Ethnic disparities in the association of impaired fasting glucose with the 10-year cumulative incidence of type 2 diabetes

Lipoprotein Insulin Resistance Index: A Simple, Accurate Method for Assessing Insulin Resistance in South Asians

Context

Identification of insulin resistance (IR) in South Asians, who are at a higher risk for type 2 diabetes, is important. Lack of standardization of insulin assays limits the clinical use of insulin-based surrogate indices. The lipoprotein insulin resistance index (LP-IR), a metabolomic marker, reflects the lipoprotein abnormalities observed in IR. The reliability of the LP-IR index in South Asians is unknown.

Objective

We evaluated the predictive accuracy of LP-IR compared with other IR surrogate indices in South Asians.

Methods

In a cross-sectional study (n = 55), we used calibration model analysis to assess the ability of the LP-IR score and other simple surrogate indices (Homeostatic Model Assessment of Insulin Resistance, Quantitative insulin sensitivity check index, Adipose insulin resistance index, and Matsuda Index) to predict insulin sensitivity (S_I) derived from the reference frequently sampled intravenous glucose tolerance test. LP-IR index was derived from lipoprotein particle concentrations and sizes measured by nuclear magnetic resonance spectroscopy. Predictive accuracy was determined by root mean squared error (RMSE) of prediction and leave-one-out cross-validation type RMSE of prediction (CVPE). The optimal cut-off of the LP-IR index was determined by the area under the receiver operating characteristic curve (AUROC) and the Youden index.

Results

The simple surrogate indices showed moderate correlations with S_I (r = 0.53-0.69, P < .0001). CVPE and RMSE were not different in any of the surrogate indices when compared with LP-IR. The AUROC was 0.77 (95% CI 0.64-0.89). The optimal cut-off for IR in South Asians was LP-IR >48 (sensitivity: 75%, specificity: 70%).

Conclusion

The LP-IR index is a simple, accurate, and clinically useful test to assess IR in South Asians.

Ethnic differences in urinary monocyte chemoattractant protein-1 and heparanase-1 levels in individuals with type 2 diabetes: the HELIUS study

INTRODUCTION

We aimed to investigate ethnic differences in two urinary inflammatory markers in participants with type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

We included 55 Dutch, 127 South-Asian Surinamese, 92 African Surinamese, 62 Ghanaian, 74 Turkish and 88 Moroccan origin participants with T2DM from the HEalthy LIfe in an Urban Setting study. Using linear regression analyses, we investigated differences in urinary monocyte chemoattractant protein-1 (MCP-1) and heparanase-1 (HPSE-1) levels across ethnic minorities compared with Dutch. Associations between the urinary markers and albuminuria (albumin:creatinine ratio (ACR)) was investigated per ethnicity.

RESULTS

Urinary MCP-1 levels were higher in the Moroccan participants (0.15 log ng/mmol, 95% CI 0.05 to 0.26) compared with Dutch after multiple adjustments. Urinary HPSE-1 levels were lower in the African Surinamese and Ghanaian participants compared with the Dutch, with a difference of -0.16 log mU/mmol (95% CI -0.29 to -0.02) in African Surinamese and -0.16 log mU/mmol (95% CI -0.31 to -0.00) in Ghanaian after multiple adjustments. In all ethnic groups except the Dutch and Ghanaian participants, MCP-1 was associated with ACR. This association remained strongest after multiple adjustment in South-Asian and African Surinamese participants, with an increase in log ACR of 1.03% (95% CI 0.58 to 1.47) and 1.23% (95% CI 0.52 to 1.94) if log MCP-1 increased 1%. Only in the Dutch participants, an association between HPSE-1 and ACR was found, with increase in log ACR of 0.40% (95% CI 0.04 to 0.76) if log HPSE-1 increased 1%.

CONCLUSIONS

We found ethnic differences in urinary MCP-1 and HPSE-1 levels, in a multi-ethnic cohort of participants with T2DM. In addition, we found ethnic differences in the association of MCP-1 and HPSE-1 levels with albuminuria. These findings suggest differences in renal inflammation across ethnic groups.

A randomized controlled trial of Baduanjin exercise to reduce the risk of atherosclerotic cardiovascular disease in patients with prediabetes

To investigate the effectiveness of long-term Baduanjin and aerobic training on the 10-year risk of atherosclerotic cardiovascular disease in prediabetic patients. This study was single-blind randomized controlled trial. A total of 98 participants with prediabetes were randomly divided into three groups: the BDJ (n = 34), AT (n = 32), and control (n = 32) groups. Participants in the BDJ and AT groups underwent one year of supervised group exercise, consisting of 60 min/session every other day. The primary outcomes were metabolic control and the 10-year risk of ASCVD. The secondary outcome was a change in blood glucose status. After the intervention, various metabolic indexes were significantly improved in the two exercise groups relative to the control group and baseline measurements (p < 0.05). Compared with no exercise, BDJ and AT had significant preventive and protective effects against the risk of ASCVD in patients with prediabetes (p < 0.001). The overall effects of the two exercise groups were similar (p > 0.05). Long-term BDJ training can effectively reduce the risk of type 2 diabetes mellitus (T2DM) and its cardiovascular complications in prediabetic patients. The effect of BDJ is similar to that of moderate-intensity aerobic exercise.

Global disease burden of stroke attributable to high fasting plasma glucose in 204 countries and territories from 1990 to 2019: An analysis of the Global Burden of Disease Study

BACKGROUND

High fasting plasma glucose (HFPG) is the leading risk factor contributing to the increase of stroke burden in the past three decades. However, the global distribution of stroke burden specifically attributable to HFPG was not studied in depth. Therefore, we analyzed the HFPG-attributable burden in stroke and its subtypes in 204 countries and territories from 1990 to 2019.

METHODS

Detailed data on stroke burden attributable to HFPG were obtained from the Global Burden of Disease Study 2019. The numbers and age-standardized rates of stroke disability-adjusted life years (DALYs), deaths, years lived with disability, and years of life lost between 1990 and 2019 were estimated by age, sex, and region.

RESULTS

In 2019, the age-standardized rate of DALYs (ASDR) of HFPG-attributable stroke was 354.95 per 100 000 population, among which 49.0% was from ischemic stroke, 44.3% from intracerebral hemorrhage, and 6.6% from subarachnoid hemorrhage. The ASDRs of HFPG-attributable stroke in lower sociodemographic index (SDI) regions surpassed those in higher SDI regions in the past three decades. Generally, the population aged over 50 years old accounted for 92% of stroke DALYs attributable to HFPG, and males are more susceptible to HFPG-attributable stroke than females across their lifetime.

CONCLUSIONS

Successful key population initiatives targeting HFPG may mitigate the stroke disease burden. Given the soaring population-attributable fractions of HFPG for stroke burden worldwide, each country should assess its disease burden and determine targeted prevention and control strategies.

Differences in the prevalence of intermediate hyperglycaemia and the associated incidence of type 2 diabetes mellitus by ethnicity: The HELIUS study

AIMS

We aimed to describe differences in the prevalence of intermediate hyperglycaemia (IH) between six ethnic groups. Moreover, to investigate differences in the association of the classifications of IH with the incidence of T2DM between ethnic groups.

METHODS

We included 3759 Dutch, 2826 African Surinamese, 1646 Ghanaian, 2571 Turkish, 2691 Moroccan and 1970 South Asian Surinamese origin participants of the HELIUS study. IH was measured by fasting plasma glucose (FPG) and HbA1c. We calculated age-, BMI and physical-activity-adjusted prevalence of IH by sex, and calculated age and sex-adjusted hazard ratios (HR)for the association between IH and T2DM in each ethnic group.

RESULTS

The prevalence of IH was higher among ethnic minority groups (68.6-41.7%) than the Dutch majority (34.9%). The prevalence of IH categories varied across subgroups. Combined increased FPG and HbA1c was most prevalent in South-Asian Surinamese men (27.6%, 95 %CI: 24.5-30.9%), and in Dutch women (4.2%, 95 %CI: 3.4-5.1%). The HRs for T2DM for each IH-classification did not differ significantly between ethnic groups. HRs were highest for the combined classification, e.g., HR = 8.1, 95 %CI: 2.5-26.6 in the Dutch.

CONCLUSION

We found a higher prevalence of IH in ethnic minority versus majority groups, but did not find evidence for a differential association of IH with incident T2DM.

Circulating metabolites and lipids are associated with glycaemic measures in South Asians

BACKGROUND

South Asians are at higher risk for diabetes (DM) than many other racial/ethnic groups. Circulating metabolites are measurable products of metabolic processes that may explain the aetiology of elevated risk. We characterized metabolites associated with prevalent DM and glycaemic measures in South Asians.

METHODS

We included 717 participants from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study, aged 40-84 years. We used baseline fasting serum for metabolomics and demographic, behavioural, glycaemic data from baseline and at 5 years. We performed LC-MS untargeted metabolomic and lipidomic analysis with targeted integration of known signals. Individual linear and ordinal logistic regression models were adjusted for age, sex, BMI, diet, exercise, alcohol, smoking and family history of DM followed by elastic net regression to identify metabolites most associated with the outcome.

RESULTS

There were 258 metabolites with detectable signal in >98% of samples. Thirty-four metabolites were associated with prevalent DM in an elastic net model. Predominant metabolites associated with DM were sphingomyelins, proline (OR 15.86; 95% CI 4.72, 53.31) and betaine (OR 0.03; 0.004, 0.14). Baseline tri- and di-acylglycerols [DG (18:0/16:0) (18.36; 11.79, 24.92)] were positively associated with fasting glucose and long-chain acylcarnitines [CAR 26:1 (-0.40; -0.54, -0.27)] were inversely associated with prevalent DM and HbA_1c at follow-up.

DISCUSSION

A metabolomic signature in South Asians may help determine the unique aetiology of diabetes in this high-risk ethnic group. Future work will externally validate our findings and determine the effects of modifiable risk factors for DM.

HIV and metabolic syndrome in an Ethiopian population

BACKGROUND

The global prevalence of metabolic syndrome (MS) is increasing due to lifestyle changes. Studies have found that MS is associated with human immunodeficiency virus (HIV) and antiretroviral treatment (ART), but controversies still exist on associations between HIV and MS.

AIMS

To assess associations between HIV and MS among ART-naïve HIV positive individuals compared to HIV negative individuals.

SUBJECTS AND METHODS

A cross-sectional study among ART-naïve HIV positive and HIV negative individuals recruited from HIV treatment and testing facilities in Ethiopia. Information was collected on components of MS: waist circumference, triglycerides, high-density lipoprotein cholesterol (HDL-C), blood pressure and fasting plasma glucose (FPG). Data were analysed using logistic and linear regression stratified by sex and adjusted for age, wealth and education.

RESULTS

Data from 329 HIV positive and 100 HIV negative individuals were included. HIV positive status was associated with higher odds of MS in women (OR: 3.56, 95%CI: 1.25; 10.15) (n = 292), but not in men (OR: 0.98, 95%CI: 0.22; 4.30) (n = 137), interaction: p= .11. Associations between HIV and components of MS were strongest for HDL-C among women and for FPG among men. The most prevalent components of MS in HIV positive individuals were elevated triglycerides, reduced HDL-C and elevated FPG.

CONCLUSIONS

HIV was associated with MS among ART-naïve women, suggesting that MS should be evaluated before initiating ART and monitored during treatment to identify those at risk of developing diabetes and cardiovascular disease (CVD).

Association between prediabetes and risk of all cause mortality and cardiovascular disease: updated meta-analysis

Objective

To evaluate the associations between prediabetes and the risk of all cause mortality and incident cardiovascular disease in the general population and in patients with a history of atherosclerotic cardiovascular disease.

Design

Updated meta-analysis.

Data sources

Electronic databases (PubMed, Embase, and Google Scholar) up to 25 April 2020.

Review methods

Prospective cohort studies or post hoc analysis of clinical trials were included for analysis if they reported adjusted relative risks, odds ratios, or hazard ratios of all cause mortality or cardiovascular disease for prediabetes compared with normoglycaemia. Data were extracted independently by two investigators. Random effects models were used to calculate the relative risks and 95% confidence intervals. The primary outcomes were all cause mortality and composite cardiovascular disease. The secondary outcomes were the risk of coronary heart disease and stroke.

Results

A total of 129 studies were included, involving 10 069 955 individuals for analysis. In the general population, prediabetes was associated with an increased risk of all cause mortality (relative risk 1.13, 95% confidence interval 1.10 to 1.17), composite cardiovascular disease (1.15, 1.11 to 1.18), coronary heart disease (1.16, 1.11 to 1.21), and stroke (1.14, 1.08 to 1.20) in a median follow-up time of 9.8 years. Compared with normoglycaemia, the absolute risk difference in prediabetes for all cause mortality, composite cardiovascular disease, coronary heart disease, and stroke was 7.36 (95% confidence interval 9.59 to 12.51), 8.75 (6.41 to 10.49), 6.59 (4.53 to 8.65), and 3.68 (2.10 to 5.26) per 10 000 person years, respectively. Impaired glucose tolerance carried a higher risk of all cause mortality, coronary heart disease, and stroke than impaired fasting glucose. In patients with atherosclerotic cardiovascular disease, prediabetes was associated with an increased risk of all cause mortality (relative risk 1.36, 95% confidence interval 1.21 to 1.54), composite cardiovascular disease (1.37, 1.23 to 1.53), and coronary heart disease (1.15, 1.02 to 1.29) in a median follow-up time of 3.2 years, but no difference was seen for the risk of stroke (1.05, 0.81 to 1.36). Compared with normoglycaemia, in patients with atherosclerotic cardiovascular disease, the absolute risk difference in prediabetes for all cause mortality, composite cardiovascular disease, coronary heart disease, and stroke was 66.19 (95% confidence interval 38.60 to 99.25), 189.77 (117.97 to 271.84), 40.62 (5.42 to 78.53), and 8.54 (32.43 to 61.45) per 10 000 person years, respectively. No significant heterogeneity was found for the risk of all outcomes seen for the different definitions of prediabetes in patients with atherosclerotic cardiovascular disease (all P>0.10).

Conclusions

Results indicated that prediabetes was associated with an increased risk of all cause mortality and cardiovascular disease in the general population and in patients with atherosclerotic cardiovascular disease. Screening and appropriate management of prediabetes might contribute to primary and secondary prevention of cardiovascular disease.

Association between prediabetes and risk of all cause mortality and cardiovascular disease: updated meta-analysis

OBJECTIVE

To evaluate the associations between prediabetes and the risk of all cause mortality and incident cardiovascular disease in the general population and in patients with a history of atherosclerotic cardiovascular disease.

DESIGN

Updated meta-analysis.

DATA SOURCES

Electronic databases (PubMed, Embase, and Google Scholar) up to 25 April 2020.

REVIEW METHODS

Prospective cohort studies or post hoc analysis of clinical trials were included for analysis if they reported adjusted relative risks, odds ratios, or hazard ratios of all cause mortality or cardiovascular disease for prediabetes compared with normoglycaemia. Data were extracted independently by two investigators. Random effects models were used to calculate the relative risks and 95% confidence intervals. The primary outcomes were all cause mortality and composite cardiovascular disease. The secondary outcomes were the risk of coronary heart disease and stroke.

RESULTS

A total of 129 studies were included, involving 10 069 955 individuals for analysis. In the general population, prediabetes was associated with an increased risk of all cause mortality (relative risk 1.13, 95% confidence interval 1.10 to 1.17), composite cardiovascular disease (1.15, 1.11 to 1.18), coronary heart disease (1.16, 1.11 to 1.21), and stroke (1.14, 1.08 to 1.20) in a median follow-up time of 9.8 years. Compared with normoglycaemia, the absolute risk difference in prediabetes for all cause mortality, composite cardiovascular disease, coronary heart disease, and stroke was 7.36 (95% confidence interval 9.59 to 12.51), 8.75 (6.41 to 10.49), 6.59 (4.53 to 8.65), and 3.68 (2.10 to 5.26) per 10 000 person years, respectively. Impaired glucose tolerance carried a higher risk of all cause mortality, coronary heart disease, and stroke than impaired fasting glucose. In patients with atherosclerotic cardiovascular disease, prediabetes was associated with an increased risk of all cause mortality (relative risk 1.36, 95% confidence interval 1.21 to 1.54), composite cardiovascular disease (1.37, 1.23 to 1.53), and coronary heart disease (1.15, 1.02 to 1.29) in a median follow-up time of 3.2 years, but no difference was seen for the risk of stroke (1.05, 0.81 to 1.36). Compared with normoglycaemia, in patients with atherosclerotic cardiovascular disease, the absolute risk difference in prediabetes for all cause mortality, composite cardiovascular disease, coronary heart disease, and stroke was 66.19 (95% confidence interval 38.60 to 99.25), 189.77 (117.97 to 271.84), 40.62 (5.42 to 78.53), and 8.54 (32.43 to 61.45) per 10 000 person years, respectively. No significant heterogeneity was found for the risk of all outcomes seen for the different definitions of prediabetes in patients with atherosclerotic cardiovascular disease (all P>0.10).

CONCLUSIONS

Results indicated that prediabetes was associated with an increased risk of all cause mortality and cardiovascular disease in the general population and in patients with atherosclerotic cardiovascular disease. Screening and appropriate management of prediabetes might contribute to primary and secondary prevention of cardiovascular disease.

Association between prediabetes and risk of all cause mortality and cardiovascular disease: updated meta-analysis

OBJECTIVE

To evaluate the associations between prediabetes and the risk of all cause mortality and incident cardiovascular disease in the general population and in patients with a history of atherosclerotic cardiovascular disease.

DESIGN

Updated meta-analysis.

DATA SOURCES

Electronic databases (PubMed, Embase, and Google Scholar) up to 25 April 2020.

REVIEW METHODS

Prospective cohort studies or post hoc analysis of clinical trials were included for analysis if they reported adjusted relative risks, odds ratios, or hazard ratios of all cause mortality or cardiovascular disease for prediabetes compared with normoglycaemia. Data were extracted independently by two investigators. Random effects models were used to calculate the relative risks and 95% confidence intervals. The primary outcomes were all cause mortality and composite cardiovascular disease. The secondary outcomes were the risk of coronary heart disease and stroke.

RESULTS

A total of 129 studies were included, involving 10 069 955 individuals for analysis. In the general population, prediabetes was associated with an increased risk of all cause mortality (relative risk 1.13, 95% confidence interval 1.10 to 1.17), composite cardiovascular disease (1.15, 1.11 to 1.18), coronary heart disease (1.16, 1.11 to 1.21), and stroke (1.14, 1.08 to 1.20) in a median follow-up time of 9.8 years. Compared with normoglycaemia, the absolute risk difference in prediabetes for all cause mortality, composite cardiovascular disease, coronary heart disease, and stroke was 7.36 (95% confidence interval 9.59 to 12.51), 8.75 (6.41 to 10.49), 6.59 (4.53 to 8.65), and 3.68 (2.10 to 5.26) per 10 000 person years, respectively. Impaired glucose tolerance carried a higher risk of all cause mortality, coronary heart disease, and stroke than impaired fasting glucose. In patients with atherosclerotic cardiovascular disease, prediabetes was associated with an increased risk of all cause mortality (relative risk 1.36, 95% confidence interval 1.21 to 1.54), composite cardiovascular disease (1.37, 1.23 to 1.53), and coronary heart disease (1.15, 1.02 to 1.29) in a median follow-up time of 3.2 years, but no difference was seen for the risk of stroke (1.05, 0.81 to 1.36). Compared with normoglycaemia, in patients with atherosclerotic cardiovascular disease, the absolute risk difference in prediabetes for all cause mortality, composite cardiovascular disease, coronary heart disease, and stroke was 66.19 (95% confidence interval 38.60 to 99.25), 189.77 (117.97 to 271.84), 40.62 (5.42 to 78.53), and 8.54 (32.43 to 61.45) per 10 000 person years, respectively. No significant heterogeneity was found for the risk of all outcomes seen for the different definitions of prediabetes in patients with atherosclerotic cardiovascular disease (all P>0.10).

CONCLUSIONS

Results indicated that prediabetes was associated with an increased risk of all cause mortality and cardiovascular disease in the general population and in patients with atherosclerotic cardiovascular disease. Screening and appropriate management of prediabetes might contribute to primary and secondary prevention of cardiovascular disease.

Causal Effects of Overall and Abdominal Obesity on Insulin Resistance and the Risk of Type 2 Diabetes Mellitus: A Two-Sample Mendelian Randomization Study

Overall and abdominal obesity were significantly associated with insulin resistance and type 2 diabetes mellitus (T2DM) risk in observational studies, though these associations cannot avoid the bias induced by confounding effects and reverse causation. This study aimed to test whether these associations are causal, and it compared the causal effects of overall and abdominal obesity on T2DM risk and glycemic traits by using a two-sample Mendelian randomization (MR) design. Based on summary-level statistics from genome-wide association studies, the instrumental variables for body mass index (BMI), waist-to-hip ratio (WHR), and WHR adjusted for BMI (WHRadjBMI) were extracted, and the horizontal pleiotropy was analyzed using MR-Egger regression and the MR-pleiotropy residual sum and outlier (PRESSO) method. Thereafter, by using the conventional MR method, the inverse-variance weighted method was applied to assess the causal effect of BMI, WHR, and WHRadjBMI on T2DM risk, Homeostatic model assessment of insulin resistance (HOMA-IR), fasting insulin, fasting glucose, and Hemoglobin A1c (HbA1c). A series of sensitivity analyses, including the multivariable MR (diastolic blood pressure, systolic blood pressure, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol as covariates), MR-Egger regression, weighted median, MR-PRESSO, and leave-one-out method, were conducted to test the robustness of the results from the conventional MR. Despite the existence of horizontal pleiotropy, consistent results were found in the conventional MR results and sensitivity analyses, except for the association between BMI and fasting glucose, and WHRadjBMI and fasting glucose. Each one standard deviation higher BMI was associated with an increased T2DM risk [odds ratio (OR): 2.741; 95% confidence interval (CI): 2.421-3.104], higher HbA1c [1.054; 1.04-1.068], fasting insulin [1.202; 1.173-1.231], and HOMA-IR [1.221; 1.187-1.255], similar to findings for causal effect of WHRadjBMI on T2DM risk [1.993; 1.704-2.33], HbA1c [1.061; 1.042-1.08], fasting insulin [1.102; 1.068-1.136], and HOMA-IR [1.127; 1.088-1.167]. Both BMI (P = 0.546) and WHRadjBMI (P = 0.443) were unassociated with fasting glucose in the multivariable MR analysis. In conclusion, overall and abdominal obesity have causal effects on T2DM risk and insulin resistance but no causal effect on fasting glucose. Individuals can substantially reduce their insulin resistance and T2DM risk through reduction of body fat mass and modification of body fat distribution.

Behavioral Circadian Timing System Disruptors and Incident Type 2 Diabetes in a Nonshift Working Multiethnic Population

OBJECTIVE

This study aimed to describe distributions of behavioral circadian disruptors in a free-living setting among a nonshift working multiethnic population, estimate the associated risk of type 2 diabetes (T2D), and determine whether disruptors account for ethnic differences in T2D.

METHODS

Participants from six ethnic groups were included (Amsterdam, the Netherlands; n = 1,347-3,077 per group). Multinomial logistic regression was used to estimate ethnic differences in disruptors, such as skipping breakfast, eating erratically, and sleep duration. Associations between disruptors and incident T2D and the interaction by ethnicity were studied by Cox regression.

RESULTS

Ethnic minority populations skipped breakfast more often, timed meals differently, had longer periods of fasting, ate more erratically, and had more short/long sleep durations than the Dutch. Night snacking from 4 am to 6 am (HR: 5.82; 95% CI: 1.42-23.91) and both short (HR: 1.48; 95% CI: 1.03-2.12) and long sleep (HR: 3.09; 95% CI: 1.54-6.22), but no other disruptors, were associated with T2D. The higher T2D risk among ethnic minority populations compared with Dutch did not decrease after adjustment for last snack or length of sleep.

CONCLUSIONS

Although prevalence of circadian disruptors was higher among ethnic minority populations and some disruptors were associated with T2D, disruptors did not account for ethnic differences in T2D risk.

Contribution of type 2 diabetes to all-cause mortality, cardiovascular disease incidence and cancer incidence in white Europeans and South Asians: findings from the UK Biobank population-based cohort study

OBJECTIVE

To investigate whether the health implications of having type 2 diabetes (T2D) were different in South Asian compared with white European participants.

RESEARCH DESIGN AND METHODS

Prospective data from UK Biobank were used, and 457 935 participants of white European and 7102 of South Asian background were included. Cox proportional regression was performed to investigate the association between T2D and health outcome by ethnicity.

RESULTS

Over a mean of 7.0 years (IQR 6.3-7.6) of follow-up, 12 974 participants had died, and 30 347 and 27 159 developed cardiovascular disease (CVD) and cancer, respectively. South Asians had a higher risk for CVD mortality (HR: 1.42, 95% CI 1.07 to 1.89) and incidence (HR: 1.78, 95% CI 1.63 to 1.94), but a decreased risk for cancer mortality (HR: 0.59, 95% CI 0.41 to 0.85) and incidence (HR: 0.80, 95% CI 0.70 to 0.92) compared with white Europeans. Compared with individuals without T2D, both white Europeans and South Asians with T2D had a higher risk for all-cause mortality (1.59 (1.48 to 1.71) vs 2.83 (1.76 to 4.53)), CVD mortality (2.04 (1.82 to 2.28) vs 4.40 (2.37 to 8.16)) and CVD incidence (1.37 (1.31 to 1.44) vs 1.60 (1.31 to 1.95)), respectively. However, the magnitude of the risk was higher for South Asians than white Europeans.

CONCLUSIONS

Although T2D was associated with a higher risk for all-cause mortality and CVD incidence and mortality, in both white Europeans and South Asians, the risk experienced by South Asians with T2D was higher than their white European counterparts.

Regional Variation in Comorbid Prediabetes and Diabetes and Associated Factors among Hypertensive Individuals in Rural Bangladesh, Pakistan, and Sri Lanka

We aimed to explore the cross-country variation in the prevalence of comorbid prediabetes or diabetes and determine the sociodemographic, lifestyle, and clinical factors, especially body mass index (BMI) and waist circumference, associated with comorbid diabetes in individuals with hypertension in rural South Asia. We analyzed cross-sectional data of 2426 hypertensive individuals of ≥40 years from 30 randomly selected rural communities in Bangladesh, Pakistan, and Sri Lanka. Prediabetes was defined as fasting plasma glucose (FPG) between 100 and 125 mg/dL without use of antidiabetic treatment and diabetes as FPG ≥126 mg/dL or use of antidiabetic medication. The prevalence (95% CI) of prediabetes or diabetes (53.5% (51.5%, 55.5%)) and diabetes (27.7% (25.9%, 29.5%)) was high in the overall hypertensive study population in rural communities in 3 countries. Rural communities in Sri Lanka had the highest crude prevalence of prediabetes or diabetes and diabetes (73.1% and 39.3%) with hypertension, followed by those in Bangladesh (47.4% and 23.1%) and Pakistan (39.2% and 20.5%). The factors independently associated with comorbid diabetes and hypertension were residing in rural communities in Sri Lanka, higher education, international wealth index, waist circumference, pulse pressure, triglyceride, and lower high-density lipoprotein. The association of diabetes with waist circumference was stronger than with BMI in hypertensive individuals. Prediabetes or diabetes are alarmingly common among adults with hypertension and vary among countries in rural South Asia. The high prevalence of comorbid diabetes in Sri Lanka among hypertensives is not fully explained by conventional risk factors and needs further etiological research. Urgent public health efforts are needed to integrate diabetes control within hypertension management programs in rural South Asia, including screening waist circumference.

Association and Interaction Analysis of Lipid Accumulation Product with Impaired Fasting Glucose Risk: A Cross-Sectional Survey

AIMS

Lipid accumulation product (LAP) is put forward as a powerful marker showing the accumulation of visceral fat. The present study is aimed at (i) analyzing the predictive performances of LAP in the identification of impaired fasting glucose (IFG) in Chinese population and (ii) exploring the potentially interactive effect between LAP and other factors on IFG risk.

METHODS

Analysis was conducted on the data obtained from a community-based cross-sectional survey in Chinese population, and all the participants enrolled were required to complete a face-to-face questionnaire survey and related health checks. Then, for the purpose of comparing predictive values between LAP and conventional obesity indices for IFG, relevant analysis was carried out on the receiver operating characteristic (ROC) curve. The assessment of interactive effects was conducted by employing the three indicators as follows: (1) RERI (the relative excess risk due to interaction), (2) AP (attributable proportion due to interaction), and (3) SI (synergy index).

RESULTS

A total of 1777 participants (748 males and 1029 females) were involved in the final analysis. It was finally obtained that the prevalence rate of IFG was 14.1% in total, 15.5% for males and 13.1% for females, respectively. In logistic regression analysis, individuals with LAP levels in the fourth quartile had a significant higher risk of getting IFG in comparison with that of the lowest quartile (crude OR: 4.58, 95% CI: 3.01-6.98; adjusted OR: 3.81, 95% CI: 2.33-6.23). In addition, it was indicated by the ROC curve analysis that LAP showed a better performance in discriminating IFG risk than BMI in both males (Z = 2.20, P = 0.028) and females (Z = 2.13, P = 0.033). However, LAP displayed a higher predictability in comparison with WC only in females (Z = 2.07, P = 0.038), but not in males (Z = 0.18, P = 0.860). Furthermore, LAP and family history of diabetes were able to impose significant synergistic interaction on the risk of IFG, which was indicated by all the parameters in females (RERI: 2.52, 95% CI: 0.19-4.84; AP: 0.47, 95% CI: 0.20-0.74; SI: 2.39, 95% CI: 1.17-4.87) and males (RERI: 2.18, 95% CI: 0.08-4.73; AP: 0.43, 95% CI: 0.07-0.79; SI: 2.15, 95% CI: 1.03-5.45). However, none of the indicators showed significant interaction between LAP and smoking on the risk of IFG in females (RERI: 0.92, 95% CI: -2.79-4.63; AP: 0.20, 95% CI: -0.50-0.92; SI: 1.37, 95% CI: 0.42-4.52). Meanwhile, there was also no significant interaction between LAP and smoking on the risk of IFG in males as indicated by the value of SI (2.22, 95% CI: 0.80-6.21).

CONCLUSION

It was concluded that LAP was significantly related to a higher risk of IFG in Chinese population, and its performance was superior to that of conventional obesity indices, especially in females. Apart from that, LAP with family history of diabetes may have an interactive effect that can impose a great influence on the development of IFG.

Development of type 2 diabetes mellitus in people with intermediate hyperglycaemia

BACKGROUND

Intermediate hyperglycaemia (IH) is characterised by one or more measurements of elevated blood glucose concentrations, such as impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and elevated glycosylated haemoglobin A1c (HbA1c). These levels are higher than normal but below the diagnostic threshold for type 2 diabetes mellitus (T2DM). The reduced threshold of 5.6 mmol/L (100 mg/dL) fasting plasma glucose (FPG) for defining IFG, introduced by the American Diabetes Association (ADA) in 2003, substantially increased the prevalence of IFG. Likewise, the lowering of the HbA1c threshold from 6.0% to 5.7% by the ADA in 2010 could potentially have significant medical, public health and socioeconomic impacts.

OBJECTIVES

To assess the overall prognosis of people with IH for developing T2DM, regression from IH to normoglycaemia and the difference in T2DM incidence in people with IH versus people with normoglycaemia.

SEARCH METHODS

We searched MEDLINE, Embase, ClincialTrials.gov and the International Clinical Trials Registry Platform (ICTRP) Search Portal up to December 2016 and updated the MEDLINE search in February 2018. We used several complementary search methods in addition to a Boolean search based on analytical text mining.

SELECTION CRITERIA

We included prospective cohort studies investigating the development of T2DM in people with IH. We used standard definitions of IH as described by the ADA or World Health Organization (WHO). We excluded intervention trials and studies on cohorts with additional comorbidities at baseline, studies with missing data on the transition from IH to T2DM, and studies where T2DM incidence was evaluated by documents or self-report only.

DATA COLLECTION AND ANALYSIS

One review author extracted study characteristics, and a second author checked the extracted data. We used a tailored version of the Quality In Prognosis Studies (QUIPS) tool for assessing risk of bias. We pooled incidence and incidence rate ratios (IRR) using a random-effects model to account for between-study heterogeneity. To meta-analyse incidence data, we used a method for pooling proportions. For hazard ratios (HR) and odds ratios (OR) of IH versus normoglycaemia, reported with 95% confidence intervals (CI), we obtained standard errors from these CIs and performed random-effects meta-analyses using the generic inverse-variance method. We used multivariable HRs and the model with the greatest number of covariates. We evaluated the certainty of the evidence with an adapted version of the GRADE framework.

MAIN RESULTS

We included 103 prospective cohort studies. The studies mainly defined IH by IFG_5.6 (FPG mmol/L 5.6 to 6.9 mmol/L or 100 mg/dL to 125 mg/dL), IFG_6.1 (FPG 6.1 mmol/L to 6.9 mmol/L or 110 mg/dL to 125 mg/dL), IGT (plasma glucose 7.8 mmol/L to 11.1 mmol/L or 140 mg/dL to 199 mg/dL two hours after a 75 g glucose load on the oral glucose tolerance test, combined IFG and IGT (IFG/IGT), and elevated HbA1c (HbA1c_5.7: HbA1c 5.7% to 6.4% or 39 mmol/mol to 46 mmol/mol; HbA1c_6.0: HbA1c 6.0% to 6.4% or 42 mmol/mol to 46 mmol/mol). The follow-up period ranged from 1 to 24 years. Ninety-three studies evaluated the overall prognosis of people with IH measured by cumulative T2DM incidence, and 52 studies evaluated glycaemic status as a prognostic factor for T2DM by comparing a cohort with IH to a cohort with normoglycaemia. Participants were of Australian, European or North American origin in 41 studies; Latin American in 7; Asian or Middle Eastern in 50; and Islanders or American Indians in 5. Six studies included children and/or adolescents.Cumulative incidence of T2DM associated with IFG_5.6, IFG_6.1, IGT and the combination of IFG/IGT increased with length of follow-up. Cumulative incidence was highest with IFG/IGT, followed by IGT, IFG_6.1 and IFG_5.6. Limited data showed a higher T2DM incidence associated with HbA1c_6.0 compared to HbA1c_5.7. We rated the evidence for overall prognosis as of moderate certainty because of imprecision (wide CIs in most studies). In the 47 studies reporting restitution of normoglycaemia, regression ranged from 33% to 59% within one to five years follow-up, and from 17% to 42% for 6 to 11 years of follow-up (moderate-certainty evidence).Studies evaluating the prognostic effect of IH versus normoglycaemia reported different effect measures (HRs, IRRs and ORs). Overall, the effect measures all indicated an elevated risk of T2DM at 1 to 24 years of follow-up. Taking into account the long-term follow-up of cohort studies, estimation of HRs for time-dependent events like T2DM incidence appeared most reliable. The pooled HR and the number of studies and participants for different IH definitions as compared to normoglycaemia were: IFG_5.6: HR 4.32 (95% CI 2.61 to 7.12), 8 studies, 9017 participants; IFG_6.1: HR 5.47 (95% CI 3.50 to 8.54), 9 studies, 2818 participants; IGT: HR 3.61 (95% CI 2.31 to 5.64), 5 studies, 4010 participants; IFG and IGT: HR 6.90 (95% CI 4.15 to 11.45), 5 studies, 1038 participants; HbA1c_5.7: HR 5.55 (95% CI 2.77 to 11.12), 4 studies, 5223 participants; HbA1c_6.0: HR 10.10 (95% CI 3.59 to 28.43), 6 studies, 4532 participants. In subgroup analyses, there was no clear pattern of differences between geographic regions. We downgraded the evidence for the prognostic effect of IH versus normoglycaemia to low-certainty evidence due to study limitations because many studies did not adequately adjust for confounders. Imprecision and inconsistency required further downgrading due to wide 95% CIs and wide 95% prediction intervals (sometimes ranging from negative to positive prognostic factor to outcome associations), respectively.This evidence is up to date as of 26 February 2018.

AUTHORS' CONCLUSIONS

Overall prognosis of people with IH worsened over time. T2DM cumulative incidence generally increased over the course of follow-up but varied with IH definition. Regression from IH to normoglycaemia decreased over time but was observed even after 11 years of follow-up. The risk of developing T2DM when comparing IH with normoglycaemia at baseline varied by IH definition. Taking into consideration the uncertainty of the available evidence, as well as the fluctuating stages of normoglycaemia, IH and T2DM, which may transition from one stage to another in both directions even after years of follow-up, practitioners should be careful about the potential implications of any active intervention for people 'diagnosed' with IH.

Ethnic differences in metabolite signatures and type 2 diabetes: a nested case-control analysis among people of South Asian, African and European origin

Accumulation of metabolites may mark or contribute to the development of type 2 diabetes mellitus (T2D), but there is a lack of data from ethnic groups at high risk. We examined sphingolipids, acylcarnitines and amino acids, and their association with T2D in a nested case–control study among 54 South Asian Surinamese, 54 African Surinamese and 44 Dutch in the Netherlands. Plasma metabolites were determined at baseline (2001–2003), and cumulative prevalence and incidence of T2D at follow-up (2011–2012). Weighted linear and logistic regression analyses were used to study associations. The mean level of most sphingolipids was lower, and amino-acid levels higher, in the Surinamese groups than among the Dutch. Surinamese individuals had higher mono- and polyunsaturated acylcarnitines and lower plasma levels of saturated acylcarnitine species than the Dutch. Several sphingolipids and amino acids were associated with T2D. Although only the shorter acylcarnitines seemed associated with prevalent T2D, we found an association of all acylcarnitines (except C0, C18 and C18:2) with incident T2D. Further analyses suggested a potentially different association of several metabolites across ethnic groups. Extension and confirmation of these findings may improve the understanding of ethnic differences and contribute to early detection of increased individual risk.

Hypertension and Cardiovascular Risk Profile in a Middle-Income Setting: The HELISUR Study

BACKGROUND

Hypertension is the leading risk factor responsible for premature death worldwide, but its burden has shifted to low- and middle-income countries. Therefore, we studied hypertension and cardiovascular risk in the population of Suriname, a middle-income country with a predominantly urban population of African and Asian ancestry.

METHODS

A random sample of 1,800 noninstitutionalized men and women aged 18-70 years was selected to be interviewed at home and examined at the local hospital for cardiovascular risk factors, asymptomatic organ damage, and cardiovascular disease.

RESULTS

The 1,157 participants examined (37% men) were mainly of self-defined Asian (43%) or African (39%) ancestry, mean age 43 years (SD 14). The majority of the population (71%) had hypertension or prehypertension, respectively, 40% and 31%. Furthermore, 72% was obese or overweight, while 63% had diabetes or prediabetes. Only 1% of the adult population had an optimal cardiovascular risk profile. Hypertension awareness, treatment, and control were respectively 68%, 56%, and 20%. In line with this, 22% of the adult population had asymptomatic organ damage, including increased arterial stiffness, left ventricular hypertrophy, microalbuminuria, or asymptomatic chronic kidney disease.

CONCLUSIONS

In this first extensive cardiovascular assessment in the general population of this middle-income Caribbean country, high prevalence of hypertension with inadequate levels of treatment and control was predominant. The findings emphasize the need for collaborative effort from national and international bodies to prioritize the implementation of affordable and sustainable public health programs that combat the escalating hypertension and cardiovascular risk factor burden.

Risk of progression to diabetes from prediabetes defined by HbA1c or fasting plasma glucose criteria in Koreans

AIMS

To examine the abilities of HbA1c and fasting plasma glucose (FPG) criteria predicting 5-year progression rate to diabetes in Korean adults with prediabetes.

METHODS

Participants included 17,971 Koreans (aged 20-79years) who underwent routine medical check-ups at a mean interval of 5.2years (3.1-6.7years). Prediabetes was defined as FPG 5.6-6.9mmol/l or HbA1c 5.7-6.4% (39-46mmol/mol). Incident diabetes was defined as FPG⩾7.0mmol/l, HbA1c⩾6.5% (48mmol/mol), or initiation of antidiabetic medications.

RESULTS

At baseline, the prevalence of prediabetes was 30.6% (n=5495) by FPG and 20.4% (n=3664) by HbA1c criteria. The 5-year progression rate to diabetes was significantly higher in prediabetes identified by HbA1c than by FPG tests (14.7% vs. 10.4%, P<0.001). Of individuals diagnosed with prediabetes by only one test, those by HbA1c alone had a higher risk of progression to diabetes than those diagnosed by FPG alone (6.0% vs. 3.9%, P<0.001). Receiver operating characteristic curve analysis showed that area under the curve was greater for HbA1c (0.855, 95% CI 0.840-0.870) than for FPG (0.830, 0.813-0.846) (P=0.016). After adjustment for conventional risk factors, the odds ratio (OR) of developing diabetes was higher in participants with prediabetes identified by HbA1c (OR 9.91, 8.24-11.9) than by FPG (OR 7.29, 5.97-8.89) (P=0.026).

CONCLUSIONS

Although fewer individuals with prediabetes were identified by HbA1c than by FPG criteria, the ability to predict progression to diabetes was stronger for HbA1c than for FPG in Koreans.

Ethnic differences in prediabetes and diabetes in the Suriname Health Study

BACKGROUND

Diabetes is increasing worldwide, and information on risk factors to develop targeted interventions is limited. Therefore, we analyzed data of the Suriname Health Study to estimate the prevalence of prediabetes and diabetes. We also explored whether ethnic differences in prediabetes or diabetes risk could be explained by biological, demographic, lifestyle, anthropometric, and metabolic risk factors.

METHOD

The study was designed according to the WHO Steps guidelines. Fasting blood glucose levels were measured in 3393 respondents, aged 15-65 years, from an Amerindian, Creole, Hindustani, Javanese, Maroon or Mixed ethnic background. Prediabetes was defined by fasting blood glucose levels between 6.1 and 7.0 mmol/L and diabetes by fasting blood glucose levels ≥7.0 mmol/L or 'self-reported diabetes medication use.' For all ethnicities, we analyzed sex, age, marital status, educational level, income status, employment, smoking status, residence, physical activity, body mass index, waist circumference, hypertension, and the levels of triglyceride, total cholesterol, high-density lipoprotein-cholesterol and low-density lipoprotein-cholesterol.

RESULTS

The prevalence of prediabetes was 7.4%, while that of diabetes was 13 0%. From these diabetes cases, 39.6% were not diagnosed previously. No ethnic differences were observed in the prevalence of prediabetes. For diabetes, Hindustanis (23.3%) had twice the prevalence compared to other ethnic groups (4.7-14.2%). The associations of the risk factors with prediabetes or diabetes varied among the ethnic groups. The differences in the associations of ethnic groups with prediabetes or diabetes were partly explained by these risk factors.

CONCLUSIONS

The prevalence of diabetes in Suriname is high and most elevated in Hindustanis. The observed variations in risk factors among ethnic groups might explain the ethnic differences between these groups, but follow-up studies are needed to explore this in more depth.

Associations Between Prediabetes, by Three Different Diagnostic Criteria, and Incident CVD Differ in South Asians and Europeans

OBJECTIVE

We examined longitudinal associations between prediabetes and cardiovascular disease (CVD) (coronary heart disease [CHD] and stroke) in Europeans and South Asians.

RESEARCH DESIGN AND METHODS

This was a U.K. cohort study of 1,336 Europeans and 1,139 South Asians, aged 40-69 years at baseline (1988-1991). Assessment included blood pressure, blood tests, anthropometry, and questionnaires. Prediabetes was determined by OGTT or HbA1c, using either International Expert Committee (IEC) (HbA1c 6.0-6.5% [42-48 mmol/mol]) or American Diabetes Association (ADA) (HbA1c 5.7-6.5% [39-48 mmol/mol]) cut points. Incident CHD and stroke were established at 20 years from death certification, hospital admission, primary care record review, and participant report.

RESULTS

Compared with normoglycemic individuals, IEC-defined prediabetes was related to both CHD and CVD risk in Europeans but not South Asians (subhazard ratio for CHD 1.68 [95% CI 1.19, 2.38] vs. 1.00 [0.75, 1.33], ethnicity interaction P = 0.008, and for CVD 1.49 [1.08, 2.07] vs. 1.03 [0.78, 1.36], ethnicity interaction P = 0.04). Conversely, IEC-defined prediabetes was associated with stroke risk in South Asians but not Europeans (1.73 [1.03, 2.90] vs. 0.85 [0.44, 1.64], ethnicity interaction P = 0.11). Risks were adjusted for age, sex, smoking, total-to-HDL cholesterol ratio, waist-to-hip ratio, systolic blood pressure, and antihypertensive use. Associations were weaker for OGTT or ADA-defined prediabetes. Conversion from prediabetes to diabetes was greater in South Asians, but accounting for time to conversion did not account for these ethnic differences.

CONCLUSIONS

Associations between prediabetes and CVD differed by prediabetes diagnostic criterion, type of CVD, and ethnicity, with associations being present for overall CVD in Europeans but not South Asians. Substantiation of these findings and investigation of potential explanations are required.

Cardiovascular Disease in South Asian Migrants

Cardiovascular disease (CVD) represents a significant cause of global mortality and morbidity. South Asians (SAs) have a particularly high burden of coronary artery disease (CAD). This review describes current literature regarding the prevalence, incidence, etiology, and prognosis of CVD in SA migrants to high-income nations. We conducted a narrative review of CVD in the SA diaspora through a search of MEDLINE and PubMed. We included observational studies, randomized clinical trials, nonsystematic reviews, systematic reviews, and meta-analyses written in English. Of 15,231 articles identified, 827 articles were screened and 124 formed the basis for review. SA migrants have a 1.5-2 times greater prevalence of CAD than age- and sex-adjusted Europids. Increased abdominal obesity and body fat and increased burden of type 2 diabetes mellitus and dyslipidemia appear to be primary drivers of the excess CAD burden in SAs. Sedentary lifestyle and changes in diet after immigration are important contributors to weight gain and adiposity. Early life factors, physical activity patterns and, in some cases, reduced adherence to medical therapy may contribute to increased CVD risks in SAs. Novel biomarkers like leptin and adipokines may show distinct patterns in SAs and provide insights into cardiometabolic risk determinants. In conclusion, SAs have distinct CVD risk predispositions, with a complex relationship to cultural, innate, and acquired factors. Although CVD risk factor management and treatment among SAs is improving, opportunities exist for further advances.