GWAS meta-analysis of kidney function traits in Japanese populations

BACKGROUND

Genetic epidemiological evidence for the kidney function traits in East Asian population including Japanese remain still relatively unclarified. Especially, the number of GWASs for kidney traits reported still remains limited, and the sample size of each independent study is relatively small. Given the genetic variability between ancestries/ethnicities, implementation of GWAS with sufficiently large sample sizes in specific population of Japanese is considered meaningful.

METHODS

We conducted the GWAS meta-analyses of kidney traits by leveraging the GWAS summary data of the representative large genome cohort studies with about 200,000 Japanese participants (n = 202,406 for estimated glomerular filtration rate [eGFR] and n = 200,845 for serum creatinine [SCr]).

RESULTS

In the present GWAS meta-analysis, we identified 110 loci with 169 variants significantly associated with eGFR (on chromosomes 1-13 and 15-22; p < 5×10-8), whereas we also identified 112 loci with 176 variants significantly associated with SCr (on chromosomes 1-22; p < 5×10-8), of which one locus (more than 1Mb distant from known loci) with one variant (CD36 rs146148222 on chromosome 7) for SCr was considered as the truly novel finding.

CONCLUSIONS

The present GWAS meta-analysis of largest genome cohort studies in Japanese provided some original genomic loci associated with kidney function in Japanese, which may contribute to the possible development of personalized prevention of kidney diseases based on genomic information in the near future.

Development and Validation of Prediction Models for the 5-year Risk of Type 2 Diabetes in a Japanese Population: Japan Public Health Center-based Prospective (JPHC) Diabetes Study

BACKGROUND

This study aimed to develop models to predict the 5-year incidence of type 2 diabetes mellitus (T2DM) in a Japanese population and validate them externally in an independent Japanese population.

METHODS

Data from 10,986 participants (aged 46-75 years) in the development cohort of the Japan Public Health Center-based Prospective Diabetes Study and 11,345 participants (aged 46-75 years) in the validation cohort of the Japan Epidemiology Collaboration on Occupational Health Study were used to develop and validate the risk scores in logistic regression models.

RESULTS

We considered non-invasive (sex, body mass index, family history of diabetes mellitus, and diastolic blood pressure) and invasive (glycated hemoglobin [HbA1c] and fasting plasma glucose [FPG]) predictors to predict the 5-year probability of incident diabetes. The area under the receiver operating characteristic curve was 0.643 for the non-invasive risk model, 0.786 for the invasive risk model with HbA1c but not FPG, and 0.845 for the invasive risk model with HbA1c and FPG. The optimism for the performance of all models was small by internal validation. In the internal-external cross-validation, these models tended to show similar discriminative ability across different areas. The discriminative ability of each model was confirmed using external validation datasets. The invasive risk model with only HbA1c was well-calibrated in the validation cohort.

CONCLUSION

Our invasive risk models are expected to discriminate between high- and low-risk individuals with T2DM in a Japanese population.

Five percent weight loss is a significant 1-year predictor and an optimal 5-year cut-off for reducing the number of obesity-related cardiovascular disease risk components: the Japan Obesity and Metabolic Syndrome Study

Objective

This study aimed to identify the amount of weight loss needed in patients with obesity to improve metabolic syndrome (MetS), a risk factor for cardiovascular disease (CVD), over a long period of time.

Methods

A total of 576 patients with obesity were enrolled in this study. Effects of continuous physician-supervised weight loss on the cumulative MetS components excluding abdominal circumference (defined as obesity-related CVD risk score) were investigated during a 5-year follow-up period. The extent of weight loss required to reduce the obesity-related CVD risk components was assessed using receiver operating characteristic (ROC) curve analyses.

Results

Of the 576 participants, 266 completed 5-year follow-up, with 39.1% and 24.1% of them achieving ≥5.0% and ≥7.5% weight loss at the 5-year follow-up, respectively. The area under the ROC curve for reducing the obesity-related CVD risk components was 0.719 [0.662-0.777] at 1 year and 0.694 [0.613-0.775] at 5 years. The optimal cut-off value for weight loss was 5.0% (0.66 sensitivity and 0.69 specificity) and the value with 0.80 specificity was 7.5% (0.45 sensitivity) at 5 years. Greater reductions in weight were associated with greater improvements in the obesity-related CVD risk score at all follow-up periods (P-trend <0.001). Obesity-related CVD risk score was significantly improved by 5.0-7.5% and ≥7.5% weight loss at 1 year (P = 0.029 and P < 0.001, respectively) and ≥7.5% weight loss at 5 years (P = 0.034).

Conclusions

A weight loss of ≥5.0% at 1 year and ≥7.5% at 5 years could reduce the number of obesity-related CVD risk components in patients with obesity.

Third Report of the Japan Diabetes Society/Japanese Cancer Association Joint Committee on Diabetes and Cancer: Summary of the results of a questionnaire survey of oncologists and diabetologists-Secondary publication

The Japan Diabetes Society and the Japan Cancer Association launched a joint committee and published their "First Joint Committee Report on Diabetes and Cancer" in 2013, compiling recommendations for physicians and health-care providers as well as for the general population. In 2016, the "Second Joint Committee Report on Diabetes and Cancer" summarized the current evidence on glycemic control and cancer risk in patients with diabetes. The current "Third Joint Committee Report on Diabetes and Cancer", for which the joint committee also enlisted the assistance of the Japanese Society of Clinical Oncology and the Japanese Society of Medical Oncology, reports on the results from the questionnaire survey, "Diabetes Management in Patients Receiving Cancer Therapy," which targeted oncologists responsible for cancer management and diabetologists in charge of glycemic control in cancer patients. The results of the current survey indicated that there is a general consensus among oncologists and diabetologists with regard to the need for guidelines on glycemic control goals, the relevance of glycemic control, and glycemic control during cancer therapy in cancer patients.

Third Report of the Japan Diabetes Society (JDS)/Japanese Cancer Association (JCA) Joint Committee on diabetes and cancer: summary of the results of a questionnaire survey of oncologists and diabetologists-secondary publication

The Japan Diabetes Society (JDS) and the Japan Cancer Association (JCA) launched a joint committee and published their "First Joint Committee Report on Diabetes and Cancer" in 2013, compiling recommendations for physicians and healthcare providers as well as for the general population. In 2016, the "Second Joint Committee Report on Diabetes and Cancer" summarized the current evidence on glycemic control and cancer risk in patients with diabetes. The current "Third Joint Committee Report on Diabetes and Cancer", for which the joint committee also enlisted the assistance of the Japanese Society of Clinical Oncology (JSCO) and the Japanese Society of Medical Oncology (JSMO), reports on the results from the questionnaire survey, "Diabetes Management in Patients Receiving Cancer Therapy," which targeted oncologists responsible for cancer management and diabetologists in charge of glycemic control in cancer patients. The results of the current survey demonstrated that there is a general consensus among oncologists and diabetologists with regard to the need for guidelines on glycemic control goals, the relevance of glycemic control, and glycemic control during cancer therapy in cancer patients.

Differences in metabolic characteristics between Metabolically Healthy Obesity (MHO) and Metabolically Unhealthy Obesity (MUO) in weight reduction therapy

Metabolically Healthy Obesity (MHO) is generally recognized as the absence of any metabolic disorders and cardiovascular diseases, including type 2 diabetes, dyslipidemia, and hypertension, in obese individuals; however, it is not clearly defined. Therefore, the present study investigated differences in metabolic characteristics between individuals with MHO and Metabolically Unhealthy Obesity (MUO) during weight reduction therapy. The key factors defining MHO and the importance of weight reduction therapy for MHO were also examined. Cohort data from the Japan Obesity and Metabolic Syndrome (JOMS) study were analyzed. Subjects were divided into the MHO (n = 25) and MUO (n = 120) groups. Prior to weight reduction therapy, serum adiponectin levels were significantly higher in the MHO group than in the MUO group. Serum adiponectin levels also negatively correlated with the area of subcutaneous adipose tissue (SAT) and Homeostasis model assessment (HOMA)-R in the MHO group, but not in the MUO group. Collectively, the present results suggest the importance of adiponectin for maintaining metabolic homeostasis in the MHO group. On the other hand, no significant differences were observed in inflammatory markers between the MHO and MUO groups, suggesting the presence of chronic inflammation in both groups. Furthermore, a positive correlation was noted between changes in serum cystatin C levels and waist circumference in the MHO group, which indicated that despite the absence of metabolic disorders, the MHO group exhibited anti-inflammatory responses during weight reduction therapy. These results underscore the significance of weight reduction even for individuals with MHO.

Independent risk factors of rapid glomerular filtration rate decline in patients with type 2 diabetes with preserved kidney function and normoalbuminuria: A multicenter cohort study

AIMS/INTRODUCTION

Research on the incidence and underlying mechanisms of rapid renal function decline in patients with type 2 diabetes mellitus with preserved renal function and normoalbuminuria is limited. This study aimed to investigate the involvement of hemoglobin level as a risk factor for rapid decliners among patients with type 2 diabetes with preserved renal function and normoalbuminuria.

MATERIALS AND METHODS

This was a retrospective observational study of 242 patients with type 2 diabetes with a baseline estimated glomerular filtration rate of ≥60 mL/min/1.73 m² and normoalbuminuria (<30 mg/gCr), followed up for >1 year. The annual rate of estimated glomerular filtration rate decline during the follow-up period was calculated using least square regression analysis; rapid decliners defined at ≥3.3%/year. Risk factors associated with rapid decliners were identified using a logistic regression analysis of variables previously identified as risk factors of rapid decliners.

RESULTS

The median follow-up period was 6.7 years, and 34 patients showed rapid decliners. On multivariate analysis, lower baseline hemoglobin level was a risk factor of rapid decliners (odds ratio 0.69, 95% confidence interval 0.47-0.99; P = 0.045). Furthermore, the baseline hemoglobin levels were correlated positively with iron and ferritin levels, implying that an impaired iron metabolism might cause lower hemoglobin levels in rapid decliners.

CONCLUSIONS

In patients with type 2 diabetes with preserved renal function and normoalbuminuria, lower hemoglobin levels were a risk factor for rapid decliners, where disturbed iron metabolism might precede the development of diabetic kidney disease.

Behavioral change stage might moderate the impact of multifaceted interventions on non-attendance from medical care among patients with type 2 diabetes: The Japan Diabetes Outcome Intervention Trial-2 Large-Scale Trial 007 (J-DOIT2-LT007)

AIMS/INTRODUCTION

Non-attendance from regular medical care is a major problem in diabetes patients. This study aimed to examine the impact of a multifaceted lifestyle intervention by face-to-face approach (FFA) on non-attendance from regular medical care in comparison with that by telephone from the technical support center (TSC).

MATERIALS AND METHODS

This was secondary analysis from a 1-year, prospective, cluster randomized, intervention study. Patients with type 2 diabetes, who were regularly visiting primary care physicians cluster-randomized into the control or intervention (TSC or FFA according to resource availability of the district medical associations) groups, were consecutively recruited. The primary end-point was non-attendance from regular medical care. The interaction between the type of intervention (TSC vs FFA) and behavioral change stage (pre- vs post-action stage) in diet and exercise for the dropout rate was assessed.

RESULTS

Among the 1,915 participants (mean age 56 ± 6 years; 36% women) enrolled, 828, 564 and 264 patients belonged to the control, TSC and FFA groups, respectively. We found evidence suggestive of an interaction between the intervention type and behavioral change stage in diet (P = 0.042) and exercise (P = 0.038) after adjusting for covariates. The hazard ratios (95% confidence interval) of FFA to TSC were 0.21 (0.05-0.93) and 7.69 (0.50-117.78) in the pre-action and post-action stages for diet, respectively, whereas they were 0.20 (0.05-0.92) and 4.75 (0.29-73.70) in the pre-action and post-action stages for exercise.

CONCLUSIONS

Among diabetes patients, the impact of multifaceted intervention on non-attendance from medical care might differ by the behavioral change stage.

Vitamin D intake and all-cause and cause-specific mortality in Japanese men and women: the Japan Public Health Center-based prospective study

While higher circulating 25-hydroxyvitamin D concentrations have been reported to be associated with decreased risk of all-cause mortality, evidence on dietary vitamin D intake is limited and inconsistent. We investigated whether vitamin D intake is associated with all-cause and cause-specific mortality among Japanese adults. Participants were 42,992 men and 50,693 women who responded to the second survey of the Japan Public Health Center-based Prospective Study (1995-1998) and who were followed up for mortality through 2018. Dietary intake was ascertained using a validated food frequency questionnaire. Hazard ratios of deaths from the second survey to December 2018 were estimated using Cox proportional hazard regression analysis. During follow-up, we identified 22,630 deaths. Overall, the third and fourth quintiles, but not the highest quintile, of vitamin D intake were each associated with a significantly lower risk of all-cause mortality. In subgroups characterized by low sunlight exposure, risk of all-cause mortality decreased linearly with increasing vitamin D intake. The multivariable-adjusted hazard ratios (95% confidence intervals) of all-cause mortality for the highest versus lowest quintile of vitamin D intake were 0.87 (0.79-0.95) in women and 0.88 (0.79-0.97) in residents of higher latitude areas. Lower risk was also observed for all-cause mortality in participants with hypertension and for heart disease mortality in those with higher calcium intake. Higher vitamin D intake was associated with decreased risk of ischemic stroke and pneumonia mortality. Higher dietary vitamin D was associated with a lower risk of mortality among individuals with low sunlight exposure or hypertension. Individuals with potentially low vitamin D may benefit from increasing dietary vitamin D intake for the prevention of premature death.

Psychological and Situational Factors Affecting Dropout from Regular Visits in Diabetes Practice: The Japan Diabetes Outcome Intervention Trial-2 Large Scale Trial 004 (J-DOIT2-LT004)

INTRODUCTION

This study explored the psychological and situational factors affecting dropout from regular visits to diabetes care using data obtained from the Japan Diabetes Outcome Intervention Trial 2 (J-DOIT2) Large-scale Trial (LT).

METHODS

A total of 2,031 patients with type 2 diabetes who participated in the J-DOIT2-LT were included in the analysis. Responses to a baseline questionnaire with 17 items asking about the experience of dropout from regular visits in diabetes care and its reasons were analyzed using principal component analysis, and factors related to dropout were extracted. Using Cox regression analysis, the association of these factors with the incidence of dropout was investigated.

RESULTS

The mean age of the 2,031 patients was 56.4 ± 5.9 years and 742 (36.5%) were women. They were followed for a median of 392 days, and 125 patients dropped out from regular visits during the follow-up period. In the principal component analysis of the questionnaire, there were four latent factors with eigenvalues of >1.0, which were labeled as "negative perceptions for regular visits," "social pressure," "lack of perceived necessity," and "environmental obstacles" based on the retained items. The Cox regression analysis demonstrated that patients with high scores of "lack of perceived necessity" and "environmental obstacles" had a significantly increased risk of dropout from regular visits.

CONCLUSIONS

The present study revealed psychological and situational factors related to dropout, which may be useful for detecting patients at high risk of dropout. Effective measures focusing on such patients to prevent dropouts should be investigated in future studies (The trial registration number: UMIN000002186, registered at the University Hospital Medical Information Network-Clinical Trials Registry).

Association of chronic kidney disease with total and site-specific cancer incidence in participants of the Japan Public Health Center-based Prospective Study

BACKGROUND

Although studies have found an association between chronic kidney disease (CKD) and cancer incidence, the results are inconsistent.

METHODS

This study included participants in the Japan Public Health Center-based Prospective Study who had data on serum creatinine measurements. We assessed the association between estimated glomerular filtration rate (eGFR) and the risk of total and site-specific cancer incidence using a systematic survey in Japan. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) with adjustment for participant demographics and lifestyle factors.

RESULTS

A total of 21 978 participants who met the inclusion criteria were followed up for a mean period of 12.9 years, within which a total of 2997 incident cancer cases were reported. In the multivariable adjusted models, an eGFR of <45 ml/ml/min/1.73 m2 was not significantly associated with total cancer incidence (adjusted HR 1.22, 95% CI 0.94-1.60), compared to an eGFR of 60-89 ml/min/1.73 m2 (reference). The HR among those with eGFRs of ≥90 ml/min/1.73 m2 was 1.10 (95% CI 1.00-1.22).

CONCLUSIONS

In this large prospective study, a low eGFR was not significantly associated with an increased risk of total cancer incidence in patients with CKD, which may be partly due to an underpowered sample size. This finding may be due to the many shared risk factors between CKD and cancer.

Cystatin C-based eGFR predicts cardiovascular disease in patients with overweight/obesity and hyperglycemia

Background

Although many clinical parameters have been identified as predictors for cardiovascular disease (CVD) development in the general population, the accurate predictor for CVD in patients with obesity is still unknown.

Objective

The study aimed to explore an additional risk factor and predictor for CVD in patients with overweight/obesity considering the interaction of obesity-related pathophysiology.

Methods

The Japan Obesity and Metabolic Syndrome study, a multicenter prospective study, enrolled 787 outpatients, of which 318 eligible patients were analyzed. Patients with fasting plasma glucose (FPG) levels ≥6.11 and < 6.11 mmol/L were considered to have high FPG (HFPG) and normal FPG (NFPG), respectively. Thirty-six patients who developed CVD during the 5 years follow-up were assigned to the CVD group.

Results

Cox's proportional hazards model revealed no significant association between CVD and cystatin C-based estimated glomerular filtration rate (eGFRcys) or creatinine-based eGFR (eGFRcr) in the NFPG group. In the HFPG group, lower eGFRcys, but not eGFRcr, was significantly associated with CVD development. A generalized linear mixed model demonstrated greater reduction in eGFRcys levels over time with HFPG than with NFPG. Although the CVD group showed gradual reduction in eGFRcys levels, the non-CVD group-matched using propensity scores-did not show a decline in eGFRcys levels.

Conclusions

Lower eGFRcys levels may be more accurate than eGFRcr in predicting CVD development in patients with overweight/obesity and hyperglycemia. Furthermore, eGFRcys reduction over time is associated with CVD development.

Clinical Trial Registry Number

UMIN000000559.

Employment status and diabetic outpatient appointment non-attendance in middle to senior working generation with type 2 diabetes: the Japan diabetes outcome intervention trial-2 large‑scale trial 005 (J-DOIT2-LT005)

AIMS

Workplace demands, support, and relationships differ according to employment status (e.g., employment that is full-time, part-time, or self-employed) and may lead to unequal opportunities to keep diabetic appointments. We investigated the association between employment status and outpatient diabetic appointment non-attendance among working-age adults with type 2 diabetes.

METHODS

This was a secondary analysis of a cluster-randomized trial (the Japan diabetes outcome intervention trial 2 large-scale trial). The analysis included 2010 trial participants (40-65 years old) with type 2 diabetes who were regularly followed by primary care physicians (PCPs). The outcome measure was the first non-attendance (defined as a failure to visit a PCP within 2 months of the original appointment) during the one-year follow-up. The association between baseline employment status and non-attendance was examined using Cox proportional hazard model in men and women.

RESULTS

During the 1279 and 789 person-year follow-up periods, 90 men and 34 women, respectively, experienced their first appointment non-attendance. Among men, self-employed participants had a higher risk of non-attendance compared with full-time employees (adjusted HR, 1.84; 95% CI, 1.15, 2.95). The trial intervention (attendance promotion) was associated with a significantly reduced risk of non-attendance among self-employed participants (HR, 0.51; 95% CI, 0.26, 0.99). Among women, a significant association between employment status and non-attendance was not observed.

CONCLUSIONS

Self-employed men with type 2 diabetes had a twofold increased risk of non-attendance than did full-time employees. Our study suggests that self-employed men with type 2 diabetes should be targeted for interventions promoting appointment adherence.

Association Between Diabetes and Adjuvant Chemotherapy Implementation in Patients with Stage III Colorectal Cancer

Aims/Introduction

Among colorectal cancer (CRC) patients, pre‐existing diabetes is suggested to influence poor prognosis, but the impact on adjuvant chemotherapy implementation is largely unknown. We aimed to compare the implementation rate of adjuvant chemotherapy between CRC patients with and without pre‐existing diabetes in a retrospective cohort study.

Materials and Methods

Colorectal cancer diagnosis information was obtained from the hospital‐based cancer registry of patients with stage III CRC who underwent curative surgery in 2013 in Japan (n = 6,344). Health claims data were used to identify diabetes and chemotherapy. We examined the association between diabetes and the implementation rate of adjuvant chemotherapy using a generalized linear model adjusted for age, sex, updated Charlson Comorbidity Index, hospital type and prefecture. Furthermore, we applied a mediation analysis to examine the extent to which postoperative complications mediated the association.

Results

Of the 6,344 patients, 1,266 (20.0%) had diabetes. The mean ages were 68.2 and 71.3 years for patients without and with diabetes, respectively. Compared with those without diabetes, patients with diabetes were less likely to receive adjuvant chemotherapy (crude rate 58.9 and 49.8%; adjusted percentage point difference 4.6; 95% confidence interval 1.7–7.5). The difference was evident for patients aged <80 years, and larger for platinum‐containing regimens than others. Mediation analysis showed that postoperative complications explained 9.1% of the inverse association between diabetes and adjuvant chemotherapy implementation.

Conclusions

We observed that patients with stage III CRC and diabetes are less likely to receive adjuvant chemotherapy than those without diabetes, and postoperative complications might partially account for the association.

Cross-sectional associations between the types/amounts of beverages consumed and the glycemia status: The Japan public health center-based Prospective Diabetes study

Background

The associations between the types/amounts of beverages consumed in daily life and measures of the glycemia status were investigated in a Japanese population-based cohort.

Methods

Data from the baseline survey of the Japan Public Health Center-based Prospective Diabetes cohort were used. A cross-sectional analysis was performed in 3852 men and 6003 women who were evaluated under the fasting condition. The daily consumptions of coffee, green tea, oolong tea, black tea, soft drinks, fruit juices, or plain water were assessed using a self-reported questionnaire. Multivariable-adjusted linear regression analyses were performed using measures of the glycemia status (fasting plasma glucose (FPG) and glycated hemoglobin (HbA1c) ) as dependent variables and the types/amounts of beverages consumed as the independent variables, to calculate the differences according to the types/amounts of beverages consumed.

Results

In the multivariable-adjusted models, coffee consumption of ≥240 mL/day was significantly associated with a change of the FPG level by −1.9 mg/dL in men (p = 0.013) and −1.4 mg/dL in women (p = 0.015), as compared to coffee consumption of 0 mL/day. No significant association of the FPG level was observed with any of the other types/amounts of beverages consumed. On the other hand, significant associations were found between the HbA1c levels and consumption of several types of beverages.

Conclusions

High coffee consumption was associated with lower FPG levels in this Japanese population. Some unexpected associations of the HbA1c levels with the consumption of some types of beverages were observed, which need to be further investigated.

Higher Serum Soluble TREM2 as a Potential Indicative Biomarker for Cognitive Impairment in Inadequately Controlled Type 2 Diabetes Without Obesity: The DOR-KyotoJ-1

OBJECTIVE

Type 2 diabetes is a risk factor for dementia. We investigated whether serum levels of soluble triggering receptor expressed on myeloid cell 2 (sTREM2), a soluble form of the cell surface receptor TREM2, were predictive of cognitive impairment in type 2 diabetes without obesity.

METHODS

A total of 166 Japanese patients with type 2 diabetes without obesity were followed-up for 2 years. We measured clinical parameters, assessed cognitive function using the mini-mental state examination (MMSE), quantified and divided serum sTREM2 levels into quartiles, and examined the longitudinal associations.

RESULTS

During the follow-up, HbA_1c levels were elevated in 98 patients and decreased in 68 patients. In the HbA_1c-elevated group, higher sTREM2 levels at baseline showed a significant association with a greater tendency for reduction in MMSE scores (P for trend = 0.015), whereas they were not significantly associated with other examined parameters. In the HbA_1c-decreased group, there was no significant association between sTREM2 levels at baseline and changes in MMSE scores, but higher sTREM2 levels at baseline were significantly associated with a greater tendency for reduction in waist circumference (P for trend = 0.027), homeostasis model assessment of insulin resistance (P for trend = 0.039), and sTREM2 levels (P for trend = 0.023).

CONCLUSIONS

Glycemic control is suggested to be important in preventing cognitive impairment in patients with type 2 diabetes without obesity. Higher serum sTREM2 levels would be a predictive marker for cognitive impairment in inadequately controlled type 2 diabetes without obesity.

Risk Classification for Metabolic Syndrome and the Incidence of Cardiovascular Disease in Japan With Low Prevalence of Obesity: A Pooled Analysis of 10 Prospective Cohort Studies

Background

It is uncertain whether risk classification under the nationwide program on screening and lifestyle modification for metabolic syndrome captures well high‐risk individuals who could benefit from lifestyle interventions. We examined the validity of risk classification by linking the incidence of cardiovascular disease (CVD).

Methods and Results

Individual‐level data of 29 288 Japanese individuals aged 40 to 74 years without a history of CVD from 10 prospective cohort studies were used. Metabolic syndrome was defined as the presence of high abdominal obesity and/or overweight plus risk factors such as high blood pressure, high triglyceride or low high‐density lipoprotein cholesterol levels, and high blood glucose levels. The risk categories for lifestyle intervention were information supply only, motivation‐support intervention, and intensive support intervention. Sex‐ and age‐specific hazard ratios and population attributable fractions of CVD, which were also further adjusted to consider non–high density lipoprotein cholesterol levels, were estimated with reference to nonobese/overweight individuals, using Cox proportional hazard regression. Since the reference category included those with risk factors, we set a supernormal group (nonobese/overweight with no risk factor) as another reference. We documented 1023 incident CVD cases (565 men and 458 women). The adjusted CVD risk was 60% to 70% higher in men and women aged 40 to 64 years receiving an intensive support intervention, and 30% higher in women aged 65 to 74 years receiving a motivation‐support intervention, compared with nonobese/overweight individuals. The population attributable fractions in men and women aged 40 to 64 years receiving an intensive support intervention were 17.7% and 6.6%, respectively, while that in women aged 65 to 74 years receiving a motivation‐support intervention was 9.4%. Compared with the supernormal group, nonobese/overweight individuals with risk factors had similar hazard ratios and population attributable fractions as individuals with metabolic syndrome.

Conclusions

Similar CVD excess and attributable risks among individuals with metabolic syndrome components in the absence and presence of obesity/overweight imply the need for lifestyle modification in both high‐risk groups.

Association between sugar and starch intakes and type 2 diabetes risk in middle-aged adults in a prospective cohort study

OBJECTIVES

We aimed to investigate the association between sugar or starch intake and the risk of type 2 diabetes (T2D) in middle-aged Japanese adults.

SUBJECTS/METHODS

Participants comprised 27,797 men and 36,880 women aged 45-75 years with no history of diabetes and critical illness before the second survey in the Japan Public Health Center-based Prospective Study. We calculated sugar (total sugar, total fructose, and sugar subtypes) and starch intakes (% energy/d) using a validated 147-item food frequency questionnaire, to estimate the average dietary intake over the previous year. T2D onset was defined by validated self-reports. ORs adjusted for potential confounders were estimated using multiple logistic regression with categorical and cubic spline models.

RESULTS

During the 5-year follow-up, 690 men and 500 women were identified with T2D. In women, the quartiles of total sugar or total fructose intakes were not significantly associated with T2D risk; however, the spline curves showed an increased risk at extremely high intake levels (ORs [95% CI]: 1.88 [1.07-3.31] at 30% energy/d for total sugar and 1.87 [1.10-3.16] at 14% energy/d for total fructose). Starch intake was positively associated with T2D risk among women in the categorical and spline models (ORs [95% CI]: 1.55 [1.13-2.12] at 50% energy/d). In men, sugar and starch intakes were not associated with T2D risk.

CONCLUSIONS

In this large-scale population-based cohort study, starch intake was associated with an increased T2D risk in Japanese women. An increased risk with extremely high intake of total sugar or total fructose among women cannot be disregarded.

Synergistic association of the copper/zinc ratio under inflammatory conditions with diabetic kidney disease in patients with type 2 diabetes: The Asahi Diabetes Complications Study

Aims/Introduction

We aimed to study the relationships among the copper (Cu)/zinc (Zn) ratio, inflammatory biomarkers, and the prevalence of diabetic kidney disease (DKD) in patients with type 2 diabetes.

Materials and Methods

A cross‐sectional study was performed on 651 patients with type 2 diabetes. DKD was defined as a urinary albumin‐to‐creatinine ratio of ≥30 mg/g creatinine and/or an estimated glomerular filtration rate using cystatin C of < 60 mL/min/1.73 m². Areas under the curves (AUCs), cutoff values, and thresholds for detecting DKD were determined for the Cu/Zn ratio, soluble tumor necrosis factor‐α receptor 1 (sTNFαR1), and high‐sensitivity C‐reactive protein (hsCRP). Patients were categorized by each cutoff value of sTNFαR1 and the Cu/Zn ratio. Odds ratios (ORs) and biological interactions for the prevalence of DKD were determined.

Results

DKD was identified in 220 patients. AUC/optimal cutoff values were 0.777/1300 pg/mL for sTNFαR1, 0.603/1.1648 for the Cu/Zn ratio, and 0.582/305 ng/mL for hsCRP. The ORs for DKD were higher, but not significantly, in the sTNFαR1 < 1300 and Cu/Zn ≥ 1.1648 group, significantly higher in the sTNFαR1 ≥ 1300 and Cu/Zn < 1.1648 group (P < 0.0001), and further synergistically elevated in the sTNFαR1 ≥ 1300 and Cu/Zn ≥ 1.1648 group (P < 0.0001) compared with the sTNFαR1 < 1300 and Cu/Zn < 1.1648 group after multivariable adjustment. Levels of sTNFαR1 were significantly higher in the sTNFαR1 ≥ 1300 and Cu/Zn ≥ 1.1648 group than in the sTNFαR1 ≥ 1300 and Cu/Zn < 1.1648 group (P = 0.0006).

Conclusions

Under an inflammatory initiation signal of elevated serum sTNFαR1 levels, an increase in the Cu/Zn ratio may further exacerbate inflammation and is synergistically associated with a high prevalence of DKD in patients with type 2 diabetes.

807Association between diabetes and adjuvant chemotherapy implementation among patients with stage III colorectal cancer

Background

Preexisting diabetes may contribute to the indication for adjuvant chemotherapy among patients with colorectal cancer (CRC); however, the association between diabetes and its implementation is largely unknown.

Methods

We analyzed the hospital-based cancer registry and health claims data of patients with stage III CRC who received curative surgery in 2013 in Japan (n = 6,344). Chemotherapy and diabetes was identified based on procedure, prescription, and diabetes codes in claims data. We examined the association between diabetes and implementation rate of adjuvant chemotherapy using the generalized linear model adjusted for age, sex, and updated Charlson Comorbidity Index, hospital type, and prefecture. We further applied a mediation analysis to examine the extent to which postoperative complications mediated the association.

Results

Of these, 1,236 (19.5%) had diabetes. Compared with those without diabetes, patients with diabetes were less likely to receive adjuvant chemotherapy (crude rate: 58.9% and 49.8%; adjusted percentage point difference: 4.7% [95% confidence limits: 1.7, 7.5]). Mediation analysis indicated that postoperative complications explained 9.4% of the association between diabetes and adjuvant chemotherapy implementation.

Conclusions

Our findings suggest that patients with stage III CRC and diabetes are less likely to receive adjuvant chemotherapy than those without diabetes, and postoperative complications may partially account for the association.

Key messages

Concomitant diabetes might negatively impact the implementation rate of adjuvant chemotherapy in patients with stage III CRC.

Validation study on diabetes definitions using Japanese Diagnosis Procedure Combination data among hospitalized patients

BackgroundValidation studies on diabetes definitions using nationwide healthcare databases are scarce. We evaluated the validity of diabetes definitions using disease codes and antidiabetic drug prescriptions in the Japanese Diagnosis Procedure Combination (DPC) data via medical chart review.MethodsWe randomly selected 500 records among 15,334 patients who participated in the Japan Public Health Center-Based Prospective Study for the Next Generation in Yokote City and who had visited a general hospital in Akita between October 2011 and August 2018. Of the 500 patients, 98 were linked to DPC data; however, only 72 had sufficient information in the medical chart. Gold standard confirmation was performed by board-certified diabetologists. DPC-based diabetes definitions were based on the International Classification of Diseases, 10th Revision codes, and antidiabetic prescriptions. Sensitivity, specificity, and the positive and negative predictive values (PPV and NPV, respectively) of DPC-based diabetes definitions were evaluated.ResultsOf 72 patients, 23 were diagnosed with diabetes by chart review; 19 had a diabetes code, and 13 had both a diabetes code and antidiabetic prescriptions. The sensitivity, specificity, PPV, and NPV were 89.5% (95% confidence interval: 66.9-98.7), 96.2% (87.0-99.5), 89.5% (66.9-98.7), and 96.2% (87.0-99.5), respectively, for (i) diabetes codes alone; 89.5% (66.9-98.7), 94.3% (84.3-98.8), 85.0% (62.1-96.8), and 96.2 (86.8-99.5) for (ii) diabetes codes and/or prescriptions; 68.4% (43.4-87.4), 100% (93.3-100), 100% (75.3-100), and 89.8% (79.2-96.2) for (iii) both diabetes codes and prescriptions.ConclusionsOur results suggest that DPC data can accurately identify diabetes among inpatients using (i) diabetes codes alone or (ii) diabetes codes and/or prescriptions.

Dietary glycemic index, glycemic load and mortality: Japan Public Health Center-based prospective study

PURPOSE

Long-term associations of dietary glycemic index (GI) and glycemic load (GL) with mortality outcomes remain unclear.

METHODS

The present analysis included 72,783 participants of the Japan Public Health Center-based Prospective Study. Participants who responded to the 5-year follow-up questionnaire in 1995-1999 were followed-up until December 2015. We estimated the risk of total and cause-specific mortality associated with GI and GL using Cox proportional hazards regression models.

RESULTS

During 1,244,553 person years of follow-up, 7535 men and 4913 women died. GI was positively associated with all-cause mortality. As compared with the lowest quartile, the multivariable HR for those who had the highest quartile of GI was 1.14 (95% CI 1.08-1.20). The HRs for death comparing the highest with the lowest quartile were 1.28 (95% CI 1.14-1.42) for circulatory system diseases, 1.33 (95% CI 1.14-1.55) for heart disease, 1.32 (95% CI 1.11-1.57) for cerebrovascular disease, and 1.45 (95% CI 1.18-1.78) for respiratory diseases. GI was not associated with mortality risks of cancer and digestive diseases. GL showed a null association with all-cause mortality (highest vs lowest quartile; HR 1.04; 95% CI 0.96-1.12). However, among those who had the highest quartile of GL, the HRs for death from circulatory system diseases was 1.24 (95% CI 1.05-1.46), cerebrovascular disease was 1.34 (95% CI 1.03-1.74), and respiratory diseases was 1.35 (95% CI 1.00-1.82), as compared with the lowest quartile.

CONCLUSION

In this large prospective cohort study, dietary GI and GL were associated with mortality risks.

Impact of telephone support programme using telemonitoring on stage of change towards healthy eating and active exercise in people with prediabetes

INTRODUCTION

This study evaluated the impact of a telephone support programme with telemonitoring on changes in healthy eating and active exercise in adults with prediabetes using the stage of change framework.

METHODS

We performed a post hoc analysis using data from the Japan Diabetes Outcome Trial-1. A total of 2607 participants aged 20-65 years with impaired fasting glucose were recruited from the workplace/community in Japan and randomized to a one year telephone support programme intervention arm (n = 1240) or self-directed control arm (n = 1367). Participants in both arms received monthly data feedback from a weight scale and pedometer. The main outcome measure was the stages of change toward healthy eating and active exercise. The secondary outcome was fasting plasma glucose (FPG).

RESULTS

After the one year intervention, the adjusted odds ratio of progressing to the action/maintenance stage in the intervention vs. control arm for healthy eating was 1.31 (95% confidence interval (CI) 1.21-1.43; p < 0.001), but that for active exercise was 1.07 (95% CI 0.99-1.15; p = 0.062). The intervention decreased FPG levels in participants in the contemplation stage, but not in the precontemplation, preparation and action/maintenance stages.

DISCUSSION

These findings suggest that the telephone support programme by healthcare providers advanced the stage of changes toward healthy eating in people with prediabetes. In particular, it decreased FPG levels in the contemplation stage.

Effect of a Multifactorial Intervention on Fracture in Patients With Type 2 Diabetes: Subanalysis of the J-DOIT3 Study

AIMS

To evaluate the effects of an intensified multifactorial intervention and patient characteristics on the incidence of fractures comorbid with type 2 diabetes.

METHODS

Fracture events were identified and analyzed among adverse events reported in the J-DOIT3 study, a multicenter, open-label, randomized, parallel-group trial that was conducted in Japan, in which patients with type 2 diabetes were randomly assigned to receive conventional therapy for glucose, blood pressure, and lipids (targets: HbA1c < 6.9%, blood pressure <130/80 mm Hg, LDL-cholesterol <120mg/dL) or intensive therapy (HbA1c < 6.2%, blood pressure <120/75 mm Hg, LDL-cholesterol <80mg/dL) (ClinicalTrials.gov registration no. NCT00300976).

RESULTS

The cumulative incidence of fractures did not differ between those receiving conventional therapy and those receiving intensive therapy (hazard ratio (HR) 1.15; 95% CI, 0.91-1.47; P = 0.241). Among the potential risk factors, only history of smoking at baseline was significantly associated with the incidence of fractures in men (HR 1.96; 95% CI, 1.04-3.07; P = 0.038). In contrast, the incidence of fractures in women was associated with the FRAX score [%/10 years] at baseline (HR 1.04; 95% CI, 1.02-1.07; P < 0.001) and administration of pioglitazone at 1 year after randomization (HR 1.59; 95% CI, 1.06-2.38; P = 0.025).

CONCLUSIONS

Intensified multifactorial intervention may be implemented without increasing the fracture risk in patients with type 2 diabetes. The fracture risk is elevated in those with a history of smoking in men, whereas it is predicted by the FRAX score and is independently elevated with administration of pioglitazone in women.

Differences in the birthweight of infants born to patients with early- or mid-to-late-detected gestational diabetes mellitus who underwent guideline-based glycemic control

AIMS

To examine the effects of strict glycemic control on the birthweight of infants born to Japanese patients with early- or mid-to-late-detected gestational diabetes mellitus (ed- or md-GDM).

METHODS

We retrospectively examined the characteristics of 101 patients with GDM who underwent guideline-based glycemic control. A 75-g oral glucose tolerance test was conducted to diagnose GDM at gestational weeks 11-15 (ed-GDM subgroup) and 24-28 (md-GDM subgroup).

RESULTS

Infant birthweight was significantly lower in the ed-GDM subgroup (n = 25) than in the md-GDM subgroup (n = 76) (2688.3 ± 470.4 g vs. 3052.4 ± 383.1 g, p < 0.05), and the proportion of low-birthweight infants (<2500 g) was significantly higher in the ed-GDM subgroup than in the md-GDM subgroup (32.0% vs. 5.3%, p < 0.005). Fasting plasma glucose (FPG) levels during early treatment and before delivery were significantly lower in the ed-GDM subgroup than in the md-GDM subgroup (76.1 ± 10.4 mg/dL vs. 85.5 ± 9.6 mg/dL, p < 0.001; 80.5 ± 10.4 mg/dL vs. 90.4 ± 10.3 mg/dL, p < 0.0001).

CONCLUSIONS

Patients with ed-GDM showed significantly lower FPG levels during treatment compared to those with md-GDM, presumably indicating an association with the delivery of low-birthweight infants.

A comparison in the ability to detect diabetic retinopathy between fasting plasma glucose and HbA1c levels in a longitudinal study

Aims

The relationship between HbA1c and diabetic retinopathy is expected to differ between different races. In this study, we verified which of HbA1c and fasting plasma glucose (FPG) is more effective for detecting the diabetic retinopathy longitudinally in a Japanese population.

Materials and Methods

The study subjects underwent health examinations twice (including eye test and questionnaire of lifestyle and health) in 2008-2009 (baseline) and in 2012-2013 (4-year follow-up). Both non-DM and DM patients at baseline were included as the participants. Of these participants, who had not been diagnosed with retinopathy at the baseline survey (n = 2427; 2150 men and 277 women) had eye fundus photographs taken four years later (follow-up survey). The odds ratios of incidence of retinopathy according to the eight groups of FPG and HbA1c were estimated using multiple logistic regression analysis adjusted for sex and age. Receiver operator characteristic analysis was used to evaluate each value associated with the presence or absence of retinopathy.

Results

The odds ratios (95% confidence intervals) of incidence of retinopathy by HbA1c level categories, in ascending order, were 1.0 (ref.), 5.66 (1.14-28.26), 1.69 (0.24-12.04), 3.03 (0.50-18.28), 1.04 (0.09-11.59), 4.73 (0.78-28.69), 4.12 (0.74-22.85) and 24.47 (5.61-106.75). For both FPG and HbA1c levels, the odds ratio for the development of retinopathy increased linearly with the increases in the levels FPG and HbA1c, and no clear threshold was observed. The AUC values (SE) for FPG and HbA1c were almost the same, at 0.750 (0.046) and 0.732 (0.048).

Conclusions

It was clarified that the higher the level of FPG and HbA1c was, the higher the incidence of retinopathy after 4 years was. There was no clear threshold. The detection ability of the incidence of retinopathy was almost the same between FPG and HbA1c, suggesting it is possible to detect the risk of retinopathy by HbA1c only.

Characteristics Associated with Early Worsening of Retinopathy in Patients with Type 2 Diabetes Diagnosed with Retinopathy at Their First Visit: A Retrospective Observational Study

MATERIALS AND METHODS

Our study design was a retrospective observational study. Subjects with type 2 diabetes diagnosed with either simple or preproliferative diabetic retinopathy by ophthalmologists at their first visit and followed up for 6-18 months thereafter were included and divided into worsening and nonworsening groups. Thereafter, baseline characteristics and changes in HbA1c and therapy over a year were investigated.

RESULTS

Among the 88 subjects with simple diabetic retinopathy, 16% improved to no retinopathy, 65% retained their simple diabetic retinopathy, 18% worsened to preproliferative diabetic retinopathy, and 1% worsened to proliferative diabetic retinopathy. Among the 47 subjects with preproliferative diabetic retinopathy, 9% improved to simple diabetic retinopathy, 72% retained their preproliferative diabetic retinopathy, and 19% worsened to proliferative diabetic retinopathy. Patients with simple diabetic retinopathy had an odds ratio of 1.44 for worsening retinopathy with a 1% increase in baseline HbA1c. Meanwhile, the odds ratios for worsening retinopathy with a 1% decrease in HbA1c from baseline at 3, 6, and 12 months were 1.34, 1.31, and 1.38, respectively. Among patients with simple diabetic retinopathy, significantly more new interventions were introduced in the worsening group than in the nonworsening group.

CONCLUSIONS

Increased baseline HbA1c, a substantial decrease in HbA1c, and intensified therapy were identified as risk factors for early worsening of diabetic retinopathy in patients with simple diabetic retinopathy at the first visit. Patients should therefore be intimately followed for retinopathy after their first visit.

Distal Vessel Imaging via Intra-arterial Flat Panel Detector CTA during Mechanical Thrombectomy

BACKGROUND AND PURPOSE

Obtaining information on invisible vasculature distal to the occlusion site helps to deploy a stent retriever safely during mechanical thrombectomy for large-vessel occlusion. It is essential to reduce the amount of contrast used for detecting the vessels distal to the occlusion site because acute ischemic stroke patients tend to have chronic kidney disease and patients with severe chronic kidney disease are at an increased risk of contrast-associated acute kidney injury. We assessed whether vessels distal to the occlusion site during acute ischemic stroke with large-vessel occlusion could be visualized on angiographic images using flat panel detector CT acquired following intra-arterial diluted contrast injection, compared with MRA findings.

MATERIALS AND METHODS

Between May 2019 and January 2020, we enrolled 28 consecutive patients with large-vessel occlusions of the anterior circulation eligible for mechanical thrombectomy following MR imaging. The patients underwent CBV imaging using flat panel detector CT with an intra-arterial diluted contrast injection instead of intravenous injection. Flat panel detector CT angiographic images reconstructed from the same dataset were evaluated for image quality, collateral status of the MCA territory, and visualization of the vessels distal to the occlusion site. These findings were compared with MRA findings.

RESULTS

Twenty-two patients were retrospectively examined. Flat panel detector CT angiographic image quality in 20 patients (91%) was excellent or good. The distal portion of the occluded vessel segment was visualized in 14 patients (70%), while the proximal portion of the segment adjacent to the occluded vessel in 3 (15%) was visualized. No visualization was observed in only 1 patient (5%) with no collateral supply. Flat panel detector CT angiographic images were shown to evaluate vessels distal to the occlusion site more accurately than MRA.

CONCLUSIONS

In acute ischemic stroke with large-vessel occlusion, flat panel detector CT angiographic images could successfully visualize vessels distal to the occlusion site with a small amount of contrast material.

Intensity-specific validity and reliability of the Japan Public Health Center-based prospective study-physical activity questionnaire

The Japan Public Health Center-based prospective study- physical activity questionnaire (JPHC-PAQ) was originally developed and validated for total physical activity (total PA). However, it is uncertain whether JPHC-PAQ could also estimate intensity-specific physical activity. The present study aims to evaluate the validity and reliability of intensity-specific physical activity by the JPHC-PAQ against 24-hour activity records (24 h-R). One-hundred and ten participants were chosen from those who had enrolled in the JPHC cohort. Time spent for total PA and intensity-specific physical activity, i.e. moderate (MPA), vigorous (VPA) and moderate-to-vigorous physical activity (MVPA) was estimated by JPHC-PAQ. In addition, the volume of PA was calculated by time of each activity multiplied by intensity of activity. For validity assessment, estimated physical activities were compared with 24 h-R. For reliability evaluation, a retest was conducted 3-6 months after the first survey was answered. Moderately strong correlation between JPHC-PAQ and 24 h-R was observed for total PA estimations (Spearman's rho = 0.672). In addition, moderate correlations were found for MPA (activity time: rho = 0.345, activity volume: rho = 0.300) and MVPA (activity time: rho = 0.563, activity volume: rho = 0.672). Whereas, little association was found for VPA time and volume. As for reliability, moderately strong correlation was found for both total and intensity-specific physical activity in the test-retest (rho = 0.482-0.745). In addition to total PA, the JPHC-PAQ showed acceptable validity and reliability for intensity-specific physical activity, especially in estimating MVPA and MPA.

Effects of dapagliflozin on renin-angiotensin-aldosterone system under renin-angiotensin system inhibitor administration

Sodium-glucose cotransporter-2 inhibitors (SGLT2Is) are reported to prevent cardiovascular events by a mechanism possibly including diuresis and sodium excretion. In this respect, diuresis-induced compensatory upregulation of the renin-angiotensin-aldosterone (RAA) system should be clarified and we performed a randomized controlled trial using dapagliflozin, an SGLT2I. Hypertensive diabetic patients taking angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers were randomly assigned to a dapagliflozin group (DAPA) or a control group (CTRL) with the difference in the changes in plasma renin activity (PRA) after 24 weeks of the treatment as the primary outcome. PRA, plasma aldosterone concentration (PAC), age, sex, BMI, blood pressure, pulse rate, eGFRcys, and HbA1c were not different between the groups at baseline. After 24 weeks, the changes in the PRA from the baseline of the DAPA (n = 44) and CTRL (n = 39) groups were 6.30 ± 15.55 and 1.42 ± 11.43 ng/mL/h, respectively (p = 0.11) although the power of detection was too small. However, post hoc nonparametric analyses revealed that there was a definite increase in the PRA and PAC in the DAPA group (p < 0.0001 and p = 0.00025, respectively) but not in the CTRL group. The PRA in the DAPA group after 24 weeks treatment was significantly elevated compared to the CTRL group (p = 0.013) but not for the PAC. Accordingly, it would be suggested that dapagliflozin may not induce a profound increase, if any, in PAC after 24 weeks of treatment in hypertensive type 2 diabetic patients under RAA suppression.

Effective coverage of medical treatment for hypertension, diabetes and dyslipidaemia in Japan: An analysis of National Health and Nutrition Surveys 2003-2017

OBJECTIVE

To examine trends in effective medical treatment coverage for hypertension, diabetes and dyslipidaemia in Japan, using a metric to assess effective coverage of health interventions derived from a health system performance assessment framework.

METHODS

We obtained cross-sectional data for 96,863 individuals aged 40-74 years from the 15 annual Japanese National Health and Nutrition Surveys (2003-2017). We defined treatment need for hypertension, diabetes and dyslipidaemia as biomarkers equal to or greater than diagnostic thresholds or medication use. For individuals needing treatment, we conducted nearest-neighbour matching to estimate treatment effects and effective coverage, defined as the fraction of potential reductions in biomarkers actually achieved in treated individuals by medications.

RESULTS

The age-standardized prevalence of treatment need for hypertension, diabetes and dyslipidaemia remained around 40%, 7% and 33%, respectively, in 2003-2017. Average treatment effects for those treated in 2013-2017 were 14.8 mmHg (95% confidence interval: 14.2-15.4) for systolic blood pressure, 1.2 percentage points (0.8-1.6) for haemoglobin A1c and 57.9 mg/dl (56.6-59.2) for non-high-density lipoprotein cholesterol. Effective coverage significantly increased between 2003-2007 (hypertension: 48.4% [44.7-52.0], diabetes: 43.8% [35.7-51.8], dyslipidaemia: 86.3% [83.1-89.5]) and 2013-2017 (hypertension: 76.2% [74.2-78.2], diabetes: 74.7% [71.0-78.5], dyslipidaemia: 94.6% [93.3-95.9]).

CONCLUSIONS

Effective coverage of medical treatment for metabolic risk factors has increased. Most of the potential reductions in non-high-density lipoprotein cholesterol have been achieved by statins. Further efforts are necessary to improve the effectiveness of antihypertensive and antidiabetic drugs.

Low carbohydrate diet and all cause and cause-specific mortality

BACKGROUND

Evidence is limited regarding the association between low-carbohydrate diet (LCD) score and mortality among Asians, a population that consumes a large amount of carbohydrates.

OBJECTIVE

The present study examined the association between low-carbohydrate diet (LCD) score (based on percentage of energy as carbohydrate, fat, and protein) and the risk of total and cause-specific mortality among Asians.

DESIGN

This study was a prospective cohort study in Japan with follow-up for a median of 16.9 years involving 43008 men and 50646 women aged 45-75 years. Association of LCD score, LCD score based on animal sources of protein and fat, and LCD score based on plant sources of protein and fat with risk of mortality was assessed using Cox proportional hazards model.

RESULTS

A U-shaped association was observed between LCD score and total mortality: the multivariable-adjusted hazard ratios (HRs) (95% CI) of total mortality for lowest through highest scores were 1.00, 0.95 (0.91, 1.01), 0.93 (0.88, 0.98), 0.93 (0.88, 0.98), and 1.01 (0.95, 1.07) (P-non-linearity <0.01). A similar association was found for mortality from cardiovascular disease (CVD) and heart disease. LCD score based on carbohydrate, animal protein, and animal fat also showed a U-shaped association for total mortality (P-non-linearity <0.01). In contrast, LCD score based on carbohydrate, plant protein, and plant fat was linearly associated with lower total (HR, 0.89; 95% CI: 0.83, 0.94 for highest versus lowest quintile), CVD [0.82 (0.73, 0.92)], heart disease [0.83 (0.71, 0.98)], and cerebrovascular disease [0.75 (0.62, 0.91) mortality.

CONCLUSIONS

Both LCD with high animal protein and fat and high-carbohydrate diet with low animal protein and fat were associated with higher risk of mortality. Meanwhile, LCD high in plant-based sources of protein and fat was associated with a lower risk of total and CVD mortality.

Multifactorial intervention has a significant effect on diabetic kidney disease in patients with type 2 diabetes

To evaluate the effect of multifactorial intervention on the onset and progression of diabetic kidney disease in the patients with type 2 diabetes, we analyzed the effects of intensified multifactorial intervention by step-wise intensification of medications and life-style modifications (intensive therapy treatment targets; HbA1c under 6.2%, blood pressure under 120/75 mmHg, low-density lipoprotein cholesterol under 80 mg/dL) comparing with the guideline-based standard care (conventional therapy treatment targets: HbA1c under 6.9%, blood pressure under 130/80 mmHg, low-density lipoprotein cholesterol under 120 mg/dL) on diabetic kidney disease. A total of 2540 eligible patients in the Japan Diabetes Optimal Integrated Treatment for three major risk factors of cardiovascular diseases (J-DOIT3) cohort were randomly assigned to intensive therapy (1269) and conventional therapy (1271) and treated for a median of 8.5 years. The prespecified kidney outcome measure was a composite of progression from normoalbuminuria to microalbuminuria or progression from normoalbuminuria to macroalbuminuria or progression from microalbuminuria to macroalbuminuria, serum creatinine levels elevated by two-fold or more compared to baseline, or kidney failure. Primary analysis was carried out on the intention-to-treat population. Changes in the estimated glomerular filtration rate and albuminuria were also analyzed. A total of 438 kidney events occurred (181 in the intensive therapy group and 257 in the conventional therapy group). Intensive therapy was associated with a significant 32% reduction in kidney events compared to conventional therapy and was associated with a change in HbA1c at one year from study initiation. Thus, prespecified analysis shows that intensified multifactorial intervention significantly reduced the onset and progression of diabetic kidney disease compared to currently recommended care.

Prevalence of diabetes in Japanese patients with cancer

Cancer patients with diabetes experience a poorer prognosis, yet the population burden of this multimorbidity remains unknown. This study aimed to estimate the latest incidence and prevalence of cancer with diabetes mellitus in Japan. We used projection of cancer incidence and latest survival data from population-based cancer registries. The incidence of cancer associated with diabetes was estimated separately for patients with pre-existing diabetes and those without diabetes, and used to estimate the 5-year cancer prevalence for those with and without diabetes. The prevalence of pre-existing diabetes in cancer patients at any cancer site was estimated to be 20.7% (647,160 men and women). Among cancer sites, diabetes prevalence was high in patients with liver and pancreatic cancers in both sexes. In conclusion, our study shows a large burden of diabetes in cancer patients in Japan, which warrants further attention by health practitioners and policy-makers.

Passive smoking and type 2 diabetes among never-smoking women: The Japan Public Health Center-based Prospective Study

AIMS/INTRODUCTION

The aim of the current study was to prospectively evaluate the association between passive smoking from a spouse and the risk of diabetes among never-smoking Japanese women. Passive smoking at a workplace (or public facilities) was assessed as a secondary measure.

MATERIALS AND METHODS

In the Japan Public Health Center-based Prospective Study (baseline 1990 or 1993), we followed 25,391 never-smoking women aged 40-69 years and without diabetes. Passive smoking was defined as having a husband who was a self-reported smoker, and the exposure at a workplace (or public facilities) was self-reported by women. The development of diabetes was identified in questionnaires administered at the 5-year and 10-year surveys. A pooled logistic regression model was used to assess the association between passive smoking and the development of diabetes with adjustment for age and possible confounders.

RESULTS

Compared with women whose husbands had never smoked, women whose husband smoked ≥40 cigarettes/day had significantly higher odds of developing diabetes in an age-adjusted model, but the association was attenuated in a multivariable model (odds ratio 1.34, 95% confidence interval 0.96-1.87). There was a dose-response trend between the number of cigarettes smoked by a husband and the odds of developing diabetes (P = 0.02). Women reporting daily passive smoking at a workplace (or public facilities) had higher odds of developing diabetes than women reporting no such exposure (odds ratio 1.23, 95% confidence interval 0.995-1.53).

CONCLUSIONS

Our results indicated a higher risk of diabetes among never-smoking Japanese women with higher exposure to passive smoking from a spouse.

Self-weighing frequency and the incidence of type 2 diabetes: post hoc analysis of a cluster-randomized controlled trial

Objectives

Frequent self-weighing is associated with weight loss and maintenance, but the relationship between frequent self-weighing and the incidence of type 2 diabetes (T2D) remains unclear. The study aim was to examine the association between self-weighing frequency and the incidence of T2D in people with impaired fasting glucose (IFG).

Results

We tested the hypothesis that self-weighing frequency and the incidence of T2D are associated in 2607 people with IFG (1240 in the intervention arm; 1367 in the self-directed control arm). Both arms received a weighing scale with storage function. Healthcare providers offered a one-year goal-focused lifestyle intervention via phone. Participants were divided into 4 categories based on self-weighing frequency (No data sent [reference group], low: < 2 times/week, middle: 3–4 times/week, and high: 5–7 times/week). The adjusted hazard ratio (AHR) and 95% confidence interval (CI) were calculated. In the intervention arm, middle- and high-frequency self-weighing were associated with a decreased incidence of T2D relative to the reference group (AHR = 0.56, 95% CI [0.32, 0.98] and AHR = 0.43, 95% CI [0.25, 0.74], respectively). In the control arm, high-frequency self-weighing was also associated with a decreased incidence of T2D relative to the reference group (AHR = 0.54, 95% CI [0.35, 0.83]).

Trial registration This trial has been registered with the University Hospital Medical Information Network (UMIN000000662).

Effects of obesity, metabolic syndrome, and non-alcoholic or alcoholic elevated liver enzymes on incidence of diabetes following lifestyle intervention: A subanalysis of the J-DOIT1

Objectives

Using annual health check‐up data, the aim of this study was to identify target populations for lifestyle interventions to effectively prevent diabetes in a real‐world setting.

Methods

The Japan Diabetes Outcome Intervention Trial‐1, a prospective, cluster‐randomized controlled trial, was launched to test if year‐long telephone‐delivered lifestyle support by health professionals can prevent the development of type 2 diabetes (T2D) in people with impaired fasting glucose (IFG) identified at health check‐ups. A total of 2607 participants aged 20‐65 years with IFG were randomized to an intervention arm (n = 1240) or a control arm (n = 1367). We performed subgroup analysis to examine the effects of the intervention on the incidence of T2D in participants with body mass index (BMI) ≥25, metabolic syndrome (MetS), and non‐alcoholic or alcoholic elevated liver enzymes at the baseline. Cox regression analysis adjusted for sex was used to calculate the hazard ratios (HRs).

Results

In addition to IFG, the presence of BMI ≥25, MetS, and elevated liver enzymes increased the incidence of diabetes by two‐ or three‐fold. During a median follow‐up period of 4.9 years, only the non‐alcoholic elevated liver enzyme group showed a low incidence rate owing to lifestyle interventions (adjusted HR: 0.42, 95% confidence interval: 0.18‐0.98).

Conclusion

The results suggest that people who have IFG and non‐alcoholic elevated liver enzymes are a good target population for lifestyle interventions to effectively reduce the incidence of diabetes in a real‐world setting.

Body mass index and mortality among middle-aged Japanese individuals with diagnosed diabetes: The Japan Public Health Center-based prospective study (JPHC study)

AIM

To examine the association between body mass index (BMI) and mortality among middle-aged people with diabetes in Japan.

METHODS

A total of 3032 men and 1615 women, aged 40-69 years, with diabetes were analyzed. Cox proportional hazards models, adjusted for potential confounding factors, were used to estimate mortality hazard ratios (HRs) across BMI categories at the baseline.

RESULTS

There were 1761 deaths during a mean follow-up period of 18.5 years. Increased all-cause mortality was observed at both ends of the BMI distribution; compared with the reference BMI category (23.0-24.9 kg/m²), the HRs were 1.25 (95% confidence interval [CI], 0.9997-1.56) in the lowest (14.0-18.9 kg/m²) and 1.36 (95% CI, 1.06-1.74) in the highest (30.0-39.9 kg/m²) categories (P = 0.001). Similar all-cause mortality trends were observed after excluding deaths within 3 years of follow-up, as well as for men and men who had ever smoked. While a similar non-linear pattern was observed for cancer-specific mortality, heart disease-specific mortality was only increased in the highest BMI category (HR, 1.86; 95% CI, 1.06-3.25).

CONCLUSION

This population-based prospective study demonstrated increased all-cause mortality at both ends of the BMI distribution among Japanese people with diabetes.

Dietary fiber intake and total and cause-specific mortality: the Japan Public Health Center-based prospective study

BACKGROUND

An inverse association has been shown between dietary fiber intake and several noncommunicable diseases. However, evidence of this effect remains unclear in the Asian population.

OBJECTIVE

We examined the association between dietary fiber intake and all-cause and cause-specific mortality, as well as the association between fiber intake from dietary sources and all-cause mortality.

METHODS

We conducted a large-scale population-based cohort study (Japan Public Health Center-based prospective study). A validated questionnaire with 138 food items was completed by 92,924 participants (42,754 men and 50,170 women) aged 45-74 y. Dietary fiber intake was calculated and divided into quintiles. HR and 95% CI of total and cause-specific mortality were reported.

RESULTS

During the mean follow-up of 16.8 y, 19,400 deaths were identified. In multivariable adjusted models, total, soluble, and insoluble fiber intakes were inversely associated with all-cause mortality. The HRs of total mortality in the highest quintile of total fiber intake compared with the lowest quintile were 0.77 (95% CI: 0.72, 0.82; Ptrend <0.0001) in men and 0.82 (95% CI: 0.76, 0.89; Ptrend <0.0001) in women. Increased quintiles of dietary fiber intake were significantly associated with decreased mortality due to total cardiovascular disease (CVD), respiratory disease, and injury in both men and women, whereas dietary fiber intake was inversely associated with cancer mortality in men but not women. Fiber from fruits, beans, and vegetables, but not from cereals, was inversely associated with total mortality.

CONCLUSION

In this large-scale prospective study with a long follow-up period, dietary fiber was inversely associated with all-cause mortality. Since intakes of dietary fiber, mainly from fruits, vegetables, and beans were associated with lower all-cause mortality, these food sources may be good options for people aiming to consume more fiber.

Bodyweight threshold for sudden onset of ketosis might exist in ketosis-prone type 2 diabetes patients

Ketosis-prone type 2 diabetes is recognized as atypical diabetes. These patients are often male, characterized by obesity, sudden onset of ketosis and a transient decrease in insulin secretion capacity that can be recovered with temporal insulin therapy. Here, we report a male patient with ketosis-prone type 2 diabetes who was followed up for 8 years. During the follow-up period, his bodyweight fluctuated and he experienced four episodes of critical ketosis recurrence in association with bodyweight gain. He discontinued insulin therapy after each ketosis episode within the first 4 years, but thereafter, he had to continue insulin therapy because of decreased insulin secretion capacity. Interestingly, his peak bodyweight just before the repeated ketosis episode gradually decreased, and the insulin secretion capacity after the recovery from repeated ketosis decreased in parallel with his peak bodyweight. This long-term clinical course might be a clue to understand the pathophysiology of ketosis-prone type 2 diabetes.

A cluster-randomized trial of the effectiveness of a triple-faceted intervention promoting adherence to primary care physician visits by diabetes patients

We aimed to assess whether a triple-faceted intervention program administered in the primary care setting could decrease the risk of insufficient adherence to primary care physician (PCP) appointments among this patient population. We conducted a cluster-randomized controlled study to assess the effects of a 1-year intervention. The primary outcome was insufficient adherence to regular PCP attendance for diabetes treatment, defined as failure to visit a PCP within 2 months of an original appointment date. The intervention consisted of mailing patient reminders of their PCP appointments, providing patients with health education aimed at lifestyle modification and benchmarking PCP procedures. Eleven municipal level district medical associations employing 192 PCPs were divided into two subregions for assignment to intervention and control clusters, with 971 and 1,265 patients assigned to the intervention and control groups, respectively. Primary outcome data were available for 2,200 patients. The intervention reduced insufficient adherence to regular PCP appointments by 63% (hazard ratio, 0.37; 95% confidence interval [CI], 0.23-0.58). In conclusion, a triple-faceted intervention program consisting of health education, appointment reminders, and physician benchmarking may decrease the risk of incomplete adherence to regular PCP appointments by diabetes patients.

Association of soy and fermented soy product intake with total and cause specific mortality: prospective cohort study

OBJECTIVE

To investigate the association between several types of soy products and all cause and cause specific mortality.

DESIGN

Population based cohort study.

SETTING

Japan Public Health Centre-based Prospective Study, which includes 11 public health centre areas in Japan.

PARTICIPANTS

92 915 participants (42 750 men and 50 165 women) aged 45 to 74 years.

EXPOSURES

Intake of total soy products, fermented soy products (natto and miso), non-fermented soy products, and tofu from a five year survey questionnaire.

MAIN OUTCOME MEASURES

All cause and cause specific mortality (cancer, total cardiovascular disease, heart disease, cerebrovascular disease, respiratory disease, and injury) obtained from residential registries and death certificates.

RESULTS

During 14.8 years of follow-up, 13 303 deaths were identified. In the multivariable adjusted models, intake of total soy products was not significantly associated with total mortality. Compared with the lowest fifth of total soy product intake, the hazard ratios in the highest fifth were 0.98 (95% confidence interval 0.91 to 1.06, P_trend=0.43) in men and 0.98 (0.89 to 1.08, P_trend=0.46) in women. Intake of fermented soy products was inversely associated with all cause mortality in both sexes (highest versus lowest fifth: 0.90 (0.83 to 0.97), P_trend=0.05 in men, and 0.89 (0.80 to 0.98), P_trend=0.01 in women). Natto showed significant and inverse associations with total cardiovascular disease related mortality in both sexes.

CONCLUSIONS

In this study a higher intake of fermented soy was associated with a lower risk of mortality. A significant association between intake of total soy products and all cause mortality was not, however, observed. The findings should be interpreted with caution because the significant association of fermented soy products might be attenuated by unadjusted residual confounding.

Clinical characterization of patients with primary aldosteronism plus subclinical Cushing's syndrome

BACKGROUND

Primary aldosteronism (PA) plus subclinical Cushing's syndrome (SCS), PASCS, has occasionally been reported. We aimed to clinically characterize patients with PASCS who are poorly profiled.

METHODS

A population-based, retrospective, single-center, observational study was conducted in 71 patients (age, 58.2 ± 11.2 years; 24 males and 47 females) who developed PA (n = 45), SCS (n = 12), or PASCS (n = 14). The main outcome measures were the proportion of patients with diabetes mellitus (DM), serum potassium concentration, and maximum tumor diameter (MTD) on the computed tomography (CT) scans.

RESULTS

The proportion of DM patients was significantly greater in the PASCS group than in the PA group (50.0% vs. 13.9%, p <  0.05), without a significant difference between the PASCS and SCS groups. Serum potassium concentration was significantly lower in the PASCS group than in the SCS group (3.2 ± 0.8 mEq/L vs. 4.0 ± 0.5 mEq/L; p <  0.01), without a significant difference between the PASCS and PA groups. Among the 3 study groups of patients who had a unilateral adrenal tumor, MTD was significantly greater in the PASCS group than in the PA group (2.7 ± 0.1 cm vs. 1.4 ± 0.1 cm; p <  0.001), without a significant difference between the PASCS and SCS groups.

CONCLUSIONS

Any reference criteria were not obtained that surely distinguish patients with PASCS from those with PA or SCS. However, clinicians should suspect the presence of concurrent SCS in patients with PA when detecting a relatively large adrenal tumor on the CT scans.

A Comparison of the Association of Fasting Plasma Glucose and HbA1c Levels with Diabetic Retinopathy in Japanese Men

INTRODUCTION

The relationship between HbA1c and diabetic retinopathy is expected to differ between different races. This study was designed to verify whether HbA1c or fasting plasma glucose (FPG) is more effective in detecting diabetic retinopathy in a Japanese population.

MATERIALS AND METHODS

The study subjects underwent health examinations between 2008 and 2009 with fasting. Of these participants, we analyzed the data for 2,921 Japanese men who had undergone an ophthalmologic examination. Retinopathy was classified into 7 categories according to a simplified diabetic retinopathy scale. The odds ratios of retinopathy according to the eight groups of FPG and HbA1c were estimated using multiple logistic regression analysis adjusted for age. Receiver operator characteristic analysis was used to evaluate each value associated with the presence or absence of retinopathy. Results and Discussion. The odds ratios (95% CI) of retinopathy for HbA1c level categories, in ascending order, were 1.0 (ref.), 0.88 (0.28-2.75), 1.27 (0.44-3.69), 1.52 (0.48-4.79), 1.89 (0.52-6.85), 2.70 (0.66-11.10), 4.10 (0.80-21.00), and 6.34 (2.37-16.97) where the odds ratios significantly increased with HbA1c ≥ 6.8%. The area under the curve (SE) for FPG and HbA1c was almost the same, at 0.668 (0.043) and 0.680 (0.043), respectively.

CONCLUSIONS

It was clarified that the higher the level of HbA1c, the higher the prevalence of retinopathy, and there was no clear threshold. The detection ability of retinopathy was almost the same, suggesting that it is possible to detect the risk of retinopathy by HbA1c only.