Fasting, non-fasting glucose and HDL dysfunction in risk of pre-diabetes, diabetes, and coronary disease in non-diabetic adults

We determined in non-diabetic persons the risk of fasting and non-fasting glucose levels for pre-diabetes, diabetes, and coronary heart disease (CHD), including the roles of serum C-reactive protein (CRP) and HDL cholesterol, and delineated risk profiles of the pre-diabetic states. Over 7¼ years, 2,619 middle-aged Turkish adults free of diabetes and CHD were studied prospectively. Using different serum glucose categories including impaired fasting glucose (IFG, 6.1-6.97 mmol/L) and impaired glucose tolerance (IGT), outcomes were analyzed by Cox regression. IFG was identified at baseline in 112 and IGT in 33 participants. Metabolic syndrome components distinguished individuals with IFG from those with normoglycemia. Participants with IGT tended to differ from adults in normal postprandial glucose categories in regard to high levels of triglycerides, apoA-I, and CRP. Diabetes risk, adjusted for sex, age, waist circumference, CRP, and HDL cholesterol, commenced at a fasting 5.6-6.1 mmol/L threshold, was fourfold at levels 6.1-6.97 mmol/L. Optimal glucose values regarding CHD risk were 5.0-6.1 mmol/L. Fasting and postprandial glucose values were not related to CHD risk in men; IGT alone predicted risk in women (HR 3.74 [1.16;12.0]), independent of age, systolic blood pressure, non-HDL cholesterol, waist circumference, smoking status, and CRP. HDL cholesterol was unrelated to the development of IFG, IGT, and diabetes, while CRP elevation independently predicted the development of diabetes. IGT independently predicts CHD risk, especially in women. HDL dysfunction associated with low-grade inflammation is a co-determinant of pre-diabetic states and their progression to diabetes.

Serum γ-glutamyltransferase: independent predictor of risk of diabetes, hypertension, metabolic syndrome, and coronary disease

Serum γ-glutamyltransferase (GGT) is associated with oxidative stress and hepatic steatosis. The extent to which its value in determining incident cardiometabolic risk (coronary heart disease (CHD), metabolic syndrome (MetS), hypertension and type 2 diabetes) is independent of obesity needs to be further explored in ethnicities. After appropriate exclusions, a cohort of 1,667 adults of a general population (age 52 ±11 years) was evaluated prospectively at 4 year's follow-up using partly Cox proportional hazard regressions. GGT activity was measured kinetically, and values were log-transformed for analyses. MetS was identified by Adult Treatment Panel-III criteria modified for male abdominal obesity. Median (interquartile range) GGT activity was 24.9 (17.0; 35.05) U/l in men, 17.0 (12.3; 24.0) U/l in women. In linear regression analysis, while smoking status was not associated, (male) sex, sex-dependent age, alcohol usage, BMI, fasting triglycerides and C-reactive protein (CRP) were significant independent determinants of circulating GGT. Each 1-s.d. increment in (= 0.53 ln GGT) GGT activity significantly predicted in each sex incident hypertension (hazard ratio (HR) 1.20 (95% confidence interval (CI) 1.10; 1.31)), and similarly MetS, after adjustment for age, alcohol usage, smoking status, BMI and menopause. Strongest independent association existed with diabetes (HR 1.3 (95% CI 1.1; 1.5)) whereas GGT activity tended to marginally predict CHD independent of total bilirubin but not of BMI. Higher serum total bilirubin levels were protective against CHD risk in women. We conclude that elevated serum GGT confers, additively to BMI, risk of hypertension, MetS, and type 2 diabetes but only mediates adiposity against CHD risk.

Depressive symptoms in a general population: associations with obesity, inflammation, and blood pressure

To determine whether obesity, inflammation, or conventional risk factors are related to depressive symptoms (DeprSy) in the general population. Responses to 3 questions served to assess sense of depression. Body mass index (BMI), C-reactive protein (CRP), and other epidemiologic data of participants were available. In 1940, individuals who consulted a psychiatrist in the preceding year, or felt depressed (together DeprSy), 248 were female. Logistic regressions for adjusted associations of BMI with DeprSy were not significant as was serum CRP level. Diabetes and, in men, fasting glucose concentrations were associated with DeprSy. Systolic blood pressure (SBP) was robustly inversely associated with DeprSy in diverse models at ORs of 0.74 (95%CI 0.63; 0.89) independent of confounders, including antihypertensive and lipid-lowering medication. The use of antidepressants could not explain the reduced BP. Women are predisposed to depression with which, not BMI and CRP, but SBP is inversely associated. Anti-inflammatory substances produced in depressed persons might explain the slightly lower BP.

[Regional distribution of all-cause mortality and coronary disease incidence in Turkey: findings of Turkish Adult Risk Factor survey 2010]

OBJECTIVES

We analyzed the distribution of cumulative all-cause and cardiovascular mortality and incident coronary heart disease (CHD) across the seven geographic regions of Turkey and presented overall and coronary mortality findings of the 2010 survey of the Turkish Adult Risk Factor Study.

STUDY DESIGN

A total of 1406 participants were surveyed. Information on the mode of death was obtained from first-degree relatives and/or health personnel of local heath offices. Information on survivors was obtained from history, physical examination, and 12-lead electrocardiography.

RESULTS

Of the surveyed participants, 686 were examined; information on health status was obtained in 577 subjects, and 32 participants (14 women, 18 men; mean age 72.3±15.6 years) were ascertained to have died. The total duration of follow-up was 2,520 person-years. Nineteen deaths were of coronary (n=16) or cerebrovascular (n=3) origin. Cumulative 20-year assessment of the entire cohort for the age bracket of 45-74 years disclosed a high coronary mortality rate, being 7.4 and 4.1 per 1000 person-years in men and women, respectively, and representing a limited decline after year 2000. Age-adjusted Cox regression analysis comprising 433 deaths and 506 incident CHD cases over a 7.3-year follow-up showed similar mortality rates across the regions, and a significantly high CHD incidence in males of the Black Sea and Marmara regions and in females of the Southeast Anatolia. Currently, 480,000 incident CHD cases are estimated yearly in Turkey.

CONCLUSION

The high age-adjusted overall mortality in Turkey shows nonsignificant differences across geographic regions, whereas the age-adjusted CHD incidence is high in the Black Sea and Marmara regions.

Diverging sex-specific long-term effects of cigarette smoking on fasting insulin and glucose levels in non-diabetic people

OBJECTIVES

We determined in non-diabetic persons the associations of current smoking with future glucose and insulin concentrations.

DESIGN AND METHODS

Middle-aged non-diabetic adults (n=1071) were studied in whom these values were measured at baseline and 5.2-years later.

RESULTS

Age-adjusted fasting insulin concentrations in 137 smoking men remained lower than never smokers at both surveys. While age-adjusted fasting glucose values in male never smokers declined at follow-up (p=0.037), they rose in male smokers. In 94 female smokers, age-adjusted fasting insulin values marginally declined, and fasting glucose was reduced (by 0.09 mmol/L, p=0.055) during follow-up. In contrast in never-smoking women, insulin and glucose concentrations rose (p<0.001 in both). Age-adjusted insulin levels in former smokers exhibited similar trends as never smokers. Trends were essentially unchanged when adjustment included body mass index. Current male smokers demonstrated evidence of reduced insulin sensitivity, female smokers of improved one, as assessed by QUICKI.

CONCLUSION

Smoking among Turks induces at long-term lower fasting insulin levels which represent improved insulin sensitivity in women, yet a reduced one in men.

Investigation of the association between dopamine D1 receptor gene polymorphisms and essential hypertension in a group of Turkish subjects

Dopamine has been shown to influence blood pressure by regulating renal sodium excretion through direct interaction with the dopamine receptors, especially with the Dopamine D1 receptor (DRD1). To better understand the role of polymorphisms in those effects, we investigated the association between two polymorphic sites in the DRD1 promoter region (A-48G, G-94A) and essential hypertension in the Turkish population. The DRD1 variants were genotyped by restriction fragment length polymorphism (RFLP) analysis. A total of 205 unrelated individuals were enrolled in the study. We found that genotype distributions and allele frequencies of the control and hypertensive subjects were very similar and did not show any significant difference with respect to blood pressure (BP) and hypertension. Contribution of the gene variances in BP or hypertension by sex differences and dependence on body mass index (BMI) were also evaluated. Distribution of genotypes and allele frequencies were found to be in line with previous reports. However, increments detected in hypertensive subjects were far from being statistically significant.

Coronary disease risk and fasting glucose levels in a non-diabetic population

We addressed whether or not the risk of coronary heart disease (CHD) in non-diabetic persons is linear at the lower end of fasting glucose levels. Middle-aged Turkish adults (n=2893) free from diabetes and CHD at baseline were studied prospectively over a 7.6-year follow-up. Participants with fasting glucose measurements were analyzed in 3 groups separated by 90 mg/dl and 110 mg/dl limits. Outcomes were analyzed by Cox regression. Cox regression for CHD incidence (n=374) showed an increased age-adjusted risk in the <90 mg/dl fasting glucose group (n=788) [HR 1.32 (1.03; 1.68)], compared with the 90-110 mg/dl group after adjustment for sex, age and the glucose groups. Further adjustment for waist circumference, C-reactive protein and conventional risk factors attenuated the HR to 1.27 (p=0.077). The risk profile in the low-glucose group could not be accounted for by age, smoking status, systolic blood pressure or fasting insulin levels but tended to show higher levels of circulating C-reactive protein. The increased CHD risk observed in individuals with lower compared with higher normal glucose concentrations is likely to be related to an associated pro-inflammatory state.

[The Turkish Adult Risk Factor survey 2009: similar cardiovascular mortality in rural and urban areas]

OBJECTIVES

We analyzed 2009 survey of the Turkish Adult Risk Factor (TARF) Study to assess the distribution of all-cause and cardiovascular mortality in urban and rural areas and sex-specific coronary mortality in the age-bracket of 45 to 74 years.

STUDY DESIGN

The Marmara and Middle East regions have been surveyed every odd year in the TARF Study. In 2009, 1,655 participants were surveyed. Information on the mode of death was obtained from first-degree relatives and/or health personnel of local heath office; 960 participants underwent physical examination and ECG recording, and 572 subjects were evaluated on the basis of information obtained regarding health status.

RESULTS

In the survey, 23 men and 20 women were ascertained to have died. Twenty-one deaths were attributed to coronary disease and four deaths to cerebrovascular events. Assessment of the entire cohort in the age bracket of 45-74 years after a 19-year follow-up disclosed a high coronary mortality with 7.5 per 1000 person-years in men and 3.9 in women. In a Cox regression analysis comprising 405 deaths (235 cardiovascular) and over 24,000 person-year follow-up, age-adjusted cardiovascular mortality was similar in rural and urban participants. All-cause mortality was higher in females living in urban areas than those living in rural areas (HR 1.41; 95% CI 1.02-1.96).

CONCLUSION

Cardiovascular mortality both in absolute terms and as a share of overall mortality persists to be high among Turkish adults, with similar rates in urban and rural areas. Age-adjusted all-cause mortality rate is higher among urban versus rural women.

Effect of intratumoral lymphocyte density on the disease-free survival and overall survival in malignant epithelial tumors of the ovary

Malignant epithelial ovarian tumors are the fifth most common cancer of females which has the highest mortality rate among gynecological malignancies. Tumor-specific or related antigens that induce an immune response have been defined in tumors. Intratumoral T lymphocytes recognize these antigens and induce a cytolytic activity. Vascular endothelial growth factor (VEGF) is a potent angiogenic factor expressed in many tumors. In this study, we studied the relation between clinicopathological findings and intratumoral T lymphocyte and VEGF expressions in malignant epithelial ovarian tumors. The presence of VEGF in ovarian surface epithelial carcinomas and CD3, CD4 and CD8 antibodies in tumor-infiltrated lymphocytes were investigated in 63 cases with an immunohistochemical method. Positive-stained intratumoral lymphocytes were graded on a scale of 0 to 3 (0 --> 0, +1 --> < or = 5, +2 --> 6-19, +3 --> > or = 20). VEGF was assessed according to the staining intensity (0: negative, +1: weak, +2: moderate, +3: strong). CD3 positivity was observed in intratumoral lymphocytes in all cases while only CD4 and CD8 positivities were observed in 30% and 80%, respectively. VEGF was positive in 73% of the cases. No significant relation was observed between VEGF expression and presence of intratumoral T lymphocyte and clinicopathological parameters. Moreover, they did not have any significant effect on disease-free survival and overall survival.

Obstructive sleep apnea syndrome is associated with metabolic syndrome rather than insulin resistance

The aim of this study was to investigate cross-sectionally the prevalence and covariates of obstructive sleep apnea syndrome (OSAS) and its relationship to metabolic syndrome (MS), insulin resistance (IR), and coronary heart disease (CHD) in a population sample of 1,946 men and women representative of Turkish adults. OSAS was identified when habitual snoring and episodes of apnea were combined with another relevant symptom. MS was diagnosed based on modified criteria of the Adult Treatment Panel III and IR by homeostatic model assessment (HOMA). OSAS was identified in 61 men (6.4%) and 58 women (5.8%), at a similar prevalence, after adjusting for covariates. Among individuals with OSAS, significantly higher odds ratios (ORs), adjusted for age, body mass index (BMI), and waist girth, were observed for MS, hypertension, and prevalent CHD, but not for HOMA or menopause. Significantly higher C-reactive protein existed only in women with OSAS who were also more frequent smokers. In logistic regression models, waist circumference, but not BMI nor hypertension, was significantly associated with OSAS among men. In women, by contrast, current cigarette smoking and hypertension were the significant independent covariates. Regression models controlling for sex, age, and smoking revealed that MS (and not IR per se) was associated significantly with OSAS (OR 1.94) in nondiabetic individuals. To conclude, abdominal rather than overall obesity in men and smoking among women are significant independent determinants of OSAS in Turkish adults. OSAS is associated with MS rather than IR per se. Relatively high prevalence of OSAS is observed in Turkish women in whom it is significantly associated with CHD.

Serum gamma glutamyltransferase as a marker of metabolic syndrome and coronary disease likelihood in nondiabetic middle-aged and elderly adults

The role of serum gamma glutamyltransferase (GGT) activity as a cardiovascular risk marker was studied basically cross-sectionally. After appropriate exclusions, 754 men and 802 women were available for analysis who were followed up briefly yielding only 16% of overall cases of coronary heart disease (CHD). GGT activity was measured kinetically. In multivariate analysis across 12 variables, waist circumference, sex, complement C3, moderate alcohol intake and uric acid were significant independent covariates of serum GGT. By analyzing the sample in tertiles, doubling in GGT activity was found associated with a rise of 74% in metabolic syndrome (MS) likelihood-independent of salient confounders (P < 0.001). This association was mediated by waist circumference. Individuals in the top versus the bottom tertile exhibited an odds ratio for CHD likelihood of 1.81 (95% CI 1.09; 3.02)-independent of age, sex, total cholesterol, systolic blood pressure, impaired fasting glucose, smoking status, alcohol usage and, notably, of waist circumference. This indicated that a doubling in serum GGT activity corresponded to a 45% excess in CHD likelihood, after adjustment for standard risk factors. In conclusion, waist circumference is a major determinant of serum GGT activity among Turkish adults. Doubling in activity is associated with a (largely waist girth mediated) rise by over one-half in the multiadjusted MS likelihood, and by nearly one-half in the CHD likelihood, independent of waist girth and major risk factors.

[Lipoprotein (a) in a population-based study: more significant in Turkish women than men?]

OBJECTIVE

Serum lipoprotein(a) [Lp(a)] concentrations, determined in 665 persons in the 2003/04 survey of the Turkish Adult Risk Factor Study, were investigated in regard to distribution, determinants and relationship to cardiovascular risk factors, metabolic syndrome (MS) and coronary heart disease (CHD).

METHODS

Diagnosis of MS was based on Adult Treatment Panel III criteria, that of CHD on the presence of clinical findings and Minnesota coding of resting electrocardiograms. Metabolic syndrome was observed in 44%, CHD in 14% of the study sample. Behring nephelometry was used for Lp(a) values measurements which were log-transformed for analyses because of skewing.

RESULTS

Geometric mean values of Lp(a) in 286 men and 379 women, aged 55.5 +/-12.0 years, were 9.46+/-2.90 mg/dL and 10.46+/-3.00 mg/dL (p>0.2), respectively. Apart from a slight correlation with age, Lp(a) exhibited significant positive correlations with apolipoproteins A-I and B, low density lipoprotein-cholesterol (LDL-C) (r =0.15), total cholesterol, high density lipoprotein-cholesterol (HDL-C), systolic blood pressure and log C-reactive protein, and inverse ones with thyroid stimulating hormone (r =-0.25) in men, and log gamma glutamyltransferase in women. Further 10 variables were not significantly correlated in either gender. In linear regression analyses for independent covariates of Lp(a), positive associations were noted with serum total cholesterol and systolic blood pressure, and inverse ones with waist circumference, triglycerides and (only in women) with gamma glutamyltransferase. Logistic regression analyses revealed in men no association with either MS or CHD likelihood. Among women, age-adjusted Lp(a) was associated inversely at a borderline significance with MS, as did levels of Lp(a) >30 mg/dl vs. the remaining sample, controlled for age and MS, display an odds ratio (OR) of 1.62 for prevalent CHD (p=0.20). An OR of 1.92 (p<0.19) was noted in all adults for the coexistence of Lp(a) >30 mg/dl and LDL-C >150 mg/dl, after controlling for age, MS, smoking status and LDL-C categories.

CONCLUSION

Lipoprotein(a), the variance of which is known to be overwhelmingly due to the apo(a) isoforms, proved to have a significant inverse independent association with a measure of abdominal obesity. Lipoprotein(a) levels appeared not to be associated with risk for MS or CHD among men. In women, however, high Lp(a) levels were accompanied with an environment less prone to MS, and - without attaining significance -- tended to be associated with CHD likelihood, independent of age and MS. Further studies are warranted in this area.

Sex difference in development of diabetes and cardiovascular disease on the way from obesity and metabolic syndrome

AIM

The objective of this study was to investigate sex-specific differences existing on the way from (abdominal) obesity and metabolic syndrome (MS) to type 2 diabetes mellitus (DM) and cardiovascular disease (CVD).

METHODS

A population sample of 1974 men and women, representative of Turkish adults (mean age, 48 years), with normal glucose metabolism (GM) and free of CVD at baseline, was prospectively evaluated at a mean 4.1 years of follow-up. The term abnormal GM designated both DM and impaired fasting glucose (IFG). Metabolic syndrome was identified in 29% of men and 40% of women by the criteria of the National Cholesterol Education Program guidelines. Fatal and nonfatal CVD, diagnosed by clinical findings and Minnesota coding of resting electrocardiograms, developed in 121 subjects.

RESULTS

The cohort was dichotomized by the presence or absence of MS and of obesity defined by a body mass index of 30 kg/m 2 or greater. Compared with the major female group with no obesity or MS, women with MS, regardless of the presence of obesity, predicted highly significantly the development of abnormal GM with relative risks exceeding 2, whereas no independent significant association was noted in men with MS. Similar divergence of sexes pertained to the prediction of diabetes. When age, smoking status, grade of physical activity, IFG, DM, and the 4 groups with obesity and MS were analyzed for the prediction of CVD by logistic regression, men with MS, regardless of the presence of obesity, predicted highly significantly CVD (with relative risks ranging from 2 to 4), but neither DM nor IFG contributed independently. Conversely, in women, abnormal GM predicted CVD independent of age, smoking status, and grade of physical activity, but the groups with obesity and MS failed to significantly contribute independently.

CONCLUSIONS

In populations with prevalent MS, whereas women with normal GM are prone to DM within the context of MS and are exposed to CVD risk primarily by way of DM, men are prone to visceral adiposity, less susceptible to DM, and run CVD risk primarily by the intermediary of MS, largely independent of the DM component.

[Distribution of risk factors according to socioeconomic status in male and female cases with coronary artery disease]

OBJECTIVE

Socioeconomic status (SES) is associated with coronary artery disease (CAD) risk factors, coronary morbidity and mortality. In industrialized countries several studies showed that the lowest SES groups have higher coronary morbidity and mortality rates and higher coronary risk factors profile. The aim of our study was to investigate the distribution of risk factors in cases with CAD in different socioeconomic groups.

METHODS

Our study group consists of 550 consecutive cases with > or = 50% lesions in at least one coronary artery. Educational level and income were taken into consideration for the determination of the SES. In both sexes the distribution of eight risk factors such as, smoking, family history, diabetes mellitus, hypertension, high low-density lipoprotein cholesterol (LDL-C), low high-density lipoprotein cholesterol (HDL-C), body mass index, central obesity was compared in three different groups determined according to the education and income levels.

RESULTS

In men, the distribution of risk factors did not differ according to education levels. In women, central obesity was found to be higher in the group with low education level. In men, the prevalence of low HDL-C, high LDL-C and obesity increased with increasing levels of economical status. In women, central obesity was found to be inversely related with the economic status.

CONCLUSION

Our data show a higher risk factor profile in men with higher income level, while in women central obesity was inversely related to the income and educational level. These data should be considered in secondary prevention efforts.

Seroprevalence of Helicobacter pylori infection among children and their parents in eastern Turkey

OBJECTIVES

To determine the seroprevalence of Helicobacter pylori infection among healthy children in eastern Turkey, to assess risk factors for seroconversion, and to assess the role of parental infection status in the transmission of H. pylori.

METHODS

A commercial enzyme immunoassay test for IgG to H. pylori was used. Demographic information obtained included age, gender, socio-economic status and living conditions.

RESULTS

One hundred and fifty-two (43.9%) of 346 children were seropositive. There was no significant difference in rates of seroprevalence between boys and girls (P > 0.05), but a significant rise was noted with increasing age (P < 0.001). We found a strong inverse correlation between family income and seropositivity (P < 0.001). Seroprevalence also varied significantly with the educational level of the mother (P < 0.001). There were no significant differences in seroprevalence associated with place of residence, water supply and the number of persons per room (P > 0.05). The prevalence of infection in the corresponding parents was 85.4% for mothers and 76.3% for fathers. Seroprevalence was higher in children whose mother was infected (P < 0.001).

CONCLUSIONS

In eastern Turkey, as in other developing countries, H. pylori infection occurs early and increases with age. Infected parents, especially infected mothers, may have a important role in the transmission of H. pylori within families.

[Relation of HLA antigens and myocardial infarction]

OBJECTIVE

Genetic predisposition and chronic inflammation play the leading role in the early stages and in the development of atherosclerosis. Previous studies have shown that substantial amounts of T-lymphocytes are present in both early fatty lesions and advanced fibrous lesions in humans. This observation suggests that HLA antigens may be used as genetic markers for the tendency to coronary artery disease. The aim of our study was to investigate the relation of atherosclerosis and HLA antigens in patients with acute myocardial infarction.

METHODS

Thirty consecutive patients with acute myocardial infarction (15 male, 15 female, aged 54+/-8 years) and 30 subjects (15 male, 15 female, aged 52+/-7 years) without evidence of coronary artery disease--according to physical, fundoscopic, electrocardiographic and radiological examination--were enrolled to the study. Histocompatibility antigens (HLA-AB, -DR, -DQ) were studied with lymphocytotoxicity method.

RESULTS

Age, gender, smoking, alcohol consumption, frequency of obesity and diabetes mellitus were similar between the two groups. In patients with myocardial infarction frequency of hypertension, family history and hyperlipidemia were significantly higher than the controls (p < 0.0003, p < 0.0001, p < 0.01 respectively). Frequency of HLA antigens in patients and in controls was 50% and 23% for HLA-A2, 63% and 20% for HLA-DQ4 and 90% and 50% for HA-DQ7. Logistic regression analysis revealed a significant relation with the disease and the presence of these antigens (p = 0.02, p = 0.02 and p = 0.03 respectively).

CONCLUSIONS

It is concluded that in the Turkish population presence of HLA-A2, HLA-DQ4 ve HLA-DQ7 (3) may be used as genetic markers for the tendency to coronary artery disease.