Trends in prevalence and incidence of diabetes mellitus from 2005 to 2014 in Taiwan

Aspirin and Risk of Specific Breast Cancer Subtype in Women with Diabetes

Purpose: Low-dose aspirin was associated with a reduced risk of breast cancer in women with diabetes. However, whether the protective effect of aspirin varies as a function of the hormone receptor status of breast cancer remained an unanswered question. This study aims to explore the association between aspirin use and the risk of specific breast cancer subtypes in women with diabetes. Methods: Population-based retrospective cohort study of women with diabetes, using the Taiwan National Health Insurance reimbursement database (year 1998 to 2011). Patients diagnosed to have diabetes with new low-dose aspirin use (75-165 mg per day) for at least 28 days of prescription were identified as the study population, while patients without low-dose aspirin use were selected as controls. The main outcome measure was breast cancer by aspirin use and hormone receptor status. Results: We studied a total of 148,739 patients with diabetes. Their mean (standard deviation) age was 63.3 (12.8) years. During follow-up, a total of 849 breast cancers occurred, including 329 hormone receptor-positive and 529 hormone receptor-negative tumors. A total of 27,378 patients were taking aspirin. The reduction in risk with aspirin use was seen among those with hormone receptor-positive breast cancer (Hazard ratio [HR]: 0.73; 95% confidence interval [CI]: 0.59-0.91) but not for women with hormone receptor-negative breast cancer (HR: 0.88; 95% CI: 0.74-1.05). A cumulative dose of aspirin use of more than 8,600 mg was found to reduce the risk of hormone receptor-positive breast cancer by 31% (HR: 0.69; 95% CI: 0.50-0.97). A cumulative dose of aspirin use of more than 88,900 mg was found to reduce both the risk of hormone receptor-positive and negative breast cancer. Conclusion: These data add to the growing evidence that supports the use of low-dose aspirin as a potential chemopreventive agent for specific subtypes of breast cancer. Further studies are necessary to confirm these findings.

Glycative Stress, Glycated Hemoglobin, and Atherogenic Dyslipidemia in Patients with Hyperlipidemia

(1) Background: Diabetes mellitus (DM) is a significant health problem and is associated with dyslipidemia; however, the association between glycative stress, in terms of glycated hemoglobin (HbA1c), and atherogenic dyslipidemia in hyperlipidemic patients with and without DM has rarely been reported. (2) Methods: We prospectively recruited 949 hyperlipidemic patients from the Lipid Clinic of the National Taiwan University Hospital. HbA1c and fasting serum lipids, including total cholesterol (TC), high- and low-density lipoprotein cholesterol (HDL-C and LDL-C), small dense LDL-C (sdLDL-C), very low-density lipoprotein cholesterol (VLDL-C), triglycerides, and advanced glycation end-products (AGEs), were measured. After fasting for 10-14 h, all subjects except those with DM underwent a standard oral glucose tolerance test (OGTT) with 75 g of glucose loading. All subjects were asked to discontinue the use of lipid-lowering agents for 8 weeks before recruitment. (3) Results: Patients with DM had a higher prevalence of hypertension and higher levels of triglyceride, TC/HDL-C ratio, AGEs, VLDL-C, and sdLDL-C. Among patients with higher HbA1c, the serum VLDL-C, AGEs, and TC/HDL-C ratio were significantly higher than those with lower HbA1c. After adjustment for covariates, multiple logistic regression analyses revealed different groups of dysglycemia with higher HbA1c had a higher odds ratio for TC/HDL-C ≥ 5, sdLDL-C ≥ 75th percentile, VLDL-C ≥ 75th percentile and AGEs ≥ 75th percentile. (4) Conclusions: A higher HbA1c was associated with a significant increase in the risk of atherogenic dyslipidemia and AGEs levels in patients with hyperlipidemia. The findings can be very promising in clinical application.

Association of Dipeptidyl Peptidase-4 Inhibitors Use with Reduced Risk of Hepatocellular Carcinoma in Type 2 Diabetes Patients with Chronic HBV Infection

Previous studies have indicated that HBV infection and T2DM are the factors that increase the risk of developing HCC. The experimental evidence has shown that antiglycemic agents may reduce the risk of HCC. However, the effect of dipeptidyl peptidase-4 inhibitors (DPP-4 inhibitors) on the risk of HCC in T2DM patients with chronic HBV infection remains unclear. In this retrospective cohort study, we extracted patients with T2DM and chronic HBV infection from the National Health Insurance Research Database (NHIRD) in Taiwan. The cases were divided into DPP-4 inhibitors use and non-use groups, according to whether they received DPP-4 inhibitors treatment, and the risk of HCC was compared between the two groups. At the end of the follow-up, approximately 2.33% of DPP-4 inhibitors users had received an HCC diagnosis compared with 3.33% of non-DPP-4 inhibitors users (p < 0.0001). After multivariate adjustment, DPP-4 inhibitors users showed a significant reduction in HCC risk (adjusted hazard ratios (aHRs): 0.53; 95% confidence intervals (CIs): 0.44-0.65). In conclusion, this population-based retrospective cohort study indicated that, in T2DM patients with chronic HBV infection, the use of DPP-4 inhibitors significantly reduced the risk of developing HCC compared with non-DPP-4 inhibitors use.

Association between a priori and a posteriori dietary patterns and the risk of type 2 diabetes: a representative cohort study in Taiwan

The present study aimed to investigate the relationship between dietary patterns and the risk of type 2 diabetes mellitus (T2DM) among Taiwanese individuals. Data were collected using a nationwide cohort study (2001-15) from the Triple-High Database. Dietary intake was assessed using the twenty-group food frequency questionnaire and used to calculate alternate Mediterranean diet (aMED) and Dietary Approaches to Stop Hypertension (DASH) scores. Principal component analysis (PCA) and partial least-squares (PLS) regression were used to derive dietary patterns, with incident T2DM as the outcome. Multivariable-adjusted hazard ratios and 95 % confidence intervals were calculated using time-dependent Cox proportional hazards (Cox PH) regression analysis, and subgroup analyses were performed. A total of 4705 participants were enrolled in the study, and 995 had newly developed T2DM during the median 5⋅28-year follow-up period (30⋅7 per 1000 person-years). Six dietary patterns were extracted (PCA: Western, prudent, dairy and plant-based; PLS: health-conscious, fish-vegetable and fruit-seafood). The highest aMED score quartile had a 25 % (hazard ratio 0⋅75; 95 % CI 0⋅61, 0⋅92; P = 0⋅039) lower risk of T2DM than the lowest quartile. This association remained significant after adjustment (adjusted hazard ratio 0⋅74; 95 % CI 0⋅60, 0⋅91; P = 0⋅010), and no effect modifier was found for aMED. The DASH scores, PCA and PLS dietary patterns were not significant after adjustment. In conclusion, high adherence to a MED-type dietary pattern by Taiwanese foods was associated with a lower risk of T2DM in the Taiwanese population, regardless of unhealthy lifestyle habits.

Proximal tubule-derived exosomes contribute to mesangial cell injury in diabetic nephropathy via miR-92a-1-5p transfer

BACKGROUND

Diabetic nephropathy (DN) is an increasing threat to human health and regarded to be the leading cause of end-stage renal disease worldwide. Exosomes delivery may play a key role in cross-talk among kidney cells and the progression of DN. However, the mechanisms underlying exosomes in DN remain unclear.

METHODS

The cross-disciplinary study, including in vivo, in vitro, and human studies was conducted to explore the cross-talk between proximal tubular epithelial cells (PTECs) and mesangial cells (MCs) in DN. We purified exosome from PTECs treated with high glucose and db/db mice and assessed their influences in the pathologic change of MCs and downstream signal pathway. Healthy individuals and type 2 diabetic patients were enrolled to examine the role of exosomes in clinical applications.

RESULTS

High glucose stimulated PTECs to secrete exosomal miR-92a-1-5p, which was taken-up by glomerular MCs, inducing myofibroblast transdifferentiation (MFT) in vitro and in vivo. PTEC-released exosomal 92a-1-5p decreased reticulocalbin-3 expression, leading to endoplasmic reticulum (ER) stress by downregulating genes essential for ER homeostasis including calreticulin and mesencephalic astrocyte-derived neurotrophic factor. Treatment with miR-92a-1-5p inhibitor ameliorated kidney damage in db/db mice with DN. Urinary miR-92a-1-5p could predict kidney injury in type 2 diabetic patients.

CONCLUSIONS

PTEC-derived exosomal miR-92a-1-5p modulated the kidney microenvironment in vivo and in vitro models, which altered ER stress and MFT in MCs resulting in DN progression. Further blocking miR-92a-1-5p epigenetic regulatory network could be a potential therapeutic strategy to prevent the progression of DN. Video Abstract.

Graves disease is more prevalent than Hashimoto disease in children and adolescents with type 1 diabetes

Introduction

Autoimmune thyroid disease (AITD) is the most common associated autoimmune disorder in type 1 diabetes (T1D). Early detection of AITD is crucial to optimize glycemic control, growth, and intellectual development. In this prospective cohort study, we sought to characterize the prevalence, incident ages and risk factors of AITD in children and adolescents with T1D.

Materials and methods

Patients with T1D diagnosed at ≤ 18 years at MacKay Children's Hospital, Taipei, from 1990 to 2019 underwent annual screening for AITD. Institutional Review Board-approved data on age, sex, and disease profile are collected. Statistical analysis was performed by using independent sample t test for continuous variables, chi-squared test for categorical variables, and Kaplan-Meier estimates of cumulative incidence of AITD were calculated. A p value of <0.05 was considered statistically significant.

Results

We prospectively followed up 808 patients with T1D, 761 patients were included in the study. Of these patients, 197 (25.9%) of them had thyroid autoimmunity, meaning positivity of thyroid autoantibodies. Females had a higher prevalence of thyroid autoimmunity than males (59.9%, p = 0.012). Altogether, 5.5% patients developed AITD (4.1% had Graves disease; 1.4% had Hashimoto disease), at a mean age of 17.8 ± 8.5 years. The cumulative incidence of AITD at 30 years of disease duration was 0.29 in the total group and was significantly higher in females (0.39, n = 397) than in males (0.15, n = 364, p<0.001).

Discussion

In Taiwan, the prevalence of AITD in pediatric population with T1D increases with age, a longer disease duration and female sex. For early detection of autoimmune thyroid disease in Taiwanese children and adolescents with T1D, an annual AITD screening program should be implemented.

Association between genetic risk score and tri-ponderal mass index growth trajectories among different dietary consumption adolescents in a prospective Taiwanese cohort

BACKGROUND

Single-nucleotide polymorphisms (SNPs) in various genetic loci are associated with childhood obesity; however, their influence on adolescent growth patterns has rarely been explored. This study investigated whether genetic variants could predict tri-ponderal mass index (TMI)-derived growth trajectories and the interaction between genetic and dietary factors.

METHODS

We conducted Taiwan Puberty Longitudinal Study, a prospective cohort that recruited 1,135 children since 2018. Anthropometric measurements were recorded every three months, while dietary nutrition assessment and biological sampling for genotyping were collected during the first visit. TMI growth trajectory groups were identified using growth mixture modeling. A multinomial logistic regression model for different growth trajectories was used to examine the effect of candidate SNPs, and the most related SNPs were used to establish the genetic risk score. We then explored the effect of the genetic risk score in subgroup analysis according to dietary calories and different dietary consumption patterns.

RESULTS

Three TMI-based growth trajectory groups were identified among adolescents. The "increased weight" trajectory group accounted for approximately 9.7% of the participants. FTO/rs7206790 was associated with the increased weight growth trajectory after adjusting for the baseline TMI and other correlated covariates (OR: 2.13, 95% CI: 1.08-4.21). We generated the genetic risk score using 4 SNPs (FTO/rs7206790, ADCY9/rs2531995, TFAP2B/rs4715210, and TMEM18/rs6548238) and selected the threshold of 10 points to define risk categories. There were 11.66% and 3.24% of participants belonged to the increased weight trajectory in high- and low-risk groups, respectively; and the predictive ability of the genetic risk score was notable among low calories intake participants (OR: 1.90, 95% CI: 1.18-3.05 vs. OR: 1.17, 95% CI: 0.78-1.75 in high calories intake group).

CONCLUSION

Our results offer a new perspective on the genetic and dietary basis of changes in adolescent obesity status. Individualized interventions for obesity prevention may be considered among high-risk children.

Risk of motorcycle collisions among patients with type 2 diabetes: a population-based cohort study with age and sex stratifications in Taiwan

AIMS

To investigate the overall and sex-age-specific absolute and relative risks of motorcycle collisions at road traffic accidents among patients with type 2 diabetes.

METHODS

A cohort study in Taiwan was conducted by following 989,495 patients with type 2 diabetes and the same number of matched controls recruited between 2010 and 2012 to the end of 2016. Collision events by motorcycle driver victims were identified from the Police-reported Traffic Accident Registry. Overall and sex-age-specific incidence rates of collision involving motorcycle driver victims were estimated under Poisson assumption. The Cox proportional hazard regression models were performed to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) of collision in association with type 2 diabetes.

RESULTS

Over an up to 7 years of follow-up, patients with type 2 diabetes had a higher incidence rate of motorcycle collision than controls at 1.16 and 0.89 per 100 person-years, respectively, which represented a significantly elevated HR of 1.28 (95% CI 1.27-1.30) after adjusting for potential confounders including various diabetic complications. The elevated HR was similarly seen in both men and women patients, and was significantly decreasing with increasing age regardless of sex. Little evidence supported the dose-response relationship between duration of type 2 diabetes and motorcycle collision risk.

CONCLUSIONS

After adjustment for common diabetic complications and comorbidities that could impair driving performance, patients with type 2 diabetes still suffered from increased risk of motorcycle collisions, regardless of sex, but was more evident in younger than in older patients.

Phenome-wide analysis of Taiwan Biobank reveals novel glycemia-related loci and genetic risks for diabetes

To explore the complex genetic architecture of common diseases and traits, we conducted comprehensive PheWAS of ten diseases and 34 quantitative traits in the community-based Taiwan Biobank (TWB). We identified 995 significantly associated loci with 135 novel loci specific to Taiwanese population. Further analyses highlighted the genetic pleiotropy of loci related to complex disease and associated quantitative traits. Extensive analysis on glycaemic phenotypes (T2D, fasting glucose and HbA_1c) was performed and identified 115 significant loci with four novel genetic variants (HACL1, RAD21, ASH1L and GAK). Transcriptomics data also strengthen the relevancy of the findings to metabolic disorders, thus contributing to better understanding of pathogenesis. In addition, genetic risk scores are constructed and validated for absolute risks prediction of T2D in Taiwanese population. In conclusion, our data-driven approach without a priori hypothesis is useful for novel gene discovery and validation on top of disease risk prediction for unique non-European population.

An investigation of physicians' prescribing behaviors related to antidiabetic agents for Type 2 diabetes mellitus patients and associated factors in Taiwan

OBJECTIVES

This study aimed to examine the factors that may influence physicians' choice of antidiabetic agents. In addition, we investigated physicians' decision-making process and treatment of T2DM patients with chronic kidney disease (CKD). Finally, we wanted to determine whether physicians knew the latest recommendations for T2DM treatment.

METHODS

The study was conducted as a cross-sectional survey using an online self-administered questionnaire to collect data from physicians in Taiwan. We enrolled licensed physicians who worked in hospitals or clinics with an average monthly T2DM patient load of 100 patients. Descriptive statistics, the independent samples t-test, and the Chi-square test were used for data analysis. Moreover, the association was examined between respondents' demographics and the proportion of respondents who answered each T2DM treatment question correctly.

RESULTS

A total of 986 invitations were sent out, and 324 completed questionnaires were received. The most important factors that may influence physicians' choice of antidiabetic agents in each factor category were major comorbidities of patients, coverage of insurance, guideline recommendations, cardiovascular disease benefit, and whether a drug is the brand-name drug, respectively. When choosing second-line antidiabetic agents for T2DM patients with CKD, the most common reasons for doing so were recommendations of clinical guidelines (83.6%) and patients' renal function (59.6%) while SGLT2is were respondents' most commonly chosen treatment. Respondents were more familiar with ADA recommendations for patients with certain major comorbidities than with the drugs' labeled indications. Moreover, physicians who were younger, female, specialty in diabetes, or working in medical centers were more likely to give correct answers to certain questions about ADA guidelines (all p < .05).

CONCLUSION

This study provides a better understanding of the influential factors, treatment choices, and reasoning related to physicians' prescribing of antidiabetic agents in Taiwan. In addition, knowledge gaps in various physician groups were identified.

Disease burden and demographic characteristics of mucormycosis: A nationwide population-based study in Taiwan, 2006-2017

BACKGROUND

Epidemiological knowledge of mucormycosis obtained from national population-based databases is scarce.

OBJECTIVES

This study aimed to depict the disease burden and demographics of mucormycosis in Taiwan by using the Taiwan National Health Insurance Research Database (NHIRD) and those of aspergillosis as a comparator.

METHODS

Data from patients with either mucormycosis or aspergillosis from 2006 to 2017 identified with the International Classification of Diseases (ICD) codes were extracted from the NHIRD. The incidence, demographics and clinical data of both diseases were analysed.

RESULTS

A total of 204 patients with mucormycosis and 2270 patients with aspergillosis who were hospitalised and treated with mould-active antifungals between 2006 and 2017 were identified. The average annual incidence of aspergillosis (0.81 cases per 100,000 population [0.81/100,000]) was 11-fold higher than that of mucormycosis (0.07/100,000). A significant increase in incidence was observed for aspergillosis (from 0.48/100,000 in 2006 to 1.19/100,000 in 2017, p < .0001) but not for mucormycosis (from 0.04/100,000 in 2006 to 0.11/100,000 in 2017, p = .07). The major underlying disease identified was diabetes mellitus (60.8%) for mucormycosis and malignant neoplasms (45.9%) for aspergillosis. The all-cause 90-day mortality rate was similar between mucormycosis and aspergillosis patients (39% vs. 37%, p = .60). For mucormycosis patients, multivariate analysis revealed that posaconazole use was associated with lower in-hospital mortality (aOR 0.38; 95% CI 0.15-0.97; p = .04).

CONCLUSIONS

Mucormycosis is an uncommon fungal disease in Taiwan, occurring mostly in diabetic patients. However, the incidence might be underestimated due to limited diagnostics. Continuous surveillance might aid in delineating the evolving features of mucormycosis.

Clinical course of adolescents with type 2 diabetes mellitus: A nationwide cohort study in Taiwan

AIMS/INTRODUCTION

The global incidence of adolescents with type 2 diabetes mellitus is increasing. This cohort study was conducted aiming to describe the characteristics, drug-use condition, and long-term outcomes of adolescents with type 2 diabetes mellitus.

MATERIALS AND METHODS

Two thousand seven hundred fifty-five newly diagnosed adolescents with type 2 diabetes mellitus (using ICD-9-CM: 250.x and having ≥3 clinic visits) were identified from the national health insurance dataset during 2000-2014. Treatments were classified into four groups: metformin, sulfonylurea (SU), metformin plus SU, and insulin with or without oral antidiabetic drugs. The multiple Cox regression model was used to compare the risks of mortality and hospitalization among these four groups.

RESULTS

The mean follow-up period was 5.4 years. After 1 year of antidiabetic treatment, they gradually needed intensified therapy, and at 3 years, half of them showed treatment failure. The mortality rate was 2.08 per 1,000 person-years. Respiratory diseases (36.2%) and dysglycemia (16.4%) were the most common causes of hospitalization among these adolescents. Compared with persons taking metformin plus SU, metformin users were associated with a lower risk of all-cause hospitalization [0.82 (0.67-0.99)]; insulin users were associated with a higher risk of dysglycemia [4.38 (2.14-8.96)], cancer [3.76 (1.39-10.1)], and respiratory hospitalization [1.66 (1.14-2.41)]; and SU users were associated with a higher risk of hospitalization for respiratory diseases [1.91 (1.13-3.23)].

CONCLUSIONS

This nationwide cohort study demonstrated that adolescents with type 2 diabetes mellitus were prone to treatment failure. Furthermore, respiratory diseases and dysglycemia were the most common causes of hospitalization.

Age Specific Risks of Uterine Cancer in Type 2 Diabetes and Associated Comorbidities in Taiwan

Introduction: The global incidence of uterine cancer has increased substantially in recent decades. We evaluated if the trend of increasing prevalence of diabetes mellitus (DM) and obesity are attributed to the development of uterine cancer. Methods: Using data derived from the National Health Insurance database and Taiwan Cancer Registry, multivariate Cox proportional hazards regression models were adapted to analyze the risk factors of uterine cancer with potential confounding variables. Results: There were a total of 5,104,242 women aged 30−70 years enrolled in the study and 147,772 of them were diagnosed with DM during 2005−2007. In a total of 11 years of follow-up, 14,398 subjects were diagnosed with uterine cancer. An elevated risk of uterine cancer was observed in women with DM of all ages (HR 1.66, 95% CI 1.53−1.81, p < 0.0001). The effect of DM was highest at age 30−39 years (RR 3.05, 95% CI 2.35−3.96, p < 0.0001). In the group of <50 years old, DM patients had at least a twofold higher risk of developing uterine cancer (HR 2.39, 95% CI 2.09−2.74, p < 0.0001). Subjects among all ages diagnosed with polycystic ovary syndrome (PCOS) (HR 2.91, 95% CI 2.47−3.42, p < 0.0001), obesity (HR 2.13, 95% CI 1.88−2.41, p < 0.0001), and those undergoing hormone replacement therapy (HRT) (HR 1.60, 95% CI 1.33−1.93, p < 0.0001) were also positively associated with uterine cancer. Positive associations of hyperlipidemia (HR 1.33, 95% CI 1.22−1.46, p < 0.0001) and statin use (HR 1.27, 95% CI 1.12−1.44, p = 0.0002) on uterine cancer were only observed in subjects <50 years. On the contrary, hyperlipidemia was negatively associated with uterine cancer in subjects ≥50 years (HR 0.91, 95% CI: 0.84−0.98, p = 0.0122). Conclusions: DM is in general the most important risk factor for uterine cancer, especially in premenopausal women. Obesity, PCOS, HPL, statin use, and HRT were also associated with uterine cancer in subjects younger than 50 years. Premenopausal women with DM and respective comorbidities should be aware of the development of uterine cancer.

Effect of diabetes mellitus comorbidity on outcomes in stages II and III colorectal cancer

AIM

The effects of diabetes mellitus (DM) on the outcomes of colorectal cancer (CRC) are controversial. This retrospective study evaluated the effects of DM on American Joint Committee on Cancer (AJCC, 7th) Stages II and III CRC patients who received curative surgery.

METHODS

We reviewed the records of CRC patients who were treated from January 2008 to December 2014 and identified the presence of DM and hypertension prior to CRC diagnosis. Cox proportional hazards analyses were used for prognostic factor determination, and survival was analyzed using the Kaplan-Meier method with the log-rank test.

RESULTS

Total of 1066 consecutive eligible patients with stage II/III CRC were enrolled. There were 326 (30.6%) patients diagnosed with DM, and 311 (29.2%) CRC patients had recurrence. Patients with DM did not have a higher recurrence risk (p = 0.183) but had higher mortality (adjusted hazard ratio [aHR] = 1.381; 95% conference interval [CI], 1.069-1.782). In addition, HbA1c (≥7 vs. <7) was not associated with recurrence (p = 0.365). Patients with DM had more hypertension than patients without DM (69.1% vs. 37.6%, p < 0.001). A lower recurrence risk was noted in patients with hypertension (p = 0.002), but the overall survival (OS) did not reach statistical significance (aHR = 0.910; 95% CI, 0.707-1.169).

CONCLUSION

In our study, DM was a poor prognostic factor for survival in curative CRC patients. More studies are required to elucidate the effects that DM and other metabolic disorders, such as hypertension, have on the prognosis of patients with CRC.

Antiplatelet agents aspirin and dipyridamole, and the risk of different carcinoma in patients with type 2 diabetes mellitus: A Taiwan retrospective cohort study

Studies have shown aspirin decreases the risk of some cancers. However, the evidence reported the association between aspirin and cancer risk in the diabetic population. In this study, we investigate whether aspirin and dipyridamole decrease the risk of cancer in patients with type 2 diabetes. A total of 5308 patients with type 2 diabetes were identified by the National Health Insurance from 1998 to 2000 and followed up until 2013. The demographic characteristics among nondipyridamole nor aspirin, aspirin, and dipyridamole users were analyzed by using the χ(2) test. Cox proportional hazard regression models were used to determine the independent effects of no aspirin nor dipyridamole, aspirin, and dipyridamole users on the risk of different cancer. After adjustment with multiple covariates, both low and high doses of aspirin and dipyridamole decrease liver cancer with risk ratios of 0.56 (95% CI, 0.37-0.83), 0.14 (95% CI, 0.05-0.39), 0.61 (95% CI, 0.38-0.99), and 0.28 (95% CI, 0.12-0.66), respectively. Both low and high doses of aspirin decrease any types of cancer with risk ratios of 0.79 (95% CI, 0.64-0.98) and 0.49 (95% CI, 0.34-0.70), respectively. Therefore, we conclude aspirin may decrease any types of cancer and liver cancer, and dipyridamole may decrease the risk of liver cancer in patients with type 2 diabetes.

Lifestyle factors associated with muscle quality in community-dwelling older people with type 2 diabetes in Japan and Taiwan: a cross-sectional study

BACKGROUND

Type 2 diabetes mellitus (T2DM), common in older people, is an important reason for muscle loss in Japanese and Taiwanese populations. However, little is known about the association between lifestyle behaviours and muscle quality. We aimed to compare the lifestyle behaviours of Japanese and Taiwanese older adults with T2DM and to the identify lifestyle factors associated with muscle quality.

METHODS

This cross-sectional study was conducted among community-dwelling individuals with T2DM aged ≥65 years in Taiwan and Japan. Totally, 114 Japanese and 226 Taiwanese participants were enrolled in the study. Outcomes were measured by blood biochemical examinations, body composition analyses and structured self-reported questionnaires to assess lifestyle behaviours and muscle quality. Linear regression models were used to examine the relationship between lifestyle factors and muscle quality using SPSS version 27.0 with a statistical significance level of P < 0.05.

RESULTS

Japanese subjects were more likely to be smokers and alcohol consumers, and they were less likely to have well-balanced diets and engage in more physical activity as compared to Taiwanese subjects. The muscle quality in the Japanese subjects was significantly poorer than that in the Taiwanese subjects. Physical activity, dietary habits and smoking were associated with muscle quality, after adjusting for age, gender and body mass index.

CONCLUSIONS

Physical activity of insufficient intensity, unhealthy dietary habits and smoking could be risk factors for poor muscle quality. These findings can contribute to the development of effective strategies to improve muscle quality in community-dwelling older Asian people with T2DM.

Clinical significance of hepatic function in Graves disease with type 2 diabetic mellitus: A single-center retrospective cross-sectional study in Taiwan

Graves disease (GD) and type 2 diabetes mellitus (T2DM) both impair liver function; we therefore explored the possibility of a relationship among diabetic control, thyroid function, and liver function. This retrospective, cross-sectional study compared serum liver function biomarkers of primary GD patients in a single center between 2016 and 2020, derived from clinical databases, and clarified the correlation of liver function in GD patients with or without T2DM. Furthermore, the diabetes mellitus group was divided into glycated hemoglobin A1C (HbA1C) <6.5% group and ≥6.5% group to further analyze the effect by disease control in patients. Statistical differences between groups were assessed using independent t tests to clarify the association of serum biomarkers between GD with T2DM. Pearson test was applied to assess within-group statistical correlation of serum biomarkers. The correlation of factors in each group was demonstrated by using the Kendall tau-b method and stepwise regression analysis. A total of 77 patients were included in the study. In the study population, glutamate pyruvate transaminase (GPT) was significantly correlated with thyroid-stimulating hormone, and HbA1C was significantly correlated with alkaline phosphatase (ALK-P), glutamate oxaloacetate transaminase (GOT), and GPT. An examination of GOT, GPT, free thyroxine (FT4), and HbA1C levels revealed a significant difference between the non-T2DM and T2DM groups. GPT also exhibited a significant correlation with triiodothyronine in the T2DM group. The T2DM group was further divided into groups: HbA1C <6.5% and ≥6.5%. The results demonstrated that ALK-P, GOT, GPT, and FT4 levels were significantly different between the groups. A significant correlation between ALK-P and thyroid-stimulating hormone and between GOT and FT4 was also identified in the HbA1C <6.5% group. Our single-center study revealed that diabetes affects liver function in patients with GD. For patients with T2DM, when liver function becomes impaired, thyroid function control deteriorates. GPT was correlated with triiodothyronine but not with FT4, which indicated the impairment of deiodination in the liver. This phenomenon was not observed in the non-T2DM population. The early detection of abnormal liver function in patients with GD and T2DM may help limit the development of comorbidities and improve disease management.

Trends in all-cause mortality and major causes of death between 2007 and 2018 among patients with diabetes in Taiwan

Optimal control of diabetes and relevant risk factors substantially reduce the risks of chronic complications and mortality. We investigated all-cause mortality rate and major causes of death between 2007 and 2018 in patients with diabetes in Taiwan. This study was conducted using data from Taiwan National Health Insurance Research Database. We selected patients with diabetes diagnosed between 2007 and 2017 (grouped according to the year of diabetes diagnosis 2007-2010 vs. 2011-2017). Information on mortality and causes of death by the end of 2018 was confirmed through linking to the National Death Registry. Standardized mortality rate (SMR) were calculated by weighting the World Health Organization (WHO) standard population (WHO 2000-2025). More than 2.7 million of patients with diabetes were analyzed and a total of 566121 deaths were identified. Overall, the SMR was 11.72 per 1000 person-years. Patients with diabetes diagnosed in 2011-2017 had a lower SMR (8.42 vs. 12.92 per 1000 person-years) than those diagnosed in 2007-2010. Similar finding were noted regarding the major causes of death (cancer, diabetes, heart disease, hypertensive disease, and cerebrovascular disease). Compared with patients who were diagnosed in 2008-2010, those who were diagnosed in 2011-2014 and 2015-2018 had a higher 3-year survival rate (0.9356 vs. 0.9438 vs. 0.946, log-rank test p<0.001) after the diagnosis of diabetes. Patients who were diagnosed with diabetes after 2011 had a lower rate of all-cause mortality and major causes of death, compared with those who were diagnosed before 2010 in Taiwan.

Effect of Influenza Vaccination on the Reduction of the Incidence of Chronic Kidney Disease and Dialysis in Patients with Type 2 Diabetes Mellitus

Patients with type 2 diabetes mellitus (T2DM) have a higher risk of chronic kidney disease (CKD) due to vascular complications and chronic inflammation. T2DM contributes to a higher risk of mortality and morbidity related to influenza. In Taiwan, influenza vaccination is recommended for patients with T2DM. A previous meta-analysis reported the efficacy of influenza vaccination in reducing hospitalization and mortality in patients with diabetes; however, the renal protective effect of the vaccine remains unclear. This study evaluated whether influenza vaccination could reduce the incidence of CKD and dialysis in patients with T2DM. The study cohort included all patients aged ≥55 years who were diagnosed as having T2DM between 1 January 2000 and 31 December 2012, by using data from Taiwan’s National Health Insurance Research Database. Each patient was followed up with to assess factors associated with CKD. A time-dependent Cox proportional hazard regression model after adjustment for potential confounders was used to calculate the hazard ratio (HR) of CKD in the vaccinated and unvaccinated patients. The study population comprised 48,017 eligible patients with DM; 23,839 (49.7%) received influenza vaccination and the remaining 24,178 (50.3%) did not. The adjusted HRs (aHRs) for CKD/dialysis decreased in the vaccinated patients compared with the unvaccinated patients (influenza season, noninfluenza season, and all seasons: aHRs: 0.47/0.47, 0.48/0.49, and 0.48/0.48, respectively, all p < 0.0001). We observed similar protective effects against CKD during the influenza and noninfluenza seasons. Regardless of comorbidities or drug use, influenza vaccination was an independent protective factor. Furthermore, aHRs for CKD/dialysis were 0.71 (0.65−0.77)/0.77 (0.68−0.87), 0.57 (0.52−0.61)/0.69 (0.56−0.70), and 0.30 (0.28−0.33)/0.28 (0.24−0.31) in the patients who received 1, 2−3, and ≥4 vaccinations during the follow-up period, respectively. This population-based cohort study demonstrated that influenza vaccination exerts a dose-dependent and synergistic protective effect against CKD in the patients with T2DM with associated risk factors.

Impact of chronic hepatitis on cardiovascular events among type 2 diabetes patients in Taiwan pay-for-performance program

To investigate the impact of chronic hepatitis on cardiovascular events in patients with type 2 diabetes mellitus (T2DM). This nationwide retrospective cohort study included 152,709 adult patients (> 20 years) with T2DM enrolled in the National Health Insurance Diabetes Pay-for-Performance Program from 2008 to 2010 and followed up until the end of 2017. Patients were categorized into groups with hepatitis B, hepatitis C, fatty liver disease, and patients without chronic hepatitis. The incidence of cardiovascular events in patients with T2DM and hepatitis C (79.9/1000 person-years) was higher than that in patients with diabetes combined with other chronic hepatitis, or without chronic hepatitis. After adjusting for confounding factors, T2DM with fatty liver (adjusted hazard ratio [HR]: 1.10; 95% confidence interval [CI]: 1.07–1.13) and hepatitis C (adjusted HR: 1.09; 95% CI: 1.03–1.12) demonstrated a significantly higher risk of cardiovascular events. The adjusted visit-to-visit coefficient of variation of HbA1c and fasting blood glucose were associated with a high risk of cardiovascular events (HRs of the highest quartile were 1.05 and 1.12, respectively). Chronic hepatitis affects cardiovascular events in adult patients with T2DM. Glucose variability could be an independent risk factor for cardiovascular events in such patients.

Relationships among phthalate exposure, oxidative stress, and insulin resistance in young military soldiers: A cumulative risk assessment and mediation approach

BACKGROUND

Epidemiological studies concerning whether oxidative stress mediates phthalate exposure-insulin resistance (IR) associations in young adults are limited. Therefore, we investigated this potential mediation by using a cumulative risk approach involving daily intake (DI) and a hazard index (HI_RfD).

METHODS

The participants were 391 Taiwanese military personnel. This study measured their IR (as homeostatic model assessment of estimated IR [HOMA-IR]), levels of oxidative stress biomarkers (8-hydroxy-2-deoxyguanosine, 8-nitroguanine, 8-iso-prostaglandin F2α, and N-acetyl-S-[tetrahydro-5-hydroxy-2-pentyl-3-furanyl]-L-cysteine [HNE-MA]), the sum of these four biomarkers (ΣOS), and urinary phthalate metabolite concentrations. The HI_RfD was estimated on the basis of urinary levels of phthalate metabolite, and the DI of five phthalates was determined: dimethyl phthalate, benzyl butyl phthalate (BBzP), diethyl phthalate, dibutyl phthalate (DBP), and di (2-ethylhexyl) phthalate (DEHP). Logistic regression models were employed to explore associations among DI, HI_RfD, oxidative stress biomarkers, and HOMA-IR values. The role played by oxidative stress in the phthalate exposure-HOMA-IR association was determined using mediation analysis.

RESULTS

We discovered positive associations between high DI of DBP, BBzP, and DEHP; high HI_RfD; and high ΣOS. High ΣOS and HNE-MA were associated with a higher likelihood of a high HOMA-IR value. Mediation analysis indicated that high ΣOS and HNE-MA were significant mediators of the associations between phthalates and IR.

CONCLUSION

Oxidative stress may partially mediate the phthalate-IR relationship in young adults.

Use of expert consensus to improve the diagnosis and management of type 1 diabetes mellitus

BACKGROUND

Although type 1 diabetes mellitus (T1DM) is recognized as a catastrophic disease among the different types of diabetes, it is often confusedly diagnosed in clinical practice and difficult in care. The objective of this study is to reach a multidisciplinary consensus for the establishment of clinical recommendations on T1DM to optimize its undoubtedly diagnostic evaluation and transitional care.

METHODS

Scientific evidence was reviewed by a committee of researchers, based on which recommendations related to T1DM diagnosis were formulated. A two-round method was conducted to compare the opinions of a panel of 32 specialists (adult endocrinologists [53.1%], pediatric endocrinologists [43.8%], a diabetes educator for child and adolescent [3.1%]) on these issues.

RESULTS

The panel reached consensus on two of the six items discussed. The four items on which no consensus was reached were related to autoantibody detection and age of onset. Up to 80% of the panelists favored items related to the glucagon test and diabetic ketoacidosis history for T1DM diagnosis. Consensus regarding transitional care through diabetes educators was established.

CONCLUSION

The assessment conducted by experts on T1DM showed a high level of professional agreement regarding the proposed diagnostic and transitional care recommendations. A comprehensive analysis of the latest evidence is warranted for the items on which consensus was not established.

Comparing Multiple Linear Regression and Machine Learning in Predicting Diabetic Urine Albumin-Creatinine Ratio in a 4-Year Follow-Up Study

The urine albumin-creatinine ratio (uACR) is a warning for the deterioration of renal function in type 2 diabetes (T2D). The early detection of ACR has become an important issue. Multiple linear regression (MLR) has traditionally been used to explore the relationships between risk factors and endpoints. Recently, machine learning (ML) methods have been widely applied in medicine. In the present study, four ML methods were used to predict the uACR in a T2D cohort. We hypothesized that (1) ML outperforms traditional MLR and (2) different ranks of the importance of the risk factors will be obtained. A total of 1147 patients with T2D were followed up for four years. MLR, classification and regression tree, random forest, stochastic gradient boosting, and eXtreme gradient boosting methods were used. Our findings show that the prediction errors of the ML methods are smaller than those of MLR, which indicates that ML is more accurate. The first six most important factors were baseline creatinine level, systolic and diastolic blood pressure, glycated hemoglobin, and fasting plasma glucose. In conclusion, ML might be more accurate in predicting uACR in a T2D cohort than the traditional MLR, and the baseline creatinine level is the most important predictor, which is followed by systolic and diastolic blood pressure, glycated hemoglobin, and fasting plasma glucose in Chinese patients with T2D.

Circulating Growth Differentiation Factor 15 Is Associated with Diabetic Neuropathy

Background: Growth differentiation factor (GDF15) is a superfamily of transforming growth factor-beta which has been suggested to be correlated with various pathological conditions. The current study aimed to investigate the predicted role of circulating GDF15 in diabetic metabolism characteristics and diabetic neuropathy. Methods: 241 diabetic patients and 42 non-diabetic subjects were included to participate in the study. The plasma GDF15 levels were measured using ELISA. Chronic kidney disease and albuminuria were defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guideline. The nerve conductive study (NCS) was performed with measurement of distal latency, amplitude, nerve conduction velocity (NCV), H-reflex, and F-wave studies. Results: The diabetic group had a significantly higher prevalence of chronic kidney disease and higher plasma GDF15 level. After adjusting for age and BMI, GDF15 was significantly positively correlated with waist circumference (r = 0.332, p = <0.001), hip circumference (r = 0.339, p < 0.001), HbA1c (r = 0.302, p < 0.001), serum creatine (r = 0.146, p = 0.017), urine albumin/creatinine ratio (r = 0.126, p = 0.040), and HOMA-IR (r = 0.166, p = 0.007). As to NCS, GDF15 was significantly correlated with all latency and amplitude of sensory and motor nerves, as well as F-wave and H-reflex latencies. The area under the curve (AUC) in predicting tibial motor nerve neuropathy (MNCV) in all subjects and in the diabetic group for GDF15 was 0.646 (p = 0.001) and 0.610 (p = 0.012), respectively; for HbA1c was 0.639 (p = 0.001) and 0.604 (p = 0.018), respectively. Predicting ulnar sensory nerve neuropathy for GDF15 was 0.639 (p = 0.001) and 0.658 (p = 0.001), respectively; for HbA1c was 0.545 (p = 0.307) and 0.545 (p = 0.335), respectively. Predicting median sensory nerve neuropathy for GDF15 was 0.633 (p = 0.007) and 0.611 (p = 0.032), respectively; for HbA1c was 0.631 (p = 0.008) and 0.607 (p = 0.038), respectively. Predicting CKD for GDF15 was 0.709 (95% CI, 0.648−0.771), p < 0.001) and 0.676 (95% CI, 0.605−0.746), p < 0.001), respectively; for HbA1c was 0.560 (95% CI, 0.493−0.627); p = 0.080) and 0.515 (95% CI, 0.441−0.588); p = 0.697), respectively. Conclusions: We suggest that there is a significant association between the increased serum GDF-15 level and metabolic parameters and diabetic neuropathy. Plasma GDF15 may be an independent predictor of diabetic neuropathy.

Fibroblast Growth Factor 21 Levels Exhibit the Association With Renal Outcomes in Subjects With Type 2 Diabetes Mellitus

Background

Whether microalbuminuria predicts renal outcomes in patients with type 2 diabetes mellitus (T2DM) is argued. Fibroblast growth factor 21 (FGF-21) levels were elevated by the pathogenic process of diabetic kidney disease. The purpose of the study was to evaluate the associations of FGF-21 and renal outcomes in subjects with T2DM.

Methods

Chinese patients with T2DM were enrolled and then observed prospectively, and FGF-21 levels at baseline were measured. The associations of FGF-21 levels and renal composite events, defined by a drop > 30% of eGFR or worsening category of albuminuria, were evaluated using Cox analysis. The appropriate cut-off value of FGF-21 was mapped by the receiver operating characteristic (ROC) curve.

Results

Among 312 subjects, higher FGF-21 levels were associated with higher risks of renal events in Cox analysis. The area under the curve of FGF-21 levels in the ROC curve was optimal (0.67, p < 0.001), and the cut-off value of 1.40 pg/dl exhibited the best sensitivity (76.2%) and specificity (53.5%). The frequency of renal composite events was higher in subjects with FGF-21 ≥ 1.40 pg/dl than in others (30% vs. 10%, p<0.001 by the log-rank test). The worse renal outcomes predicted by FGF-21 ≥ 1.40 pg/dl were confirmed using the adjustments of Cox sequential models (hazard ratio 2.28, 95% confidence interval 1.23-4.24, p=0.009) and consistent across subjects with different status of baseline characteristics and renal risks.

Conclusion

FGF-21 levels were proportional to the risks of renal events in broad- spectrum Chinese T2DM subjects, making it a potential biomarker to predict the renal outcomes of T2DM.

The Incidence of Adult-Onset Type 1 Diabetes: A Systematic Review From 32 Countries and Regions

BACKGROUND

The epidemiology of adult-onset type 1 diabetes (T1D) incidence is not well-characterized due to the historic focus on T1D as a childhood-onset disease.

PURPOSE

We assess the incidence of adult-onset (≥20 years) T1D, by country, from available data.

DATA SOURCES

A systematic review of MEDLINE, Embase, and the gray literature, through 11 May 2021, was undertaken.

STUDY SELECTION

We included all population-based studies reporting on adult-onset T1D incidence and published from 1990 onward in English.

DATA EXTRACTION

With the search we identified 1,374 references of which 46 were included for data extraction. Estimates of annual T1D incidence were allocated into broad age categories (20-39, 40-59, ≥60, or ≥20 years) as appropriate.

DATA SYNTHESIS

Overall, we observed the following patterns: 1) there is a paucity of data, particularly in low- and middle-income countries; 2) the incidence of adult-onset T1D is lowest in Asian and highest in Nordic countries; 3) adult-onset T1D is higher in men versus women; 4) it is unclear whether adult-onset T1D incidence declines with increasing age; and 5) it is unclear whether incidence of adult-onset T1D has changed over time.

LIMITATIONS

Results are generalizable to high-income countries, and misclassification of diabetes type cannot be ruled out.

CONCLUSIONS

From available data, this systematic review suggests that the incidence of T1D in adulthood is substantial and highlights the pressing need to better distinguish T1D from T2D in adults so that we may better assess and respond to the true burden of T1D in adults.

Beyond Sarcopenia: older adults with type II diabetes mellitus tend to experience an elevated risk of poor dynamic balance-a case-control study

Background

People with type 2 diabetes mellitus (T2DM) tend to be vulnerable to geriatric syndromes such as sarcopenia and frailty. Reduced physical activity also accompanies sarcopenia and frailty, which is generally typical of patients with T2DM. However, a comprehensive assessment of physical fitness in patients with T2DM has seldom been carried out and verified. This study is thus an attempt to determine the associations among sarcopenia, frailty, and the SFT in diabetic patients and non-diabetic controls to provide a more comprehensive understanding of such associations in future evaluations of T2DM in older individuals.

Methods

Sarcopenia, frailty, and the senior fitness test (SFT) were compared between 78 older men with T2DM (66.5 ± 9.0 years) and 48 age-matched normoglycemic controls (65.8 ± 5.3 years) in this case–control study. The skeletal muscle index (SMI), grip strength, and 4-m walk test were employed to assess for sarcopenia. Frailty was evaluated using the Study of Osteoporotic Fractures index (SOF). The SFT comprises five components, including body composition, muscle strength, flexibility, balance, and aerobic endurance.

Results

The risk level of sarcopenia was significantly higher (p < 0.05) in the T2DM group as compared to the control group. No significant difference between-group differences were found in SMI and grip strength in the T2DM and control groups. However, the T2DM group showed a significant decrease in gait speed (p < 0.01) in comparison with the control group, as well as significant increases in frailty (p < 0.01) and depression (p < 0.05). With respect to the SFT, obvious elevation in BMI, significant declines in extremity muscle strength (elbow extensor, knee flexor, hip abductor, hip flexor, sit to stand), static/dynamic balance (single leg stand: p < 0.05; up-and-go: p < 0.01) and aerobic endurance (2-min step: p < 0.01; 6-min walk: p < 0.01) were found in the T2DM group. Furthermore, the SOF (OR = 2.638, 95% CI = 1.333–5.221), BMI (OR = 1.193, 95% CI = 1.041–1.368) and up-and-go (OR = 2.089, 95% CI = 1.400–3.117) were found to be positively and significantly associated with T2DM.

Conclusions

The findings of this study indicated the importance of countering frailty and maintaining physical fitness, especially dynamic balance, during the early physical deterioration taking place in diabetic patients.

Assessment of diabetic small-fiber neuropathy by using short-wave infrared hyperspectral imaging

Among patients with type 2 diabetes mellitus (T2DM), the association between hyperspectral imaging (HSI) examination and diabetic neuropathy (DN) is ascertained using HSI of the feet using four types of spectral difference measurements. DN was evaluated by traditional Michigan Neuropathy Screening Instrument (MNSI), evaluation of painful neuropathy (ID-Pain, DN4) and sudomotor function by measuring electrochemical skin conductance (ESC). Of the 120 T2DM patients and 20 healthy adults enrolled, T2DM patients are categorized into normal sudomotor (ESC >60 μS) and sudomotor dysfunction (ESC ≤ 60 μS) groups. Spectral difference analyses reveal significant intergroup differences, whereas traditional examinations cannot distinguish between the two groups. HSI waveform reflectance gradually increases with disease severity, at 1400 to 1600 nm. The area under the curve (AUC) of receiver operating characteristic (ROC) analysis for abnormal ESC is ≥0.8 for all four HSI methods. HSI could be an objective, sensitive, rapid, noninvasive and remote approach to identify early small-fiber DN.

Association of dipeptidyl peptidase-4 inhibitor use and the risk of asthma development among type 2 diabetes patients

Background:

Numerous studies have shown that dipeptidyl peptidase-4 inhibitors (DPP-4i) may regulate immunological pathways implicated in asthma. The association between DPP-4i use and risk of asthma development is limited, however.

Aim:

We aimed to evaluate if DPP-4i treatment in individuals with type 2 diabetes mellitus (T2DM) is associated with a lower risk and severity of asthma.

Methods:

We performed a population-based retrospective cohort study using the Longitudinal National Health Insurance Research database between 2008 and 2015. After one-to-four propensity score matching from 1,914,201 patients with defined criteria, we enrolled 3001 patients who were on DPP-4i (DPP-4i group) for a diagnosis of T2DM but without a diagnosis of asthma for further analysis. Cox proportional hazards regression analysis was performed to estimate and compare the risk of developing and severity of asthma, including no acute exacerbations event (No-AE), acute exacerbations (AEs), status asthmaticus (Status), and required endotracheal intubation (ET-tube intubated), between the two groups.

Results:

The participants had a mean age of 66.05 ± 17.23 years and the mean follow-up time was 4.96 ± 4.39 years. The risk of asthma development was significantly lower in the DPP-4i group than in the non-DPP-4i group [adjusted hazard ratio (HR) = 0.65; 95% confidence interval (CI) = 0.29–0.83; p < 0.001], with a class effect. This trend was observed for severity of asthma as No-AE (HR = 0.55; 95% CI = 0.24–0.70; p < 0.001), AE (HR = 0.57; 95% CI = 0.26–0.73; p < 0.001), and Status (HR = 0.78; 95% CI = 0.35–0.99; p = 0.047), but not in ET-tube intubated cases (HR = 0.96; 95% CI = 0.43–1.22; p = 0.258).

Conclusion:

The use of DPP-4i decreased the risk and severity of asthma with a class effect among No-AE, AE, status of asthma events, but not in ET-tube intubated events. Our report suggests that DPP-4i may play a role in attenuating the impact of asthma on incidence in the future and on more severe forms of disease exacerbation in T2DM patients.

Validation of Diabetes Knowledge Questionnaire (DKQ) in the Taiwanese Population - Concurrent Validity with Diabetes-Specific Quality of Life Questionnaire Module

PURPOSE

Diabetes knowledge is important for people with type 2 diabetes mellitus (DM) to improve their health. Therefore, it is important to validate an instrument for assessing diabetes knowledge. The present study aimed to validate the 24-item Diabetes Knowledge Questionnaire (DKQ).

PATIENTS AND METHODS

The 24-item DKQ and Diabetes-specific Quality of Life Module (DMQoL) were administered to 425 patients (mean±SD age=58.4±11.6) with type 2 DM.

RESULTS

The 24-item DKQ was first examined for its factor structure using exploratory factor analysis (EFA). Items with low factors loadings were removed and 18 items were retained to make a DKQ-18. In DKQ-18, five factors were identified, which were named as diabetes etiology and symptoms (F1), intermediate nursing (F2), complications (F3), diet and treatment (F4), and elementary nursing (F5). The DKQ-18 had satisfactory internal consistency (Cronbach's α= 0.732 and McDonald's ω=0.748), good known-group validity (participants with a higher level of education showed better score in DKQ-18; participants with HbA1c ≤7 had better score in DKQ-18 compared to group of HbA1c level >8.5), acceptable test-retest reliability (r=0.69), adequate responsiveness (DKQ-18 can detect knowledge change), and concurrent validity with DMQoL.

CONCLUSION

The DKQ-18 is a valid measure for assessing diabetes knowledge. The DKQ-18 could evaluate participants' diabetes knowledge and improve their diabetes knowledge and self-care through a diabetes team and serve as a tool to evaluate the knowledge of participants with type 2 DM.

Association of exposure to air pollutants with gestational diabetes mellitus in Chiayi City, Taiwan

INTRODUCTION

We investigated the associations of exposure to particulate matter with an aerodynamic diameter less than 2.5 μm (PM_2.5) and several gaseous pollutants with risk of gestational diabetes mellitus (GDM) in Taiwan.

METHODS

We retrospectively identified pregnant women who underwent a two-step approach to screen for GDM between 2006 and 2014. Information on concentrations of air pollutants (including PM_2.5, sulfur dioxide [SO₂], nitrogen oxides [NO_x], and ozone [O₃]) were collected from a single fixed-site monitoring station. We conducted logistic regression analyses to determine the associations between exposure to air pollutants and risk of GDM.

RESULTS

A total of 11210 women were analyzed, and 705 were diagnosed with GDM. Exposure to PM_2.5 during the second trimester was associated with a nearly 50% higher risk of GDM (odds ratio [OR] 1.47, 95% CI 0.96 to 2.24, p=0.077). The associations were consistent in the two-pollutant model (PM_2.5 + SO₂ [OR 1.73, p=0.038], PM_2.5 + NO_x [OR 1.52, p=0.064], PM_2.5 + O₃ [OR 1.96, p=0.015]), and were more prominent in women with age <30 years and body mass index <25 kg/m² (interaction p values <0.01).

DISCUSSION

Exposure to PM_2.5 was associated with risk of GDM, especially in women who were younger or had a normal body mass index.

Retinal Thickness Associates with Cognition Dysfunction in Young Adult with Type 1 Diabetes in Taiwan

BACKGROUND

Several factors could affect the cognitive dysfunction in patients with type 1 diabetes (T1D).

OBJECTIVES

To report the characteristic of cognitive dysfunction in T1D and find its association with the retinal thickness.

SUBJECTS

We recruited one hundred and seven patients with T1D in our study.

METHODS

Detailed clinical and demographic factors and Cambridge Automated Neuropsychological Test Battery (CANTAB) were performed in all participants. The age at onset>5 years old and ≤5 years old groups was defined as old- and young-onset groups. The levels of the average values of 5-year glycated hemoglobin (HbA1c_5) before study were collected. Ophthalmic study and central retinal thickness (CRT) were performed.

RESULTS

The median age of T1D was 24.9 years old and 57 participants were women. The median age at onset was 7.4 years old, and mean disease duration was 17.2 years. After adjusting off multiple covariates by the regression analyses, the young-onset group had significantly a longer latency in sustained attention than old-onset group (P = 0.02). The HbA1c_5 showed a significantly negative association with the sustained attention (P = 0.03). The average values of CRT showed significantly negative correlations with the reaction time in sustained attention and visual searching (P = 0.04 and P < 0.01, respectively).

CONCLUSIONS

Our results suggest that age at onset and glycemic control had significant impacts on different cognitive domains in T1D. The CRT had a significant correlation with sustained attention, which could be a surrogate markers of brain structural changes in T1D.

Epidemiological characteristics of diabetic kidney disease in Taiwan

Diabetic kidney disease (DKD) is a critical microvascular complication of diabetes. With the continuous increase in the prevalence of diabetes since 2000, the prevalence of DKD has also been increasing in past years. The prevalence of DKD among individuals with type 2 diabetes in Taiwan increased from 13.32% in 2000 to 17.92% in 2014. The cumulative incidence of DKD among individuals with type 1 diabetes in Taiwan was higher than 30% during 1999-2012. DKD is the leading cause of end-stage renal disease (ESRD), with a prevalence of approximately 45% in a population on chronic dialysis in Taiwan. Among individuals with type 2 diabetes, the prevalence of ESRD in the receipt of dialysis also increased from 1.32% in 2005 to 1.47% in 2014. Risk factors for DKD development are age, race, family history, hyperglycemia, hypertension, dyslipidemia, dietary patterns, and lifestyles. Prognostic factors that aggravate DKD progression include age, family history, sex, glycemic control, blood pressure (BP), microvascular complications, and atherosclerosis. This review summarizes updated information on the onset and progression of DKD, particularly in the Taiwanese population. Translating these epidemiological features is essential to optimizing the kidney care and improving the prognosis of DKD in Asian populations.

Early-onset type 2 diabetes <60 years and risk of vascular complications

AIM

To compare long-term outcomes among three groups with different ages of diabetes onset.

METHOD

66,520 paired age-, and sex-matched persons with and without type 2 diabetes were selected from the Taiwan National Health Insurance Research Database from 2000 to 2012. Cox proportional hazards models were used to compare the outcomes. Using late-onset diabetes as a reference, adjusted difference in differences analyses were performed to assess excessive odds comparing diabetes versus non-diabetes for young-onset diabetes (YOD) and early-onset diabetes in the risks of mortality and vascular complications.

RESULTS

Persons with type 2 diabetes, irrespective of the onset age, had higher associated risks of all-cause mortality and vascular complications than their matched counterparts without diabetes. Compared to the odds of complications between those with diabetes and non-diabetes in the late-onset diabetes group, the excess odds in YOD are generally greater than in the early-onset diabetes (for stroke: 1.90 vs. 1.32; heart failure: 2.03 vs. 1.58; myocardial infarction: 3.02 vs. 1.56; and microvascular complications: 3.52 vs. 3.01).

CONCLUSIONS

Diabetes with different ages of onset may imply distinct long-term health outcomes. The persons with young-onset and early-onset diabetes seem to bear excess risk for mortality and vascular complications.

Association between Lung Function and New-Onset Diabetes Mellitus in Healthy Individuals after a 6-Year Follow-up

BACKGROUND

We analyzed hemoglobin A1c (HbA1c) levels and various lung function test results in healthy individuals after a 6-year follow-up period to explore the influence of lung function changes on glycemic control.

METHODS

Subjects whose HbA1c levels did not qualify as diabetes mellitus (DM) and who had at least two consecutive lung function tests were selected among the people who visited a health promotion center. Lung function parameters, including forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), FEV/FVC ratio, and forced expiratory flow 25% to 75% (FEF25%-75%), were divided into four groups based on their baseline quantiles. To evaluate future DM onset risk in relation to lung function changes, the correlation between baseline HbA1c levels and changes in lung function parameters after a 6-year follow-up period was analyzed.

RESULTS

Overall, 17,568 individuals were included; 0.9% of the subjects were diagnosed with DM. The individuals included in the quartile with FEV1/FVC ratio values of 78% to 82% had lower risk of DM than those in the quartile with FEV1/FVC ratio values of ≥86% after adjusting for age, sex, and body mass index (P=0.04). Baseline percent predicted FEV1, FVC, FEV1/FVC ratio, and FEF25%-75%, and differences in the FEV1/FVC ratio or FEF25%-75%, showed negative linear correlations with baseline HbA1c levels.

CONCLUSION

Healthy subjects with FEV1/FVC ratio values between 78% and 82% had 40% lower risk for future DM. Smaller differences and lower baseline FEV1/FVC ratio or FEF25%-75% values were associated with higher baseline HbA1c levels. These findings suggest that airflow limitation affects systemic glucose control and that the FEV1/FVC ratio could be one of the factors predicting future DM risk in healthy individuals.

A Head-To-Head Comparison of Benzbromarone and Allopurinol on the Risk of Type 2 Diabetes Mellitus in People With Asymptomatic Hyperuricemia

Objective: The study aimed to thoroughly address the influence of benzbromarone and allopurinol on the risk of the development of type 2 diabetes mellitus (T2DM) in people with asymptomatic hyperuricemia. Methods: We conducted a retrospective cohort study to examine the 2000-2015 national dataset containing all claims data of 23 million beneficiaries in Taiwan. Subjects who already had diabetes mellitus, gout-related diseases, and any cancer prior to the index date were excluded. Asymptomatic hyperuricemia was defined as subjects taking urate-lowering drugs who never had a gout flare. Subjects aged 20-84 with asymptomatic hyperuricemia who had benzbromarone prescriptions were selected as the benzbromarone group. Sex-matched and age-matched subjects with asymptomatic hyperuricemia who had allopurinol prescriptions were identified as the allopurinol group. The maximum follow-up duration was set as 5 years in our study. The outcome was set as subjects who had a new diagnosis of T2DM. The incidence density of T2DM was calculated in the benzbromarone and allopurinol groups. The hazard ratio (HR) and 95% confidence interval (CI) for T2DM was utilized to estimate the association between medications and the risk of T2DM. Results: The incidence of T2DM among benzbromarone users was significantly lower than that of allopurinol users (7.91 versus 8.48 per 100 person-years, incidence rate ratio = 0.93, and 95% CI = 0.87-0.99). After adjustment for co-variables, the adjusted HR of T2DM would be 0.91 (95% CI = 0.85-0.98 and p = 0.008) in benzbromarone users as compared to allopurinol users. Conclusion: There is a small but statistically significant risk reduction of developing T2DM in people with asymptomatic hyperuricemia taking benzbromarone as compared to those taking allopurinol during 5 years of follow-up. It indicates a future research direction for the use of individual urate-lowering drugs on the prevention of T2DM in the general population.

Associations of Reduced Ambient PM2.5 Level With Lower Plasma Glucose Concentration and Decreased Risk of Type 2 Diabetes in Adults: A Longitudinal Cohort Study

It remains unknown whether reduced air pollution levels can prevent type 2 diabetes mellitus. In this study, we investigated the associations between dynamic changes in long-term exposure to ambient fine particulate matter, defined as particulate matter with an aerodynamic diameter ≤2.5 μm (PM2.5), and changes in fasting plasma glucose (FPG) levels and incidence of type 2 diabetes. A total of 151,398 adults (ages ≥18 years) were recruited in Taiwan between 2001 and 2014. All participants were followed up for a mean duration of 5.0 years. Change in PM2.5 (ΔPM2.5) was defined as the value at a follow-up visit minus the corresponding value at the immediately preceding visit. The PM2.5 concentration in Taiwan increased during 2002-2004 and began to decrease in 2005. Compared with participants with little or no change in PM2.5 exposure, those with the largest decrease in PM2.5 had a decreased FPG level (β = -0.39, 95% confidence interval: -0.47, -0.32) and lower risk of type 2 diabetes (hazard ratio = 0.86, 95% confidence interval: 0.80, 0.93). The sensitivity analysis and analyses stratified by sex, age, body mass index, smoking, alcohol drinking, and hypertension generally yielded similar results. Improved PM2.5 air quality is associated with a better FPG level and a decreased risk of type 2 diabetes development.

Trends in prevalence and incidence of type 2 diabetes among adults in Beijing, China, from 2008 to 2017

AIMS

To describe secular trends in diagnosed type 2 diabetes prevalence and incidence in Beijing, China.

METHODS

Using health insurance claims for 17.7 million adults ≥20 years in 2008-2017, we identified people with diabetes using hospital diagnoses and drug prescriptions. Results were age-standardised using data for Beijing from China's 2010 census. Trends in prevalence and incidence were analysed using Joinpoint regression analysis.

RESULTS

From 2008 to 2017, we identified 2,104,159 people diagnosed with type 2 diabetes. Type 2 diabetes prevalence increased from 3.7% [95% CI: (3.6, 3.8)] to 6.6% (6.4, 6.7), but the annual rate of increase slowed from 18.1% (14.4, 22.0) to 1.5% (0.8, 2.2) before and after 2011 respectively. Women had a higher diabetes prevalence than men, for all years. The yearly increase in prevalence was greater in people younger than 40 years, with an average annual percentage change of 13.6% (10.7, 16.5) compared to 6.5% (5.6, 7.4) in those over 40 years. Over the 10 years, the overall incidence decreased from 24.3 (24.2, 24.4) to 11.5 (11.5, 11.6) per 1000 person-years, but it increased in people younger than 40 years. The average age at diabetes diagnosis dropped from 62 to 56 years (p < 0.001). Among incident cases of diabetes, the percentage of people under 40 years increased from 3.0% to 10.9% (p < 0.001).

CONCLUSIONS

The prevalence of diagnosed type 2 diabetes in Beijing increased continuously over the 10 years, the incidence decreased, except in people under 40 years. Continuous efforts are needed to prevent diabetes in China.

Electronic dashboard-based remote glycemic management program reduces length of stay and readmission rate among hospitalized adults

AIMS/INTRODUCTION

Currently, the impact of hospital-wide glycemic control interventions on length of hospital stay (LOS) and readmission rates are largely unknown. We investigated the impact of a 4-year hospital-wide remote glycemic management program on LOS and 30-day readmission rates among hospitalized adults who received glucose monitoring.

MATERIALS AND METHODS

In this retrospective study, hospitalized patients who received glucose monitoring were classified into groups 1 (high glucose variability), 2 (hypoglycemia), 3 (hyperglycemia) and 4 (relatively stable). The monthly percentage changes, and average monthly percentage changes of hyperglycemia, hypoglycemia and treat to target were determined using joinpoint regression analysis.

RESULTS

A total of 106,528 hospitalized patients (mean age 60.9 ± 18.5 years, 57% men) were enrolled. We observed a significant reduction in the percentage of inpatients in poor glycemic control groups (groups 1, 2 and 3, all P < 0.001), and a reciprocal increase in the relatively stable group (group 4) from 2016 to 2019. We found a significant reduction in LOS by 11.4% (10.5-9.3 days, P = 0.002, after adjustment for age, sex, and admission department). The 30-day readmission rate decreased from 29.9% to 29.3%, mainly among those in group 4 in 2019 (P < 0.001 after adjustment of sex, age, admission department and LOS).

CONCLUSIONS

Improved glycemic control through a hospital-wide electronic remote glycemic management system reduced LOS and 30-day readmission rates. Findings observed in this study might be associated with the reduction in cost of avoidable hospitalizations.

Distinct associations of self-monitoring of blood glucose with glycemic control and hypoglycemia between groups of recently diagnosed and long-term follow-up type 2 diabetes: The Taiwan Diabetes Registry

BACKGROUND

We investigated the uses and frequency of self-monitoring of blood glucose (SMBG) with glycemic control and hypoglycemia in two groups of type 2 diabetes (T2D) (recently diagnosed and long-term follow-up) using real-world data in Taiwan (the Taiwan Diabetes Registry).

METHODS

Patients with T2D recently diagnosed within 6 months (n = 3297, mean age 54.4 ± 13.9 years) and T2D patients with long-term follow-up (n = 1201, mean age 65.5 ± 12.1 years, mean diabetes duration 14.3 ± 7.8 years) from the Taiwan Diabetes Registry were analysed. All patients were interviewed by certified diabetes educators. Information about SMBG and hypoglycemia was recorded. Demography, personal history, and laboratory data were obtained from electronic medical records. Logistic regression analyses were used to examine the associations of SMBG with glycated haemoglobin (HbA1c) <7% and hypoglycemia.

RESULTS

Mean HbA1c values were 8.4 ± 2.5 and 7.6 ± 1.4%, respectively, in the recently diagnosed and long-term follow-up T2D groups. The self-reported rates of hypoglycemic events within 3 months were 10.5% and 19.0%, respectively. SMBG was associated with higher odds of HbA1c <7% (OR 1.21, 95% CI 1.01-1.44) in patients with recently diagnosed T2D, but with lower odds of HbA1c <7% in T2D patients with long-term follow-up (OR 0.60, 95% CI 0.44-0.82). In both study populations, SMBG was independently associated with hypoglycemia (OR 3.90 [95% CI 2.99-5.08] and OR 3.93 [95% CI 2.73-5.66], respectively). The aforementioned findings were consistent across the strata of SMBG frequency.

CONCLUSION

We reported different associations between SMBG and glycemic control in patients recently diagnosed with T2D and in T2D patients with long-term follow-up. SMBG was associated with higher detection of hypoglycemic episodes in both study populations.

Clinical Outcomes and Oral Health-Related Quality of Life after Periodontal Treatment with Community Health Worker Strategy in Patients with Type 2 Diabetes: A Randomized Controlled Study

Interventions engaging community health workers (CHW) for diabetes management aim to improve diabetes care and self-management behaviors among patients. We evaluated the effects of nonsurgical periodontal treatment (NSPT) with the CHW strategy on oral self-care behaviors, periodontal status and oral health-related quality of life (OHQoL) in patients with type 2 diabetes mellitus (T2DM). The participants were randomly assigned to experimental (EG; n = 35) and control (CG; n = 33) groups. All participants received NSPT, whereas the patients in the EG also received one-on-one 30 min lessons from a CHW over 4 weeks. The EG exhibited greater improvement in the probing pocket depth (β = −0.2, effect size [ES] = 0.61) and clinical attachment level (β = −0.2, ES = 0.59) at 1-month follow-up than the CG did. The ES increased over the 1-, 3- and 6-month follow-ups, indicating an increase in OHQoL (ES = 0.19, 0.60, and 0.62, respectively) in the EG. The patients in the EG were more likely to change their oral self-care behaviors than patients in the CG were. The NSPT with CHW strategy had a positive effect on 1-month periodontal treatment outcomes, long-term OHQoL and oral self-care behaviors in patients with T2DM.

Deep Learning for Automated Diabetic Retinopathy Screening Fused With Heterogeneous Data From EHRs Can Lead to Earlier Referral Decisions

Purpose

Fundus images are typically used as the sole training input for automated diabetic retinopathy (DR) classification. In this study, we considered several well-known DR risk factors and attempted to improve the accuracy of DR screening.

Metphods

Fusing nonimage data (e.g., age, gender, smoking status, International Classification of Disease code, and laboratory tests) with data from fundus images can enable an end-to-end deep learning architecture for DR screening. We propose a neural network that simultaneously trains heterogeneous data and increases the performance of DR classification in terms of sensitivity and specificity. In the current retrospective study, 13,410 fundus images and their corresponding nonimage data were collected from the Chung Shan Medical University Hospital in Taiwan. The images were classified as either nonreferable or referable for DR by a panel of ophthalmologists. Cross-validation was used for the training models and to evaluate the classification performance.

Results

The proposed fusion model achieved 97.96% area under the curve with 96.84% sensitivity and 89.44% specificity for determining referable DR from multimodal data, and significantly outperformed the models that used image or nonimage information separately.

Conclusions

The fusion model with heterogeneous data has the potential to improve referable DR screening performance for earlier referral decisions.

Translational Relevance

Artificial intelligence fused with heterogeneous data from electronic health records could provide earlier referral decisions from DR screening.

Adolescent Tri-ponderal Mass Index Growth Trajectories and Incident Diabetes Mellitus in Early Adulthood

PURPOSE

Studies have reported the influence of adolescent obesity on development of adult diabetes, but the effect of the growth pattern during this period has rarely been explored. Also, the tri-ponderal mass index (TMI) was thought to be a better estimation of adolescent body fat levels than the body mass index (BMI), so we sought to investigate whether growth trajectories derived by these two indices could predict incident diabetes.

METHODS

We conducted a study by using the Taipei City Hospital Radiation Building Database, a longitudinal cohort established in 1996. Physical exam results including blood test results were collected annually and the BMI z-score/TMI growth trajectory groups during 13 to 18 years of age were identified using growth mixture modeling. A Cox proportional hazard model for incident diabetes was used to examine the risk of baseline obese status and different BMI/TMI growth trajectories.

RESULTS

Five growth trajectory groups were identified for the BMI z-score and the TMI. During approximately 20 400 person-years follow-up, 33 of 1387 participants developed diabetes. Baseline obesity defined by the BMI z-score and the TMI were both related to adult diabetes. The persistent increase TMI growth trajectory exhibited a significantly increased risk of diabetes after adjusting for baseline obese status and other correlated covariates (hazard ratio: 2.85, 95% confidence interval: 1.01-8.09). There was no association between BMI growth trajectory groups and incident diabetes.

CONCLUSIONS

A specific TMI growth trajectory pattern during adolescence might be critical for diabetes prevention efforts.

A Delphi Study on the Healthcare Needs of Patients with Type 1 Diabetes during the Transition from Adolescence to Adulthood: Consensus among Patients, Primary Caregivers, and Healthcare Providers

Patients with type 1 diabetes mellitus at the age of 16-25 face the challenges of the deterioration of disease control and accelerated exacerbation. Providing interventions that meet patient's healthcare needs can reduce the impact and improve health outcome. The purpose of this study was to identify the healthcare needs of patients with type 1 diabetes during the adolescence to adulthood transition period from the perspectives of patients, parents and healthcare providers. A two-round Delphi study was conducted among 48 participants, and included 17 patients, 16 primary caregivers, and 15 healthcare providers. The central tendency and dispersion were computed to establish a consensus. Seventy-one healthcare needs were identified across five dimensions-technology, external support, internal support, management, and healthcare-and 56 were considered as important healthcare needs and with a moderate to high level of agreement. Meanwhile, patients, primary caregivers, and healthcare providers were found to display significantly different opinions (p < 0.05) for 23 healthcare needs. This study concluded the consensus of the healthcare needs of patients with type 1 diabetes mellitus during the adolescence to adulthood transition period from a systematic investigation. The findings can serve as reference for developing transitional intervention strategies.

Life satisfaction and emotional distress in people living with type 2 diabetes mellitus: The mediating effect of cognitive function

AIMS AND OBJECTIVES

To explore the relationships among emotional distress, cognitive function and life satisfaction in people living with type 2 diabetes mellitus (T2DM), and to verify the mediating role of cognitive function.

BACKGROUND

People with T2DM face cognitive decline caused by age and disease complications. Emotional distress will reduce their life satisfaction, and cognitive function will also affect the life satisfaction, but whether cognitive function mediates the effect of emotional distress on life satisfaction has not been verified.

DESIGN

A cross-sectional study.

METHODS

A total of 200 people living with T2DM in the community by convenience sampling were enrolled from November-December 2018. Data collection involved a demographic and disease characteristic questionnaire, Problem Areas in Diabetes Scale, Subjective and Objective Cognitive Function Evaluation and Life Satisfaction Questionnaire. Data analysis included descriptive statistics and structural equation modelling. This report followed the STROBE guideline.

RESULTS

The emotional distress and subjective memory complaints of cognitive function had a significant positive correlation, while both emotional distress and cognitive function showed significant negative correlations with life satisfaction. In addition, cognitive function completely mediated the relationship between emotional distress and life satisfaction.

CONCLUSION

The cognitive function played a mediating role in life satisfaction and explains how emotional distress affects life satisfaction of people with T2DM. Therefore, it is suggested that diabetes nurses should early identify the decline of cognitive function, and to intervene at an early stage.

RELEVANCE TO CLINICAL PRACTICE

This study provides opinions on the mediating factors of cognitive function. Coping strategies and supporting resources to help the T2DM people to improve their life satisfaction are suggested.

Obesity-Related Indices Are Associated with Peripheral Artery Occlusive Disease in Patients with Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (DM) is an increasing global health issue. Peripheral artery occlusive disease (PAOD) is a common complication of diabetes, and it is a complex and costly disease. The association between type 2 DM and obesity is well known, however, the relationship between obesity and PAOD in patients with type 2 DM has yet to be elucidated. Therefore, the aim of this study was to examine associations between obesity-related indices and PAOD in patients with type 2 DM. A total of 1872 outpatients with type 2 DM were recruited from two hospitals in southern Taiwan. An ankle–brachial index (ABI) < 0.9 in either leg was considered to indicate the presence of PAOD. The following obesity-related indices were investigated: conicity index (CI), waist–hip ratio (WHR), body roundness index (BRI), waist-to-height ratio (WHtR), abdominal volume index, a body shape index (ABSI), visceral adiposity index (VAI), lipid accumulation product (LAP), body adiposity index, body mass index and triglyceride–glucose index. Overall, 4.1% of the enrolled patients had an ABI < 0.9. High values of the following obesity-related indices were significantly associated with a low ABI: WHtR (p = 0.045), VAI (p = 0.003), CI (p = 0.042), BRI (p = 0.021) and ABSI (p = 0.043). Furthermore, WHR (area under the curve (AUC) = 0.661), CI (AUC = 0.660) and LAP (AUC = 0.642) had the best performance (all p < 0.001) to predict PAOD. In conclusion, high WHtR, BRI, CI, VAI and BAI values were associated with a low ABI in the enrolled patients, and WHR, CI and LAP were the most powerful predictors of PAOD.

Social Determinants of Diabetes-Related Preventable Hospitalization in Taiwan: A Spatial Analysis

Diabetes-Related Preventable Hospitalization (DRPH) has been identified as an important indicator of efficiency and quality of the health system and can be modified by social determinants. However, the spatial disparities, clustering, and relationships between DRPH and social determinants have rarely been investigated. Accordingly, this study examined the association of DRPH with area deprivation, densities of certificated diabetes health-promoting clinics (DHPC) and hospitals (DHPH), and the presence of elderly social services (ESS) using both statistical and spatial analyses. Data were obtained from the 2010-2016 National Health Insurance Research Database (NHIRD) and government open data. Township-level ordinary least squares (OSL) and geographically weighted regression (GWR) were conducted. DRPH rates were found to be negatively associated with densities of DHPC (β = -66.36, p = 0.029; 40.3% of all townships) and ESS (β = -1.85, p = 0.027; 28.4% of all townships) but positively associated with area deprivation (β = 2.96, p = 0.002; 25.6% of all townships) in both OLS and GWR models. Significant relationships were found in varying areas in the GWR model. DRPH rates are high in townships of Taiwan that have lower DHPC densities, lower ESS densities, and greater socioeconomic deprivation. Spatial analysis could identify areas of concern for potential intervention.

Risk factors of falls and the gender differences in older adults with diabetes at outpatient clinics

AIMS

To explore the risk factors of falls and the gender differences based on demographic and disease characteristics, physical capability, and fear of falling in older adults with diabetes visiting outpatient clinics in Taiwan.

DESIGN

Cross-sectional design.

METHODS

A total of 485 patients with type 2 diabetes aged between 65 and 80 years were recruited from three endocrine outpatient clinics in Taiwan. Demographic and disease characteristics, fall history in the previous one year and fear of falling were collected by a self-reported questionnaire. Calf circumference, handgrip strength, one-leg standing and time up-and-go tests were all performed to assess the physical capability of participants. Data were collected from May 2019 to May 2020.

RESULTS

Female gender (OR = 1.75), handgrip strength (OR = 2.43) and fear of falling (OR = 3.38) were important risk factors of falls overall, although fear of falling (OR = 4.69) was the only important risk factor of falls in males, while handgrip strength (OR = 3.48) and fear of falling (OR = 2.86) were important risk factors of falls in females. The sensitivity of simultaneous screening handgrip strength and fear of falling were 85.7, 86.4 and 86.2 in males, females and older adults overall with diabetes, respectively.

CONCLUSION

Fear of falling was an important risk factor of falls in both genders, especially in males. Handgrip strength was an important risk factor of falls specifically for females. By simultaneously screening fear of falling and handgrip strength, risk of falls in older adults with diabetes at outpatient clinics could be identified in a more timely manner. Impact Nurses could periodically and simultaneously assess fear of falling and handgrip strength of older adults with diabetes at outpatient clinics. For those are identified at risk of falls on either fear of falling or handgrip strength, nurses could provide corresponding interventions to reduce the fear of falling or improve muscle strength to prevent such falls.

Effective Dose of Rhizoma Coptidis Extract Granules for Type 2 Diabetes Treatment: A Hospital-Based Retrospective Cohort Study

Rhizoma Coptidis is a popular phytomedicine for the treatment of type 2 diabetes in Asia, but its effective dose for diabetes treatment remains confused because of diverse origins. This study aimed to investigate the dose-response effects of Rhizoma Coptidis extract granules (RCEG), produced with standardized quality control, on hypoglycemic effects in patients with type 2 diabetes. We conducted a retrospective analysis of Chang Gung Research Database from January 01, 2008 to November 30, 2017. Outpatients visiting traditional Chinese medicine clinics and receiving RCEG for type 2 diabetes treatment were included. Plasma glucose, lipid, and other parameters were analyzed from 93 patients with a total of 737 visits within 60 weeks. Scatter plots with the LOESS analysis were used to explore the association between RCEG dose and hypoglycemic effect. The minimal effective dose was chosen to divide the study population into the high-dose and low-dose RCEG groups. Non-parametric tests were used for between-group and within-group comparisons. The multivariate nonlinear mixed-effects model was applied to access the effect of treatment length and groups simultaneously on the change of HbA1c and fasting plasma glucose. The “arule” package in R was used to present the network diagram of RCEG and other co-prescriptions. We first discovered a significant relationship between RCEG dose and HbA1c reduction when the dose reached 0.08 g/kg/day or higher. We thus defined 0.08 g/kg/day of RCEG as the minimum effective dose, and a threshold to separate patients into the high-dose (≥0.08 g/kg/d) and low-dose (<0.08 g/kg/d) RCEG groups. In the high-dose RCEG group, a significant decrease in total cholesterol and a trend toward triglyceride reduction were also noted. Patients more effectively responded to RCEG treatment if they had a higher initial HbA1c level, higher heart rates, better liver function tests, and better tolerance to the higher dose and treatment duration of RCEG. In addition, digestive/tonic/dampness draining formulas and blood regulation recipes were two of the most frequent co-prescriptions with RCEG. This study concluded that RCEG at a dose exceeding 0.08 g/kg/d had beneficial effects on glycemic and lipid control, without showing nephro- or hepatotoxicity, in patients with type 2 diabetes.