Long-term complications and mortality in young-onset diabetes: type 2 diabetes is more hazardous and lethal than type 1 diabetes

Relation of Aortic Stiffness to Left Ventricular Remodeling in Younger Adults With Type 2 Diabetes

Individuals with type 2 diabetes have a three- to fivefold increased risk of developing heart failure. Diabetic cardiomyopathy is typified by left ventricular (LV) concentric remodeling, which is a recognized predictor of adverse cardiovascular events. Although the mechanisms underlying LV remodeling in type 2 diabetes are unclear, progressive aortic stiffening may be a key determinant. The aim of this study was to assess the relationship between aortic stiffness and LV geometry in younger adults with type 2 diabetes, using multiparametric cardiovascular MRI. We prospectively recruited 80 adults (aged 18-65 years) with type 2 diabetes and no cardiovascular disease and 20 age- and sex-matched healthy control subjects. All subjects underwent comprehensive bio-anthropometric assessment and cardiac MRI, including measurement of aortic stiffness by aortic distensibility (AD). Type 2 diabetes was associated with increased LV mass, concentric LV remodeling, and lower AD compared with control subjects. On multivariable linear regression, AD was independently associated with concentric LV remodeling in type 2 diabetes. Aortic stiffness may therefore be a potential therapeutic target to prevent the development of heart failure in type 2 diabetes.

Advances in the Genetics of Youth-Onset Type 2 Diabetes

PURPOSE OF REVIEW

To provide an update on knowledge the role of genetics in youth-onset type 2 diabetes (T2D).

RECENT FINDINGS

The prevalence in youth of T2D, once thought to be exclusively a disease of adults, has increased by over 35% since 2001. Youth with T2D tend to have higher rates of complications, more aggressive disease, with more rapid loss of beta-cell function and a less favorable response to treatment than adults. Obesity is the most important risk factor for T2D, and the rise in childhood overweight and obesity appears responsible for the dramatic increase in T2D in youth. However, some obese children do not develop T2D, consistent with genetic differences in susceptibility to the disease in the setting of obesity and insulin resistance, currently far less well characterized in youth than in adults. Recent studies have begun to show associations of several established adult T2D genetic risk variants with youth-onset T2D and related glycemic quantitative traits, including the strongest known cross-population T2D genetic contributor TCF7L2. Maturity-onset diabetes of the young (MODY), a diabetes subtype distinct from type 1 diabetes (T1D) and T2D, is now known to result from a highly penetrant gene mutation in one of several genes. MODY has been shown to account for or contribute to at least 4.5% of clinically diagnosed T2D, even among those who are overweight or obese, impacting treatment decisions. The recently formed ProDiGY (Progress in Diabetes Genetics in Youth) Consortium is using genome-wide association studies and whole exome sequencing to understand the genetic architecture of T2D in youth, including how it differs from that of adults. The limited amount of research conducted to date on the genetics of youth-onset T2D, which tends to be a more aggressive disease than adult T2D, suggests some overlap with genes involved in adult T2D and a sizeable influence of highly penetrant monogenic diabetes variants. The ProDiGY Consortium is expected to provide a more comprehensive understanding of youth T2D genetics.

Mortality in youth-onset type 1 and type 2 diabetes: The SEARCH for Diabetes in Youth study

AIMS

To estimate short-term mortality rates for individuals with type 1 or type 2 diabetes diagnosed before age 20 years from the SEARCH for Diabetes in Youth study.

METHODS

We included 8358 individuals newly-diagnosed with type 1 (n = 6840) or type 2 (n = 1518) diabetes from 1/1/2002-12/31/2008. We searched the National Death Index through 12/31/2010. We calculated standardized mortality ratios (SMRs) based on age, sex, and race for the comparable US population in the geographic areas of the SEARCH study.

RESULTS

During 44,893 person-years (PY) of observation (median follow-up = 5.3 years), 41 individuals died (91.3 deaths/100,000 PY); 26 with type 1 (70.6 deaths/100,000 PY) and 15 with type 2 (185.6 deaths/100,000 PY) diabetes. The expected mortality rate was 70.9 deaths/100,000 PY. The overall SMR (95% CI) was 1.3 (1.0, 1.8) and was high among individuals with type 2 diabetes 2.4 (1.3, 3.9), females 2.2 (1.3, 3.3), 15-19 year olds 2.7 (1.7,4.0), and non-Hispanic blacks 2.1 (1.2, 3.4).

CONCLUSIONS

Compared to the state populations of similar age, sex, and race, our results show excess mortality in individuals with type 2 diabetes, females, older youth, and non-Hispanic blacks. We did not observe excess short-term mortality in individuals with type 1 diabetes.

A tailored intervention to promote uptake of retinal screening among young adults with type 2 diabetes - an intervention mapping approach

BACKGROUND

Young adults (18-39 years) with type 2 diabetes are at risk of early development and rapid progression of diabetic retinopathy, a leading cause of vision loss and blindness in working-age adults. Retinal screening is key to the early detection of diabetic retinopathy, with risk of vision loss significantly reduced by timely treatment thereafter. Despite this, retinal screening rates are low among this at-risk group. The objective of this study was to develop a theoretically-grounded, evidence-based retinal screening promotion leaflet, tailored to young adults with type 2 diabetes.

METHODS

Utilising the six steps of Intervention Mapping, our multidisciplinary planning team conducted a mixed-methods needs assessment (Step 1); identified modifiable behavioural determinants of screening behaviour and constructed a matrix of change objectives (Step 2); designed, reviewed and debriefed leaflet content with stakeholders (Steps 3 and 4); and developed program implementation and evaluation plans (Steps 5 and 6).

RESULTS

Step 1 included in-depth qualitative interviews (N = 10) and an online survey that recruited a nationally-representative sample (N = 227), both informed by literature review. The needs assessment highlighted the crucial roles of knowledge (about diabetic retinopathy and screening), perception of personal risk, awareness of the approval of significant others and engagement with healthcare team, on retinal screening intentions and uptake. In Step 2, we selected five modifiable behavioural determinants to be targeted: knowledge, attitudes, normative beliefs, intention, and behavioural skills. In Steps 3 and 4, the "Who is looking after your eyes?" leaflet was developed, containing persuasive messages targeting each determinant and utilising engaging, cohort-appropriate imagery. In Steps 5 and 6, we planned Statewide implementation and designed a randomised controlled trial to evaluate the leaflet.

CONCLUSIONS

This research provides an example of a systematic, evidence-based approach to the development of a simple health intervention designed to promote uptake of screening in accordance with national guidelines. The methods and findings illustrate how Intervention Mapping can be employed to develop tailored retinal screening promotion materials for specific priority populations. This paper has implications for future program planners and is intended to assist those wishing to use Intervention Mapping to create similar theoretically-driven, tailored resources.

Diabetes Intervention Accentuating Diet and Enhancing Metabolism (DIADEM-I): a randomised controlled trial to examine the impact of an intensive lifestyle intervention consisting of a low-energy diet and physical activity on body weight and metabolism in early type 2 diabetes mellitus: study protocol for a randomized controlled trial

Background

Type 2 diabetes mellitus (T2DM) and obesity are syndemic and will have a significant impact on affected individuals and healthcare services worldwide. Evidence shows that T2DM remission can be achieved with significant weight loss in those who are younger with early diabetes and requiring fewer medications for glycaemic control. DIADEM-I aims to examine the impact of an intensive lifestyle intervention (ILI) using a low-energy diet (LED) meal replacement approach combined with physical activity in younger individuals with early T2DM.

Methods

The planned study is an ongoing, non-blinded, pragmatic, randomised controlled, parallel-group trial examining the impact of an LED-based ILI on body weight and diabetes remission in younger (18–50 years) T2DM individuals with early diabetes (≤ 3-year duration). The ILI will be compared to usual medical care (UMC). The primary outcome will be weight loss at 12 months. Other key outcomes of interest include diabetes remission, glycaemic control, diabetes complications, cardiovascular health, physical activity, mental health, and quality of life. It is planned for the study to include 138 subjects for assessment of the primary outcome. Safety will be assessed throughout.

Discussion

If DIADEM-I demonstrates a clinically significant effect for younger individuals with early T2DM, it will inform clinical guidelines and services of the future for management of T2DM.

Trial registration

ISRCTN: ISRCTN20754766 (date assigned: 7 June 2017); ClinicalTrials.gov, ID: NCT03225339 Registered on 26 June 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2660-1) contains supplementary material, which is available to authorized users.

Predictors of Loss to Follow-Up among Children with Type 2 Diabetes

BACKGROUND/AIMS

Youth with type 2 diabetes (T2D) have poor compliance with medical care. This study aimed to determine which demographic and clinical factors differ between youth with T2D who receive care in a pediatric diabetes center versus youth lost to follow-up for >18 months.

METHODS

Data were analyzed from 496 subjects in the Pe-diatric Diabetes Consortium registry. Enrollment variables were selected a priori and analyzed with univariable and multivariable logistic regression models.

RESULTS

After a median of 1.3 years from enrollment, 55% of patients were lost to follow-up. The final model included age, race/ethnicity, parent education, and estimated distance to study site. The odds ratio (99% confidence interval) of loss to follow-up was 2.87 (1.34, 6.16) for those aged 15 to <18 years versus those aged 10 to <13 years and 6.57 (2.67, 16.15) for those aged ≥18 years versus those aged 10 to <13 years. Among patients living more than 50 miles from the clinic, the odds ra tio of loss to follow-up was 3.11 (1.14, 8.49) versus those living within 5 miles of the site.

CONCLUSION

Older adolescents with T2D are more likely to be lost to follow-up, but other socioeconomic factors were not significant predictors of clinic follow-up.

Diabetes Mellitus and Ischemic Heart Disease: The Role of Ion Channels

Diabetes mellitus is one the strongest risk factors for cardiovascular disease and, in particular, for ischemic heart disease (IHD). The pathophysiology of myocardial ischemia in diabetic patients is complex and not fully understood: some diabetic patients have mainly coronary stenosis obstructing blood flow to the myocardium; others present with coronary microvascular disease with an absence of plaques in the epicardial vessels. Ion channels acting in the cross-talk between the myocardial energy state and coronary blood flow may play a role in the pathophysiology of IHD in diabetic patients. In particular, some genetic variants for ATP-dependent potassium channels seem to be involved in the determinism of IHD.

The Evolving Epidemiology of Atherosclerotic Cardiovascular Disease in People with Diabetes

Atherosclerotic cardiovascular disease (ASCVD) is a leading global cause of death and accounts for most deaths among individuals with diabetes. This article reviews the latest observational and trial data on changes in the relationship between diabetes and ASCVD risk, remaining gaps in how the role of each risk factor is understood, and current knowledge about specific interventions. Differences between high-income countries and low-income and middle-income countries are examined, barriers and facilitators are discussed, and a discussion around the concept of ideal cardiovascular health factors (Life's Simple 7) is focused on.

Insulin sensitivity across the lifespan from obese adolescents to obese adults with impaired glucose tolerance: Who is worse off?

OBJECTIVE

Youth type 2 diabetes mellitus (T2DM) occurs decades earlier than adult T2DM and is characterized by high therapeutic failure rates and decreased response to insulin sensitizers suggesting a more severe disease process than in adults. To explain these observations, we hypothesized that insulin resistance is worse in obese youth than adults with impaired glucose tolerance (IGT), a state of high-risk for T2DM. As proof-of-concept, we compared insulin sensitivity between BMI-, sex-, and race-matched obese youth vs adults with IGT.

METHODS

This retrospective analysis of IGT youth and adults included 34 obese adolescents matched (2:1) for BMI, sex, and race to 17 adults. Hepatic and peripheral insulin sensitivity were measured by [6,6-² H₂ ]glucose and hyperinsulinemic-euglycemic clamp. Body composition (DEXA) and serum lipid profile were examined.

RESULTS

Despite similar percent body fat, obese adolescents had 2-fold higher fasting insulin concentration, lower hepatic (~53%) and peripheral (~42%) insulin sensitivity and lower HDL compared with adults (all P < .01). Surrogate estimate of insulin sensitivity, 1/fasting insulin was lower and HOMA-IR was higher in adolescents vs adults. Adults had a more atherogenic lipid profile with higher total-, LDL-, and non-HDL cholesterol.

CONCLUSIONS

Obese youth and adults with IGT differ in that youth are more insulin resistant than adults in spite of similar adiposity. This could potentially explain the earlier onset of T2DM in youth through an early and amplified burden on a β-cell destined to decompensate, and explicate their lower therapeutic response to insulin sensitizers.

Age, age at diagnosis and diabetes duration are all associated with vascular complications in type 2 diabetes

BACKGROUND

Type 2 diabetes (T2DM) is increasingly diagnosed in younger patients. The trajectory of complications in patients diagnosed at a younger or older age is not well understood. We examine the associations between age, age at diagnosis and diabetes duration and vascular complications in patients with T2DM.

METHODS

A cross-sectional study of pre-specified demographic and clinical data, from 3419 adults with T2DM participating in the Australian National Diabetes Audit (2015). Factors associated with diabetes complications were analysed using logistic regression.

RESULTS

Mean (±SD) current age was 62.9±12.5years, age at diagnosis was 49.4±12.3years and mean diabetes duration was 13.5±9.4years. Macrovascular complications were more prevalent in patients who were older at diabetes diagnosis whereas microvascular complications were more prevalent in patients who were younger at diabetes diagnosis. Age, age at diagnosis and diabetes duration were all independently associated with increased risk of macrovascular complications after adjustment for sex, smoking, BMI and microvascular complications (all p<0.001). In contrast, only diabetes duration was independently associated with microvascular complications after adjustment for sex, smoking, BMI and macrovascular complications (p<0.001).

CONCLUSIONS

Age, age at diagnosis, and diabetes duration were all independently associated with macrovascular complications whereas only diabetes duration was independently associated with microvascular complications.

Identification of bioactive heterocyclic compounds from mulberry and their protective effect against streptozotocin-induced apoptosis in INS-1 cells

A phytochemical investigation of the MeOH extracts from mulberries (the fruit of Morus alba L.) led to the identification of six heterocyclic compounds (1‑6). These compounds were screened to detect whether they protected pancreatic INS‑1 cells from streptozotocin (STZ)‑induced cytotoxicity. Compound 3 was the most effective at preventing STZ‑induced cytotoxicity and the production of reactive oxygen species (ROS) in INS‑1 cells. In addition, compound 3 effectively prevented apoptosis induced by STZ in INS‑1 cells. Compound 3 also prevented STZ‑mediated cleavage of caspase‑8, caspase‑3 and poly (ADP‑ribose) polymerase and increased the expression of B‑cell lymphoma‑2 (Bcl‑2), an anti‑apoptotic Bcl‑2 family protein. In conclusion, the results of the present study indicate that compound 3 extracted from the fruit of M. alba was highly effective in preventing type 1 diabetes mellitus and may be a novel treatment option.

Suppressive Effects of Clerodendrum volubile P Beauv. [Labiatae] Methanolic Extract and Its Fractions on Type 2 Diabetes and Its Complications

Type 2 diabetes is the most prominent of all diabetes types, contributing to global morbidity and mortality. Availability and cost of treatment with little or no side effect especially in developing countries, remains a huge burden. This has led to the search of affordable alternative therapies especially from medicinal plants. In this study, the antidiabetic effect of the methanolic extract, dichloromethane (DCM), butanol (BuOH) and aqueous fractions of Clerodendrum volubile leaves were investigated in type 2 diabetic rats for their effect on glucose homeostasis, serum insulin level and hepatic biomarkers, lipid profile, pancreatic redox balance and Ca2+ levels, and β-cell distribution and function. The DCM was further fractionated to isolate the active compounds, biochanin and 5,7,4'-trimethoxykaempferol. They were investigated for their toxicity and ADMET properties, α-glucosidase and angiotensin I converting enzyme (ACE) inhibitory activities in silico. There were significant (p < 0.05) decrease in blood glucose, cholesterol, LDL-C, vLDL-C, triglyceride, AST and ALT levels in all treated groups, with DCM fraction showing the best activity. All treated rats showed significantly (p < 0.05) improved anti-oxidative activities. Treatment with the DCM fraction led to significant (p < 0.05) increased serum insulin and pancreatic Ca2+ levels, as well as improved β-cell distribution and function. DCM fraction also showed improved glucose tolerance. DCM fraction dose-dependently inhibited ACE activity. The toxicity class of the isolated compounds was predicted to be 5. They were also predicted to be potent inhibitors of cytochrome P (CYPs) 1A2, 2D6 and 3A4. They docked well with α-glucosidase and ACE. These results indicate the therapeutic potential of the plant against type 2 diabetes, with the DCM fraction being the most potent which may be attributed to the isolated flavones. It further suggests antihypertensive potentials of the DCM fraction. However, inhibition of CYPs by the flavones may suggest caution in usage with other prescribed drugs metabolized by these enzymes.

Type 2 diabetes in adolescents and young adults

The prevalence of type 2 diabetes in adolescents and young adults is dramatically increasing. Similar to older-onset type 2 diabetes, the major predisposing risk factors are obesity, family history, and sedentary lifestyle. Onset of diabetes at a younger age (defined here as up to age 40 years) is associated with longer disease exposure and increased risk for chronic complications. Young-onset type 2 diabetes also affects more individuals of working age, accentuating the adverse societal effects of the disease. Furthermore, evidence is accumulating that young-onset type 2 diabetes has a more aggressive disease phenotype, leading to premature development of complications, with adverse effects on quality of life and unfavourable effects on long-term outcomes, raising the possibility of a future public health catastrophe. In this Review, we describe the epidemiology and existing knowledge regarding pathophysiology, risk factors, complications, and management of type 2 diabetes in adolescents and young adults.

Type 2 diabetes in young adults in Central Auckland: demography and complications

BACKGROUND

Type 2 diabetes (T2D) in young adults is associated with a high risk of diabetes complications.

AIMS

To investigated the demography and the emergence of complications of young adults with T2D in the central Auckland region where there has been substantial immigration.

METHODS

In total, 310 young adults with T2D (<40 years) were registered with the Auckland Diabetes Centre in 2015. We documented demographic, anthropometric and metabolic variables and prevalence and the emergence of complications.

RESULTS

Three demographic groups accounted for 243 participants (78%): 135 (44%) were migrants of Asian or Pacific Island origin, diagnosed a median 9 years after migration at a mean age of 28 ± 6 years; 88 (29%) were New Zealand-born Pāsifika descent, with a high prevalence of morbid obesity and 37 (12%) had major mental illness or intellectual disability. At diagnosis, the median HbA1c was 80 mmol/mol, and in 28%, it was ≥100 mmol/mol. A median 6 years after diagnosis, 56% had some degree of retinopathy, with the prevalence related both to the duration of diabetes and glycaemic control (P = 0.001). Forty-four percent of subjects had abnormal albuminuria at diagnosis (12% with macroalbuminuria). Increased albuminuria was strongly associated with obesity (P = 0.002). The development of CKD stages 4-5 was related both to the severity of retinopathy and degree of albuminuria at diagnosis (P = 0.0001). Major cardiovascular events were related to the severity of retinopathy at diagnosis (P = 0.0001).

CONCLUSIONS

New migrants, New Zealand-born Pāsifika and patients with mental illness or an intellectual disability comprise the bulk of young onset T2D. The disease is aggressive, and by the age of 40, patients are already developing advanced complications.

A Systematic Review and Meta-Analysis of the Effect of Lifestyle Modification on Metabolic Control in Overweight Children

Childhood obesity is associated with type 2 diabetes mellitus. We aimed to determine the effects of lifestyle modification programs on fasting plasma glucose (FPG) levels in overweight children. We queried six relevant electronic databases and manually searched for studies published before December 2016. Overweight/obese children who underwent a lifestyle modification for more than 6 months were included. A total of 3923 children from eight randomized controlled trials (RCTs) were included. Compared with the control group, the lifestyle modification group had significantly lower FPG levels by 1.3 mg/dL. The mean differences were significantly decreased for both secondary outcomes; BMI z-score decreased by 0.16 units and insulin levels decreased by 2.4 mU/L. The metaregression showed that the follow-up duration was associated with FPG levels and BMI and insulin levels and half year is a suitable follow-up duration for this population. This study showed that lifestyle modification programs may be effective in reducing the FPG levels of overweight/obese children. Further high-quality RCTs with longer follow-up periods are needed to evaluate the long-term effect of this complementary approach for diabetes mellitus prevention on overweight/obese children.

Prevalences and Management of Diabetes and Pre-diabetes among Korean Teenagers and Young Adults: Results from the Korea National Health and Nutrition Examination Survey 2005-2014

The rapid increases in childhood obesity and physical inactivity are linked to the incidence of diabetes among young individuals. However, few studies have evaluated the prevalence of diabetes among this population. Therefore, we used Korea National Health and Nutrition Examination Survey (KNHANES) data to evaluate the prevalence and management of diabetes and pre-diabetes among young Koreans. We evaluated KNHANES data (2005-2014) from 10-29-year-old individuals. Individuals were considered eligible if they had completed the health examination and the health interview survey, and we excluded individuals with missing data regarding fasting glucose or glycated haemoglobin levels. Among the 100,101 potentially eligible individuals who participated in KNHANES (2005-2014), we included 83,577 (37,677 male and 45,900 female) individuals. The overall prevalences of diabetes and pre-diabetes among 10-19-year-old individuals were 0.2% and 11.9%, respectively. Among 20-29-year-old individuals, the prevalences of diabetes and pre-diabetes were 0.9% and 9.6%, respectively. The overall rates of diabetes awareness during the study period were 36.6% for 10-19-year-old individuals and 50.8% for 20-29-year-old individuals. However, the prevalence of diabetes and pre-diabetes had noticeably increased at the 2013-2014 KNHANES: 0.6% and 25.9% among 10-19-year-old individuals, and 0.8% and 19.2% among 20-29-year-old individuals. The prevalence of diabetes and pre-diabetes is rapidly increasing among Korean teenagers and young adults. Pre-emptive interventions to diagnose and treat diabetes and pre-diabetes are needed to improve glycaemic control among this population.

Real-Life Glycemic Control in Children with Type 2 Diabetes: A Population-Based Study

OBJECTIVES

To characterize children and adolescents with type 2 diabetes mellitus (T2DM) insured by a large health maintenance organization, and to identify variables associated with treatment quality and disease outcome.

STUDY DESIGN

Children and adolescents diagnosed with T2DM over a 9-year period were identified from the database of Clalit Health Services, a large health maintenance organization in Israel (1 213 362 members aged 0-18 years). Demographic, anthropometric, clinical, and laboratory data were analyzed.

RESULTS

A total of 96 patients (47 males) met our inclusion criteria. The mean age at diagnosis of T2DM was 14.25 ± 2.51 years. At the time of diagnosis, the median hemoglobin A1c (HbA1c) level was 7.8%, and additional components of the metabolic syndrome were present in 14.9%-67.4% of the patients. At the end of the follow-up period (3.11 ± 1.75 years), >50% of the patients were being treated with insulin; the median HbA1c value was 7.97%, and 44.6% of the patients achieved the target HbA1c of <7.0%. On multivariate linear regression analysis, the variables found to predict worse glycemic control (ie, higher HbA1c) were a higher HbA1c at diagnosis, a higher body mass index SD score at diagnosis, fewer annual HbA1c tests, and Arabic ethnicity [F(4,81) = 7.139; P < .001; R² = 0.271].

CONCLUSION

This population-based study of pediatric patients with T2DM demonstrates that reasonable glycemic control can be achieved in both community and outpatient hospital settings. Nevertheless, there is room for improvement in intervention programs to optimize outcomes and decrease the risk of complications.

Distinct Predictors and Comorbidities in Early Onset Type 2 Diabetes Mellitus Among Asian Indians

BACKGROUND

The incidence of type 2 diabetes mellitus (T2DM) is increasing worldwide, and the age of disease onset is falling. Although there is rising prevalence of early onset T2DM in India, little is known about their clinical characteristics and cardiovascular risks profiles. The aim of this study was to address this knowledge gap by comparing the characteristics of early onset T2DM and usual onset T2DM patients from our clinic population in India.

METHODS

We studied the clinical and biochemical parameters of 98 consecutive early onset T2DM patients of age <45 and <5 years of disease duration and compared those parameters with 86 consecutive usual onset T2DM patients of age >50 years and similar disease duration.

RESULTS

There was a strong component of family history of T2DM in early onset T2DM patients; however, no difference was observed in body mass index or waist circumference between the groups. When compared with usual onset group, the early onset T2DM patients were more hypertriglycedemic, with higher total cholesterol, higher total cholesterol/high-density lipoprotein (HDL) ratio, higher low-density lipoprotein levels, and lower HDL cholesterol. Early onset T2DM patients showed significantly worse glycemic control and rapid decline in insulin secretion compared with usual onset T2DM patients.

CONCLUSIONS

Our results demonstrate that early onset T2DM in Asian Indians appears to be a disease phenotype with adverse risk factors having poor glycemic control and longer disease duration demanding strategies for novel clinical management.

Bariatric Surgery for Adolescents with Type 2 Diabetes: an Emerging Therapeutic Strategy

PURPOSE OF REVIEW

Type 2 diabetes (T2D) is a growing public health problem in youth, but conventional treatments are often insufficient to treat this disease and its comorbidities. We review evidence supporting an emerging role for bariatric surgery as a treatment for adolescent T2D.

RECENT FINDINGS

Paralleling what has been seen in adult patients, bariatric surgery dramatically improves glycemic control in patients with T2D. In fact, remission of T2D has been observed in as many as 95-100% of adolescents with diabetes after bariatric surgery, particularly vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB) surgery. This striking outcome may be due to both weight-dependent- and weight-independent factors, and recent studies suggest that T2D-related comorbidities may also improve after surgery. Bariatric surgery including RYGB and VSG is a powerful therapeutic option for obese adolescents with T2D. Benefits must be weighed against risk for postoperative complications such as nutritional deficiencies, but earlier surgical intervention might lead to more complete metabolic remission in obese patients with T2D.

BMI and All-Cause Mortality in Normoglycemia, Impaired Fasting Glucose, Newly Diagnosed Diabetes, and Prevalent Diabetes: A Cohort Study

OBJECTIVE

This study examined associations between BMI and mortality in individuals with normoglycemia, impaired fasting glucose (IFG), newly diagnosed diabetes, and prevalent diabetes and identified BMI ranges associated with the lowest mortality in each group.

RESEARCH DESIGN AND METHODS

A total of 12,815,006 adults were prospectively monitored until 2013. Diabetes status was defined as follows: normoglycemia (fasting glucose <100 mg/dL), IFG (100-125 mg/dL), newly diagnosed diabetes (≥126 mg/dL), and prevalent diabetes (self-reported). BMI (kg/m²) was measured. Cox proportional hazards model hazard ratios were calculated after adjusting for confounders.

RESULTS

During a mean follow-up period of 10.5 years, 454,546 men and 239,877 women died. U-shaped associations were observed regardless of diabetes status, sex, age, and smoking history. Optimal BMI (kg/m²) for the lowest mortality by group was 23.5-27.9 (normoglycemia), 25-27.9 (IFG), 25-29.4 (newly diagnosed diabetes), and 26.5-29.4 (prevalent diabetes). Higher optimal BMI by worsening diabetes status was more prominent in younger ages, especially in women. The relationship between worsening diabetes status and higher mortality was stronger with lower BMI, especially at younger ages. Given the same BMI, people with prevalent diabetes had higher mortality compared with those with newly diagnosed diabetes, and this was more striking in women than men.

CONCLUSIONS

U-curve relationships existed regardless of diabetes status. Optimal BMI for lowest mortality became gradually higher with worsening diabetes for each sex and each age-group.

The rs7903146 Variant in the TCF7L2 Gene Increases the Risk of Prediabetes/Type 2 Diabetes in Obese Adolescents by Impairing β-Cell Function and Hepatic Insulin Sensitivity

OBJECTIVE

In this study, we aimed to explore the mechanism by which TCF7L2 rs7903146 risk allele confers susceptibility to impaired glucose tolerance (IGT) or type 2 diabetes (T2D) in obese adolescents.

RESEARCH DESIGN AND METHODS

The rs7903146 variant in the TCF7L2 gene was genotyped in a multiethnic cohort of 955 youths. All subjects underwent an oral glucose tolerance test with the use of the Oral Minimal Model to assess insulin secretion, and 33 subjects underwent a hyperinsulinemic-euglycemic clamp. In 307 subjects, a follow-up oral glucose tolerance test was repeated after 3.11 ± 2.36 years.

RESULTS

The TCF7L2 rs7903146 risk allele was associated with higher 2-h glucose levels in Caucasians (P = 0.006) and African Americans (P = 0.009), and a trend was seen also in Hispanics (P = 0.072). Also, the T allele was associated with decreased β-cell responsivity and IGT (P < 0.05). Suppression of endogenous hepatic glucose production was lower in subjects with the risk variant (P = 0.006). Finally, the odds of showing IGT/T2D at follow-up were higher in subjects carrying the minor allele (odds ratio 2.224; 95% CI 1.370-3.612; P = 0.0012).

CONCLUSIONS

The rs7903146 variant in the TCF7L2 gene increases the risk of IGT/T2D in obese adolescents by impairing β-cell function, and hepatic insulin sensitivity predicts the development of IGT/T2D over time.

Weight change in the management of youth-onset type 2 diabetes: the TODAY clinical trial experience

BACKGROUND

The Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial documented that metformin plus rosiglitazone, but not metformin plus lifestyle intervention, provided superior durability of glycemic control relative to metformin monotherapy.

OBJECTIVES

We examined weight changes among TODAY participants that completed at least 6 months of treatment, evaluated predictors of lifestyle outcome, and examined whether weight changes were related to cardiometabolic outcomes across treatment arms.

METHODS

The 595 youth with type 2 diabetes, (85.1% of randomized participants aged 11-17 years) completed assessments of weight-related and cardiometabolic measures at months 0, 6, 12 and 24. Repeated measures models were used to investigate associations over time.

RESULTS

Lifestyle intervention did not enhance outcome relative to metformin alone and no predictors of response to lifestyle treatment were identified. However, changes in percent overweight across treatment arms were associated with changes in multiple cardiometabolic risk factors, and decreases of ≥ 7% in overweight were associated with significant benefits over 24 months.

CONCLUSIONS

Although adjunctive intensive lifestyle intervention did not improve weight-related outcomes, weight changes in the full TODAY sample were associated with small, but significant improvements in cardiometabolic status, highlighting the importance of optimizing weight management in youth with T2DM.

Type 2 diabetes

415 million people live with diabetes worldwide, and an estimated 193 million people have undiagnosed diabetes. Type 2 diabetes accounts for more than 90% of patients with diabetes and leads to microvascular and macrovascular complications that cause profound psychological and physical distress to both patients and carers and put a huge burden on health-care systems. Despite increasing knowledge regarding risk factors for type 2 diabetes and evidence for successful prevention programmes, the incidence and prevalence of the disease continues to rise globally. Early detection through screening programmes and the availability of safe and effective therapies reduces morbidity and mortality by preventing or delaying complications. Increased understanding of specific diabetes phenotypes and genotypes might result in more specific and tailored management of patients with type 2 diabetes, as has been shown in patients with maturity onset diabetes of the young. In this Seminar, we describe recent developments in the diagnosis and management of type 2 diabetes, existing controversies, and future directions of care.

Vascular and Endothelial Function in Youth with Type 2 Diabetes Mellitus

PURPOSE OF REVIEW

This review aims to discuss the burden of type 2 diabetes in youth and summarize the studies that have utilized noninvasive techniques to assess early vascular disease in youth with type 2 diabetes.

RECENT FINDINGS

Noninvasive imaging modalities provide researchers with tools to investigate the vasculature in adolescents with type 2 diabetes. The data published to date consistently show adolescents with type 2 diabetes have greater vascular thickness and stiffness and worse endothelial function compared to their obese and lean peers. As the prevalence of type 2 diabetes continues to increase adolescent youth, there is concern adolescents with type 2 diabetes are at risk to develop early onset cardiovascular disease and complications. Future studies need to address treatments that have the potential to improve or reverse vascular dysfunction and decrease the rate of cardiovascular disease and complications.

Younger-onset versus older-onset type 2 diabetes: Clinical profile and complications

AIMS

To compare the clinical profile and complications between younger and older onset type 2 diabetes (T2DM) patients at a tertiary care diabetes center in south India.

METHODS

We compared individuals with T2DM detected at age ≤25years (n=267) and at age≥50years (n=267), matched for gender and duration of diabetes. We reviewed electronic patient charts and extracted data on biochemical parameters (plasma glucose, serum lipids and glycated hemoglobin). We estimated prevalence of complications (retinopathy, nephropathy, neuropathy, and peripheral vascular disease). We examined odds of having each complication, after adjusting for clinical differences between younger- and older-onset T2DM.

RESULTS

Individuals with younger-onset T2DM had significantly greater glycated hemoglobin (8.7 vs. 7.5%), serum cholesterol (160 vs. 148mg/dl), serum triglycerides (147 vs. 128mg/dl), LDL cholesterol (92 vs. 82mg/dl) and lower HDL cholesterol levels (39 vs. 42mg/dl). However, waist circumference (90.4 vs. 92.6cm) and systolic blood pressure (125 vs. 133mmHg) were significantly higher in older onset T2DM. Prevalence of retinopathy (47.6 vs. 31.0%) was higher in younger onset T2DM while neuropathy (41.8 vs. 9.2%) and peripheral vascular disease (6.2 vs. 1.2%) were higher in older onset T2DM. In multiple logistic regression analysis, after adjusting for glycated hemoglobin, hypertension, and hypercholesterolemia, younger onset T2DM had a higher odds of developing retinopathy [Odds Ratio: 2.19; Confidence Intervals: 1.42-3.38] when compared to older onset T2DM.

CONCLUSIONS

Younger onset T2DM patients have worse glycemic and lipid control, and higher prevalence of retinopathy compared to older onset T2DM patients. This underscores the need for more aggressive metabolic control in young-onset T2DM.

Socioeconomic status and type 2 diabetes complications among young adult patients in Japan

Objective

To assess the relationship between socioeconomic status (SES) and complications of type 2 diabetes among young adults in Japan.

Design

A cross-sectional study.

Setting

Outpatient wards of 96 member hospitals and clinics of the Japan Federation of Democratic Medical Institutions.

Participants

A total of 782 outpatients with type 2 diabetes (525 males, 257 females), aged 20–40 years as of March 31, 2012. After excluding 110 participants whose retinopathy diagnosis was in question, 672 participants were analyzed.

Measurements

We examined the relations between SES (educational level, income, type of public healthcare insurance, and employment status) and diabetes complications (retinopathy and nephropathy) using a multivariate logistic regression analysis.

Results

The prevalence of type 2 diabetic retinopathy was 23.2%, while that of nephropathy was 8.9%. The odds of having retinopathy were higher among junior high school graduates (OR 1.91, 95% CI 1.09–3.34), patients receiving public assistance (OR 2.19, 95% CI 1.20–3.95), and patients with irregular (OR 1.72, 95% CI 1.03–2.86) or no employment (OR 2.23, 95% CI 1.36–3.68), compared to those with a higher SES, even after covariate adjustment (e.g., age, gender, body mass index). Similarly, the odds of having nephropathy were higher among patients with middle (OR 3.61, 95% CI 1.69–8.27) or low income levels (OR 2.53, 95% CI 1.11–6.07), even after covariate adjustment.

Conclusions

Low SES was associated with a greater likelihood of type 2 diabetes complications in young adults. These findings suggest the necessity of health policies that mitigate socioeconomic disparity and thereby reduce the prevalence of diabetic complications.

The characteristics of newly diagnosed adult early-onset diabetes: a population-based cross-sectional study

To investigate the characteristics of newly diagnosed early-onset diabetes in the Chinese population, 2801 newly diagnosed diabetes participants without known diabetes or pre-diabetes in a national cross-sectional survey were analysed. Participants were divided into quartiles (22-43, 44-52, 53-61 and >61 years) according to age of diabetes onset and the first group were defined as early-onset diabetes group. Early-onset diabetes group had lower systolic blood pressure (SBP), total cholesterol, low density lipoprotein cholesterol, 2-hour post prandial blood glucose and urine albumin creatinine ratio. There was no difference in body mass index, Homeostasis model assessment (HOMA) of beta cell function and diabetes family history between early-onset diabetes participants and any other age groups. HOMA of insulin resistance (IR) scores and disposition index 30 minutes after glucose load (DI₃₀) were increased in early-onset diabetes participants. The beta cell function declination was more deteriorated in early-onset diabetes participants. Male gender, triglycerides, HOMA-IR and DI₃₀ were positively associated with an earlier age at diagnosis. In conclusion, patients diagnosed with diabetes at a younger age are characterized by a similar cardiovascular risk profile with increased insulin resistance and more severe beta cell failure than patients diagnosed at a later age.

Trends in Drug Utilization, Glycemic Control, and Rates of Severe Hypoglycemia, 2006-2013

OBJECTIVE

To examine temporal trends in utilization of glucose-lowering medications, glycemic control, and rate of severe hypoglycemia among patients with type 2 diabetes (T2DM).

RESEARCH DESIGN AND METHODS

Using claims data from 1.66 million privately insured and Medicare Advantage patients with T2DM from 2006 to 2013, we estimated the annual 1) age- and sex-standardized proportion of patients who filled each class of agents; 2) age-, sex-, race-, and region-standardized proportion with hemoglobin A1c (HbA1c) <6%, 6 to <7%, 7 to <8%, 8 to <9%, ≥9%; and 3) age- and sex-standardized rate of severe hypoglycemia among those using medications. Proportions were calculated overall and stratified by age-group (18-44, 45-64, 65-74, and ≥75 years) and number of chronic comorbidities (zero, one, and two or more).

RESULTS

From 2006 to 2013, use increased for metformin (from 47.6 to 53.5%), dipeptidyl peptidase 4 inhibitors (0.5 to 14.9%), and insulin (17.1 to 23.0%) but declined for sulfonylureas (38.8 to 30.8%) and thiazolidinediones (28.5 to 5.6%; all P < 0.001). The proportion of patients with HbA1c <7% declined (from 56.4 to 54.2%; P < 0.001) and with HbA1c ≥9% increased (9.9 to 12.2%; P < 0.001). Glycemic control varied by age and was poor among 23.3% of the youngest and 6.3% of the oldest patients in 2013. The overall rate of severe hypoglycemia remained the same (1.3 per 100 person-years; P = 0.72), declined modestly among the oldest patients (from 2.9 to 2.3; P < 0.001), and remained high among those with two or more comorbidities (3.2 to 3.5; P = 0.36).

CONCLUSIONS

During the recent 8-year period, the use of glucose-lowering drugs has changed dramatically among patients with T2DM. Overall glycemic control has not improved and remains poor among nearly a quarter of the youngest patients. The overall rate of severe hypoglycemia remains largely unchanged.

Antidiabetic effects of Morus alba fruit polysaccharides on high-fat diet- and streptozotocin-induced type 2 diabetes in rats

ETHNOPHARMACOLOGICAL RELEVANCE

Type 2 diabetes mellitus (T2DM) is becoming a serious threat to human health. The fruit of Morus alba L. is widely used as a traditional Chinese medicine for the treatment of DM, dizziness, tinnitus, insomnia, and premature graying, as well as to protect the liver and kidneys. Several studies have demonstrated that the aqueous extracts of the roots bark, leaves, and ramuli of mulberry, which are known to contain polyphenols and polysaccharides, have antihyperglycemic and antihyperlipidemic activities. The aim of the present study was to further investigate the active polysaccharides from M. alba fruit by evaluating the antidiabetic activities of different fractions on T2DM rats and elucidate the mechanism underlying these activities.

MATERIALS AND METHODS

Diabetic rats were treated with two fractions of M. alba fruit polysaccharides (MFP50 and MFP90). The disease models were induced by a high-fat diet and low dose injection of streptozotocin and were compared to normal rats and metformin-treated diabetic rats. After seven weeks, the fasting blood glucose (FBG), oral glucose tolerance test (OGTT), fasting serum insulin (FINS) levels, homeostasis model of assessment-insulin resistance (HOMA-IR), glycated serum protein (GSP), and serum alanine transaminase (ALT) levels, as well as serum lipid profiles and histopathological changes in the pancreas were measured. Next, the expressions of the insulin signaling pathway were measured by western blot analysis to elucidate the potential mechanism underlying these antidiabetic activities.

RESULTS

After seven weeks of treatment, a significant reduction in the FBG levels, OGTT-area under the curve (OGTT-AUC), FINS, HOMA-IR, ALT, and triglyceride (TG) values of the MFP50 group was observed. On the other hand, in the MFP90 group, the FBG, OGTT-AUC, FINS, HOMA-IR, GSP, and TG levels were significantly reduced. The level of high-density lipoprotein cholesterol (HDL-c) and the proportion of HDL-c to total cholesterol (TC) significantly increased in the MFP50 group. Moreover, MFP50 and MFP90 induced repair of damaged pancreatic tissues of the diabetic rats. The hypoglycemic effect of MFP50 was more stable than MFP90, whereas the hypolipidemic effect of MFP90 was slightly better than MFP50. Moreover, the expression levels of InsR, IRS-2, Akt and GLUT4 in the MFP90 group significantly increased relative to that of the T2DM group.

CONCLUSIONS

MFP50 and MFP90 have markedly antihyperglycemic and antihyperlipidemic effects and can clearly relieve diabetes symptoms in the T2DM rat model. The M. alba fruit polysaccharides may potentially be utilized as an effective treatment for T2DM. Further research into the structures of active M. alba fruit polysaccharides and their mechanisms in promoting antidiabetic effects are underway.

Reversal of type 2 diabetes in youth who adhere to a very-low-energy diet: a pilot study

AIMS/HYPOTHESIS

The aim of the study was to investigate whether a very-low-energy diet (VLED) is a feasible and acceptable treatment option for type 2 diabetes in children and adolescents, and whether adherence can lead to rapid weight loss, reversal of type 2 diabetes and reduced liver fat as seen in adult studies.

METHODS

Eight participants with type 2 diabetes and obesity, aged 7-16 years, non-medicated (n = 1) or treated with metformin (n = 7) and in some cases insulin (n = 3), followed a VLED (<3360 kJ/day) for 8 weeks, then transitioned to a hypocaloric diet (∼6300 kJ/day) that they followed to 34 weeks. HbA_1c, fasting glucose and 2 h post-glucose load plasma glucose (2hG) were determined from fasting blood and an OGTT. Liver fat concentration was quantified using proton magnetic resonance spectroscopy. Adherence was defined as ≥5% weight loss during the 8 week VLED.

RESULTS

Adherers (n = 5) and non-adherers (n = 3) had median weight loss of 7.5% and 0.5%, respectively, at 8 weeks. Overall, HbA_1c (mean [SE] 8.1% [0.7%] to 6.6% [0.5%]; p = 0.004) and 2hG (15.6 [1.6] mmol/l to 11.3 [1.0] mmol/l; p = 0.009) were significantly reduced at 8 weeks compared with baseline. Liver fat was also significantly reduced from baseline (14.7% [2.2%]) to 8 weeks (5.8% [1.7%]; p = 0.001). Only three out of eight participants met non-alcoholic fatty liver disease (NAFLD) criteria (≥5.5%) at 8 weeks, compared with eight out of eight at baseline. The three participants on insulin therapy at baseline were able to cease therapy during the 8 week VLED. At 34 weeks, adherers (n = 5) achieved 12.3% weight loss, none met NAFLD criteria and four did not meet American Diabetes Association criteria for type 2 diabetes.

CONCLUSIONS/INTERPRETATION

A VLED appears to be a feasible treatment option for some youth with type 2 diabetes on metformin therapy. Youth who agree to participate and adhere to a VLED achieve rapid weight loss, dramatic reductions in liver fat and reversal of type 2 diabetes. This highlights the capacity of a VLED to be used as a first-line treatment option in newly diagnosed youth. A larger trial with a control group and longer follow-up will be required to encourage a change in standard treatment.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registration Number (ACTRN) ACTRN12616000375459 ( www.ANZCTR.org.au/ACTRN12616000375459.aspx ).

Association of Type 1 Diabetes vs Type 2 Diabetes Diagnosed During Childhood and Adolescence With Complications During Teenage Years and Young Adulthood

Importance

The burden and determinants of complications and comorbidities in contemporary youth-onset diabetes are unknown.

Objective

To determine the prevalence of and risk factors for complications related to type 1 diabetes vs type 2 diabetes among teenagers and young adults who had been diagnosed with diabetes during childhood and adolescence.

Design, Setting, and Participants

Observational study from 2002 to 2015 in 5 US locations, including 2018 participants with type 1 and type 2 diabetes diagnosed at younger than 20 years, with single outcome measures between 2011 and 2015.

Exposures

Type 1 and type 2 diabetes and established risk factors (hemoglobin A1c level, body mass index, waist-height ratio, and mean arterial blood pressure).

Main Outcomes and Measures

Diabetic kidney disease, retinopathy, peripheral neuropathy, cardiovascular autonomic neuropathy, arterial stiffness, and hypertension.

Results

Of 2018 participants, 1746 had type 1 diabetes (mean age, 17.9 years [SD, 4.1]; 1327 non-Hispanic white [76.0%]; 867 female patients [49.7%]), and 272 had type 2 (mean age, 22.1 years [SD, 3.5]; 72 non-Hispanic white [26.5%]; 181 female patients [66.5%]). Mean diabetes duration was 7.9 years (both groups). Patients with type 2 diabetes vs those with type 1 had higher age-adjusted prevalence of diabetic kidney disease (19.9% vs 5.8%; absolute difference [AD], 14.0%; 95% CI, 9.1%-19.9%; P < .001), retinopathy (9.1% vs 5.6%; AD, 3.5%; 95% CI, 0.4%-7.7%; P = .02), peripheral neuropathy (17.7% vs 8.5%; AD, 9.2%; 95% CI, 4.8%-14.4%; P < .001), arterial stiffness (47.4% vs 11.6%; AD, 35.9%; 95% CI, 29%-42.9%; P < .001), and hypertension (21.6% vs 10.1%; AD, 11.5%; 95% CI, 6.8%-16.9%; P < .001), but not cardiovascular autonomic neuropathy (15.7% vs 14.4%; AD, 1.2%; 95% CI, -3.1% to 6.5; P = .62). After adjustment for established risk factors measured over time, participants with type 2 diabetes vs those with type 1 had significantly higher odds of diabetic kidney disease (odds ratio [OR], 2.58; 95% CI, 1.39-4.81; P=.003), retinopathy (OR, 2.24; 95% CI, 1.11-4.50; P = .02), and peripheral neuropathy (OR, 2.52; 95% CI, 1.43-4.43; P = .001), but no significant difference in the odds of arterial stiffness (OR, 1.07; 95% CI, 0.63-1.84; P = .80) and hypertension (OR, 0.85; 95% CI, 0.50-1.45; P = .55).

Conclusions and Relevance

Among teenagers and young adults who had been diagnosed with diabetes during childhood or adolescence, the prevalence of complications and comorbidities was higher among those with type 2 diabetes compared with type 1, but frequent in both groups. These findings support early monitoring of youth with diabetes for development of complications.

Incidence of complications in young-onset diabetes: Comparing type 2 with type 1 (the young diab study)

BACKGROUND

There is little data on the incidence of diabetes complications in young onset type 1 diabetes (T1DM) and type 2 diabetes (T2DM) in non European populations.

METHODS

From a tertiary diabetes centre, Chennai, India, we recruited 108 T1DM (defined by abrupt onset of symptoms or diabetic ketoacidosis, absent insulin reserve requiring insulin treatment) and 90 T2DM participants (defined by absence of ketosis, good beta-cell reserve, and good response to oral agents) who were diagnosed between the ages of 10 and 25years, and without any evidence of diabetes complications at diagnosis. We estimated the incidence of various complications (median follow up of five years); retinopathy was defined by presence of at least one definite microaneurysm by retinal photography, nephropathy by urinary albumin excretion ⩾30μg/mg of creatinine, neuropathy by vibration perception threshold ⩾20V on biothesiometry, peripheral vascular disease by an ankle-brachial index <0.9, and ischemic heart disease (IHD) by history of myocardial infarction or coronary revascularization or Q waves on ECG or on drug treatment for IHD.

RESULTS

The mean ages at diagnosis of T1DM and T2DM participants were 17.1±4.2vs. 21.6±3.6years respectively. The incidence of various complications reported in numbers/1000 person years of follow up of T1DM and T2DM were: retinopathy 77.4vs. 78.0/1000 person years, nephropathy, 62.0vs. 58.8, neuropathy 7.8 vs. 13.9 and ischemic heart disease 1.2vs. 5.4. In Cox regression analysis, after adjustment for age, glycated hemoglobin, systolic blood pressure and serum cholesterol, T2DM participants had 2.11 times (95%CI: 1.27-3.51) higher risk of developing any diabetes complication, compared to T1DM.

CONCLUSIONS

Young-onset T2DM have a more aggressive disease course than T1DM.

Preserved glucagon-like peptide-1 responses to oral glucose, but reduced incretin effect, insulin secretion and sensitivity in young Asians with type 2 diabetes mellitus

OBJECTIVE

Youth onset type 2 diabetes mellitus (YT2DM) is a globally rising phenomenon with substantial Asians representation. The understanding of its pathophysiology is derived largely from studies in the obese African-American and Caucasian populations, while studies on incretin effect are scarce. We examined the insulin resistance, β-cell function (BC), glucagon-like peptide (GLP)-1 hormone and incretin effect in Asian YT2DM.

RESEARCH DESIGN AND METHODS

This case-control study recruited 25 Asian YT2DM and 15 healthy controls, matched for gender, ethnicity and body mass index. Serum glucose, insulin, C peptide and GLP-1 were sampled during 2-hour oral glucose tolerance tests (OGTTs) and 1-hour intravenous glucose tolerance tests (IVGTTs). Insulin sensitivity was derived from the Quantitative Insulin Sensitivity Check Index (QUICKI), Oral Glucose Insulin Sensitivity Index (OGIS) in OGTT and surrogate index of SI from the minimal model (calculated SI, CSI). Acute insulin response (AIR) was obtained from IVGTT. Total BC was computed as incremental area under the curve of insulin/incremental area under the curve of glucose, during OGTT (BC_OG) and IVGTT (BC_IV), respectively. Disposition index (DI) was calculated using the product of insulin sensitivity and insulin secretion. GLP-1 response to oral glucose was calculated as incremental area under the curve of GLP-1 (ΔAUC_GLP-1). Per cent incretin effect was estimated as 100×(BC_OG-BC_IV)/BC_OG).

RESULTS

The YT2DM had marked impairment in BC (>80% reduction in AIR and BC_OG, p<0.001) and lower QUICKI (p<0.001), OGIS (p<0.001) and CSI (p=0.015) compared with controls. There was no difference in GLP-1 at all time points and ΔAUC_GLP-1 but the per cent incretin effect was reduced in the YT2DM compared with controls (12.1±8.93 vs 70.0±4.03, p<0.001).

CONCLUSIONS

Asian YT2DM showed similar GLP-1 response to oral glucose as controls but reduced incretin effect, BC and insulin sensitivity. The lack of compensatory mechanisms, as shown by the DI may be partly ascribed to the impaired incretin effect, similar to that of adult T2DM.

TRIAL REGISTRATION NUMBER

NMRR-12-1042-13254.

Characteristics and cardiovascular complications of a large cohort of adults diagnosed with type 2 diabetes <45 years

BACKGROUND

The aim was to evaluate the characteristics and cardiovascular complications of a large Belgian cohort of adults diagnosed with type 2 diabetes (T2DM) <45 years.

METHODS

Retrospective analysis of 886 patients diagnosed with T2DM <45 years and 933 T2DM patients diagnosed at the age between 60 and 70 years. To compare variables between groups, the independent t test or paired t test was used for normally distributed continuous variables, the Mann-Whitney's U-test for non-normally distributed continuous variables and the Chi squared test or McNemar test for categorical variables. Multivariable logistic regression was used to adjust for confounders.

RESULTS

In the young-onset T2DM cohort, the age at diagnosis was 37.3 ± 6.4 years, 44.1% of patients were female and 12.1% were from an ethnic minority (EM) background. At last visit, age of patients was 57.3 ± 12.5 years with a diabetes duration of 20.5 ± 11.8 years and a mean HbA1c of 7.3% ± 1.3 (56 mmol/mol ± 14). Of all patients, 56.8% were obese, 49.9% were hypertensive, 34.1% did not reach the LDL cholesterol target and 20.1% had a cardiac event by time of last visit. Compared to women, men had a higher HbA1c [7.3% ± 1.4 (56 mmol/mol ± 15) vs. 7.1% ± 1.2 (54 mmol/mol ± 13), p = 0.021] and a significantly higher rate of cardiac events, even after adjustment for confounders (24.3 vs. 14.8%, p = 0.010). Compared to Caucasians, EM patients were younger at diagnosis (35.4 ± 6.8 years vs. 37.6 ± 6.2 years, p = 0.001) and were less often obese (43.3 vs. 55.6%, p = 0.007). Compared to the first visit, glycemic control improved [7.3% ± 1.3 (56 mmol/mol ± 14) vs. 7.9% ± 1.7 (62 mmol/mol ± 19), p < 0.0001] by the time of the last visit. Compared to the older-onset T2DM cohort, young-onset T2DM patients showed a higher HbA1c [7.3 ± 1.3% (56 mmol/mol ± 14) vs. 6.9 ± 1.0% (51 mmol/mol ± 11), p = <0.0001] and a higher BMI (31.2 ± 5.8 vs. 29.6 ± 5.5 kg/m², p = <0.0001) at last contact. When adjusted for age, diabetes duration, HbA1c and cardiovascular risk factors, there was no difference in cardiovascular events between the two cohorts.

CONCLUSIONS

A diagnosis of T2DM <45 years has an important impact on patients' lives. Prevention measures are essential, but also specific attention to this high-risk group is needed for them to better achieve their therapeutic targets.

Small and large fiber neuropathy in those with type 1 and type 2 diabetes: a 5-year follow-up study

The purpose of this study was to evaluate progression of diabetic polyneuropathy and differences in the spectrum and evolution of large- and small-fiber involvement in patients with diabetes type 1 and 2 over 5 years. Fifty-nine patients (35 type 1 and 24 type 2) were included. Nerve conduction studies (NCS), quantitative sensory testing, skin biopsy for quantification of intraepidermal nerve fiber density (IENFD), symptom scoring and clinical evaluations were performed. Z-scores were calculated to adjust for the physiologic effects of age and height/gender. Neuropathic symptoms were not significantly more frequent in type 2 than in type 1 diabetic patients at follow-up (54% vs. 37%). The overall mean NCS Z-score remained within the normal range, but there was a small significant decline after 5 years in both groups: type 1 (p = 0.004) and type 2 (p = 0.02). Mean IENFD Z-scores changed from normal to abnormal in both groups, but only significantly in those with type 2 diabetes (reduction from 7.9 ± 4.8 to 4.3 ± 2.8 fibers/mm, p = 0.006). Cold perception threshold became more abnormal only in those with type 2 diabetes (p = 0.049). There was a minimal progression of large fiber neuropathy in both groups. Reduction of small fibers predominated and progressed more rapidly in those with type 2 diabetes.

Correlates of Medication Adherence in the TODAY Cohort of Youth With Type 2 Diabetes

OBJECTIVE

To identify factors that predict medication adherence and to examine relationships among adherence, glycemic control, and indices of insulin action in TODAY (Treatment Options for Type 2 Diabetes in Adolescents and Youth).

RESEARCH DESIGN AND METHODS

A total of 699 youth 10-17 years old with recent-onset type 2 diabetes and ≥80% adherence to metformin therapy for ≥8 weeks during a run-in period were randomized to receive one of three treatments. Participants took two study pills twice daily. Adherence was calculated by pill count from blister packs returned at visits. High adherence was defined as taking ≥80% of medication; low adherence was defined as taking <80% of medication. Depressive symptoms, insulin sensitivity (1/fasting insulin), insulinogenic index, and oral disposition index (oDI) were measured. Survival analysis examined the relationship between medication adherence and loss of glycemic control. Generalized linear mixed models analyzed trends in adherence over time.

RESULTS

In this low socioeconomic cohort, high and low adherence did not differ by sex, age, family income, parental education, or treatment group. Adherence declined over time (72% high adherence at 2 months, 56% adherence at 48 months, P < 0.0001). A greater percentage of participants with low adherence had clinically significant depressive symptoms at baseline (18% vs. 12%, P = 0.0415). No adherence threshold predicted the loss of glycemic control. Longitudinally, participants with high adherence had significantly greater insulin sensitivity and oDI than those with low adherence.

CONCLUSIONS

In the cohort, the presence of baseline clinically significant depressive symptoms was associated with subsequent lower adherence. Medication adherence was positively associated with insulin sensitivity and oDI, but, because of disease progression, adherence did not predict long-term treatment success.

Empagliflozin in combination with oral agents in young and overweight/obese Type 2 diabetes mellitus patients: A pooled analysis of three randomized trials

AIMS

This analysis aimed to evaluate efficacy and safety of empagliflozin in combination therapy in <65 y.o. patients, overweight/obese, and with uncontrolled T2DM.

METHODS

Pooled analysis from three phase-III trials, in <65 y.o. patients, with BMI 25-35kg/m², and HbA1c ≥8% at baseline. Patients (N=439) were randomized to placebo (n=138), empagliflozin 10mg (n=160), or empagliflozin 25mg (n=141) once daily (24weeks) as add-on to metformin, to metformin plus sulfonylurea, or to pioglitazone ± metformin.

RESULTS

At week 24, adjusted mean (SE) changes from baseline in HbA1c were -0.19% (0.07) for placebo vs. -1.10% (0.07) and -1.10% (0.07) for empagliflozin 10 and 25mg, respectively (both p<0.001). Adjusted mean (SE) changes from baseline in weight were -0.33kg (0.21) for placebo vs. -1.94kg (0.19) and -2.14kg (0.20) for empagliflozin 10 and 25mg, respectively (both p<0.001). Adverse events were reported in 57.2% on placebo, 64.4% on empagliflozin 10mg and 59.6% on empagliflozin 25mg. Genital infection AEs were reported in 1.4% on placebo, 3.8% on empagliflozin 10mg, and 5.0% on empagliflozin 25mg.

CONCLUSIONS

In this specific population, empagliflozin in combination with other oral agents, significantly reduced HbA1c and body weight and was well tolerated.

Evaluating health-related quality of life in type 1 diabetes: a systematic literature review of utilities for adults with type 1 diabetes

Background and aims

Type 1 diabetes is a chronic condition associated with micro- and macrovascular complications that have a notable impact on health-related quality of life, the magnitude of which can be quantified via the use of utility values. The aim of this review was to conduct a systematic literature review to identify and compare published health state utility values for adults with type 1 diabetes both, with and without diabetes-related complications.

Methods

Literature searches of the PubMed, EMBASE, and Cochrane Library databases were performed to identify English language studies on adults with type 1 diabetes, published from 2000 onward, reporting utility values for patients with or without diabetes-related complications or assessing the impact of changes in HbA1c or body mass index on quality of life. For inclusion, studies were required to report utilities elicited using validated methods.

Results

A total of 20 studies were included in the final review that included utility values elicited using the EuroQuol five dimensions questionnaire (n=9), 15D questionnaire (n=2), Quality of Well-Being scale (n=4), time trade-off (n=3), and standard gamble (n=2) methods. For patients with no complications, reported utility values ranged from 0.90 to 0.98. Complications including stroke (reported disutility range, −0.105 to −0.291), neuropathy (range, −0.055 to −0.358), and blindness (range, −0.132 to −0.208) were associated with the largest decrements in utility values. The magnitude of utility values and utility decrements was influenced by the assessment method used.

Conclusion

Complications lead to impaired health-related quality of life in patients with type 1 diabetes, the magnitude of which is influenced by the method used to determine utilities. There is currently a lack of utility data for certain complications of type 1 diabetes, meaning that many economic evaluations have relied on a combination of type 1 and type 2 diabetes utilities, despite differences between the conditions and populations, or type 1 diabetes-specific utilities derived from different instruments.

Significant retinopathy in young-onset type 2 vs. type 1 diabetes: a clinical observation

OBJECTIVE

Little is known about the burden of severe retinal disease between young-onset type 2 (T2D) and type 1 diabetes (T1D). This study assessed the prevalence of significant retinopathy in young-onset T2D vs. T1D and its predictive factors.

METHODS

This was a cross-sectional study. Subjects with T1D and T2D diagnosed below age 40 were identified from diabetes eye screening register. Preproliferative, proliferative, maculopathy changes and/or previous laser photocoagulation treatment were considered to have significant retinopathy (SigDR).

RESULTS

A total of 1306 subjects were identified, of whom 842 and 464 had T1D and T2D, respectively. The mean age of diagnosis was significantly lower in T1D subjects (T1D vs. T2D; 20.1 ± 10.3 vs. 32.1 ± 6.0 years, p < 0.0005). Although the T2D cohort had shorter diabetes duration (T1D vs. T2D; 20.8 ± 13.0 vs. 13.7 ± 9.0 years, p < 0.0005), the overall prevalence of SigDR was similar to T1D (T1D vs. T2D; 21.6 vs. 20.9%, p = NS). After adjusting for diabetes duration, the T2D cohort experienced significantly higher prevalence of this complication than T1D after 10 years duration. The age threshold beyond which the T2D cohort began to experience greater burden of SigDR was approximately 50 years. The prevalence of any retinopathy after 15 years duration was 75-80% for both young-onset cohort. Risk factors for SigDR (older age, diabetes duration, systolic BP, HbA1c and creatinine) were similar in both young-onset diabetes cohort with poor glycaemic control being the strongest variable. Lower age of T2D diagnosis was not a predictive factor.

CONCLUSIONS

Irrespective of diabetes type, subjects with young-onset diabetes possessed high lifetime risk for retinopathy. However, young-onset T2D cohort was more susceptible to severe retinal disease with substantial burden of this complication by the fifth decade of life.

Childhood type 2 diabetes: Risks and complications

The universal endocrine pathological state affecting young individuals and adults is type 2 diabetes mellitus, which has seen a significant increase in the last 30 years, particularly in children. Genetic and evnironmental factors are the causative agents for this pathological state in children. This rapid and wide spread of the disease can be controlled by enforcing amendments in environmental factors such as diet, physical activities and obesity. In young infants breastfeeding may be a key modulator of the disease. Associated disorders co-observed in the patients of type 2 diabetes mellitus include renal failure, heart problems and circulatory dysfunctionalities, such as cardiac failure and vision disability. These associated disorders become more pronounced in young patients when they reach puberty. To overcome the lethal outcomes of the disease, early screening of the disease is crucial. The present review focused on the latest updates in the field, as well as plausible risks and complications of this pathological state.

Association between impaired fasting glycaemia in pediatric obesity and type 2 diabetes in young adulthood

Objectives:

In adults, impaired fasting glycemia (IFG) increases the risk for type 2 diabetes mellitus (T2DM). This study aimed to investigate to which extent children with obesity develop T2DM during early adulthood, and to determine whether IFG and elevated hemoglobin A1c (HbA1c) in obese children are risk markers for early development of T2DM.

Methods:

In this prospective cohort study, 1620 subjects from the Swedish Childhood Obesity Treatment Registry – BORIS who were ⩾18 years at follow-up and 8046 individuals in a population-based comparison group, matched on gender age and living area, were included. IFG was defined according to both ADA (cut-off 5.6 mmol l⁻¹) and WHO (6.1 mmol l⁻¹). Elevated HbA1c was defined according to ADA (cut-off 39 mmol l⁻¹). Main outcome was T2DM medication, as a proxy for T2DM. Data on medications were retrieved from a national registry.

Results:

The childhood obesity cohort were 24 times more likely to receive T2DM medications in early adulthood compared with the comparison group (95% confidence interval (CI): 12.52–46). WHO-defined IFG predicted future use of T2DM medication with an adjusted hazard ratio (HR) of 3.73 (95% CI: 1.87–7.45) compared with those who had fasting glucose levels <5.6 mmol l⁻¹. A fasting glucose level of 5.6–6.0 mmol l⁻¹, that is, the IFG-interval added by American Diabetes Association (ADA), did not increase the use of T2DM medication more than pediatric obesity itself, adjusted HR=1.72 (0.84–3.52). Elevated levels of HbA1c resulted in an adjusted HR=3.12 (1.50–6.52). More severe degree of obesity also increased the future T2DM risk.

CONCLUSION:

IFG according to WHO and elevated HbA1c (39–48 mmol l⁻¹), but not the additional fasting glucose interval added by ADA (5.6–6.0 mmol l⁻¹), can be considered as prediabetes in the obese pediatric population in Sweden.

The Effectiveness of Different Diet Strategies to Reduce Type 2 Diabetes Risk in Youth

Type 2 diabetes in children and adolescents has become a prominent clinical issue in recent decades. Increasing numbers of young people have risk factors for type 2 diabetes, particularly obesity, indicating the need for effective type 2 diabetes prevention strategies. The aim of this review was to identify specific dietary strategies that optimize improvements in risk factors for type 2 diabetes in youth and hence reduce the risk of type 2 diabetes development. Our review of the current literature indicates that dietary interventions lead to weight loss when intervention adherence is high. However, in addition to weight loss, a diet that is reduced in carbohydrates may optimize improvements in other type 2 diabetes risk factors, including insulin resistance and hyperglycemia. While further research is needed to confirm this finding, reduced carbohydrate diets may include a very low-carbohydrate diet, a very low-energy diet, a lower-glycemic-index diet, and/or an intermittent fasting diet. This array of dietary strategies provides a suite of intervention options for clinicians to recommend to young people at risk of type 2 diabetes. However, these findings are in contrast to current guidelines for the prevention of type 2 diabetes in adults which recommends a low-fat, high-carbohydrate diet.