2019 Clinical Practice Guidelines for Type 2 Diabetes Mellitus in Korea

Cumulative exposure to impaired fasting glucose and gastrointestinal cancer risk: A nationwide cohort study

BACKGROUND

Impaired fasting glucose (IFG) is associated with the risk of various cancers, but the cumulative effect of IFG on gastrointestinal cancer risk remains unclear. This study evaluated the association between the cumulative exposure to IFG and gastrointestinal cancer risk.

METHODS

The authors extracted data from the Korean National Health Insurance Service and health examination data sets. Among individuals ≥40 years old who were free of diabetes or cancer, 1,430,054 who underwent national health examinations over 4 consecutive years from 2009 to 2012 were selected and followed up until gastrointestinal cancer diagnosis, death, or December 31, 2019. The IFG exposure score (range, 0-4) was based on the number of IFG diagnoses over 4 years.

RESULTS

The median follow-up duration was 6.4 years. Consistent normoglycemia for 4 years was found in 44.3% of the population, whereas 5.0% had persistent IFG and 50.7% had intermittent IFG. Compared to the group with an IFG exposure score of 0, groups with IFG exposure scores of 1, 2, 3, and 4 had a 5%, 8%, 9%, and 12% increased risk of gastrointestinal cancer, respectively (score 1: adjusted hazard ratio [aHR], 1.05; 95% confidence interval [CI], 1.01-1.08; score 2: aHR, 1.08; 95% CI, 1.04-1.12; score 3: aHR, 1.09; 95% CI, 1.05-1.14; score 4: aHR, 1.12; 95% CI, 1.06-1.19). Persistent IFG exposure was also associated with higher risks of individual cancer types (colorectum, stomach, pancreas, biliary tract, and esophagus).

CONCLUSIONS

Cumulative exposure to IFG is associated with an increased risk of developing gastrointestinal cancer, in a dose-dependent manner.

PLAIN LANGUAGE SUMMARY

Hyperglycemia, including both diabetes and prediabetes, has been associated with an increased risk of various cancers. However, the cumulative effect of impaired fasting glucose on the risk of developing gastrointestinal cancer remains unclear. A frequent diagnosis of impaired fasting glucose was dose-dependently associated with a higher risk of developing overall gastrointestinal cancer. Furthermore, risks of individual cancer types increased with persistent impaired fasting glucose. Early detection of hyperglycemia and strict glycemic control can lower the risk of gastrointestinal cancer by reducing hyperglycemic burden. Additionally, for some individuals, lifestyle changes such as managing metabolic syndrome or abstaining from alcohol may also be helpful.

Real-World Outcomes of Individualized Targeted Therapy with Insulin Glargine 300 Units/mL in Insulin-Naïve Korean People with Type 2 Diabetes: TOBE Study

INTRODUCTION

The TOujeo BEyond glucose control (TOBE) study evaluated clinical outcomes with insulin glargine 300 units/mL (Gla-300) in insulin-naïve Korean people with type 2 diabetes mellitus (T2DM) in a real-world setting.

METHODS

This 24-week, prospective, non-interventional, multicenter, open-label, single-arm, observational study included adults aged ≥ 20 years with T2DM suboptimally controlled with oral hypoglycemic agents and/or glucagon-like peptide 1 receptor agonists who require basal insulin. Eligible participants were assigned to either general target glycated hemoglobin (HbA1c < 7%) or individualized target groups as per physician's discretion considering guidelines and participants' characteristics. The primary endpoint was the proportion of participants achieving the HbA1c target (individualized or general) at 24 weeks.

RESULTS

Among 369 participants, 19.5% (72/369) of participants achieved the HbA1c target at week 24; 37.5% (33/88) in the individualized and 13.9% (39/281) in the general target group. In both target groups, similar reductions in fasting plasma glucose and body weight were observed, with low incidence of hypoglycemia, and T2DM duration was significantly shorter in participants who did versus those who did not achieve the target HbA1c (individualized target group: 9.6 ± 8.0 versus 13.1 ± 8.4 years, P = 0.0454; general target group: 10.2 ± 8.6 versus 12.8 ± 7.4 years, P = 0.0378).

CONCLUSIONS

This study showed that initiation of insulin therapy with Gla-300 in people with T2DM using an individualized approach is more effective in achieving an HbA1c target. Moreover, earlier initiation of insulin therapy in people with suboptimally controlled T2DM may increase the success rate of glycemic control. A graphical abstract is available with this article.

The Potential Role of Presepsin in Predicting Severe Infection in Patients with Diabetic Foot Ulcers

Background/Objectives: Diabetic foot ulcers are one of the complications in patients with diabetes, which can be caused by infection, neuropathy, and blood vessel disorder. Among them, infection is the most common cause, and if it becomes worse, amputation may be necessary. So, it is important to detect and treat infections early, and determining indicators that can confirm infection is also important. Known infection markers include white blood cells (WBCs), the erythrocyte sediment rate (ESR), C-reactive protein (CRP), and procalcitonin, but they are not specific to diabetic foot ulcers. Presepsin, also known as soluble CD14, is known to be an early indicator of sepsis. Recent studies have reported that presepsin can be used as an early indicator of infection. This study investigated whether presepsin could be used as an early marker of severe infection in patients with diabetic foot ulcers. Methods: We retrospectively studied 73 patients who were treated for diabetic foot ulcerations from January 2021 to June 2023 at Yeungnam University Hospital. Results: Out of a total of 73 patients, 46 patients underwent amputations with severe infections, and the WBC level, ESR, and CRP, procalcitonin, and presepsin levels were significantly higher in the group of patients who underwent amputations. The cutoff of presepsin, which can predict serious infections that need amputation, was 675 ng/mL. A regression analysis confirmed that presepsin, HbA1c, and osteomyelitis significantly increased the risk of severe infections requiring amputation. Conclusions: Presepsin will be available as an early predictor of patients with severe infections requiring amputations for diabetic foot ulcerations.

The clinical relevance of a polygenic risk score for type 2 diabetes mellitus in the Korean population

The clinical utility of a type 2 diabetes mellitus (T2DM) polygenic risk score (PRS) in the East Asian population remains underexplored. We aimed to examine the potential prognostic value of a T2DM PRS and assess its viability as a clinical instrument. We first established a T2DM PRS for 5490 Korean individuals using East Asian Biobank data (269,487 samples). Subsequently, we assessed the predictive capability of this T2DM PRS in a prospective longitudinal study with baseline data and data from seven additional follow-ups. Our analysis showed that the T2DM PRS could predict the transition of glucose tolerance stages from normal glucose tolerance to prediabetes and from prediabetes to T2DM. Moreover, T2DM patients in the top-decile PRS group were more likely to be treated with insulin (hazard ratio = 1.69, p value = 2.31E-02) than were those in the remaining PRS groups. T2DM PRS values were significantly high in the severe diabetes subgroup, characterized by insulin resistance and β -cell dysfunction (p value = 0.0012). The prediction models with the T2DM PRS had significantly greater Harrel's C-indices than did corresponding models without it. By utilizing prospective longitudinal study data and extensive clinical risk factor information, our analysis provides valuable insights into the multifaceted clinical utility of the T2DM PRS.

Effectiveness and Safety of Sodium-Glucose Cotransporter 2 Inhibitors Added to Dual or Triple Treatment in Patients with Type 2 Diabetes Mellitus

INTRODUCTION

We evaluated the effectiveness and safety of sodium-glucose cotransporter 2 inhibitor (SGLT2i) add-on treatment in patients with type 2 diabetes mellitus (T2DM) in the real-world setting.

METHODS

This single-center retrospective study used the clinical database of Seoul National University Hospital in South Korea. Patients who received metformin monotherapy or combination therapy with ≥ 1 other oral hypoglycemic medication and had a baseline glycosylated hemoglobin (HbA1c) between 7.0% and 10.5% were included. Propensity score matching was applied between patients treated with and without SGLT2 inhibitors (SGLT2i and non-SGLT2i groups, respectively). Changes in HbA1c from baseline to week 26 were compared between the SGLT2i and non-SGLT2i groups, and risk of adverse events (AE) were also assessed.

RESULTS

A total of 1106 patients were included. At week 26, HbA1c was significantly more reduced by 0.35 percentage points in the SGLT2i group than in the non-SGLT2i group (95% CI 0.30-0.41, P < 0.001). Likewise, the proportion of patients achieving HbA1c < 7% was also significantly higher (51.9% vs. 37.6%, P < 0.05) in the SGLT2i group than in the non-SGLT2i group. The risk of adverse events in the SGLT2i group was mostly comparable with those in the non-SGLT2i group except for diseases of the liver, pain, hypertensive diseases, and metabolic disorders, which showed significantly higher odds in the SGLT2i group.

CONCLUSIONS

SGLT2i add-on treatment is an effective and safe therapeutic option for patients with T2DM in the real-world practice setting.

Serum-based ATR-FTIR spectroscopy combined with multivariate analysis for the diagnosis of pre-diabetes and diabetes

Diabetes mellitus (DM) is a metabolic disease with an increasing prevalence that is causing worldwide concern. The pre-diabetes stage is the only reversible stage in the patho-physiological process towards DM. Due to the limitations of traditional methods, the diagnosis and detection of DM and pre-diabetes are complicated, expensive, and time-consuming. Therefore, it would be of great benefit to develop a simple, rapid and inexpensive diagnostic test. Herein, the infrared (IR) spectra of serum samples from 111 DM patients, 111 pre-diabetes patients and 333 healthy volunteers were collected using attenuated total reflection Fourier-transform IR (ATR-FTIR) spectroscopy and this was combined with the multivariate analysis of principal component analysis linear discriminant analysis (PCA-LDA) to develop a discriminant model to verify the diagnostic potential of this approach. The study found that the accuracy of the test model established by ATR-FTIR spectroscopy combined with PCA-LDA was 97%, and the sensitivity and specificity were 100% and 100% in the control group, 94% and 98% in the pre-diabetes group, and 91% and 98% in the DM group, respectively. This indicates that this method can effectively diagnose DM and pre-diabetes, which has far-reaching clinical significance.

Risk factors for carotid plaque formation in type 2 diabetes mellitus

OBJECT

Patients with type 2 diabetes mellitus (T2DM) are at higher risk of developing atherosclerosis. Previous studies have analyzed the factors associated with diabetic macrovascular disease, although whether these factors are applicable to T2DM patients with carotid atherosclerosis remains unclear. Therefore, the aim of this study was to investigate the risk factors for the formation of carotid atherosclerotic plaque in hospitalized T2DM patients and to provide a theoretical basis for early prevention and treatment of carotid atherosclerosis in these patients.

METHODS

A total of 949 patients with T2DM were included in the study. Carotid ultrasound identified 531 patients with carotid atherosclerotic plaque. The waist-to-hip ratio (WHR), blood glucose, liver and kidney function, blood lipid profile, islet function, and other indicators were measured at the same time to identify the risk factors and predictive significance of T2DM carotid plaque.

RESULTS

The proportions of men, diabetes nephropathy (DN) and hypertension in T2DM patients with carotid plaque are higher than those without carotid plaque(P < 0.05). Age, duration of diabetes, WHR, Postprandial glucose (PPG), lipoprotein (a) [Lip (a)], carcinoembryonic antigen(CEA) and estimated glomerular filtration rate (eGFR) in T2DM patients with carotid plaque were higher than those without plaque (P < 0.05). Age, WHR, duration of diabetes, hypertension, males, and Lip (a) were independent risk factors for T2DM patients with carotid plaque. Age, WHR, duration of diabetes, and Lip (a) had a higher AUC to predict T2DM with carotid artery plaque (AUC: 0.750, 0.640, 0.678, 0.552 respectively; P all < 0.001). After constructing the logit (P) value of the above risk factors, the area under the ROC curve was 0.816 (0.789-0.842, P < 0.001).

CONCLUSION

Age, WHR, duration of diabetes, hypertension, males, and Lip (a) levels are the main risk factors for the formation of carotid plaque in T2DM patients. Combining the above risk factors provides a better prediction of carotid plaque formation in T2DM.

Health and Productivity Benefits with Early Intensified Treatment in Patients with Type 2 Diabetes: Results from Korea

The available evidence suggests positive health outcomes associated with early treatment intensification in Type 2 diabetes mellitus (T2DM). Our study estimated the productivity effects arising from improved health correlated with early intensified treatment in T2DM in Korea. Using a recently published methodology and model, we investigated the association between early intensified treatment and the probability of experiencing fewer diabetes-related complication events. Treatment strategies leading to better health outcomes are expected to be associated with social value through increased participation in paid and unpaid work activities. Therefore, we translated the lower incidence of complications into monetary terms related to productivity for the Korean population. We quantified productivity by considering (a) absenteeism, (b) presenteeism, (c) permanent loss of labor force, and (d) activity restriction. Deterministic and probabilistic sensitivity analyses in the base case parameter were performed. Approximately, 1.7 thousand (standard deviation [SD] ±580 events) micro- and macrovascular complication events could potentially be avoided by early treatment intensification. This led to a societal gain attributed to increased productivity of 23 million USD (SD ± $8.2 million). This article demonstrates the likelihood of achieving better health and productivity through early intensified treatment in diabetes.

Fruits and the Risk of Type 2 Diabetes: The Korean Genome and Epidemiology Study Cohort

BACKGROUND

To determine the association between type 2 diabetes mellitus and the consumption of various fruits.

METHODS

The Korean Genome And Epidemiology Study is an ongoing prospective longitudinal cohort study of community dwellers and participants (men and women, aged 40-69 years) recruited from the national health examinee registry of Korea. Their individual consumption habits for 12 different fruit types were recorded using food frequency questionnaires. The fruits were then divided into three groups according to their glycemic indexes and glycemic loads. Participants with extreme caloric intakes, pre-existing type 2 diabetes mellitus, chronic kidney diseases, chronic liver diseases, and ongoing cancer treatments were excluded. The incidence of type 2 diabetes in the cohort was identified through self-reporting and supplemented by glycated hemoglobin and fasting blood glucose levels.

RESULTS

A total of 2,549 cases of type 2 diabetes were documented during 283,033.8 person-years of follow-up. After adjusting for personal, lifestyle, and dietary risk factors for diabetes, the pooled hazard ratio of type 2 diabetes for every serving per week of total whole fruit consumption was 1.02 (95% confidence interval [CI], 0.99-1.06; P=0.2). With mutual adjustment of individual fruits, the pooled hazard ratios of type 2 diabetes for every serving per week were 0.94 (95% CI, 0.88-1.00; P=0.039) for bananas, and 0.90 (95% CI, 0.84-0.96; P<0.001) for grapes.

CONCLUSION

Our findings suggest associations between the consumption of certain fruits and the risk of developing type 2 diabetes. A greater consumption of grapes was significantly associated with a lower risk of type 2 diabetes in our cohort, but the total amount of fruit consumption was not associated with a reduced risk.

Association of low muscle strength with metabolic dysfunction-associated fatty liver disease: A nationwide study

BACKGROUND

There is limited evidence regarding the association between muscle strength and metabolic dysfunction-associated fatty liver disease (MAFLD).

AIM

To investigate the association between muscle strength and MAFLD in the general population in Korea.

METHODS

This nationwide representative cross-sectional study included 31649 individuals aged ≥ 19 years who participated in the Korea National Health and Nutrition Examination Survey between 2015 and 2018. Odds ratios (ORs) and 95% confidence intervals (95%CIs) for MAFLD according to sex-specific quartiles of muscle strength, defined by relative handgrip strength, were calculated using multivariable logistic regression analysis. Additionally, multivariable logistic regression analysis was used to assess the association between muscle strength and probable liver fibrosis in patients with MAFLD.

RESULTS

Of all the participants, 29.3% had MAFLD. The prevalence of MAFLD was significantly higher in the lower muscle strength quartile groups for all participants, sexes, and age groups (P < 0.001). A 1.92-fold (OR = 1.92, 95%CI: 1.70-2.16) and 3.12-fold (OR = 3.12, 95%CI: 2.64-3.69) higher risk of MAFLD was observed in the lowest quartile (Q1) group than in the other groups (Q2-Q4) and the highest quartile (Q4) group, respectively. The ORs of MAFLD were significantly increased in the lower muscle strength quartile groups in a dose-dependent manner (P for trend < 0.001). These associations persisted in both sexes. An inverse association between muscle strength and the risk of MAFLD was observed in all subgroups according to age, obesity, and diabetes mellitus. In patients with MAFLD, the odds of severe liver fibrosis were higher in Q1 (OR = 1.83, 95%CI: 1.25-2.69) than in other groups (Q2-Q4).

CONCLUSION

Among Korean adults, low muscle strength was associated with an increased risk of MAFLD and liver fibrosis in patients with MAFLD.

Predictive value of the Framingham steatosis index for cardiovascular risk: a nationwide population-based cohort study

Background

Non-alcoholic fatty liver disease (NAFLD) is common and is associated with cardiovascular (CV) disease and mortality. The Framingham steatosis index (FSI) was recently proposed as a diagnostic marker of NAFLD and was calculated from age, body mass index, triglyceride, aspartate aminotransferase, alanine aminotransferase, diabetes history, and hypertension status. We aimed to evaluate the predictive ability of FSI for CV risk using a large-scale population dataset from the Korean National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS).

Methods

Among 514,866 individuals in the NHIS-HEALS, we excluded those who died, had a history of admission due to a CV event, and were heavy drinkers. The final study cohort comprised 283,427 participants. We employed both unadjusted and covariate-adjusted models in Cox proportional hazards regression analyses to determine the association between FSI and major adverse cardiovascular events (MACEs), CV events, and CV mortality.

Results

During a median follow-up of 5.9 years, we documented 9,674, 8,798, and 1,602 cases of MACEs, CV events, and CV mortality, respectively. The incidence of MACEs was 1.28%, 2.99%, 3.94%, and 4.82% in the first to fourth quartiles of FSI, respectively. The adjusted hazard ratios (95% confidence interval) for MACEs gradually and significantly increased with the FSI quartiles [1.302 (1.215-1.395) in Q2, 1.487 (1.390-1.590) in Q3, and 1.792 (1.680-1.911) in Q4], following an adjustment for conventional CV risk factors, including age, sex, smoking, drinking, physical activities, low-density lipoprotein cholesterol, estimated glomerular filtration rate, and waist circumference. Participants in the higher quartiles of FSI exhibited a noteworthy increase in the occurrence of CV event. However, upon adjusting for relevant risk factors, the association between FSI and CV mortality did not reach statistical significance.

Conclusion

Our study suggests that the FSI, which is a surrogate marker of NAFLD, has a prognostic value for detecting individuals at higher risk of CV events.

β-hydroxybutyrate as a biomarker of β-cell function in new-onset type 2 diabetes and its association with treatment response at 6 months

AIMS

Increasing attention has been paid to the potential metabolic benefits of ketone bodies, but the clinical relevance of ketone bodies in newly diagnosed type 2 diabetes mellitus (T2D) remains unclear. We investigated the clinical implications of ketone bodies at the time of diagnosis in patients with drug-naïve T2D.

METHODS

Clinical data including serum β-hydroxybutyrate (βHB) levels, were collected from 369 patients with newly diagnosed drug-naïve T2D from 2017 to 2021. Subjects were categorized into four βHB groups based on the level of initial serum βHB. The associations of initial serum βHB and urinary ketone levels with glucometabolic indices were analyzed.

RESULTS

Higher serum βHB group was associated with higher levels of glycemic parameters including glycated hemoglobin (HbA1c) with lower levels of indices for insulin secretory function at the point of initial diagnosis of T2D. Nevertheless, higher serum βHB group was an independent determinant of a greater relative improvement in HbA1c after 6 months of anti-diabetic treatment, regardless of the type of anti-diabetic drug. In addition, patients in higher serum βHB group were more likely to have well-controlled HbA1c levels (≤6.5%) after 6 months of anti-diabetic treatment.

CONCLUSION

In patients with newly diagnosed T2D, a higher initial βHB level was a significant predictive marker of greater glycemic improvement after antidiabetic treatment, despite its associations with hyperglycemia and decreased insulin secretion at baseline.

Diabetes severity is strongly associated with the risk of active tuberculosis in people with type 2 diabetes: a nationwide cohort study with a 6-year follow-up

BACKGROUND

Many have the rising coincidence of diabetes mellitus (DM) and endemic tuberculosis (TB). We evaluated whether the severity of diabetes is associated with an increased risk of active TB infection.

METHODS

 Using a nationally representative database from the Korean National Health Insurance System, 2, 489, 718 people with type 2 DM who underwent a regular health checkup during 2009-2012 were followed up until the end of 2018. The diabetes severity score parameters included the number of oral hypoglycemic agents (≥ 3), insulin use, diabetes duration (≥ 5 years), and the presence of chronic kidney disease (CKD) or cardiovascular disease. Each of these characteristics was scored as one point, and their sum (0-5) was used as the diabetes severity score.

RESULTS

We identified 21, 231 cases of active TB during a median follow-up of 6.8 years. Each parameter of the diabetes severity score was associated with an increased risk of active TB (all P < 0.001). Insulin use was the most significant factor related to the risk of TB, followed by CKD. The risk of TB increased progressively with increasing diabetes severity score. After adjusting for possible confounding factors, the hazard ratio (95% confidence interval) for TB were 1.23 (1.19-1.27) in participants with one parameter, 1.39 (1.33-1.44) in those with two parameters, 1.65 (1.56-1.73) in those with three parameters, 2.05 (1.88-2.23) in those with four parameters, and 2.62 (2.10-3.27) in those with five parameters compared with participants with no parameters.

CONCLUSION

Diabetes severity was strongly associated in a dose-dependent manner with the occurrence of active TB. People with a higher diabetes severity score may be a targeted group for active TB screening.

Identifying the Associations of Nightly Fasting Duration and Meal Timing with Type 2 Diabetes Mellitus Using Data from the 2016–2020 Korea National Health and Nutrition Survey

Nightly fasting duration and meal timing are associated with metabolic disorders. This study aimed to investigate the relationships of nightly fasting duration and meal timing with type 2 diabetes mellitus (T2DM) using data from the 2016–2020 Korea National Health and Nutrition Survey. A total of 22,685 adults ≥ 19 years were included in this study. Nightly fasting duration was calculated by subtracting the interval between the day’s first and last meal eating times from 24 h. The meal timing were analyzed using various parameters, including the times of the first and last eating episodes and the percentage of energy intake during the morning (05:00 to 9:00 a.m.), evening (06:00 to 09:00 p.m.), and night (after 09:00 p.m.). Men who fasted nightly for ≥ 12 h had lower odds of T2DM (odds ratio (OR): 0.86; 95% confidence interval (CI): 0.75–0.99) than those who fasted for < 12 h. Individuals who had their last meal after 09:00 p.m. had higher odds of T2DM (OR: 1.19, 95% CI: 1.03–1.38, men; OR: 1.19, 95% CI: 1.01–1.40, women). Additionally, the percentage of energy intake during the evening was associated with increased odds of T2DM (OR: 1.41, 95% CI: 1.08–1.84, men; OR: 1.32, 95% CI: 1.02–1.70, women). These findings emphasize the importance of nightly fasting duration and meal timing in modulating the risk of T2DM among Korean adults.

Developing a Classification Algorithm for Prediabetes Risk Detection From Home Care Nursing Notes: Using Natural Language Processing

This study developed and validated a rule-based classification algorithm for prediabetes risk detection using natural language processing from home care nursing notes. First, we developed prediabetes-related symptomatic terms in English and Korean. Second, we used natural language processing to preprocess the notes. Third, we created a rule-based classification algorithm with 31 484 notes, excluding 315 instances of missing data. The final algorithm was validated by measuring accuracy, precision, recall, and the F1 score against a gold standard testing set (400 notes). The developed terms comprised 11 categories and 1639 words in Korean and 1181 words in English. Using the rule-based classification algorithm, 42.2% of the notes comprised one or more prediabetic symptoms. The algorithm achieved high performance when applied to the gold standard testing set. We proposed a rule-based natural language processing algorithm to optimize the classification of the prediabetes risk group, depending on whether the home care nursing notes contain prediabetes-related symptomatic terms. Tokenization based on white space and the rule-based algorithm were brought into effect to detect the prediabetes symptomatic terms. Applying this algorithm to electronic health records systems will increase the possibility of preventing diabetes onset through early detection of risk groups and provision of tailored intervention.

Cardiovascular Outcomes according to Comorbidities and Low-Density Lipoprotein Cholesterol in Korean People with Type 2 Diabetes Mellitus

BACKGROUND

There are no clear data to support the cardiovascular (CV) risk categories and low-density lipoprotein cholesterol (LDL-C) treatment goals in Korean people with type 2 diabetes mellitus (T2DM). We evaluated the incidence of cardiovascular disease (CVD) according to comorbidities and suggested LDL-C treatment goals in Korean people with T2DM in nationwide cohort data.

METHODS

Using the Korean National Health Insurance Service database, 248,002 people aged 30 to 90 years with T2DM who underwent routine health check-ups during 2009 were included. Subjects with previous CVD were excluded from the study. The primary outcome was incident CVD, defined as a composite of myocardial infarction and ischemic stroke during the follow-up period from 2009 to 2018.

RESULTS

The mean age of the study participants was 59.6±10.9 years, and median follow-up period was 9.3 years. CVD incidence increased in the order of DM duration of 5 years or more (12.04/1,000 person-years), hypertension (HT) (12.27/1,000 personyears), three or more CV risk factors (14.10/1,000 person-years), and chronic kidney disease (18.28/1,000 person-years). The risk of incident CVD increased linearly from an LDL-C level of ≥70 mg/dL in most patients with T2DM. In T2DM patients without HT or with a DM duration of less than 5 years, the CVD incidence increased from LDL-C level of ≥100 mg/dL.

CONCLUSION

For primary prevention of CVD in Korean adults with T2DM, it can be helpful to lower LDL-C targets when there are chronic kidney disease, HT, a long duration of diabetes mellitus, or three or more CV risk factors.

Lipid Management in Korean People with Type 2 Diabetes Mellitus: Korean Diabetes Association and Korean Society of Lipid and Atherosclerosis Consensus Statement

Dyslipidemia in patients with diabetes is an important treatment target as a modifiable risk factor for cardiovascular disease (CVD). Although the primary treatment goal for dyslipidemia is to control low-density lipoprotein cholesterol (LDL-C), achieving this goal remains suboptimal according to recent studies. It is important to set the target goal for LDL-C control based on an accurate risk assessment for CVD. Here, we summarize the latest evidence on lipid management in patients with diabetes and present a consensus of the Korean Diabetes Association and Korean Society of Lipid and Atherosclerosis on the treatment goals of LDL-C according to the duration of diabetes, presence of CVD, target organ damage, or major cardiovascular risk factors. In patients with type 2 diabetes mellitus (T2DM) and CVD, an LDL-C goal of <55 mg/dL and a reduction in LDL-C level by 50% or more from the baseline is recommended. For the primary prevention of CVD in patients with T2DM with a duration of diabetes ≥10 years, major cardiovascular risk factors, or target organ damage, an LDL-C goal of <70 mg/dL is recommended. In patients with T2DM with a duration of diabetes <10 years and no major cardiovascular risk factors, an LDL-C goal of <100 mg/dL is recommended.

Impaired ketogenesis is associated with metabolic-associated fatty liver disease in subjects with type 2 diabetes

AIMS

The ketogenic pathway is an effective mechanism by which the liver disposes of fatty acids (FAs) to the peripheral tissues. Impaired ketogenesis is presumed to be related to the pathogenesis of metabolic-associated fatty liver disease (MAFLD), but the results of previous studies have been controversial. Therefore, we investigated the association between ketogenic capacity and MAFLD in subjects with type 2 diabetes (T2D).

METHODS

A total of 435 subjects with newly diagnosed T2D was recruited for the study. They were classified into two groups based on median serum β-hydroxybutyrate (β-HB) level: intact vs. impaired ketogenesis groups. The associations of baseline serum β-HB and MAFLD indices of hepatic steatosis index, NAFLD liver fat score (NLFS), Framingham Steatosis index (FSI), Zhejian University index, and Chinese NAFLD score were investigated.

RESULTS

Compared to the impaired ketogenesis group, the intact ketogenesis group showed better insulin sensitivity, lower serum triglyceride level, and higher low-density lipoprotein-cholesterol and glycated hemoglobin levels. Serum levels of liver enzymes were not different between the two groups. Of the hepatic steatosis indices, NLFS (0.8 vs. 0.9, p=0.045) and FSI (39.4 vs. 47.0: p=0.041) were significantly lower in the intact ketogenesis group. Moreover, intact ketogenesis was significantly associated with lower risk of MAFLD as calculated by FSI after adjusting for potential confounders (adjusted odds ratio 0.48, 95% confidence interval 0.25-0.91, p=0.025).

CONCLUSIONS

Our study suggests that intact ketogenesis might be associated with decreased risk of MAFLD in T2D.

Lipid Management in Korean People With Type 2 Diabetes Mellitus: Korean Diabetes Association and Korean Society of Lipid and Atherosclerosis Consensus Statement

Dyslipidemia in patients with diabetes is an important treatment target as a modifiable risk factor for cardiovascular disease (CVD). Although the primary treatment goal for dyslipidemia is to control low-density lipoprotein cholesterol (LDL-C), achieving this goal remains suboptimal according to recent studies. It is important to set the target goal for LDL-C control based on an accurate risk assessment for CVD. Here, we summarize the latest evidence on lipid management in patients with diabetes and present a consensus of the Korean Diabetes Association and Korean Society of Lipid and Atherosclerosis on the treatment goals of LDL-C according to the duration of diabetes, presence of CVD, target organ damage, or major cardiovascular risk factors. In patients with type 2 diabetes mellitus (T2DM) and CVD, an LDL-C goal of <55 mg/dL and a reduction in LDL-C level by 50% or more from the baseline is recommended. For the primary prevention of CVD in patients with T2DM with a duration of diabetes ≥10 years, major cardiovascular risk factors, or target organ damage, an LDL-C goal of <70 mg/dL is recommended. In patients with T2DM with a duration of diabetes <10 years and no major cardiovascular risk factors, an LDL-C goal of <100 mg/dL is recommended.

A causal relationship between alcohol intake and type 2 diabetes mellitus: A two-sample Mendelian randomization study

BACKGROUND AND AIMS

We investigated whether alcohol intake has a causal relationship with type 2 diabetes mellitus (T2DM) risk in adults of the Korean Genomic Epidemiology Study using two-sample Mendelian randomization (MR) analysis.

METHODS AND RESULTS

Daily alcohol intake was calculated based on the type, average amount, and frequency of alcohol consumption for six months before the interview. The participants were divided into low- and high-alcohol intake of 20 g/day. After adjusting for the covariates related to T2DM, the independent genetic variants (instrumental variables) related to alcohol intake were explored by GWAS analysis in a city hospital-based cohort (n = 58,701). SNPs with a significant level of p-value <5 × 10^-8 and linkage disequilibrium of r² < 0.001 were retrieved. MR methods were used to analyze the causality between alcohol intake and the T2DM risk, and the heterogeneity and leave-one-out sensitivity analyses were conducted in Ansan/Ansung plus rural cohorts (n = 13,598). High alcohol intake increased T2DM risk when the inverse-variance weighted (P = 0.012) and weighted median (P = 0.034) methods were used, but not when the MR-Egger method was used. No significant heterogeneity and horizontal pleiotropy between alcohol intake and T2DM were detected. A single genetic variant did not affect the causal association in a leave-one-out sensitivity analysis.

CONCLUSION

This study supports that heavy alcohol intake appears to be causally associated with T2DM risk.

Predictors for successful weight reduction during treatment with Dapagliflozin among patients with type 2 diabetes mellitus in primary care

Aims

Studies on factors affecting weight loss effect after start of dapagliflozin in type 2 diabetes mellitus (T2DM) patients are few. The aim of this study was to identify if there were any patient characteristics that could predict weight loss after starting treatment with dapagliflozin.

Methods

The study included 200 Korean patients with T2DM who were prescribed dapagliflozin in a family medicine clinic during 2014–2019. We studied patients for 1 year after starting dapagliflozin treatment. Data were collected from medical records. Clinically meaningful weight reduction was defined as ≥3% decrease in body weight and odds ratios (ORs) and 95% confidence intervals (CIs) for succeeding this weight reduction was calculated for different baseline characteristics.

Results

In total, 113 (56.5%) patients were male. Weight loss of ≥3% in 1 year treatment with dapagliflozin was achieved in 122 (61%) patients. The likelihood of this level of weight loss was significantly increased with regular exercise (OR 2.13, 95% CI 1.07–4.25), with concomitant metformin treatment (OR 2.90, 95% CI 1.23–6.80), and in patients with normal renal function (OR 13.84, 95% CI 1.33–144.26). Patients receiving sulfonylurea treatment were less likely to achieve ≥3% weight reduction (OR 0.39, 95 CI 0.19–0.79).

Conclusions

T2DM patients that performed regular exercise, had normal renal function and were receiving metformin were more likely to have clinically meaningful body weight reduction after one year treatment with dapagliflozin.

Early glycaemic variability increases 28-day mortality and prolongs intensive care unit stay in critically ill patients with pneumonia

OBJECTIVE

This study aimed to evaluate the effect of early glycaemic variability (GV) on 28-day mortality in critically ill patients with pneumonia.

PATIENTS AND METHODS

This single-centre retrospective study included patients admitted to the intensive care unit (ICU) due to pneumonia between 2018 and 2019. A total of 282 patients (mean age, 68.6 years) with blood sugar test (BST) results measured more than three times within 48 h after hospitalization and haemoglobin A1c (HbA1c) levels recorded within 2 months were enrolled. Coefficient of variation (CV) was calculated using the BST values. The effects of GV on 28-day mortality and prolonged ICU stay (>14 days) were also assessed.

RESULTS

The mean age was 60.6 years (male to female ratio, 2.5:1). The 28-day mortality rate was 31.6% (n = 89) and was not different according to the presence of diabetes (DM vs. non-DM) or HbA1c levels (≥7.5 vs. <7.5%; both p > .05). However, the mortality rate was significantly higher in patients with high GV (CV ≥ 36%) than in those with low GV (CV < 36%; 37.5 vs. 25.4%, p = .028). The risk of mortality in patients with high GV was prominent in the subgroups with DM or low HbA1c levels. Among the surviving patients (n = 193), 44 remained in the ICU for more than 14 days. Compared to low GV, high GV was associated with a higher rate of prolonged ICU stay, although not statistically significant (27.8 vs. 18.5%, p = .171). After adjusting for the severity of illness and treatment strategy, CV was an independent risk factor for 28-day mortality (hazard ratio [HR], 1.01, p = .04) and prolonged ICU stay (odds ratio, 1.02; p = .04).

CONCLUSIONS

High GV within 48 h of ICU admission was associated with an increased 28-day mortality risk and prolonged ICU stay. Early phase GV should be carefully managed in critically ill patients with pneumonia.KEY MESSAGESThe presence of diabetes or HbA1c alone is insufficient to predict 28-day mortality and prolonged ICU stay in critically ill patients with pneumonia.High glycaemic variability (GV) within 48 h of ICU admission increases 28-day mortality and prolongs ICU stay, which is consistent after adjusting for severity of illness and treatment strategy.Patients with high GV, especially those with DM or low HbA1c levels (<7.5%) should be more carefully treated to reduce mortality.

Does Pitavastatin Therapy for Patients with Type 2 Diabetes and Dyslipidemia Affect Serum Adiponectin Levels and Insulin Sensitivity?

(1) Background: We aimed to demonstrate the effects of pitvastatin therapy on the serum levels of total adiponectin and high-molecular-weight (HMW) adiponectin in type 2 diabetes and the correlation with insulin sensitivity. (2) Methods: This study was designed as an open-labelled randomized trial. Patients with diabetes who were prescribed pitavastatin therapy were enrolled and randomized to either treatment with 2 mg of pitavastatin once daily (n = 44) (PITA group) or diet and exercise only, except their antidiabetic medications (n = 49), for 24 weeks. (3) Results: In lipid profiles, the reduction in total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) was significantly increased in the PITA group (TC; 207.5 ± 20 vs. 195.5 ± 30.0 ng/dL, p < 0.001, LDL-C; 132.0 ± 15.8 vs. 123.1 ± 25.7 mg/dL, p < 0.001). Adiponectin and HMW adiponectin were elevated in the PITA group, compared to the control group without significance. The PITA group showed a lower level of HOMA-IR and HOMA-β levels. However, there was no significance (HOMA-IR; p = 0.5921 -at 12 weeks and p = 0.3645 at 24 weeks; HOMA-β; p = 0.8915 at 12 weeks and p = 0.7313 in 6 months). (4) Conclusions: The present study did not show a significant change in serum adiponectin or HMW adiponectin from baseline in serum adiponectin following pitavastatin therapy. Although statin has been considered as a risk for dysglycemia, pitavastatin did not affect insulin sensitivity.

Improving Machine Learning Diabetes Prediction Models for the Utmost Clinical Effectiveness

The early prediction of diabetes can facilitate interventions to prevent or delay it. This study proposes a diabetes prediction model based on machine learning (ML) to encourage individuals at risk of diabetes to employ healthy interventions. A total of 38,379 subjects were included. We trained the model on 80% of the subjects and verified its predictive performance on the remaining 20%. Furthermore, the performances of several algorithms were compared, including logistic regression, decision tree, random forest, eXtreme Gradient Boosting (XGBoost), Cox regression, and XGBoost Survival Embedding (XGBSE). The area under the receiver operating characteristic curve (AUROC) of the XGBoost model was the largest, followed by those of the decision tree, logistic regression, and random forest models. For the survival analysis, XGBSE yielded an AUROC exceeding 0.9 for the 2- to 9-year predictions and a C-index of 0.934, while the Cox regression achieved a C-index of 0.921. After lowering the threshold from 0.5 to 0.25, the sensitivity increased from 0.011 to 0.236 for the 2-year prediction model and from 0.607 to 0.994 for the 9-year prediction model, while the specificity showed negligible changes. We developed a high-performance diabetes prediction model that applied the XGBSE algorithm with threshold adjustment. We plan to use this prediction model in real clinical practice for diabetes prevention after simplifying and validating it externally.

Differences in health behavior and nutrient intake status between diabetes-aware and unaware Korean adults based on the Korea national health and nutrition examination survey 2016-18 data: A cross-sectional study

Background

The aim of this study was to investigate the nutritional intakes and treatment regimens of Korean patients with type 2 diabetes who were aware of their condition.

Methods

Participants (n = 16582) aged ≥ 19 years from the 2016-18 National Health and Nutrition Survey were divided into diabetes-aware and unaware groups and the variables were compared.

Results

Among 1,906 (11.5%) diabetic adults, 1,433 (75.2%) were aware of their condition; 130 (9.1%) had nutrition education, and 1,340 (93.5%) were in the diabetes-aware treatment group. The diabetes-aware group had higher average age (P < 0.0001) and lower average BMI (P = 0.0015) than the unaware group. Intake of total fat (P = 0.0034), saturated fatty acids (P = 0.0021), riboflavin (P = 0.0035) and niacin (P = 0.0228) was significantly higher in the unaware group than in the diabetes-aware group, after adjusting energy intake for age and sex. Current smoking (P = 0.0046) and heavy drinking (P < 0.0001) rates were higher in the unaware group, whereas fiber intake (P = 0.0054) was lower in the unaware group. Higher levels of glycated hemoglobin were found in the group treated for diabetes (7.2%) than in the no-treatment (6.8%) group (P = 0.0048). Diabetes control was significantly better in the high income group.

Conclusions

There is a need to strengthen nutritional education to prevent diabetes and improve the health status of diabetic patients in Korea.

Perfluorinated compounds in adults and their association with fasting glucose and incident diabetes: a prospective cohort study

BACKGROUND

The endocrine disruption of perfluorinated compounds is an emerging issue. We aimed to examine the association of serum perfluorooctanoic acid (PFOA) and perfluorooctanesulfonic acid (PFOS) levels with incident diabetes and fasting serum glucose concentration.

METHODS

This prospective cohort study was based on an urban-based cohort subpopulation from the Korean Genome and Epidemiology Study. Serum samples (600 µL) were received from 100 participants in the normoglycemic baseline survey (2004-2013), and concentrations of PFOA and PFOS were measured using mass spectrometry. The incidence of diabetes was tracked in the follow-up survey (2012-2016).

RESULTS

The mean age was 56.4 years (men, 59%). The median serum PFOA and PFOS concentrations were 4.29 ng/mL and 9.44 ng/mL, respectively. PFOA and PFOS concentrations differed according to age, sex, and residential area. After 60 months, 23 patients had diabetes. Log-transformed PFOA (lnPFOA) and log-transformed PFOS (lnPFOS) were significantly higher in those who transitioned to diabetes than in those who did not (both p < 0.05). After multivariate adjustment, lnPFOA (coefficient = 6.98, 95% CI -0.04-14, p = 0.054) and lnPFOS (coefficient = 7.06, 95% CI -0.96-15.08, p = 0.088) predicted increased fasting glucose without statistical significance. In addition, lnPFOA, but not lnPFOS, significantly predicted incident diabetes (HR = 3.98, 95% CI 1.42-11.1, p < 0.01).

CONCLUSION

Exposure to PFOA and PFOS may have a potential dysglycemic effect. In particular, exposure to PFOA increased the risk of diabetes. Further research with larger sample size is warranted.

Safety of sodium-glucose cotransporter 2 inhibitors in Asian type 2 diabetes populations

The prevalence of type 2 diabetes mellitus continues to increase in many Asian countries, with possible contributing factors, such as younger-onset disease, diabetes development at lower body mass index, higher visceral fat accumulation and poorer β-cell function, among Asian populations. Sodium-glucose cotransporter 2 inhibitors have been shown to confer favorable effects in type 2 diabetes mellitus patients, such as improved glycemic control, weight and blood pressure reduction, and importantly, cardiorenal benefits. Sodium-glucose cotransporter 2 inhibitors are generally well-tolerated, and have a well-defined safety profile based on evidence from numerous clinical trials and post-marketing pharmacovigilance reporting. To our knowledge, this review is the first to provide a comprehensive coverage of the adverse events of sodium-glucose cotransporter 2 inhibitors, as well as their management and counseling aspects for Asian type 2 diabetes mellitus populations.

Association of the Estimated Pulse Wave Velocity with Cardio-Vascular Disease Outcomes among Men and Women Aged 40-69 Years in the Korean Population: An 18-Year Follow-Up Report on the Ansung-Ansan Cohort in the Korean Genome Environment Study

The estimated pulse wave velocity (ePWV) can predict adverse cardiovascular disease (CVD) outcomes in patients with increased CVD risks. However, data on its predictive capacity for CVD outcomes in the general population are limited. This study aimed to investigate the association between the ePWV and CVD outcomes among Korean adults. Ten thousand thirty patients aged 40–69 years from the Ansung–Ansan cohort in a prospective community-based cohort study were followed up for over 18 years. The ePWV was categorized into quartiles. Cox proportional hazard models were used to estimate the risk of cardiovascular (CV) mortality and CVD outcomes (composites of CV mortality, myocardial infarction, coronary artery disease, stroke, heart failure, and peripheral artery disease). The incidence of CV mortality and CVD outcomes was 7.0% and 22.1% in the fourth (highest) ePWV quartile and 0.1% and 4.5% in the first (lowest) quartile, respectively. After relevant covariate adjustments, the patients in the fourth quartile showed a significantly higher CV mortality risk (hazard ratio (HR), 7.57; 95% confidence interval (CI), 1.83–31.25). The patients in the third and fourth quartiles had higher CVD outcome risks (third: HR, 1.61; 95% CI, 1.19–2.16; fourth: HR, 1.56; 95% CI, 1.05–2.31) than those in the first quartile. This association was more clearly observed among women than among men. An elevated ePWV is associated with CV mortality and CVD outcomes. The ePWV is expected to serve as a potential marker for identifying high-risk groups for CVD events.

Integrated metagenomics and metabolomics analysis illustrates the systemic impact of the gut microbiota on host metabolism after bariatric surgery

AIM

To explore how bariatric surgery (BS) modified the obesity-associated gut microbiome, the host metabolome, and their interactions in obese Korean patients.

MATERIALS AND METHODS

Stool and fasting blood samples were obtained before and 1, 3, 6, and 12 months after BS from 52 patients enrolled in the Korean Obesity Surgical Treatment Study. We analysed the gut microbiome by 16S rRNA gene sequencing and the serum metabolome, including bile acids, by nuclear magnetic resonance spectroscopy and ultrahigh-performance liquid chromatography/triple quadrupole mass spectrometry.

RESULTS

Stool metagenomics showed that 27 microbiota were enriched and 14 microbiota were reduced after BS, whereas the abundances and diversity of observed features were increased. The levels of branched-chain amino acids and metabolites of energy metabolism in serum were decreased after surgery, whereas the levels of metabolites related to microbial metabolism, including dimethyl sulphone, glycine, and secondary bile acids, were increased in the serum samples. In addition, we found notable mutual associations among metabolites and gut microbiome changes attributed to BS.

CONCLUSIONS

Changes in the gut microbiome community and systemic levels of amino acids and sugars were directly derived from anatomical changes in the gastrointestinal tract after BS. We hypothesized that the observed increases in microbiome-related serum metabolites were a result of complex and indirect changes derived from BS. Ethnic-specific environmental or genetic factors could affect Korean-specific postmetabolic modification in obese patients who undergo BS.

Development of Various Diabetes Prediction Models Using Machine Learning Techniques

BACKGROUND

There are many models for predicting diabetes mellitus (DM), but their clinical implication remains vague. Therefore, we aimed to create various DM prediction models using easily accessible health screening test parameters.

METHODS

Two sets of variables were used to develop eight DM prediction models. One set comprised 62 easily accessible examination results of commonly used variables from a tertiary university hospital. The second set comprised 27 of the 62 variables included in the national routine health checkups. Gradient boosting and random forest algorithms were used to develop the models. Internal validation was performed using the stratified 10-fold cross-validation method.

RESULTS

The area under the receiver operating characteristic curve (ROC-AUC) for the 62-variable DM model making 12-month predictions for subjects without diabetes was the largest (0.928) among those of the eight DM prediction models. The ROC-AUC dropped by more than 0.04 when training with the simplified 27-variable set but still showed fairly good performance with ROC-AUCs between 0.842 and 0.880. The accuracy was up to 11.5% higher (from 0.807 to 0.714) when fasting glucose was included.

CONCLUSION

We created easily applicable diabetes prediction models that deliver good performance using parameters commonly assessed during tertiary university hospital and national routine health checkups. We plan to perform prospective external validation, hoping that the developed DM prediction models will be widely used in clinical practice.

Analysis of Continuity of Care and Its Related Factors in Diabetic Patients: A Cross-Sectional Study

BACKGROUND

Continuity of care in primary care settings is crucial for managing diabetes. We aimed to statistically define and analyze continuity factors associated with demographics, clinical workforce, and geographical relationships.

METHODS

We used 2014-2015 National Health Insurance Service claims data from the Korean registry, with 39,096 eligible outpatient attendance. We applied multivariable logistic regression to analyze factors that may affect the continuity of care indices for each patient: the most frequent provider continuity index (MFPCI), modified-modified continuity index (MMCI), and continuity of care index (COCI).

RESULTS

The mean continuity of care indices were 0.90, 0.96, and 0.85 for MFPCI, MMCI and COCI, respectively. Among patient factors, old age >80 years (MFPCI: odds ratio [OR], 0.81; 95% confidence interval [CI], 0.74-0.89; MMCI: OR, 0.84; 95% CI, 0.76-0.92; and COCI: OR, 0.81; 95% CI, 0.74-0.89) and mild disability were strongly associated with lower continuity of care. Another significant factor was the residential area: the farther the patients lived from their primary care clinic, the lower the continuity of diabetes care (MFPCI: OR, 0.74; 95% CI, 0.70-0.78; MMCI: OR, 0.70; 95% CI, 0.66-0.73; and COCI: OR, 0.74; 95% CI, 0.70-0.78).

CONCLUSION

The geographical proximity of patients' residential areas and clinic locations showed the strongest correlation as a continuity factor. Further efforts are needed to improve continuity of care to address the geographical imbalance in diabetic care.

Effects of exercise initiation and smoking cessation after new-onset type 2 diabetes mellitus on risk of mortality and cardiovascular outcomes

Lifestyle changes after a diagnosis of type 2 diabetes mellitus (DM) can affect vascular health outcomes. The objective of this study was to investigate the effects of changes in smoking and exercise on the risk of cardiovascular disease (CVD) and mortality in patients with newly diagnosed DM. Data were analyzed for 181,591 people with newly diagnosed type 2 DM who underwent 2 serial health examinations within 2 years before and after DM diagnosis. The study population was followed from the baseline to the date of death or cardiovascular events, or until December 31, 2018 and median follow-up was 6.07 years. Based on the change in status from before to after the diagnosis, participants were grouped into smoking groups (continuous smokers, quitters, new smokers, and nonsmokers) and exercise groups (constant exercisers, new exercisers, exercise dropouts, and nonexercisers). Compared with the nonexercisers, those who initiated exercise after their DM diagnosis had a lower risk of myocardial infarction (MI), stroke, and all-cause mortality: the hazard ratio (HR; 95% confidence interval [CI]) was 0.85 (0.76–0.94) for MI, 0.86 (0.78–0.94) for stroke, and 0.84 (0.89–0.90) for all-cause mortality. Quitters had a higher risk of MI, stroke, and all-cause mortality than nonsmokers, but their risk level was much lower than that in continuous smokers. When the group of continuous smokers and nonexercisers was considered as the reference group, participants who quit smoking and remained nonexercisers had a 21% lower risk of CVD (HR 0.79; 95% CI 0.70–0.90). Those who quit smoking and started exercising had a 46% reduced risk of CVD (HR 0.54; 95% CI 0.41–0.71) and a 22% reduced risk in all-cause mortality (HR 0.78; 95% CI 0.63–0.96). Smoking cessation and exercise initiation after a diagnosis of new-onset type 2 DM was associated with a reduced risk of CVD and all-cause mortality.

Implications of the heterogeneity between guideline recommendations for the use of low dose aspirin in primary prevention of cardiovascular disease

The most recent primary cardiovascular disease (CVD) prevention clinical guidelines used in Europe, Italy, the USA, China, and South Korea differ in aspects of their approach to CVD risk assessment and reduction. Low dose aspirin use is recommended in certain high-risk patients by most but not all the countries. Assessment of traditional risk factors and which prediction models are commonly used differ between countries. The assessments and tools may not, however, identify all patients at high risk but without manifest CVD. The use of coronary artery calcium (CAC) score to guide decisions regarding primary prevention aspirin therapy is recommended only by the US primary prevention guidelines and the 2021 European Society of Cardiology guidelines. A more consistent and comprehensive global approach to CVD risk estimation in individual patients could help to personalize primary CVD prevention. Wider detection of subclinical atherosclerosis, together with structured assessment and effective mitigation of bleeding risk, may appropriately target patients likely to gain net benefit from low dose aspirin therapy.

Sodium Glucose Cotransporter-2 Inhibitors as an Add-on Therapy to Metformin Plus Dipeptidyl Peptidase-4 Inhibitor in Patients with Type 2 Diabetes

PURPOSE

To date, no study has compared the effects of adding sodium glucose cotransporter-2 (SGLT-2) inhibitors to the combination of metformin plus dipeptidyl peptidase-4 (DPP-4) inhibitors to the effects of adding other conventional anti-diabetic drugs (ADDs) to the dual therapy. We aimed to compare the effect of adding SGLT-2 inhibitors with that of adding sulfonylurea (SU) in type 2 diabetes (T2D) patients inadequately controlled with metformin plus DPP-4 inhibitors.

MATERIALS AND METHODS

This study was designed to evaluate the non-inferiority of SGLT-2 inhibitor to SU as an add-on therapy to the dual combination of metformin plus DPP-4 inhibitors. A total of 292 T2D patients who started SU or SGLT-2 inhibitors as an add-on therapy to metformin plus DPP-4 inhibitors due to uncontrolled hyperglycemia, defined as glycated hemoglobin (HbA1c) ≥7%, were recruited. After propensity score matching, 90 pairs of patients remained, and 12-week changes in HbA1c levels were reviewed to assess glycemic effectiveness. Data from these patients were analyzed retrospectively.

RESULTS

After 12 weeks of triple therapy, both groups showed significant changes in HbA1c levels, with a mean of -0.9% in each group. The inter-group difference was 0.01% [95% confidence interval (CI): -0.26-0.27], and the upper limit of the 95% CI was within the limit for non-inferiority (0.40%). There were no inter-group differences in the changes of liver enzyme levels and kidney function.

CONCLUSION

Adding SGLT-2 inhibitors is not inferior to adding SU as a third-line ADD to metformin plus DPP-4 inhibitor combination therapy.

Improvement in Age at Mortality and Changes in Causes of Death in the Population with Diabetes: An Analysis of Data from the Korean National Health Insurance and Statistical Information Service, 2006 to 2018

BACKGRUOUND

Diabetes is a leading cause of death that is responsible for 1.6 million annual deaths worldwide. However, the life expectancy and age at death of people with diabetes have been a matter of debate.

METHODS

The National Health Insurance Service claims database, merged with death records from the National Statistical Information Service in Korea from 2006 to 2018, was analyzed.

RESULTS

In total, 1,432,567 deaths were collected. The overall age at death increased by 0.44 and 0.26 year/year in the diabetes and control populations, respectively. The disparity in the mean age at death between the diabetes and control populations narrowed from 5.2 years in 2006 to 3.0 years in 2018 (p<0.001). In a subgroup analysis according to the presence of comorbid diseases, the number and proportion of deaths remained steady in the group with diabetes only, but steadily increased in the groups with diabetes combined with dyslipidemia and/or hypertension. Compared to the control population, the increase in the mean death age was higher in the population with diabetes. This trend was more prominent in the groups with dyslipidemia and/or hypertension than in the diabetes only group. Deaths from vascular disease and diabetes decreased, whereas deaths from cancer and pneumonia increased. The decline in the proportion of deaths from vascular disease was greater in the diabetes groups with hypertension and/or dyslipidemia than in the control population.

CONCLUSION

The age at death in the population with diabetes increased more steeply and reached a comparable level to those without diabetes.

Association of the atherogenic index of plasma with cardiovascular risk beyond the traditional risk factors: a nationwide population-based cohort study

Background

The atherogenic index of plasma (AIP) is composed of triglycerides and high-density lipoprotein cholesterol and is a novel marker for assessing the risk of atherogenicity and cardiometabolic health. An association between AIP and greater frequency of major adverse cardiovascular events (MACEs) in patients with type 2 diabetes mellitus and high cardiovascular (CV) disease risk has been reported. However, only few studies have examined the correlation between AIP and CV risk in general populations. We thus aimed to evaluate the relationship between AIP and CV diseases using a large-scale population dataset from the Korean National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS).

Methods

A total of 514,866 participants were enrolled from the NHIS-HEALS and classified according to the AIP quartiles. We performed univariate and multivariate Cox proportional hazards regression analyses to determine the association between AIP and MACEs, CV events, and CV mortality.

Results

During follow-up, we documented 12,133, 11,055, and 1942 cases of MACEs, CV events, and CV mortality, respectively. The multivariate-adjusted hazard ratios [HRs; 95% confidence interval (CI)] for MACEs gradually and significantly increased with the AIP quartiles [1.113 (1.054–1.175) in Q2, 1.175 (1.113–1.240) in Q3, and 1.278 (1.209–1.350) in Q4], following an adjustment for the conventional CV risk factors, including age, sex, body mass index, smoking, alcohol drinking, physical activities, household income, fasting glucose, systolic blood pressure, low-density lipoprotein cholesterol, and estimated glomerular filtration rate. In subgroup analyses, the association of AIP with MACEs and CV events was particularly outstanding in patients with diabetes.

Conclusions

AIP was significantly associated with CV risks after adjusting for the traditional risk factors. Therefore, it may be used as an effective mass screening method to identify patients at a high risk of CV events.

Supplementary information

The online version contains supplementary material available at 10.1186/s12933-022-01522-8.

Relationship between the early initiation of insulin treatment and diabetic complications in patients newly diagnosed with type 2 diabetes mellitus in Korea: A nationwide cohort study

AIMS/INTRODUCTION

To evaluate the relationship between early insulin initiation within a year after type 2 diabetes mellitus diagnosis and the risk of diabetic complications.

MATERIALS AND METHODS

We carried out a cohort study using the Korean National Health Insurance Service database. The study participants were newly diagnosed with type 2 diabetes mellitus between 2009 and 2013. After applying propensity score matching (1:1) to the cohort of patients who received two or more oral antidiabetic drugs (OADs) or insulin as the first prescription within 1 year after type 2 diabetes mellitus diagnosis, we computed hazard ratios (HRs) and 95% confidence intervals (CIs) using a Cox proportional hazards regression to compare the risk of diabetes-related microvascular and macrovascular complications and all-cause mortality in insulin versus OAD initiators.

RESULTS

Within the cohort, 52,188 and 1,804 patients received OAD and insulin, respectively. After matching, each group contained 534 patients. Compared with the OAD group, the risk of overall microvascular complications was significantly higher for insulin (HR 1.48, 95% CI 1.28-1.71). No increased risks of overall macrovascular complications (HR 0.90, 95% CI 0.62-1.30) and all-cause mortality were observed (HR 1.06, 95% CI 0.67-1.68).

CONCLUSIONS

In the present study, early insulin treatment was not associated with the risk of macrovascular complications and all-cause mortality compared with OAD treatment; however, the risk of microvascular complications was higher in the insulin group.

Long-term effect of the eradication of Helicobacter pylori on the hemoglobin A1c in type 2 diabetes or prediabetes patients

BACKGROUND/AIMS

The long-term effect of Helicobacter pylori eradication on the metabolic syndrome or diabetes are unclear. The aim of this study was to evaluate the effect of H. pylori eradication on glycemic control in type 2 diabetes mellitus (T2DM) or prediabetes mellitus (preDM).

METHODS

A total of 124 asymptomatic subjects with T2DM or preDM were divided into H. pylori-negative (n = 40), H. pylori-positive with non-eradicated (n = 34), and eradicated (n = 50) groups. We measured H. pylori status (culture, histology, and rapid urease test) and glycated hemoglobin A1c (A1C) levels and followed-up at the 1st year and the 5th year of follow-up.

RESULTS

The A1C levels significantly decreased in the eradicated group compared to the negative group and the non-eradicated groups (at the 1st year, p = 0.024; at the 5th year, p = 0.009). The A1C levels decreased in male, and/or subjects < 65 years of age in subgroup analyses (in male subjects, p = 0.047 and p = 0.020 at the 1st and the 5th year; in subjects < 65 years of age, p = 0.028 and p = 0.006 at the 1st and the 5th year; in male subjects < 65 years of age, p = 0.039 and p = 0.032 at the 1st and the 5th year). The eradication of H. pylori was related to the decrease in A1C values throughout the follow-up period, compared to the non-eradicated group (p = 0.017).

CONCLUSION

H. pylori eradication was related to the decreasing of A1C levels in patients with T2DM or preDM over a long-term follow-up period, especially in male and subjects < 65 years of age.

The use of complex marketing analysis and QSPR methodology for the necessity of a drug development grounding for the treatment of type 2 diabetes mellitus with increased bioavailability

In order to guarantee qualitative medical and pharmaceutical care it is necessary for all participants of the process to provide consistent interconnected actions, including the use of modern approaches in pharmacotherapy, assessment of the urgent needs of the population in medicines (drugs), development and introduction of modern qualitative, safe and effective drugs into the market. Today, one of the key indicators in determining the population‘s need for drugs is the epidemiological indicators in a particular region and their dynamics.

In recent years, the actuality of optimal and effective approaches developing in the prevention and treatment of socially significant diseases, including diabetes mellitus (DM), has been increasingly emphasized at the global level. All actions that are proposed for the development of standardized guidelines, treatment protocols, programs for on-time detection and prevention of diabetes are aimed at forming a system of measures are patient-oriented, based on understanding the patient‘s problems, lifestyle, habits, income and expenses for treatment, as well as other components associated with achieving optimal results for patients.

Comparative Study of Ex Vivo Antiplatelet Activity of Aspirin and Cilostazol in Patients with Diabetes and High Risk of Cardiovascular Disease

BACKGROUND

The role of aspirin in primary cardiovascular disease prevention in patients with diabetes remains controversial. However, some studies have suggested beneficial effects of cilostazol on cardiovascular disease in patients with diabetes. We prospectively investigated the antiplatelet effects of cilostazol compared with aspirin in patients with diabetes and cardiovascular risk factors.

METHODS

We randomly assigned 116 patients with type 2 diabetes and cardiovascular risk factors but no evident cardiovascular disease to receive aspirin at a dose of 100 mg or cilostazol at a dose of 200 mg daily for 14 days. The primary efficacy outcome was antiplatelet effects of aspirin and cilostazol assessed with the VerifyNow system (aspirin response units [ARU]) and PFA-100 (closure time [CT]). Secondary outcomes were changes of clinical laboratory data (ClinicalTrials.gov Identifier: NCT02933788).

RESULTS

After 14 days, there was greater decrease in ARU in aspirin (-28.9%±9.9%) compared cilostazol (-0.4%±7.1%, P<0.001) and was greater increase in CT in aspirin (99.6%±63.5%) compared cilostazol (25.7%±54.1%, P<0.001). The prevalence of aspirin resistance was 7.5% according to VerifyNow (defined by ARU ≥550) and 18.9% according to PFA-100 (CT <192 seconds). Compared with aspirin, cilostazol treatment was associated with increased high density lipoprotein cholesterol (7.1%±12.7% vs. 4.2%±18.0%, P=0.006) and decreased triglycerides (-9.4%±33.7% vs. 4.4%±17.57%, P=0.016). However, there were no significant changes in total and low density lipoprotein cholesterol, C-reactive protein level, and cluster of differentiation 40 ligand between cilostazol and aspirin groups.

CONCLUSION

Aspirin showed better antiplatelet effects assessed with VerifyNow and PFA-100 compared with cilostazol. However, there were favorable changes in atherogenic dyslipidemia only in the cilostazol.

Atherogenic Index of Plasma and Its Association with Risk Factors of Coronary Artery Disease and Nutrient Intake in Korean Adult Men: The 2013–2014 KNHANES

Coronary artery disease (CAD) has been linked to one of the highest death rates globally. The atherogenic index of plasma (AIP) may be an important predictor of atherosclerosis and cardiovascular disease, superior to the standard atherosclerotic lipid profile. This study investigated the relationship between AIP and obesity indices, blood glucose, lipid profile, and nutrient intake status in Korean adult men. The study included 1292 males aged ≥19 years old who participated in the Korea National Health and Nutrition Examination Survey, 2013–2014. Participants were divided into four groups according to AIP quartiles, calculated as log (triglyceride (TG)/high-density lipoprotein cholesterol (HDL-C)). Body mass index, waist circumference, fasting blood glucose, hemoglobin A1c, total cholesterol, TG, and low-density lipoprotein cholesterol levels increased as AIP levels increased, whereas HDL-C level declined. As the level of AIP increased, intake of saturated fatty acid, calcium, phosphorus, riboflavin, milk, and dairy product decreased significantly, and the contribution rate of milk and dairy products to fat intake decreased. AIP was linked to obesity indices, blood glucose, and blood lipid profile in Korean men, suggesting that it could predict CAD.

Performance of Diabetes and Kidney Disease Screening Scores in Contemporary United States and Korean Populations

BACKGROUND

Risk assessment tools have been actively studied, and they summarize key predictors with relative weights/importance for a disease. Currently, standardized screening scores for type 2 diabetes mellitus (DM) and chronic kidney disease (CKD)-two key global health problems-are available in United States and Korea. We aimed to compare and evaluate screening scores for DM (or combined with prediabetes) and CKD, and assess the risk in contemporary United States and Korean populations.

METHODS

Four (2×2) models were evaluated in the United States-National Health and Nutrition Examination Survey (NHANES 2015-2018) and Korea-NHANES (2016-2018)-8,928 and 16,209 adults. Weighted statistics were used to describe population characteristics. We used logistic regression for predictors in the models to assess associations with study outcomes (undiagnosed DM and CKD) and diagnostic measures for temporal and cross-validation.

RESULTS

Korean adult population (mean age 47.5 years) appeared to be healthier than United States counterpart, in terms of DM and CKD risks and associated factors, with exceptions of undiagnosed DM, prediabetes and prehypertension. Models performed well in own country and external populations regarding predictor-outcome association and discrimination. Risk tests (high vs. low) showed area under the curve >0.75, sensitivity >84%, specificity >45%, positive predictive value >8%, and negative predictive value >99%. Discrimination was better for DM, compared to the combined outcome of DM and prediabetes, and excellent for CKD due to age.

CONCLUSION

Four easy-to-use screening scores for DM and CKD are well-validated in contemporary United States and Korean populations. Prevention of DM and CKD may serve as first-step in public health, with these self-assessment tools as basic tools to help health education and disparity.

Real-world comparison of mono and dual combination therapies of metformin, sulfonylurea, and dipeptidyl peptidase-4 inhibitors using a common data model: A retrospective observational study

The comparative effectiveness of oral hypoglycemic agents on glycemic control and chronic complications in clinical practice is unknown in Korea. This study aimed to compare glycemic control and the incidence of hypoglycemia and chronic complications among adult patients with type 2 diabetes prescribed metformin, dipeptidyl peptidase-4 inhibitors (DPP4I), and sulfonylurea (SU) as monotherapy or dual combination therapy.We retrospectively analyzed propensity-matched cohort data from 3 national university hospitals in Korea. All electronic health records were transformed into a unified Observational Medical Outcomes Partnership Common Data Model and analyzed using ATLAS, an open-source analytical tool, and R software. Glycemic control was assessed as the first observation of a reduction in glycosylated hemoglobin (HbA1c) level below 7% after prescription of the drug. Differences in the incidence of chronic complications were compared based on the first observation of each complication. Glycemic control and chronic complications were evaluated in patients who maintained the same prescription for at least 3 and 12 months, respectively.Patients who received metformin had lower hazard of reaching HbA1c levels below 7% as compared with those who received SU, and had higher hazard compared with those who received DPP4I (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.75-0.98; and HR, 1.68; 95% CI, 1.42-1.99, respectively). The incidence of hypoglycemia was significantly higher in the SU group than in the metformin and DPP4I groups (metformin vs SU; HR, 0.30; 95% CI, 0.21-0.43; SU vs DPP4I; HR, 4.42; 95% CI, 2.35-8.31). Metformin + DPP4I had similar hazard of reaching HbA1c levels below 7% compared with metformin + SU (HR, 1.19; 95% CI, 0.99-1.43) and the incidence of hypoglycemia was significantly lower in the metformin + DPP4I group (HR 0.13; 95% CI 0.05-0.30). There was no significant difference in the analysis of the occurrence of chronic complications.SU followed by metformin was effective, and both drugs showed an increased hazard of reaching HbA1c levels below 7% compared with DPP4I. Metformin + DPP4I is comparatively effective for HbA1c level reduction below 7% compared with metformin + SU. Hypoglycemia was high in the SU-containing therapy.

Position of Sulfonylureas in the Current ERA: Review of National and International Guidelines

Sulfonylureas (SUs) are one of the commonly prescribed oral anti-hyperglycemic agents (AHA) in low- and middle-income countries (LMICs), either in combination with metformin therapy or alone. However, concern about cardiovascular safety has limited the use of SUs in the management of type 2 diabetes mellitus (T2DM). Additionally, lack of uniformity in the national and international guidelines regarding the positioning of SUs in the management of diabetes has also been reported. The objective of this review was to assess the various national and international guidelines on diabetes management and understand the recommendations specific to SUs in various scenarios. A total of 33 national and international guidelines on the management of T2DM published in English were evaluated. These guidelines have considered the latest evidence and suggest the use of certain second-generation SUs as second-line therapy or in combination with other AHAs in select population and specific scenarios. Identification of the appropriate population, classification based on underlying risk, thorough assessment of the comorbid conditions, and a step-wise approach for the selection of appropriate SUs is essential for the effective management of T2DM. Additionally, cost-to–benefit ratio should be considered, particularly in LMICs, and SUs could continue to play an important role in such settings.

Sodium-Glucose Cotransporter-2 Inhibitor-Related Diabetic Ketoacidosis: Accuracy Verification of Operational Definition

BACKGROUND

The most important aspect of a retrospective cohort study is the operational definition (OP) of the disease. We developed a detailed OP for the detection of sodium-glucose cotransporter-2 inhibitors (SGLT2i) related to diabetic ketoacidosis (DKA). The OP was systemically verified and analyzed.

METHODS

All patients prescribed SGLT2i at four university hospitals were enrolled in this experiment. A DKA diagnostic algorithm was created and distributed to each hospital; subsequently, the number of SGLT2i-related DKAs was confirmed. Then, the algorithm functionality was verified through manual chart reviews by an endocrinologist using the same OP.

RESULTS

A total of 8,958 patients were initially prescribed SGLT2i. According to the algorithm, 0.18% (16/8,958) were confirmed to have SGLT2i-related DKA. However, based on manual chart reviews of these 16 cases, there was only one case of SGLT2i-related DKA (positive predictive value = 6.3%). Even after repeatedly narrowing the diagnosis range of the algorithm, the effect of a positive predictive value was insignificant (6.3-10.0%, P > 0.999).

CONCLUSION

Owing to the nature of electronic medical record data, we could not create an algorithm that clearly differentiates SGLT2i-related DKA despite repeated attempts. In all retrospective studies, a portion of the samples should be randomly selected to confirm the accuracy of the OP through chart review. In retrospective cohort studies in which chart review is not possible, it will be difficult to guarantee the reliability of the results.

Relationship between the dynamics of non-alcoholic fatty liver disease and incident diabetes mellitus

The aim of the current study was to evaluate the association between changes in non-alcoholic fatty liver disease (NAFLD) over time and risk of incident diabetes mellitus (DM). In total, 3047 subjects without underlying DM were followed up for 14 years from the Anseong-Ansan cohort. NAFLD status was determined biennially using the hepatic steatosis index (HSI), and subjects were clustered into seven groups according to changes in HSI, body mass index (BMI), and homeostatic model assessment of insulin resistance (HOMA-IR): none, persistent, transient, transient resolved, resolved, incident, and recurrent NAFLD (Groups 1-7, respectively). Predictive abilities were compared between the dynamics of HSI and single time points. Regarding the changes in HSI, the risk of incident DM was highest in Group 2 (hazard ratio [HR] 2.710; P < 0.001), followed by Groups 7 (HR 2.062; P < 0.001) and 3 (HR 1.559; P = 0.027). The predictive ability for DM was powerful in order of HOMA-IR, HSI and BMI. The dynamics of NAFLD were less predictive of incident DM than single time-point NAFLD. In conclusion, NAFLD is more useful than BMI in predicting incident DM. However, NAFLD status at single time points can better predict incident DM than dynamic changes in HSI.

Sodium-glucose co-transporter-2 inhibitors do not increase the risk of fractures in real-world clinical practice in Korea: A national observational cohort study

AIMS/INTRODUCTION

This study aimed to determine whether sodium-glucose cotransporter-2 inhibitors (SGLT2i) were related to increased fracture risk in adults with type 2 diabetes compared to dipeptidyl peptidase-4 inhibitors (DPP-4i).

MATERIALS AND METHODS

Between May 1, 2016, and December 31, 2018, we conducted a new-user cohort study using the Korean National Health Insurance Service database. Propensity score matching was performed on 478,826 new users of an SGLT2 inhibitor or DPP-4 inhibitor. After propensity score matching on > 80 covariates, 84,460 individuals were initiated on SGLT2i or DPP-4i, with 42,230 individuals in each treatment group. The time to first fracture event was compared between the SGLT2i and DPP-4i groups using Cox proportional hazard models, and the results are reported as hazard ratios (HRs) with 95% confidence intervals (CIs) for fracture occurrence. Subgroup analyses investigated fractures between treatment groups according to baseline characteristics.

RESULTS

Individuals who were started on SGLT2i were not linked with increased fracture risk in both as-treated (AT) and intention-to-treat (ITT) analyses (AT: HR 0.98, 95% CI 0.92-1.04; ITT: HR 0.94, 95% CI 0.89-1.00). We identified no significant interaction between the individuals' age, sex, fracture history, or thiazolidinedione usage in any subgroup analyses, indicating that none of these variables appeared to be impact modifiers in the connection between SGLT2i and fractures.

CONCLUSIONS

Our study found no increase in the risk of fracture among individuals treated with SGLT2i in a real-world clinical setting for type 2 diabetes.

Relationship of the Triglyceride-Glucose Index with Subclinical White Matter Hypersensitivities of Presumed Vascular Origin Among Community-Dwelling Koreans

Purpose

The triglyceride-glucose (TyG) index, a widely accessible measure, has been a surrogate indicator of peripheral insulin resistance, and its clinical importance continues to grow in East Asia. We hypothesized that the TyG index is relevant to subclinical white matter hypersensitivities (WMHs) of presumed vascular origin among community-dwelling Koreans.

Methods

We investigated the relationship between the TyG index and WMHs on brain magnetic resonance imaging scans in 2417 Koreans over 45 years of age without a history of cancer, stroke, or ischemic heart disease. The study population was divided into four groups according to the TyG index quartiles. Using multiple logistic regression analysis, we assessed the odds ratios (ORs) and 95% confidence intervals (95% CIs) for WMHs across the TyG index quartiles.

Results

The prevalence of WMHs was significantly higher in the fourth TyG index quartile, with an overall rate of 9.3%. After adjusting for potential confounding variables, the ORs of WMHs for the TyG index quartiles were 1.00, 1.47 (95% CI, 0.91–2.40), 1.76 (95% CI, 1.05–2.97), and 6.79 (95% CI, 3.85–1.54), respectively.

Conclusion

We found that higher TyG index values were associated with the brain’s WMHs of presumed vascular origin. Our findings suggest that the serum TyG index could be an additional valuable biomarker for assessing the risk of cerebral small vessel disease in the preclinical stage.

Retinal Vascular Caliber Changes in Early Type 2 Diabetic Patients without Retinopathy

Purpose: To evaluate the retinal vascular caliber in early type 2 diabetic patients without retinopathy.Methods: This retrospective study reviewed the medical records of 85 patients who were diagnosed with type 2 diabetes (age, 10-48 years) and sex-matched healthy controls. Dilated fundus examinations were performed to confirm the absence of diabetic retinopathy. Fundus photographs were acquired and analyzed using software that semi-automatically measured retinal vascular caliber. Central retinal arteriolar equivalent (CRAE), central retinal venular equivalent (CRVE), and arteriovenous ratio (AVR) were determined using the revised Parr-Hubbard formula. Healthy controls were examined using the same approach.Results: There were no significant differences between patients and controls in terms of CRAE (149.92 ± 21.29 µm and 144.85 ± 17.14 µm, respectively; p = 0.137) or CRVE (195.85 ± 22.94 µm and 196.69 ± 18.43 µm, respectively; p = 0.829). However, AVR was significantly higher in the patient group (0.768 ± 0.088 vs. 0.737 ± 0.061; p = 0.031). In the patient group, AVR was significantly correlated with hemoglobin A1c (r = 0.325, p = 0.006), but not with body mass index (p = 0.478).Conclusions: An increase in peripapillary AVR may be an early feature of retinal vessels observed in patients with type 2 diabetes, which is closely related to elevated blood sugar.

Low fasting glucose-to-estimated average glucose ratio was associated with superior response to insulin degludec/aspart compared with basal insulin in patients with type 2 diabetes

AIMS/INTRODUCTION

The benefits of once-daily insulin degludec/aspart (IDegAsp) compared with basal insulin in type 2 diabetes patients have not been established.

MATERIALS AND METHODS

This was a retrospective observational study. From a basal insulin cohort from three referral hospitals, patients were enrolled who initiated once-daily IDegAsp. A control group maintaining basal insulin was selected by propensity score matching. Glycated hemoglobin (HbA1c) changes over a period of 6 months and associated clinical factors were evaluated.

RESULTS

The IDegAsp group and the control group comprised of 87 patients, respectively. Baseline HbA1c was comparable between the two groups (8.7 ± 0.9 vs 8.6 ± 0.9%, mean and standard deviation). After 6 months with matched insulin doses, HbA1c in the IDegAsp group was lower than that in the control group (8.1 ± 1.0 vs 8.4 ± 1.1%, P = 0.029). Among baseline variables, fasting plasma glucose (FPG) and fasting C-peptide in the IDegAsp were lower than that in the control (FPG 124.2 ± 38.4 vs 148.0 ± 50.6 mg/dL, P < 0.001). Considering that the lower FPG despite the comparable HbA1c could be related with the efficacy of IDegAsp, subgroup analysis was carried out according to a ratio of FPG-to-estimated average glucose, which is calculated from HbA1c. When compared with each control group, the superiority of IDegAsp in the reduction of HbA1c was significant only in the patients with a lower FPG-to-estimated average glucose ratio (0.49 ± 0.09), but not in those with a higher FPG-to-estimated average glucose ratio (0.79 ± 0.20).

CONCLUSIONS

We observed that IDegAsp was more effective than basal insulin in patients with an FPG lower than predicted by HbA1c, which might be related with insulin deficiency and postprandial hyperglycemia in patients on basal insulin therapy.