1
|
Cardoso P, Young KG, Nair ATN, Hopkins R, McGovern AP, Haider E, Karunaratne P, Donnelly L, Mateen BA, Sattar N, Holman RR, Bowden J, Hattersley AT, Pearson ER, Jones AG, Shields BM, McKinley TJ, Dennis JM. Phenotype-based targeted treatment of SGLT2 inhibitors and GLP-1 receptor agonists in type 2 diabetes. Diabetologia 2024; 67:822-836. [PMID: 38388753 PMCID: PMC10955037 DOI: 10.1007/s00125-024-06099-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/04/2024] [Indexed: 02/24/2024]
Abstract
AIMS/HYPOTHESIS A precision medicine approach in type 2 diabetes could enhance targeting specific glucose-lowering therapies to individual patients most likely to benefit. We aimed to use the recently developed Bayesian causal forest (BCF) method to develop and validate an individualised treatment selection algorithm for two major type 2 diabetes drug classes, sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1-RA). METHODS We designed a predictive algorithm using BCF to estimate individual-level conditional average treatment effects for 12-month glycaemic outcome (HbA1c) between SGLT2i and GLP1-RA, based on routine clinical features of 46,394 people with type 2 diabetes in primary care in England (Clinical Practice Research Datalink; 27,319 for model development, 19,075 for hold-out validation), with additional external validation in 2252 people with type 2 diabetes from Scotland (SCI-Diabetes [Tayside & Fife]). Differences in glycaemic outcome with GLP1-RA by sex seen in clinical data were replicated in clinical trial data (HARMONY programme: liraglutide [n=389] and albiglutide [n=1682]). As secondary outcomes, we evaluated the impacts of targeting therapy based on glycaemic response on weight change, tolerability and longer-term risk of new-onset microvascular complications, macrovascular complications and adverse kidney events. RESULTS Model development identified marked heterogeneity in glycaemic response, with 4787 (17.5%) of the development cohort having a predicted HbA1c benefit >3 mmol/mol (>0.3%) with SGLT2i over GLP1-RA and 5551 (20.3%) having a predicted HbA1c benefit >3 mmol/mol with GLP1-RA over SGLT2i. Calibration was good in hold-back validation, and external validation in an independent Scottish dataset identified clear differences in glycaemic outcomes between those predicted to benefit from each therapy. Sex, with women markedly more responsive to GLP1-RA, was identified as a major treatment effect modifier in both the UK observational datasets and in clinical trial data: HARMONY-7 liraglutide (GLP1-RA): 4.4 mmol/mol (95% credible interval [95% CrI] 2.2, 6.3) (0.4% [95% CrI 0.2, 0.6]) greater response in women than men. Targeting the two therapies based on predicted glycaemic response was also associated with improvements in short-term tolerability and long-term risk of new-onset microvascular complications. CONCLUSIONS/INTERPRETATION Precision medicine approaches can facilitate effective individualised treatment choice between SGLT2i and GLP1-RA therapies, and the use of routinely collected clinical features for treatment selection could support low-cost deployment in many countries.
Collapse
Affiliation(s)
- Pedro Cardoso
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Katie G Young
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Anand T N Nair
- Division of Molecular & Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Rhian Hopkins
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Andrew P McGovern
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Eram Haider
- Division of Molecular & Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Piyumanga Karunaratne
- Division of Molecular & Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Louise Donnelly
- Division of Molecular & Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Bilal A Mateen
- Institute of Health Informatics, University College London, London, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Rury R Holman
- Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
- Oxford NIHR Biomedical Research Centre, Churchill Hospital, Oxford, UK
| | - Jack Bowden
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Andrew T Hattersley
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Ewan R Pearson
- Division of Molecular & Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Angus G Jones
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Beverley M Shields
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Trevelyan J McKinley
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, UK
| | - John M Dennis
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, UK.
| |
Collapse
|
2
|
Venkatesan U, Amutha A, Jones AG, Shields BM, Anjana RM, Unnikrishnan R, Mappillairaju B, Mohan V. Performance of European prediction models for classification of type 1 and type 2 diabetes in Indians. Diabetes Metab Syndr 2024; 18:103007. [PMID: 38636306 DOI: 10.1016/j.dsx.2024.103007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 03/15/2024] [Accepted: 04/07/2024] [Indexed: 04/20/2024]
Abstract
AIM We aimed to determine the performance of European prediction models in an Indian population to classify type 1 diabetes(T1D) and type 2 diabetes(T2D). METHODS We assessed discrimination and calibration of published models of diabetes classification, using retrospective data from electronic medical records of 83309 participants aged 18-50 years living in India. Diabetes type was defined based on C-peptide measurement and early insulin requirement. Models assessed combinations of clinical measurements: age at diagnosis, body mass index(mean = 26.6 kg/m2), sex(male = 64.9 %), Glutamic acid decarboxylase(GAD) antibody, serum cholesterol, serum triglycerides, and high-density lipoprotein(HDL) cholesterol. RESULTS 67955 participants met inclusion criteria, of whom 0.8 % had T1D, which was markedly lower than model development cohorts. Model discrimination for clinical features was broadly similar in our Indian cohort compared to the European cohort: area under the receiver operating characteristic curve(AUC ROC) was 0.90 vs. 0.90 respectively, but was lower in the subset of young participants with measured GAD antibodies(n = 2404): and an AUC ROC of 0.87 when clinical features, sex, lipids and GAD antibodies were combined. All models substantially overestimated the likelihood of T1D, reflecting the lower prevalence of T1D in the Indian population. However, good model performance was achieved after recalibration by updating the model intercept and slope. CONCLUSION Models for diabetes classification maintain the discrimination of T1D and T2D in this Indian population, where T2D is far more common, but require recalibration to obtain appropriate model probabilities. External validation and recalibration are needed before these tools can be used in non-European populations.
Collapse
Affiliation(s)
- Ulagamadesan Venkatesan
- Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India; School of Public Health, SRM Institute of Science and Technology, Kattankulathur, Tamil Nadu, India.
| | | | - Angus G Jones
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, EX2 5DW, UK
| | - Beverley M Shields
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, EX2 5DW, UK
| | - Ranjit Mohan Anjana
- Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India; Dr. Mohan's Diabetes Specialties Centre, Chennai, Tamil Nadu, India
| | - Ranjit Unnikrishnan
- Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India; Dr. Mohan's Diabetes Specialties Centre, Chennai, Tamil Nadu, India
| | - Bagavandas Mappillairaju
- Centre for Statistics, SRM Institute of Science and Technology, Kattankulathur, Tamil Nadu, India
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India; Dr. Mohan's Diabetes Specialties Centre, Chennai, Tamil Nadu, India
| |
Collapse
|
3
|
Kirolos A, Harawa PP, Chimowa T, Divala O, Freyne B, Jones AG, Lelijveld N, Lissauer S, Maleta K, Gladstone MJ, Kerac M. Long-term outcomes after severe childhood malnutrition in adolescents in Malawi (LOSCM): a prospective observational cohort study. Lancet Child Adolesc Health 2024; 8:280-289. [PMID: 38368896 DOI: 10.1016/s2352-4642(23)00339-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 12/03/2023] [Accepted: 12/04/2023] [Indexed: 02/20/2024]
Abstract
BACKGROUND Research on long-term outcomes of severe childhood malnutrition is scarce. Existing evidence suggests potential associations with cardiometabolic disease and impaired cognition. We aimed to assess outcomes in adolescents who were exposed to severe childhood malnutrition compared with peers not exposed to severe childhood malnutrition. METHODS In Long-term Outcomes after Severe Childhood Malnutrition (LOCSM), we followed up adolescents who had 15 years earlier received treatment for severe childhood malnutrition at Queen Elizabeth Central Hospital in Blantyre, Malawi. Adolescents with previous severe childhood malnutrition included in LOCSM had participated in an earlier follow-up study (ChroSAM) at 7 years after treatment for severe childhood malnutrition, where they were compared to siblings and age-matched children in the community without previous severe childhood malnutrition. We measured anthropometry, body composition, strength, glucose tolerance, cognition, behaviour, and mental health during follow-up visits between Sept 9, 2021, and July 22, 2022, comparing outcomes in adolescents exposed to previous severe childhood malnutrition with unexposed siblings and adolescents from the community assessed previously (for ChroSAM) and newly recruited during current follow-up. We used a linear regression model to adjust for age, sex, disability, HIV, and socioeconomic status. This study is registered with the International Standard Randomised Controlled Trial Number Registry (ISRCTN17238083). FINDINGS We followed up 168 previously malnourished adolescents (median age 17·1 years [IQR 16·5 to 18·0]), alongside 123 siblings (18·2 years [15·0 to 20·5]), and 89 community adolescents (17·1 years [16·3 to 18·1]). Since last measured 8 years previously, mean height-for-age Z (HAZ) scores had improved in previously malnourished adolescents (difference 0·33 [95% CI 0·20 to 0·46]) and siblings (0·32 [0·09 to 0·55]), but not in community adolescents (difference -0·01 [-0·24 to 0·23]). Previously malnourished adolescents had sustained lower HAZ scores compared with siblings (adjusted difference -0·32 [-0·58 to -0·05]) and community adolescents (-0·21 [-0·52 to 0·10]). The adjusted difference in hand-grip strength between previously malnourished adolescents and community adolescents was -2·0 kg (-4·2 to 0·3). For child behaviour checklist internalising symptom scores, the adjusted difference for previously malnourished adolescents was 2·8 (0·0 to 5·5) compared with siblings and 2·1 (-0·1 to 4·3) compared with community adolescents. No evidence of differences between previously malnourished adolescents and unexposed groups were found in any of the other variables measured. INTERPRETATION Catch-up growth into adolescence was modest compared with the rapid improvement seen in childhood, but provides optimism for ongoing recovery of height deficits. We found little evidence of heightened non-communicable disease risk in adolescents exposed to severe childhood malnutrition, although long-term health implications need to be monitored. Further investigation of associated home and environmental factors influencing long-term outcomes is needed to tailor preventive and treatment interventions. FUNDING The Wellcome Trust.
Collapse
Affiliation(s)
- Amir Kirolos
- Department of Women and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
| | - Philliness P Harawa
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Takondwa Chimowa
- Department of Paediatrics, Zomba Central Hospital, Zomba, Malawi
| | - Oscar Divala
- Department of Public Health and Family Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Bridget Freyne
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi; Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi; School of Medicine, University College Dublin, Dublin, Ireland
| | - Angus G Jones
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - Natasha Lelijveld
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK; Emergency Nutrition Network, Kidlington, UK
| | - Samantha Lissauer
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi; Institute of Infection, Veterinary, and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Kenneth Maleta
- Department of Public Health and Family Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Melissa J Gladstone
- Department of Women and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Marko Kerac
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK; Centre for Maternal, Adolescent, and Reproductive Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
4
|
Thomas NJ, Jones AG. Comments on the notion of false positivity in measurements of autoantibodies. Reply to Grill V, Sørgjerd E, Hals I, Carlsson S [letter]. Diabetologia 2024; 67:569-570. [PMID: 38175204 DOI: 10.1007/s00125-023-06062-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/17/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Nicholas J Thomas
- Department of Clinical and Biological Sciences, University of Exeter, Exeter, UK
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Angus G Jones
- Department of Clinical and Biological Sciences, University of Exeter, Exeter, UK.
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK.
| |
Collapse
|
5
|
Jones AG, Shields BM, Oram RA, Dabelea DM, Hagopian WA, Lustigova E, Shah AS, Knupp J, Mottl AK, D'Agostino RB, Williams A, Marcovina SM, Pihoker C, Divers J, Redondo MJ. Clinical Prediction Models Combining Routine Clinical Measures Have High Accuracy in Identifying Youth-Onset Type 2 Diabetes Defined by Maintained Endogenous Insulin Secretion: The SEARCH for Diabetes in Youth Study. Diabetes Care 2024:dc231815. [PMID: 38252849 DOI: 10.2337/dc23-1815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/21/2023] [Indexed: 01/24/2024]
Abstract
OBJECTIVE With high prevalence of obesity and overlapping features between diabetes subtypes, accurately classifying youth-onset diabetes can be challenging. We aimed to develop prediction models that, using characteristics available at diabetes diagnosis, can identify youth who will retain endogenous insulin secretion at levels consistent with type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS We studied 2,966 youth with diabetes in the prospective SEARCH for Diabetes in Youth study (diagnosis age ≤19 years) to develop prediction models to identify participants with fasting C-peptide ≥250 pmol/L (≥0.75 ng/mL) after >3 years' (median 74 months) diabetes duration. Models included clinical measures at the baseline visit, at a mean diabetes duration of 11 months (age, BMI, sex, waist circumference, HDL cholesterol), with and without islet autoantibodies (GADA, IA-2A) and a Type 1 Diabetes Genetic Risk Score (T1DGRS). RESULTS Models using routine clinical measures with or without autoantibodies and T1DGRS were highly accurate in identifying participants with C-peptide ≥0.75 ng/mL (17% of participants; 2.3% and 53% of those with and without positive autoantibodies) (area under the receiver operating characteristic curve [AUCROC] 0.95-0.98). In internal validation, optimism was very low, with excellent calibration (slope 0.995-0.999). Models retained high performance for predicting retained C-peptide in older youth with obesity (AUCROC 0.88-0.96) and in subgroups defined by self-reported race/ethnicity (AUCROC 0.88-0.97), autoantibody status (AUCROC 0.87-0.96), and clinically diagnosed diabetes types (AUCROC 0.81-0.92). CONCLUSIONS Prediction models combining routine clinical measures at diabetes diagnosis, with or without islet autoantibodies or T1DGRS, can accurately identify youth with diabetes who maintain endogenous insulin secretion in the range associated with T2D.
Collapse
Affiliation(s)
| | | | | | - Dana M Dabelea
- University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Eva Lustigova
- Kaiser Permanente Southern California, Los Angeles, CA
| | - Amy S Shah
- University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | - Amy K Mottl
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | | | | | - Maria J Redondo
- Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| |
Collapse
|
6
|
Abstract
Diagnosing type 1 diabetes in adults is difficult since type 2 diabetes is the predominant diabetes type, particularly with an older age of onset (approximately >30 years). Misclassification of type 1 diabetes in adults is therefore common and will impact both individual patient management and the reported features of clinically classified cohorts. In this article, we discuss the challenges associated with correctly identifying adult-onset type 1 diabetes and the implications of these challenges for clinical practice and research. We discuss how many of the reported differences in the characteristics of autoimmune/type 1 diabetes with increasing age of diagnosis are likely explained by the inadvertent study of mixed populations with and without autoimmune aetiology diabetes. We show that when type 1 diabetes is defined by high-specificity methods, clinical presentation, islet-autoantibody positivity, genetic predisposition and progression of C-peptide loss remain broadly similar and severe at all ages and are unaffected by onset age within adults. Recent clinical guidance recommends routine islet-autoantibody testing when type 1 diabetes is clinically suspected or in the context of rapid progression to insulin therapy after a diagnosis of type 2 diabetes. In this moderate or high prior-probability setting, a positive islet-autoantibody test will usually confirm autoimmune aetiology (type 1 diabetes). We argue that islet-autoantibody testing of those with apparent type 2 diabetes should not be routinely undertaken as, in this low prior-prevalence setting, the positive predictive value of a single-positive islet antibody for autoimmune aetiology diabetes will be modest. When studying diabetes, extremely high-specificity approaches are needed to identify autoimmune diabetes in adults, with the optimal approach depending on the research question. We believe that until these recommendations are widely adopted by researchers, the true phenotype of late-onset type 1 diabetes will remain largely misunderstood.
Collapse
Affiliation(s)
- Nicholas J Thomas
- Department of Clinical and Biological Sciences, University of Exeter, Exeter, UK
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Angus G Jones
- Department of Clinical and Biological Sciences, University of Exeter, Exeter, UK.
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK.
| |
Collapse
|
7
|
Young KG, McInnes EH, Massey RJ, Kahkoska AR, Pilla SJ, Raghavan S, Stanislawski MA, Tobias DK, McGovern AP, Dawed AY, Jones AG, Pearson ER, Dennis JM. Treatment effect heterogeneity following type 2 diabetes treatment with GLP1-receptor agonists and SGLT2-inhibitors: a systematic review. Commun Med (Lond) 2023; 3:131. [PMID: 37794166 PMCID: PMC10551026 DOI: 10.1038/s43856-023-00359-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/15/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND A precision medicine approach in type 2 diabetes requires the identification of clinical and biological features that are reproducibly associated with differences in clinical outcomes with specific anti-hyperglycaemic therapies. Robust evidence of such treatment effect heterogeneity could support more individualized clinical decisions on optimal type 2 diabetes therapy. METHODS We performed a pre-registered systematic review of meta-analysis studies, randomized control trials, and observational studies evaluating clinical and biological features associated with heterogenous treatment effects for SGLT2-inhibitor and GLP1-receptor agonist therapies, considering glycaemic, cardiovascular, and renal outcomes. After screening 5,686 studies, we included 101 studies of SGLT2-inhibitors and 75 studies of GLP1-receptor agonists in the final systematic review. RESULTS Here we show that the majority of included papers have methodological limitations precluding robust assessment of treatment effect heterogeneity. For SGLT2-inhibitors, multiple observational studies suggest lower renal function as a predictor of lesser glycaemic response, while markers of reduced insulin secretion predict lesser glycaemic response with GLP1-receptor agonists. For both therapies, multiple post-hoc analyses of randomized control trials (including trial meta-analysis) identify minimal clinically relevant treatment effect heterogeneity for cardiovascular and renal outcomes. CONCLUSIONS Current evidence on treatment effect heterogeneity for SGLT2-inhibitor and GLP1-receptor agonist therapies is limited, likely reflecting the methodological limitations of published studies. Robust and appropriately powered studies are required to understand type 2 diabetes treatment effect heterogeneity and evaluate the potential for precision medicine to inform future clinical care.
Collapse
Affiliation(s)
- Katherine G Young
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, RILD Building, Royal Devon & Exeter Hospital, Exeter, UK
| | - Eram Haider McInnes
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Robert J Massey
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Anna R Kahkoska
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Scott J Pilla
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sridharan Raghavan
- Section of Academic Primary Care, US Department of Veterans Affairs Eastern Colorado Health Care System, Aurora, CO, USA
| | - Maggie A Stanislawski
- Department of Biomedical Informatics, School of Medicine, University of Colorado, Aurora, USA
| | - Deirdre K Tobias
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew P McGovern
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, RILD Building, Royal Devon & Exeter Hospital, Exeter, UK
| | - Adem Y Dawed
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Angus G Jones
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, RILD Building, Royal Devon & Exeter Hospital, Exeter, UK
| | - Ewan R Pearson
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK.
| | - John M Dennis
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, RILD Building, Royal Devon & Exeter Hospital, Exeter, UK.
| |
Collapse
|
8
|
Tobias DK, Merino J, Ahmad A, Aiken C, Benham JL, Bodhini D, Clark AL, Colclough K, Corcoy R, Cromer SJ, Duan D, Felton JL, Francis EC, Gillard P, Gingras V, Gaillard R, Haider E, Hughes A, Ikle JM, Jacobsen LM, Kahkoska AR, Kettunen JLT, Kreienkamp RJ, Lim LL, Männistö JME, Massey R, Mclennan NM, Miller RG, Morieri ML, Most J, Naylor RN, Ozkan B, Patel KA, Pilla SJ, Prystupa K, Raghavan S, Rooney MR, Schön M, Semnani-Azad Z, Sevilla-Gonzalez M, Svalastoga P, Takele WW, Tam CHT, Thuesen ACB, Tosur M, Wallace AS, Wang CC, Wong JJ, Yamamoto JM, Young K, Amouyal C, Andersen MK, Bonham MP, Chen M, Cheng F, Chikowore T, Chivers SC, Clemmensen C, Dabelea D, Dawed AY, Deutsch AJ, Dickens LT, DiMeglio LA, Dudenhöffer-Pfeifer M, Evans-Molina C, Fernández-Balsells MM, Fitipaldi H, Fitzpatrick SL, Gitelman SE, Goodarzi MO, Grieger JA, Guasch-Ferré M, Habibi N, Hansen T, Huang C, Harris-Kawano A, Ismail HM, Hoag B, Johnson RK, Jones AG, Koivula RW, Leong A, Leung GKW, Libman IM, Liu K, Long SA, Lowe WL, Morton RW, Motala AA, Onengut-Gumuscu S, Pankow JS, Pathirana M, Pazmino S, Perez D, Petrie JR, Powe CE, Quinteros A, Jain R, Ray D, Ried-Larsen M, Saeed Z, Santhakumar V, Kanbour S, Sarkar S, Monaco GSF, Scholtens DM, Selvin E, Sheu WHH, Speake C, Stanislawski MA, Steenackers N, Steck AK, Stefan N, Støy J, Taylor R, Tye SC, Ukke GG, Urazbayeva M, Van der Schueren B, Vatier C, Wentworth JM, Hannah W, White SL, Yu G, Zhang Y, Zhou SJ, Beltrand J, Polak M, Aukrust I, de Franco E, Flanagan SE, Maloney KA, McGovern A, Molnes J, Nakabuye M, Njølstad PR, Pomares-Millan H, Provenzano M, Saint-Martin C, Zhang C, Zhu Y, Auh S, de Souza R, Fawcett AJ, Gruber C, Mekonnen EG, Mixter E, Sherifali D, Eckel RH, Nolan JJ, Philipson LH, Brown RJ, Billings LK, Boyle K, Costacou T, Dennis JM, Florez JC, Gloyn AL, Gomez MF, Gottlieb PA, Greeley SAW, Griffin K, Hattersley AT, Hirsch IB, Hivert MF, Hood KK, Josefson JL, Kwak SH, Laffel LM, Lim SS, Loos RJF, Ma RCW, Mathieu C, Mathioudakis N, Meigs JB, Misra S, Mohan V, Murphy R, Oram R, Owen KR, Ozanne SE, Pearson ER, Perng W, Pollin TI, Pop-Busui R, Pratley RE, Redman LM, Redondo MJ, Reynolds RM, Semple RK, Sherr JL, Sims EK, Sweeting A, Tuomi T, Udler MS, Vesco KK, Vilsbøll T, Wagner R, Rich SS, Franks PW. Second international consensus report on gaps and opportunities for the clinical translation of precision diabetes medicine. Nat Med 2023; 29:2438-2457. [PMID: 37794253 PMCID: PMC10735053 DOI: 10.1038/s41591-023-02502-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/14/2023] [Indexed: 10/06/2023]
Abstract
Precision medicine is part of the logical evolution of contemporary evidence-based medicine that seeks to reduce errors and optimize outcomes when making medical decisions and health recommendations. Diabetes affects hundreds of millions of people worldwide, many of whom will develop life-threatening complications and die prematurely. Precision medicine can potentially address this enormous problem by accounting for heterogeneity in the etiology, clinical presentation and pathogenesis of common forms of diabetes and risks of complications. This second international consensus report on precision diabetes medicine summarizes the findings from a systematic evidence review across the key pillars of precision medicine (prevention, diagnosis, treatment, prognosis) in four recognized forms of diabetes (monogenic, gestational, type 1, type 2). These reviews address key questions about the translation of precision medicine research into practice. Although not complete, owing to the vast literature on this topic, they revealed opportunities for the immediate or near-term clinical implementation of precision diabetes medicine; furthermore, we expose important gaps in knowledge, focusing on the need to obtain new clinically relevant evidence. Gaps include the need for common standards for clinical readiness, including consideration of cost-effectiveness, health equity, predictive accuracy, liability and accessibility. Key milestones are outlined for the broad clinical implementation of precision diabetes medicine.
Collapse
Affiliation(s)
- Deirdre K Tobias
- Division of Preventative Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jordi Merino
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, MA, USA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Abrar Ahmad
- Department of Clinical Sciences, Lund University Diabetes Centre, Lund University, Malmö, Sweden
| | - Catherine Aiken
- Department of Obstetrics and Gynaecology, The Rosie Hospital, Cambridge, UK
- NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Jamie L Benham
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dhanasekaran Bodhini
- Department of Molecular Genetics, Madras Diabetes Research Foundation, Chennai, India
| | - Amy L Clark
- Division of Pediatric Endocrinology, Department of Pediatrics, Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, St. Louis, MO, USA
| | - Kevin Colclough
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
| | - Rosa Corcoy
- CIBER-BBN, ISCIII, Madrid, Spain
- Institut d'Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Sara J Cromer
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, MA, USA
- Programs in Metabolism and Medical & Population Genetics, Broad Institute, Cambridge, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Daisy Duan
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jamie L Felton
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, University School of Medicine, Indianapolis, IN, USA
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ellen C Francis
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
| | | | - Véronique Gingras
- Department of Nutrition, Université de Montréal, Montreal, Quebec, Quebec, Canada
- Research Center, Sainte-Justine University Hospital Center, Montreal, Quebec, Quebec, Canada
| | - Romy Gaillard
- Department of Pediatrics, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Eram Haider
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Alice Hughes
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
| | - Jennifer M Ikle
- Department of Pediatrics, Stanford School of Medicine, Stanford University, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford School of Medicine, Stanford University, Stanford, CA, USA
| | | | - Anna R Kahkoska
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jarno L T Kettunen
- Helsinki University Hospital, Abdominal Centre/Endocrinology, Helsinki, Finland
- Folkhalsan Research Center, Helsinki, Finland
- Institute for Molecular Medicine Finland FIMM, University of Helsinki, Helsinki, Finland
| | - Raymond J Kreienkamp
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, MA, USA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Programs in Metabolism and Medical & Population Genetics, Broad Institute, Cambridge, MA, USA
- Department of Pediatrics, Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
| | - Lee-Ling Lim
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Asia Diabetes Foundation, Hong Kong SAR, China
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jonna M E Männistö
- Departments of Pediatrics and Clinical Genetics, Kuopio University Hospital, Kuopio, Finland
- Department of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Robert Massey
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Niamh-Maire Mclennan
- Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Rachel G Miller
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mario Luca Morieri
- Metabolic Disease Unit, University Hospital of Padova, Padova, Italy
- Department of Medicine, University of Padova, Padova, Italy
| | - Jasper Most
- Department of Orthopedics, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Rochelle N Naylor
- Departments of Pediatrics and Medicine, University of Chicago, Chicago, IL, USA
| | - Bige Ozkan
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kashyap Amratlal Patel
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
| | - Scott J Pilla
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Katsiaryna Prystupa
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Sridharan Raghavan
- Section of Academic Primary Care, US Department of Veterans Affairs Eastern Colorado Health Care System, Aurora, CO, USA
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Mary R Rooney
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Martin Schön
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- Institute of Diabetes Research and Metabolic Diseases (IDM), Helmholtz Center Munich, Neuherberg, Germany
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Zhila Semnani-Azad
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Magdalena Sevilla-Gonzalez
- Programs in Metabolism and Medical & Population Genetics, Broad Institute, Cambridge, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Pernille Svalastoga
- Mohn Center for Diabetes Precision Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway
- Children and Youth Clinic, Haukeland University Hospital, Bergen, Norway
| | - Wubet Worku Takele
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Claudia Ha-Ting Tam
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Anne Cathrine B Thuesen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mustafa Tosur
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Division of Pediatric Diabetes and Endocrinology, Texas Children's Hospital, Houston, TX, USA
- Children's Nutrition Research Center, USDA/ARS, Houston, TX, USA
| | - Amelia S Wallace
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Caroline C Wang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jessie J Wong
- Stanford University School of Medicine, Stanford, CA, USA
| | | | - Katherine Young
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
| | - Chloé Amouyal
- Department of Diabetology, APHP, Paris, France
- Sorbonne Université, INSERM, NutriOmic team, Paris, France
| | - Mette K Andersen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Maxine P Bonham
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Victoria, Australia
| | - Mingling Chen
- Monash Centre for Health Research and Implementation, Monash University, Clayton, Victoria, Australia
| | - Feifei Cheng
- Health Management Center, The Second Affiliated Hospital of Chongqing Medical University, Chongqing Medical University, Chongqing, China
| | - Tinashe Chikowore
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- MRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Sydney Brenner Institute for Molecular Bioscience, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sian C Chivers
- Department of Women and Children's Health, King's College London, London, UK
| | - Christoffer Clemmensen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Dana Dabelea
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Adem Y Dawed
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Aaron J Deutsch
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Programs in Metabolism and Medical & Population Genetics, Broad Institute, Cambridge, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Laura T Dickens
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, Kovler Diabetes Center, University of Chicago, Chicago, IL, USA
| | - Linda A DiMeglio
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, University School of Medicine, Indianapolis, IN, USA
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Carmella Evans-Molina
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, University School of Medicine, Indianapolis, IN, USA
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
- Richard L. Roudebush VAMC, Indianapolis, IN, USA
| | - María Mercè Fernández-Balsells
- Biomedical Research Institute Girona, IdIBGi, Girona, Spain
- Diabetes, Endocrinology and Nutrition Unit Girona, University Hospital Dr Josep Trueta, Girona, Spain
| | - Hugo Fitipaldi
- Department of Clinical Sciences, Lund University Diabetes Centre, Lund University, Malmö, Sweden
| | - Stephanie L Fitzpatrick
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Stephen E Gitelman
- University of California at San Francisco, Department of Pediatrics, Diabetes Center, San Francisco, CA, USA
| | - Mark O Goodarzi
- Division of Endocrinology, Diabetes and Metabolism, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jessica A Grieger
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Marta Guasch-Ferré
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Public Health and Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nahal Habibi
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Chuiguo Huang
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Arianna Harris-Kawano
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, University School of Medicine, Indianapolis, IN, USA
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Heba M Ismail
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, University School of Medicine, Indianapolis, IN, USA
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Benjamin Hoag
- Division of Endocrinology and Diabetes, Department of Pediatrics, Sanford Children's Hospital, Sioux Falls, SD, USA
- University of South Dakota School of Medicine, E Clark St, Vermillion, SD, USA
| | - Randi K Johnson
- Department of Biomedical Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Angus G Jones
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Robert W Koivula
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Aaron Leong
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Gloria K W Leung
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Victoria, Australia
| | | | - Kai Liu
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - S Alice Long
- Center for Translational Immunology, Benaroya Research Institute, Seattle, WA, USA
| | - William L Lowe
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robert W Morton
- Department of Pathology & Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Translational Medicine, Medical Science, Novo Nordisk Foundation, Hellerup, Denmark
| | - Ayesha A Motala
- Department of Diabetes and Endocrinology, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Suna Onengut-Gumuscu
- Center for Public Health Genomics, Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - James S Pankow
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Maleesa Pathirana
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Sofia Pazmino
- Department of Chronic Diseases and Metabolism, Clinical and Experimental Endocrinologyó, KU Leuven, Leuven, Belgium
| | - Dianna Perez
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, University School of Medicine, Indianapolis, IN, USA
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John R Petrie
- School of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Camille E Powe
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, MA, USA
- Programs in Metabolism and Medical & Population Genetics, Broad Institute, Cambridge, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Alejandra Quinteros
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Rashmi Jain
- Sanford Children's Specialty Clinic, Sioux Falls, SD, USA
- Department of Pediatrics, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, USA
| | - Debashree Ray
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mathias Ried-Larsen
- Centre for Physical Activity Research, Rigshospitalet, Copenhagen, Denmark
- Institute for Sports and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Zeb Saeed
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Vanessa Santhakumar
- Division of Preventative Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sarah Kanbour
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
- AMAN Hospital, Doha, Qatar
| | - Sudipa Sarkar
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Gabriela S F Monaco
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, University School of Medicine, Indianapolis, IN, USA
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Denise M Scholtens
- Department of Preventive Medicine, Division of Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Elizabeth Selvin
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Wayne Huey-Herng Sheu
- Institute of Molecular and Genomic Medicine, National Health Research Institutes, Zhunan, Taiwan
- Divsion of Endocrinology and Metabolism, Taichung Veterans General Hospital, Taichung, Taiwan
- Division of Endocrinology and Metabolism, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cate Speake
- Center for Interventional Immunology, Benaroya Research Institute, Seattle, WA, USA
| | - Maggie A Stanislawski
- Department of Biomedical Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nele Steenackers
- Department of Chronic Diseases and Metabolism, Clinical and Experimental Endocrinologyó, KU Leuven, Leuven, Belgium
| | - Andrea K Steck
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Norbert Stefan
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- Institute of Diabetes Research and Metabolic Diseases (IDM), Helmholtz Center Munich, Neuherberg, Germany
- University Hospital of Tübingen, Tübingen, Germany
| | - Julie Støy
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | | | - Sok Cin Tye
- Sections on Genetics and Epidemiology, Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Marzhan Urazbayeva
- Division of Pediatric Diabetes and Endocrinology, Texas Children's Hospital, Houston, TX, USA
- Gastroenterology, Baylor College of Medicine, Houston, TX, USA
| | - Bart Van der Schueren
- Department of Chronic Diseases and Metabolism, Clinical and Experimental Endocrinologyó, KU Leuven, Leuven, Belgium
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Camille Vatier
- Sorbonne University, Inserm U938, Saint-Antoine Research Centre, Institute of Cardiometabolism and Nutrition, Paris, France
- Department of Endocrinology, Diabetology and Reproductive Endocrinology, Assistance Publique-Hôpitaux de Paris, Saint-Antoine University Hospital, National Reference Center for Rare Diseases of Insulin Secretion and Insulin Sensitivity (PRISIS), Paris, France
| | - John M Wentworth
- Royal Melbourne Hospital Department of Diabetes and Endocrinology, Parkville, Victoria, Australia
- Walter and Eliza Hall Institute, Parkville, Victoria, Australia
- University of Melbourne Department of Medicine, Parkville, Victoria, Australia
| | - Wesley Hannah
- Deakin University, Melbourne, Victoria, Australia
- Department of Epidemiology, Madras Diabetes Research Foundation, Chennai, India
| | - Sara L White
- Department of Women and Children's Health, King's College London, London, UK
- Department of Diabetes and Endocrinology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Gechang Yu
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yingchai Zhang
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Shao J Zhou
- Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
- School of Agriculture, Food and Wine, University of Adelaide, Adelaide, South Australia, Australia
| | - Jacques Beltrand
- Institut Cochin, Inserm U 10116, Paris, France
- Pediatric Endocrinology and Diabetes, Hopital Necker Enfants Malades, APHP Centre, Université de Paris, Paris, France
| | - Michel Polak
- Institut Cochin, Inserm U 10116, Paris, France
- Pediatric Endocrinology and Diabetes, Hopital Necker Enfants Malades, APHP Centre, Université de Paris, Paris, France
| | - Ingvild Aukrust
- Mohn Center for Diabetes Precision Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway
| | - Elisa de Franco
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
| | - Sarah E Flanagan
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
| | - Kristin A Maloney
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrew McGovern
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
| | - Janne Molnes
- Mohn Center for Diabetes Precision Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway
| | - Mariam Nakabuye
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Pål Rasmus Njølstad
- Mohn Center for Diabetes Precision Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway
- Children and Youth Clinic, Haukeland University Hospital, Bergen, Norway
| | - Hugo Pomares-Millan
- Department of Clinical Sciences, Lund University Diabetes Centre, Lund University, Malmö, Sweden
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Michele Provenzano
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Cécile Saint-Martin
- Department of Medical Genetics, AP-HP Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Cuilin Zhang
- Global Center for Asian Women's Health, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Obstetrics and Gynecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yeyi Zhu
- Kaiser Permanente Northern California Division of Research, Oakland, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Sungyoung Auh
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Russell de Souza
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Andrea J Fawcett
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Clinical and Organizational Development, Chicago, IL, USA
| | | | - Eskedar Getie Mekonnen
- College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- Global Health Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Emily Mixter
- Department of Medicine and Kovler Diabetes Center, University of Chicago, Chicago, IL, USA
| | - Diana Sherifali
- Population Health Research Institute, Hamilton, Ontario, Canada
- School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Robert H Eckel
- Division of Endocrinology, Metabolism, Diabetes, University of Colorado, Aurora, CO, USA
| | - John J Nolan
- Department of Clinical Medicine, School of Medicine, Trinity College Dublin, Dublin, Ireland
- Department of Endocrinology, Wexford General Hospital, Wexford, Ireland
| | - Louis H Philipson
- Department of Medicine and Kovler Diabetes Center, University of Chicago, Chicago, IL, USA
| | - Rebecca J Brown
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Liana K Billings
- Division of Endocrinology, NorthShore University HealthSystem, Skokie, IL, USA
- Department of Medicine, Prtizker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Kristen Boyle
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Tina Costacou
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - John M Dennis
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
| | - Jose C Florez
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, MA, USA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Programs in Metabolism and Medical & Population Genetics, Broad Institute, Cambridge, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Anna L Gloyn
- Department of Pediatrics, Stanford School of Medicine, Stanford University, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford School of Medicine, Stanford University, Stanford, CA, USA
- Department of Genetics, Stanford School of Medicine, Stanford University, Stanford, CA, USA
| | - Maria F Gomez
- Department of Clinical Sciences, Lund University Diabetes Centre, Lund University, Malmö, Sweden
- Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Peter A Gottlieb
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Siri Atma W Greeley
- Departments of Pediatrics and Medicine and Kovler Diabetes Center, University of Chicago, Chicago, IL, USA
| | - Kurt Griffin
- Department of Pediatrics, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, USA
- Sanford Research, Sioux Falls, SD, USA
| | - Andrew T Hattersley
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Irl B Hirsch
- University of Washington School of Medicine, Seattle, WA, USA
| | - Marie-France Hivert
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, MA, USA
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Department of Medicine, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Korey K Hood
- Stanford University School of Medicine, Stanford, CA, USA
| | - Jami L Josefson
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Soo Heon Kwak
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Lori M Laffel
- Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA
| | - Siew S Lim
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Ruth J F Loos
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ronald C W Ma
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong SAR, China
| | | | | | - James B Meigs
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Broad Institute, Cambridge, MA, USA
| | - Shivani Misra
- Division of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Diabetes & Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Viswanathan Mohan
- Department of Diabetology, Madras Diabetes Research Foundation & Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Rinki Murphy
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
- Auckland Diabetes Centre, Te Whatu Ora Health New Zealand, Auckland, New Zealand
- Medical Bariatric Service, Te Whatu Ora Counties, Health New Zealand, Auckland, New Zealand
| | - Richard Oram
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Katharine R Owen
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
- Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Susan E Ozanne
- University of Cambridge, Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome-MRC Institute of Metabolic Science, Cambridge, UK
| | - Ewan R Pearson
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Wei Perng
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Toni I Pollin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rodica Pop-Busui
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA
| | | | | | - Maria J Redondo
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Division of Pediatric Diabetes and Endocrinology, Texas Children's Hospital, Houston, TX, USA
| | - Rebecca M Reynolds
- Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Robert K Semple
- Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
- MRC Human Genetics Unit, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | | | - Emily K Sims
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, University School of Medicine, Indianapolis, IN, USA
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Arianne Sweeting
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Tiinamaija Tuomi
- Helsinki University Hospital, Abdominal Centre/Endocrinology, Helsinki, Finland
- Folkhalsan Research Center, Helsinki, Finland
- Institute for Molecular Medicine Finland FIMM, University of Helsinki, Helsinki, Finland
| | - Miriam S Udler
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, MA, USA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Programs in Metabolism and Medical & Population Genetics, Broad Institute, Cambridge, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Kimberly K Vesco
- Kaiser Permanente Northwest, Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Tina Vilsbøll
- Clinial Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Robert Wagner
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- Department of Endocrinology and Diabetology, University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Stephen S Rich
- Center for Public Health Genomics, Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Paul W Franks
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Department of Clinical Sciences, Lund University Diabetes Centre, Lund University, Malmö, Sweden.
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK.
- Department of Translational Medicine, Medical Science, Novo Nordisk Foundation, Hellerup, Denmark.
| |
Collapse
|
9
|
Jones AG, Shields BM, Oram RA, Dabelea DM, Hagopian WA, Lustigova E, Shah AS, Knupp J, Mottl AK, DÀgostino RB, Williams A, Marcovina SM, Pihoker C, Divers J, Redondo MJ. Clinical prediction models combining routine clinical measures identify participants with youth-onset diabetes who maintain insulin secretion in the range associated with type 2 diabetes: The SEARCH for Diabetes in Youth Study. medRxiv 2023:2023.09.27.23296128. [PMID: 37808789 PMCID: PMC10557841 DOI: 10.1101/2023.09.27.23296128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Objective With the high prevalence of pediatric obesity and overlapping features between diabetes subtypes, accurately classifying youth-onset diabetes can be challenging. We aimed to develop prediction models that, using characteristics available at diabetes diagnosis, can identify youth who will retain endogenous insulin secretion at levels consistent with type 2 diabetes (T2D). Methods We studied 2,966 youth with diabetes in the prospective SEARCH study (diagnosis age ≤19 years) to develop prediction models to identify participants with fasting c-peptide ≥250 pmol/L (≥0.75ng/ml) after >3 years (median 74 months) of diabetes duration. Models included clinical measures at baseline visit, at a mean diabetes duration of 11 months (age, BMI, sex, waist circumference, HDL-C), with and without islet autoantibodies (GADA, IA-2A) and a Type 1 Diabetes Genetic Risk Score (T1DGRS). Results Models using routine clinical measures with or without autoantibodies and T1DGRS were highly accurate in identifying participants with c-peptide ≥0.75 ng/ml (17% of participants; 2.3% and 53% of those with and without positive autoantibodies) (area under receiver operator curve [AUCROC] 0.95-0.98). In internal validation, optimism was very low, with excellent calibration (slope=0.995-0.999). Models retained high performance for predicting retained c-peptide in older youth with obesity (AUCROC 0.88-0.96), and in subgroups defined by self-reported race/ethnicity (AUCROC 0.88-0.97), autoantibody status (AUCROC 0.87-0.96), and clinically diagnosed diabetes types (AUCROC 0.81-0.92). Conclusion Prediction models combining routine clinical measures at diabetes diagnosis, with or without islet autoantibodies or T1DGRS, can accurately identify youth with diabetes who maintain endogenous insulin secretion in the range associated with type 2 diabetes.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Amy S Shah
- University of Cincinnati & Cincinnati Children's Hospital Medical Center
| | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Brown AA, Fernandez-Tajes JJ, Hong MG, Brorsson CA, Koivula RW, Davtian D, Dupuis T, Sartori A, Michalettou TD, Forgie IM, Adam J, Allin KH, Caiazzo R, Cederberg H, De Masi F, Elders PJM, Giordano GN, Haid M, Hansen T, Hansen TH, Hattersley AT, Heggie AJ, Howald C, Jones AG, Kokkola T, Laakso M, Mahajan A, Mari A, McDonald TJ, McEvoy D, Mourby M, Musholt PB, Nilsson B, Pattou F, Penet D, Raverdy V, Ridderstråle M, Romano L, Rutters F, Sharma S, Teare H, 't Hart L, Tsirigos KD, Vangipurapu J, Vestergaard H, Brunak S, Franks PW, Frost G, Grallert H, Jablonka B, McCarthy MI, Pavo I, Pedersen O, Ruetten H, Walker M, Adamski J, Schwenk JM, Pearson ER, Dermitzakis ET, Viñuela A. Genetic analysis of blood molecular phenotypes reveals common properties in the regulatory networks affecting complex traits. Nat Commun 2023; 14:5062. [PMID: 37604891 PMCID: PMC10442420 DOI: 10.1038/s41467-023-40569-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/02/2023] [Indexed: 08/23/2023] Open
Abstract
We evaluate the shared genetic regulation of mRNA molecules, proteins and metabolites derived from whole blood from 3029 human donors. We find abundant allelic heterogeneity, where multiple variants regulate a particular molecular phenotype, and pleiotropy, where a single variant associates with multiple molecular phenotypes over multiple genomic regions. The highest proportion of share genetic regulation is detected between gene expression and proteins (66.6%), with a further median shared genetic associations across 49 different tissues of 78.3% and 62.4% between plasma proteins and gene expression. We represent the genetic and molecular associations in networks including 2828 known GWAS variants, showing that GWAS variants are more often connected to gene expression in trans than other molecular phenotypes in the network. Our work provides a roadmap to understanding molecular networks and deriving the underlying mechanism of action of GWAS variants using different molecular phenotypes in an accessible tissue.
Collapse
Affiliation(s)
- Andrew A Brown
- Population Health and Genomics, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, United Kingdom
| | - Juan J Fernandez-Tajes
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, OX3 7BN, United Kingdom
| | - Mun-Gwan Hong
- Science for Life Laboratory, School of Biotechnology, KTH - Royal Institute of Technology, Solna, SE-171 21, Sweden
| | - Caroline A Brorsson
- Department of Health Technology, Technical University of Denmark, Kongens Lyngby, Denmark
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, DK-2100, Denmark
| | - Robert W Koivula
- Oxford Centre for Diabetes Endocrinology and Metabolism, University of Oxford, Oxford, OX3 7LJ, United Kingdom
| | - David Davtian
- Population Health and Genomics, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, United Kingdom
| | - Théo Dupuis
- Population Health and Genomics, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, United Kingdom
| | - Ambra Sartori
- Department of Genetic Medicine and Development, University of Geneva Medical School, Geneva, 1211, Switzerland
- Institute for Genetics and Genomics in Geneva (iGE3), University of Geneva, Geneva, 1211, Switzerland
- Swiss Institute of Bioinformatics, Geneva, 1211, Switzerland
| | - Theodora-Dafni Michalettou
- Biosciences Institute, Faculty of Medical Sciences, University of Newcastle, Newcastle upon Tyne, NE1 4EP, United Kingdom
| | - Ian M Forgie
- Population Health and Genomics, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, United Kingdom
| | - Jonathan Adam
- German Center for Diabetes Research (DZD), Neuherberg, 85764, Germany
- Research Unit of Molecular Epidemiology, Institute of Epidemiology, German Research Center for Environmental Health, Helmholtz Zentrum München, Neuherberg, 85764, Germany
| | - Kristine H Allin
- The Novo Nordisk Center for Basic Metabolic Research, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, DK-2100, Denmark
| | - Robert Caiazzo
- University of Lille, Inserm, Lille Pasteur Institute, Lille, France
| | - Henna Cederberg
- Internal Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Federico De Masi
- Department of Health Technology, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Petra J M Elders
- Department of General Practice, Amsterdam UMC- location Vumc, Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Giuseppe N Giordano
- Department of Clinical Science, Genetic and Molecular Epidemiology, Lund University Diabetes Centre, Malmö, Sweden
| | - Mark Haid
- Metabolomics and Proteomics Core, German Research Center for Environmental Health, Helmholtz Zentrum München, Neuherberg, 85764, Germany
| | - Torben Hansen
- The Novo Nordisk Center for Basic Metabolic Research, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, DK-2100, Denmark
| | - Tue H Hansen
- The Novo Nordisk Center for Basic Metabolic Research, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, DK-2100, Denmark
| | - Andrew T Hattersley
- Department of Clinical and Biomedical Sciences, University of Exeter College of Medicine & Health, Exeter, EX25DW, United Kingdom
| | - Alison J Heggie
- Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Cédric Howald
- Department of Genetic Medicine and Development, University of Geneva Medical School, Geneva, 1211, Switzerland
- Institute for Genetics and Genomics in Geneva (iGE3), University of Geneva, Geneva, 1211, Switzerland
- Swiss Institute of Bioinformatics, Geneva, 1211, Switzerland
| | - Angus G Jones
- Department of Clinical and Biomedical Sciences, University of Exeter College of Medicine & Health, Exeter, EX25DW, United Kingdom
| | - Tarja Kokkola
- Internal Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Markku Laakso
- Internal Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Anubha Mahajan
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, OX3 7BN, United Kingdom
| | - Andrea Mari
- Institute of Neuroscience, National Research Council, Padova, 35127, Italy
| | - Timothy J McDonald
- Blood Sciences, Royal Devon and Exeter NHS Foundation Trust, Exeter, EX2 5DW, United Kingdom
| | - Donna McEvoy
- Diabetes Research Network, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Miranda Mourby
- Nuffield Department of Population Health, Centre for Health, Law and Emerging Technologies (HeLEX), University of Oxford, Oxford, OX2 7DD, United Kingdom
| | - Petra B Musholt
- Global Development, Sanofi-Aventis Deutschland GmbH, Hoechst Industrial Park, Frankfurt am Main, 65926, Germany
| | - Birgitte Nilsson
- Department of Health Technology, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Francois Pattou
- University of Lille, Inserm, Lille Pasteur Institute, Lille, France
| | - Deborah Penet
- Department of Genetic Medicine and Development, University of Geneva Medical School, Geneva, 1211, Switzerland
- Institute for Genetics and Genomics in Geneva (iGE3), University of Geneva, Geneva, 1211, Switzerland
- Swiss Institute of Bioinformatics, Geneva, 1211, Switzerland
| | - Violeta Raverdy
- University of Lille, Inserm, Lille Pasteur Institute, Lille, France
| | | | - Luciana Romano
- Department of Genetic Medicine and Development, University of Geneva Medical School, Geneva, 1211, Switzerland
- Institute for Genetics and Genomics in Geneva (iGE3), University of Geneva, Geneva, 1211, Switzerland
- Swiss Institute of Bioinformatics, Geneva, 1211, Switzerland
| | - Femke Rutters
- Epidemiology and Data Science, VUMC, Amsterdam, The Netherlands
| | - Sapna Sharma
- Research Unit of Molecular Epidemiology, Institute of Epidemiology, German Research Center for Environmental Health, Helmholtz Zentrum München, Neuherberg, 85764, Germany
- Food Chemistry and Molecular and Sensory Science, Technical University of Munich, München, Germany
| | - Harriet Teare
- Centre for Health Law and Emerging Technologies, Department of Population Health, University of Oxford, Old Road Campus, Oxford, OX3 7DQ, United Kingdom
| | - Leen 't Hart
- Epidemiology and Data Science, VUMC, Amsterdam, The Netherlands
- Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Biomedical Data Sciences, Molecular Epidemiology section, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Jagadish Vangipurapu
- Internal Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Henrik Vestergaard
- The Novo Nordisk Center for Basic Metabolic Research, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, DK-2100, Denmark
- Steno Diabetes Center Copenhagen, Copenhagen, Denmark
| | - Søren Brunak
- Department of Health Technology, Technical University of Denmark, Kongens Lyngby, Denmark
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, DK-2100, Denmark
| | - Paul W Franks
- Department of Clinical Science, Genetic and Molecular Epidemiology, Lund University Diabetes Centre, Malmö, Sweden
| | - Gary Frost
- Nutrition and Dietetics Research Group, Imperial College London, London, SW7 2AZ, United Kingdom
| | - Harald Grallert
- German Center for Diabetes Research (DZD), Neuherberg, 85764, Germany
- Research Unit of Molecular Epidemiology, Institute of Epidemiology, German Research Center for Environmental Health, Helmholtz Zentrum München, Neuherberg, 85764, Germany
| | - Bernd Jablonka
- Sanofi Partnering, Sanofi-Aventis Deutschland GmbH, Frankfurt am Main, 65926, Germany
| | - Mark I McCarthy
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, OX3 7BN, United Kingdom
- GENENTECH, 1 DNA Way, San Francisco, CA, 94080, USA
| | - Imre Pavo
- Eli Lilly Regional Operations Ges.m.b.H, Vienna, 1030, Austria
| | - Oluf Pedersen
- Center for Clinical Metabolic Research, Herlev and Gentofte University Hospital, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, DK-2100, Denmark
| | - Hartmut Ruetten
- Sanofi Partnering, Sanofi-Aventis Deutschland GmbH, Frankfurt am Main, 65926, Germany
| | - Mark Walker
- Translational and Clinical Research Institute, Faculty of Medical Sciences, University of Newcastle, Newcastle upon Tyne, United Kingdom
| | - Jerzy Adamski
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117597, Singapore
- Institute of Experimental Genetics, German Research Center for Environmental Health, Helmholtz Zentrum München, Neuherberg, 85764, Germany
- Institute of Biochemistry, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Jochen M Schwenk
- Science for Life Laboratory, School of Biotechnology, KTH - Royal Institute of Technology, Solna, SE-171 21, Sweden
| | - Ewan R Pearson
- Population Health and Genomics, Ninewells Hospital and Medical School, University of Dundee, Dundee, DD1 9SY, United Kingdom
| | - Emmanouil T Dermitzakis
- Department of Genetic Medicine and Development, University of Geneva Medical School, Geneva, 1211, Switzerland.
- Institute for Genetics and Genomics in Geneva (iGE3), University of Geneva, Geneva, 1211, Switzerland.
- Swiss Institute of Bioinformatics, Geneva, 1211, Switzerland.
| | - Ana Viñuela
- Biosciences Institute, Faculty of Medical Sciences, University of Newcastle, Newcastle upon Tyne, NE1 4EP, United Kingdom.
| |
Collapse
|
11
|
Young KG, McGovern AP, Barroso I, Hattersley AT, Jones AG, Shields BM, Thomas NJ, Dennis JM. HbA 1c screening for the diagnosis of diabetes. Reply to Brož J, Brabec M, Krollová P et al [letter]. Diabetologia 2023; 66:1578-1579. [PMID: 37272950 DOI: 10.1007/s00125-023-05939-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 06/06/2023]
Affiliation(s)
- Katherine G Young
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK.
| | - Andrew P McGovern
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Inês Barroso
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
| | - Andrew T Hattersley
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Angus G Jones
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Beverley M Shields
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
| | - Nicholas J Thomas
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - John M Dennis
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
| |
Collapse
|
12
|
Thomas NJ, McGovern A, Young KG, Sharp SA, Weedon MN, Hattersley AT, Dennis J, Jones AG. Corrigendum to 'Identifying type 1 and 2 diabetes in research datasets where classification biomarkers are unavailable: assessing the accuracy of published approaches' [Journal of Clinical Epidemiology (2023) 34-44]. J Clin Epidemiol 2023; 159:356. [PMID: 37316353 DOI: 10.1016/j.jclinepi.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Nicholas J Thomas
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK; Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Andrew McGovern
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK; Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Katherine G Young
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Seth A Sharp
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Michael N Weedon
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Andrew T Hattersley
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK; Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - John Dennis
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Angus G Jones
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK; Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| |
Collapse
|
13
|
Venkatasubramaniam A, Mateen BA, Shields BM, Hattersley AT, Jones AG, Vollmer SJ, Dennis JM. Comparison of causal forest and regression-based approaches to evaluate treatment effect heterogeneity: an application for type 2 diabetes precision medicine. BMC Med Inform Decis Mak 2023; 23:110. [PMID: 37328784 PMCID: PMC10276367 DOI: 10.1186/s12911-023-02207-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 06/01/2023] [Indexed: 06/18/2023] Open
Abstract
OBJECTIVE Precision medicine requires reliable identification of variation in patient-level outcomes with different available treatments, often termed treatment effect heterogeneity. We aimed to evaluate the comparative utility of individualized treatment selection strategies based on predicted individual-level treatment effects from a causal forest machine learning algorithm and a penalized regression model. METHODS Cohort study characterizing individual-level glucose-lowering response (6 month reduction in HbA1c) in people with type 2 diabetes initiating SGLT2-inhibitor or DPP4-inhibitor therapy. Model development set comprised 1,428 participants in the CANTATA-D and CANTATA-D2 randomised clinical trials of SGLT2-inhibitors versus DPP4-inhibitors. For external validation, calibration of observed versus predicted differences in HbA1c in patient strata defined by size of predicted HbA1c benefit was evaluated in 18,741 patients in UK primary care (Clinical Practice Research Datalink). RESULTS Heterogeneity in treatment effects was detected in clinical trial participants with both approaches (proportion predicted to have a benefit on SGLT2-inhibitor therapy over DPP4-inhibitor therapy: causal forest: 98.6%; penalized regression: 81.7%). In validation, calibration was good with penalized regression but sub-optimal with causal forest. A strata with an HbA1c benefit > 10 mmol/mol with SGLT2-inhibitors (3.7% of patients, observed benefit 11.0 mmol/mol [95%CI 8.0-14.0]) was identified using penalized regression but not causal forest, and a much larger strata with an HbA1c benefit 5-10 mmol with SGLT2-inhibitors was identified with penalized regression (regression: 20.9% of patients, observed benefit 7.8 mmol/mol (95%CI 6.7-8.9); causal forest 11.6%, observed benefit 8.7 mmol/mol (95%CI 7.4-10.1). CONCLUSIONS Consistent with recent results for outcome prediction with clinical data, when evaluating treatment effect heterogeneity researchers should not rely on causal forest or other similar machine learning algorithms alone, and must compare outputs with standard regression, which in this evaluation was superior.
Collapse
Affiliation(s)
| | - Bilal A Mateen
- The Alan Turing Institute, British Library, 96 Euston Road, London, NW1 2DB, UK
- University College London, Institute of Health Informatics, 222 Euston Rd, London, NW1 2DA, UK
| | - Beverley M Shields
- University of Exeter Medical School, Institute of Biomedical & Clinical Science, RILD Building, Royal Devon & Exeter Hospital, Barrack Road, Exeter, EX2 5DW, UK
| | - Andrew T Hattersley
- University of Exeter Medical School, Institute of Biomedical & Clinical Science, RILD Building, Royal Devon & Exeter Hospital, Barrack Road, Exeter, EX2 5DW, UK
| | - Angus G Jones
- University of Exeter Medical School, Institute of Biomedical & Clinical Science, RILD Building, Royal Devon & Exeter Hospital, Barrack Road, Exeter, EX2 5DW, UK
| | | | - John M Dennis
- University of Exeter Medical School, Institute of Biomedical & Clinical Science, RILD Building, Royal Devon & Exeter Hospital, Barrack Road, Exeter, EX2 5DW, UK.
| |
Collapse
|
14
|
Young KG, McGovern AP, Barroso I, Hattersley AT, Jones AG, Shields BM, Thomas NJ, Dennis JM. Correction to: The impact of population-level HbA 1c screening on reducing diabetes diagnostic delay in middle-aged adults: a UK Biobank analysis. Diabetologia 2023:10.1007/s00125-023-05933-4. [PMID: 37212888 DOI: 10.1007/s00125-023-05933-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Affiliation(s)
- Katherine G Young
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK.
| | - Andrew P McGovern
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Inês Barroso
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
| | - Andrew T Hattersley
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Angus G Jones
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Beverley M Shields
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
| | - Nicholas J Thomas
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - John M Dennis
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
| |
Collapse
|
15
|
Young KG, McInnes EH, Massey RJ, Kahkohska AR, Pilla SJ, Raghaven S, Stanislawski MA, Tobias DK, McGovern AP, Dawed AY, Jones AG, Pearson ER, Dennis JM. Precision medicine in type 2 diabetes: A systematic review of treatment effect heterogeneity for GLP1-receptor agonists and SGLT2-inhibitors. medRxiv 2023:2023.04.21.23288868. [PMID: 37131814 PMCID: PMC10153311 DOI: 10.1101/2023.04.21.23288868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background A precision medicine approach in type 2 diabetes requires identification of clinical and biological features that are reproducibly associated with differences in clinical outcomes with specific anti-hyperglycaemic therapies. Robust evidence of such treatment effect heterogeneity could support more individualized clinical decisions on optimal type 2 diabetes therapy. Methods We performed a pre-registered systematic review of meta-analysis studies, randomized control trials, and observational studies evaluating clinical and biological features associated with heterogenous treatment effects for SGLT2-inhibitor and GLP1-receptor agonist therapies, considering glycaemic, cardiovascular, and renal outcomes. Results After screening 5,686 studies, we included 101 studies of SGLT2-inhibitors and 75 studies of GLP1-receptor agonists in the final systematic review. The majority of papers had methodological limitations precluding robust assessment of treatment effect heterogeneity. For glycaemic outcomes, most cohorts were observational, with multiple analyses identifying lower renal function as a predictor of lesser glycaemic response with SGLT2-inhibitors and markers of reduced insulin secretion as predictors of lesser response with GLP1-receptor agonists. For cardiovascular and renal outcomes, the majority of included studies were post-hoc analyses of randomized control trials (including meta-analysis studies) which identified limited clinically relevant treatment effect heterogeneity. Conclusions Current evidence on treatment effect heterogeneity for SGLT2-inhibitor and GLP1-receptor agonist therapies is limited, likely reflecting the methodological limitations of published studies. Robust and appropriately powered studies are required to understand type 2 diabetes treatment effect heterogeneity and evaluate the potential for precision medicine to inform future clinical care. Plain language summary This review identifies research that helps understand which clinical and biological factors that are associated with different outcomes for specific type 2 diabetes treatments. This information could help clinical providers and patients make better informed personalized decisions about type 2 diabetes treatments. We focused on two common type 2 diabetes treatments: SGLT2-inhibitors and GLP1-receptor agonists, and three outcomes: blood glucose control, heart disease, and kidney disease. We identified some potential factors that are likely to lessen blood glucose control including lower kidney function for SGLT2-inhibitors and lower insulin secretion for GLP1-receptor agonists. We did not identify clear factors that alter heart and renal disease outcomes for either treatment. Most of the studies had limitations, meaning more research is needed to fully understand the factors that influence treatment outcomes in type 2 diabetes.
Collapse
Affiliation(s)
- Katherine G Young
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, RILD Building, Royal Devon & Exeter Hospital, Barrack Road, Exeter, UK
| | - Eram Haider McInnes
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Robert J Massey
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Anna R Kahkohska
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Scott J Pilla
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sridharan Raghaven
- Section of Academic Primary Care, US Department of Veterans Affairs Eastern Colorado Health Care System, Aurora, CO, USA
| | - Maggie A Stanislawski
- Department of Biomedical Informatics, School of Medicine, University of Colorado, Aurora, USA, 80045
| | - Deirdre K Tobias
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew P McGovern
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, RILD Building, Royal Devon & Exeter Hospital, Barrack Road, Exeter, UK
| | - Adem Y Dawed
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Angus G Jones
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, RILD Building, Royal Devon & Exeter Hospital, Barrack Road, Exeter, UK
| | - Ewan R Pearson
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - John M Dennis
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, RILD Building, Royal Devon & Exeter Hospital, Barrack Road, Exeter, UK
| | | |
Collapse
|
16
|
Umapathysivam MM, Araldi E, Hastoy B, Dawed AY, Vatandaslar H, Sengupta S, Kaufmann A, Thomsen S, Hartmann B, Jonsson AE, Kabakci H, Thaman S, Grarup N, Have CT, Færch K, Gjesing AP, Nawaz S, Cheeseman J, Neville MJ, Pedersen O, Walker M, Jennison C, Hattersley AT, Hansen T, Karpe F, Holst JJ, Jones AG, Ristow M, McCarthy MI, Pearson ER, Stoffel M, Gloyn AL. Type 2 Diabetes risk alleles in Peptidyl-glycine Alpha-amidating Monooxygenase influence GLP-1 levels and response to GLP-1 Receptor Agonists. medRxiv 2023:2023.04.07.23288197. [PMID: 37090505 PMCID: PMC10120798 DOI: 10.1101/2023.04.07.23288197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
Patients with type 2 diabetes vary in their response to currently available therapeutic agents (including GLP-1 receptor agonists) leading to suboptimal glycemic control and increased risk of complications. We show that human carriers of hypomorphic T2D-risk alleles in the gene encoding peptidyl-glycine alpha-amidating monooxygenase (PAM), as well as Pam-knockout mice, display increased resistance to GLP-1 in vivo. Pam inactivation in mice leads to reduced gastric GLP-1R expression and faster gastric emptying: this persists during GLP-1R agonist treatment and is rescued when GLP-1R activity is antagonized, indicating resistance to GLP-1's gastric slowing properties. Meta-analysis of human data from studies examining GLP-1R agonist response (including RCTs) reveals a relative loss of 44% and 20% of glucose lowering (measured by glycated hemoglobin) in individuals with hypomorphic PAM alleles p.S539W and p.D536G treated with GLP-1R agonist. Genetic variation in PAM has effects on incretin signaling that alters response to medication used commonly for treatment of T2D.
Collapse
Affiliation(s)
- Mahesh M Umapathysivam
- Oxford Centre for Diabetes, Endocrinology & Metabolism, University of Oxford, UK
- Department of Endocrinology, Queen Elizabeth Hospital, SA Health, Australia
- Southern Adelaide and Diabetes and Endocrinology Service, Bedford Park, Australia
- NHRMC Centre of Clinical research Excellence in Nutritional Physiology, Interventions and outcomes University of Adelaide, South Australia, Australia
| | - Elisa Araldi
- Institute of Molecular Health Sciences, Department of Biology, ETH Zurich, Zürich, Switzerland
- Institute of Translational Medicine, Department of Health Sciences and Technology, ETH Zurich, Zürich, Switzerland
- Department of Cardiology and Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Benoit Hastoy
- Oxford Centre for Diabetes, Endocrinology & Metabolism, University of Oxford, UK
| | - Adem Y Dawed
- Division of Population Health & Genomics, School of Medicine, University of Dundee, UK
| | - Hasan Vatandaslar
- Institute of Molecular Health Sciences, Department of Biology, ETH Zurich, Zürich, Switzerland
| | - Shahana Sengupta
- Oxford Centre for Diabetes, Endocrinology & Metabolism, University of Oxford, UK
| | - Adrian Kaufmann
- Institute of Molecular Health Sciences, Department of Biology, ETH Zurich, Zürich, Switzerland
| | - Søren Thomsen
- Oxford Centre for Diabetes, Endocrinology & Metabolism, University of Oxford, UK
| | - Bolette Hartmann
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University Copenhagen, Denmark
| | - Anna E Jonsson
- Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Hasan Kabakci
- Institute of Molecular Health Sciences, Department of Biology, ETH Zurich, Zürich, Switzerland
| | - Swaraj Thaman
- Division of Endocrinology, Department of Pediatrics, Stanford School of Medicine, Stanford, USA
| | - Niels Grarup
- Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Christian T Have
- Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Kristine Færch
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University Copenhagen, Denmark
- Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Anette P Gjesing
- Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Sameena Nawaz
- Oxford Centre for Diabetes, Endocrinology & Metabolism, University of Oxford, UK
| | - Jane Cheeseman
- Oxford Centre for Diabetes, Endocrinology & Metabolism, University of Oxford, UK
- National Institute of Health Research, Oxford Biomedical Research Centre, Churchill Hospital, Headington, Oxford, UK
| | - Matthew J Neville
- Oxford Centre for Diabetes, Endocrinology & Metabolism, University of Oxford, UK
- National Institute of Health Research, Oxford Biomedical Research Centre, Churchill Hospital, Headington, Oxford, UK
| | - Oluf Pedersen
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Denmark
| | - Mark Walker
- Translational and Clinical Research Institute, Newcastle University, UK
| | | | | | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Denmark
| | - Fredrik Karpe
- Oxford Centre for Diabetes, Endocrinology & Metabolism, University of Oxford, UK
- National Institute of Health Research, Oxford Biomedical Research Centre, Churchill Hospital, Headington, Oxford, UK
| | - Jens J Holst
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Denmark
| | - Angus G Jones
- University of Exeter College of Medicine & Health, Exeter, UK
| | - Michael Ristow
- Institute of Molecular Health Sciences, Department of Biology, ETH Zurich, Zürich, Switzerland
| | - Mark I McCarthy
- Oxford Centre for Diabetes, Endocrinology & Metabolism, University of Oxford, UK
- National Institute of Health Research, Oxford Biomedical Research Centre, Churchill Hospital, Headington, Oxford, UK
- Wellcome Trust Centre for Human Genetics, University of Oxford, UK
| | - Ewan R Pearson
- Division of Population Health & Genomics, School of Medicine, University of Dundee, UK
| | - Markus Stoffel
- Institute of Molecular Health Sciences, Department of Biology, ETH Zurich, Zürich, Switzerland
- Medical Faculty, University of Zürich, Zürich, Switzerland
| | - Anna L Gloyn
- Oxford Centre for Diabetes, Endocrinology & Metabolism, University of Oxford, UK
- Division of Endocrinology, Department of Pediatrics, Stanford School of Medicine, Stanford, USA
- National Institute of Health Research, Oxford Biomedical Research Centre, Churchill Hospital, Headington, Oxford, UK
- Wellcome Trust Centre for Human Genetics, University of Oxford, UK
- Stanford Diabetes Research Centre, Stanford, USA
| |
Collapse
|
17
|
Thomas NJ, Hill AV, Dayan CM, Oram RA, McDonald TJ, Shields BM, Jones AG. Age of Diagnosis Does Not Alter the Presentation or Progression of Robustly Defined Adult-Onset Type 1 Diabetes. Diabetes Care 2023; 46:1156-1163. [PMID: 36802355 DOI: 10.2337/dc22-2159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/19/2023] [Indexed: 02/23/2023]
Abstract
OBJECTIVE To determine whether presentation, progression, and genetic susceptibility of robustly defined adult-onset type 1 diabetes (T1D) are altered by diagnosis age. RESEARCH DESIGN AND METHODS We compared the relationship between diagnosis age and presentation, C-peptide loss (annual change in urine C-peptide-creatinine ratio [UCPCR]), and genetic susceptibility (T1D genetic risk score [GRS]) in adults with confirmed T1D in the prospective StartRight study, 1,798 adults with new-onset diabetes. T1D was defined in two ways: two or more positive islet autoantibodies (of GAD antibody, IA-2 antigen, and ZnT8 autoantibody) irrespective of clinical diagnosis (n = 385) or one positive islet autoantibody and a clinical diagnosis of T1D (n = 180). RESULTS In continuous analysis, age of diagnosis was not associated with C-peptide loss for either definition of T1D (P > 0.1), with mean (95% CI) annual C-peptide loss in those diagnosed before and after 35 years of age (median age of T1D defined by two or more positive autoantibodies): 39 (31-46) vs. 44% (38-50) with two or more positive islet autoantibodies and 43 (33-51) vs. 39% (31-46) with clinician diagnosis confirmed by one positive islet autoantibody (P > 0.1). Baseline C-peptide and T1D GRS were unaffected by age of diagnosis or T1D definition (P > 0.1). In T1D defined by two or more autoantibodies, presentation severity was similar in those diagnosed before and after 35 years of age: unintentional weight loss, 80 (95% CI 74-85) vs. 82% (76-87); ketoacidosis, 24 (18-30) vs. 19% (14-25); and presentation glucose, 21 (19-22) vs. 21 mmol/L (20-22) (all P ≥ 0.1). Despite similar presentation, older adults were less likely to be diagnosed with T1D, insulin-treated, or admitted to hospital. CONCLUSIONS When adult-onset T1D is robustly defined, the presentation characteristics, progression, and T1D genetic susceptibility are not altered by age of diagnosis.
Collapse
Affiliation(s)
- Nicholas J Thomas
- University of Exeter College of Medicine & Health, Exeter, U.K.,Royal Devon University Healthcare NHS Foundation Trust, Exeter, U.K
| | - Anita V Hill
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, U.K
| | | | - Richard A Oram
- University of Exeter College of Medicine & Health, Exeter, U.K.,Royal Devon University Healthcare NHS Foundation Trust, Exeter, U.K
| | - Timothy J McDonald
- University of Exeter College of Medicine & Health, Exeter, U.K.,Royal Devon University Healthcare NHS Foundation Trust, Exeter, U.K
| | | | - Angus G Jones
- University of Exeter College of Medicine & Health, Exeter, U.K.,Royal Devon University Healthcare NHS Foundation Trust, Exeter, U.K
| | | |
Collapse
|
18
|
Shields BM, Dennis JM, Angwin CD, Warren F, Henley WE, Farmer AJ, Sattar N, Holman RR, Jones AG, Pearson ER, Hattersley AT. Patient stratification for determining optimal second-line and third-line therapy for type 2 diabetes: the TriMaster study. Nat Med 2023; 29:376-383. [PMID: 36477733 PMCID: PMC7614216 DOI: 10.1038/s41591-022-02120-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/07/2022] [Indexed: 12/13/2022]
Abstract
Precision medicine aims to treat an individual based on their clinical characteristics. A differential drug response, critical to using these features for therapy selection, has never been examined directly in type 2 diabetes. In this study, we tested two hypotheses: (1) individuals with body mass index (BMI) > 30 kg/m2, compared to BMI ≤ 30 kg/m2, have greater glucose lowering with thiazolidinediones than with DPP4 inhibitors, and (2) individuals with estimated glomerular filtration rate (eGFR) 60-90 ml/min/1.73 m2, compared to eGFR >90 ml/min/1.73 m2, have greater glucose lowering with DPP4 inhibitors than with SGLT2 inhibitors. The primary endpoint for both hypotheses was the achieved HbA1c difference between strata for the two drugs. In total, 525 people with type 2 diabetes participated in this UK-based randomized, double-blind, three-way crossover trial of 16 weeks of treatment with each of sitagliptin 100 mg once daily, canagliflozin 100 mg once daily and pioglitazone 30 mg once daily added to metformin alone or metformin plus sulfonylurea. Overall, the achieved HbA1c was similar for the three drugs: pioglitazone 59.6 mmol/mol, sitagliptin 60.0 mmol/mol and canagliflozin 60.6 mmol/mol (P = 0.2). Participants with BMI > 30 kg/m2, compared to BMI ≤ 30 kg/m2, had a 2.88 mmol/mol (95% confidence interval (CI): 0.98, 4.79) lower HbA1c on pioglitazone than on sitagliptin (n = 356, P = 0.003). Participants with eGFR 60-90 ml/min/1.73 m2, compared to eGFR >90 ml/min/1.73 m2, had a 2.90 mmol/mol (95% CI: 1.19, 4.61) lower HbA1c on sitagliptin than on canagliflozin (n = 342, P = 0.001). There were 2,201 adverse events reported, and 447/525 (85%) randomized participants experienced an adverse event on at least one of the study drugs. In this precision medicine trial in type 2 diabetes, our findings support the use of simple, routinely available clinical measures to identify the drug class most likely to deliver the greatest glycemic reduction for a given patient. (ClinicalTrials.gov registration: NCT02653209 ; ISRCTN registration: 12039221 .).
Collapse
Affiliation(s)
- Beverley M Shields
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - John M Dennis
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - Catherine D Angwin
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - Fiona Warren
- Clinical Trials Unit, University of Exeter Medical School, Exeter, UK
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - William E Henley
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Andrew J Farmer
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Naveed Sattar
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - Rury R Holman
- Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Angus G Jones
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - Ewan R Pearson
- Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Andrew T Hattersley
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK.
| | | |
Collapse
|
19
|
Shields BM, Angwin CD, Shepherd MH, Britten N, Jones AG, Sattar N, Holman R, Pearson ER, Hattersley AT. Patient preference for second- and third-line therapies in type 2 diabetes: a prespecified secondary endpoint of the TriMaster study. Nat Med 2023; 29:384-391. [PMID: 36477734 PMCID: PMC7614215 DOI: 10.1038/s41591-022-02121-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/07/2022] [Indexed: 12/12/2022]
Abstract
Patient preference is very important for medication selection in chronic medical conditions, like type 2 diabetes, where there are many different drugs available. Patient preference balances potential efficacy with potential side effects. As both aspects of drug response can vary markedly between individuals, this decision could be informed by the patient personally experiencing the alternative medications, as occurs in a crossover trial. In the TriMaster (NCT02653209, ISRCTN12039221), randomized double-blind, three-way crossover trial patients received three different second- or third-line once-daily type 2 diabetes glucose-lowering drugs (pioglitazone 30 mg, sitagliptin 100 mg and canagliflozin 100 mg). As part of a prespecified secondary endpoint, we examined patients' drug preference after they had tried all three drugs. In total, 448 participants were treated with all three drugs which overall showed similar glycemic control (HbA1c on pioglitazone 59.5 sitagliptin 59.9, canagliflozin 60.5 mmol mol-1, P = 0.19). In total, 115 patients (25%) preferred pioglitazone, 158 patients (35%) sitagliptin and 175 patients (38%) canagliflozin. The drug preferred by individual patients was associated with a lower HbA1c (mean: 4.6; 95% CI: 3.9, 5.3) mmol mol-1 lower versus nonpreferred) and fewer side effects (mean: 0.50; 95% CI: 0.35, 0.64) fewer side effects versus nonpreferred). Allocating therapy based on the individually preferred drugs, rather than allocating all patients the overall most preferred drug (canagliflozin), would result in more patients achieving the lowest HbA1c for them (70% versus 30%) and the fewest side effects (67% versus 50%). When precision approaches do not predict a clear optimal therapy for an individual, allowing patients to try potential suitable medications before they choose long-term therapy could be a practical alternative to optimizing treatment for type 2 diabetes.
Collapse
Affiliation(s)
- Beverley M Shields
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - Catherine D Angwin
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - Maggie H Shepherd
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Nicky Britten
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Angus G Jones
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Rury Holman
- Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Ewan R Pearson
- Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Andrew T Hattersley
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK.
| |
Collapse
|
20
|
Young KG, McGovern AP, Barroso I, Hattersley AT, Jones AG, Shields BM, Thomas NJ, Dennis JM. The impact of population-level HbA 1c screening on reducing diabetes diagnostic delay in middle-aged adults: a UK Biobank analysis. Diabetologia 2023; 66:300-309. [PMID: 36411396 PMCID: PMC9807472 DOI: 10.1007/s00125-022-05824-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/14/2022] [Indexed: 11/23/2022]
Abstract
AIMS/HYPOTHESIS Screening programmes can detect cases of undiagnosed diabetes earlier than symptomatic or incidental diagnosis. However, the improvement in time to diagnosis achieved by screening programmes compared with routine clinical care is unclear. We aimed to use the UK Biobank population-based study to provide the first population-based estimate of the reduction in time to diabetes diagnosis that could be achieved by HbA1c-based screening in middle-aged adults. METHODS We studied UK Biobank participants aged 40-70 years with HbA1c measured at enrolment (but not fed back to participants/clinicians) and linked primary and secondary healthcare data (n=179,923) and identified those with a pre-existing diabetes diagnosis (n=13,077, 7.3%). Among the remaining participants (n=166,846) without a diabetes diagnosis, we used an elevated enrolment HbA1c level (≥48 mmol/mol [≥6.5%]) to identify those with undiagnosed diabetes. For this group, we used Kaplan-Meier analysis to assess the time between enrolment HbA1c measurement and subsequent clinical diabetes diagnosis up to 10 years, and Cox regression to identify clinical factors associated with delayed diabetes diagnosis. RESULTS In total, 1.0% (1703/166,846) of participants without a diabetes diagnosis had undiagnosed diabetes based on calibrated HbA1c levels at UK Biobank enrolment, with a median HbA1c level of 51.3 mmol/mol (IQR 49.1-57.2) (6.8% [6.6-7.4]). These participants represented an additional 13.0% of diabetes cases in the study population relative to the 13,077 participants with a diabetes diagnosis. The median time to clinical diagnosis for those with undiagnosed diabetes was 2.2 years, with a median HbA1c at clinical diagnosis of 58.2 mmol/mol (IQR 51.0-80.0) (7.5% [6.8-9.5]). Female participants with lower HbA1c and BMI measurements at enrolment experienced the longest delay to clinical diagnosis. CONCLUSIONS/INTERPRETATION Our population-based study shows that HbA1c screening in adults aged 40-70 years can reduce the time to diabetes diagnosis by a median of 2.2 years compared with routine clinical care. The findings support the use of HbA1c screening to reduce the time for which individuals are living with undiagnosed diabetes.
Collapse
Affiliation(s)
- Katherine G Young
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK.
| | - Andrew P McGovern
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Inês Barroso
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
| | - Andrew T Hattersley
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Angus G Jones
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Beverley M Shields
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
| | - Nicholas J Thomas
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - John M Dennis
- Exeter Centre of Excellence in Diabetes (EXCEED), University of Exeter Medical School, Exeter, UK
| |
Collapse
|
21
|
Katte JC, McDonald TJ, Sobngwi E, Jones AG. The phenotype of type 1 diabetes in sub-Saharan Africa. Front Public Health 2023; 11:1014626. [PMID: 36778553 PMCID: PMC9912986 DOI: 10.3389/fpubh.2023.1014626] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 01/10/2023] [Indexed: 01/29/2023] Open
Abstract
The phenotype of type 1 diabetes in Africa, especially sub-Saharan Africa, is poorly understood. Most previously conducted studies have suggested that type 1 diabetes may have a different phenotype from the classical form of the disease described in western literature. Making an accurate diagnosis of type 1 diabetes in Africa is challenging, given the predominance of atypical diabetes forms and limited resources. The peak age of onset of type 1 diabetes in sub-Saharan Africa seems to occur after 18-20 years. Multiple studies have reported lower rates of islet autoantibodies ranging from 20 to 60% amongst people with type 1 diabetes in African populations, lower than that reported in other populations. Some studies have reported much higher levels of retained endogenous insulin secretion than in type 1 diabetes elsewhere, with lower rates of type 1 diabetes genetic susceptibility and HLA haplotypes. The HLA DR3 appears to be the most predominant HLA haplotype amongst people with type 1 diabetes in sub-Saharan Africa than the HLA DR4 haplotype. Some type 1 diabetes studies in sub-Saharan Africa have been limited by small sample sizes and diverse methods employed. Robust studies close to diabetes onset are sparse. Large prospective studies with well-standardized methodologies in people at or close to diabetes diagnosis in different population groups will be paramount to provide further insight into the phenotype of type 1 diabetes in sub-Saharan Africa.
Collapse
Affiliation(s)
- Jean Claude Katte
- Institute of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, United Kingdom,National Obesity Centre and Endocrinology and Metabolic Diseases Unit, Yaounde Central Hospital, Yaoundé, Cameroon,*Correspondence: Jean Claude Katte ✉
| | - Timothy J. McDonald
- Institute of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, United Kingdom,Academic Department of Clinical Biochemistry, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Eugene Sobngwi
- National Obesity Centre and Endocrinology and Metabolic Diseases Unit, Yaounde Central Hospital, Yaoundé, Cameroon,Department of Internal Medicine and Specialities, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - Angus G. Jones
- Institute of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, United Kingdom,Macleod Diabetes and Endocrine Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| |
Collapse
|
22
|
Dawed AY, Mari A, Brown A, McDonald TJ, Li L, Wang S, Hong MG, Sharma S, Robertson NR, Mahajan A, Wang X, Walker M, Gough S, Hart LM', Zhou K, Forgie I, Ruetten H, Pavo I, Bhatnagar P, Jones AG, Pearson ER. Pharmacogenomics of GLP-1 receptor agonists: a genome-wide analysis of observational data and large randomised controlled trials. Lancet Diabetes Endocrinol 2023; 11:33-41. [PMID: 36528349 DOI: 10.1016/s2213-8587(22)00340-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND In the treatment of type 2 diabetes, GLP-1 receptor agonists lower blood glucose concentrations, body weight, and have cardiovascular benefits. The efficacy and side effects of GLP-1 receptor agonists vary between people. Human pharmacogenomic studies of this inter-individual variation can provide both biological insight into drug action and provide biomarkers to inform clinical decision making. We therefore aimed to identify genetic variants associated with glycaemic response to GLP-1 receptor agonist treatment. METHODS In this genome-wide analysis we included adults (aged ≥18 years) with type 2 diabetes treated with GLP-1 receptor agonists with baseline HbA1c of 7% or more (53 mmol/mol) from four prospective observational cohorts (DIRECT, PRIBA, PROMASTER, and GoDARTS) and two randomised clinical trials (HARMONY phase 3 and AWARD). The primary endpoint was HbA1c reduction at 6 months after starting GLP-1 receptor agonists. We evaluated variants in GLP1R, then did a genome-wide association study and gene-based burden tests. FINDINGS 4571 adults were included in our analysis, of these, 3339 (73%) were White European, 449 (10%) Hispanic, 312 (7%) American Indian or Alaskan Native, and 471 (10%) were other, and around 2140 (47%) of the participants were women. Variation in HbA1c reduction with GLP-1 receptor agonists treatment was associated with rs6923761G→A (Gly168Ser) in the GLP1R (0·08% [95% CI 0·04-0·12] or 0·9 mmol/mol lower reduction in HbA1c per serine, p=6·0 × 10-5) and low frequency variants in ARRB1 (optimal sequence kernel association test p=6·7 × 10-8), largely driven by rs140226575G→A (Thr370Met; 0·25% [SE 0·06] or 2·7 mmol/mol [SE 0·7] greater HbA1c reduction per methionine, p=5·2 × 10-6). A similar effect size for the ARRB1 Thr370Met was seen in Hispanic and American Indian or Alaska Native populations who have a higher frequency of this variant (6-11%) than in White European populations. Combining these two genes identified 4% of the population who had a 30% greater reduction in HbA1c than the 9% of the population with the worse response. INTERPRETATION This genome-wide pharmacogenomic study of GLP-1 receptor agonists provides novel biological and clinical insights. Clinically, when genotype is routinely available at the point of prescribing, individuals with ARRB1 variants might benefit from earlier initiation of GLP-1 receptor agonists. FUNDING Innovative Medicines Initiative and the Wellcome Trust.
Collapse
Affiliation(s)
- Adem Y Dawed
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK.
| | - Andrea Mari
- National Research Council Institute of Neuroscience, Padua, Italy
| | - Andrew Brown
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Timothy J McDonald
- Institute of Biomedical and Clinical Sciences, University of Exeter, Exeter, UK
| | - Lin Li
- BioStat Solutions, Fredrick, MD, USA
| | | | - Mun-Gwan Hong
- Science for Life Laboratory, School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Sapna Sharma
- Research Unit Molecular Epidemiology, Institute of Epidemiology II, Helmholtz Zentrum Muenchen, Neuherberg, Germany
| | - Neil R Robertson
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Anubha Mahajan
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Xuan Wang
- Science for Life Laboratory, Department of Medical Cell Biology, Uppsala University, Uppsala, Sweden
| | - Mark Walker
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen Gough
- Global Chief Medical Office, Novo Nordisk, Søborg, Denmark
| | - Leen M 't Hart
- Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, Netherlands; Department of Biomedical Data Sciences, Section Molecular Epidemiology, Leiden University Medical Center, Leiden, Netherlands; Department of Epidemiology and Data Sciences, Amsterdam Public Health Institute, Amsterdam University Medical Center, location VUMC, Amsterdam, Netherlands
| | - Kaixin Zhou
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Ian Forgie
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | | | - Imre Pavo
- Eli Lilly Research Laboratories, Indianapolis, IN, USA
| | | | - Angus G Jones
- Institute of Biomedical and Clinical Sciences, University of Exeter, Exeter, UK
| | - Ewan R Pearson
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK.
| | | |
Collapse
|
23
|
Thomas NJ, McGovern A, Young KG, Sharp SA, Weedon MN, Hattersley AT, Dennis J, Jones AG. Identifying type 1 and 2 diabetes in research datasets where classification biomarkers are unavailable: assessing the accuracy of published approaches. J Clin Epidemiol 2023; 153:34-44. [PMID: 36368478 DOI: 10.1016/j.jclinepi.2022.10.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/05/2022] [Accepted: 10/31/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVES We aimed to compare the performance of approaches for classifying insulin-treated diabetes within research datasets without measured classification biomarkers, evaluated against two independent biological definitions of diabetes type. STUDY DESIGN AND SETTING We compared accuracy of ten reported approaches for classifying insulin-treated diabetes into type 1 (T1D) and type 2 (T2D) diabetes in two cohorts: UK Biobank (UKBB) n = 26,399 and Diabetes Alliance for Research in England (DARE) n = 1,296. The overall performance for classifying T1D and T2D was assessed using: a T1D genetic risk score and genetic stratification method (UKBB); C-peptide measured at >3 years diabetes duration (DARE). RESULTS Approaches' accuracy ranged from 71% to 88% (UKBB) and 68% to 88% (DARE). When classifying all participants, combining early insulin requirement with a T1D probability model (incorporating diagnosis age and body image issue [BMI]), and interview-reported diabetes type (UKBB available in only 15%) consistently achieved high accuracy (UKBB 87% and 87% and DARE 85% and 88%, respectively). For identifying T1D with minimal misclassification, models with high thresholds or young diagnosis age (<20 years) had highest performance. Findings were incorporated into an online tool identifying optimum approaches based on variable availability. CONCLUSION Models combining continuous features with early insulin requirement are the most accurate methods for classifying insulin-treated diabetes in research datasets without measured classification biomarkers.
Collapse
Affiliation(s)
- Nicholas J Thomas
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK; Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Andrew McGovern
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK; Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Katherine G Young
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Seth A Sharp
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Michael N Weedon
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Andrew T Hattersley
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK; Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - John Dennis
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Angus G Jones
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK; Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
| |
Collapse
|
24
|
Dennis JM, Young KG, McGovern AP, Mateen BA, Vollmer SJ, Simpson MD, Henley WE, Holman RR, Sattar N, Pearson ER, Hattersley AT, Jones AG, Shields BM. Development of a treatment selection algorithm for SGLT2 and DPP-4 inhibitor therapies in people with type 2 diabetes: a retrospective cohort study. Lancet Digit Health 2022; 4:e873-e883. [PMID: 36427949 DOI: 10.1016/s2589-7500(22)00174-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Current treatment guidelines do not provide recommendations to support the selection of treatment for most people with type 2 diabetes. We aimed to develop and validate an algorithm to allow selection of optimal treatment based on glycaemic response, weight change, and tolerability outcomes when choosing between SGLT2 inhibitor or DPP-4 inhibitor therapies. METHODS In this retrospective cohort study, we identified patients initiating SGLT2 and DPP-4 inhibitor therapies after Jan 1, 2013, from the UK Clinical Practice Research Datalink (CPRD). We excluded those who received SGLT2 or DPP-4 inhibitors as first-line treatment or insulin at the same time, had estimated glomerular filtration rate (eGFR) of less than 45 mL/min per 1·73 m2, or did not have a valid baseline glycated haemoglobin (HbA1c) measure (<53 or ≥120 mmol/mol). The primary efficacy outcome was the HbA1c value reached 6 months after drug initiation, adjusted for baseline HbA1c. Clinical features associated with differential HbA1c outcome on the two therapies were identified in CPRD (n=26 877), and replicated in reanalysis of 14 clinical trials (n=10 414). An algorithm to predict individual-level differential HbA1c outcome on the two therapies was developed in CPRD (derivation; n=14 069) and validated in head-to-head trials (n=2499) and CPRD (independent validation; n=9376). In CPRD, we further explored heterogeneity in 6-month weight change and treatment discontinuation. FINDINGS Among 10 253 patients initiating SGLT2 inhibitors and 16 624 patients initiating DPP-4 inhibitors in CPRD, baseline HbA1c, age, BMI, eGFR, and alanine aminotransferase were associated with differential HbA1c outcome with SGLT2 inhibitor and DPP-4 inhibitor therapies. The median age of participants was 62·0 years (IQR 55·0-70·0). 10 016 (37·3%) were women and 16 861 (62·7%) were men. An algorithm based on these five features identified a subgroup, representing around four in ten CPRD patients, with a 5 mmol/mol or greater observed benefit with SGLT2 inhibitors in all validation cohorts (CPRD 8·8 mmol/mol [95% CI 7·8-9·8]; CANTATA-D and CANTATA-D2 trials 5·8 mmol/mol [3·9-7·7]; BI1245.20 trial 6·6 mmol/mol [2·2-11·0]). In CPRD, predicted differential HbA1c response with SGLT2 inhibitor and DPP-4 inhibitor therapies was not associated with weight change. Overall treatment discontinuation within 6 months was similar in patients predicted to have an HbA1c benefit with SGLT2 inhibitors over DPP-4 inhibitors (median 15·2% [13·2-20·3] vs 14·4% [12·9-16·7]). A smaller subgroup predicted to have greater HbA1c reduction with DPP-4 inhibitors were twice as likely to discontinue SGLT2 inhibitors than DPP-4 inhibitors (median 26·8% [23·4-31·0] vs 14·8% [12·9-16·8]). INTERPRETATION A validated treatment selection algorithm for SGLT2 inhibitor and DPP-4 inhibitor therapies can support decisions on optimal treatment for people with type 2 diabetes. FUNDING BHF-Turing Cardiovascular Data Science Award and the UK Medical Research Council.
Collapse
Affiliation(s)
- John M Dennis
- University of Exeter Medical School, Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, Exeter, UK.
| | - Katherine G Young
- University of Exeter Medical School, Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, Exeter, UK
| | - Andrew P McGovern
- University of Exeter Medical School, Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, Exeter, UK
| | - Bilal A Mateen
- The Alan Turing Institute, British Library, London, UK; Institute of Health Informatics, University College London, London, UK
| | | | | | - William E Henley
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Rury R Holman
- Oxford Centre for Diabetes, Endocrinology, and Metabolism, University of Oxford, Churchill Hospital, Oxford, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Ewan R Pearson
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Andrew T Hattersley
- University of Exeter Medical School, Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, Exeter, UK
| | - Angus G Jones
- University of Exeter Medical School, Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, Exeter, UK
| | - Beverley M Shields
- University of Exeter Medical School, Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, Exeter, UK
| | | |
Collapse
|
25
|
Eason RJ, Thomas NJ, Hill AV, Knight BA, Carr A, Hattersley AT, McDonald TJ, Shields BM, Jones AG. Routine Islet Autoantibody Testing in Clinically Diagnosed Adult-Onset Type 1 Diabetes Can Help Identify Misclassification and the Possibility of Successful Insulin Cessation. Diabetes Care 2022; 45:2844-2851. [PMID: 36205650 DOI: 10.2337/dc22-0623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 08/23/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Recent joint American Diabetes Association and European Association for the Study of Diabetes guidelines recommend routine islet autoantibody testing in all adults newly diagnosed with type 1 diabetes. We aimed to assess the impact of routine islet autoantibody testing in this population. RESEARCH DESIGN AND METHODS We prospectively assessed the relationship between islet autoantibody status (GADA, IA-2A, and ZNT8A), clinical and genetic characteristics, and progression (annual change in urine C-peptide-to-creatinine ratio [UCPCR]) in 722 adults (≥18 years old at diagnosis) with clinically diagnosed type 1 diabetes and diabetes duration <12 months. We also evaluated changes in treatment and glycemia over 2 years after informing participants and their clinicians of autoantibody results. RESULTS Of 722 participants diagnosed with type 1 diabetes, 24.8% (179) were autoantibody negative. This group had genetic and C-peptide characteristics suggestive of a high prevalence of nonautoimmune diabetes: lower mean type 1 diabetes genetic risk score (islet autoantibody negative vs. positive: 10.85 vs. 13.09 [P < 0.001] [type 2 diabetes 10.12]) and lower annual change in C-peptide (UCPCR), -24% vs. -43% (P < 0.001).After median 24 months of follow-up, treatment change occurred in 36.6% (60 of 164) of autoantibody-negative participants: 22.6% (37 of 164) discontinued insulin, with HbA1c similar to that of participants continuing insulin (57.5 vs. 60.8 mmol/mol [7.4 vs. 7.7%], P = 0.4), and 14.0% (23 of 164) added adjuvant agents to insulin. CONCLUSIONS In adult-onset clinically diagnosed type 1 diabetes, negative islet autoantibodies should prompt careful consideration of other diabetes subtypes. When routinely measured, negative antibodies are associated with successful insulin cessation. These findings support recent recommendations for routine islet autoantibody assessment in adult-onset type 1 diabetes.
Collapse
Affiliation(s)
- Russell J Eason
- University of Exeter College of Medicine & Health, Exeter, U.K.,Royal Devon University Healthcare NHS Foundation Trust, Exeter, U.K
| | - Nicholas J Thomas
- University of Exeter College of Medicine & Health, Exeter, U.K.,Royal Devon University Healthcare NHS Foundation Trust, Exeter, U.K
| | - Anita V Hill
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, U.K
| | - Bridget A Knight
- University of Exeter College of Medicine & Health, Exeter, U.K.,Royal Devon University Healthcare NHS Foundation Trust, Exeter, U.K
| | - Alice Carr
- University of Exeter College of Medicine & Health, Exeter, U.K
| | - Andrew T Hattersley
- University of Exeter College of Medicine & Health, Exeter, U.K.,Royal Devon University Healthcare NHS Foundation Trust, Exeter, U.K
| | - Timothy J McDonald
- University of Exeter College of Medicine & Health, Exeter, U.K.,Royal Devon University Healthcare NHS Foundation Trust, Exeter, U.K
| | | | - Angus G Jones
- University of Exeter College of Medicine & Health, Exeter, U.K.,Royal Devon University Healthcare NHS Foundation Trust, Exeter, U.K
| | | | | |
Collapse
|
26
|
Grace SL, Bowden J, Walkey HC, Kaur A, Misra S, Shields BM, McKinley TJ, Oliver NS, McDonald TJ, Johnston DG, Jones AG, Patel KA. Islet Autoantibody Level Distribution in Type 1 Diabetes and Their Association With Genetic and Clinical Characteristics. J Clin Endocrinol Metab 2022; 107:e4341-e4349. [PMID: 36073000 PMCID: PMC9693812 DOI: 10.1210/clinem/dgac507] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT The importance of the autoantibody level at diagnosis of type 1 diabetes (T1D) is not clear. OBJECTIVE We aimed to assess the association of glutamate decarboxylase (GADA), islet antigen-2 (IA-2A), and zinc transporter 8 (ZnT8A) autoantibody levels with clinical and genetic characteristics at diagnosis of T1D. METHODS We conducted a prospective, cross-sectional study. GADA, IA-2A, and ZnT8A were measured in 1644 individuals with T1D at diagnosis using radiobinding assays. Associations between autoantibody levels and the clinical and genetic characteristics for individuals were assessed in those positive for these autoantibodies. We performed replication in an independent cohort of 449 people with T1D. RESULTS GADA and IA-2A levels exhibited a bimodal distribution at diagnosis. High GADA level was associated with older age at diagnosis (median 27 years vs 19 years, P = 9 × 10-17), female sex (52% vs 37%, P = 1 × 10-8), other autoimmune diseases (13% vs 6%, P = 3 × 10-6), and HLA-DR3-DQ2 (58% vs 51%, P = .006). High IA-2A level was associated with younger age of diagnosis (median 17 years vs 23 years, P = 3 × 10-7), HLA-DR4-DQ8 (66% vs 50%, P = 1 × 10-6), and ZnT8A positivity (77% vs 52%, P = 1 × 10-15). We replicated our findings in an independent cohort of 449 people with T1D where autoantibodies were measured using enzyme-linked immunosorbent assays. CONCLUSION Islet autoantibody levels provide additional information over positivity in T1D at diagnosis. Bimodality of GADA and IA-2A autoantibody levels highlights the novel aspect of heterogeneity of T1D. This may have implications for T1D prediction, treatment, and pathogenesis.
Collapse
Affiliation(s)
- Sian Louise Grace
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, Devon EX2 5DW, UK
| | - Jack Bowden
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, Devon EX2 5DW, UK
| | - Helen C Walkey
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London SW7 2AZ, UK
| | - Akaal Kaur
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London SW7 2AZ, UK
| | - Shivani Misra
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London SW7 2AZ, UK
| | - Beverley M Shields
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, Devon EX2 5DW, UK
| | - Trevelyan J McKinley
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, Devon EX2 5DW, UK
| | - Nick S Oliver
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London SW7 2AZ, UK
| | - Timothy J McDonald
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, Devon EX2 5DW, UK
- Academic Department of Clinical Biochemistry, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon EX2 5DW, UK
| | - Desmond G Johnston
- Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London SW7 2AZ, UK
| | - Angus G Jones
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, Devon EX2 5DW, UK
- Macleod Diabetes and Endocrine Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon EX2 5DW, UK
| | - Kashyap A Patel
- Correspondence: Kashyap A. Patel, PhD, Institute of Biomedical & Clinical Science, University of Exeter Medical School, Level 3 RILD Bldg, RD&E Wonford, Barrack Road, Exeter, Devon EX2 5DW, UK.
| |
Collapse
|
27
|
Tatovic D, Jones AG, Evans C, Long AE, Gillespie K, Besser REJ, Leslie RD, Dayan CM. Diagnosing Type 1 diabetes in adults: Guidance from the UK T1D Immunotherapy consortium. Diabet Med 2022; 39:e14862. [PMID: 35488476 PMCID: PMC9320853 DOI: 10.1111/dme.14862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 11/29/2022]
|
28
|
Jones AG, Eichmann M. T-Cell Autoreactivity in Type 2 Diabetes: Benign or Pathogenic, Smoke or Fire? Diabetes 2022; 71:1167-1169. [PMID: 35594448 DOI: 10.2337/dbi22-0007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/11/2022] [Indexed: 01/16/2023]
|
29
|
Kibirige D, Sekitoleko I, Balungi P, Kyosiimire-Lugemwa J, Lumu W, Jones AG, Hattersley AT, Smeeth L, Nyirenda MJ. Islet autoantibody positivity in an adult population with recently diagnosed diabetes in Uganda. PLoS One 2022; 17:e0268783. [PMID: 35604955 PMCID: PMC9126391 DOI: 10.1371/journal.pone.0268783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 05/07/2022] [Indexed: 12/02/2022] Open
Abstract
Aims This study aimed to investigate the frequency of islet autoantibody positivity in adult patients with recently diagnosed diabetes in Uganda and its associated characteristics. Methods Autoantibodies to glutamic acid decarboxylase-65 (GADA), zinc transporter 8 (ZnT8-A), and tyrosine phosphatase (IA-2A) were measured in 534 adult patients with recently diagnosed diabetes. Islet autoantibody positivity was defined based on diagnostic thresholds derived from a local adult population without diabetes. The socio-demographic, clinical, and metabolic characteristics of islet autoantibody-positive and negative participants were then compared. The differences in these characteristics were analysed using the x2 test for categorical data and the Kruskal Wallis test for continuous data. Multivariate analysis was performed to identify predictors of islet autoantibody positivity. Results Thirty four (6.4%) participants were positive for ≥1 islet autoantibody. GADA, IA-2A and ZnT8-A positivity was detected in 17 (3.2%), 10 (1.9%), and 7 (1.3%) participants, respectively. Compared with those negative for islet autoantibodies, participants positive for islet autoantibodies were more likely to live in a rural area (n = 18, 52.9% Vs n = 127, 25.5%, p = 0.005), to be initiated on insulin therapy (n = 19, 55.9% Vs n = 134, 26.8%, p<0.001), to have a lower median waist circumference (90 [80–99] cm Vs 96 [87–104.8], p = 0.04), waist circumference: height ratio (0.55 [0.50–0.63] vs 0.59 [0.53–0.65], p = 0.03), and fasting C-peptide concentration (0.9 [0.6–1.8] Vs 1.4 [0.8–2.1] ng/ml, p = 0.01). On multivariate analysis, living in a rural area (odds ratio or OR 3.62, 95%CI 1.68–7.80, p = 0.001) and being initiated on insulin therapy (OR 3.61, 95% CI 1.67–7.83, p = 0.001) were associated with islet autoantibody positivity. Conclusion The prevalence of islet autoantibody positivity was relatively low, suggesting that pancreatic autoimmunity is a rare cause of new-onset diabetes in this adult Ugandan population. Living in a rural area and being initiated on insulin therapy were independently associated with islet autoantibody positivity in this study population.
Collapse
Affiliation(s)
- Davis Kibirige
- Non-Communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Non-Communicable Diseases Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Isaac Sekitoleko
- Non-Communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Priscilla Balungi
- Non-Communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Clinical Diagnostics Laboratory Services, Medical Research Council/Uganda Virus Research Institute, and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Jacqueline Kyosiimire-Lugemwa
- Clinical Diagnostics Laboratory Services, Medical Research Council/Uganda Virus Research Institute, and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - William Lumu
- Department of Medicine, Mengo Hospital, Kampala, Uganda
| | - Angus G. Jones
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Barrack Road, Exeter, United Kingdom
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Andrew T. Hattersley
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Barrack Road, Exeter, United Kingdom
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Liam Smeeth
- Department of Non-Communicable Diseases Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Moffat J. Nyirenda
- Non-Communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Non-Communicable Diseases Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| |
Collapse
|
30
|
Garbutt J, England C, Jones AG, Andrews RC, Salway R, Johnson L. Is glycaemic control associated with dietary patterns independent of weight change in people newly diagnosed with type 2 diabetes? Prospective analysis of the Early-ACTivity-In-Diabetes trial. BMC Med 2022; 20:161. [PMID: 35430794 PMCID: PMC9014614 DOI: 10.1186/s12916-022-02358-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is unclear whether diet affects glycaemic control in type 2 diabetes (T2D), over and above its effects on bodyweight. We aimed to assess whether changes in dietary patterns altered glycaemic control independently of effects on bodyweight in newly diagnosed T2D. METHODS We used data from 4-day food diaries, HbA1c and potential confounders in participants of the Early-ACTivity-In-Diabetes trial measured at 0, 6 and 12 months. At baseline, a 'carb/fat balance' dietary pattern and an 'obesogenic' dietary pattern were derived using reduced-rank regression, based on hypothesised nutrient-mediated mechanisms linking dietary intake to glycaemia directly or via obesity. Relationships between 0 and 6 month change in dietary pattern scores and baseline-adjusted HbA1c at 6 months (n = 242; primary outcome) were assessed using multivariable linear regression. Models were repeated for periods 6-12 months and 0-12 months (n = 194 and n = 214 respectively; secondary outcomes). RESULTS Reductions over 0-6 months were observed in mean bodyweight (- 2.3 (95% CI: - 2.7, - 1.8) kg), body mass index (- 0.8 (- 0.9, - 0.6) kg/m2), energy intake (- 788 (- 953, - 624) kJ/day), and HbA1c (- 1.6 (- 2.6, -0.6) mmol/mol). Weight loss strongly associated with lower HbA1c at 0-6 months (β = - 0.70 [95% CI - 0.95, - 0.45] mmol/mol/kg lost). Average fat and carbohydrate intakes changed to be more in-line with UK healthy eating guidelines between 0 and 6 months. Dietary patterns shifting carbohydrate intakes higher and fat intakes lower were characterised by greater consumption of fresh fruit, low-fat milk and boiled/baked potatoes and eating less of higher-fat processed meats, butter/animal fats and red meat. Increases in standardised 'carb/fat balance' dietary pattern score associated with improvements in HbA1c at 6 months independent of weight loss (β = - 1.54 [- 2.96, - 0.13] mmol/mol/SD). No evidence of association with HbA1c was found for this dietary pattern at other time-periods. Decreases in 'obesogenic' dietary pattern score were associated with weight loss (β = - 0.77 [- 1.31, - 0.23] kg/SD) but not independently with HbA1c during any period. CONCLUSIONS Promoting weight loss should remain the primary nutritional strategy for improving glycaemic control in early T2D. However, improving dietary patterns to bring carbohydrate and fat intakes closer to UK guidelines may provide small, additional improvements in glycaemic control. TRIAL REGISTRATION ISRCTN92162869 . Retrospectively registered on 25 July 2005.
Collapse
Affiliation(s)
- James Garbutt
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, 8 Priory Road, Bristol, BS8 1TZ, UK.
| | - C England
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, 8 Priory Road, Bristol, BS8 1TZ, UK.,NIHR Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - A G Jones
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, University of Exeter, Exeter, UK.,Diabetes and Endocrinology, Royal Devon and Exeter Hospital, Exeter, UK
| | - R C Andrews
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - R Salway
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, 8 Priory Road, Bristol, BS8 1TZ, UK
| | - L Johnson
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, 8 Priory Road, Bristol, BS8 1TZ, UK
| |
Collapse
|
31
|
Kibirige D, Sekitoleko I, Lumu W, Jones AG, Hattersley AT, Smeeth L, Nyirenda MJ. Understanding the pathogenesis of lean non-autoimmune diabetes in an African population with newly diagnosed diabetes. Diabetologia 2022; 65:675-683. [PMID: 35138411 PMCID: PMC8894297 DOI: 10.1007/s00125-021-05644-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/12/2021] [Indexed: 11/25/2022]
Abstract
AIMS/HYPOTHESIS Apparent type 2 diabetes is increasingly reported in lean adult individuals in sub-Saharan Africa. However, studies undertaking robust clinical and metabolic characterisation of lean individuals with new-onset type 2 diabetes are limited in this population. This cross-sectional study aimed to perform a detailed clinical and metabolic characterisation of newly diagnosed adult patients with diabetes in Uganda, in order to compare features between lean and non-lean individuals. METHODS Socio-demographic, clinical, biophysical and metabolic (including oral glucose tolerance test) data were collected on 568 adult patients with newly diagnosed diabetes. Participants were screened for islet autoantibodies to exclude those with autoimmune diabetes. The remaining participants (with type 2 diabetes) were then classified as lean (BMI <25 kg/m2) or non-lean (BMI ≥25 kg/m2), and their socio-demographic, clinical, biophysical and metabolic characteristics were compared. RESULTS Thirty-four participants (6.4%) were excluded from analyses because they were positive for pancreatic autoantibodies, and a further 34 participants because they had incomplete data. For the remaining 500 participants, the median (IQR) age, BMI and HbA1c were 48 years (39-58), 27.5 kg/m2 (23.6-31.4) and 90 mmol/mol (61-113) (10.3% [7.7-12.5]), respectively, with a female predominance (approximately 57%). Of the 500 participants, 160 (32%) and 340 (68%) were lean and non-lean, respectively. Compared with non-lean participants, lean participants were mainly male (60.6% vs 35.3%, p<0.001) and had lower visceral adiposity level (5 [4-7] vs 11 [9-13], p<0.001) and features of the metabolic syndrome (uric acid, 246.5 [205.0-290.6] vs 289 [234-347] μmol/l, p<0.001; leptin, 660.9 [174.5-1993.1] vs 3988.0 [1336.0-6595.0] pg/ml, p<0.001). In addition, they displayed markedly reduced markers of beta cell function (oral insulinogenic index 0.8 [0.3-2.5] vs 1.6 [0.6-4.6] pmol/mmol; 120 min serum C-peptide 0.70 [0.33-1.36] vs 1.02 [0.60-1.66] nmol/l, p<0.001). CONCLUSIONS/INTERPRETATION Approximately one-third of participants with incident adult-onset non-autoimmune diabetes had BMI <25 kg/m2. Diabetes in these lean individuals was more common in men, and predominantly associated with reduced pancreatic secretory function rather than insulin resistance. The underlying pathological mechanisms are unclear, but this is likely to have important management implications.
Collapse
Affiliation(s)
- Davis Kibirige
- Non-Communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Isaac Sekitoleko
- Non-Communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - William Lumu
- Department of Medicine, Mengo Hospital, Kampala, Uganda
| | - Angus G. Jones
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Andrew T. Hattersley
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Moffat J. Nyirenda
- Non-Communicable Diseases Program, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
32
|
Niwaha AJ, Rodgers LR, Carr ALJ, Balungi PA, Mwebaze R, Hattersley AT, Shields BM, Nyirenda MJ, Jones AG. Continuous glucose monitoring demonstrates low risk of clinically significant hypoglycemia associated with sulphonylurea treatment in an African type 2 diabetes population: results from the OPTIMAL observational multicenter study. BMJ Open Diabetes Res Care 2022; 10:10/2/e002714. [PMID: 35450869 PMCID: PMC9024213 DOI: 10.1136/bmjdrc-2021-002714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/27/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION People living with diabetes in low-resource settings may be at increased hypoglycemia risk due to food insecurity and limited access to glucose monitoring. We aimed to assess hypoglycemia risk associated with sulphonylurea (SU) and insulin therapy in people living with type 2 diabetes in a low-resource sub-Saharan African setting. RESEARCH DESIGN AND METHODS This study was conducted in the outpatients' diabetes clinics of two hospitals (one rural and one urban) in Uganda. We used blinded continuous glucose monitoring (CGM) and self-report to compare hypoglycemia rates and duration in 179 type 2 diabetes patients treated with sulphonylureas (n=100) and insulin (n=51) in comparison with those treated with metformin only (n=28). CGM-assessed hypoglycemia was defined as minutes per week below 3mmol/L (54mg/dL) and number of hypoglycemic events below 3.0 mmol/L (54 mg/dL) for at least 15 minutes. RESULTS CGM recorded hypoglycemia was infrequent in SU-treated participants and did not differ from metformin: median minutes/week of glucose <3 mmol/L were 39.2, 17.0 and 127.5 for metformin, sulphonylurea and insulin, respectively (metformin vs sulphonylurea, p=0.6). Hypoglycemia risk was strongly related to glycated haemoglobin (HbA1c) and fasting glucose, with most episodes occurring in those with tight glycemic control. After adjusting for HbA1c, time <3 mmol/L was 2.1 (95% CI 0.9 to 4.7) and 5.5 (95% CI 2.4 to 12.6) times greater with sulphonylurea and insulin, respectively, than metformin alone. CONCLUSIONS In a low-resource sub-Saharan African setting, hypoglycemia is infrequent among people with type 2 diabetes receiving sulphonylurea treatment, and the modest excess occurs predominantly in those with tight glycemic control.
Collapse
Affiliation(s)
- Anxious J Niwaha
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
- NCD Theme, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Lauren R Rodgers
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Alice L J Carr
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Priscilla A Balungi
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
- NCD Theme, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Raymond Mwebaze
- Department of Medicine, St. Francis Hospital Nsambya, Kampala, Uganda
| | - Andrew T Hattersley
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
- Macleod Diabetes and Endocrine Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Beverley M Shields
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Moffat J Nyirenda
- NCD Theme, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- NCD Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Angus G Jones
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
- Macleod Diabetes and Endocrine Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| |
Collapse
|
33
|
Katte JC, Lemdjo G, Dehayem MY, Jones AG, McDonald TJ, Sobngwi E, Mbanya JC. Mortality amongst children and adolescents with type 1 diabetes in sub-Saharan Africa: The case study of the Changing Diabetes in Children program in Cameroon. Pediatr Diabetes 2022; 23:33-37. [PMID: 34820965 DOI: 10.1111/pedi.13294] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/28/2021] [Accepted: 11/15/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Type 1 diabetes in Africa has been associated with high mortality attributed mainly to poor insulin access. Free insulin provision programs for people with type 1 diabetes have been introduced across Africa recently. We aimed to determine the mortality rate and associated factors in a cohort of children and adolescents with type 1 diabetes who receive free insulin treatment in sub-Saharan Africa. METHODS We conducted a retrospective analysis using the Changing Diabetes in Children (CDiC) medical records in Cameroon between 2011 and 2015. RESULTS The overall mortality rate was 33.0 per 1000 person-years (95% CI 25.2-43.2). Most deaths (71.7%) occurred outside of the hospital setting, and the cause of death was known only in 13/53 (24.5%). Mortality was substantially higher in CDiC participants followed up in regional clinics compared to the main urban CDiC clinic in Yaounde; 41 per 1000 years (95% CI 30.8-56.0) versus 17.5 per 1000 years (95% CI 9.4-32.5), and in those with no formal education compared to those who had some level of education; 68.0 per 1000 years (95% CI 45.1-102.2) versus 23.6 per 1000 years (95% CI 16.5-33.8). In Cox proportional multivariable analysis, urban place of care (HR = 0.23, 95% CI 0.09-0.57; p = 0.002) and formal education (HR = 0.42, 95% CI 0.22-0.79; p = 0.007) were independently associated with mortality. CONCLUSION Despite free insulin provision, mortality remains high in children and adolescents with type 1 diabetes in Cameroon and is substantially higher in rural settings and those with no formal education.
Collapse
Affiliation(s)
- Jean Claude Katte
- National Institute for Health Research (NIHR) Global Health Research, University of Exeter Medical School, Exeter, UK.,National Obesity Centre and Endocrinology and Metabolism Diseases Unit, Yaounde Central Hospital, Yaounde, Cameroon
| | - Gaelle Lemdjo
- National Obesity Centre and Endocrinology and Metabolism Diseases Unit, Yaounde Central Hospital, Yaounde, Cameroon
| | - Mesmin Y Dehayem
- National Obesity Centre and Endocrinology and Metabolism Diseases Unit, Yaounde Central Hospital, Yaounde, Cameroon.,Department of Internal Medicine and Specialities, Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Yaounde, Cameroon
| | - Angus G Jones
- National Institute for Health Research (NIHR) Global Health Research, University of Exeter Medical School, Exeter, UK
| | - Timothy J McDonald
- National Institute for Health Research (NIHR) Global Health Research, University of Exeter Medical School, Exeter, UK
| | - Eugene Sobngwi
- National Obesity Centre and Endocrinology and Metabolism Diseases Unit, Yaounde Central Hospital, Yaounde, Cameroon.,Department of Internal Medicine and Specialities, Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Yaounde, Cameroon
| | - Jean Claude Mbanya
- National Obesity Centre and Endocrinology and Metabolism Diseases Unit, Yaounde Central Hospital, Yaounde, Cameroon.,Department of Internal Medicine and Specialities, Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Yaounde, Cameroon
| |
Collapse
|
34
|
Leslie RD, Evans-Molina C, Freund-Brown J, Buzzetti R, Dabelea D, Gillespie KM, Goland R, Jones AG, Kacher M, Phillips LS, Rolandsson O, Wardian JL, Dunne JL. Adult-Onset Type 1 Diabetes: Current Understanding and Challenges. Diabetes Care 2021; 44:2449-2456. [PMID: 34670785 PMCID: PMC8546280 DOI: 10.2337/dc21-0770] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 08/12/2021] [Indexed: 02/03/2023]
Abstract
Recent epidemiological data have shown that more than half of all new cases of type 1 diabetes occur in adults. Key genetic, immune, and metabolic differences exist between adult- and childhood-onset type 1 diabetes, many of which are not well understood. A substantial risk of misclassification of diabetes type can result. Notably, some adults with type 1 diabetes may not require insulin at diagnosis, their clinical disease can masquerade as type 2 diabetes, and the consequent misclassification may result in inappropriate treatment. In response to this important issue, JDRF convened a workshop of international experts in November 2019. Here, we summarize the current understanding and unanswered questions in the field based on those discussions, highlighting epidemiology and immunogenetic and metabolic characteristics of adult-onset type 1 diabetes as well as disease-associated comorbidities and psychosocial challenges. In adult-onset, as compared with childhood-onset, type 1 diabetes, HLA-associated risk is lower, with more protective genotypes and lower genetic risk scores; multiple diabetes-associated autoantibodies are decreased, though GADA remains dominant. Before diagnosis, those with autoantibodies progress more slowly, and at diagnosis, serum C-peptide is higher in adults than children, with ketoacidosis being less frequent. Tools to distinguish types of diabetes are discussed, including body phenotype, clinical course, family history, autoantibodies, comorbidities, and C-peptide. By providing this perspective, we aim to improve the management of adults presenting with type 1 diabetes.
Collapse
Affiliation(s)
- R David Leslie
- Centre for Immunobiology, Blizard Institute, Queen Mary University of London, London, U.K.
| | - Carmella Evans-Molina
- Departments of Pediatrics and Medicine and Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN
- Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | | | - Raffaella Buzzetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Dana Dabelea
- Lifecourse Epidemiology of Adiposity & Diabetes Center, Colorado School of Public Health, and Departments of Epidemiology and Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Kathleen M Gillespie
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, U.K
| | - Robin Goland
- Naomi Berrie Diabetes Center, Columbia University, New York, NY
| | - Angus G Jones
- Institute of Biomedical and Clinical Science, University of Exeter, Exeter, U.K
| | | | - Lawrence S Phillips
- Atlanta VA Medical Center and Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Olov Rolandsson
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Jana L Wardian
- College of Medicine, University of Nebraska Medical Center, Omaha, NE
| | | |
Collapse
|
35
|
Niwaha AJ, Rodgers LR, Greiner R, Balungi PA, Mwebaze R, McDonald TJ, Hattersley AT, Shields BM, Nyirenda MJ, Jones AG. HbA1c performs well in monitoring glucose control even in populations with high prevalence of medical conditions that may alter its reliability: the OPTIMAL observational multicenter study. BMJ Open Diabetes Res Care 2021; 9:9/1/e002350. [PMID: 34535465 PMCID: PMC8451306 DOI: 10.1136/bmjdrc-2021-002350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/22/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The utility of HbA1c (glycosylated hemoglobin) to estimate glycemic control in populations of African and other low-resource countries has been questioned because of high prevalence of other medical conditions that may affect its reliability. Using continuous glucose monitoring (CGM), we aimed to determine the comparative performance of HbA1c, fasting plasma glucose (FPG) (within 5 hours of a meal) and random non-fasting glucose (RPG) in assessing glycemic burden. RESEARCH DESIGN AND METHODS We assessed the performance of HbA1c, FPG and RPG in comparison to CGM mean glucose in 192 Ugandan participants with type 2 diabetes. Analysis was undertaken in all participants, and in subgroups with and without medical conditions reported to affect HbA1c reliability. We then assessed the performance of FPG and RPG, and optimal thresholds, in comparison to HbA1c in participants without medical conditions thought to alter HbA1c reliability. RESULTS 32.8% (63/192) of participants had medical conditions that may affect HbA1c reliability: anemia 9.4% (18/192), sickle cell trait and/or hemoglobin C (HbC) 22.4% (43/192), or renal impairment 6.3% (12/192). Despite high prevalence of medical conditions thought to affect HbA1c reliability, HbA1c had the strongest correlation with CGM measured glucose in day-to-day living (0.88, 95% CI 0.84 to 0.91), followed by FPG (0.82, 95% CI 0.76 to 0.86) and RPG (0.76, 95% CI 0.69 to 0.81). Among participants without conditions thought to affect HbA1c reliability, FPG and RPG had a similar diagnostic performance in identifying poor glycemic control defined by a range of HbA1c thresholds. FPG of ≥7.1 mmol/L and RPG of ≥10.5 mmol/L correctly identified 78.2% and 78.8%, respectively, of patients with an HbA1c of ≥7.0%. CONCLUSIONS HbA1c is the optimal test for monitoring glucose control even in low-income and middle-income countries where medical conditions that may alter its reliability are prevalent; FPG and RPG are valuable alternatives where HbA1c is not available.
Collapse
Affiliation(s)
- Anxious J Niwaha
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, UK
- NCD Theme, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Lauren R Rodgers
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Rosamund Greiner
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Priscilla A Balungi
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, UK
- NCD Theme, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Raymond Mwebaze
- Department of Medicine, St. Francis Hospital Nsambya, Kampala, Uganda
| | - Timothy J McDonald
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Andrew T Hattersley
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Beverley M Shields
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Moffat J Nyirenda
- NCD Theme, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- NCD Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Angus G Jones
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, UK
| |
Collapse
|
36
|
Grace SL, Cooper A, Jones AG, McDonald TJ. Zinc transporter 8 autoantibody testing requires age-related cut-offs. BMJ Open Diabetes Res Care 2021; 9:9/1/e002296. [PMID: 34348918 PMCID: PMC8340275 DOI: 10.1136/bmjdrc-2021-002296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/17/2021] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Zinc transporter 8 autoantibodies (ZnT8A) are biomarkers of beta cell autoimmunity in type 1 diabetes that have become more widely available to clinicians in recent years. Robust control population-defined thresholds are essential to ensure high clinical specificity in islet autoantibody testing. We aimed to determine the optimal cut-offs for ZnT8A testing. RESEARCH DESIGN AND METHODS 97.5th and 99th centile cut-offs were determined using residual clinical sera from 1559 controls aged between 0 and 83 years with no history of diabetes and a hemoglobin A1c level of less than 6.0% (<42 mmol/mol). ZnT8A were measured by ELISA (RSR, Cardiff, UK) on a Dynex DS2 ELISA robot (Dynex, Preston, UK). We assessed the impact of age-related cut-offs in comparison with the manufacturer's recommended threshold in a mixed cohort of young-onset (<age 30) diabetes (UNITED study (Using pharmacogeNetics to Improve Treatment in Early-onset Diabetes), n=145). RESULTS Using the manufacturer's limit of detection, 6 WHO U/mL, 16.2% of people in the control cohort had detectable levels of ZnT8A and those who had detectable ZnT8A were much more likely to be younger (p<0.0001). The 97.5th and 99th centile thresholds were substantially higher in younger participants: 18 and 127 WHO U/mL (tested under 30 years) in comparison with 9 and 21 WHO U/mL (tested 30 years and over). In the UNITED cohort some of those found to be ZnT8A-positive by the manufacturer's threshold but negative using the appropriate 99% centile cut-off (127 WHO U/mL) displayed characteristics suggestive of type 2 diabetes. CONCLUSIONS Age-related thresholds are needed for ZnT8A testing. In those aged <30 years, use of manufacturers' recommended cut-offs may result in low test specificity and potentially high rates of false positive test results in patients who do not have autoimmune diabetes.
Collapse
Affiliation(s)
- Sian Louise Grace
- The Institute of Biomedical & Clinical Science, University of Exeter, Exeter, UK
| | - Angela Cooper
- Academic Department of Clinical Biochemistry, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Angus G Jones
- The Institute of Biomedical & Clinical Science, University of Exeter, Exeter, UK
- Macleod Diabetes and Endocrine Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Timothy James McDonald
- The Institute of Biomedical & Clinical Science, University of Exeter, Exeter, UK
- Academic Department of Clinical Biochemistry, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| |
Collapse
|
37
|
Jones AG, McDonald TJ, Shields BM, Hagopian W, Hattersley AT. Latent Autoimmune Diabetes of Adults (LADA) Is Likely to Represent a Mixed Population of Autoimmune (Type 1) and Nonautoimmune (Type 2) Diabetes. Diabetes Care 2021; 44:1243-1251. [PMID: 34016607 PMCID: PMC8247509 DOI: 10.2337/dc20-2834] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 03/11/2021] [Indexed: 02/03/2023]
Abstract
Latent autoimmune diabetes of adults (LADA) is typically defined as a new diabetes diagnosis after 35 years of age, presenting with clinical features of type 2 diabetes, in whom a type 1 diabetes-associated islet autoantibody is detected. Identifying autoimmune diabetes is important since the prognosis and optimal therapy differ. However, the existing LADA definition identifies a group with clinical and genetic features intermediate between typical type 1 and type 2 diabetes. It is unclear whether this is due to 1) true autoimmune diabetes with a milder phenotype at older onset ages that initially appears similar to type 2 diabetes but later requires insulin, 2) a disease syndrome where the pathophysiologies of type 1 and type 2 diabetes are both present in each patient, or 3) a heterogeneous group resulting from difficulties in classification. Herein, we suggest that difficulties in classification are a major component resulting from defining LADA using a diagnostic test-islet autoantibody measurement-with imperfect specificity applied in low-prevalence populations. This yields a heterogeneous group of true positives (autoimmune type 1 diabetes) and false positives (nonautoimmune type 2 diabetes). For clinicians, this means that islet autoantibody testing should not be undertaken in patients who do not have clinical features suggestive of autoimmune diabetes: in an adult without clinical features of type 1 diabetes, it is likely that a single positive antibody will represent a false-positive result. This is in contrast to patients with features suggestive of type 1 diabetes, where false-positive results will be rare. For researchers, this means that current definitions of LADA are not appropriate for the study of autoimmune diabetes in later life. Approaches that increase test specificity, or prior likelihood of autoimmune diabetes, are needed to avoid inclusion of participants who have nonautoimmune (type 2) diabetes. Improved classification will allow improved assignment of prognosis and therapy as well as an improved cohort in which to analyze and better understand the detailed pathophysiological components acting at onset and during disease progression in late-onset autoimmune diabetes.
Collapse
Affiliation(s)
- Angus G Jones
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, U.K
- MacLeod Diabetes and Endocrine Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, U.K
| | - Timothy J McDonald
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, U.K
- Blood Sciences, Royal Devon and Exeter NHS Foundation Trust, Exeter, U.K
| | - Beverley M Shields
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, U.K
| | | | - Andrew T Hattersley
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, U.K
- MacLeod Diabetes and Endocrine Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, U.K
| |
Collapse
|
38
|
Jones AG, Fleming H, Griffith BA, Takahashi T, Lee MRF, Harris P. Data to identify key drivers of animal growth and carcass quality for temperate lowland sheep production systems. Data Brief 2021; 35:106977. [PMID: 33869691 PMCID: PMC8042253 DOI: 10.1016/j.dib.2021.106977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/24/2021] [Accepted: 03/15/2021] [Indexed: 11/25/2022] Open
Abstract
With the growing demand for animal-sourced foods and a serious concern over climate impacts associated with livestock farming, the sheep industry worldwide faces the formidable challenge of increasing the overall product supply while improving its resource use efficiency. As an evidence base for research to identify key drivers behind animal growth and carcass quality, longitudinal matched data of 741 ewes and 2978 lambs were collected at the North Wyke Farm Platform, a farm-scale grazing trial in Devon, UK, between 2011 and 2019. A subset of these data was subsequently analysed in a study to assess the feasibility of using a lamb's early-life liveweight as a predictor of carcass quality [1]. The data also have the potential to offer insight into key performance indicators (KPIs) for the sheep industry, or what variables farmers should measure and target to increase profitability.
Collapse
Affiliation(s)
- A G Jones
- Rothamsted Research, North Wyke, Okehampton, Devon EX20 2SB, UK.,University of Bristol, Bristol Veterinary School, Langford, Somerset BS40 5DU, UK
| | - H Fleming
- Rothamsted Research, North Wyke, Okehampton, Devon EX20 2SB, UK
| | - B A Griffith
- Rothamsted Research, North Wyke, Okehampton, Devon EX20 2SB, UK
| | - T Takahashi
- Rothamsted Research, North Wyke, Okehampton, Devon EX20 2SB, UK.,University of Bristol, Bristol Veterinary School, Langford, Somerset BS40 5DU, UK
| | - M R F Lee
- Harper Adams University, Newport, Shropshire TF10 8NB, UK
| | - P Harris
- Rothamsted Research, North Wyke, Okehampton, Devon EX20 2SB, UK
| |
Collapse
|
39
|
Bizzotto R, Jennison C, Jones AG, Kurbasic A, Tura A, Kennedy G, Bell JD, Thomas EL, Frost G, Eriksen R, Koivula RW, Brage S, Kaye J, Hattersley AT, Heggie A, McEvoy D, 't Hart LM, Beulens JW, Elders P, Musholt PB, Ridderstråle M, Hansen TH, Allin KH, Hansen T, Vestergaard H, Lundgaard AT, Thomsen HS, De Masi F, Tsirigos KD, Brunak S, Viñuela A, Mahajan A, McDonald TJ, Kokkola T, Forgie IM, Giordano GN, Pavo I, Ruetten H, Dermitzakis E, McCarthy MI, Pedersen O, Schwenk JM, Adamski J, Franks PW, Walker M, Pearson ER, Mari A. Processes Underlying Glycemic Deterioration in Type 2 Diabetes: An IMI DIRECT Study. Diabetes Care 2021; 44:511-518. [PMID: 33323478 DOI: 10.2337/dc20-1567] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/31/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We investigated the processes underlying glycemic deterioration in type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS A total of 732 recently diagnosed patients with T2D from the Innovative Medicines Initiative Diabetes Research on Patient Stratification (IMI DIRECT) study were extensively phenotyped over 3 years, including measures of insulin sensitivity (OGIS), β-cell glucose sensitivity (GS), and insulin clearance (CLIm) from mixed meal tests, liver enzymes, lipid profiles, and baseline regional fat from MRI. The associations between the longitudinal metabolic patterns and HbA1c deterioration, adjusted for changes in BMI and in diabetes medications, were assessed via stepwise multivariable linear and logistic regression. RESULTS Faster HbA1c progression was independently associated with faster deterioration of OGIS and GS and increasing CLIm; visceral or liver fat, HDL-cholesterol, and triglycerides had further independent, though weaker, roles (R 2 = 0.38). A subgroup of patients with a markedly higher progression rate (fast progressors) was clearly distinguishable considering these variables only (discrimination capacity from area under the receiver operating characteristic = 0.94). The proportion of fast progressors was reduced from 56% to 8-10% in subgroups in which only one trait among OGIS, GS, and CLIm was relatively stable (odds ratios 0.07-0.09). T2D polygenic risk score and baseline pancreatic fat, glucagon-like peptide 1, glucagon, diet, and physical activity did not show an independent role. CONCLUSIONS Deteriorating insulin sensitivity and β-cell function, increasing insulin clearance, high visceral or liver fat, and worsening of the lipid profile are the crucial factors mediating glycemic deterioration of patients with T2D in the initial phase of the disease. Stabilization of a single trait among insulin sensitivity, β-cell function, and insulin clearance may be relevant to prevent progression.
Collapse
Affiliation(s)
| | | | - Angus G Jones
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K.,Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, U.K
| | - Azra Kurbasic
- Genetic and Molecular Epidemiology Unit, Lund University Diabetes Centre, Department of Clinical Sciences, Clinical Research Centre, Lund University, Skåne University Hospital, Malmö, Malmö, Sweden
| | - Andrea Tura
- CNR Institute of Neuroscience, Padova, Italy
| | - Gwen Kennedy
- Immunoassay Biomarker Core Laboratory, School of Medicine, Ninewells Hospital, Dundee, U.K
| | - Jimmy D Bell
- School of Life Sciences, Research Centre for Optimal Health, University of Westminster, London, U.K
| | - E Louise Thomas
- School of Life Sciences, Research Centre for Optimal Health, University of Westminster, London, U.K
| | - Gary Frost
- Section for Nutrition Research, Faculty of Medicine, Hammersmith Campus, Imperial College London, London, U.K
| | - Rebeca Eriksen
- Section for Nutrition Research, Faculty of Medicine, Hammersmith Campus, Imperial College London, London, U.K
| | - Robert W Koivula
- Genetic and Molecular Epidemiology Unit, Lund University Diabetes Centre, Department of Clinical Sciences, Clinical Research Centre, Lund University, Skåne University Hospital, Malmö, Malmö, Sweden.,Radcliffe Department of Medicine, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, U.K
| | - Soren Brage
- MRC Epidemiology Unit, University of Cambridge, Cambridge, U.K
| | - Jane Kaye
- Faculty of Law, Centre for Health, Law and Emerging Technologies, University of Oxford, Oxford, U.K.,Melbourne Law School, Centre for Health, Law and Emerging Technologies, University of Melbourne, Carlton, Victoria, Australia
| | - Andrew T Hattersley
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K.,Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, U.K
| | - Alison Heggie
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, U.K
| | - Donna McEvoy
- Diabetes Research Network, Royal Victoria Infirmary, Newcastle upon Tyne, U.K
| | - Leen M 't Hart
- Department of Epidemiology and Data Science, Amsterdam UMC-Location VUmc, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands.,Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Biomedical Data Sciences, Molecular Epidemiology Section, Leiden University Medical Center, Leiden, the Netherlands
| | - Joline W Beulens
- Department of Epidemiology and Data Science, Amsterdam UMC-Location VUmc, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Petra Elders
- Department of General Practice, Amsterdam UMC-Location VUmc, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Petra B Musholt
- R&D Global Development, Translational Medicine & Clinical Pharmacology, Sanofi Deutschland GmbH, Frankfurt, Germany
| | - Martin Ridderstråle
- Clinical Pharmacology and Translational Medicine, Novo Nordisk A/S, Søborg, Denmark
| | - Tue H Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kristine H Allin
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Vestergaard
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Bornholms Hospital, Rønne, Denmark
| | - Agnete T Lundgaard
- Novo Nordisk Foundation Center for Protein Research, University of Copenhagen, Copenhagen, Denmark.,Department of Systems Biology, Center for Biological Sequence Analysis, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Henrik S Thomsen
- Faculty of Medical and Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Federico De Masi
- Department of Health Technology, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Konstantinos D Tsirigos
- Novo Nordisk Foundation Center for Protein Research, University of Copenhagen, Copenhagen, Denmark.,Department of Systems Biology, Center for Biological Sequence Analysis, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Søren Brunak
- Novo Nordisk Foundation Center for Protein Research, University of Copenhagen, Copenhagen, Denmark.,Department of Systems Biology, Center for Biological Sequence Analysis, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Ana Viñuela
- Department of Genetic Medicine and Development, University of Geneva Medical School, Geneva, Switzerland.,Faculty of Medical Sciences, Biosciences Institute, Newcastle University, Newcastle, U.K
| | - Anubha Mahajan
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, U.K
| | - Timothy J McDonald
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K.,Blood Sciences, Royal Devon and Exeter NHS Foundation Trust, Exeter, U.K
| | - Tarja Kokkola
- Department of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Ian M Forgie
- Population Health and Genomics, School of Medicine, University of Dundee, Dundee, U.K
| | - Giuseppe N Giordano
- Genetic and Molecular Epidemiology Unit, Lund University Diabetes Centre, Department of Clinical Sciences, Clinical Research Centre, Lund University, Skåne University Hospital, Malmö, Malmö, Sweden
| | - Imre Pavo
- Eli Lilly Regional Operations GmbH, Vienna, Austria
| | - Hartmut Ruetten
- R&D Global Development, Translational Medicine & Clinical Pharmacology, Sanofi Deutschland GmbH, Frankfurt, Germany
| | - Emmanouil Dermitzakis
- Department of Genetic Medicine and Development, University of Geneva Medical School, Geneva, Switzerland
| | - Mark I McCarthy
- Radcliffe Department of Medicine, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, U.K.,Wellcome Centre for Human Genetics, University of Oxford, Oxford, U.K.,Oxford NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, U.K
| | - Oluf Pedersen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jochen M Schwenk
- Affinity Proteomics, Science for Life Laboratory, School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH Royal Institute of Technology, Solna, Sweden
| | - Jerzy Adamski
- Research Unit of Molecular Endocrinology and Metabolism, Helmholtz Zentrum München, Neuherberg, Germany.,Lehrstuhl für Experimentelle Genetik, Technische Universität München, Freising-Weihenstephan, Germany.,Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Paul W Franks
- Genetic and Molecular Epidemiology Unit, Lund University Diabetes Centre, Department of Clinical Sciences, Clinical Research Centre, Lund University, Skåne University Hospital, Malmö, Malmö, Sweden
| | - Mark Walker
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle, U.K
| | - Ewan R Pearson
- Population Health and Genomics, School of Medicine, University of Dundee, Dundee, U.K
| | | | | |
Collapse
|
40
|
Deshmukh HA, Madsen AL, Viñuela A, Have CT, Grarup N, Tura A, Mahajan A, Heggie AJ, Koivula RW, De Masi F, Tsirigos KK, Linneberg A, Drivsholm T, Pedersen O, Sørensen TIA, Astrup A, Gjesing AAP, Pavo I, Wood AR, Ruetten H, Jones AG, Koopman ADM, Cederberg H, Rutters F, Ridderstrale M, Laakso M, McCarthy MI, Frayling TM, Ferrannini E, Franks PW, Pearson ER, Mari A, Hansen T, Walker M. Genome-Wide Association Analysis of Pancreatic Beta-Cell Glucose Sensitivity. J Clin Endocrinol Metab 2021; 106:80-90. [PMID: 32944759 PMCID: PMC7765651 DOI: 10.1210/clinem/dgaa653] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 09/14/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Pancreatic beta-cell glucose sensitivity is the slope of the plasma glucose-insulin secretion relationship and is a key predictor of deteriorating glucose tolerance and development of type 2 diabetes. However, there are no large-scale studies looking at the genetic determinants of beta-cell glucose sensitivity. OBJECTIVE To understand the genetic determinants of pancreatic beta-cell glucose sensitivity using genome-wide meta-analysis and candidate gene studies. DESIGN We performed a genome-wide meta-analysis for beta-cell glucose sensitivity in subjects with type 2 diabetes and nondiabetic subjects from 6 independent cohorts (n = 5706). Beta-cell glucose sensitivity was calculated from mixed meal and oral glucose tolerance tests, and its associations between known glycemia-related single nucleotide polymorphisms (SNPs) and genome-wide association study (GWAS) SNPs were estimated using linear regression models. RESULTS Beta-cell glucose sensitivity was moderately heritable (h2 ranged from 34% to 55%) using SNP and family-based analyses. GWAS meta-analysis identified multiple correlated SNPs in the CDKAL1 gene and GIPR-QPCTL gene loci that reached genome-wide significance, with SNP rs2238691 in GIPR-QPCTL (P value = 2.64 × 10-9) and rs9368219 in the CDKAL1 (P value = 3.15 × 10-9) showing the strongest association with beta-cell glucose sensitivity. These loci surpassed genome-wide significance when the GWAS meta-analysis was repeated after exclusion of the diabetic subjects. After correction for multiple testing, glycemia-associated SNPs in or near the HHEX and IGF2B2 loci were also associated with beta-cell glucose sensitivity. CONCLUSION We show that, variation at the GIPR-QPCTL and CDKAL1 loci are key determinants of pancreatic beta-cell glucose sensitivity.
Collapse
Affiliation(s)
- Harshal A Deshmukh
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Anne Lundager Madsen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ana Viñuela
- Department of Genetic Medicine and Development, University of Geneva Medical School, Geneva
| | - Christian Theil Have
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Niels Grarup
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrea Tura
- Institute of Neuroscience, National Research Council, Corso Stati Uniti 4, Padua, Italy
| | - Anubha Mahajan
- Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Alison J Heggie
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Robert W Koivula
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Department of Clinical Sciences, Genetic and Molecular Epidemiology Unit, Skåne University Hospital Malmö, Lund University, 205 02 Malmö, Sweden
| | - Federico De Masi
- Integrative Systems Biology Group, Department of Health Technology, Technical University of Denmark (DTU), Kemitorvet, Building 208, 2800 Kgs. Lyngby, Denmark
| | - Konstantinos K Tsirigos
- Integrative Systems Biology Group, Department of Health Technology, Technical University of Denmark (DTU), Kemitorvet, Building 208, 2800 Kgs. Lyngby, Denmark
| | - Allan Linneberg
- Center for Clinical Research and Disease Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Drivsholm
- Center for Clinical Research and Disease Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region, Copenhagen, Denmark
- Section of General Practice, Institute of Public Health, Faculty of Health Sciences, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, Denmark
| | - Oluf Pedersen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thorkild I A Sørensen
- Novo Nordisk Foundation Centre for Basic Metabolic Research (Section of Metabolic Genetics), Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Public Health (Section of Epidemiology), Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Arne Astrup
- Department of Nutrition, Exercise and Sports (NEXS), Faculty of Science, University of Copenhagen, Copenhagen, Denmark
| | - Anette A P Gjesing
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Imre Pavo
- Eli Lilly Regional Operations Ges.m.b.H., Koelblgasse 8–10, Vienna, Austria
| | - Andrew R Wood
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Hartmut Ruetten
- Diabetes Division, Sanofi-Aventis Deutschland GmbH, Frankfurt, 65926 Frankfurt am Main, Germany
| | - Angus G Jones
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, UK
| | - Anitra D M Koopman
- Department of Epidemiology and Biostatistics, VUMC, de Boelelaan 1089a, HV, Amsterdam, the Netherlands
| | - Henna Cederberg
- Department of Endocrinology, Abdominal Centre, Helsinki University Hospital, Helsinki, Finland
| | - Femke Rutters
- Department of Epidemiology and Biostatistics, VUMC, de Boelelaan 1089a, HV, Amsterdam, the Netherlands
| | - Martin Ridderstrale
- Department of Clinical Sciences, Diabetes & Endocrinology Unit, Lund University, Skåne University Hospital Malmö, CRC, 91-12, 205 02, Malmö, Sweden
| | - Markku Laakso
- Institute of Clinical Medicine, Internal Medicine, University of Eastern Finland, Kuopio, Finland
| | - Mark I McCarthy
- Oxford Centre for Diabetes Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Tim M Frayling
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, UK
| | | | - Paul W Franks
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Department of Clinical Sciences, Genetic and Molecular Epidemiology Unit, Skåne University Hospital Malmö, Lund University, 205 02 Malmö, Sweden
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, Massachusetts
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Ewan R Pearson
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Andrea Mari
- Institute of Neuroscience, National Research Council, Corso Stati Uniti 4, Padua, Italy
- Correspondence and Reprint Requests: Prof Mark Walker, Translational and Clinical Research Institute (Diabetes), The Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH. E-mail: ; Prof Torben Hansen, Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Maersk Tower, Blegdamsvej 3B, 07-8-26, DK-2200, Copenhagen N, Denmark. E-mail: ; Dr Andrea Mari, Institute of Neuroscience, National Research Council, Corso Stati Uniti 4, 35127 Padova, Italy. E-mail:
| | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Correspondence and Reprint Requests: Prof Mark Walker, Translational and Clinical Research Institute (Diabetes), The Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH. E-mail: ; Prof Torben Hansen, Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Maersk Tower, Blegdamsvej 3B, 07-8-26, DK-2200, Copenhagen N, Denmark. E-mail: ; Dr Andrea Mari, Institute of Neuroscience, National Research Council, Corso Stati Uniti 4, 35127 Padova, Italy. E-mail:
| | - Mark Walker
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Correspondence and Reprint Requests: Prof Mark Walker, Translational and Clinical Research Institute (Diabetes), The Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH. E-mail: ; Prof Torben Hansen, Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Maersk Tower, Blegdamsvej 3B, 07-8-26, DK-2200, Copenhagen N, Denmark. E-mail: ; Dr Andrea Mari, Institute of Neuroscience, National Research Council, Corso Stati Uniti 4, 35127 Padova, Italy. E-mail:
| |
Collapse
|
41
|
Jones AG, Takahashi T, Fleming H, Griffith BA, Harris P, Lee MRF. Using a lamb's early-life liveweight as a predictor of carcass quality. Animal 2020; 15:100018. [PMID: 33487555 PMCID: PMC8169456 DOI: 10.1016/j.animal.2020.100018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 07/20/2020] [Accepted: 07/28/2020] [Indexed: 11/29/2022] Open
Abstract
The commercial value of lamb carcasses is primarily determined by their weight and quality, with the latter commonly quantified according to muscle coverage and fat depth. The ability to predict these quality scores early in the season could be of substantial value to sheep producers, as this would enable tailored flock management strategies for different groups of animals. Existing methods of carcass quality prediction, however, require either expensive equipment or information immediately before slaughter, leaving them unsuitable as a decision support tool for small to medium-scale enterprises. Using seven-year high-resolution data from the North Wyke Farm Platform, a system-scale grazing trial in Devon, UK, this paper investigates the feasibility of using a lamb's early-life liveweight to predict the carcass quality realised when the animal reaches the target weight. The results of multinomial regression models showed that lambs which were heavier at weaning, at 13 weeks of age, were significantly more likely to have leaner and more muscular carcasses. An economic analysis confirmed that these animals produced significantly more valuable carcasses at slaughter, even after accounting for seasonal variation in lamb price that often favours early finishers. As the majority of heavier-weaned lambs leave the flock before lighter-weaned lambs, an increase in the average weaning weight could also lead to greater pasture availability for ewes in the latter stage of the current season, and thus an enhanced ewe condition and fertility for the next season. All information combined, therefore, a stronger focus on ewes' nutrition before and during lactation was identified as a key to increase system-wide profitability.
Collapse
Affiliation(s)
- A G Jones
- Rothamsted Research, North Wyke, Okehampton, Devon, EX20 2SB, UK; University of Bristol, Bristol Veterinary School, Langford, Somerset, BS40 5DU, UK
| | - T Takahashi
- Rothamsted Research, North Wyke, Okehampton, Devon, EX20 2SB, UK; University of Bristol, Bristol Veterinary School, Langford, Somerset, BS40 5DU, UK.
| | - H Fleming
- Rothamsted Research, North Wyke, Okehampton, Devon, EX20 2SB, UK
| | - B A Griffith
- Rothamsted Research, North Wyke, Okehampton, Devon, EX20 2SB, UK
| | - P Harris
- Rothamsted Research, North Wyke, Okehampton, Devon, EX20 2SB, UK
| | - M R F Lee
- Rothamsted Research, North Wyke, Okehampton, Devon, EX20 2SB, UK; University of Bristol, Bristol Veterinary School, Langford, Somerset, BS40 5DU, UK
| |
Collapse
|
42
|
Carr ALJ, Perry DJ, Lynam AL, Chamala S, Flaxman CS, Sharp SA, Ferrat LA, Jones AG, Beery ML, Jacobsen LM, Wasserfall CH, Campbell-Thompson ML, Kusmartseva I, Posgai A, Schatz DA, Atkinson MA, Brusko TM, Richardson SJ, Shields BM, Oram RA. Histological validation of a type 1 diabetes clinical diagnostic model for classification of diabetes. Diabet Med 2020; 37:2160-2168. [PMID: 32634859 PMCID: PMC8086995 DOI: 10.1111/dme.14361] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/31/2020] [Accepted: 07/01/2020] [Indexed: 12/21/2022]
Abstract
AIMS Misclassification of diabetes is common due to an overlap in the clinical features of type 1 and type 2 diabetes. Combined diagnostic models incorporating clinical and biomarker information have recently been developed that can aid classification, but they have not been validated using pancreatic pathology. We evaluated a clinical diagnostic model against histologically defined type 1 diabetes. METHODS We classified cases from the Network for Pancreatic Organ donors with Diabetes (nPOD) biobank as type 1 (n = 111) or non-type 1 (n = 42) diabetes using histopathology. Type 1 diabetes was defined by lobular loss of insulin-containing islets along with multiple insulin-deficient islets. We assessed the discriminative performance of previously described type 1 diabetes diagnostic models, based on clinical features (age at diagnosis, BMI) and biomarker data [autoantibodies, type 1 diabetes genetic risk score (T1D-GRS)], and singular features for identifying type 1 diabetes by the area under the curve of the receiver operator characteristic (AUC-ROC). RESULTS Diagnostic models validated well against histologically defined type 1 diabetes. The model combining clinical features, islet autoantibodies and T1D-GRS was strongly discriminative of type 1 diabetes, and performed better than clinical features alone (AUC-ROC 0.97 vs. 0.95; P = 0.03). Histological classification of type 1 diabetes was concordant with serum C-peptide [median < 17 pmol/l (limit of detection) vs. 1037 pmol/l in non-type 1 diabetes; P < 0.0001]. CONCLUSIONS Our study provides robust histological evidence that a clinical diagnostic model, combining clinical features and biomarkers, could improve diabetes classification. Our study also provides reassurance that a C-peptide-based definition of type 1 diabetes is an appropriate surrogate outcome that can be used in large clinical studies where histological definition is impossible. Parts of this study were presented in abstract form at the Network for Pancreatic Organ Donors Conference, Florida, USA, 19-22 February 2019 and Diabetes UK Professional Conference, Liverpool, UK, 6-8 March 2019.
Collapse
Affiliation(s)
- A L J Carr
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - D J Perry
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida Diabetes Institute, Gainesville, FL, USA
| | - A L Lynam
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - S Chamala
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida Diabetes Institute, Gainesville, FL, USA
| | - C S Flaxman
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - S A Sharp
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - L A Ferrat
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - A G Jones
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - M L Beery
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida Diabetes Institute, Gainesville, FL, USA
| | - L M Jacobsen
- Department of Pediatrics, College of Medicine, University of Florida Diabetes Institute, Gainesville, FL, USA
| | - C H Wasserfall
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida Diabetes Institute, Gainesville, FL, USA
| | - M L Campbell-Thompson
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida Diabetes Institute, Gainesville, FL, USA
| | - I Kusmartseva
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida Diabetes Institute, Gainesville, FL, USA
| | - A Posgai
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida Diabetes Institute, Gainesville, FL, USA
| | - D A Schatz
- Department of Pediatrics, College of Medicine, University of Florida Diabetes Institute, Gainesville, FL, USA
| | - M A Atkinson
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida Diabetes Institute, Gainesville, FL, USA
- Department of Pediatrics, College of Medicine, University of Florida Diabetes Institute, Gainesville, FL, USA
| | - T M Brusko
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida Diabetes Institute, Gainesville, FL, USA
| | - S J Richardson
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - B M Shields
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - R A Oram
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| |
Collapse
|
43
|
Milln JM, Walugembe E, Ssentayi S, Nkabura H, Jones AG, Nyirenda MJ. Comparison of oral glucose tolerance test and ambulatory glycaemic profiles in pregnant women in Uganda with gestational diabetes using the FreeStyle Libre flash glucose monitoring system. BMC Pregnancy Childbirth 2020; 20:635. [PMID: 33076849 PMCID: PMC7574406 DOI: 10.1186/s12884-020-03325-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 10/09/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The diagnosis of hyperglycaemia in sub-Saharan Africa (SSA) is challenging. Blood glucose levels obtained during oral glucose tolerance test (OGTT) may not reflect home glycaemic profiles. We compare OGTT results with home glycaemic profiles obtained using the FreeStyle Libre continuous glucose monitoring device (FSL-CGM). METHODS Twenty-eight women (20 with gestational diabetes [GDM], 8 controls) were recruited following OGTT between 24 and 28 weeks of gestation. All women wore the FSL-CGM device for 48-96 h at home in early third trimester, and recorded a meal diary. OGTT was repeated on the final day of FSL-CGM recording. OGTT results were compared with ambulatory glycaemic variables, and repeat OGTT was undertaken whilst wearing FSL-CGM to determine accuracy of the device. RESULTS FSL-CGM results were available for 27/28 women with mean data capture 92.8%. There were significant differences in the ambulatory fasting, post-prandial peaks, and mean glucose between controls in whom both primary and secondary OGTT was normal (n = 6) and those with two abnormal OGTTs or "true" GDM (n = 7). There was no difference in ambulatory mean glucose between these controls and the 13 women who had an abnormal primary OGTT and normal repeat OGTT. These participants had significantly lower body mass index (BMI) than the true GDM group (29.0 Vs 36.3 kg/m2, p-value 0.014). Paired OGTT/FSL-CGM readings revealed a Mean Absolute difference (MAD) -0.58 mmol/L and Mean Absolute Relative Difference (MARD) -11.9%. Bland-Altman plot suggests FSL-CGM underestimated blood glucose by approximately 0.78 mmol/L. CONCLUSION Diagnosis of GDM on a single OGTT identifies a proportion of women who do not have a significantly higher home glucose levels than controls. This raises questions about factors which may affect the reproducibility of OGTT in this population, including food insecurity and atypical phenotypes of diabetes. More investigation is needed to understand the suitability of the OGTT as a diagnostic test in sub-Saharan Africa.
Collapse
Affiliation(s)
- J M Milln
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda.
- Department of Endocrinology and Diabetes, Queen Mary University of London, Mile End Road, London, UK.
| | - E Walugembe
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda
| | - S Ssentayi
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda
| | - H Nkabura
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda
| | - A G Jones
- National Institute for Health and Research (NIHR), Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, UK
| | - M J Nyirenda
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Plot 51-59, Nakiwogo Road, P. O. BOX 49, Entebbe, Uganda
- Department of Non-Communicable Diseases Epidemiology, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| |
Collapse
|
44
|
Jones AG, Shields BM, Dennis JM, Hattersley AT, McDonald TJ, Thomas NJ. The challenge of diagnosing type 1 diabetes in older adults. Diabet Med 2020; 37:1781-1782. [PMID: 32043618 DOI: 10.1111/dme.14272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2020] [Indexed: 11/30/2022]
Affiliation(s)
- A G Jones
- Institute of Clinical and Biological Sciences, University of Exeter Medical School, Exeter, UK
- Diabetes and Endocrinology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - B M Shields
- Institute of Clinical and Biological Sciences, University of Exeter Medical School, Exeter, UK
| | - J M Dennis
- Institute of Clinical and Biological Sciences, University of Exeter Medical School, Exeter, UK
| | - A T Hattersley
- Institute of Clinical and Biological Sciences, University of Exeter Medical School, Exeter, UK
- Diabetes and Endocrinology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - T J McDonald
- Institute of Clinical and Biological Sciences, University of Exeter Medical School, Exeter, UK
- Blood Sciences, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - N J Thomas
- Institute of Clinical and Biological Sciences, University of Exeter Medical School, Exeter, UK
- Diabetes and Endocrinology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| |
Collapse
|
45
|
Agbaje OF, Coleman RL, Hattersley AT, Jones AG, Pearson ER, Shields BM, Holman RR. Predicting post one-year durability of glucose-lowering monotherapies in patients with newly-diagnosed type 2 diabetes mellitus - A MASTERMIND precision medicine approach (UKPDS 87). Diabetes Res Clin Pract 2020; 166:108333. [PMID: 32702468 DOI: 10.1016/j.diabres.2020.108333] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/27/2020] [Accepted: 07/13/2020] [Indexed: 11/16/2022]
Abstract
AIMS Predicting likely durability of glucose-lowering therapies for people with type 2 diabetes (T2D) could help inform individualised therapeutic choices. METHODS We used data from UKPDS patients with newly-diagnosed T2D randomised to first-line glucose-lowering monotherapy with chlorpropamide-glibenclamide-basal insulin or metformin. In 2339 participants who achieved one-year HbA1c values <7.5% (<59 mmol/mol)-we assessed relationships between one-year characteristics and time to monotherapy-failure (HbA1c ≥ 7.5% or requiring second-line therapy). Model validation was performed using bootstrap sampling. RESULTS Follow-up was median (IQR) 11.0 (8.0-14.0) years. Monotherapy-failure occurred in 72%-82%-75% and 79% for those randomised to chlorpropamide-glibenclamide-basal insulin or metformin respectively-after median 4.5 (3.0-6.6)-3.7 (2.6-5.6)-4.2 (2.7-6.5) and 3.8 (2.6- 5.2) years. Time-to-monotherapy-failure was predicted primarily by HbA1c and BMI values-with other risk factors varying by type of monotherapy-with predictions to within ±2.5 years for 55%-60%-56% and 57% of the chlorpropamide-glibenclamide-basal insulin and metformin monotherapy cohorts respectively. CONCLUSIONS Post one-year glycaemic durability can be predicted robustly in individuals with newly-diagnosed T2D who achieve HbA1c values < 7.5% one year after commencing traditional monotherapies. Such information could be used to help guide glycaemic management for individual patients.
Collapse
Affiliation(s)
| | | | - Andrew T Hattersley
- Institute of Biomedical & Clinical Science-University of Exeter Medical School, Exeter, UK
| | - Angus G Jones
- Institute of Biomedical & Clinical Science-University of Exeter Medical School, Exeter, UK
| | - Ewan R Pearson
- Medical Research Institute, University of Dundee, Dundee, UK
| | - Beverley M Shields
- Institute of Biomedical & Clinical Science-University of Exeter Medical School, Exeter, UK
| | - Rury R Holman
- Diabetes Trials Unit, University of Oxford, Oxford, UK
| |
Collapse
|
46
|
Lynam AL, Dennis JM, Owen KR, Oram RA, Jones AG, Shields BM, Ferrat LA. Logistic regression has similar performance to optimised machine learning algorithms in a clinical setting: application to the discrimination between type 1 and type 2 diabetes in young adults. Diagn Progn Res 2020; 4:6. [PMID: 32607451 PMCID: PMC7318367 DOI: 10.1186/s41512-020-00075-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 03/26/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND There is much interest in the use of prognostic and diagnostic prediction models in all areas of clinical medicine. The use of machine learning to improve prognostic and diagnostic accuracy in this area has been increasing at the expense of classic statistical models. Previous studies have compared performance between these two approaches but their findings are inconsistent and many have limitations. We aimed to compare the discrimination and calibration of seven models built using logistic regression and optimised machine learning algorithms in a clinical setting, where the number of potential predictors is often limited, and externally validate the models. METHODS We trained models using logistic regression and six commonly used machine learning algorithms to predict if a patient diagnosed with diabetes has type 1 diabetes (versus type 2 diabetes). We used seven predictor variables (age, BMI, GADA islet-autoantibodies, sex, total cholesterol, HDL cholesterol and triglyceride) using a UK cohort of adult participants (aged 18-50 years) with clinically diagnosed diabetes recruited from primary and secondary care (n = 960, 14% with type 1 diabetes). Discrimination performance (ROC AUC), calibration and decision curve analysis of each approach was compared in a separate external validation dataset (n = 504, 21% with type 1 diabetes). RESULTS Average performance obtained in internal validation was similar in all models (ROC AUC ≥ 0.94). In external validation, there were very modest reductions in discrimination with AUC ROC remaining ≥ 0.93 for all methods. Logistic regression had the numerically highest value in external validation (ROC AUC 0.95). Logistic regression had good performance in terms of calibration and decision curve analysis. Neural network and gradient boosting machine had the best calibration performance. Both logistic regression and support vector machine had good decision curve analysis for clinical useful threshold probabilities. CONCLUSION Logistic regression performed as well as optimised machine algorithms to classify patients with type 1 and type 2 diabetes. This study highlights the utility of comparing traditional regression modelling to machine learning, particularly when using a small number of well understood, strong predictor variables.
Collapse
Affiliation(s)
- Anita L. Lynam
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, EX2 5DW UK
| | - John M. Dennis
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, EX2 5DW UK
| | - Katharine R. Owen
- Oxford Centre for Diabetes Endocrinology and Metabolism, University of Oxford, Churchill Hospital, Oxford, OX3 7LE UK
- Oxford NIHR Biomedical Research Centre, Oxford University Hospitals Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Richard A. Oram
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, EX2 5DW UK
| | - Angus G. Jones
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, EX2 5DW UK
| | - Beverley M. Shields
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, EX2 5DW UK
| | - Lauric A. Ferrat
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, EX2 5DW UK
| |
Collapse
|
47
|
McGovern AP, Hogg M, Shields BM, Sattar NA, Holman RR, Pearson ER, Hattersley AT, Jones AG, Dennis JM. Risk factors for genital infections in people initiating SGLT2 inhibitors and their impact on discontinuation. BMJ Open Diabetes Res Care 2020; 8:e001238. [PMID: 32448787 PMCID: PMC7252998 DOI: 10.1136/bmjdrc-2020-001238] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/16/2020] [Accepted: 04/23/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION To identify risk factors, absolute risk, and impact on treatment discontinuation of genital infections with sodium-glucose co-transporter-2 inhibitors (SGLT2i). RESEARCH DESIGN AND METHODS We assessed the relationship between baseline characteristics and genital infection in 21 004 people with type 2 diabetes initiating SGLT2i and 55 471 controls initiating dipeptidyl peptidase-4 inhibitors (DPP4i) in a UK primary care database. We assessed absolute risk of infection in those with key risk factors and the association between early genital infection and treatment discontinuation. RESULTS Genital infection was substantially more common in those treated with SGLT2i (8.1% within 1 year) than DPP4i (1.8%). Key predictors of infection with SGLT2i were female sex (HR 3.64; 95% CI 3.23 to 4.11) and history of genital infection; <1 year before initiation (HR 4.38; 3.73 to 5.13), 1-5 years (HR 3.04; 2.64 to 3.51), and >5 years (HR 1.79; 1.55 to 2.07). Baseline HbA1c was not associated with infection risk for SGLT2i, in contrast to DPP4i where risk increased with higher HbA1c. One-year absolute risk of genital infection with SGLT2i was highest for those with a history of prior infection (females 23.7%, males 12.1%), compared with those without (females 10.8%, males 2.7%). Early genital infection was associated with a similar discontinuation risk for SGLT2i (HR 1.48; 1.21-1.80) and DPP4i (HR 1.58; 1.21-2.07). CONCLUSIONS Female sex and history of prior infection are simple features that can identify subgroups at greatly increased risk of genital infections with SGLT2i therapy. These data can be used to risk-stratify patients. High HbA1c is not a risk factor for genital infections with SGLT2i.
Collapse
Affiliation(s)
- Andrew P McGovern
- University of Exeter Medical School, Institute of Biomedical and Clinical Science, University of Exeter, Exeter, Devon, UK
| | - Michael Hogg
- University of Exeter Medical School, Institute of Biomedical and Clinical Science, University of Exeter, Exeter, Devon, UK
| | - Beverley M Shields
- University of Exeter Medical School, Institute of Biomedical and Clinical Science, University of Exeter, Exeter, Devon, UK
| | - Naveed A Sattar
- Institute of Cardiovascular Sciences, University of Glasgow, Glasgow, UK
| | - Rury R Holman
- Radcliffe Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Ewan R Pearson
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Andrew T Hattersley
- University of Exeter Medical School, Institute of Biomedical and Clinical Science, University of Exeter, Exeter, Devon, UK
| | - Angus G Jones
- University of Exeter Medical School, Institute of Biomedical and Clinical Science, University of Exeter, Exeter, Devon, UK
| | - John M Dennis
- University of Exeter Medical School, Institute of Biomedical and Clinical Science, University of Exeter, Exeter, Devon, UK
| |
Collapse
|
48
|
Dennis JM, Shields BM, Henley WE, Jones AG, Hattersley AT. Clusters provide a better holistic view of type 2 diabetes than simple clinical features - Authors' reply. Lancet Diabetes Endocrinol 2019; 7:669. [PMID: 31439274 DOI: 10.1016/s2213-8587(19)30250-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 06/24/2019] [Indexed: 11/29/2022]
Affiliation(s)
- John M Dennis
- Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, University of Exeter Medical School, Exeter, UK
| | - Beverley M Shields
- Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, University of Exeter Medical School, Exeter, UK
| | - William E Henley
- Health Statistics Group, Institute of Health Research, Royal Devon and Exeter Hospital, University of Exeter Medical School, Exeter, UK
| | - Angus G Jones
- Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, University of Exeter Medical School, Exeter, UK
| | - Andrew T Hattersley
- Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, University of Exeter Medical School, Exeter, UK.
| |
Collapse
|
49
|
Dennis JM, Henley WE, McGovern AP, Farmer AJ, Sattar N, Holman RR, Pearson ER, Hattersley AT, Shields BM, Jones AG. Time trends in prescribing of type 2 diabetes drugs, glycaemic response and risk factors: A retrospective analysis of primary care data, 2010-2017. Diabetes Obes Metab 2019; 21:1576-1584. [PMID: 30828962 PMCID: PMC6618851 DOI: 10.1111/dom.13687] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/13/2019] [Accepted: 02/28/2019] [Indexed: 12/25/2022]
Abstract
AIM To describe population-level time trends in prescribing patterns of type 2 diabetes therapy, and in short-term clinical outcomes (glycated haemoglobin [HbA1c], weight, blood pressure, hypoglycaemia and treatment discontinuation) after initiating new therapy. MATERIALS AND METHODS We studied 81 532 people with type 2 diabetes initiating a first- to fourth-line drug in primary care between 2010 and 2017 inclusive in United Kingdom electronic health records (Clinical Practice Research Datalink). Trends in new prescriptions and subsequent 6- and 12-month adjusted changes in glycaemic response (reduction in HbA1c), weight, blood pressure and rates of hypoglycaemia and treatment discontinuation were examined. RESULTS Use of dipeptidyl peptidase-4 inhibitors as second-line therapy near doubled (41% of new prescriptions in 2017 vs. 22% in 2010), replacing sulphonylureas as the most common second-line drug (29% in 2017 vs. 53% in 2010). Sodium-glucose co-transporter-2 inhibitors, introduced in 2013, comprised 17% of new first- to fourth-line prescriptions by 2017. First-line use of metformin remained stable (91% of new prescriptions in 2017 vs. 91% in 2010). Over the study period there was little change in average glycaemic response and in the proportion of people discontinuing treatment. There was a modest reduction in weight after initiating second- and third-line therapy (improvement in weight change 2017 vs. 2010 for second-line therapy: -1.5 kg, 95% confidence interval [CI] -1.9, -1.1; P < 0.001), and a slight reduction in systolic blood pressure after initiating first-, second- and third-line therapy (improvement in systolic blood pressure change 2017 vs. 2010 range: -1.7 to -2.1 mmHg; all P < 0.001). Hypoglycaemia rates decreased over time with second-line therapy (incidence rate ratio 0.94 per year, 95% CI 0.88, 1.00; P = 0.04), mirroring the decline in use of sulphonylureas. CONCLUSIONS Recent changes in prescribing of therapy for people with type 2 diabetes have not led to a change in glycaemic response and have resulted in modest improvements in other population-level short-term clinical outcomes.
Collapse
Affiliation(s)
- John M. Dennis
- Health Statistics GroupInstitute of Health Research, University of Exeter Medical SchoolExeterUK
| | - William E. Henley
- Health Statistics GroupInstitute of Health Research, University of Exeter Medical SchoolExeterUK
| | - Andrew P. McGovern
- Institute of Biomedical and Clinical ScienceRoyal Devon and Exeter HospitalExeterUK
| | - Andrew J. Farmer
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical SciencesUniversity of GlasgowGlasgowUK
| | - Rury R. Holman
- Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and MetabolismUniversity of OxfordOxfordUK
| | - Ewan R. Pearson
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical SchoolUniversity of DundeeDundeeUK
| | - Andrew T. Hattersley
- Institute of Biomedical and Clinical ScienceRoyal Devon and Exeter HospitalExeterUK
| | - Beverley M. Shields
- Institute of Biomedical and Clinical ScienceRoyal Devon and Exeter HospitalExeterUK
| | - Angus G. Jones
- Institute of Biomedical and Clinical ScienceRoyal Devon and Exeter HospitalExeterUK
| | | |
Collapse
|
50
|
Thomas NJ, Lynam AL, Hill AV, Weedon MN, Shields BM, Oram RA, McDonald TJ, Hattersley AT, Jones AG. Type 1 diabetes defined by severe insulin deficiency occurs after 30 years of age and is commonly treated as type 2 diabetes. Diabetologia 2019; 62:1167-1172. [PMID: 30969375 PMCID: PMC6559997 DOI: 10.1007/s00125-019-4863-8] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/22/2019] [Indexed: 01/08/2023]
Abstract
AIMS/HYPOTHESIS Late-onset type 1 diabetes can be difficult to identify. Measurement of endogenous insulin secretion using C-peptide provides a gold standard classification of diabetes type in longstanding diabetes that closely relates to treatment requirements. We aimed to determine the prevalence and characteristics of type 1 diabetes defined by severe endogenous insulin deficiency after age 30 and assess whether these individuals are identified and managed as having type 1 diabetes in clinical practice. METHODS We assessed the characteristics of type 1 diabetes defined by rapid insulin requirement (within 3 years of diagnosis) and severe endogenous insulin deficiency (non-fasting C-peptide <200 pmol/l) in 583 participants with insulin-treated diabetes, diagnosed after age 30, from the Diabetes Alliance for Research in England (DARE) population cohort. We compared characteristics with participants with retained endogenous insulin secretion (>600 pmol/l) and 220 participants with severe insulin deficiency who were diagnosed under age 30. RESULTS Twenty-one per cent of participants with insulin-treated diabetes who were diagnosed after age 30 met the study criteria for type 1 diabetes. Of these participants, 38% did not receive insulin at diagnosis, of whom 47% self-reported type 2 diabetes. Rapid insulin requirement was highly predictive of severe endogenous insulin deficiency: 85% required insulin within 1 year of diagnosis, and 47% of all those initially treated without insulin who progressed to insulin treatment within 3 years of diagnosis had severe endogenous insulin deficiency. Participants with late-onset type 1 diabetes defined by development of severe insulin deficiency had similar clinical characteristics to those with young-onset type 1 diabetes. However, those with later onset type 1 diabetes had a modestly lower type 1 diabetes genetic risk score (0.268 vs 0.279; p < 0.001 [expected type 2 diabetes population median, 0.231]), a higher islet autoantibody prevalence (GAD-, islet antigen 2 [IA2]- or zinc transporter protein 8 [ZnT8]-positive) of 78% at 13 years vs 62% at 26 years of diabetes duration; (p = 0.02), and were less likely to identify as having type 1 diabetes (79% vs 100%; p < 0.001) vs those with young-onset disease. CONCLUSIONS/INTERPRETATION Type 1 diabetes diagnosed over 30 years of age, defined by severe insulin deficiency, has similar clinical and biological characteristics to that occurring at younger ages, but is frequently not identified. Clinicians should be aware that patients progressing to insulin within 3 years of diagnosis have a high likelihood of type 1 diabetes, regardless of initial diagnosis.
Collapse
Affiliation(s)
- Nicholas J Thomas
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Barrack Road, Exeter, EX25DW, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Anita L Lynam
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Barrack Road, Exeter, EX25DW, UK
| | - Anita V Hill
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Barrack Road, Exeter, EX25DW, UK
| | - Michael N Weedon
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Barrack Road, Exeter, EX25DW, UK
| | - Beverley M Shields
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Barrack Road, Exeter, EX25DW, UK
| | - Richard A Oram
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Barrack Road, Exeter, EX25DW, UK
- Renal Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Timothy J McDonald
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Barrack Road, Exeter, EX25DW, UK
- Academic Department of Blood Sciences, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Andrew T Hattersley
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Barrack Road, Exeter, EX25DW, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Angus G Jones
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Barrack Road, Exeter, EX25DW, UK.
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
| |
Collapse
|