Doppler imaging early diastolic velocity and E/Em ratio compared with the normal-weight individuals without type 2 diabetes group at baseline and after 8 years. Participants in overweight/obese individuals with type 2 diabetes group also showed the higher prevalence and odds of left ventricular hypertrophy (16.0%; adjusted odds ratio: 2.24; 95% confidence interval: 1.22-5.06) and left ventricular diastolic dysfunction (49.1%; 3.45; 1.01-4.32). Among participants with normal left ventricular structure and function at baseline, only overweight/obese individuals with type 2 diabetes group was associated with greater incidence of left ventricular hypertrophy (relative risk: 2.28; 1.04-4.98) over 8 years but not diastolic dysfunction.

CONCLUSION

Cross-sectional and longitudinal observations suggest that increasing body mass index category and its associated metabolic abnormalities at baseline are associated with an increased risk for left ventricular hypertrophy and greater impairment in left ventricular diastolic parameters.

Trends in Hyperglycemic Crisis Hospitalizations and in- and out-of-Hospital Mortality in the Last Decade Based on Korean National Health Insurance Claims Data

BACKGROUND

Hyperglycemic crisis is a metabolic emergency associated with diabetes mellitus. However, accurate epidemiologic information on cases of hyperglycemic crisis in Korea remains scarce. We evaluated trends in hyperglycemic crisis hospitalizations and in- and out-of-hospital mortality in Korea. We also predicted future trends.

METHODS

We extracted claims data with hyperglycemic crisis as the principal diagnosis from the National Health Insurance Service database in Korea from January 2004 to December 2013. We investigated the numbers of claims with hyperglycemic crisis and identified trends in hyperglycemic crisis based on those claims data. We predicted future trends by statistical estimation.

RESULTS

The total annual number of claims of hyperglycemic crisis increased from 2,674 in 2004 to 5,540 in 2013. Statistical analysis revealed an increasing trend in hyperglycemic crisis hospitalizations (P for trend <0.01). In contrast, the hospitalization rate per 1,000 diabetes cases showed a decreasing trend (P for trend <0.01) during this period. The mortality rate per 1,000 diabetes cases also showed a decreasing trend (P for trend <0.0001). However, no distinct linear trend in the case-related fatality rate at <60 days over the last decade was observed. The predicted number of annual claims of hyperglycemic crisis will increase by 2030.

CONCLUSION

The number of hyperglycemic crisis hospitalizations in Korea increased in the last decade, although the hospitalization rate per 1,000 diabetes cases and mortality rate decreased. Also, the predicted number of annual claims will increase in the future. Thus, it is necessary to establish long-term healthcare policies to prevent hyperglycemic crisis.

High Proportion of Adult Cases and Prevalence of Metabolic Syndrome in Type 1 Diabetes Mellitus Population in Korea: A Nationwide Study

BACKGROUND

The prevalence and incidence of type 1 diabetes mellitus (T1DM) in all age groups and the prevalence of metabolic syndrome in patients with T1DM in Korea were estimated.

METHODS

The incidence and prevalence of T1DM between 2007 and 2013 were calculated using the Korean National Health Insurance Service (NHIS) datasets of claims. Clinical characteristics and prevalence of metabolic syndrome in individuals with T1DM between 2009 and 2013 were determined using the database of NHIS preventive health checkups.

RESULTS

The prevalence of T1DM in Korea between 2007 and 2013 was 0.041% to 0.047%. The annual incidence rate of T1DM in Korea in 2007 to 2013 was 2.73 to 5.02/100,000 people. Although the incidence rate of typical T1DM was highest in teenagers, it remained steady in adults over 30 years of age. In contrast, the incidence rate of atypical T1DM in 2013 was higher in people aged 40 years or older than in younger age groups. Age- and sex-adjusted prevalence of metabolic syndrome in patients with T1DM was 51.65% to 55.06% between 2009 and 2013.

CONCLUSION

T1DM may be more common in Korean adults than previously believed. Metabolic syndrome may be a frequent finding in individuals with T1DM in Korea.

Clinical characteristics of diabetic ketoacidosis in users and non-users of SGLT2 inhibitors

AIM

This study investigated the clinical characteristics of diabetic ketoacidosis (DKA) and compared the DKA characteristics between patients treated with and without SGLT2 inhibitors.

METHODS

Data were collected from patients aged ≥ 18 years admitted for DKA at nine centres in Korea between September 2014 and April 2017. The electronic medical records of these subjects were retrospectively reviewed. Based on their history of medications taken before admission, subjects were classified as either users or non-users of SGLT2 inhibitors and their clinical characteristics of DKA were compared.

RESULTS

During the study, the main subtype of DKA episodes (n = 523) was identified as type 2 diabetes (51%). Average hospitalization duration was 11 days, and average intensive care unit (ICU) time was 2.5 days. The in-hospital mortality rate was 3%, but no users of SGLT2 inhibitors died during DKA treatment. In patients taking SGLT2 inhibitors (n = 15), DKA manifested at 124 days, on average, after starting the inhibitors (range: 7-380 days). Also, SGLT2 inhibitors users had significantly lower plasma glucose levels (413 mg/dL) compared with non-users (554 mg/dL), and longer ICU stays (4 vs. 2 days; P = 0.019).

CONCLUSION

In this report of recent data on the clinical features of DKA in Korea, patients using SGLT2 inhibitors needed longer treatment in ICUs compared with non-users and had lower levels of blood glucose, whereas DKA associated with SGLT2 inhibitors was rare.

Mortality and causes of death in patients with atrial fibrillation: A nationwide population-based study

Background

Patients with atrial fibrillation are known to have a high risk of mortality. There is a paucity of population-based studies about the impact of atrial fibrillation on the mortality risk stratified by age, sex, and detailed causes of death.

Methods

A total of 15,411 patients with atrial fibrillation from the Korean National Health Insurance Service-National Sample Cohort were enrolled, and causes of death were identified according to codes of the 10th revision of the International Classification of Diseases.

Results

From 2002 to 2013, a total of 4,479 (29%) deaths were confirmed, and the crude mortality rate for all-cause death was 63.3 per 1,000 patient-years. Patients with atrial fibrillation had a 3.7-fold increased risk of all-cause death compared with the general population. The standardized mortality ratio for all-cause death was the highest in young patients and decreased with increasing age (standardized mortality ratio 21.93, 95% confidence interval 7.60–26.26 in patients aged <20 years; standardized mortality ratio 2.77, 95% confidence interval 2.63–2.91 in patients aged ≥80 years). Women with atrial fibrillation exhibited a greater excess mortality risk than men (standardized mortality ratio 3.81, 95% confidence interval 3.65–3.98 in women; standardized mortality ratio 3.35, 95% confidence interval 3.21–3.48 in men). Cardiovascular disease was the leading cause of death (38.5%), and cerebral infarction was the most common specific disease. Patients with atrial fibrillation had an about 5 times increased risk of death due to cardiovascular disease compared with the general population.

Conclusions

Patients with atrial fibrillation had a 4 times increased risk of mortality compared with the general population. However, the impact of atrial fibrillation on mortality decreased with age and in men. Cerebral infarction was the most common cause of death, and more attention should be paid to reducing the risk of stroke.

Development and Validation of the Korean Diabetes Risk Score: A 10-Year National Cohort Study

BACKGROUND

A diabetes risk score in Korean adults was developed and validated.

METHODS

This study used the National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS) of 359,349 people without diabetes at baseline to derive an equation for predicting the risk of developing diabetes, using Cox proportional hazards regression models. External validation was conducted using data from the Korean Genome and Epidemiology Study. Calibration and discrimination analyses were performed separately for men and women in the development and validation datasets.

RESULTS

During a median follow-up of 10.8 years, 37,678 cases (event rate=10.4 per 1,000 person-years) of diabetes were identified in the development cohort. The risk score included age, family history of diabetes, alcohol intake (only in men), smoking status, physical activity, use of antihypertensive therapy, use of statin therapy, body mass index, systolic blood pressure, total cholesterol, fasting glucose, and γ glutamyl transferase (only in women). The C-statistics for the models for risk at 10 years were 0.71 (95% confidence interval [CI], 0.70 to 0.73) for the men and 0.76 (95% CI, 0.75 to 0.78) for the women in the development dataset. In the validation dataset, the C-statistics were 0.63 (95% CI, 0.53 to 0.73) for men and 0.66 (95% CI, 0.55 to 0.76) for women.

CONCLUSION

The Korean Diabetes Risk Score may identify people at high risk of developing diabetes and may be an effective tool for delaying or preventing the onset of condition as risk management strategies involving modifiable risk factors can be recommended to those identified as at high risk.

Association of blood pressure components with mortality and cardiovascular events in prehypertensive individuals: a nationwide population-based cohort study

BACKGROUND

The effects of each blood pressure index [systolic and diastolic blood pressure (SBP, DBP), pulse pressure (PP), mean arterial pressure (MAP)] on the occurrence of mortality and cardiovascular (CV) events have not yet been investigated in prehypertensive populations.

METHODS

A total of 30,258 prehypertensive Korean participants underwent periodic health examination between 2003 and 2004 were enrolled, and the associations of BP components with mortality and CV events were investigated. Moreover, based on the DBP [80 ≤ DBP <90 mmHg (N = 21,323) and DBP <80 mmHg (N = 8,935)], the effects of BP components were also evaluated.

RESULTS

Multivariate Cox analyses in prehypertensive group revealed that the hazard ratios (HRs) were 1.121 and 1.130 per 10 mmHg increase in SBP and PP for mortality, respectively. Additionally, 10 mmHg increase of SBP (HR:1.090) was still significantly, but increase of PP (HR:1.060) was marginally associated with higher incidence of CV events. However, there were no significant associations with increase in DBP or MAP on adverse clinical outcomes in prehypertensive group. In the prehypertensive subjects with DBP <80 mmHg, CV events more frequently occurred by 38.8% and 28.5% per 10 mmHg increase in SBP and PP, respectively.

CONCLUSIONS

Prehypertensive subjects might need to be cautioned when they have high SBP or PP with low DBP even in healthy populations. Key message Prehypertensive subjects should be cautioned when they have high-systolic blood pressure or pulse pressure with low-diastolic blood pressure, even without previous hypertension, diabetes mellitus or chronic kidney disease.

Elevated N-acetyl-β-d-glucosaminidase, a urinary tubular damage marker, is a significant predictor of carotid artery atherosclerosis in type 1 diabetes, independent of albuminuria: A cross-sectional study

AIMS

Recent evidence has shown that renal tubulointerstitial injuries play an important role in diabetic nephropathy. In this study, we evaluated the association between urinary N-acetyl-β-d-glucosaminidase (uNAG), an early renal tubular damage marker, and carotid artery atherosclerosis in patients with type 1 diabetes (T1D).

METHODS

This was a cross-sectional study of 88 patients with T1D. Demographic and laboratory data; urinary indices, including urinary NAG-to-creatinine ratio (uNCR), and albumin-to-creatinine ratio (uACR); and carotid ultrasonography were investigated.

RESULTS

Eighty-eight subjects were divided into three groups based on uNCR tertiles. Subjects belonging to the highest tertile of uNCR had the highest average mean and maximum carotid intima-media thickness (IMT). An elevated uNCR was also significantly correlated with increased average mean and maximum carotid IMT, whereas an elevated uACR was not. Even after adjusting for confounding factors, uNCR continued to be a meaningful predictive marker for increased average mean and maximum IMT. Conversely, the uACR could not predict carotid IMT after adjustment for confounding factors.

CONCLUSIONS

Elevated levels of uNAG are significantly associated with carotid artery atherosclerosis in patients with T1D independently of albuminuria, a marker of glomerular damage.

Clinical Utility and Cross-Reactivity of Insulin and C-Peptide Assays by the Lumipulse G1200 System

BACKGROUND

Measurement of insulin and C-peptide concentrations is important for deciding whether insulin treatment is required in diabetic patients. We aimed to investigate the analytical performance of insulin and C-peptide assays using the Lumipulse G1200 system (Fujirebio Inc., Tokyo, Japan).

METHODS

We examined the precision, linearity, and cross-reactivity of insulin and C-peptide using five insulin analogues and purified proinsulin. A method comparison was conducted between the Lumipulse G1200 and Roche E170 (Roche Diagnostics, Mannheim, Germany) systems in 200 diabetic patients on insulin treatment. Reference intervals for insulin and C-peptide concentrations were determined in 279 healthy individuals.

RESULTS

For insulin and C-peptide assays, within-laboratory precision (% CV) was 3.78-4.14 and 2.89-3.35%, respectively. The linearity of the insulin assay in the range of 0-2,778 pmol/L was R²=0.9997, and that of the C-peptide assay in the range of 0-10 nmol/L was R²=0.9996. The correlation coefficient (r) between the Roche E170 and Lumipulse G1200 results was 0.943 (P<0.001) for insulin and 0.996 (P<0.001) for C-peptide. The mean differences in insulin and C-peptide between Lumipulse G1200 and the Roche E170 were 19.4 pmol/L and 0.2 nmol/L, respectively. None of the insulin analogues or proinsulin showed significant cross-reactivity with the Lumipulse G1200. Reference intervals of insulin and C-peptide were 7.64-70.14 pmol/L and 0.17-0.85 nmol/L, respectively.

CONCLUSIONS

Insulin and C-peptide tests on the Lumipulse G1200 show adequate analytical performance and are expected to be acceptable for use in clinical areas.

Association of Body Mass Index with Risk of Major Adverse Cardiovascular Events and Mortality in People with Diabetes

Background

The relationship between cardiovascular and all-cause mortality and obesity in people with diabetes is still controversial. We investigated the association of body mass index (BMI) with the risk of major adverse cardiovascular events (MACE) and all-cause mortality in people with diabetes.

Methods

In total, 48,438 people with diabetes were enrolled in the Korean National Health Insurance Service-National Health Screening Cohort from 2002 to 2003 and were followed until 2013. Baseline BMI was categorized as underweight (<18.5 kg/m²), normal-weight (18.5–22.9 kg/m²), overweight (23.0–24.9 kg/m²), obese class I (25.0–29.9 kg/m²), and obese class II (≥30.0 kg/m²).

Results

During a median of 10.7 years of follow-up (interquartile range, 10.2–11.2 years), there were 7,360 MACE and 5,766 deaths. Compared to those in the normal-weight group, the fully adjusted hazard ratios (HRs) for MACE were 1.09 (95% confidence interval [CI], 0.92–1.29), 0.91 (95% CI, 0.85–0.97), 0.93 (95% CI, 0.88–0.98), and 0.95 (95% CI, 0.84–1.06) for underweight, overweight, obese class I, and obese class II groups, respectively. The HRs for all-cause mortality were 1.75 (95% CI, 1.54–1.99), 0.74 (95% CI, 0.69–0.79), 0.67 (95% CI, 0.63–0.71), and 0.73 (95% CI, 0.63–0.85) for underweight, overweight, obese class I, and obese class II groups, respectively.

Conclusion

In people with diabetes, underweight people had a higher risk for all-cause mortality, whereas overweight or obese people had a lower risk for MACE and all-cause mortality than those with a normal weight.

House dust mite and Cockroach specific Immunoglobulin E sensitization is associated with diabetes mellitus in the adult Korean population

Immunoglobulin E (IgE) is known to activate mast cells. Prior studies have shown that mast cells contribute to diet-induced obesity and diabetes mellitus (DM). We aimed to determine whether adults with IgE sensitization were at risk of DM. We performed assays regarding serum total IgE and allergen-specific IgE levels against the house dust mite, the cockroach, and the dog on 1,528 adults randomly sampled from every age and gender group in various districts. The total and three allergen-specific IgE levels were positively correlated with fasting glucose level and insulin resistance. Subjects with increased levels of total IgE (>100 kU/L), compared to those without, had an odds ratio (OR) of 1.72 (95% confidence interval [95% CI], 1.17–2.54) for DM after adjusting for various covariates. Further controlling for previous allergic disease did not attenuate the association between total IgE level and DM. Subjects sensitized to the house dust mite (OR 1.63, 95% CI, 1.03–2.59) and the cockroach (OR 2.27, 95% CI, 1.40–3.66) were also at increased risk of DM. We found a strong positive association between IgE sensitization and DM in a general Korean population, suggesting that IgE may be an important independent risk factor for metabolic diseases in Koreans.

Fasting glucose and risk of colorectal cancer in the Korean Multi-center Cancer Cohort

Previous cohort studies have demonstrated a positive association between diabetes mellitus (DM) and colorectal cancer (CRC). However, there are few comparisons between DM groups categorized by fasting glucose level. This study examined associations between diabetes as defined by fasting glucose level and self-reported history of DM and CRC risk among Korean adults. Data from the Korean Multi-center Cancer Cohort between 1993 and 2005 were analyzed. The study population comprised 14,570 participants aged 20 years or older. Participants were followed until December 31, 2012 (median follow-up: 11.9 years). Among participants with high fasting glucose (≥126mg/dL), the risk of developing CRC was significantly higher (HR: 1.51 [1.02-2.25]) than among participants with low fasting glucose (<126mg/dL). Risk was not significantly higher among participants with self-reported history of DM (HR: 1.34 [0.78-2.31]). When both fasting glucose and history of DM were considered together, the risk of CRC among participants with both high fasting glucose and history of DM was 54% (HR: 1.54 [0.97-2.43]), and the risk of CRC among participants with high fasting glucose and no history of DM was 50% (HR: 1.50 [0.73-3.05]). When the first 5 years of follow-up were excluded, among participants with high fasting glucose, the risk of developing CRC was significantly higher (HR: 1.61 [1.02-2.56]) than among participants with low fasting glucose. Risk of CRC was also significantly higher among participants with high fasting glucose and no history of DM (HR: 1.69 [1.01-2.84]). High fasting glucose and self-reported history of DM were associated with increased risk of CRC in this Korean population.

Alteration of oxidative stress and inflammatory cytokines induces apoptosis in diabetic nephropathy

Diabetic nephropathy (DN) is one of the most significant long‑term complications in terms of morbidity and mortality for diabetic patients; however, the exact cause remains unknown. To address this, the DN model was established, and oxidative stress indexes, including malondialdehyde (MDA), superoxide dismutase (SOD), glutathione peroxidase (GSH‑Px), and inflammatory cytokines, includinginterleukin‑6 (IL‑6), tumor necrosis factor‑alpha (TNF‑α) and transforming growth factor‑beta (TGF‑β), were examined by ELISA. Renal pathological alterations and cell apoptosis was examined by hematoxylin and eosin and terminal deoxynucleotidyl transferase mediated dUTP nick‑end labeling staining, respectively. The expression levels of B‑cell lymphoma‑2 (Bcl‑2), Bcl‑2 associated X (Bax) and caspase‑3 wereexamined by immunohistochemistry and western blotting. The DN model was correctly established, with lower body weight and the higher blood glucose in the diabetes model group. The expression levels of SOD and GSH‑Px were significantly decreased in the diabetes model group; however, MDA, IL‑6, TNF‑α and TGF‑β were significantly increased. The kidney was severely damaged in the diabetes model group, with inflammatory cell invasion, increasing amount of interstitial matrix and hypertrophy with vacuolar degeneration of renal tubular cells. Cell apoptosis levels were significantly increased, and Bcl‑2 was significantly decreased in the diabetes model group in contrast with that of the sham group; however, Bax and caspase‑3 were significantly increased. It suggested that increased oxidative stress and inflammatory cytokines may enhance the apoptosis levels in DN, and may provide a significant diagnostic reference for DN in diabetes patients.

Factors associated with greater benefit of a national reimbursement policy for blood glucose test strips in adult patients with type 1 diabetes: A prospective cohort study

AIMS/INTRODUCTION

We aimed to identify factors independently associated with greater benefit of a national reimbursement policy for blood glucose test strips in adult patients with type 1 diabetes, in terms of glycemic control and the rate of severe hypoglycemia.

MATERIALS AND METHODS

This was a prospective cohort study of 466 adult patients with type 1 diabetes from five tertiary referral hospitals who registered for a national reimbursement program for blood glucose strips and were then followed-up for 12 months. Factors associated with a > 5% reduction in glycated hemoglobin (HbA1c) and decreased rate of severe hypoglycemia (SH) at 12 months from baseline were evaluated.

RESULTS

At the end of the 12 months of follow up, 158 of 466 patients (33.9%) achieved >5% reduction in HbA1c, and 47 of 111 patients (42.3%) had a decreased rate of SH relative to baseline. Higher HbA1c (P < 0.001), lower total daily insulin dose at baseline (P = 0.048) and an increase in self-monitoring of blood glucose (SMBG) frequency during follow up (P = 0.001) were independently associated with >5% reduction in HbA1c. A higher SMBG frequency (P < 0.001), higher rate of SH at baseline (P = 0.029) and lack of hypoglycemic unawareness (P = 0.044) were independently associated with an increase in the frequency of SMBG during follow up. Higher SMBG frequency at baseline (P < 0.001) was independently associated with a decreased rate of SH.

CONCLUSIONS

Several factors, including higher SMBG frequency at baseline, were independently associated with reduced HbA1c and a decreased rate of severe hypoglycemia, showing that patients with these characteristics derive the most benefit from reimbursement of blood glucose test strips.

BMI and All-Cause Mortality in Normoglycemia, Impaired Fasting Glucose, Newly Diagnosed Diabetes, and Prevalent Diabetes: A Cohort Study

OBJECTIVE

This study examined associations between BMI and mortality in individuals with normoglycemia, impaired fasting glucose (IFG), newly diagnosed diabetes, and prevalent diabetes and identified BMI ranges associated with the lowest mortality in each group.

RESEARCH DESIGN AND METHODS

A total of 12,815,006 adults were prospectively monitored until 2013. Diabetes status was defined as follows: normoglycemia (fasting glucose <100 mg/dL), IFG (100-125 mg/dL), newly diagnosed diabetes (≥126 mg/dL), and prevalent diabetes (self-reported). BMI (kg/m²) was measured. Cox proportional hazards model hazard ratios were calculated after adjusting for confounders.

RESULTS

During a mean follow-up period of 10.5 years, 454,546 men and 239,877 women died. U-shaped associations were observed regardless of diabetes status, sex, age, and smoking history. Optimal BMI (kg/m²) for the lowest mortality by group was 23.5-27.9 (normoglycemia), 25-27.9 (IFG), 25-29.4 (newly diagnosed diabetes), and 26.5-29.4 (prevalent diabetes). Higher optimal BMI by worsening diabetes status was more prominent in younger ages, especially in women. The relationship between worsening diabetes status and higher mortality was stronger with lower BMI, especially at younger ages. Given the same BMI, people with prevalent diabetes had higher mortality compared with those with newly diagnosed diabetes, and this was more striking in women than men.

CONCLUSIONS

U-curve relationships existed regardless of diabetes status. Optimal BMI for lowest mortality became gradually higher with worsening diabetes for each sex and each age-group.

Obesity and Metabolic Unhealthiness Have Different Effects on Colorectal Neoplasms

CONTEXT

Obesity and insulin resistance are risk factors for colorectal neoplasms (CRN), but data regarding metabolic status, obesity, and CRN are lacking.

OBJECTIVE

To investigate the relationship between metabolic status, obesity, and CRN in Koreans who underwent colonoscopy.

DESIGN

Retrospective, cross-sectional.

PARTICIPANTS

Subjects were divided based on metabolic and obesity criteria, as follows: metabolically healthy nonobese (MHNO), metabolically healthy obese (MHO), metabolically unhealthy nonobese (MUNO), and metabolically unhealthy obese (MUO).

MAIN OUTCOME MEASURES

Multiple regression was used to identify CRN and advanced CRN risk factors, with the MHNO group as reference.

RESULTS

A total of 10,235 subjects was included, as follows: 5096 MHNO, 1538 MHO, 1746 MUNO, and 1855 MUO. Of these, 3297 had CRN (32.2%), and 434 (4.2%) had advanced CRN. Number of subjects with CRN in each group were: MHNO 25.8%, MHO 33.9%, MUNO 38.9%, and MUO 42.0% (P for trend < 0.001). Risk of CRN was increased in the MHO [odds ratio (OR) 1.239, 95% confidence interval (CI) 1.082 to 1.418, P = 0.002], the MUNO (OR 1.233, 95% CI 1.086 to 1.400, P = 0.001), and the MUO groups (OR 1.510, 95% CI 1.338 to 1.706, P < 0.001), whereas risk of advanced CRN was increased in the MUNO (OR 1.587, 95% CI 1.222 to 2.062, P = 0.001) and the MUO groups (OR 1.456, 95% CI 1.116 to 1.900, P = 0.006).

CONCLUSIONS

Obesity increased CRN risk with metabolically unhealthy status adding risk. For advanced CRN, metabolically unhealthy status increased the risk but obesity did not.

Stepwise Approach to Problematic Hypoglycemia in Korea: Educational, Technological, and Transplant Interventions

Impaired awareness of hypoglycemia has been found to be prevalent in 20% to 40% of people with type 1 diabetes. If a similar prevalence exists in Koreans with type 1 diabetes, at a minimum, thousands of people with type 1 diabetes suffer at least one unpredicted episode of severe hypoglycemia per year in Korea. For patients with problematic hypoglycemia, an evidence-based stepwise approach was suggested in 2015. The first step is structured education regarding multiple daily injections of an insulin analog, and the second step is adding a technological intervention, such as continuous subcutaneous insulin infusion or real-time continuous glucose monitoring. The next step is a sensor-augmented pump, preferably with a low glucose suspension feature or very frequent contact, and the final step is islet or pancreas transplantation. In Korea, however, none of these treatments are reimbursed by the National Health Insurance, and thus have not been widely implemented. The low prevalence of type 1 diabetes means that Korean physicians are relatively unfamiliar with the new technologies in this field. Therefore, the roles of new technologies and pancreas or islet transplantation in the treatment of problematic hypoglycemia need to be defined in the current clinical setting of Korea.

Differential association of body mass index on glycemic control in type 1 diabetes

BACKGROUND

In contrast to type 2 diabetes, the association of body mass index (BMI) with glycemic control in type 1 diabetes (T1D) remains unclear. We investigated the relationship between BMI and average HbA_1c levels in subjects with T1D.

METHOD

In this multi-centre observational study, we analysed 719 subjects with T1D aged ≥18 years. Average HbA_1c levels over 18 months and other clinical and laboratory parameters were evaluated.

RESULTS

The mean age and duration of diabetes at baseline were 41.5 ± 13.9 and 11.3 ± 8.7 years, respectively. A U-shaped correlation between BMI and 18-month average HbA_1c levels was documented by a spline curve. Based on this finding, subjects were divided into three groups according to BMI (group I, <21; group II, 21-23; and group III, ≥23 kg/m² ). In group I, the BMI negatively correlated with average HbA_1c (r = -0.172, p = 0.011), while a positive relationship was observed (r = 0.162, p = 0.012) in group III. Average HbA_1c levels were lower and the proportion of individuals with well-controlled glycemia (HbA_1c <7%) were increased in the higher BMI tertile group among subjects with group I as well as in the lower BMI tertile group among subjects with group III BMI. After adjustment with additional covariates in the multiple regression model, these associations between BMI and HbA_1c levels according to the different BMI ranges remained significant.

CONCLUSIONS

In Korean subjects with T1D, an inverse relationship of BMI with HbA_1c levels was observed in the low BMI group, while a positive correlation was shown in the high BMI group. Copyright © 2016 John Wiley & Sons, Ltd.