Cigarette Smoking, Diabetes, and Diabetes Complications: Call for Urgent Action

A systematic review of oral health outcomes following smoking cessation in type 2 diabetes: Clinical and research implications

OBJECTIVE

This systematic review analyzes the effects of smoking cessation on oral health outcomes in individuals with type 2 diabetes.

DATA

The review followed PRISMA guidelines, and the protocol was registered on PROSPERO (CRD42024604271). Risk of bias was assessed using the Joanna Briggs Institute's critical appraisal tools.

SOURCES

PubMed, Scopus, and Web of Science were searched on November 7, 2024, alongside references from highly cited journals and conference proceedings. No language or date restrictions were applied.

STUDY SELECTION

Inclusion criteria were human clinical studies (randomized controlled trials, cohort, case-control, or cross-sectional studies) involving patients with type 2 diabetes, stratified by smoking status (former, current, never smokers), assessing oral health outcomes (e.g., periodontal disease, caries). Studies without detailed smoking status data were excluded.

RESULTS

The search retrieved 549 studies, of which 4 (N = 926 participants) met the inclusion criteria. These studies examined smoking status in relation to periodontitis progression and response to periodontal therapy. Overall, the effects smoking cessation in improving periodontal outcomes in this population appears limited. However, methodological limitations were identified, and the studies may have been underpowered for the smoking status subgroup.

CONCLUSION

Evidence on the impact of smoking cessation on oral health in patients with type 2 diabetes remains inconclusive, as large prospective studies specifically designed for this purpose are lacking. While smoking cessation benefits oral health in the general population, its effects on oral outcomes in patients with diabetes remain unclear. Further research is needed to elucidate its impact on patients with type 2 diabetes.

CLINICAL SIGNIFICANCE

A multidisciplinary approach to managing diabetic patients is essential, where dentists not only address oral health but also support healthy behaviors, including smoking cessation, to improve overall diabetes-related complications.

Diabetic neuropathy: cutting-edge research and future directions

Diabetic neuropathy (DN) is a prevalent and debilitating complication of diabetes mellitus, significantly impacting patient quality of life and contributing to morbidity and mortality. Affecting approximately 50% of patients with diabetes, DN is predominantly characterized by distal symmetric polyneuropathy, leading to sensory loss, pain, and motor dysfunction, often resulting in diabetic foot ulcers and lower-limb amputations. The pathogenesis of DN is multifaceted, involving hyperglycemia, dyslipidemia, oxidative stress, mitochondrial dysfunction, and inflammation, which collectively damage peripheral nerves. Despite extensive research, disease-modifying treatments remain elusive, with current management primarily focusing on symptom control. This review explores the complex mechanisms underlying DN and highlights recent advances in diagnostic and therapeutic strategies. Emerging insights into the molecular and cellular pathways have unveiled potential targets for intervention, including neuroprotective agents, gene and stem cell therapies, and innovative pharmacological approaches. Additionally, novel diagnostic tools, such as corneal confocal microscopy and biomarker-based tests, have improved early detection and intervention. Lifestyle modifications and multidisciplinary care strategies can enhance patient outcomes. While significant progress has been made, further research is required to develop therapies that can effectively halt or reverse disease progression, ultimately improving the lives of individuals with DN. This review provides a comprehensive overview of current understanding and future directions in DN research and management.

Impact of smoking cessation on metabolic parameters and renal function in patients with and without diabetes mellitus

BACKGROUD AND OBJECTIVES

As patients with diabetes are at a significantly higher risk of cardiovascular diseases than those without diabetes, it is important to gain a clinical understanding of the differential effects of smoking cessation on several risk factors between patients with and without diabetes.

MATERIALS AND METHODS

Patients who participated in a smoking cessation program received an assessment of the outcomes of interest. The outcomes were changes in metabolic parameters and renal function from baseline to 6-month follow-up after the smoking cessation program.

RESULT

A total of 1954 patients joined the smoking cessation program, and 1381 patients were in the smoking cessation failure (SCF) group and 573 were in the smoking cessation success (SCS) group. The decrease in HbA1c after smoking cessation was only observed in patients with diabetes. Smoking cessation was also associated with a significant decrease in LDL cholesterol in patients with diabetes. In terms of renal function, smoking cessation was associated with an improvement in eGFR, and the trend was similar in patients with and without diabetes.

CONCLUSION

Successful smoking cessation was associated with improvement in renal function. Moreover, it was associated with improvements in HbA1c and LDL cholesterol in patients with diabetes, despite significant weight gain.

Alzheimer's Disease as Type 3 Diabetes: Understanding the Link and Implications

Alzheimer's disease (AD) and type 2 diabetes mellitus (T2DM) are two prevalent conditions that present considerable public health issue in aging populations worldwide. Recent research has proposed a novel conceptualization of AD as "type 3 diabetes", highlighting the critical roles of insulin resistance and impaired glucose metabolism in the pathogenesis of the disease. This article examines the implications of this association, exploring potential new avenues for treatment and preventive strategies for AD. Key evidence linking diabetes to AD emphasizes critical metabolic processes that contribute to neurodegeneration, including inflammation, oxidative stress, and alterations in insulin signaling pathways. By framing AD within this metabolic context, we can enhance our understanding of its etiology, which in turn may influence early diagnosis, treatment plans, and preventive measures. Understanding AD as a manifestation of diabetes opens up the possibility of employing novel therapeutic strategies that incorporate lifestyle modifications and the use of antidiabetic medications to mitigate cognitive decline. This integrated approach has the potential to improve patient outcomes and deepen our comprehension of the intricate relationship between neurodegenerative diseases and metabolic disorders.

Effects of combustible cigarettes and electronic nicotine delivery systems on immune cell-driven inflammation: Evidences from diabetic patients and multiple low dose streptozotocin-treated diabetic mice

Considering detrimental impacts of combustible cigarettes (CCs) on the exacerbation of diabetes mellitus (DM), a significant number of DM patients have substituted CCs with electronic nicotine delivery systems (ENDS). Herewith, we compared CCs and ENDS-dependent modulation of immune cell-driven inflammation in DM patients who used ENDS (DMENDS), CCs (DMCC) or were non-smokers (DMAIR), paving the way for the better understanding of ENDS-induced biological effects. Multiple low dose streptozotocin (MLD-STZ)-induced mice model of DM was used to support clinical findings. Both CCs and ENDS aggravated MLD-STZ-induced DM. Pancreatic injury and inflammation were more severe in CC-exposed than in ENDS-exposed diabetic mice. CCs promoted activation of NLRP3 inflammasome, enhanced production of inflammatory cytokines in neutrophils, macrophages and remarkably improved antigen presenting capacity of dendritic cells which resulted in the expansion of TNF-α, IFN-γ and IL-17-producing Th1 and Th17 lymphocytes, NK and NKT cells. Compared to CCs, ENDS more intensively promoted expansion of FoxP3-expressing, IL-10-producing NK and NKT cells and triggered less intense systemic inflammatory response in diabetic animals. Similar findings were observed in DM patients. The highest numbers of inflammatory, TNF-α and IL-1β-producing neutrophils and monocytes, TNF-α and IFN-γ-producing T lymphocytes, NK and NKT cells were determined in the blood of DMCC patients, while total number of immunosuppressive, TGF-β-producing CD3 + CD4 + T cells was the highest in the blood of DMENDS patients. In conclusion, although both CC and ENDS aggravate on-going inflammation in DM, ENDS have weaker capacity to induce production of inflammatory cytokines in immune cells than CCs.

The Increased Frequency of Type 1 Regulatory T (Tr1) Cells and the Altered Expression of Aryl Hydrocarbon Receptor (AHR) and Interferon Regulatory Factor-4 (IRF4) Genes in Type 1 Diabetes: A Case-Control Study

Background and aim Type 1 diabetes is an autoimmune disorder characterized by the destruction of pancreatic beta cells, leading to insulin deficiency and hyperglycemia. Regulatory T cells (Tregs), particularly type 1 regulatory T (Tr1) cells, play a crucial role in modulating autoimmune responses. Therefore, this study aimed to evaluate the frequency of Tr1 cells and their association with aryl hydrocarbon receptor (AHR) and interferon regulatory factor-4 (IRF4) gene expression levels in type 1 diabetes mellitus (T1DM) compared to the healthy controls. Method A case-control study design was used. The case group included patients diagnosed with T1DM, while the control group consisted of healthy individuals, matched for age and sex. Blood samples were collected, and peripheral blood mononuclear cells (PBMCs) were isolated. Serum interleukin 10 (IL-10) and interleukin 21 (IL-21) levels were measured using enzyme-linked immunosorbent assay (ELISA). The gene expression of AHR and IRF4 was analyzed using quantitative real-time polymerase chain reaction (qPCR), and Tr1 cell populations were determined using flow cytometry. Data were summarized with mean and standard error of the mean (SEM) for quantitative variables. Independent sample t-test, chi-square test, and the Mann-Whitney U test were used to compare groups. Statistical analyses were performed using SPSS version 25 (IBM SPSS Statistics, Armonk, NY), with significance levels set at p < 0.05. Figures were created using GraphPad Prism (GraphPad Software, San Diego, CA). Results A total of 45 cases were enrolled in the study, with 30 T1DM patients and 15 healthy controls. The mean IL-10 concentration was significantly higher in the patients (10.4 ± 1.1 pg/mL) compared to the healthy controls (5.1 ± 0.7 pg/mL), with a p-value of 0.001. There was no significant difference in IL-21 levels between the patients (76.1 ± 9.0 pg/mL) and healthy controls (88.2 ± 17.5 pg/mL), indicated by a p-value of 0.480. AHR gene expression was significantly lower in patients, with a p-value of 0.037. Although IRF4 gene expression was higher in patients, the difference was not statistically significant (p = 0.449). Tr1 cell frequency was significantly higher in T1DM patients (1.45% of cluster of differentiation 4+ {CD4+} T cells) compared to the healthy controls (0.40% of CD4+ T cells), with a p-value of 0.045. Conclusions The study demonstrated that T1DM is associated with higher IL-10 levels, decreased AHR gene expression, and a higher frequency of Tr1 cells. Policymakers should focus on developing targeted immunomodulatory therapies to address these immunological abnormalities. Healthcare providers should prioritize monitoring cytokine levels and gene expression in T1DM patients to tailor treatment plans effectively. Further research is needed to explore the therapeutic potential of modulating Tr1 cells and their related pathways in T1DM management.

Phenotypical characterization of exteroceptive sensation and pain symptoms on diabetic patients

BACKGROUD

Diabetic neuropathy (DN) is one of the most common complications of diabetes, affecting about half of individuals with the disease. Among the various symptoms of DN, the development of chronic pain stands out and manifests as exacerbated responses to sensorial stimuli. The conventional clinical treatments used for general neuropathy and associated painful symptoms, still brings uncomplete and unsatisfactory pain relief. Patients with neuropathic pain syndromes are heterogeneous. They present with a variety of sensory symptoms and pain qualities which difficult the correct diagnosis of sensory comorbidities and consequently, the appropriate chronic pain management.

AIMS

Herein, we aimed to demonstrate the existence of different sensory profiles on diabetic patients by investigating epidemiological and clinical data on the symptomatology of a group of patients with DN.

METHODS

This is a longitudinal and observational study, with a sample of 57 volunteers diagnosed with diabetes from outpatient day clinic of Hospital Universitário of the University of São Paulo-Brazil. After being invited and signed the Informed Consent Form (ICF), patients were submitted to clinical evaluation and filled out pain and quality of life questionnaires. They also performed quantitative sensory test (QST) and underwent skin biopsy for correlation with cutaneous neuropathology.

RESULTS

Data demonstrate that 70% of the studied sample presented some type of pain, manifesting in a neuropathic or nociceptive way, what has a negative impact on the life of patients with DM. We also demonstrated a positive association between pain and anxiety and depression, in addition to pain catastrophic thoughts. Three distinct profiles were identified in the sample, separated according to the symptoms of pain: (i) subjects without pain; (ii) with mild or moderate pain; (iii) subjects with severe pain. We also identified through skin biopsy that diabetic patients presented advanced sensory impairment, as a consequence of the degeneration of the myelinated and unmyelinated peripheral fibers. This study characterized the painful symptoms and exteroceptive sensation profile in these diabetic patients, associated to a considerable level of sensory degeneration, indicating, and reinforcing the importance of the long-term clinical monitoring of individuals diagnosed with DM, regarding their symptom profiles and exteroceptive sensitivity.

The interaction between diet quality and cigarette smoking on the incidence of hypertension, stroke, cardiovascular diseases, and all-cause mortality

This study aimed to examine the interaction between diet quality indices (DQIs) and smoking on the incidence of hypertension (HTN), stroke, cardiovascular diseases, and all-cause mortality. We prospectively followed 5720 participants and collected dietary data via a validated food frequency questionnaire to calculate DQI-international (DQI-I) and DQI-revised (DQI-R). Considering an interaction analysis, we classified participants based on diet quality (median: higher/lower) and smoking status. Over 9 years of follow-up, higher diet quality scores were associated with a lower risk of stroke and mortality. While current smokers had a higher risk of stroke and mortality but had a lower risk of developing HTN. Compared to the current smokers with lower diet quality, nonsmokers with higher diet quality according to the DQI-I [HR 0.24; 95% CI (0.08, 0.66)], and DQI-R [HR 0.20; 95% CI (0.07, 0.57)] had a lower risk of stroke. Moreover, the lower risk of mortality was more evident in nonsmokers with higher DQI-I [HR 0.40; 95% CI (0.22-0.75)] and DQI-R scores [HR 0.34; 95% CI (0.18-0.63)] compared to nonsmokers with lower diet quality. While higher DQI-I and DQI-R scores were associated with a lower risk of stroke and mortality, this beneficial effect may be negated by smoking.

Cigarette smoking and cardiovascular disease incidence and all-cause mortality: the modifying role of diet quality

BACKGROUND

This study examines the potential long-term joint association between smoking and diet quality as modifiable risk factors concerning cardiovascular diseases (CVDs) incidence and all-cause mortality among current and former smokers.

METHODS

The study followed 955 smokers from the third and fourth examinations of the Tehran Lipid and Glucose Study to March 2018. Dietary data was collected using a food frequency questionnaire. Three diet quality indices (DQIs) were computed at baseline: DQI-international (DQI-I), DQI-revised (DQI-R), and Mediterranean-DQI (Med-DQI). Cox proportional hazards regression models were used to determine the HR (95% CI) of the joint association between smoking and diet quality among heavy and light smokers, based on the number of cigarettes per day and pack-years, as well as between current and former smokers based on smoking habits.

RESULTS

Over a follow-up period of almost eight years, 94 cases of CVDs (9.80%) and 40 cases of mortality (4.20%) were documented. The lower diet quality based on the Med-DQI was associated with a higher risk of mortality among current smokers (HR:3.45; 95%CI:1.12, 10.57). Light smokers with good diet quality, compared to heavy smokers with poor diet quality, had a lower risk of CVDs incident (HR:0.35; 95%CI: 0.15, 0.83) and all-cause mortality (HR:0.20; 95%CI:0.05, 0.77). Current smokers with good DQI had a lower risk of mortality compared to current smokers with poor DQI (HR:0.26; 95%CI:0.08, 0.80). However, this lower risk was more significant in former smokers with good DQI (HR:0.10; 95%CI:0.02, 0.45).

CONCLUSIONS

Light and former smokers had a lower risk of developing CVDs and experiencing mortality. However, when coupled with a high-quality diet, this protective effect is even more pronounced.

Tobacco smoking and diabetes. A comparative survey among diabetologists and smoking cessation specialists

AIMS

Because tobacco smoking is a major risk factor of mortality in diabetes and guidelines suggest evaluating smoking behavior among individuals with diabetes and helping smokers quit, we aimed to assess knowledge about the tobacco smoking - diabetes relationship among diabetologists and smoking cessation specialists (SCS).

METHODS

An online cross sectional survey was conceived by the Working Group on Smoking and Diabetes, France. The questionnaire was tested by the members of the Working Group and deemed to be completed in less than 5 min. Only questions receiving the highest number of approval ratings were kept for the survey. The questionnaire was sent to all members of the French Language Society of Diabetes (Société Francophone du Diabète, SFD), N = 969 and the French Language Society on Tobacco (Société Francophone de Tabacologie, SFT), N = 307. The mailing lists of members were obtained with the previous agreement of the societies' board.

RESULTS

225 diabetologists and 97 SCS (response rate 23.2% and 31.5%, respectively) completed the questionnaire. Over 90% of the diabetologists reported recording smoking status of their patients. Although diabetologists were aware that smoking increases all-cause mortality of individuals with diabetes, only 29.3% were aware that smoking is a risk factor for type 2 diabetes (76.3% among SCS), for poor glycemic control: 32.9% (86.6% among SCS). Significantly less diabetologists (64%) than SCS (76.3%) were aware of smoking being a risk factor for microangiopathy. More diabetologists considered that smoking cessation is more important than optimizing glycemic control among individuals with type 2 (69.3%) than among those with type 1 diabetes (47.1%). Few diabetologists (11.1%) and SCS (14.4%) reported to be trained for smoking cessation among persons with diabetes.

CONCLUSION

Specific knowledge about the negative tobacco smoking - diabetes association seems to be insufficient among French diabetologists. Diabetologists but also other health care professionals should be trained to help individuals with diabetes who smoke to quit smoking.

Factors Influencing Hypoglycemia in Type 2 Diabetes Mellitus Outpatients with State Health Insurance at Regional General Hospitals in Jakarta, Indonesia

BACKGROUND

Hypoglycemia is an acute episode that can lead to death in patients with diabetes mellitus (DM). This condition is preventable with patient education, and identifying factors influencing their occurrence is essential to creating effective and efficient education. It also leads to prevention and control by re-organizing the service system and diabetes policies. This study aimed to determine factors contributing to hypoglycemic episodes in type 2 DM outpatients covered by the state-provided Jaminan Kesehatan Nasional (JKN) health insurance.

METHODS

The study used a cross-sectional design and collected data from five regional general hospitals in Jakarta, Indonesia. The outpatients were sampled consecutively from two hospitals in September-November 2021, one in January-March 2022, and two others in April-June 2023. Interviews produced primary data related to experienced hypoglycemic episodes, and medical records provided secondary data on patients' clinical characteristics and treatments. Binary logistic regression analysis was employed to process the contributing factors statistically.

RESULTS

From 501 patients who met the inclusion and exclusion criteria, it was found that the prevalence of hypoglycemia was 53.3%. Factors that significantly increased hypoglycemic risk (p < 0.05) were high HbA1c levels (OR 1.9; 95% CI 1.2-2.9), comorbidities (OR 1.6; 95% CI 1.1-2.4), insulin/sulfonylurea therapy (OR 2; 95% CI 1-4), non-smoking habit (OR 2.2; 95% CI 1.3-3.6) and physically active lifestyle (OR 1.8; 95% CI 1.2-2.6).

CONCLUSION

The prevalence of hypoglycemia in type 2 diabetes mellitus (DM) outpatients with the state-provided health insurance Jaminan Kesehatan Nasional (JKN) at general hospitals in Jakarta is high. The diabetes self-management education (DSME) services provided by health professionals for these outpatients must be further improved.

Ethylene oxide exposure increases impaired glucose metabolism in the US general population: a national cross-sectional study

BACKGROUND

Current experimental evidence supports that ethylene oxide (EO) exposure-related pathophysiologies may affect glucose metabolism, but few population-based studies have explored the potential links.

METHODS

This study used cross-sectional data from 15560 participants in the National Health and Nutrition Examination Survey (NHANES) from 2017 to 2020. EO exposure levels were calculated by testing hemoglobin adducts of EO (HbEO) via a modified Edman reaction. We focused on the association of EO exposure with prediabetes and diabetes as well as indicators of impaired glucose metabolism and further analyzed the potential pathogenic mechanisms. Statistics included logistic regression, generalized additive model fitting, penalized spline method, two-piecewise linear regression, recursive algorithm, mediation analysis, and Pearson's analysis.

RESULTS

EO exposure was associated with changes in glucose metabolic indicators and increased prevalence of prediabetes and diabetes, showing age-consistency and being more pronounced in obese and non-smoking populations. For each one pmol/g Hb, one SD, or two-fold SD increase in log2-HbEO, the risk of prediabetes increased by 12%, 16%, and 33%, with an increased risk of diabetes by 18%, 26%, and 61%, respectively. Dose-response curves revealed that this positive correlation was approximately linear with prediabetes and "J" shaped with diabetes. When log2-HbEO > 8.03 pmol/g Hb, the risk of diabetes would be further increased. Pearson's correlation revealed that EO exposure was associated with reduced fasting insulin and elevated HbA1c in the prediabetic stage. While in the diabetes stage, EO exposure was correlated with elevated fasting glucose, HbA1c, and HOMA-IR, suggesting an exacerbation of diabetes progression by EO exposure. A potential mechanism that the early stages of impaired glucose metabolism may be initiated by EO-related inflammation and oxidative stress damaging pancreatic β-cells, resulting in decreased insulin secretion. These speculations were partially supported by mediation analysis and mediators' Pearson analysis.

CONCLUSION

Elevated ethylene oxide exposure increases the incidence of impaired glucose metabolism in the general U.S. population and a potential intervention may be to effectively suppress inflammation and oxidative stress imbalances.

Influence of Diabetes Mellitus and Smoking on Pro- and Anti-Inflammatory Cytokine Profiles in Gingival Crevicular Fluid

Smoking and diabetes mellitus have been recognized as significant modifying factors of the evolution of periodontitis, being considered at the moment as descriptive factors in the periodontitis grading system. The purpose of this study was to assess the consequence of smoking, type 2 diabetes, and the combination of these two factors on clinical periodontal parameters, on the levels of gingival crevicular fluid (GCF), and also on ratios of pro-inflammatory and anti-inflammatory cytokines by using a commercially available kit-based multiplex fluorescent immunoassay. The study was carried out on 124 volunteers (control (C) group = 29, diabetes mellitus (DM) group = 32, smoking (S) group = 31, and S + DM group = 32). Total mean bleeding on probing was significantly lower in the S and S + DM groups, compared to that of the other groups (p < 0.05). Total amounts of TGF-β, MIP-1α, IL-6, IL-2, and IL-17 were significantly increased in the periodontally healthy sites of diabetes patients (p < 0.05), compared to those of the controls. Systemically healthy smoking patients had higher values of GM-CSF, TGF-β, IL-4, TNF-α, IL-5, and IL-7, while diabetic smoking patients showed higher values of IL-4, TGF-β, and MIP-1α. In smoking and systemically healthy patients, IL-23, IL-7, and IL-12 showed increased concentrations, while concentrations of TGF-β, MIP-1α, IL-2, IL-7, IL-12, IL-17, IL-21, and IL-23 were higher in smoking DM patients. In conclusion, in our study, diabetes mellitus induced a general pro-inflammatory state, while smoking mainly stimulated immunosuppression in the periodontal tissues of periodontitis subjects.

Nicotine exacerbates diabetic nephropathy through upregulation of Grem1 expression

BACKGROUND

Diabetic nephropathy (DN) is a major complication of diabetes mellitus. Clinical reports indicate that smoking is a significant risk factor for chronic kidney disease, and the tobacco epidemic exacerbates kidney damage in patients with DN. However, the underlying molecular mechanisms remain unclear.

METHOD

In the present study, we used a diabetic mouse model to investigate the molecular mechanisms for nicotine-exacerbated DN. Twelve-week-old female mice were injected with streptozotocin (STZ) to establish a hyperglycemic diabetic model. After four months, the control and hyperglycemic diabetic mice were further divided into four groups (control, nicotine, diabetic mellitus, nicotine + diabetic mellitus) by intraperitoneal injection of nicotine or PBS. After two months, urine and blood were collected for kidney injury assay, and renal tissues were harvested for further molecular assays using RNA-seq analysis, real-time PCR, Western blot, and immunohistochemistry. In vitro studies, we used siRNA to suppress Grem1 expression in human podocytes. Then we treated them with nicotine and high glucose to compare podocyte injury.

RESULT

Nicotine administration alone did not cause apparent kidney injury, but it significantly increased hyperglycemia-induced albuminuria, BUN, plasma creatinine, and the kidney tissue mRNA expression of KIM-1 and NGAL. Results from RNA-seq analysis, real-time PCR, Western blot, and immunohistochemistry analysis revealed that, compared to hyperglycemia or nicotine alone, the combination of nicotine treatment and hyperglycemia significantly increased the expression of Grem1 and worsened DN. In vitro experiments, suppression of Grem1 expression attenuated nicotine-exacerbated podocyte injury.

CONCLUSION

Grem1 plays a vital role in nicotine-exacerbated DN. Grem1 may be a potential therapeutic target for chronic smokers with DN.

Prevalence of diabetes in the USA from the perspective of demographic characteristics, physical indicators and living habits based on NHANES 2009-2018

Objective

To determine differences in DM in the U.S. population according to demographic characteristics, physical indicators and living habits.

Methods

23 546 participants in the 2009 to 2018 National Health and Nutrition Examination Survey (NHANES) who were 20 year of age or older and not pregnant. All analyses used weighted samples and considered the stratification and clustering of the design. Specific indicators include length of leg (cm), BMI (kg/cm2), TCHOL (mg/dL), fasting plasma glucose (mg/dL) and comparison of means and the proportion of participants with DM.

Results

The prevalence of DM in the USA has been rising modestly in the past decade, and were consistent and robust for the observed differences in age, sex, and ethnicity. Compared with white participants, black participants and Mexican-American were both more likely (P<0.001) to have diabetes: 14.6% (CI, 13.6% to 15.6%) among black participants, 10.6% (CI, 9.9% to 11.3%) among white participants, and 13.5% (CI, 11.9% to 15.2%) among Mexican-American participants. The prevalence of diabetes is increasing with age, males peaked around the 60s, and women around the 70s. The overall mean leg length and TCHOL was lower in diabetics than in non-diabetics (1.07 cm, 18.67 mg/dL, respectively), while mean BMI were higher in diabetics than in non-diabetics (4.27 kg/cm2). DM had the greatest effect on decline of TCHOL in white participants (23.6 mg/dL), less of an effect in black participants (9.67 mg/dL), and the least effect in Mexican-American participants (8.25 mg/dL). Notably, smoking had great effect on percent increment of DM in whites (0.2%), and have little effect on black and Mexican-Americans.

Conclusions

DM is more common in the general population than might be clinically recognized, and the prevalence of DM was associated to varying degrees with many indicators of demographic characteristics, physical indicators, and living habits. These indicators should be linked with medical resource allocation and scientific treatment methods to comprehensively implement the treatment of DM.

Risk Factors of Severe COVID-19: A Review of Host, Viral and Environmental Factors

The clinical course and outcome of COVID-19 are highly variable, ranging from asymptomatic infections to severe disease and death. Understanding the risk factors of severe COVID-19 is relevant both in the clinical setting and at the epidemiological level. Here, we provide an overview of host, viral and environmental factors that have been shown or (in some cases) hypothesized to be associated with severe clinical outcomes. The factors considered in detail include the age and frailty, genetic polymorphisms, biological sex (and pregnancy), co- and superinfections, non-communicable comorbidities, immunological history, microbiota, and lifestyle of the patient; viral genetic variation and infecting dose; socioeconomic factors; and air pollution. For each category, we compile (sometimes conflicting) evidence for the association of the factor with COVID-19 outcomes (including the strength of the effect) and outline possible action mechanisms. We also discuss the complex interactions between the various risk factors.

Diabetes Prevention and Measures to Ensuring a Healthy Lifestyle during COVID-19 Pandemic and after

The incidence of diabetes mellitus (DM) is increasing exponentially globally, with 90% of the confirmed cases being type 2 DM. The global incidence of DM is expected to increase by 48% during 2017-2045. The coronavirus disease 2019 (COVID-19) pandemic continues to have a massive impact on human health, causing sudden lifestyle changes through quarantine measures, such as lockdown, social distancing, various curfews, and isolation at home. This in turn might increase the risk of developing numerous chronic diseases, such as DM, obesity, and cardiovascular diseases, which increase the severity of COVID-19. To this end, we performed a comprehensive review to determine viable measures for the prevention of DM and its subsequent upsurge globally. Additionally, we have determined strategies that should be adopted globally to ensure a healthy lifestyle during the COVID-19 pandemic and later.

Associations of Chronic Diabetes Complications and Cardiovascular Risk with the Risk of Obstructive Sleep Apnea in Patients with Type 2 Diabetes

Background: Type 2 diabetes mellitus (T2DM) is associated with increased mortality and morbidity, including cardiovascular diseases and obstructive sleep apnea (OSA). The aim of this study was to assess the associations between cardiovascular risk, chronic diabetes complications and the risk of OSA in adult patients with T2DM. Methods: The study included 529 patients with T2DM in whom moderate-to-severe OSA risk was assessed using the STOP-Bang questionnaire, dividing the subjects into two groups: group 1: STOP-Bang score <5, and group 2: STOP-Bang score ≥5, respectively. In all the subjects, cardiovascular risk was assessed using the UKPDS risk engine. Statistical analysis was performed using SPSS 26.0, the results being statistically significant if p value was <0.05. Results: 59% of the subjects scored ≥5 on the STOP-Bang questionnaire. We recorded statistically significant differences between the two groups regarding diabetes duration, HbA1c, HOMA-IR, albuminuria, as well as cardiovascular risk at 10 years for both coronary heart disease (CHD) and stroke (p < 0.05). Furthermore, through logistic regression, adjusting for confounding factors, we demonstrated that the STOP-Bang score ≥ 5 is a risk factor for 10-year fatal and nonfatal CHD risk. Conclusions: It is extremely important to screen and diagnose OSA in patients with T2DM, in order to improve the primary and secondary prevention of cardiovascular events in these patients.

Nicotine aggravates vascular adiponectin resistance via ubiquitin-mediated adiponectin receptor degradation in diabetic Apolipoprotein E knockout mouse

There is limited and discordant evidence on the role of nicotine in diabetic vascular disease. Exacerbated endothelial cell dysregulation in smokers with diabetes is associated with the disrupted adipose function. Adipokines possess vascular protective, anti-inflammatory, and anti-diabetic properties. However, whether and how nicotine primes and aggravates diabetic vascular disorders remain uncertain. In this study, we evaluated the alteration of adiponectin (APN) level in high-fat diet (HFD) mice with nicotine (NIC) administration. The vascular pathophysiological response was evaluated with vascular ring assay. Confocal and co-immunoprecipitation analysis were applied to identify the signal interaction and transduction. These results indicated that the circulating APN level in nicotine-administrated diabetic Apolipoprotein E-deficient (ApoE^−/−) mice was elevated in advance of 2 weeks of diabetic ApoE^−/− mice. NIC and NIC addition in HFD groups (NIC + HFD) reduced the vascular relaxation and signaling response to APN at 6 weeks. Mechanistically, APN receptor 1 (AdipoR1) level was decreased in NIC and further significantly reduced in NIC + HFD group at 6 weeks, while elevated suppressor of cytokine signaling 3 (SOCS3) expression was induced by NIC and further augmented in NIC + HFD group. Additionally, nicotine provoked SOCS3, degraded AdipoR1, and attenuated APN-activated ERK1/2 in the presence of high glucose and high lipid (HG/HL) in human umbilical vein endothelial cells (HUVECs). MG132 (proteasome inhibitor) administration manifested that AdipoR1 was ubiquitinated, while inhibited SOCS3 rescued the reduced AdipoR1. In summary, this study demonstrated for the first time that nicotine primed vascular APN resistance via SOCS3-mediated degradation of ubiquitinated AdipoR1, accelerating diabetic endothelial dysfunction. This discovery provides a potential therapeutic target for preventing nicotine-accelerated diabetic vascular dysfunction.

Risk of Typical Diabetes-Associated Complications in Different Clusters of Diabetic Patients: Analysis of Nine Risk Factors

Objectives: Diabetic patients are often diagnosed with several comorbidities. The aim of the present study was to investigate the relationship between different combinations of risk factors and complications in diabetic patients. Research design and methods: We used a longitudinal, population-wide dataset of patients with hospital diagnoses and identified all patients (n = 195,575) receiving a diagnosis of diabetes in the observation period from 2003–2014. We defined nine ICD-10-codes as risk factors and 16 ICD-10 codes as complications. Using a computational algorithm, cohort patients were assigned to clusters based on the risk factors they were diagnosed with. The clusters were defined so that the patients assigned to them developed similar complications. Complication risk was quantified in terms of relative risk (RR) compared with healthy control patients. Results: We identified five clusters associated with an increased risk of complications. A combined diagnosis of arterial hypertension (aHTN) and dyslipidemia was shared by all clusters and expressed a baseline of increased risk. Additional diagnosis of (1) smoking, (2) depression, (3) liver disease, or (4) obesity made up the other four clusters and further increased the risk of complications. Cluster 9 (aHTN, dyslipidemia and depression) represented diabetic patients at high risk of angina pectoris “AP” (RR: 7.35, CI: 6.74–8.01), kidney disease (RR: 3.18, CI: 3.04–3.32), polyneuropathy (RR: 4.80, CI: 4.23–5.45), and stroke (RR: 4.32, CI: 3.95–4.71), whereas cluster 10 (aHTN, dyslipidemia and smoking) identified patients with the highest risk of AP (RR: 10.10, CI: 9.28–10.98), atherosclerosis (RR: 4.07, CI: 3.84–4.31), and loss of extremities (RR: 4.21, CI: 1.5–11.84) compared to the controls. Conclusions: A comorbidity of aHTN and dyslipidemia was shown to be associated with diabetic complications across all risk-clusters. This effect was amplified by a combination with either depression, smoking, obesity, or non-specific liver disease.

Reducing the smoking-related health burden in the USA through diversion to electronic cigarettes: a system dynamics simulation study

BACKGROUND

Electronic cigarettes ("e-cigarettes") have altered tobacco smoking trends, and their impacts are controversial. Given their lower risk relative to combustible tobacco, e-cigarettes have potential for harm reduction. This study presents a simulation-based analysis of an e-cigarette harm reduction policy set in the USA.

METHODS

A system dynamics simulation model was constructed, with separate aging chains representing people in different stages of use (both of combustible cigarettes and e-cigarettes). These structures interact with a policy module to close the gap between actual (simulated) and goal numbers of individuals who smoke, chosen to reduce the tobacco-attributable death rate (i.e., mostly combustible cigarette-attributable, but conservatively allowing e-cigarette-attributable deaths) to that due to all accidents in the general population. The policy is two-fold, removing existing e-liquid flavor bans and providing an informational campaign promoting e-cigarettes as a lower-risk alternative. Realistic practical implementation challenges are modeled in the policy sector, including time delays, political resistance, and budgetary limitations. Effects of e-cigarettes on tobacco smoking occur through three mechanisms: (1) diversion from ever initiating smoking; (2) reducing progression to established smoking; and (3) increasing smoking cessation. An important unintended effect of possible death from e-cigarettes was conservatively included.

RESULTS

The base-case model replicated the historical exponential decline in smoking and the exponential increase in e-cigarette use since 2010. Simulations suggest tobacco smoking could be reduced to the goal level approximately 40 years after implementation. Implementation obstacles (time delays, political resistance, and budgetary constraints) could delay and weaken the effect of the policy by up to 62% in the worst case, relative to the ideal-case scenario; however, these discrepancies substantially decreased over time in dampened oscillations as negative feedback loops stabilize the system after the one-time "shock" introduced by policy changes.

CONCLUSIONS

The simulation suggests that the promotion of e-cigarettes as a harm-reduction policy is a viable strategy, given current evidence that e-cigarettes offset or divert from smoking. Given the strong effects of implementation challenges on policy effectiveness in the short term, accurately modeling such obstacles can usefully inform policy design. Ongoing research is needed, given continuing changes in e-cigarette use prevalence, new policies being enacted for e-cigarettes, and emerging evidence for substitution effects between combustible cigarettes and e-cigarettes.

Genetic and biochemical investigation of the gamma-glutamylcyclotransferase role in predisposition to type 2 diabetes mellitus

Background. Imbalance in the system of redox homeostasis is an important link in the pathogenesis of type 2 diabetes (T2D). Gamma-glutamyl cyclotransferase is an antioxidant defense enzyme directly involved in the metabolism of glutathione, an endogenous antioxidant. The aim of the study was to examine the association of single nucleotide polymorphisms (SNP) rs38420 (G A), rs4270 (T C), rs6462210 (C T) and rs28679 (G A) in GGCT gene with the risk of developing T2D. Materials and Methods. The study included 1022 T2D patients and 1064 healthy volunteers. Genotyping of GGCT gene loci was performed using iPLEX technology on a MassARRAY Analyzer 4 genome time-of-flight mass spectrometer (Agena Bioscience). Results. As a result, we identified for the first time the association of SNP rs4270 in the GGCT gene with the risk of T2D in the Russian population. We have also established genetic and environmental interactions associated with predisposition to the disease: protective effect of gamma-glutamyl cyclotransferase gene was observed only in non-smokers under condition of daily consumption of fresh vegetables and fruits, whereas in persons with insufficient consumption of plant foods, as well as in all smoking patients protective effect of GGCT was not observed. In patients with T2D, the level of hydrogen peroxide and glutathione monomer was sharply increased compared to the controls. SNP rs4270 was also found to be associated with elevated levels of reduced glutathione in the plasma of type 2 diabetics. Conclusion. Thus, for the first time it was established that polymorphic locus rs4270 in the GGCT gene is associated with a predisposition to T2D, but its relationship with the disease is modulated by smoking and fresh plant foods consumption.

Prevalence and associated factors of vascular complications among inpatients with type 2 diabetes: A retrospective database study at a tertiary care department, Ningbo, China

To determine the prevalence of vascular complications among inpatients with type 2 diabetes mellitus (T2DM) and factors independently associated with vascular complications in a tertiary care department in Ningbo, China, the authors conducted a cross-sectional study using an existing computerised medical records database. A total of 3370 adult patients with T2DM were admitted to this tertiary care department for the first time between 2012 and 2017. Patients were categorised as those (1) with at least one vascular complication, (2) with at least one microvascular complication, and (3) with at least one macrovascular complication. Over 5 years, the prevalence of vascular, microvascular, and macrovascular complications among inpatients with T2DM was 73.2%, 57.5%, and 51.4%, respectively. The odds of vascular, microvascular, and macrovascular complications increased with age and were higher in patients with hypertension. The odds of vascular and microvascular complications were higher in single, divorced, or widowed patients, patients with T2DM for a long time, and patients on advanced T2DM therapeutic regimen. The odds of vascular and macrovascular complications were lower in women. The odds of microvascular complications decreased with education. The odds of macrovascular complications were higher in smokers. In conclusion, in the tertiary care department, more than half of inpatients with T2DM had vascular complications, and factors independently associated with vascular complications were identified. The study findings could be used in future interventional studies to prevent and manage vascular complications among these patients.

Combined lifestyle factors and risk of incident type 2 diabetes and prognosis among individuals with type 2 diabetes: a systematic review and meta-analysis of prospective cohort studies

AIMS/HYPOTHESIS

A healthy lifestyle has been widely recommended for the prevention and management of type 2 diabetes. However, no systematic review has summarised the relationship between combined lifestyle factors (including, but not limited to, smoking, alcohol drinking, physical activity, diet and being overweight or obese) and incident type 2 diabetes and risk of health outcomes among diabetic individuals.

METHODS

EMBASE and PubMed were searched up to April 2019 without language restrictions. References included in articles in relevant publications were also screened. Cohort studies investigating the combined associations of at least three lifestyle factors with incident type 2 diabetes and health outcomes among diabetic individuals were included. Reviewers were paired and independently screened studies, extracted data and evaluated study quality. Random-effects models were used to calculate summary HRs. Heterogeneity and publication bias tests were also conducted.

RESULTS

Compared with participants considered to have the least-healthy lifestyle, those with the healthiest lifestyle had a 75% lower risk of incident diabetes (HR 0.25 [95% CI 0.18, 0.35]; 14 studies with approximately 1 million participants). The associations were largely consistent and significant among individuals from different socioeconomic backgrounds and baseline characteristics. Among individuals with type 2 diabetes (10 studies with 34,385 participants), the HRs (95% CIs) were 0.44 (0.33, 0.60) for all-cause death, 0.51 (0.30, 0.86) for cardiovascular death, 0.69 (0.47, 1.00) for cancer death and 0.48 (0.37, 0.63) for incident cardiovascular disease when comparing the healthiest lifestyle with the least-healthy lifestyle.

CONCLUSIONS/INTERPRETATION

Adoption of a healthy lifestyle is associated with substantial risk reduction in type 2 diabetes and long-term adverse outcomes among diabetic individuals. Tackling multiple risk factors, instead of concentrating on one certain lifestyle factor, should be the cornerstone for reducing the global burden of type 2 diabetes.

Food consumption and glycemic testing of adults and elderly diabetic patients from Public Health: A systematic review of assessment methods

AIMS

To map and discuss the different methods used to assess food consumption and glycemic testing of adults and elderly diabetic patients from Public Health.

MATERIALS AND METHODS

A total of 710 records were identified by searching databases integrated by the Virtual Health Library website, between September and October 2017. The Newcastle Ottawa scale was used for study quality assessment. A total of 8 studies met inclusion criteria for analysis. Study characteristics were extracted and synthesized to generate comparisons.

RESULTS

Food consumption was evaluated by Food Frequency Questionnaire, 24-hour Dietary Recall, Eating Attitudes Test (EAT-26), Questionnaire On Eating and Weight Patterns (QEWP-R), and questioning the salt intake. Glucose testing methods included Postprandial Glucose, Glycated Hemoglobin (HbA1C), fasting glucose, and self-reported diabetes.

CONCLUSIONS

Most methods that access food consumption use single questionnaires, which are easy to administer and yield easily interpreted results. For glycemic testing, the majority used are conventional methods.

Cigarette smoking, type 2 diabetes mellitus, and glucagon-like peptide-1 receptor agonists as a potential treatment for smokers with diabetes: An integrative review

Tobacco use disorder (TUD), in particular cigarette smoking, contributes significantly to the macro- and micro-vascular complications of type 2 diabetes mellitus (DM). Persons with DM who regularly use tobacco products are twice as likely to experience mortality and negative health outcomes. Despite these risks, TUD remains prevalent in persons with DM. The objective of this integrative review is to summarize the relationship between TUD and DM based on epidemiological and preclinical biological evidence. We conclude with a review of the literature on the glucagon-like peptide-1 (GLP-1) as a potential treatment target for addressing comorbid TUD in smokers with DM.

Insulin resistance (HOMA-IR) and body fat (%) are associated to low intake of fruit and vegetables in Swedish, young adults: the cross-sectional lifestyle, biomarkers and atherosclerosis study

Background

In the cross-sectional Lifestyle, Biomarkers, and Atherosclerosis study (LBA study) we have previously reported a high prevalence (15%) of homeostasis model assessment of insulin resistance (HOMA-IR) in Swedish, young adults. The aim of the present study was to report the dietary habits of subjects 18.0–25.9 years, and to associate dietary habits to body composition measures; body mass index (BMI), body fat (%), waist circumference and to HOMA-IR, a risk marker for diabetes.

Method

The subjects (577 women and 257 men) filled in a validated computerized food frequency questionnaire. The questionnaire was based on recommendations from the Swedish national food administration. To associate the dietary habits to BMI, body fat (%), waist circumference and to HOMA-IR the subjects were divided in two groups. Subjects “eating as recommended” and subjects “eating less/more than recommended”.

Results

Recommended intake of fish and seafood (P < 0.05), fruit and vegetables (P < 0.001), and sweets (P < 0.05) were associated to lower HOMA-IR values compared to subjects not eating as recommended. When split by sex no difference in HOMA-IR was detected with recommended intake of fish and seafood, but women eating fish and seafood as recommended had less body fat (%) (P < 0.05) compared to women not eating fish and seafood as recommended. Recommended intake of fruit and vegetables was associated to lower HOMA-IR in women (P < 0.01), and in women and men to less body fat (%) (P < 0.05) compared to subjects not eating the recommended 500 g of fruit and vegetables per day. Both women and men with higher consumption of sweets than recommended had higher HOMA-IR (P < 0.05), but no difference in the body composition measures BMI, body fat (%) or waist circumference compared to subjects eating sweets as recommended.

Conclusion

The results highlight the importance of reducing a high intake of sweets and to increase the intake of fish, fruit and vegetables, in young adults, to reduce the risk of future diabetes.

Complications of type 2 diabetes mellitus in Ramallah and al-Bireh: The Palestinian Diabetes Complications and Control Study (PDCCS)

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a growing pandemic that will lead, if not managed and controlled, to frequent complications, poor quality of life, and high rates of disability and death. Little is known about T2DM complications in Palestine. The aim of this study is to estimate the prevalence of T2DM complications in Ramallah and al-Bireh governorate of Palestine.

METHODS

The study was conducted in eleven primary healthcare clinics offering services for persons with T2DM. Macrovascular complications were assessed using the Diabetes complication index. Microvascular complications were measured by physical examinations and laboratory tests. Questionnaires, laboratory tests, and physical examinations were used to assess socio-demographic characteristics, co-morbidities and other risk factors.

RESULTS

517 adult men and nonpregnant women participated in the study (166 men, 351 women). The response rate was 84%. Mean age and mean duration of diabetes were 58.1 and 9.4 years respectively. Prevalence of diagnosed microvascular and macrovascular complications was 67.2% and 28.6% respectively. 78.2% of the participants had poor glycemic control (HbA1c≥7.0%).

CONCLUSION

Significant proportions of persons with T2DM had macro- and microvascular complications and poor metabolic control. These findings are important for policy development and the planning of health services.

Exploring the association between polycyclic aromatic hydrocarbons and diabetes among adults in the United States

OBJECTIVE

To explore the association between polycyclic aromatic hydrocarbons (PAHs) and diabetes and to determine whether effects are heterogeneous when examined by body mass index (BMI).

METHODS

Cross-sectional data from 8664 participants were analyzed from the National Health and Nutrition Examination Survey for years 2005-2014. Multivariable logistic regression was used to explore the association between urinary biomarkers of PAHs and diabetes. All models were adjusted for age, sex, race, poverty-income ratio, and serum cotinine.

RESULTS

When compared with the lowest quintiles of exposure, the highest quintiles of exposure to 2-hydroxynaphthalene, 2-hydroxyfluorene, 9-hydroxyfluorene, 2-hydroxyphenanthrene, and a summed variable of all low molecular weight PAHs (aOR = 1.73; 95% CI: 1.17-2.55) showed a positive association with diabetes. Stratified analyses by BMI indicated that the positive association between PAHs and diabetes was found among both normal weight and obese participants.

CONCLUSIONS

High levels of exposure to PAHs are positively associated with diabetes in the U.S. general population and these effects are modified by BMI. These findings suggest the importance of strong environmental regulation of PAHs to protect population health.

Nicotine enhances mesangial cell proliferation and fibronectin production in high glucose milieu via activation of Wnt/β-catenin pathway

Diabetic nephropathy (DN) is a major complication of diabetes mellitus. Clinic reports indicate cigarette smoking is an independent risk factor for chronic kidney disease including DN; however, the underlying molecular mechanisms are not clear. Recent studies have demonstrated that nicotine, one of the active compounds in cigarette smoke, contributes to the pathogenesis of the cigarette smoking-accelerated chronic kidney disease. One of the characteristics of DN is the expansion of mesangium, a precursor of glomerular sclerosis. In the present study, we examined the involvement of Wnt/β-catenin pathway in nicotine-mediated mesangial cell growth in high glucose milieu. Primary human renal mesangial cells were treated with nicotine in the presence of normal (5 mM) or high glucose (30 mM) followed by evaluation for cell growth. In the presence of normal glucose, nicotine increased both the total cell numbers and Ki-67 positive cell ratio, indicating that nicotine stimulated mesangial cell proliferation. Although high glucose itself also stimulated mesangial cell proliferation, nicotine further enhanced the mitogenic effect of high glucose. Similarly, nicotine increased the expression of Wnts, β-catenin, and fibronectin in normal glucose medium, but further increased mesangial cell expression of these proteins in high glucose milieu. Pharmacological inhibition or genetic knockdown of β-catenin activity or expression with specific inhibitor FH535 or siRNA significantly impaired the nicotine/glucose-stimulated cell proliferation and fibronectin production. We conclude that nicotine may enhance renal mesangial cell proliferation and fibronectin production under high glucose milieus partly through activating Wnt/β-catenin pathway. Our study provides insight into molecular mechanisms involved in DN.

Smoke exposure and cardio-metabolic profile in youth with type 1 diabetes

BACKGROUND

To evaluate the relationship between smoking and metabolic parameters in patients affected by type 1 diabetes (T1D).

PATIENTS AND METHODS

We enrolled 104 children and young adults (50 females and 54 males) with T1D (aged 16.4 ± 8.6 years). The subjects were divided into three groups according to their smoking habits: no smoking (NS), passive smoking (PS), active smoking (AS). The physical examination of the participants included nutritional status assessment by anthropometry and pubertal stage according to Marshall and Tanner as well as blood pressure measurement. In all patients, metabolic blood assays including fasting blood glucose, insulin, total cholesterol, high-density lipoprotein cholesterol, and triglycerides were measured. Insulin resistance was determined by glucose disposal rate (eGDR). Physical activity was also recorded.

RESULTS

Significant differences in biochemical and functional parameters among the three groups were demonstrated, in particular for systolic (p = 0.002) and diastolic pressure (p = 0.02) and eGDR (p = 0.039). No differences in daily insulin dose (p = 0.75) and glycated hemoglobin (p = 0.39) were observed. AS group had significantly higher blood pressure (p < 0.05) and lower eGDR (p ≤ 0.001) compared to NS and PS. Significant difference was also detected between PS and NS in systolic and diastolic (p = 0.02) pressure and eGDR (p = 0.01). In a multivariable model adjusted for age, gender, BMI and physical activity, smoking habits did not maintain any independent association with metabolic parameters.

CONCLUSION

This is the first study in a Mediterranean population, looking at tobacco smoke and cardio-metabolic factors in youth with T1D. The relationship between smoking and unfavorable metabolic profile was demonstrated. On the basis of these findings, smoking tobacco should be considered an important modifiable risk factor for young patients with diabetes mellitus, highlighting the need for intensified smoking prevention and cessation programs.