Increasing incidence of diagnosed type 2 diabetes in Taiwan: analysis of data from a national cohort

Impact of the trans-ancestry polygenic risk score on type 2 diabetes risk, onset age and progression among population in Taiwan

Type 2 diabetes (T2D) prevalence in adults at a younger age has increased but the disease status may go unnoticed. This study aimed to determine whether the onset age and subsequent diabetic complications can be attributed to the polygenic architecture of T2D in the Taiwan Han population. A total of 9,627 cases with T2D and 85,606 controls from the Taiwan Biobank were enrolled. Three diabetic polygenic risk scores (PRSs), PRS_EAS and PRS_EUR, and a trans-ancestry PRS (PRS_META), calculated using summary statistic from East Asian and European populations. The onset age was identified by linking to the National Taiwan Insurance Research Database, and the incidence of different diabetic complications during follow-up was recorded. PRS_META (7.4%) explained a higher variation for T2D status. And the higher percentile of PRS is also correlated with higher percentage of T2D family history and prediabetes status. More, the PRS was negatively associated with onset age (β = -0.91 yr), and this was more evident among males (β = -1.11 vs. -0.76 for males and females, respectively). The hazard ratio of diabetic retinopathy (DR) and diabetic foot were significantly associated with PRS_EAS and PRS_META, respectively. However, the PRS was not associated with other diabetic complications, including diabetic nephropathy, cardiovascular disease, and hypertension. Our findings indicated that diabetic PRS which combined susceptibility variants from cross-population could be used as a tool for early screening of T2D, especially for high-risk populations, such as individuals with high genetic risk, and may be associated with the risk of complications in subjects with T2D. NEW & NOTEWORTHY Our findings indicated that diabetic polygenic risk score (PRS) which combined susceptibility variants from Asian and European population affect the onset age of type 2 diabetes (T2D) and could be used as a tool for early screening of T2D, especially for individuals with high genetic risk, and may be associated with the risk of diabetic complications among people in Taiwan.

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.

Secular trends of intrahepatic cholangiocarcinoma in a high endemic area: A population-based study

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) is one of the most aggressive malignancies. However, because of its scarcity there are limited population-based data available for investigations into its epidemiologic characteristics. In Taiwan, we have a national cancer registry database that can be used to evaluate the secular trends of ICC.

AIM

To evaluate secular trends of ICC according to age, sex, and risk factors in Taiwan.

METHODS

In this population-based study, we used the national Taiwan Cancer Registry database. Age-standardized and relative percent changes in incidence rates were used to describe secular trends in incidence rates and sex ratios of ICC in Taiwan.

RESULTS

The age-standardized ICC incidence rate among males increased from 1.51 per 100000 in 1993-1997 to 4.07 per 100000 in 2013-2017 and among female from 1.73 per 100000 to 2.95 per 100000. The incidence in females tended to plateau after 2008-2012. For males, the ICC incidence increased as age increased. In the long-term incidence trend of ICC in females, the incidence of the four age groups (40-44, 45-49, 50-54 and 55-59 years) remained stable in different years; although, the incidence of the 60-64 group had a peak in 2003-2007, and the peak incidence of the 65-69 and 70-74 groups occurred in 2008-2012. Among males, beginning at the age of 65, there were increases in the incidence of ICC for the period of 2003-2017 as compared with females in the period of 2003-2017.

CONCLUSION

Increased incidence of ICC occurred in Taiwan over the past two decades. The increased incidence has progressively shifted toward younger people for both males and females.

Association of Incidence of Acid-related Upper Gastrointestinal Disorders With Glycated Hemoglobin Level

CONTEXT

Previous cross-sectional studies show diabetes and higher levels of plasma hemoglobin A1c (HbA1c) are associated with a higher prevalence of gastrointestinal (GI) complications. However, whether the glycemic status is associated with incident acid-related upper GI disorders remains unclear.

OBJECTIVE

We aimed to determine the effect of hyperglycemia per se, in terms of HbA1c, on the incidence of acid-related disorders.

METHODS

We analyzed consecutive subjects who had undergone repeated upper endoscopies as part of the health examinations at the National Taiwan University Hospital from 2005 to 2011. Acid-related endoscopic abnormalities were defined as erosive esophagitis (EE), Barrett's esophagus (BE), and peptic ulcer disease (PUD), which included gastric ulcers (GUs) and duodenal ulcers (DUs). All subjects were categorized by 3 tertiles of HbA1c levels. We analyzed the occurrence of respective acid-related disorders during the follow-up period.

RESULTS

A total of 11 391 participants (mean HbA1c level 5.6 ± 0.7%) were enrolled in this longitudinal study. During the 38 426.3 person-years of follow-up (mean duration 3.37 ± 1.59 years), the incidence of EE, BE, GU, DU, PUD, and any acid-related disorders were 22.1%, 0.5%, 4.5%, 8.6%, 12.3%, and 30.3%, respectively. The higher HbA1c level was associated with higher risk of disease incidents, except BE, during the follow-up (all log-rank P < .001). In the Cox regression analyses with confounding factors fully adjusted, the hazard ratios for EE, GU, DU, PUD, and acid-related disorders were 1.174, 1.339, 1.24, 1.24, and 1.186, respectively, for the third tertile of HbA1c (all P < .05).

CONCLUSION

Higher HbA1c level was associated with a higher risk of acid-related upper GI endoscopic abnormalities. Efforts toward better glycemic control may help to prevent the development of late GI complications.

Sleep Duration and Effort-Reward Imbalance (ERI) Associated with Obesity and Type II Diabetes Mellitus (T2DM) among Taiwanese Middle-Aged Public Servants

(1) Limited evidence has shown the mediating effects of work characteristics and sleep duration on obesity and type 2 diabetes mellitus (T2DM) among adults. The objective of this study is to assess the interaction effects between sleep duration and effort–reward imbalance (ERI) on the risk of obesity and T2DM among Taiwanese public servants aged 40–60. (2) A national survey for Taiwanese public servants was conducted by multistage stratified random cluster sampling based on proportional probabilistic sampling. A total of 11,875 participants aged 40–60 years old were collected; (3) 3.6% of participants had self-reporting T2DM diagnosed by a physician and the prevalence of overweight and obesity were 44.0% and 15.8%, respectively. There was a significant correlation between sleep hours for the workday and risk of T2DM in non-obese and obese groups (odds ratio, OR = 1.48 and 1.39, respectively), but this did not exist for the weekend/vacation group. Similar trends in the two groups by sleep hours on a workday, obesity and overweight were significantly associated with the risks of T2DM. Clearly, sleep duration and ERI were moderating factors on the association between BMI and on the prevalence of T2DM. (4) A short sleep duration and heavy job stress contributes to the risk of weight gain and T2DM development.

Urban-rural disparity in lower extremities amputation in patients with diabetes after nearly two decades of universal health Insurance in Taiwan

Background

To assess the prevalence of urban-rural disparity in lower extremities amputation (LEA) among patients with diabetes and to explore whether patient-related or physician-related factors might have contributed to such disparity.

Methods

This was a population-based study including patients with diabetes aged ≥55 years from 2009 to 2013. Among them, 9236 received LEA. Data were retrieved from Taiwan’s National Health Insurance (NHI) claims. A multiple Poisson regression model was also employed to assess the urban-rural difference in LEA prevalence by simultaneously taking into account socio-demographic variables and density of practicing physicians.

Results

Between 2009 and 2013, the annual prevalence of LEA declined from 30.4 to 20.5 per 10,000 patients. Compared to patients from urban areas, those who lived in sub-urban and rural areas suffered from a significantly elevated prevalence of LEA, with a prevalence rate ratio (PRR) of 1.47 (95% CI, 1.39–1.55) and 1.68 (95% CI, 1.56–1.82), respectively. The density of physicians who presumably provided diabetes care can barely explain the urban-rural disparity in LEA prevalence.

Conclusions

Although the universal health insurance has largely removed financial barriers to health care, the urban-rural disparity in LEA prevalence still exists in Taiwan after nearly two decades of the NHI program.

Trends in incidence of total or type 2 diabetes: systematic review

OBJECTIVE

To assess what proportions of studies reported increasing, stable, or declining trends in the incidence of diagnosed diabetes.

DESIGN

Systematic review of studies reporting trends of diabetes incidence in adults from 1980 to 2017 according to PRISMA guidelines.

DATA SOURCES

Medline, Embase, CINAHL, and reference lists of relevant publications.

ELIGIBILITY CRITERIA

Studies of open population based cohorts, diabetes registries, and administrative and health insurance databases on secular trends in the incidence of total diabetes or type 2 diabetes in adults were included. Poisson regression was used to model data by age group and year.

RESULTS

Among the 22 833 screened abstracts, 47 studies were included, providing data on 121 separate sex specific or ethnicity specific populations; 42 (89%) of the included studies reported on diagnosed diabetes. In 1960-89, 36% (8/22) of the populations studied had increasing trends in incidence of diabetes, 55% (12/22) had stable trends, and 9% (2/22) had decreasing trends. In 1990-2005, diabetes incidence increased in 66% (33/50) of populations, was stable in 32% (16/50), and decreased in 2% (1/50). In 2006-14, increasing trends were reported in only 33% (11/33) of populations, whereas 30% (10/33) and 36% (12/33) had stable or declining incidence, respectively.

CONCLUSIONS

The incidence of clinically diagnosed diabetes has continued to rise in only a minority of populations studied since 2006, with over a third of populations having a fall in incidence in this time period. Preventive strategies could have contributed to the fall in diabetes incidence in recent years. Data are limited in low and middle income countries, where trends in diabetes incidence could be different.

SYSTEMATIC REVIEW REGISTRATION

Prospero CRD42018092287.

C-Reactive Protein Gene Variants and Their Serum Levels in Early Adult-onset Type 2 Diabetes Mellitus

BACKGROUND/AIM

C-Reactive protein (CRP) is a common marker of inflammation. Elevated CRP levels have been associated with increased risk of development of type 2 diabetes mellitus (T2DM). This study aimed to evaluate the association of CRP gene polymorphisms with early-onset T2DM and the effect of genetic variants on CRP level.

MATERIALS AND METHODS

In total, 948 individuals with early-onset (n=271) or late-onset (n=677) T2DM were enrolled in the study. Five single-nucleotide polymorphisms (SNPs) in the CRP gene, namely rs3093077, rs2808630, rs1800947, rs11265263, and rs11265265, were selected for genotyping, and CRP levels were measured.

RESULTS

Genotypic, allelic, and haplotype frequencies of these five SNPs were not significantly different between patients with early- and those with late-onset. T2DM Higher serum CRP levels were independently associated with the C-allele of rs3093077 and T-allele of rs11265265 (p<0.001). Furthermore, the C-allele of rs3093077 was associated with higher CRP level in both early- (p=0.016) and late-onset (p<0.001) T2DM.

CONCLUSION

CRP gene variants may contribute to the risk of early-onset T2DM by affecting the serum CRP level.

Assessing quality of primary diabetes care in South Korea and Taiwan using avoidable hospitalizations

Quality of primary diabetes care is a key health policy concern in many OECD countries with an aging population. This cross-national, population-based study examined the extent and attributes of diabetes-related avoidable hospitalizations (DRAHs) in South Korea and Taiwan, both of which have social health insurance-based health systems with limited gate-keeping for hospitalizations. We analyzed comparable, nationally representative health insurance beneficiary datasets for the two countries (2002-2013), linked with community health resource data. The age- and sex-standardized DRAH rates were calculated, and multivariate, multi-level longitudinal modeling approaches were adopted. The DRAH rate decreased in Taiwan consistently during 2002-2013 and in Korea after 2011 only. Under the universal health coverage, people enjoyed high accessibility to care. A higher number of physician visits reduced DRAHs in Korea but not in Taiwan. Socio-economic disparities in DRAHs still existed in both countries, especially in Taiwan. We found a different trajectory in two similar health systems for the selected health system performance indicator for primary diabetes care. This can be partly explained by different policy approaches to diabetes management in the two countries over the years. Necessary are policy efforts to improve the quality and equality of primary diabetes care and better control of hospital admissions in these two health systems that provide generous access to care at a low cost in East Asia.

Is there a relationship between body mass index and diabetic retinopathy in type II diabetic patients? A cross sectional study

BACKGROUND

Type 2 diabetes mellitus (T2DM) is one of the most important leading causes of disability, premature mortality and Diabetic Retinopathy (DR) that is one of the diabetes-related complications in diabetic patients and the most common cause of vision loss in diabetic patients. The aim of the study was to evaluate the association between DR and body mass index (BMI) in those patients with T2DM.

METHODS

This was a central-based, cross-sectional study on 518 diabetic patients. Their medical history and the laboratory data were collected. All the patients received examination of diabetic retinopathy by professional ophthalmologist. Based on their optic fundi findings, they were classified into five groups: No retinopathy, Mild Non-proliferative Diabetic Retinopathy (NPDR), Moderate NPDR, Severe NPDR, Proliferative diabetic retinopathy (PDR). To analysis data SPSS v18 software used. Frequency, percent, mean and standard deviation were used for population description. t test, spearman correlation, partial correlation, analysis of variance (ANOVA) and Chi-square test (χ2) were used for analytic analysis. Multivariate logistic regression was used to estimate the odds ratio.

RESULTS

518 patients with T2DM 198 male (38%), 320 female (62%) included in this study. The mean age of patients was 61.02 ± 10.18 years. The mean age at onset was 49.06 + 10.52 years and the mean duration of diabetes was 12.09 ± 7.81 years. There was a strong relationship between duration of diabetes and DR (P = 0.001). There were strong significant association between the development of DR and Insulin therapy (OR = 5.975). Correlation analysis between Retinopathy and BMI showed that BMI had inverse relationship with DR when BMI considered as a continuous variable (p-value = 0.009 and correlation coefficient = -0.467).

CONCLUSION

BMI in diabetic patient is one of the most important clinical parameter for their health and disease progression. We conclude that BMI had inverse relationship with DR when BMI considered as a continuous variable.

The Global Epidemiology of Diabetes and Kidney Disease

The prevalence of diabetes is increasing worldwide, with the greatest increases occurring in low- and middle-income countries. In most developed countries, type 2 diabetes is presently the leading cause of end-stage renal disease and also contributes substantially to cardiovascular disease. In countries with weaker economies type 2 diabetes is rapidly replacing communicable diseases as a leading cause of kidney disease and is increasingly competing for scarce health care resources. Here, we present a narrative review of the prevalence and incidence of diabetes-related kidney disease worldwide. Mortality among those with diabetes and kidney disease will also be explored. Given the high morbidity and mortality associated with chronic kidney disease, we will also examine the level of awareness of this disease among people who have it.

Aerobic-Strength Exercise Improves Metabolism and Clinical State in Parkinson's Disease Patients

Regular exercise ameliorates motor symptoms in Parkinson’s disease (PD). Here, we aimed to provide evidence that exercise brings additional benefits to the whole-body metabolism and skeletal muscle molecular and functional characteristics, which might help to explain exercise-induced improvements in the clinical state. 3-months supervised endurance/strength training was performed in early/mid-stage PD patients and age/gender-matched individuals (n = 11/11). The effects of exercise on resting energy expenditure (REE), glucose metabolism, adiposity, and muscle energy metabolism (³¹P-MRS) were evaluated and compared to non-exercising PD patients. Two muscle biopsies were taken to determine intervention-induced changes in fiber type, mitochondrial content, and expression of genes related to muscle energy metabolism, as well as proliferative and regenerative capacity. Exercise improved the clinical disability score (MDS-UPDRS), bradykinesia, balance, walking speed, REE, and glucose metabolism and increased muscle expression of energy sensors (AMPK). However, the exercise-induced increase in muscle mass/strength, mitochondrial content, type II fiber size, and postexercise phosphocreatine (PCr) recovery (³¹P-MRS) were found only in controls. Nevertheless, MDS-UPDRS was associated with muscle AMPK and mechano-growth factor (MGF) expression. Improvements in fasting glycemia were positively associated with muscle function and the expression of Sirt1 and Cox7a1, and the parameters of fitness/strength were positively associated with the expression of MyHC2, MyHC7, and MGF. Moreover, reduced bradykinesia was associated with better muscle metabolism (maximal oxidative capacity and postexercise PCr recovery; ³¹P-MRS). Exercise training improved the clinical state in early/mid-stage Parkinson’s disease patients, including motor functions and whole-body metabolism. Although the adaptive response to exercise in PD was different from that of controls, exercise-induced improvements in the PD clinical state were associated with specific adaptive changes in muscle functional, metabolic, and molecular characteristics.

Depressive symptom trajectories in the first 10 years of diabetes diagnosis: antecedent factors and link with future disability in Taiwan

PURPOSE

This study identified depressive symptom trajectories in the years after diabetes diagnosis, examined factors that predict the probability for people following a specific trajectory, and investigated how the trajectories are associated with subsequent disability.

METHODS

We drew data from a nationally representative survey in Taiwan to identify adults aged 50 and older diagnosed with diabetes; 487 patients newly diagnosed with diabetes during 1996-2007 were included. Time axis was set to zero when diabetes was first reported in any given wave in the survey, and data related to depressive symptoms after that were recorded. We used group-based semi-parametric mixture models to identify trajectories of depressive symptoms and multinomial logistic regressions to examine factors associated with the trajectories.

RESULTS

Older adults with newly diagnosis of diabetes in Taiwan follow different trajectories of depressive symptoms over time. Being female, lower educated, not married/partnered, with lower self-rated health, hospitalizations, more limitations in physical function, less regular exercise before diagnosis, and not regularly using anti-diabetic medication at the beginning of their diagnosis were factors associated with increasing or high stable depressive symptom trajectories. Those who experienced high depressive symptoms were more likely than individuals with stable depressive symptoms to have physical limitations in the last follow-up interview.

CONCLUSIONS

Depressive symptom trajectories after diabetes diagnosis were associated with select sociodemographic, health, and lifestyle factors before diagnosis, and also predicted subsequent disability. Risk groups identified in the present study may be used for personalized diabetes care that prevents diabetes-related distress and future disability.

Incidence and mortality of pancreatic cancer on a rapid rise in Taiwan, 1999-2012

BACKGROUND

Accumulating data has revealed a rapidly rising incidence of pancreatic cancer in Western countries, but convincing evidence from the East remains sparse. We aimed to quantify how the incidence and mortality rates of pancreatic malignancy changed over time in Taiwan, and to develop future projection for the next decade.

METHODS

This nationwide population-based study analyzed the Taiwan National Cancer Registry and the National Cause of Death Registry to calculate the annual incidence and mortality rates of pancreatic malignancy from 1999 to 2012 in this country. The secular trend of the incidence was also examined by data from the National Health Insurance Research Database.

RESULTS

A total of 21,986 incident cases of pancreatic cancer and 20,720 related deaths occurred during the study period. The age-standardized incidence rate increased from 3.7 per 100,000 in 1999 to 5.0 per 100,000 in 2012, with a significant rising trend (P<0.01). The increase was nationwide, consistently across subgroups stratified by age, gender, geographic region, and urbanization. Data from the National Health Insurance Research Database corroborated the rise of incident pancreatic cancer. Mortality also increased with time, with the age-standardized rate rising from 3.5 per 100,000 in 1999 to 4.1 per 100,000 in 2012 (P<0.01). In accordance with the incidence, the mortality trend was consistent in all subgroups. Both the incidence and mortality were projected to further increase by approximately 20% from 2012 to 2027.

CONCLUSION

The incidence and mortality of pancreatic cancer have been rapidly rising and presumably will continue to rise in Taiwan.

Association between type 2 diabetes and cancer incidence in Taiwan: data from a prospective community-based cohort study

AIMS

Evidence of a role for type 2 diabetes in overall cancer risk and risk for specific types of cancer is limited in ethnic Chinese populations. We therefore investigated whether there is an association between diabetes and cancer incidence in Taiwan.

METHODS

This study recruited a total of 3602 adults aged 35 years or over (average 54.9 ± 12.3 years, 52.8% women). Participants with fasting glucose ≥126 mg/dL, or taking hypoglycemic medications, were classed as having type 2 diabetes. Cancer incidence was established through regular follow-up interviews and medical records. Cox proportional hazard regression models were used to examine associations for diabetes with risk of all-cause and site-specific cancers.

RESULTS

During a median of follow-up of 10.5 years, 275 individuals developed cancer, including 157 digestive cancers and 31 urinary cancers. Younger participants (aged < 55 years) with diabetes had a greater risk of all cancers [adjusted relative risk (RR) 3.42; 95% confidence interval (CI), 1.78-6.57], digestive cancers (adjusted RR 2.88; 95% CI 1.15-6.94) and urinary cancers (adjusted RR 13.4; 95% CI 2.70-66.3) compared with individuals in the same age group without diabetes.

CONCLUSIONS

Our results clearly demonstrate that middle-aged individuals of Chinese ethnicity with diabetes have a greater risk of all-cause cancer and specific subtypes of cancer.

Factors Associated with Cancer- and Non-Cancer-Related Deaths among Taiwanese Patients with Diabetes after 17 Years of Follow-Up

OBJECTIVE

A previous 12-year follow-up of a large diabetes cohort in Taiwan suggested a survival advantage in the patients with obesity. The present study further investigated additional determinants for cancer and non-cancer death in the cohort after a follow-up of 17 years.

METHODS

A cohort of 92546 diabetes patients recruited since 1995 was followed for vital status by matching the National Death Certificate Database until 2011. Cox regression estimated the hazard ratios for the following variables: age at baseline, sex, diabetes type, screen-detected diabetes (diabetes diagnosed accidentally through epidemiological screening programs or during visits to medical settings without a history of diabetes), diabetes duration, body mass index, insulin use, hypertension, smoking, and living region. Fasting glucose and history of dyslipidemia were available for additional adjustment in a subcohort of the patients (n = 14559).

RESULTS

A total of 40229 diabetes patients (43.5% of the cohort) died during follow-up and 10.9% died under the age of 60. Insulin use and smoking significantly predicted cancer and non-cancer death. The adjusted hazard ratio (95% confidence interval) associated with insulin use was 1.161 (1.052-1.281) for cancer death and 1.469 (1.413-1.526) for non-cancer death. Screen-detected diabetes and body mass index were consistently associated with a lower risk, but diabetes duration a higher risk, for non-cancer death, with adjusted hazard ratio of 0.683 (0.666-0.702), 0.955 (0.951-0.958) and 1.018 (1.017-1.020), respectively. Diabetes type had a null association disregarding the causes of death and living in rural areas was significantly associated with a higher mortality from non-cancer death. Hypertension, fasting glucose and dyslipidemia showed differential impacts on cancer and non-cancer death, and were significantly predictive for non-cancer death.

CONCLUSIONS

Screen-detected diabetes and a higher body mass index provide a survival advantage, especially for non-cancer death. However, insulin use is associated with a significantly higher risk of either cancer or non-cancer death.

Factors that could explain the increasing prevalence of type 2 diabetes among adults in a Canadian province: a critical review and analysis

BACKGROUND

The prevalence of diabetes has increased since the last decade in New Brunswick. Identifying factors contributing to the increase in diabetes prevalence will help inform an action plan to manage the condition. The objective was to describe factors that could explain the increasing prevalence of type 2 diabetes in New Brunswick since 2001.

METHODS

A critical literature review was conducted to identify factors potentially responsible for an increase in prevalence of diabetes. Data from various sources were obtained to draw a repeated cross-sectional (2001-2014) description of these factors concurrently with changes in the prevalence of type 2 diabetes in New Brunswick. Linear regressions, Poisson regressions and Cochran Armitage analysis were used to describe relationships between these factors and time.

RESULTS

Factors identified in the review were summarized in five categories: individual-level risk factors, environmental risk factors, evolution of the disease, detection effect and global changes. The prevalence of type 2 diabetes has increased by 120% between 2001 and 2014. The prevalence of obesity, hypertension, prediabetes, alcohol consumption, immigration and urbanization increased during the study period and the consumption of fruits and vegetables decreased which could represent potential factors of the increasing prevalence of type 2 diabetes. Physical activity, smoking, socioeconomic status and education did not present trends that could explain the increasing prevalence of type 2 diabetes. During the study period, the mortality rate and the conversion rate from prediabetes to diabetes decreased and the incidence rate increased. Suggestion of a detection effect was also present as the number of people tested increased while the HbA1c and the age at detection decreased. Period and birth cohort effect were also noted through a rise in the prevalence of type 2 diabetes across all age groups, but greater increases were observed among the younger cohorts.

CONCLUSIONS

This study presents a comprehensive overview of factors potentially responsible for population level changes in prevalence of type 2 diabetes. Recent increases in type 2 diabetes in New Brunswick may be attributable to a combination of some individual-level and environmental risk factors, the detection effect, the evolution of the disease and global changes.

Variations in Incidence and Prevalence of Parkinson's Disease in Taiwan: A Population-Based Nationwide Study

Demographic, socioeconomic, and urbanization level variations in Parkinson's disease (PD) are rarely investigated, especially in Asia. This study describes an eight-year trend in PD incidence and prevalence in Taiwan as well as assessing the effects of sociodemographics and urbanization on the incidence and prevalence of PD. The data analyzed were acquired from the Taiwan National Health Insurance Research Database (NHIRD) entries between 2002 and 2009. The calendar year, sex, and age-specific rates were standardized, and the effects of the sociodemographics and urbanization on PD were assessed using Poisson regression analysis. PD incidence and prevalence showed a significantly increasing trend, with a greater magnitude noted for prevalence than for incidence (87.3% versus 9.2%). The PD incidence and prevalence increased with age and were slightly higher in men than in women. The people who were not under the labor force (i.e., dependents) or with lower monthly incomes were at significantly increased adjusted incidence rate ratio (1.50–1.56) and adjusted prevalence rate ratio (1.66–1.71) of PD. Moreover, significantly higher PD incidence and prevalence were noted in areas with lesser urbanization. This information emphasizes the need for preventive and clinical care strategies targeting the segment of Taiwanese population that exhibited a greater incidence and prevalence of PD.

Use of metformin and risk of kidney cancer in patients with type 2 diabetes

BACKGROUND

The anticancer effect of metformin has been reported in the literature but requires additional confirmation in epidemiologic studies. With respect to kidney cancer scarce data are available. This study investigates whether metformin use in patients with type 2 diabetes mellitus (T2DM) might affect kidney cancer risk.

METHODS

The reimbursement database of the National Health Insurance in Taiwan was used. T2DM patients aged ≥ 40 years and newly treated with either metformin (n=171,753, "ever users of metformin") or other antidiabetic drugs (n=75,499, "never users of metformin") within 1998-2002 were followed for at least 6 months for kidney cancer until 31 December 2009. The treatment effect was estimated by Cox regression using propensity score weighting by inverse probability of treatment weighting approach. Hazard ratios were estimated for ever versus never users, and for tertiles of cumulative duration of metformin therapy.

RESULTS

During follow-up, 917 ever users and 824 never users developed kidney cancer, with respective incidence of 80.09 and 190.30 per 100,000 person-years. The hazard ratio (95% confidence intervals) for ever versus never users is 0.279 (0.254-0.307); and is 0.598 (0.535-0.668), 0.279 (0.243-0.321) and 0.104 (0.088-0.124), respectively, for the first, second, and third tertile of cumulative duration of <14.5, 14.5-45.8 and >45.8 months. In subgroup analyses, the lower risk of kidney cancer associated with metformin use is consistently observed in both sexes, and in patients with or without concomitant use of other antidiabetic drugs.

CONCLUSION

Metformin use is associated with a decreased risk of kidney cancer in patients with T2DM.

Type 2 Diabetes Mellitus and Kidney Cancer Risk: A Retrospective Cohort Analysis of the National Health Insurance

Purpose

To evaluate the association between incidence of any kidney cancer and type 2 diabetes mellitus.

Methods

A random sample of 1,000,000 subjects covered by the National Health Insurance was recruited. A total of 998728 people (115655 diabetes and 883073 non-diabetes) without kidney cancer at recruitment were followed from 2003 to 2005. The cumulative incidence of kidney cancer from 2003 to 2005 in diabetic patients and non-diabetic people in all ages and in age <40, 40–64, 65–74 and ≥75 years were calculated in the diabetic patients and the non-diabetic people, respectively. Logistic regression was used to estimate the odds ratios comparing diabetic patients to non-diabetic people in the respective age groups. Multivariable-adjusted odds ratios for kidney cancer with regards to diabetes status and diabetes duration (as a continuous variable or categorized into subgroups of non-diabetes, diabetes duration <1 year, 1–2.9 years, 3–4.9 years and ≥5 years) were estimated after multivariable adjustment. The multivariable-adjusted odds ratios for all baseline variables were also estimated for diabetic patients and non-diabetic people, respectively.

Results

The 3-year cumulative incidence of kidney cancer in the diabetic patients and the non-diabetic people was 166.9 and 33.1 per 100,000 person-years, respectively. The incidence increased with regards to increasing age in both the diabetic patients and the non-diabetic people, but a higher risk of kidney cancer for the diabetic patients compared to the non-diabetic people was consistently observed in different age groups. After multivariable adjustment, the odds ratio for diabetic patients versus non-diabetic people was 1.7 (95% confidence interval: 1.3–2.1, P<0.01). While compared to the non-diabetic people, the odds ratio (95% confidence interval) for diabetes duration <1, 1–2.9 years, 3–4.9 years and ≥5 years was 1.5 (0.8–2.7), 1.6 (1.0–2.4), 1.6 (1.1–2.4) and 1.7 (1.3–2.3), respectively (P-trend <0.01). Analyses conducted in the diabetic patients and the non-diabetic people, respectively, consistently showed age, nephropathy and end-stage renal disease as significant risk factors of kidney cancer. Additionally, living in metropolitan Taipei region might also be associated with a higher risk of kidney cancer in the non-diabetic people, indicating a potential link between kidney cancer and some factors related to urbanization.

Conclusions

Patients with type 2 diabetes mellitus have a significantly higher risk of kidney cancer.

Trends in childhood type 1 diabetes mellitus incidence in Beijing from 1995 to 2010: a retrospective multicenter study based on hospitalization data

BACKGROUND

The incidence of type 1 diabetes mellitus (T1DM) is increasing rapidly worldwide for children of every age group.

MATERIALS AND METHODS

A retrospective analysis of hospital registration data from five tertiary hospitals in Beijing, China, identified 485 patients (210 boys, 275 girls) younger than 15 years of age with newly diagnosed T1DM between 1995 and 2010.

RESULTS

From 1995 to 2010, the incidence of T1DM in patients <15 years of age ranged from 0.935-3.26 per 100,000 per year. During this period, the average age-standardized incidence rate was 1.7 per 100,000 per year, and the average annual increase in T1DM incidence was 4.36%. The highest rate increases occurred in boys and in patients <5 years of age. For both genders and all age groups, T1DM incidence increased at an accelerated rate after 2006. By 2020, the incidence of T1DM among children in Beijing is projected to increase by a factor of 1.69.

CONCLUSIONS

The incidence of T1DM among patients younger than 15 years of age in Beijing increased from 1995 to 2010, with rates growing at an accelerated pace since 2006. Based on recent trends, we project continued rapid growth in the number of new childhood T1DM cases in Beijing.

An updated review on cancer risk associated with incretin mimetics and enhancers

Incretin-based therapies, including the use of incretin mimetics of glucagon-like peptide-1 receptor (GLP-1R) agonists and incretin enhancers of dipeptidyl-peptidase 4 (DPP-4) inhibitors, are widely used by clinicians for glucose lowering in patients with type 2 diabetes mellitus. These agents have benefits of a lower risk of hypoglycemia, being neutral for body weight for DPP-4 inhibitors and having a potential for weight reduction with GLP-1R agonists. They may also have a neutral or beneficial cardiovascular effect. Despite these benefits, an increased risk of cancer (especially pancreatic cancer and thyroid cancer) associated with incretin-based therapies has been reported. In this article, we reviewed related literature of experimental animal and observational human studies, clinical trials, and meta-analyses published until December 15, 2014. Current studies suggested a probable role of GLP-1R activation on the development of pancreatic cancer and thyroid cancer in rodents, but such an effect in humans is not remarkable due to the lower or lack of expression of GLP-1R on human pancreatic ductal cells and thyroid tissues. Findings in human studies are controversial and inconclusive. In the analyses of the US Food and Drug Administration adverse events reporting system, a significantly higher risk of pancreatic cancer was observed for GLP-1R agonists and DPP-4 inhibitors, but a significantly higher risk of thyroid cancer was only observed for GLP-1R agonists. Such a higher risk of pancreatic cancer or thyroid cancer could not be similarly demonstrated in other human observational studies or analyses of data from clinical trials. With regards to cancers other than pancreatic cancer and thyroid cancer, available studies supported a neutral association in humans. Some preliminary studies even suggested a potentially beneficial effect on the development of other cancers with the use of incretins. Based on current evidence, continuous monitoring of the cancer issues related to incretin-based therapies is required, even though the benefits may outweigh the potential cancer risk in the general patients with type 2 diabetes mellitus.

Separate and joint effects of diabetes mellitus and chronic kidney disease on the risk of acute coronary syndrome: a population-based cohort study

Patient with diabetes (DM) and chronic kidney disease (CKD) are at a higher risk of developing acute coronary syndrome (ACS). However, only a few studies have investigated the separate and joint effects of DM and CKD on the risk of ACS, especially population-based studies under age-, sex- and various cardiovascular risk factor-stratifications. By using a national diabetes cohort derived from the Taiwan National Health Insurance Research Database, we identified a total of 416,143 DM and 541,724 non-DM patients, including 51,208 DM/CKD and 8,894 non-DM/CKD patients, in 2000 who did not have a history of ACS (ICD-9: 410.X, 413.9, 411.1) before 2000. We then prospectively investigated the incidence of ACS by linking to inpatient claims data from 2000 to 2007. A Cox proportional hazard model was used to estimate the relative risk of ACS in individuals with DM and/or CKD under various stratifications. Age- and sex-specific incidence rates were similar between the non-DM/CKD and DM/non-CKD groups, except for female patients under 45 years, in whom DM was associated with a higher risk of ACS than CKD (8.21 vs. 3.82 per 1000 person-years). In the group aged <45 years, the DM/non-CKD patients were associated with a higher relative hazard of ACS than those in the non-DM/CKD group when compared with the non-DM/non-CKD group (men: adjusted hazard ratios [AHR]:1.77; 95% confidence interval [CI]:1.61-1.93 vs. 1.42 [95% CI: 0.73-2.73]; women 1.97 [95% CI: 1.76-2.20] vs. 1.13 [95% CI: 0.36-3.52]). This discrepancy in AHR was reduced with increasing age. The co-existence of DM and CKD further enhanced the AHR in a multiplicative independent manner. A significant age-modification effect was noted in the DM individuals regardless of their CKD status, but not in the non-DM/CKD group. In stratification by various cardiovascular risk factors, diabetes had a higher risk of ACS than CKD in patients with ≤2 selected risk factors, with the exception of the hyperlipidemia and hypertension subgroup. When all three selected risk factors were included, CKD was associated with a higher risk of ACS than DM (AHR: 1.43 [1.27-1.60] vs. 1.25 [1.22-1.29]). In conclusion, DM and CKD were associated with different levels of risk for ACS according to age, sex and certain cardiovascular risk factors. Strategies aimed at preventing ACS should therefore be individualized according to the presence of DM, CKD and various cardiovascular risk factors.

Determinants of new-onset diabetes in older adults—Results of a national cohort study

BACKGROUND & AIMS

Diabetes mellitus is prevalent in many countries around the world, but the potential causal factors are not clearly known. We attempted to determine the risk factors for new-onset diabetes in ≥53-year old Taiwanese.

METHODS

We analyzed the 1999 and 2003 datasets of the Taiwan Longitudinal Survey on Aging (TLSA). We performed logistic regression analyses to determine the cross-sectional and longitudinal (1999-2003) associations of the sociodemographic, lifestyle, and health-related variables with diabetes and new-onset diabetes, respectively. We excluded those who were diabetic at baseline in the longitudinal analysis.

RESULTS

Results of the cross-sectional analysis showed that higher weight, past betel-quid chewing, IADL dependency, hypertension, heart disease, chronic kidney disease and depressive symptoms were positively associated with diabetes while alcohol drinking was negatively associated with diabetes. Longitudinal analysis showed that excessive weight, physical inactivity, depressive symptoms, and hypertension were associated with increased likelihood of new-onset diabetes while higher physical activity was associated with reduced likelihood of new-onset diabetes. Cigarette-smoking and moderate alcohol drinking showed no clear impacts on new-onset diabetes in older Taiwanese.

CONCLUSIONS

Results show that excessive weight, physical inactivity, hypertension and depressive symptoms are the major risk factors for new-onset diabetes for both Eastern and Western populations, whereas smoking and alcohol drinking have varying impacts among these populations. Better understanding of these relationships should be helpful for planning effective health promotion strategies for reducing the risk of new-onset diabetes in older adults.

HIV and noncommunicable diseases: the Asian perspective

Asia is seeing a rise in noncommunicable diseases in their general population and among people living with HIV. Many Asians have low body weight, which can lead to higher plasma concentrations of antiretrovirals and, as a result, their toxicities. Examples are metabolic complications from protease inhibitors, chronic kidney disease from tenofovir, and hepatotoxicity from nevirapine. Asia has not only the highest burden of hepatitis B viral infection than any other continent but also a predominance of genotypes B and C, the latter associated with higher risk for hepatocellular carcinoma. HIV-associated neurocognitive disorders are equally common among Asians as other populations. Diastolic dysfunction and asymptomatic myocardial ischemia are not infrequent. Non-Hodgkin lymphoma is the most common AIDS-related cancer, whereas Kaposi sarcoma is relatively infrequent. Emerging data show high prevalence of human papillomavirus-associated anal dysplasia in men who have sex with men. Resource-limited countries in Asia suffer from lack of resources for national screening programs of noncommunicable diseases, which, in turn, limits the epidemiologic data that exist to guide the use of national health resources.

Treatment with human insulin does not increase thyroid cancer risk in patients with type 2 diabetes

BACKGROUND

Whether human insulin therapy may increase thyroid cancer risk in patients with type 2 diabetes mellitus (T2DM) has not been investigated.

MATERIALS AND METHODS

The reimbursement databases of all Taiwanese diabetic patients from 1996 to 2009 were retrieved from the Bureau of National Health Insurance. The entry date was set at 1 January 2004, and 968,384 patients with T2DM were followed up for thyroid cancer incidence until the end of 2009. Ever-users, never-users and subgroups of human insulin exposure (using tertile cut-offs of time since starting insulin, duration of therapy and cumulative dose) at entry date were calculated for thyroid cancer incidence. Insulin glargine was not marketed until after the entry date. Therefore, to exclude the potential contamination of insulin glargine, patients who happened to use insulin glargine were censored at the time of its initiation when calculating the period of follow-up. Hazard ratios were estimated by Cox regression.

RESULTS

There were 111,121 ever-users and 857,263 never-users of human insulin, with respective numbers of incident thyroid cancer of 118 (0·11%) and 1047 (0·12%), and respective incidences of 23·9 and 23·8 per 100,000 person-years. The overall hazard ratios (95% confidence intervals) did not show a significant association with human insulin in either the age-sex-adjusted or the fully adjusted model: 0·942 (0·778-1·141) and 1·096 (0·888-1·353), respectively. When categorized into tertiles of the dose-response parameters, none of the hazard ratios was significant.

CONCLUSIONS

This study does not support the role of human insulin therapy in increasing the risk of thyroid cancer in patients with T2DM.

Diabetes but not insulin increases the risk of lung cancer: a Taiwanese population-based study

Background

The trend of lung cancer incidence in Taiwan is unknown, and the association between type 2 diabetes/insulin use and lung cancer is rarely studied.

Methods

The trends of lung cancer incidence in 1979–2007 in the Taiwanese general population were calculated. A random sample of 1,000,000 subjects covered by the National Health Insurance in 2005 was recruited. A total of 494,002 men and 502,948 women and without lung cancer were followed for the annual cumulative incidence of lung cancer in 2005, with calculation of the risk ratios between diabetic and non-diabetic subjects. Logistic regression estimated the adjusted odds ratios for risk factors.

Results

The trends increased significantly in both sexes (P<0.0001). The sex-specific annual cumulative incidence increased with age in either the diabetic or non-diabetic subjects, but the risk ratios attenuated with age. In logistic regressions, diabetes was associated with a significantly higher risk, with odds ratios (95% confidence interval) for diabetes duration <1, 1–3, 3–5 and ≥5 years versus non-diabetes of 2.189 (1.498-3.200), 1.420 (1.014-1.988), 1.545 (1.132-2.109), and 1.329 (1.063-1.660), respectively. Such an association was not related to a higher detection with chest X-ray examination. Insulin use and medications including oral anti-diabetic drugs, statin, fibrate, and anti-hypertensive agents were not significantly associated with lung cancer. Age, male sex, and chronic obstructive pulmonary disease were positively; but dyslipidemia, stroke and higher socioeconomic status were negatively associated with lung cancer.

Conclusions

Diabetes is significantly associated with a higher risk of lung cancer, but insulin use does not increase the risk.

Trend analysis of diabetic prevalence and incidence in a rural area of South Korea between 2003-2008

Aims/Introduction:  This study determined the change in prevalence of diabetes and prediabetes over a period of 5 years in South Korea. The incidence of diabetes and prediabetes and risk factors associated with the development of diabetes were also investigated.

Materials and Methods:  The Dalseong population‐based cohort survey recruited 1806 subjects who were over 20‐years‐old in 2003. Five years later, 1287 of the original subjects were re‐evaluated and 187 new subjects were added to the study. All participants completed a questionnaire, were given a physical examination, and provided blood samples for analysis including 2 h oral glucose tolerances.

Results:  Age‐adjusted prevalence of diabetes rose from 6.7% in 2003 to 9.1% in 2008. The prevalence of prediabetes also increased from 18.5% in 2003 to 28.4% in 2008. The incidence rates of diabetes and prediabetes were 18.3 per 1000 person‐years and 55.4 per 1000 person‐years, respectively. The development of diabetes was associated with impaired fasting glucose (IFG) (odds ratio [OR] 5.661), impaired glucose tolerance (IGT) (OR: 6.013), age (OR 1.013), and waist‐to‐hip ratio (OR 1.513). After excluding the IFG and IGT, systolic blood pressure (OR 1.023), high‐sensitivity C‐reactive protein (hsCRP; OR 1.097), triglyceride (OR 1.002) and waist‐to‐hip ratio (OR 1.696) were statistically significant risk factors in a multivariate logistic regression analysis.

Conclusions:  A significant rise in the prevalence of diabetes and prediabetes was observed between 2003 and 2008. In addition, this study newly demonstrated that waist‐to‐hip ratio and hsCRP were associated with the development of diabetes after adjusting for several confounding factors. (J Diabetes Invest, doi: 10.1111/j.2040‐1124.2010.00045.x, 2010)

A review on thiazolidinediones and bladder cancer in human studies

There is a concern of an increased risk of bladder cancer associated with the use of thiazolidinediones, a class of oral glucose-lowering drugs commonly used in patients with type 2 diabetes with a mechanism of improving insulin resistance. Human studies on related issues are reviewed, followed by a discussion on potential concerns on the causal inference in current studies. Pioglitazone and rosiglitazone are discussed separately, and findings from different geographical regions are presented. Randomized controlled trials designed for primarily answering such a cancer link are lacking, and evidence from clinical trials with available data for evaluating the association may not be informative. Observational studies have been reported with the use of population-based administrative databases, single-hospital records, drug adverse event reporting system, and case series collection. Meta-analysis has also been performed by six different groups of investigators. These studies showed a signal of higher risk of bladder cancer associated with pioglitazone, especially at a higher cumulative dose or after prolonged exposure; however, a weaker signal or null association is observed with rosiglitazone. In addition, there are some concerns on the causal inference, which may be related to the use of secondary databases, biases in sampling, differential detection, and confounding by indications. Lack of full control of smoking and potential biases related to study designs and statistical approaches such as prevalent user bias and immortal time bias may be major limitations in some studies. Overlapping populations and opposing conclusions in studies using the same databases may be of concern and weaken the reported conclusions of the studies. Because randomized controlled trials are expensive and unethical in providing an answer to this cancer issue, observational studies are expected to be the main source in providing an answer in the future. Furthermore, international comparison studies using well-designed and uniform methodology to clarify the risk in specific sexes, ethnicities, and other subgroups and to evaluate the interaction with other environmental risk factors or medications will be helpful to identify patients at risk.

Higher risk of mortality from lung cancer in Taiwanese people with diabetes

BACKGROUND

The association between diabetes and lung cancer is rarely studied in the Asian populations. This study investigated lung cancer mortality trends, mortality rate ratios between people with diabetes and the general population, and associated risk factors in people with diabetes in Taiwan.

METHODS

Age-standardized trends from 1995 to 2006 were evaluated, followed by calculation of age-sex-specific average mortality rates within the 12-year period in the general population. A total of 113,347 men and 131,573 women with diabetes, aged ≥25 years and recruited in 1995-1998 were followed to 2006. Age-sex-specific mortality rate ratios between people with diabetes and the general population were calculated. Cox regression evaluated the risk factors in the people with diabetes.

RESULTS

A steady age-standardized trend was observed for either sex. A total of 1580 men and 931 women with diabetes died of lung cancer. Mortality rate ratios showed a significantly higher risk in patients with diabetes: 1.16 (1.04-1.30), 1.42 (1.33-1.53), 1.79 (1.61-1.99) and 4.37 (3.75-5.09) for ≥75, 65-74, 55-64 and 25-54 years old, respectively, for men; and 1.35 (1.18-1.54), 1.41 (1.27-1.57), 1.88 (1.66-2.13) and 3.57 (2.95-4.33), respectively, for women. Age and smoking were significantly associated with lung cancer mortality in the people with diabetes, but sex, diabetes type and insulin use were not. Diabetes duration was significant when those who died of lung cancer within 5 years of diabetes diagnosis were excluded from analysis.

CONCLUSIONS

People with diabetes have a higher risk of lung cancer mortality and this was most remarkable in the youngest age.

The role of triglyceride in cardiovascular disease in asian patients with type 2 diabetes--a systematic review

In Asian populations, diabetes mellitus is increasing and has become an important health problem in recent decades. Cardiovascular disease (CVD) is one of the most important complications and the most common cause of death in diabetic patients. Among the risk factors of CVD, elevated low-density lipoprotein cholesterol has been a major concern. Studies suggested that serum triglyceride may also play a role in predicting CVD in patients with type 2 diabetes mellitus, but the association is still debated. In this review, we summarized published studies focusing on the relationship between serum triglyceride and CVD disease in Asian diabetic patients. Ten studies conducted in six different Asian countries (three from Hong Kong, two from Taiwan, tow from Japan, one from Indonesia, one from South India, and one from South Korea) were summarized and discussed. CVD was subdivided into coronary heart disease, stroke, and peripheral arterial disease. Of the ten studies analyzed, one focused on CVD, five on coronary heart disease, three on stroke, three on peripheral arterial disease, and one on mortality from CVD. Studies from Hong Kong, Taiwan, and Japan suggested that triglyceride is a significant and independent risk factor for coronary heart disease, but not a significant risk factor for stroke (studies conducted in Japan and South Korea) or peripheral arterial disease (studies conducted in Taiwan, Indonesia, and South India). Although serum triglyceride may be a significant risk factor for coronary heart disease in Asian diabetic patients, clinical trials evaluating whether lowering triglycerides using fibrates can reduce the risk of coronary heart disease in these patients need to be initiated.

Prescription pattern of chinese herbal products for diabetes mellitus in taiwan: a population-based study

Background. Traditional Chinese medicine (TCM), when given as a therapy for symptom relief, has gained widespread popularity among diabetic patients. The aim of this study is to analyze the utilization of TCM among type 2 diabetic patients in Taiwan. Methods. The use of TCM for type 2 diabetic patients were evaluated using a randomly sampled cohort of 1,000,000 beneficiaries recruited from the National Health Insurance Research Database. Results. Overall, 77.9% (n = 31,289) of type 2 diabetic patients utilized TCM and 13.9% (n = 4,351) of them used TCM for the treatment of type 2 diabetes. Among the top ten most frequently prescribed herbal formulae, four remedies, Zhi-Bo-Di-Huang-Wan, Qi-Ju-Di-Huang-Wan, Ji-Sheng-Shen-Qi-Wan and Ba-Wei-Di-Huang-Wan are derivative formulae of Liu-Wei-Di-Huang-Wan. In other words, Liu-Wei-Di-Huang-Wan and its derivatives were found to be the most common herbal formulae prescribed by TCM doctors for the treatment of diabetes in Taiwan. Conclusion. Although some evidence does support the use TCM to treat diabetes, the results from the current study may have been confounded by placebo effect, which emphasize the need for well conducted, double-blind, randomized, placebo-controlled studies in order to further evaluate the efficacy of Liu-Wei-Di-Huang-Wan on patients with type 2 diabetes.

Diabetes and thyroid cancer mortality: a 12-year prospective follow-up of Taiwanese

BACKGROUND

The association between diabetes and thyroid cancer is rarely studied. This study evaluated thyroid cancer mortality trend in Taiwanese population, mortality rate ratios between diabetic patients and general population, and risk factors in diabetic patients.

METHODS

In general population, age-standardized trends were evaluated from 1995 to 2006. A total of 113,347 diabetic men and 131,573 diabetic women aged ≥ 25 years recruited during 1995-1998 were followed to 2006. Age- and sex-specific mortality rate ratios were calculated and Cox's regression evaluated the risk factors.

RESULTS

A steady trend of thyroid cancer mortality was observed in the general population. A total of 20 diabetic men and 45 diabetic women died of thyroid cancer, with overall mortality rate 2.32 and 4.26 per 100,000 person-years, respectively. Mortality rate ratios showed positive association with magnitude increased with decreasing age: 1.85 (0.77, 4.43), 1.21 (0.54, 2.73), 2.53 (1.14, 5.59) and 5.80 (2.10, 16.01) for ≥ 75, 65-74, 55-64 and 25-54 years old, respectively, for men; and 0.78 (0.35, 1.74), 2.03 (1.31, 3.13), 2.99 (1.77, 5.04) and 5.34 (2.20, 13.00), respectively, for women. After adjustment, only age was significantly associated with thyroid cancer mortality. Sex, diabetes duration, diabetes type, body mass index, smoking, insulin use and area of residence were not significantly predictive for thyroid cancer mortality.

CONCLUSIONS

The annual thyroid cancer mortality during 1995-2006 in the Taiwanese general population has been steady. Our data suggest a higher risk in diabetic patients, with especially higher mortality rate ratios in younger age. Obesity, smoking and insulin use are not modifiable risk factor.

Time trend analysis of the prevalence and incidence of diagnosed type 2 diabetes among adults in Taiwan from 2000 to 2007: a population-based study

Background

The prevalence of type 2 diabetes has rapidly increased in the Taiwanese population with the increasing prevalence of a sedentary lifestyle and high-calorie dietary intake. This study aims to determine the annual trends of the prevalence and incidence of diagnosed type 2 diabetes among adults in Taiwan from 2000 to 2007.

Methods

A population-based study of all residents aged 20 years and over (12,191,076 in 2000 and 18,772,180 in 2007) enrolled in the National Health Insurance (NHI) program, the database of which was used to identify patients diagnosed with type 2 diabetes. The annual prevalence and incidence of diagnosed type 2 diabetes were estimated using the International Classification of Diseases, 9^th Revision, Clinical Modification diagnostic codes based on age, gender, insurance premium, and urbanization degree. Logistic regression was used to estimate the odds ratios (OR) of risk factors, as well as to examine the trend in the annual prevalence or incidence of diagnosed type 2 diabetes from 2000 to 2007.

Results

The crude annual prevalence of diagnosed type 2 diabetes increased significantly from 5.79% in 2000 to 8.30% in 2007. The increase was highest in 2007, among men, individuals aged ≥ 80 years, and individuals residing in aging society areas [OR (95% CI): 1.416 (1.412–1.420), 1.033 (1.032–1.034), 31.810 (31.690–31.931), and 1.090 (1.085–1.094), respectively]. The crude incidence fluctuated throughout the study period, ranging from 7.72 per 1,000 in 2006 to 8.98 per 1,000 in 2000. The decrease was highest in 2006, among individuals with an insurance premium ≥ median value [0.933 (0.925–0.942) and 0.810 (0.805–0.815), respectively]. The greatest increase was among men, individuals aged 60 to 79 years, and individuals residing in aging society areas [1.150 (1.145–1.155), 15.452 (15.329–15.576), and 1.127 (1.113–1.142), respectively].

Conclusion

This study demonstrated the substantial increase in annual prevalence of diagnosed type 2 diabetes among adults in Taiwan from 2000 to 2007. The incidence fluctuated between 2000 and 2007.

High HbA1c level was the most important factor associated with prevalence of diabetic retinopathy in Taiwanese type II diabetic patients with a fixed duration

BACKGROUND

To identify the prevalence and related risk factors for diabetic retinopathy (DR) in non-insulin dependent diabetes in Taiwan.

METHODS

A retrospective review of type II diabetic patients in the Diabetes Shared Care System database of our Hospital enrolled from 2002 to 2009. A retinopathy severity score was assigned according to fundus examination by indirect ophthalmoscopy or binocular biomicroscopy.

RESULTS

Data was collected on 901 subjects, 497 males and 404 females. Of these, 230 (25.53 %) had DR at enrolment. Compared with patients without DR, those with DR were more likely to be female (p = 0.03) or have higher HbA1c (p < 0.001), longer duration of diabetes (p < 0.001), hypertension (p < 0.001), higher systolic blood pressure (p < 0.001), higher diastolic blood pressure (p = 0.05), as well as impaired renal function (p = 0.001). In subgroup analysis stratified by diabetes duration, HbA1c was the most consistent independent risk factor associated to the prevalence of DR. Higher systolic blood pressure and female sex were significantly independent risk factors only in patients with a duration of diabetes < 4 years. On the contrary, old onset age showed a protective effect against DR only in those with a disease duration > 8 years.

CONCLUSIONS

High HbA1c level was the most important factor associated with prevalence of DR in Taiwanese type II DM patients with a fixed duration.

Prognostic value of C-reactive protein and neutrophil-to-lymphocyte ratio in patients with hepatocellular carcinoma

BACKGROUND

Accumulating evidence indicates that components of the systemic inflammatory response, such as C-reactive protein (CRP) and neutrophil-to-lymphocyte ratio (NLR), have been associated with prognosis of various cancers. We aimed to elucidate whether CRP and NLR could serve as potential surrogate markers for response and survival in patients with hepatocellular carcinoma (HCC).

METHODS

The study population consisted of 318 consecutive patients with HCC. CRP and NLR were measured at baseline with follow-up measurements.

RESULTS

With the mean follow-up of 13.9 months, the median survival time was 13.8 months. Child-Pugh class, tumor size > 5 cm, tumor multiplicity, presence of portal vein thrombosis, α-fetoprotein > 200 ng/mL, CRP > 6.3 mg/L and NLR > 2.3 were identified as independent factors for worse survival of HCC (all p < 0.05). Patients with elevated CRP (> 6.3 mg/L) and elevated NLR (> 2.3) had a significantly shorter overall survival than those with low CRP and low NLR (all p < 0.001). The combined use of CRP and NLR provided incremental prognostic information. With significant inter-correlations, levels of CRP and NLR escalated with aggravating Child-Pugh class from A to C or progressing tumor stage from I to IV. CRP and NLR on baseline and serial measurements were well predictive of treatment response (p < 0.001).

CONCLUSIONS

CRP and NLR are independent indicators for survival in HCC patients, reflecting tumor burden and hepatic reserve. Their role in predicting tumor response and survival is more enhanced when used in combination. This study suggests that CRP and NLR are important prognostic biomarkers for HCC.

Type 2 diabetes, smoking, insulin use, and mortality from hepatocellular carcinoma: a 12-year follow-up of a national cohort in Taiwan

BACKGROUND

The effect of smoking and insulin use in the association between diabetes and hepatocellular carcinoma (HCC) is not known.

MATERIALS AND METHODS

Age-standardized HCC mortality trends during 1995-2006 in the general population were calculated. A total of 88,694 type 2 diabetic patients aged ≥25 years recruited in 1995-1998 were followed till 2006. Age- and sex-specific mortality rates and the mortality rate ratios (vs. the average mortality rates in the general population) were calculated. Risk factors were evaluated by Cox regression.

RESULTS

The age-standardized mortality trend slightly increased significantly in women but was steady in men. For diabetic patients aged ≥25 years, 830 men and 515 women died of HCC during 1995-2006. Mortality rate ratios (95 % confidence interval) were larger with the decreasing age: 7.36 (6.52, 8.31), 2.48 (2.22, 2.78), 1.79 (1.59, 2.02), and 1.87 (1.51, 2.32) for age 25-54, 55-64, 65-74, and ≥75 years for men, respectively, 10.12 (7.73, 13.25), 4.08 (3.57, 4.67), 2.45 (2.15, 2.78), and 1.71 (1.34, 2.19) for women. Age, male sex, lower BMI, smoking, and insulin use were associated with HCC mortality, but diabetes duration was not. Smoking and insulin use carried a significantly higher risk of 22-29 % and 37-58 %, respectively, without interaction. A dose-responsive pattern between the duration of insulin use and HCC mortality was noted, with a relative risk of 1.5-1.7 in those who used insulin for ≥10 years.

CONCLUSIONS

Diabetic patients have a higher risk of HCC mortality, which is more remarkable in the younger age. Smoking and insulin are potentially modifiable risk factors.

Obesity paradox: differential effects on cancer and noncancer mortality in patients with type 2 diabetes mellitus

OBJECTIVE

To investigate associations between body mass index (BMI) and cause-specific mortality in patients with type 2 diabetes mellitus (T2DM).

METHODS

Prospective follow-up of a nationally representative cohort of 89,056 Taiwanese patients with T2DM recruited since 1995. Vital status was matched with the National Death Certificate Database until the end of 2006. Self-reported body weight and height were used to calculate BMI, which was treated either as a continuous or categorical variable (underweight, <18.5; normal, 18.5-22.9; overweight, 23.0-24.9; obesity I, 25.0-29.9; and obesity II, ≥30.0 kg/m(2)). Causes of death were classified as all-cause, cancer, diabetes complications (macrovascular and microvascular), and other. Cox regression was used to estimate the hazard ratios.

RESULTS

A total of 26,951 patients (30.3% of the cohort) died during follow-up (cancer 5.4%, diabetes complications 17.4%, and other causes 7.5%). As a continuous variable, BMI was inversely associated with mortality from all-cause, cancer, diabetes complications, and other causes, with respective adjusted hazard ratios (95% confidence intervals) of 0.942 (0.939-0.946), 0.966 (0.958-0.975), 0.935 (0.930-0.939), and 0.942 (0.935-0.949). Compared to normal weight, underweight was significantly predictive for any of causes of death, while overweight, obesity I, and obesity II were all significantly associated with mortality in an inverse pattern. After excluding patients with a follow-up duration <2 years, most BMI categories were not significantly predictive of mortality from cancer, suggesting a potential bias of cancer-induced weight loss.

CONCLUSIONS

The obesity paradox, mainly observed in noncancer mortality, exists in patients with T2DM, suggesting a survival advantage in obese diabetic patients.

Cancer risk in patients with pyogenic liver abscess: a nationwide cohort study

BACKGROUND

There has been no large-scale population-based study on the relationship between pyogenic liver abscesses (PLA) and subsequent cancer risk.

AIM

To estimate all cancer risk following a diagnosis of PLA.

METHODS

Based on Taiwan's National Health Insurance Research Database, 1257 patients with PLA without prior cancers in the period 1996-2008 were identified and followed-up. The standard incidence ratio (SIR) of each cancer was calculated as the number of observed cancer cases arising among the PLA patients divided by the expected case number of cancer cases according to the national cancer rates.

RESULTS

Of the 1257 PLA patients identified, 598 (47.6%) had diabetes mellitus. After a median (±s.d.) follow-up of 3.33 ± 3.45 years, 186 were diagnosed with cancers, including 56 liver cancer, 22 biliary tract cancer and 40 colorectal cancer patients. Patients with PLA had a higher risk of all cancers (SIR, 3.83; 95% CI, 3.30-4.42), liver cancer (SIR, 7.87; 95% CI, 5.94-10.21), biliary tract cancer (SIR, 34.58; 95% CI, 21.67-52.36) and colorectal cancer (SIR, 5.27; 95% CI, 3.76-7.18). The highest SIRs of all cancers, liver cancer, biliary tract cancer and colorectal cancer occurred within 90 days of follow-up (360.82; 95% CI, 278.46-459.91, 257.28; 95% CI, 186.17-346.56, 1153.38; 95% CI 694.08-1801.24, and 52.63; 95% CI 25.2-96.8 respectively).

CONCLUSIONS

Pyogenic liver abscesses may herald the onset of cancer, especially hepato-biliary and colon cancer. Further surveys should be conducted for the detection of occult cancers in such patients.

Diabetes but not insulin is associated with higher colon cancer mortality

AIM: To evaluate whether diabetic patients had a higher risk of colon cancer mortality and its associated risk factors.

METHODS: The sex-specific crude and age-standardized (to the 2000 World Health Organization population) mortality rates of colon cancer in the Taiwanese general population were first calculated from 1995 to 2006. The trends were evaluated by linear regression. A total of 113 347 diabetic men and 131 573 diabetic women aged ≥ 25 years at recruitment from 1995 to 1998 were followed up until the end of 2006. Age/sex-specific colon cancer mortality rate ratios were calculated comparing the mortality rates of the diabetic patients with the average mortality rates of the general population within 12 years (1995-2006). A sub-cohort of diabetic patients (42 260 men and 49 405 women) was interviewed using a baseline questionnaire and Cox’s regression was used to evaluate the risk factors for colon cancer mortality in these diabetic patients.

RESULTS: The crude and age-standardized trends of colon cancer mortality from 1995 to 2006 increased significantly for both sexes in the general population. A total of 641 diabetic men and 573 diabetic women died of colon cancer, with a mortality rate of 74.4 and 54.3 per 100 000 person-years, respectively. Mortality rate ratios [95% confidence intervals (CIs)] showed a significantly higher risk of mortality from colon cancer for the diabetic patients compared to the general population, with the magnitude increasing with decreasing age: 1.65 (1.40-1.95), 2.01 (1.78-2.27), 2.75 (2.36-3.21) and 5.69 (4.65-6.96) for ≥ 75, 65-74, 55-64 and 25-54 years old, respectively, for men; and 1.46 (1.24-1.72), 2.09 (1.84-2.38), 2.67 (2.27-3.14) and 3.05 (2.29-4.06), respectively, for women. Among the sub-cohort of diabetic patients who had been interviewed with the baseline questionnaire, including information on age, sex, diabetes duration, diabetes type, body mass index, smoking, insulin use and area of residence, age and smoking were significantly predictive for colon cancer mortality, with respective adjusted hazard ratios (HRs) (95% CIs) of 1.077 (1.066-1.088) and 1.384 (1.068-1.792). Diabetes duration became a significant factor when those who died of colon cancer within 5 years of diabetes diagnosis were excluded to minimize the possible contamination of diabetes caused by incipient colon cancer, with an adjusted hazard ratio of 1.021 (1.007-1.034). Sex, diabetes type, insulin use, body mass index and area of residence were not significant predictors for colon cancer mortality in the diabetic patients. Although insulin use was categorized into subgroups of duration of use (non-users and users < 5 years, 5-9 years and ≥ 10 years), none of the HRs for colon cancer mortality was significant with regards to different durations of insulin use.

CONCLUSION: Colon cancer mortality is increasing in Taiwan. A higher risk is observed in diabetic patients. Smoking, but not insulin use, is a modifiable risk factor.

Oral cancer in Taiwan: is diabetes a risk factor?

OBJECTIVES

The association between diabetes and oral cancer is rarely studied. We investigated the trends of oral cancer in the Taiwanese general population and the possible link with diabetes.

MATERIALS AND METHODS

The trend of age-standardized oral cancer incidence in 1979-2007 in Taiwan was calculated from the Taiwan Cancer Registry database. A total of 494,817 men and 503,723 women without oral cancer from a random sample of 1,000,000 individuals covered by the National Health Insurance were followed up from 2003 to 2005. Cox regression evaluated the adjusted relative risk considering potential detection bias and covariates.

RESULTS

The trends increased significantly in both sexes. Diabetic patients had a higher chance of oral cancer detection because they more frequently visited related medical professionals. Although diabetes status and duration were significantly associated with oral cancer in unadjusted models, none was significant after multivariable adjustment. For comorbidities, chronic obstructive pulmonary disease (a surrogate for smoking) and alcohol-related diagnoses were significant for men, and hypertension and alcohol-related diagnoses were significant for women. Additionally, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and insulin were significant with relative risk (95 % confidence interval) of 1.642 (1.174-2.295) and 2.136 (1.003-4.547), respectively, in men.

CONCLUSIONS

Oral cancer is increasing in Taiwan. Diabetes is not a risk factor after multivariable adjustment.

CLINICAL RELEVANCE

The increasing trend of oral cancer may not be ascribed to diabetes. The association between oral cancer and some comorbidities and medications requires confirmation and may provide strategies for the prevention of oral cancer.

Diabetes, insulin use, and non-Hodgkin lymphoma mortality in Taiwan

The objective was to evaluate non-Hodgkin lymphoma (NHL) mortality trends and mortality rate ratios between diabetes patients and the general population, and to study NHL risk factors among diabetes patients in Taiwan. A cohort of 80 397 patients with type 2 diabetes mellitus older than 45 years was recruited in 1995-1998 and followed up until 2006. Age-standardized NHL mortality in 1995-2006 was calculated. Non-Hodgkin lymphoma risk factors in diabetes patients were evaluated using Cox regression. Age-standardized NHL mortality trend was steady. Eighty-two male and 69 female diabetes patients died of NHL (crude mortality rates, 35.1 and 23.0 per 100 000 person-years, respectively; corresponding overall mortality rate ratios comparing diabetes patients to the general population, 2.06 and 2.14). The mortality rate ratios were 1.47, 2.33, and 2.78 for men aged at least 65, 55 to 64, and 45 to 54 years, respectively; the corresponding ratios for women were 1.48, 2.22, and 2.79. Age and male sex were significant risk factors, whereas insulin use, diabetes duration, smoking, body mass index, and area of residence were not. Diabetes duration became a significant factor after excluding patients who died of NHL within 5 years of diabetes diagnosis. Patients with diabetes have a higher risk of mortality from NHL, but insulin use is not associated with NHL mortality. Future studies are needed to fully elucidate any association between increased mortality rate ratio and younger age as well as the lack of association between NHL and insulin use demonstrated herein.