Relationships between blood pressure and blood glucose among offspring of parents with type 2 diabetes: Prediction of incident dysglycemia in a biracial cohort

Association of urinary albumin-to-creatinine ratio with cardiometabolic risk markers and pre-diabetes in adults with normoglycemia, normoalbuminuria, and normotension with parental type 2 diabetes

INTRODUCTION

This is a post hoc analysis of urinary albumin-to-creatinine ratio (uACR) within the normoalbuminuric range in relation to cardiometabolic risk factors among initially normoglycemic, normotensive participants in the Pathobiology of Prediabetes in a Biracial Cohort (POP-ABC) Study.

RESEARCH DESIGN AND METHODS

308 healthy African American (AA) and European American (EA) participants in the POP-ABC Study underwent baseline assessments, including oral glucose tolerance test, anthropometry, urinary albumin-to-creatinine ratio (uACR), lipids, adipocytokines, insulin sensitivity and secretion. Participants were followed quarterly for 5.5 years (mean 2.62 years) for the primary outcome of incident pre-diabetes.

RESULTS

The cohort's mean fasting glucose was 92.1±6.90 mg/dL, 2-hour plasma glucose was 123±25.0 mg/dL, systolic blood pressure was 123±15.9 mm Hg, and diastolic blood pressure was 74±8.80 mm Hg. Baseline uACR levels (range 1-29 mg/g) were similar in AA versus EA participants (6.40 mg/g±4.80 vs 6.80±5.40 mg/g, p=0.52), higher in women than men (7.30 mg/g±5.30 vs 4.60±3.90 mg/g, p<0.0001), and showed significant associations with cardiometabolic risk factors, including age, insulin sensitivity, high-density lipoprotein cholesterol, and adiponectin levels (p=0.03-0.004). During 5.5 years of follow-up, 104 participants developed pre-diabetes and 204 maintained normoglycemia. Baseline uACR quartiles were associated with incident pre-diabetes (r=0.19, p=0.0011).

CONCLUSIONS

Baseline uACR levels were associated with cardiometabolic risk markers and incident pre-diabetes risk among adults with normoglycemia, normoalbuminuria and normotension with parental diabetes.

Outcome of lifestyle intervention in relation to duration of pre-diabetes: the Pathobiology and Reversibility of Prediabetes in a Biracial Cohort (PROP-ABC) study

INTRODUCTION

In studies that enrolled people with prevalent pre-diabetes of unknown duration, lifestyle intervention (LI) delayed progression to type 2 diabetes (T2D) but did not reverse pre-diabetes in most participants. Here, we assessed the effects of LI among individuals with pre-diabetes of known duration to determine whether outcomes are related to duration of pre-diabetes.

RESEARCH DESIGN AND METHODS

The Pathobiology and Reversibility of Prediabetes in a Biracial Cohort study initiated LI in subjects with incident pre-diabetes during follow-up of initially normoglycemic African Americans and European Americans with parental T2D. Participants were stratified into those initiating LI after <3, 3-5, or >5 years of pre-diabetes diagnosis. Assessments included anthropometry, body fat, fasting and 2-hour plasma glucose (FPG, 2hPG), and insulin sensitivity and secretion. The outcomes were normal glucose regulation (NGR; ie, normal FPG and 2hPG), persistent pre-diabetes, or T2D. Participants who maintained normal FPG and normal 2hPG levels during follow-up served as the control. The control subjects did not receive lifestyle or other intervention to alter the course of glycemia or body weight.

RESULTS

Of 223 participants (age 53.3±9.28 years, body mass index 30.6±6.70 kg/m²), 72 (control) maintained normoglycemia during follow-up and 138 subjects with incident pre-diabetes initiated LI after 4.08±2.02 years (range 3 months-8.3 years) of diagnosis. Compared with control, LI participants showed decrease in glucose, weight, and body fat; 42.8% reverted to NGR, 50% had persistent pre-diabetes, and 7.2% developed T2D after 5 years. These outcomes were similar across race and pre-diabetes duration strata, but greater glycemic decrease occurred when LI was initiated within 5 years of pre-diabetes diagnosis.

CONCLUSIONS

Ninety-three per cent of adults with parental T2D who initiated LI within 3 months to 8.3 years of developing pre-diabetes did not progress to T2D; nearly half reverted to NGR.Trial registration number NCT02027571.

Spline Longitudinal Multi-response Model for the Detection of Lifestyle- Based Changes in Blood Glucose of Diabetic Patients

BACKGROUND

Blood sugar and lifestyle problems have long been problems in diabetes. There has also been a lot of research on that. However, we see that diabetic patients are still increasing even though many patients are not aware of the start of the disease occurrence. Therefore, we consider it very important to examine these two main problems of diabetes by using a more flexible statistical approach to obtain more specific results regarding the patient's condition.

OBJECTIVE

The form of data for type 2 diabetes patients is repeated measurements so that it is approached through longitudinal studies. We investigated various intervals of pattern change that can occur in blood glucose, namely fasting, random, and 2 hours after meals based on blood pressure and carbohydrate diets in diabetic patients in South Sulawesi Province, Indonesia.

METHODS

This research is a longitudinal study proposing a flexible and accurate statistical approach. It is a weighted spline multi-response nonparametric regression model. This model is able to detect any pattern of changes in irregular data in large dimensions. The data were obtained from Hasanuddin University Teaching Hospital in South Sulawesi Province, Indonesia. The number of samples analyzed was 418 from 50 patients with different measurements.

RESULTS

The optimal spline model was obtained at 2 knots for blood pressure and 3 knots for carbohydrate diets. There are three blood pressure intervals that give different patterns of increase in patient blood glucose levels, namely below 126.6 mmHg, 126.6-163.3 mmHg, and above 163.3 mmHg. It was found that blood sugar rose sharply at blood pressure above 163.3 mmHg. Furthermore, there are four carbohydrate diet intervals that are formed, which are below 118.6 g, 118.6-161.8 g, 161.8-205 g, and above 205 g. The result is that blood sugar decreased significantly at intervals of carbohydrate diet 161.8-205 g.

CONCLUSION

Blood glucose increases with a very high increase in blood pressure, whereas for a carbohydrate diet, there is no guarantee that a high diet will be able to reduce blood glucose significantly. This may be affected by the patient's saturation of a very high carbohydrate diet.

Pathobiology and Reversibility of Prediabetes in a Biracial Cohort (PROP-ABC) Study: design of lifestyle intervention

INTRODUCTION

Intensive lifestyle intervention (ILI) prevents progression from prediabetes to type 2 diabetes (T2D) but reversal of prediabetes is less well studied.

RESEARCH DESIGN AND METHODS

The overall objectives of the Pathobiology and Reversibility of Prediabetes in a Biracial Cohort (PROP-ABC) Study (ClinicalTrials.gov ID: NCT02027571) are to determine the natural history and reversibility of prediabetes. The study tests specific hypotheses on the patterns of progression to prediabetes among normoglycemic African-American (AA) and European-American (EA) offspring of parents with T2D; emergence of microvascular and macrovascular complications during transition from normal to impaired glucose regulation; significance of the 'metabolically healthy' obese phenotype; and effect of duration of the prediabetic state on its reversibility with lifestyle intervention. Participants who developed incident prediabetes were offered ILI and evaluated quarterly for 5 years. The primary outcome was restoration of normal glucose regulation (fasting plasma glucose <100 mg/dL and two-hour plasma glucose (2hrPG)<140 mg/dL).

RESULTS

Of the 223 subjects enrolled in the PROP-ABC Study, 158 participants with incident prediabetes started ILI. The mean age was 53.3±9.28 years; body mass index 30.6±6.70 kg/m²; 70% were female, 52.4% AA and 47.6% EA. The ILI program used goal setting, weight-based calorie restriction, physical activity (180 min/week), self-monitoring, and meal replacement. Monthly face-to-face (F2F) counseling sessions during the initial 6 months, and quarterly visits thereafter, were supplemented with electronic and postal contacts. Attendance at F2F sessions was highly correlated with weight loss (r=0.98, p<0.0001). Meal replacement induced ~5 kg weight loss within 3 months in participants with recrudescent weight pattern. Self-reported exercise minutes correlated with pedometer step counts (r=0.47, p<0.0001).

CONCLUSION

The PROP-ABC Study has demonstrated the feasibility of executing an ILI program designed to test reversibility of incident prediabetes in a biracial cohort.

Amino acid signature predictive of incident prediabetes: A case-control study nested within the longitudinal pathobiology of prediabetes in a biracial cohort

OBJECTIVE

Circulating branched-chain amino acids (BCAAs, isoleucine, leucine, valine) and aromatic amino acids (AAAs, tyrosine and phenylalanine) predicted type 2 diabetes mellitus (T2DM) risk in a Caucasian population. Here, we assessed amino acid levels in relation to incident prediabetes among initially normoglycemic African Americans (AA) and European Americans (EA).

RESEARCH DESIGN AND METHODS

Using a nested case-control design, we studied 70 adults (35 AA, 35 EA) who developed prediabetes (progressors) and 70 matched participants who maintained normoglycemia (nonprogressors) during 5.5 years of follow-up in the Pathobiology of Prediabetes in a Biracial Cohort study. Assessments included plasma amino acid levels, insulin sensitivity, and beta-cell function.

RESULTS

The total level of all 18 amino acid assayed was significantly associated with lean mass (r = 0.36, P < 0.0001), waist circumference (r = 0.27, P = 0.001), fasting plasma glucose (r = 0.24, P = 0.005), HOMA-IR (r = 0.22, P = 0.01) and HDL cholesterol (r = -0.18, P = 0.03). Individual amino acid levels were significantly associated with insulin sensitivity and insulin secretion. Compared with nonprogressors, progressors had higher baseline levels of asparagine and aspartic acid (P <0.0001), glutamine/glutamic acid (P = 0.005) and phenylalanine (P = 0.02), and lower histidine (P = 0.02) levels. In fully-adjusted logistic regression models, aspartic acid/asparagine (OR 2.72 [95% CI 1.91-3.87]) and histidine (OR 0.90 [95% CI 0.85-0.96]) were the only amino acids that significantly predicted incident prediabetes.

CONCLUSIONS

Baseline plasma aspartic acid and asparagine levels predicted progression to prediabetes, whereas histidine levels were protective of prediabetes risk. Thus, the amino acid signature associated with prediabetes in a diverse population may be distinct from that previously linked to T2DM in Caucasians.

Strategy for early identification of prediabetes in lean populations: New insight from a prospective Chinese twin cohort of children and young adults

AIMS

To identify certain subgroups in young and lean populations, who may be at a high risk of developing prediabetes/diabetes, which is not captured by current BMI-based screening algorithms.

METHODS

Incidence of prediabetes/diabetes was assessed using oral glucose tolerance tests among 1859 children and 1073 young adults from a prospective Chinese twin cohort.

RESULTS

Over a 6-year follow-up, 507 (27.3%) children and 293 (27.3%) adults developed prediabetes/diabetes. Of the 800 incidents, 737(92.1%) and 644(80.5%) were lean at baseline and follow-up, respectively. Baseline fasting glucose in the top tertile of the normal range was associated with an increased risk of prediabetes/diabetes: odds ratio, 1.85 (95% CI 1.32-2.59) and 3.29 (95%CI 2.10-5.17) among normal weight and underweight children, respectively, and 2.74 (95% CI 1.78-4.23) and 3.08 (95% CI 1.69-5.58) among normal weight and overweight/obese adults, respectively, compared with the low tertile of fasting glucose.

CONCLUSIONS

We showed that majority incident cases of prediabetes/diabetes were not overweight/obese (at baseline), who would have been missed by traditional screening algorithm emphasizing overweight/obesity. Our findings revealed that an upper end of normal fasting glucose was a simple and robust predictor of future higher risk of prediabetes/diabetes in this young and lean population.

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 IFG5.6 (FPG mmol/L 5.6 to 6.9 mmol/L or 100 mg/dL to 125 mg/dL), IFG6.1 (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 (HbA1c5.7: HbA1c 5.7% to 6.4% or 39 mmol/mol to 46 mmol/mol; HbA1c6.0: 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 IFG5.6, IFG6.1, IGT and the combination of IFG/IGT increased with length of follow-up. Cumulative incidence was highest with IFG/IGT, followed by IGT, IFG6.1 and IFG5.6. Limited data showed a higher T2DM incidence associated with HbA1c6.0 compared to HbA1c5.7. 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: IFG5.6: HR 4.32 (95% CI 2.61 to 7.12), 8 studies, 9017 participants; IFG6.1: 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; HbA1c5.7: HR 5.55 (95% CI 2.77 to 11.12), 4 studies, 5223 participants; HbA1c6.0: 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.