The changing face of diabetes complications

Vaccination of people with solid tumors and diabetes: existing evidence and recommendations. A position statement from a multidisciplinary panel of scientific societies

Diabetes and cancer are two of the most common public health concerns worldwide. The complex interplay of these two conditions is a growing area of research, as patients with diabetes are at increased risk for developing cancer, and vice versa. Furthermore, both patient populations show increased risk of many communicable infectious diseases and their adverse consequences, while vaccination can play a crucial role in their prevention, improving patient outcomes. Vaccination should represent a standard part of care for patients with cancer, diabetes, and both the diseases simultaneously, including people undergoing cancer treatment or in remission. Several international guidelines provide recommendations for vaccinating people with cancer or diabetes, but the two conditions have not been specifically evaluated together. Here we present a multidisciplinary consensus position paper on vaccination in patients with cancer and diabetes. The position paper is the result of a collaborative effort between experts from the Italian Association of Medical Oncology (AIOM), Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Italian Society of Endocrinology (SIE), and Italian Society of Pharmacology (SIF). The paper provides a comprehensive overview of the current state-of-the-art knowledge on vaccination in patients with cancer and diabetes. It discusses the importance of vaccination in preventing infections, focuses attention on the need to consider the unique challenges faced by patients with cancer and diabetes when it comes to vaccine administration, and highlights the need for coordinated care to optimize treatment outcomes. Overall, the consensus position paper provides healthcare professionals caring for patients with cancer and diabetes recommendations on the use of various vaccines, including influenza, COVID-19, HZV, and HPV vaccines, as well as guidance on how to address common concerns and challenges related to vaccine administration.

Risk of Ischemic and Hemorrhagic Stroke in Individuals With Type 1 and Type 2 Diabetes: A Nationwide Cohort Study in Sweden

BACKGROUND AND OBJECTIVES

Diabetes significantly increases the risk of cardiovascular events, including stroke. Although the association with ischemic stroke is well established, the relationship with hemorrhagic stroke remains unclear. This study aimed to evaluate the risk of ischemic and hemorrhagic stroke in individuals with type 1 and type 2 diabetes compared with diabetes-free controls from the general population.

METHODS

This cohort study included individuals with type 1 or type 2 diabetes from the Swedish National Diabetes Register between 2005 and 2019, matched to diabetes-free controls by age and sex. Data on baseline characteristics, comorbidities, medications, and outcomes were collected from multiple national registers. Stroke incidence rates and adjusted hazard ratios were estimated using Cox proportional hazard models, stratified by diabetes type, for ischemic and hemorrhagic stroke.

RESULTS

The study included 47,720 individuals with type 1 diabetes (mean age 34.4, 44.8% female) and 686,158 with type 2 diabetes (mean age 65.3, 43.3% female), matched to 143,160 and 2,058,474 controls, respectively. In individuals with type 1 diabetes, the ischemic stroke risk was 2.54 times higher (95% CI 2.36-2.73) and the hemorrhagic stroke risk was 1.88 times higher (95% CI 1.57-2.26) compared with controls. In individuals with type 2 diabetes, the ischemic stroke risk was 1.37 times higher (95% CI 1.35-1.38) while the hemorrhagic stroke risk was not significantly increased (HR: 0.99, 95% CI 0.96-1.02). Higher HbA1c levels were associated with increased ischemic stroke risk for both diabetes types. For hemorrhagic stroke, individuals with type 1 diabetes had significantly higher risk starting at HbA1c > 52 mmol/mol while in those with type 2 diabetes, a modest risk increase was observed only at HbA1c > 72 mmol/mol.

DISCUSSION

The risk of ischemic stroke was higher for both diabetes types. Individuals with type 1 diabetes also exhibited a higher risk of hemorrhagic stroke compared with diabetes-free controls while type 2 diabetes was significantly associated with risk of hemorrhagic stroke only when HbA1c was higher than 72 mmol/mol. These findings highlight the increased stroke risk in diabetes, with distinct patterns by stroke subtype and diabetes type. Tailored prevention strategies are essential to address these differences.

Rising tide: the growing global burden and inequalities of early-onset type 2 diabetes among youths aged 15-34 years (1990-2021)

BACKGROUND

Type 2 diabetes mellitus (T2DM) is increasingly affecting people aged 15-34, posing a serious public health challenge due to its faster progression and higher complication risks. This study examines the global, regional, and national burden of early-onset T2DM from 1990 to 2021, emphasizing trends and disparities across different sociodemographic contexts.

METHODS

Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021, we analyzed incidence, prevalence, mortality, disability-adjusted life years (DALYs), years lived with disability (YLDs), and years of life lost (YLLs) in people aged 15-34. Stratifications included age, sex, and the Socio-Demographic Index (SDI). Joinpoint regression significant temporal shifts, and decomposition analysis attributed changes in T2DM burden to factors such as prevalence, population growth, aging, and case fatality rates. Inequality was assessed with the Slope Index of Inequality and Concentration Index.

RESULTS

From 1990 to 2021, early-onset T2DM incidence and prevalence rose significantly worldwide, especially in high-SDI regions. Although global mortality and DALYs appeared relatively stable, low-SDI regions showed worrisome increases. Rising T2DM prevalence was the principal driver of mortality and DALYs, notably in low- and middle-SDI regions. Inequality analyses indicated widening disparities, with higher incidence and prevalence in high-SDI countries and more severe outcomes in low-SDI countries.

CONCLUSIONS

The global burden of early-onset T2DM among youths is escalating, with significant disparities across different sociodemographic levels. The findings underscore the urgent need for targeted public health interventions. Future research should focus on the underlying factors driving these trends and explore strategies for effective prevention and management of early-onset T2DM.

Triglyceride-glucose related indices as predictors for major adverse cardiovascular events and overall mortality in type-2 diabetes mellitus patients

BACKGROUND

Recent studies have indicated that triglyceride glucose (TyG)-waist height ratio (WHtR) and TyG-waist circumference (TyG-WC) are effective indicators for evaluating insulin resistance. However, research on the association in TyG-WHtR, TyG-WC, and the risk and prognosis of major adverse cardiovascular events (MACEs) in type 2 diabetes mellitus (T2DM) cases are limited.

AIM

To clarify the relation in TyG-WHtR, TyG-WC, and the risk of MACEs and overall mortality in T2DM patients.

METHODS

Information for this investigation was obtained from Action to Control Cardiovascular Risk in Diabetes (ACCORD)/ACCORD Follow-On (ACCORDION) study database. The Cox regression model was applied to assess the relation among TyG-WHtR, TyG-WC and future MACEs risk and overall mortality in T2DM cases. The RCS analysis was utilized to explore the nonlinear correlation. Subgroup and interaction analyses were conducted to prove the robustness. The receiver operating characteristic curves were applied to analysis the additional predicting value of TyG-WHtR and TyG-WC.

RESULTS

After full adjustment for confounding variables, the highest baseline TyG-WHtR cohort respectively exhibited a 1.353-fold and 1.420-fold higher risk for MACEs and overall mortality, than the lowest quartile group. Similarly, the highest baseline TyG-WC cohort showed a 1.314-fold and 1.480-fold higher risk for MACEs and overall mortality, respectively. Each 1 SD increase in TyG-WHtR was significantly related to an 11.7% increase in MACEs and a 14.9% enhance in overall mortality. Each 1 SD increase in TyG-WC corresponded to an 11.5% in MACEs and a 16.6% increase in overall mortality. Including these two indexes in conventional models significantly improved the predictive power for MACEs and overall mortality.

CONCLUSION

TyG-WHtR and TyG-WC were promising predictors of MACEs and overall mortality risk in T2DM cases.

Association of oxidative balance score with incident cardiovascular disease in patients with type 2 diabetes: findings of the UK Biobank study

BACKGROUND & AIMS

To clarify how dietary and lifestyle factors work on diabetes-related cardiovascular disease (CVD), we investigated whether the increased risk of CVD in patients with type 2 diabetes mellitus (T2DM) could be offset by an increase in diet and/or lifestyle with antioxidant potential.

RESEARCH DESIGN AND METHODS

A total of 7,658 individuals from UK Biobank (UKB) with T2DM but no diagnosed CVD were included in this study. We screened combinations of 16 nutrients and/or 4 lifestyles to calculate the Oxidative Balance Score (OBS), dietary OBS (DOBS), and lifestyle OBS (LOBS). Cox proportional hazards (CPH) regression models and mediation statistical models were performed.

RESULTS

After adjusting for covariates, CPH regression models showed inverse associations between both OBS and LOBS and CVD. The highest tertile of LOBS was significantly associated with a lower risk of CVD compared to the lowest tertile, with hazard ratios and 95% CIs as follows: Atherosclerotic Cardiovascular Disease (ASCVD) 0.81 (0.68-0.97), Coronary Artery Disease (CAD) 0.79 (0.67-0.93), Atrial Fibrillation (AF) 0.56 (0.45-0.70) and CVD mortality 0.67(0.51-0.88). Correspondingly, the results of associations between the highest tertile of OBS and risks of CVDs above were ASCVD 0.80 (0.64-0.99), CAD 0.83(0.68-1.01), AF 0.73 (0.57-0.92) and CVD mortality 0.68 (0.50-0.92). No associations between DOBS and CVDs were observed [ASCVD 0.83 (0.66-1.05), CAD 0.86 (0.70-1.05), AF 0.77 (0.60-1.00), and CVD mortality 0.79 (0.57-1.10)]. These results were consistent in stratified analyses. Additionally, we identified a mediating role for C-reactive protein (CRP) and white blood cell count (WBC) in the observed relations, with indirect effect and mediation estimates as follows: CRP - 0.003 6.0% (OBS and CAD), -0.008 17.2%, -0.003 11.7%, and - 0.010 14.5% (OBS/DOBS/LOBS and CVD mortality); WBC - 0.006 14.3%, -0.006 12.6%, -0.006 13.4%, -0.005 23.3% (OBS and CVDs), -0.008 11.8%, -0.008 11.9%, -0.008 11.8%, and - 0.005 5.3% (LOBS and CVDs).

CONCLUSION

Sustained adherence to diets and lifestyles with high antioxidant potential may significantly reduce the risk of CVD in individuals with T2DM.

Angiogenic effects of Type 2 diabetes on the dental pulp

AIM

To investigate the influence of type 2 diabetes (T2D) and hyperglycaemia on blood vessels and angiogenic markers in the dental pulp.

METHODOLOGY

Extracted non-carious permanent molar teeth were collected from patients with well-controlled T2D (n = 10) and non-T2D (controls) (n = 10). The pulp was examined qualitatively using haematoxylin and eosin and Van Gieson stains. Immunohistochemistry (IHC) identified the primary receptor for VEGF, VEGFR2, and the endothelial cell marker CD34. Primary human dental pulp cell (hDPC) lines (n = 3) were established from tissue explants and cells were grown in media containing 5.5 mM D-glucose (control), 12.5 mM (prediabetes) and 25 mM (T2D) D-glucose under normoxic conditions for 24, 48 and 72 h. Assays for metabolic activity (PrestoBlue) and cell viability (Crystal Violet staining) assessed the hDPC response to hyperglycaemia. The expression of angiogenic genes VEGFA, KDR, FLT-1, ANGPT1, ANGPT2, TIE1 and TEK were analysed using quantitative real-time polymerase chain reaction. ELISAs were used to quantify the level of expressed protein for VEGFA, ANG1, ANG2, TIE1, and TIE2 in the media. Data analyses were performed using GraphPad Prism and anova tests at p < .05.

RESULTS

Blood vessels in T2D samples had thicker walls and stained strongly for elastin and collagen compared with non-T2D samples. VEGFR2 protein was not seen in any T2D samples but consistently detected in healthy specimens. Culturing healthy cells in high glucose (25 mM) significantly reduced cell viability at 24 h compared to the control (p = .005) and 12.5 mM glucose (p = .001) but the metabolic activity was not greatly affected by glucose and time. VEGFA mRNA and VEGFA protein expression were detected in the hDPCs in the presence of hyperglycaemia over time; however, the primary receptor, VEGFR2/KDR, was not detected. Genes for the ANG1 and ANG2 and their receptors were expressed at all glucose concentrations but hyperglycaemia upregulated ANG2 mRNA. Proteins for all growth factors were detected in the media however proteins for TIE1 and TIE2 receptors were not.

CONCLUSION

T2D and hyperglycaemia may impair the angiogenic response in the pulp similar to other body site. The scarcity of VEGFR2 and increased expression of ANG2 in response to hyperglycaemia suggests that VEGF and ANG-Tie1/Tie2 signalling may be compromised.

Impact of lipoprotein (a) on coronary atherosclerosis and plaque progression in patients with type 2 diabetes mellitus

OBJECTIVES

To explore the association between baseline Lp (a) levels and high-risk plaques, plaque volume, and plaque progression in patients with diabetes mellitus.

METHODS

Patients with diabetes mellitus and intermediate pretest probability of coronary artery disease (CAD) were prospectively enrolled. All patients underwent baseline coronary computed tomography angiography (CCTA), and patients with recurrent symptoms underwent mid-term follow-up CCTA. Plaque quantification and qualification were performed to compare coronary atherosclerosis features and plaque progression between the elevated and normal Lp (a) groups.

RESULTS

In this study, 1694 subjects (mean age: 62.0 ± 7.0 years; 1031 males) were enrolled for baseline analysis, and 246 subjects with repeat CCTA (mean interval of 2.3 ± 0.74 years) were included for follow-up analysis. The total plaque volume, noncalcified plaque volume, low attenuation plaque (LAP) volume, fibro-fatty plaque volume, and fibrotic plaque volume were higher in the elevated Lp (a) group than in the normal Lp (a) group at baseline (all p < 0.001). At follow-up, the elevated Lp (a) group showed a higher mean annual increase in LAP volume than the normal Lp (a) group (3.03 ± 22.26 mm3 vs -3.09 ± 12.22 mm3; p = 0.011). In multivariate linear regression analysis, elevated Lp (a) levels were associated with accelerated LAP volume progression after adjusting for confounders (Beta = 4.50, 95% confidence interval: 0.06-8.93; p = 0.045).

CONCLUSION

Elevated Lp (a) level in patients with diabetes mellitus was associated with high coronary artery plaque burden at baseline and LAP volume progression at follow-up.

KEY POINTS

Question The relationship between Lp (a) levels and coronary artery plaque volume and progression in patients with diabetes mellitus remains unclear. Findings Elevated Lp (a) level was associated with high total coronary plaque volume at baseline and low-attenuation plaque (LAP) volume progression at follow-up. Clinical relevance Elevated Lp (a) level in patients with diabetes mellitus was associated with high coronary artery plaque burden at baseline and LAP volume progression at follow-up, which supports the modulation of LAP level to improve prognosis.

Association of pericoronary inflammation with atherosclerotic plaque progression in diabetic patients with improved modifiable cardiovascular risk factors: a longitudinal CCTA cohort study

BACKGROUND

Pericoronary adipose tissue (PCAT) attenuation, as assessed by coronary computed tomography angiography (CCTA), has been identified as a marker of pericoronary inflammation and a predictor of future adverse atherosclerotic events. However, the impact of changes in PCAT attenuation, as evaluated by consecutive CCTAs, on plaque progression in high-risk atherosclerotic patients with improved modifiable cardiovascular risk factors (mCRFs) remains unclear.

METHODS

Consecutive patients with type 2 diabetes mellitus (T2DM) who had improved mCRFs and underwent serial, clinically indicated CCTA examinations (time interval ≥ 12 months) at our center between July 2019 and July 2022 were screened. Eligible participants had at least one study plaque, defined as a plaque without significant anatomic stenosis, located in one of the major coronary arteries, which had not been intervened upon or caused adverse events between serial CCTA scans. Percent atheroma volume (PAV) and PCAT attenuation were measured for each study plaque at baseline and follow-up using CCTA plaque analysis software. Changes in PAV (δPAV = follow-up PAV - baseline PAV) were compared based on changes in PCAT attenuation [δPCAT attenuation] (> 0 or ≤ 0). Multivariate linear regression models were used to evaluate the relationship between δPCAT attenuation and δPAV.

RESULTS

A total of 98 T2DM patients (mean age: 59.9 years; 75.3% men; 152 plaques) had mCRFs that reached therapeutic targets at follow-up CCTA. However, overall PAV progressed from baseline in all patients [(41.68 ± 12.47)% vs. (43.71 ± 12.24)%, p = 0.035], accompanied by an increase in coronary inflammation (i.e., PCAT attenuation) during a median follow-up of 13.5 months (interquartile range [IQR]: 12.2, 17.5 months).Compared to patients with δPCAT attenuation ≤ 0, those with δPCAT attenuation > 0 had a significantly greater increase in overall PAV from baseline [(4.09 ± 12.09)% vs. (-0.82 ± 10.74)%, p = 0.011], calcified PAV [1.57% (IQR: 0.13%, 3.84%) vs. 0.38% (IQR: -0.26%, 2.58%), p = 0.008], and a numerical but non-significant increase in non-calcified PAV [(1.29 ± 11.75)% vs. (-1.87 ± 10.47)%, p = 0.089]. Multivariate linear regression models demonstrated that increased PCAT attenuation was significantly associated with the progression of overall PAV (β = 0.339, 95% CI: 0.129-0.549), non-calcified PAV (β = 0.237, 95% CI: 0.019-0.455), and calcified PAV (β = 0.109, 95% CI: 0.019-0.200), independent of age, sex, cardiovascular risk factors, medications, and baseline PCAT attenuation and PAV (all p < 0.05). The effect of elevated PCAT attenuation on overall plaque progression was consistent across subgroups (all p for interaction > 0.05).

CONCLUSION

In this longitudinal CCTA cohort of T2DM patients with improved mCRFs, increased pericoronary inflammation was associated with the progression of atherosclerotic plaque, particularly non-calcified plaque.

Multiple long-term conditions as the next transition in the global diabetes epidemic

Several transitions, or new patterns and dynamics in the contributors and health outcomes, have altered the character and burden of the multi-decade, worldwide growth in prevalence of type 2 diabetes (T2DM). These changes have led to different needs for prevention and care. These dynamics have been driven by diverse demographic, socio-economic, behavioural, and health system response factors. In this Perspective, we describe these transitions and how their attributes have set the stage for multimorbidity, or multiple long-term conditions (MLTCs), to be the next major challenge in the diabetes epidemic. We also describe how the timing and character of these stages differ in high-, middle-, and low-income countries. These challenges call for innovation and a stronger focus on MLTCs across the spectrum of cause, effectiveness, and implementation studies to guide prevention and treatment priorities.

Healthy lifestyle factors and combined macrovascular and microvascular events in diabetes patients with high cardiovascular risk: results from ADVANCE

BACKGROUND

To explore whether healthy lifestyle factors (HLFs) predict a lower risk of major macrovascular and microvascular events and death in people with type 2 diabetes (T2D) with a high risk of vascular complications.

METHODS

Post hoc analyses of 11,133 participants with T2D in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial who were assigned a score ranging from 0 to 4 based on the number of baseline HLFs: never smoked, moderate-to-vigorous physical activity, ideal waist/hip ratio, and low-to-moderate alcohol consumption. Multivariable Cox models were used to determine associations of 0, 1, 2, and ≥ 3 HLFs with vascular events and all-cause mortality.

RESULTS

Compared to participants with no HLFs, hazard ratios for participants with 3 or 4 HLFs were 0.68 (95% confidence interval [CI] 0.57-0.81) for the composite of major macrovascular or microvascular events, 0.58 (0.46-0.75) for major macrovascular events, 0.78 (0.61-0.99) for microvascular events, and 0.48 (0.37-0.63) for all-cause mortality during a median follow-up of 5 years. Each increment in HLF score was significantly associated with lower rates of these outcomes. There was no heterogeneity in the effect on any outcome by HLF across randomized intensive blood glucose control and blood pressure lowering treatments.

CONCLUSIONS

HLFs are associated with lower risks of major macrovascular and microvascular events and lower rates of death in high-risk adults with T2D.

Red blood cell distribution width is an independent predictor of mortality following amputation for diabetic foot

Red blood cell distribution width (RDW) is a prognostic factor in various disorders. This study aimed to assess the prognostic value of RDW in patients undergoing amputation for diabetic foot. We retrospectively analyzed data on 415 patients who underwent diabetic foot amputation between January 2009 and January 2019. After establishing an optimal cutoff value of preoperative RDW for all-cause mortality, univariable and multivariable analyses with Cox proportional hazard model for survivorship and logistic regression analysis for prolonged hospital length of stay (> 30 days) were performed to identify significant prognostic factors. A preoperative RDW of 14.5% was the optimal cutoff value for predicting all-cause mortality. RDW ≥ 14.5% was significantly associated with increased all-cause mortality (hazard ratio, 2.55; 95% confidence interval [CI], 1.55-4.19; P < 0.001) on multivariable Cox proportional model analysis. Preoperative RDW ≥ 14.5% was also associated with a prolonged hospital length of stay after surgery (odds ratio, 2.17; 95% CI, 1.29-3.66; P = 0.004). Higher preoperative RDW was an independent predictive factor for increased all-cause mortality and prolonged hospital length of stay after diabetic foot amputation. These results suggest that RDW may be a useful laboratory parameter for risk stratification in patients undergoing amputation for diabetic foot.

Incidence of early-onset type 2 diabetes and sociodemographic predictors of complications: A nationwide registry study

AIMS

Early-onset type 2 diabetes (T2DM) (18-45 years) is rising globally, yet complication incidence in this group remains unclear. We investigated the incidence of early-onset T2DM, the incidence of micro- and macrovascular complications, and how comorbidities (e.g., severe mental illness) and sociodemographic factors (e.g., education level) influence complication risk and timing in Denmark.

METHODS

Using nationwide registers, we followed 8,129,005 individuals from 1996 to 2020 to estimate the incidence rate (IR) of early-onset T2DM. 49,850 individuals with early-onset T2DM were followed to calculate IRs for microvascular (nephropathy, retinopathy) and macrovascular (cardiovascular disease, amputation) complications. Incidence rate ratios (IRRs) assessed associations between comorbidities, sociodemographic factors, and complications. Poisson regression models calculated IRs and IRRs.

RESULTS

From 1996 to 2020, the IR of early-onset T2DM more than doubled in men and tripled in women, with women dominating younger age groups. During follow-up (7.9-9.8 years), 37.6 % developed complications. Higher complication IRs were observed in men, those with sociodemographic disadvantages, and individuals with comorbidities. Early complications (≤5 years) were more common among the unemployed, single individuals, and those with comorbidities.

CONCLUSIONS

The rising IR of early-onset T2DM in younger women, and complications disproportionately affecting men and those with comorbidities or sociodemographic disadvantages, highlight the need for targeted interventions.

Knowledge, attitudes, and practices of elderly diabetes patients regarding home emergency management of acute complications

AIMS

This study aims to assess the knowledge, attitudes, and practices (KAP) of elderly diabetic patients regarding the home emergency management of acute diabetic complications, which is critical for preventing severe outcomes and ensuring timely intervention in emergencies.

METHODS

This cross-sectional study was conducted between September and October 2024 at the Second Hospital of Shanxi Medical University, among all elderly diabetic patients who voluntarily participated. Demographic information and KAP scores were evaluated.

RESULTS

A total of 409 valid questionnaires were analyzed, yielding an effective rate of 98.32 %. Among the participants, 218 (53.3 %) were female, and 134 (32.76 %) had been diagnosed with diabetes for less than 1 year. The mean scores for KAP were 12.98 ± 6.65 (possible range: 0-28), 45.76 ± 6.30 (possible range: 11-55), and 51.74 ± 8.24 (possible range: 13-65), respectively. Structural equation modeling (SEM) revealed that education level, diabetes health education, and main treatment method significantly influenced knowledge. Additionally, knowledge and complicating diseases impacted attitude, while both knowledge and attitude strongly influenced practice. Education level, diabetes health education, and main treatment method also indirectly affected attitude and practice.

CONCLUSION

Elderly diabetic patients demonstrated inadequate knowledge but exhibited generally positive attitudes and practices regarding the home emergency management of acute diabetic complications.

Related Factors Mining of Diabetes Complications Based on Manifold-Constrained Multi-Label Feature Selection

The primary cause of mortality among individuals with diabetes stems from complications. Identifying related factors for these complications holds immense potential for early prevention. Previous research predominantly employed traditional machine-learning techniques to establish prediction models utilizing medical indicators for related factor selection. However, uncovering the intricate correlations among complication labels and identifying similar characteristics among medical indicators has been challenging. We propose a novel embedded multi-label feature selection approach called LCFSM(Label Cosine and Feature Similar Manifold) to address the issue. LCFSM introduces manifold constraints into the objective function to uncover risk factors associated with diabetes complications. Label cosine similarity is set to optimize feature weights, forming label manifold constraints. Similarly, feature manifold constraints are established to utilize feature kernel similarity in optimizing feature weights. LCFSM formulates an objective function based on the regularized Least Squares and previous manifolds constraints, employing the Sylvester equation for convergence assurance. The experimental evaluation compares LCFSM against eight baselines, demonstrating superior performance in top-10 feature selection and feature stacking.LCFSM is applied to identify primary risk factors for diabetes complications. Related factors involve Electromyogram, Urine Routine Protein Positive, etc, offering valuable insights for early treatment.

The risk of type 2-diabetes among persons with intellectual disability: a Danish population-based matched cohort study

BACKGROUND

Previous research shows that obesity, unhealthy eating, physical inactivity and a high use of psychotropic medications are prevalent among persons with intellectual disability (ID), which might increase the risk of type 2-diabetes (T2DM). This study aims to investigate: (1) whether persons with ID have an increased risk of T2DM compared with an age- and sex-matched reference group and (2) differences in T2DM risk by sex, birth year, ID inclusion diagnosis and ID severity.

METHODS

This study is a nationwide cohort study, including 65 293 persons with ID and 659 723 persons in an age- and sex-matched reference group without ID. Incidence rates for T2DM were calculated and Cox proportional regression models were used to estimate adjusted hazard ratios (aHRs) for the association between ID and T2DM. Follow-up began from the 1 January 1977 (when T2DM data were available), participants' 22nd birthday or from the date the participants immigrated to Denmark, whichever came last and continued until the onset of T2DM, emigration, death or end of follow-up (31 December 2021), whichever came first.

RESULTS

Persons with ID had more than double risk of T2DM compared with the reference group [aHR = 2.15, 95% confidence interval (CI): 2.09-2.20]. The strongest associations were found among women, persons born between 1980 and 1999 and among persons with mild ID.

CONCLUSIONS

Persons with ID have an increased risk of T2DM. This knowledge is important in relation to the development and prioritising of preventive initiatives among persons with ID in the healthcare sector. Future research should focus on the underlying mechanisms that can explain the possible association between ID and T2DM as it allows a more targeted prevention strategy.

Cardiovascular Therapy Benefits of Novel Antidiabetic Drugs in Patients With Type 2 Diabetes Mellitus Complicated With Cardiovascular Disease: A Network Meta-Analysis

OBJECTIVE

Provide an evidence-based basis for the selection of cardiovascular benefit drugs in Type 2 diabetes mellitus (T2DM) patients with cardiovascular disease (CVD).

METHODS

Conduct a comprehensive search of all relevant literature from PubMed, Embase, Web of Science, Cochrane Library, and Clinical Trials.gov from their establishment until December 13, 2023, and select randomized controlled trials (RCTs) that meet the pre-established inclusion and exclusion criteria. Use the Cochrane bias risk assessment tool to evaluate the quality of the included literature. Use R 4.3.2 software to conduct network meta-analysis for drug category comparison.

RESULTS

A total of 24 large-scale randomized controlled trials (RCTs) were included, including 19 intervention measures, and 172 803 patients participated in the study. The results of the network meta-analysis show that: GLP1RA (OR 0.89, 95% CI 0.81-0.97) and SGLT2i (OR 0.91, 95% CI 0.83-0.99) can reduce the occurrence of major adverse cardiovascular events (MACE), GLP1RA (OR 0.88, 95% CI 0.79-0.97) and SGLT2i (OR 0.89, 95% CI 0.81-0.99) reduced the risk of cardiovascular death. SGLT2i (OR 0.68, 95% CI 0.62-0.75) reduced the occurrence of hospitalization for heart failure, GLP1RA (OR 0.88, 95% CI 0.81-0.97) and SGLT2i (OR 0.89, 95% CI 0.80-0.97) reduced the occurrence of all-cause death.

CONCLUSION

In the comparison of new hypoglycemic drug classes, GLP1RA and SGLT2i reduced MACE, cardiovascular mortality and all-cause mortality in T2DM patients with CVD, with no significant difference in efficacy, and DPP4i was noninferior to placebo. Only GLP1RA reduced the risk of nonfatal stroke, and only SGLT2i reduced the risk of HHF.

Prevalence of Musculoskeletal Manifestations and its Associated Factors in Patients with Type 2 Diabetes Mellitus in Ernakulam District: A Cross-Sectional Study

Introduction

India is referred to as the "Diabetes Capital of the World" with a weighted prevalence of diabetes of 11.4%. In addition to microvascular and macrovascular complications, musculoskeletal manifestations of diabetes mellitus (MMDMs) also cause significant pain, morbidity, and a decrease in quality of life. Previous studies in our country were from tertiary healthcare centres, and the actual community-based prevalence of MMDMs is unknown. The study aims to determine the prevalence of MMDMs and the factors associated with them in the Ernakulam district of Kerala.

Methods

A community-based cross-sectional study was done in 600 adults with diabetes in the Ernakulam district of Kerala. Cluster sampling was adopted. Through the probability proportional to sample size method, 20 clusters were identified with each having 30 participants. The study participants were clinically examined for various MMDMs.

Results

The prevalence of MMDMs was found to be 44.83%. Osteoarthritis knee emerged as the most prevalent MMDM involving 22% of the participants, followed by frozen shoulder, in 12.2%. Diabetic cheiroarthropathy, trigger finger, and carpal tunnel syndrome were noted in 6.7%, 4.7%, and 3.8% of participants, respectively. Multivariable analysis showed a significant association between MMDMs and increased BMI, higher socioeconomic status, longer duration of diabetes, and unsatisfactory physical activity.

Conclusion

This study highlights the need for regular musculoskeletal system assessment in patients with diabetes which needs to be made mandatory in clinical practice and also conducting screening for the same in the community level to prevent further complications and to improve quality of life.

Medication adherence and related factors among older adults with type 2 diabetes who use home health care

Medication adherence is important for diabetes management, to reduce complications and mortality. Home health care (HHC) has been recognized as a solution for medication adherence, because it provides easy community access and implementation of interventions. However, little is known about the relationship between HHC and medication adherence. Therefore, this study aimed to identify medication adherence and associated factors among older adults receiving HHC for type 2 diabetes, analyzing dispensing records in South Korea. The patients' average medication possession ratio was 88.5 %, with 64.6 % categorized as the adherence group. Factors affecting medication adherence included the number of HHC advanced practice nurses with specific certifications, out-of-pocket medication costs, sex, age, residence, dementia or cognitive impairment, the number of concomitant medications, and the Charlson Comorbidity Index. Notably, a higher number of HHC advanced practice nurses with specific certifications were significantly associated with adherence, suggesting that HHC could be an alternative approach to enhance medication adherence.

Microbiology and Antimicrobial Resistance Profile in Patients with Diabetic Foot Sepsis at a Central Hospital in Johannesburg, South Africa

Background: Diabetic foot sepsis (DFS) is the leading cause of lower extremity amputations and timely initiation of effective antimicrobial therapy is paramount during its management. This study investigated causative microorganisms and their antimicrobial susceptibility profile in patients with DFS. Materials and Methods: A retrospective review was conducted on patients who were 18-years and older admitted with DFS. Data collected included demographic information, comorbidities, clinical findings, types of specimens collected and results of microscopy, culture, and sensitivity (MC&S), treatment, and outcomes. Results: One hundred and sixty-eight records were found, of which 64.3% were of male patients. The median (IQR) age of males was 58 years (IQR 54-65) compared to 61 years (IQR 54-67) for females. Results of MC&S were available in 63.1% of the records, and E. faecalis was cultured in 16%, P. mirabilis in 10%, and S. aureus in 8% of cases. Amoxicillin/Clavulanic acid was prescribed in 69% of the cases. Resistance to at least one antimicrobial was shown in 88% of S. aureus and 80% of P. mirabilis species. Conclusions: The commonly cultured organisms in patients with DFS were E. faecalis 16%, P. mirabilis 10%, and S. aureus. Amoxicillin/Clavulanic was prescribed empirically in 69% of the cases despite high rates of resistance, and in 37% treatment was not preceded by collection of specimens for MC&S. We therefore recommend collection of specimens for MC&S before initiation of antimicrobial therapy in all patients with DFS.

TRPV1: A novel target for the therapy of diabetes and diabetic complications

BACKGROUND

Diabetes mellitus is a chronic metabolic disease characterized by abnormally elevated blood glucose levels. Type II diabetes accounts for approximately 90% of all cases. Several drugs are available for hyperglycemia treatment. However, the current therapies for managing high blood glucose do not prevent or reverse the disease progression, which may result in complications and adverse effects, including diabetic neuropathy, retinopathy, and nephropathy. Hence, developing safer and more effective methods for lowering blood glucose levels is imperative. Transient receptor potential vanilloid-1 (TRPV1) is a significant member of the transient receptor potential family. It is present in numerous body tissues and organs and performs vital physiological functions.

PURPOSE

This review aimed to develop new targeted TRPV1 hypoglycemic drugs by systematically summarizing the mechanism of action of the TRPV1-based signaling pathway in preventing and treating diabetes and its complications.

METHODS

Literature searches were performed in the PubMed, Web of Science, Google Scholar, Medline, and Scopus databases for 10 years from 2013 to 2023. The search terms included "diabetes," "TRPV1," "diabetic complications," and "capsaicin."

RESULTS

TRPV1 is an essential potential target for treating diabetes mellitus and its complications. It reduces hepatic glucose production and food intake and promotes thermogenesis, metabolism, and insulin secretion. Activation of TRPV1 ameliorates diabetic nephropathy, retinopathy, myocardial infarction, vascular endothelial dysfunction, gastroparesis, and bladder dysfunction. Suppression of TRPV1 improves diabetes-related osteoporosis. However, the therapeutic effects of activating or suppressing TRPV1 may vary when treating diabetic neuropathy and periodontitis.

CONCLUSION

This review demonstrates that TRPV1 is a potential therapeutic target for diabetes and its complications. Additionally, it provides a theoretical basis for developing new hypoglycemic drugs that target TRPV1.

Glycemic control and cancer outcomes in oncologic patients with diabetes: an Italian Association of Medical Oncology (AIOM), Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Italian Society of Endocrinology (SIE), Italian Society of Pharmacology (SIF) multidisciplinary critical view

BACKGROUND

 Increasing evidence suggests that diabetes increases the risk of developing different types of cancer. Hyperinsulinemia, hyperglycemia and chronic inflammation, characteristic of diabetes, could represent possible mechanisms involved in cancer development in diabetic patients. At the same time, cancer increases the risk of developing new-onset diabetes, mainly caused by the use of specific anticancer therapies. Of note, diabetes has been associated with a ∼10% increase in mortality for all cancers in comparison with subjects who did not have diabetes. Diabetes is associated with a worse prognosis in patients with cancer, and more recent findings suggest a key role for poor glycemic control in this regard. Nevertheless, the association between glycemic control and cancer outcomes in oncologic patients with diabetes remains unsettled and poorly debated.

PURPOSE

 The current review seeks to summarize the available evidence on the effect of glycemic control on cancer outcomes, as well as on the possibility that timely treatment of hyperglycemia and improved glycemic control in patients with cancer and diabetes may favorably affect cancer outcomes.

Knowledge, attitude, and diabetes self-care among individuals at high-risk of diabetes-related blindness in Bangladesh: a cross-sectional study

BACKGROUND/AIM

Adequate knowledge, attitude, and self-care practice (KAP) are paramount in reducing diabetes complications. This study examined diabetes-related KAP in individuals who have been previously reported to be at a higher risk of blindness such as those on insulin treatment or with a longer (>6 years) duration of diabetes in Bangladesh.

METHODS

Six hundred community-dwelling individuals (mean age = 52.7±11.6 years) who had been diagnosed with diabetes by their doctor were interviewed. A semi-structured questionnaire obtained self-reported information about diabetes-related KAP, duration, treatment of diabetes, and sociodemographic parameters including age, gender, and education level. Data were collected using a purposive sample technique and analyzed using Fischer's exact test or independent samples t-tests.

RESULTS

There were 271 males (45.2%) and 329 (54.8%) females. Of the total participants (mean diabetes duration = 6.6±6.2 years), 36.5% had diabetes for more than the median duration of 6 years, 80.7% were receiving insulin or insulin combined with tablets (insulin group) and the remaining 19.3% were on tablet only and/or diet control (non-insulin group). One-fifth (19.8%) of all the participants did not consider diabetes a serious disease, 31.3% were unaware that uncontrolled diabetes can cause blindness, 40.5% had never had their eyes tested for diabetic retinopathy and 41.5% stated that they would not attend diabetic retinopathy screening until their eyesight became worse. Among those in the insulin group, 42.1% reported being unaware that smoking may be harmful to diabetes compared to 30.2% of those in the non-insulin group (p= 0.02). Additionally, 64.7% of those in the insulin group were unaware that a diabetic retinal screening is different from a routine eye test for spectacles, compared to 44.8% in the non-insulin group (p< 0.001). Sixty-two percent of participants with diabetes duration of more than 6 years reported that diabetes management was a shared responsibility between the doctor and the patient compared to 48.3% with a shorter duration (p< 0.001). Those with a longer duration of diabetes (>6 years) also reported forgetting to take their medication more often than those with a shorter duration (p = 0.02). Twenty-one percent of participants with a duration of diabetes longer than six years had checked their eyes within the previous year compared to 63.5% of those with a shorter duration of diabetes (p< 0.001).

CONCLUSION

Individuals on insulin treatment demonstrated poorer knowledge and awareness of diabetes and diabetes eye screening. Those with a longer diabetes duration exhibited poorer self-care practices, particularly not taking the medication regularly, and neglecting diabetic retinal checkups. These issues need to be addressed in designing targeted educational interventions to prevent blindness from uncontrolled diabetes in the high-risk groups in Bangladesh.

Explainable machine learning model for predicting the risk of significant liver fibrosis in patients with diabetic retinopathy

BACKGROUND

Diabetic retinopathy (DR), a prevalent complication in patients with type 2 diabetes, has attracted increasing attention. Recent studies have explored a plausible association between retinopathy and significant liver fibrosis. The aim of this investigation was to develop a sophisticated machine learning (ML) model, leveraging comprehensive clinical datasets, to forecast the likelihood of significant liver fibrosis in patients with retinopathy and to interpret the ML model by applying the SHapley Additive exPlanations (SHAP) method.

METHODS

This inquiry was based on data from the National Health and Nutrition Examination Survey 2005-2008 cohort. Utilizing the Fibrosis-4 index (FIB-4), liver fibrosis was stratified across a spectrum of grades (F0-F4). The severity of retinopathy was determined using retinal imaging and segmented into four discrete gradations. A ten-fold cross-validation approach was used to gauge the propensity towards liver fibrosis. Eight ML methodologies were used: Extreme Gradient Boosting, Random Forest, multilayer perceptron, Support Vector Machines, Logistic Regression (LR), Plain Bayes, Decision Tree, and k-nearest neighbors. The efficacy of these models was gauged using metrics, such as the area under the curve (AUC). The SHAP method was deployed to unravel the intricacies of feature importance and explicate the inner workings of the ML model.

RESULTS

The analysis included 5,364 participants, of whom 2,116 (39.45%) exhibited notable liver fibrosis. Following random allocation, 3,754 individuals were assigned to the training set and 1,610 were allocated to the validation cohort. Nine variables were curated for integration into the ML model. Among the eight ML models scrutinized, the LR model attained zenith in both AUC (0.867, 95% CI: 0.855-0.878) and F1 score (0.749, 95% CI: 0.732-0.767). In internal validation, this model sustained its superiority, with an AUC of 0.850 and an F1 score of 0.736, surpassing all other ML models. The SHAP methodology unveils the foremost factors through importance ranking.

CONCLUSION

Sophisticated ML models were crafted using clinical data to discern the propensity for significant liver fibrosis in patients with retinopathy and to intervene early.

PRACTICE IMPLICATIONS

Improved early detection of liver fibrosis risk in retinopathy patients enhances clinical intervention outcomes.

Association between triglyceride-glucose index and in-hospital all-cause mortality under different glucose metabolism status among patients with coronary artery disease

BACKGROUND

This current study aimed to investigate the relationship between the triglyceride-glucose (TyG) index and in-hospital all-cause mortality of coronary artery disease (CAD) in patients with different glucose metabolic statuses.

METHODS

Participants were divided into three groups according to tertiles of the TyG index. Glucose metabolic status was classified as normal glucose regulation, pre-diabetes mellitus, and diabetes mellitus (DM). The primary outcome was in hospital all-cause mortality.

RESULTS

We observed a significant relationship between the TyG index and in-hospital deaths of patients with CAD in this study. After adjusting for multiple factors in the logistic regression model, the TyG index was still an independent risk factor, and the T3 group (OR, 2.311; 95% CI = 1.237-4.317; P = 0.009) was correlated with a 2.311-fold risk compared with the T1 group. In the subgroup analysis of different glucose metabolic status, the T3 group (OR, 1.541; 95% CI: 1.013-2.344; P = 0.043) were associated with a significantly higher risk of in-hospital deaths in CAD patients with DM.

CONCLUSIONS

An increased TyG index was correlated with a higher risk of in-hospital all-cause mortality. Our study indicated that TyG index could be a valuable predictor of in-hospital death of CAD patients, especially for individuals with DM.

Dynamics trajectory of patient-reported quality of life and its associated risk factors among hepatocellular carcinoma patients receiving immune checkpoint inhibitors: a prospective cohort study

Objective

We aimed to characterize quality of life (QOL) trajectories among patients with intermediate and advanced hepatocellular carcinoma patients treated with immunotherapy.

Methods

Barcelona Clinic Liver Cancer (BCLC) stage B-C HCC patients receiving immunotherapy at Guangxi Medical University Cancer Hospital were included. Trajectories of QOL, assessed using the Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep) questionnaire, were identified through iterative estimations of group-based trajectory models. Associations with trajectory group membership were analyzed using multivariable multinomial logistic regression.

Results

Three trajectory groups were identified (n=156): excellent (35.3%), poor (43.6%), and deteriorating (21.1%) QOL. The deteriorating trajectory group reported a mean QOL score of 124.79 (95% CI, 116.58-133.00), but then declined significantly at month-2 (estimated QOL score 98.67 [95% CI, 84.33-113.00]), and the lowest mean score is reached at month-6 (estimated QOL score 16.58 [95% CI, 0-46.07]). Factors associated with membership to the deteriorating group included no drinking (odds ratio [OR] vs yes [95% CI], 3.70 [1.28-11.11]), no received radiotherapy (OR vs yes [95% CI], 8.33 [1.41-50.00]), diabetes (OR vs no [95% CI], 6.83 [1.57-29.73]), and extrahepatic metastasis (OR vs no [95% CI], 3.08 [1.07-8.87]). Factors associated with membership to the poor group also included body mass index ≤24.0 kg/m2 (OR vs no [95% CI], 4.49 [1.65-12.22]).

Conclusions

This latent-class analysis identified a high-risk cluster of patients with severe, persistent post-immunotherapy QOL deterioration. Screening relevant patient-level characteristics may inform tailored interventions to mitigate the detrimental impact of immunotherapy and preserve QOL.

A critical review on diabetes mellitus type 1 and type 2 management approaches: from lifestyle modification to current and novel targets and therapeutic agents

Diabetes mellitus (DM) has emerged as an international health epidemic due to its rapid rise in prevalence. Consequently, scientists and or researchers will continue to find novel, safe, effective, and affordable anti-diabetic medications. The goal of this review is to provide a thorough overview of the role that lifestyle changes play in managing diabetes, as well as the standard medications that are currently being used to treat the condition and the most recent advancements in the development of novel medical treatments that may be used as future interventions for the disease. A literature search was conducted using research databases such as PubMed, Web of Science, Scopus, ScienceDirect, Wiley Online Library, Google Scholar, etc. Data were then abstracted from these publications using words or Phrases like "pathophysiology of diabetes", "Signe and symptoms of diabetes", "types of diabetes", "major risk factors and complication of diabetes", "diagnosis of diabetes", "lifestyle modification for diabetes", "current antidiabetic agents", and "novel drugs and targets for diabetes management" that were published in English and had a strong scientific foundation. Special emphasis was given to the importance of lifestyle modification, as well as current, novel, and emerging/promising drugs and targets helpful for the management of both T1DM and T2DM.

From Diabetes to Dementia: Identifying Key Genes in the Progression of Cognitive Impairment

OBJECTIVES

To provide a basis for further research on the molecular mechanisms underlying type 2 diabetes-associated mild cognitive impairment (DCI) using two bioinformatics methods to screen key genes involved in the progression of mild cognitive impairment (MCI) and type 2 diabetes.

METHODS

RNA sequencing data of MCI and normal cognition groups, as well as expression profile and sample information data of clinical characteristic data of GSE63060, which contains 160 MCI samples and 104 normal samples, were downloaded from the GEO database. Hub genes were identified using weighted gene co-expression network analysis (WGCNA). Protein-protein interaction (PPI) analysis, combined with least absolute shrinkage and selection operator (LASSO) and receiver operating characteristic (ROC) curve analyses, was used to verify the genes. Moreover, RNA sequencing and clinical characteristic data for GSE166502 of 13 type 2 diabetes samples and 13 normal controls were downloaded from the GEO database, and the correlation between the screened genes and type 2 diabetes was verified by difference and ROC curve analyses. In addition, we collected clinical biopsies to validate the results.

RESULTS

Based on WGCNA, 10 modules were integrated, and six were correlated with MCI. Six hub genes associated with MCI (TOMM7, SNRPG, COX7C, UQCRQ, RPL31, and RPS24) were identified using the LASSO algorithm. The ROC curve was screened by integrating the GEO database, and revealed COX7C, SNRPG, TOMM7, and RPS24 as key genes in the progression of type 2 diabetes.

CONCLUSIONS

COX7C, SNRPG, TOMM7, and RPS24 are involved in MCI and type 2 diabetes progression. Therefore, the molecular mechanisms of these four genes in the development of type 2 diabetes-associated MCI should be studied.

The burden of diabetes-associated multiple long-term conditions on years of life spent and lost

Diabetes mellitus is a central driver of multiple long-term conditions (MLTCs), but population-based studies have not clearly characterized the burden across the life course. We estimated the age of onset, years of life spent and loss associated with diabetes-related MLTCs among 46 million English adults. We found that morbidity patterns extend beyond classic diabetes complications and accelerate the onset of severe MLTCs by 20 years earlier in life in women and 15 years earlier in men. By the age of 50 years, one-third of those with diabetes have at least three conditions, spend >20 years with them and die 11 years earlier than the general population. Each additional condition at the age of 50 years is associated with four fewer years of life. Hypertension, depression, cancer and coronary heart disease contribute heavily to MLTCs in older age and create the greatest community-level burden on years spent (813 to 3,908 years per 1,000 individuals) and lost (900 to 1,417 years per 1,000 individuals). However, in younger adulthood, depression, severe mental illness, learning disabilities, alcohol dependence and asthma have larger roles, and when they occur, all except alcohol dependence were associated with long periods of life spent (11-14 years) and all except asthma associated with many years of life lost (11-15 years). These findings provide a baseline for population monitoring and underscore the need to prioritize effective prevention and management approaches.

Mechanistic Insights and Potential Therapeutic Implications of NRF2 in Diabetic Encephalopathy

Diabetic encephalopathy (DE) is a complication of diabetes, especially type 2 diabetes (T2D), characterized by damage in the central nervous system and cognitive impairment, which has gained global attention. Despite the extensive research aimed at enhancing our understanding of DE, the underlying mechanism of occurrence and development of DE has not been established. Mounting evidence has demonstrated a close correlation between DE and various factors, such as Alzheimer's disease-like pathological changes, insulin resistance, inflammation, and oxidative stress. Of interest, nuclear factor erythroid 2-related factor 2 (NRF2) is a transcription factor with antioxidant properties that is crucial in maintaining redox homeostasis and regulating inflammatory responses. The activation and regulatory mechanisms of NRF2 are a relatively complex process. NRF2 is involved in the regulation of multiple metabolic pathways and confers neuroprotective functions. Multiple studies have provided evidence demonstrating the significant involvement of NRF2 as a critical transcription factor in the progression of DE. Additionally, various molecules capable of activating NRF2 expression have shown potential in ameliorating DE. Therefore, it is intriguing to consider NRF2 as a potential target for the treatment of DE. In this review, we aim to shed light on the role and the possible underlying mechanism of NRF2 in DE. Furthermore, we provide an overview of the current research landscape and address the challenges associated with using NRF2 activators as potential treatment options for DE.

Prevalence of very high cardiovascular disease risk in patients with type 2 diabetes mellitus: A population-based cross-sectional screening study

AIM

The 2019 ESC/EASD guidelines categorize cardiovascular disease risk (CVD) in patients with diabetes mellitus (DM). Assessing CVD risk is necessary to identify individuals at very high risk of CVD, enabling tailored and precise intervention for this high-risk population. This study aims to evaluate the severity of a very high risk for CVD stratification among patients with type 2 DM (T2DM) across different regions in China.

METHODS

We conducted a cross-sectional screening study from 1 January 2020 to 30 December 2022. Disease duration, body mass index (BMI), targeted organ damage, such as atherosclerotic heart disease, proteinuria, impaired renal function, left ventricular hypertrophy, retinopathy and known CVD risk factors, were collected from diabetic patients by professionally trained physicians. The risk of CV in patients with DM was categorized into two groups: very high risk and others, according to the 2019 ESC/EASD guidelines.

RESULTS

In total, 1 870 720 participants from 1669 hospitals in 30 provinces of China, excluding Tibet, Taiwan, Hong Kong and Macao, were enrolled from 2020 to 2022, among whom 67.50% of patients with T2DM were at very high risk for CVD. The proportions of very high-risk T2DM were higher in Northeast China (75.82%), Central China (73.65%) and Southwest China (72.66%), while the lowest prevalence of very high-risk T2DM was found in Southern China (60.15%). The multivariate binary logistic regression analyses suggested that the category of very high risk for CVD is associated with age [odds ratio (OR) = 1.04; 95% confidence interval (CI): 1.04-1.04; p < .0001], BMI (OR = 1.07; 95% CI: 1.07-1.07; p < .0001), duration of DM (OR = 1.05; 95% CI: 1.05-1.05; p < .0001), hypertension (OR = 3.75; 95% CI: 3.72-3.78; p < .0001), dyslipidaemia (OR = 5.22; 95% CI: 5.18-5.27; p < .0001) and smoking (OR = 2.92; 95% CI: 2.89-2.95; p < .0001).

CONCLUSIONS

This study represented the largest observational study of CVD risk assessment in patients with T2DM in China. The CVD risk situation of patients with diabetes in China is critical, and comprehensive control and management of CVD risk factors, such as hypertension, BMI and dyslipidaemia, in patients with DM need to be strengthened in patients with T2DM in China.

Healthy lifestyle associated with dynamic progression of type 2 diabetes: A multi-state analysis of a prospective cohort

Background

Although the association of a healthy lifestyle with type 2 diabetes (T2D) has been extensively studied, its impact on the dynamic trajectory, including progression, onset and prognosis, of T2D has not been investigated.

Methods

Using data from the UK Biobank, 461 168 participants without diabetes or diabetes-related events were included. We incorporated four lifestyle factors to construct the healthy lifestyle score (HLS). We employed a multi-state model to examine the relationship between a healthy lifestyle and transition in T2D progression, including transitions from baseline to diabetes, complications, and further to death. The cumulative probability of above transitions based on the health lifestyle score was calculated.

Results

The results indicated that adhering to 3-4 healthy lifestyles had an inverse association with the risk of transition from baseline to diabetes (hazard ratio (HR) = 0.966; 95% confidence interval (CI) = 0.935-0.998, P = 0.038), diabetes to complications (HR = 0.869; 95% CI = 0.818-0.923, P = 5.2 × 10-6), baseline to death (HR = 0.528; 95% CI = 0.502-0.553, P < 2 × 10-16, and diabetes to death (HR = 0.765; 95% CI = 0.591-0.990, P = 0.041) compared with maintaining 0-1 healthy lifestyles. In addition, the transition probability of the above transitions can be lower with maintaining 3-4 healthy lifestyles.

Conclusions

Healthy lifestyles are negatively associated with the risk of multiple outcomes during the dynamic progression of T2D. Adherence to 3-4 healthy lifestyle behaviours before diabetes onset can lower the risk of developing T2D, further reducing the risk of diabetes complications and death in patients with T2D.

Non-alcoholic fatty liver disease: A new predictor of recurrent ischemic stroke and transient ischemic attack in patients with carotid atherosclerosis

PURPOSE

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease. This study focused on assessing the predictive significance of NAFLD for recurrent stroke and transient ischemic attack (TIA) risk to determine the value of NAFLD.

METHOD

This study included 742 participants (mean age: 64.26 ± 9.42 years, 497 males) with carotid atherosclerosis who underwent carotid CT angiography (CTA) between January 2013 and December 2021 in this retrospective study. NAFLD was diagnosed by non-enhanced abdominal CT. The clinical endpoint was a recurrent ischemic stroke or TIA. Cox proportional hazards and Kaplan-Meier analysis assessed whether NAFLD was associated with the endpoint. We accessed the predictive values of NAFLD, clinical, plaque characteristics, and combined model by the C statistics. The predictive performance of the combined model was assessed by receiver operating characteristic curve (ROC) analysis.

RESULTS

A total of 742 participants (mean age: 64.26 ± 9.42 years, 497 males) were included. During 2.9 years of follow-up (interquartile range, 2.1-3.9), 166 patients reached the clinical endpoint. Multivariable cox analyses showed NAFLD was associated with recurrent stroke or TIA in all groups (all P<0.05). Patients with NAFLD had a lower event-free survival (EFS) rate than those without NAFLD (P<0.05). The combined model, including NAFLD, clinical data and plaque features, showed the best performance in predicting the clinical endpoint (AUC=0.79).

CONCLUSIONS

NAFLD contributes to the prediction of recurrent ischemic stroke or TIA. NAFLD may be a novel imaging marker that offers a new perspective on preventing cardiovascular disease in the clinic.

Circular RNA HMGCS1 sponges MIR4521 to aggravate type 2 diabetes-induced vascular endothelial dysfunction

Noncoding RNA plays a pivotal role as novel regulators of endothelial cell function. Type 2 diabetes, acknowledged as a primary contributor to cardiovascular diseases, plays a vital role in vascular endothelial cell dysfunction due to induced abnormalities of glucolipid metabolism and oxidative stress. In this study, aberrant expression levels of circHMGCS1 and MIR4521 were observed in diabetes-induced human umbilical vein endothelial cell dysfunction. Persistent inhibition of MIR4521 accelerated development and exacerbated vascular endothelial dysfunction in diabetic mice. Mechanistically, circHMGCS1 upregulated arginase 1 by sponging MIR4521, leading to decrease in vascular nitric oxide secretion and inhibition of endothelial nitric oxide synthase activity, and an increase in the expression of adhesion molecules and generation of cellular reactive oxygen species, reduced vasodilation and accelerated the impairment of vascular endothelial function. Collectively, these findings illuminate the physiological role and interacting mechanisms of circHMGCS1 and MIR4521 in diabetes-induced cardiovascular diseases, suggesting that modulating the expression of circHMGCS1 and MIR4521 could serve as a potential strategy to prevent diabetes-associated cardiovascular diseases. Furthermore, our findings provide a novel technical avenue for unraveling ncRNAs regulatory roles of ncRNAs in diabetes and its associated complications.

The relationship between hypomagnesemia and albuminuria in patients with type 2 diabetes mellitus

OBJECTIVE

Diabetic nephropathy is a prevalent cause of chronic kidney disease worldwide. Magnesium plays a critical role in insulin resistance, and insulin, in turn, regulates magnesium levels. We aimed to investigate the association between hypomagnesemia and albuminuria in patients with type 2 diabetes mellitus (T2DM).

DESIGN, PATIENTS AND MEASUREMENTS

This retrospective single-centre study encompassed 1178 patients aged 18 and above with T2DM, who attended our outpatient clinic between January 2019 and August 2020. Albuminuria levels were categorised according to Kidney Disease Outcomes Quality Initiative guidelines. In the literature, when examining cut-off values for hypomagnesemia, it is observed that studies typically use hospital normal level as a reference point. Hypomagnesemia, defined as magnesium levels below 1.6 mg/dL, was compared to normomagnesemia (magnesium between 1.6 and 2.4 mg/dL). The primary objective was to explore the impact of magnesium levels on albuminuria, while the secondary objective was to determine the prevalence of hypomagnesemia. The multivariate logistic regression analyses were performed according to age, gender (male), HbA1c, and presence of hypomagnesemia.

RESULTS

The mean age of the participants was 58.7 ± 12.2 years, with 44% being male. Hypomagnesemia was identified in 5.3% of the patients. Advanced age and female gender were more common among patients with hypomagnesemia (p = .001). Magnesium levels exhibited a negative correlation with HbA1c and fasting blood glucose, and a positive correlation with creatinine levels (r = -.117, r = -.131, r = .117, p < .001 for all three variables). Hypomagnesemia was significantly more prevalent in patients with albuminuria (15.9% vs. 4.7%, p < .001). Moreover, participants with the presence of hypomagnesemia were independently associated with a higher risk of albuminuria (odds ratio 3,64 1.76-7.52, p = .001).

CONCLUSION

Albuminuria is more frequently observed in patients with hypomagnesemia.

The role of kidney biopsy in deciphering diabetic versus non-diabetic origin of kidney disease among patients with type 2 diabetes mellitus and nephrotic range proteinuria: A retrospective study

Background

Diabetes mellitus (DM) is tightly associated with the increased prevalence of diabetic kidney disease (DKD). Nonetheless, severe renal function impairment and/or nephrotic range-proteinuria could also result from non-diabetic renal disease (non-DRD) among patients with DM. The 'Gold standard' for the differential diagnosis between DKD and non-DRD is kidney biopsy, although no real consensus exists. Thus, this study intends to associate the clinical and biochemical profile of patients with DM and renal disease with the histopathological data of kidney biopsy.In addition, we aimed to evaluate the role of kidney biopsy, especially when other causes, other than DM, are highly suspected among patients with DM and kidney disease.

Methods

Thirty two patients with T2DM and nephrotic range levels of proteinuria or with co-existing factors pointing towards a non-diabetic origin of kidney disease were studied, retrospectively. All 32 patients underwent kidney biopsy and were classified according to histopathological findings into 3 groups: a) isolated diabetic kidney disease (DKD), b) non-diabetic kidney disease (NDKD) and c) mixed kidney disease (MKD).

Results

Fifteen out of the 32 patients had findings of an isolated DKD, while 17 out of 32 patients suffered from NDKD (13 patients) or MKD (4 patients). DKD patients were younger (p = 0.016) and had a higher HbA1c value (p = 0.069, borderline statistical significance), while the NDKD patients had significantly shorter disease duration (p = 0.04). Furthermore, the incidence of diabetic retinopathy (DR) was lower among the NDKD patients (p < 0.001), who had also significantly less interstitial fibrosis (p = 0.02). Finally, the presence of DR, higher levels of interstitial fibrosis and longer T2DM duration were recognized as factors, which were positively associated with DKD.

Conclusion

This study advocates the usefulness of kidney biopsy in patients with T2DM and nephrotic range levels of proteinuria, especially when DR is absent and shorter disease duration is observed.

Deciphering the role of classical oestrogen receptor in insulin resistance and type 2 diabetes mellitus: From molecular mechanism to clinical evidence

The biological actions of oestrogen are mediated by the oestrogen receptor α or β (ERα or ERβ), which are members of a broad nuclear receptor superfamily. Numerous in vivo and in vitro studies have demonstrated that loss of circulating oestrogen modulated by classical ERα and ERβ led to rapid changes in pancreatic β-cell and islet function, GLUT4 expression, insulin sensitivity and glucose tolerance, dysfunctional lipid homeostasis, oxidative stress, and inflammatory cascades. Remarkably, 17β-oestradiol (E2) can completely reverse these effects. This review evaluates the current understanding of the protective role of classical ER in critical pathways and molecular mechanisms associated with insulin resistance and type 2 diabetes mellitus (T2DM). It also examines the effectiveness of menopausal hormone therapy (MHT) in reducing the risk of developing T2DM in menopausal women. Clinical trials have shown the protective effects of MHT on glucose metabolism, which may be useful to treat T2DM in perimenopausal women. However, there are concerns about E2's potential side effects of obesity and hyperlipidaemia in menopausal women. Further studies are warranted to gain understanding and find other oestrogen alternatives for treatment of insulin resistance and T2DM in postmenopausal women.

Continuous Glucose, Insulin and Lifestyle Data Augmentation in Artificial Pancreas Using Adaptive Generative and Discriminative Models

Artificial pancreas requires data from multiple sources for accurate insulin dose estimation. These include data from continuous glucose sensors, past insulin dosage information, meal quantity and time and physical activity data. The effectiveness of closed-loop diabetes management systems might be hampered by the absence of these data caused by device error or lack of compliance by patients. In this study, we demonstrate the effect of output sequence length-driven generative and discriminative model selection in high quality data generation and augmentation. This novel generative adversarial network (GAN) based architecture automatically selects the generator and discriminator architecture based on the desired output sequence length. The proposed model is able to generate glucose, physical activity, meal information data for individual patients. The discriminative scores for Ohio T1DM (2018) dataset were 0.17 ±0.03 (Inputs: CGM, CHO, Insulin) and 0.15 ±0.02 (Inputs: CGM, CHO, Insulin, Heart Rate, Steps) and for Ohio T1D (2020) dataset was 0.16 ±0.02 (Inputs: CGM, CHO, Insulin) and 0.15 ±0.02 (Inputs: CGM, CHO, Insulin, acceleration). A mixture of generated and real data was used to test predictive scores for glucose forecasting models. The best RMSE and MARD achieved for OhioT1DM patients were 17.19 ±3.22 and 7.14 ±1.76 for PH=30 min with CGM, CHO, Insulin, heartrate and steps as inputs. Similarly, the RMSE and MARD for real+synthetic data were 15.63 ±2.57 and 5.86 ±1.69 respectively. Compared to existing generative models, we demonstrate that sequence length based architecture selection leads to better synthetic data generation for multiple output sequences (CGM, CHO, Insulin) and forecasting accuracy.

Pharmacokinetic, Pharmacodynamic, and Safety Profiles of Proline Henagliflozin in Chinese Subjects with Varying Degrees of Liver Dysfunction

Proline henagliflozin, a novel selective inhibitor of sodium glucose cotransporter 2, is a treatment for type 2 diabetes mellitus. We designed a parallel-group, open-label, and multicenter study to evaluate the pharmacokinetic (PK), pharmacodynamic (PD), and safety profiles of henagliflozin in Chinese subjects with varying degrees of liver dysfunction. Thirty-two subjects were enrolled and divided into four groups based on liver function (normal liver function, mild, moderate, or severe liver dysfunction). The area under the plasma concentration from time zero to infinity of henagliflozin in subjects with mild liver dysfunction, moderate liver dysfunction, and severe liver dysfunction compared with normal liver function was increased by 137%, 197%, and 204%, respectively. The maximum plasma concentration was also increased by 123%, 129%, and 139%, respectively. PK parameters of three metabolites varied to different degrees in the liver dysfunction groups than in the normal liver function group. The mean accumulative excretion amounts and fraction of dose excreted in urine expressed as a percentage were all increased with the decrease of liver function. The PD parameters were significantly higher in liver dysfunction groups than those in the normal liver function group. However, the urine creatinine (UCr) was not significantly different among the groups. No notable adverse events or adverse drug reactions were observed. Due to the higher exposures in subjects with liver dysfunction, the benefit: risk ratio should be individually assessed because the long-term safety profile and efficacy have not been specifically studied in this population.

Preventing diabetes complications

The key aim of diabetes management is to prevent complications, which are a major cause of morbidity and mortality. At an individual level, people with diabetes are less likely than they were several decades ago to experience classical macrovascular and microvascular complications as a result of improvements in modifiable cardiovascular risk factors and preventive healthcare. However, a significant burden of diabetes complications persists at a population level because of the increasing incidence of diabetes, as well as longer lifetime exposure to diabetes because of younger diagnosis and increased life expectancy. Trials have shown that the most effective strategy for preventing complications of diabetes is a multifactorial approach focussing simultaneously on the management of diet, exercise, glucose levels, blood pressure and lipids. In addition to the cornerstone strategies of addressing diet, exercise and lifestyle measures, the introduction of newer glucose-lowering agents, including sodium-glucose transport protein 2 inhibitors and glucagon-like peptide-1 agonists, have brought about a paradigm shift in preventing the onset and progression of complications of type 2 diabetes, particularly cardiovascular and renal disease. The improvement in rates of classical complications of diabetes over time has been accompanied by a growing awareness of non-traditional complications, including non-alcoholic fatty liver disease. These emerging complications may not respond to a glycaemic-centred approach alone and highlight the importance of foundational strategies centred on lifestyle measures and supported by pharmaceutical therapy to achieve weight loss and reduce metabolic risk in patients living with diabetes.

Predictive Factors for Altered Quality of Life in Patients with Type 2 Diabetes Mellitus

Objectives: To evaluate the quality of life (QoL) in a group of patients with type 2 diabetes (T2DM) and to identify predictive factors to apply the necessary measures to improve it. Methods: For this, 299 patients with T2DM were enrolled in a cross-sectional study, and their QoL was assessed using the EQ-5D-3L questionnaire. All patients underwent clinical exams, routine laboratory tests, and nerve conduction velocity (NCV) at the common peroneal nerve. Results: Patients had a median age of 66 (57; 70) years, median duration of T2DM of 10 (6; 15) years, median HbA1c of 8 (7; 9.3)%, and mean EQ-5D-3L score of 55%. In addition, 9.7% presented extreme difficulty in mobility, 18.5% severe difficulty in self-care, and 16.4% in usual activities. One-third presented with severe pain or discomfort, anxiety, or depression (level 3 EQ-5D-3L). DPN, heart failure (HF), cerebral stroke, and insulin therapy increased the likelihood of a reduced QoL (EQ-5D-3L < 50). The EQ-5D-3L score inversely correlated with serum creatinine, glycemic control, lipid profile, diabetes duration, age, mobility, self-care, pain/discomfort, usual activities, and anxiety/depression and positively correlated with NCV, HDLc, and eGFR. Conclusions: Preventing neuropathic complications, chronic kidney disease, stroke, and HF and obtaining the glycemic and lipid targets could improve the QoL in patients with T2DM.

Glymphatic function and its influencing factors in different glucose metabolism states

BACKGROUND

Dysfunction of the glymphatic system in the brain in different stages of altered glucose metabolism and its influencing factors are not well characterized.

AIM

To investigate the function of the glymphatic system and its clinical correlates in patients with different glucose metabolism states, the present study employed diffusion tensor imaging along the perivascular space (DTI-ALPS) index.

METHODS

Sample size was calculated using the pwr package in R software. This cross-sectional study enrolled 22 patients with normal glucose metabolism (NGM), 20 patients with prediabetes, and 22 patients with type 2 diabetes mellitus (T2DM). A 3.0T magnetic resonance imaging was used to evaluate the function of the glymphatic system. The mini-mental state examination (MMSE) was used to assess general cognitive function. The DTI-ALPS index of bilateral basal ganglia and the mean DTI-ALPS index was calculated. Further, the correlation between DTI-ALPS and clinical features was assessed.

RESULTS

The left-side, right-side, and mean DTI-ALPS index in the T2DM group were significantly lower than that in the NGM group. The right-side DTI-ALPS and mean DTI-ALPS index in the T2DM group were significantly lower than those in the prediabetes group. DTI-ALPS index lateralization was not observed. The MMSE score in the T2DM group was significantly lower than that in the NGM and prediabetes group. After controlling for sex, the left-side DTI-ALPS and mean DTI-ALPS index in the prediabetes group were positively correlated with 2-hour postprandial blood glucose level; the left-side DTI-ALPS index was negatively correlated with total cholesterol and low-density lipoprotein level. The right-side DTI-ALPS and mean DTI-ALPS index were negatively correlated with the glycosylated hemoglobin level and waist-to-hip ratio in the prediabetes group. The left-side, right-side, and mean DTI-ALPS index in the T2DM group were positively correlated with height. The left-side and mean DTI-ALPS index in the T2DM group were negatively correlated with high-density lipoprotein levels.

CONCLUSION

Cerebral glymphatic system dysfunction may mainly occur in the T2DM stage. Various clinical variables were found to affect the DTI-ALPS index in different glucose metabolism states. This study enhances our understanding of the pathophysiology of diabetic brain damage and provides some potential biological evidence for its early diagnosis.

Retinopathy as a predictive indicator for significant hepatic fibrosis according to T2DM status: A cross-sectional study based on the national health and nutrition examination survey data

INTRODUCTION AND OBJECTIVES

Type 2 Diabetes Mellitus (T2DM), a prevalent metabolic disorder, often coexists with a range of complications, with retinopathy being particularly common. Recent studies have shed light on a potential connection between diabetic retinopathy (DR) and hepatic fibrosis, indicating a possible shared pathophysiological foundation in T2DM. This study investigates the correlation between retinopathy and hepatic fibrosis among individuals with T2DM, as well as evaluates the diagnostic value of DR for significant hepatic fibrosis.

MATERIALS AND METHODS

Our cross-sectional analysis incorporated 5413 participants from the National Health and Nutrition Examination Survey (NHANES) 2005-2008. The Fibrosis-4 score (FIB-4) classified hepatic fibrosis into different grades (F0-F4), with significant hepatic fibrosis marked as F2 or higher. Retinopathy severity was determined using retinal imaging and categorized into four levels. The analysis of variance or Chi-square tests facilitated group comparisons. Additionally, the receiver operating characteristic (ROC) analysis appraised the predictive accuracy of retinopathy for significant hepatic fibrosis in the T2DM population.

RESULTS

Among 5413 participants, the mean age was 59.56 ± 12.41, with 50.2% male. And 20.6% were diagnosed with T2DM. Hepatic fibrosis grading was positively associated with retinopathy severity (OR [odds ratio]: 1.521, 95%CI [confidence interval]: 1.152-2.008, P = 0.003) across the entire population. The association was amplified in the T2DM population according to Pearson's analysis results. The ROC curve demonstrated retinopathy's diagnostic capacity for significant hepatic fibrosis in the T2DM population (AUC [area under curve] = 0.72, 95%CI: 0.651-0.793, P < 0.001).

CONCLUSIONS

Retinopathy could serve as an independent predictor of significant hepatic fibrosis in T2DM population. Ophthalmologists are advised to closely monitor T2DM patients with retinopathy.

Impact of health practice index and cardiovascular health metrics on incident cardiovascular disease according to glucose tolerance status

Aims

To evaluate and compare the association of incident cardiovascular disease (CVD) with the Health Practice Index (HPI) reflecting only lifestyle habits and Ideal Cardiovascular Health Metrics (ICVHMs) consisting of lifestyle habits and factors targeted for control in the same population according to glucose status.

Methods

This retrospective cohort study included 1,28,162 participants aged 18-72 years with no history of CVD followed for ≥ 3 years between 2008 and 2016. Participants were classified according to normal glucose tolerance (86,174), prediabetes (36,096), or diabetes (5892). HPI and ICVHMs scores were classified into three groups (high/medium/low). Multivariate Cox regression hazard analysis examined CVD risk.

Results

During a mean follow-up of 5.2 years, 1057 CVD events occurred. In prediabetes, CVD risk was significantly higher in groups with both medium and low HPI scores and ICVHMs scores compared to high scores for normal glucose tolerance (hazard ratios [HRs] for high/medium/low HPI scores were 0.95 [0.78-1.17], 1.56 [1.29-1.89], and 2.41 [1.74-3.34] and for ICVHMs scores were 0.74 [0.50-1.11], 1.58 [1.26-1.98], and 2.63 [2.10-3.31], respectively). Regarding diabetes, compared with high HPI/ICVHMs scores in the normal glucose tolerance group, a significantly increased CVD risk was observed in the high-score HPI group, but not in the high-score ICVHMs group (HPI high/medium/low HR, 1.63 [1.22-2.18], 2.19 [1.69-2.83], and 2.26 [1.34 -3.83]; ICVHMs high/medium/low HR, 1.14 [0.47-2.81], 2.38 [1.75-3.23], and 3.31 [2.50-4.38], respectively).

Conclusions

In diabetes, ideal lifestyle practices alone were insufficient for primary prevention of CVD but had a greater impact on primary prevention of CVD in prediabetes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13340-024-00708-7.

The effect of multi-component exercise on cognition function in patients with diabetes: A systematic review and meta-analysis

BACKGROUND

This meta-analysis investigated the influence of exercise on cognitive function in people living with diabetes.

METHODS

Stringent criteria for literature inclusion and exclusion were defined. Searches were conducted across four English databases to gather randomized controlled trials investigating exercise interventions for cognitive function in people living with diabetes. Outcome indicators from 1193 subjects across 12 articles were analyzed using RevMan 5.4 software.

RESULTS

Exercise intervention demonstrated the ability to mitigate cognitive decline in people living with diabetes, with a combined effect size (standardized mean difference) of 0.91, 95% CI: 0.28, 1.54, P < 0.00001. The intervention effect showed significant modulation by intervention content (I2 = 95%), intervention duration (I2 = 95%), intervention frequency (I2 = 95%), and intervention cycle (I2 = 96%). Among these factors, multi-component exercise, sessions >40 minutes, exercise frequency >4 times per week, and sustained exercise for >6 months were paramount, all with P < 0.05.

CONCLUSION

Exercise intervention emerges as a viable strategy for delaying cognitive decline in people living with diabetes. Its efficacy is subject to modulation by various variables. Optimal intervention includes multi-component exercise, individual sessions lasting 40-60 minutes, exercising >4 times a week, and continuous exercise for over 6 months.

Identifying subtypes of type 2 diabetes mellitus with machine learning: development, internal validation, prognostic validation and medication burden in linked electronic health records in 420 448 individuals

INTRODUCTION

None of the studies of type 2 diabetes (T2D) subtyping to date have used linked population-level data for incident and prevalent T2D, incorporating a diverse set of variables, explainable methods for cluster characterization, or adhered to an established framework. We aimed to develop and validate machine learning (ML)-informed subtypes for type 2 diabetes mellitus (T2D) using nationally representative data.

RESEARCH DESIGN AND METHODS

In population-based electronic health records (2006-2020; Clinical Practice Research Datalink) in individuals ≥18 years with incident T2D (n=420 448), we included factors (n=3787), including demography, history, examination, biomarkers and medications. Using a published framework, we identified subtypes through nine unsupervised ML methods (K-means, K-means++, K-mode, K-prototype, mini-batch, agglomerative hierarchical clustering, Birch, Gaussian mixture models, and consensus clustering). We characterized clusters using intracluster distributions and explainable artificial intelligence (AI) techniques. We evaluated subtypes for (1) internal validity (within dataset; across methods); (2) prognostic validity (prediction for 5-year all-cause mortality, hospitalization and new chronic diseases); and (3) medication burden.

RESULTS

Development: We identified four T2D subtypes: metabolic, early onset, late onset and cardiometabolic. Internal validity: Subtypes were predicted with high accuracy (F1 score >0.98). Prognostic validity: 5-year all-cause mortality, hospitalization, new chronic disease incidence and medication burden differed across T2D subtypes. Compared with the metabolic subtype, 5-year risks of mortality and hospitalization in incident T2D were highest in late-onset subtype (HR 1.95, 1.85-2.05 and 1.66, 1.58-1.75) and lowest in early-onset subtype (1.18, 1.11-1.27 and 0.85, 0.80-0.90). Incidence of chronic diseases was highest in late-onset subtype and lowest in early-onset subtype. Medications: Compared with the metabolic subtype, after adjusting for age, sex, and pre-T2D medications, late-onset subtype (1.31, 1.28-1.35) and early-onset subtype (0.83, 0.81-0.85) were most and least likely, respectively, to be prescribed medications within 5 years following T2D onset.

CONCLUSIONS

In the largest study using ML to date in incident T2D, we identified four distinct subtypes, with potential future implications for etiology, therapeutics, and risk prediction.

Diabetes-Related Macrovascular Complications Are Associated With an Increased Risk of Diabetic Microvascular Complications: A Prospective Study of 1518 Patients With Type 1 Diabetes and 20 802 Patients With Type 2 Diabetes in the UK Biobank

BACKGROUND

Diabetic vascular complications share common pathophysiological mechanisms, but the relationship between diabetes-related macrovascular complications (MacroVCs) and incident diabetic microvascular complications remains unclear. We aimed to investigate the impact of MacroVCs on the risk of microvascular complications.

METHODS AND RESULTS

There were 1518 participants with type 1 diabetes (T1D) and 20 802 participants with type 2 diabetes from the UK Biobank included in this longitudinal cohort study. MacroVCs were defined by the presence of macrovascular diseases diagnosed after diabetes at recruitment, including coronary heart disease, peripheral artery disease, stroke, and ≥2 MacroVCs. The primary outcome was incident microvascular complications, a composite of diabetic retinopathy, diabetic kidney disease, and diabetic neuropathy. During a median (interquartile range) follow-up of 11.61 (5.84-13.12) years and 12.2 (9.50-13.18) years, 596 (39.3%) and 4113 (19.8%) participants developed a primary outcome in T1D and type 2 diabetes, respectively. After full adjustment for conventional risk factors, Cox regression models showed significant associations between individual as well as cumulative MacroVCs and the primary outcome, except for coronary heart disease in T1D (T1D: diabetes coronary heart disease: 1.25 [0.98-1.60]; diabetes peripheral artery disease: 3.00 [1.86-4.84]; diabetes stroke: 1.71 [1.08-2.72]; ≥2: 2.57 [1.66-3.99]; type 2 diabetes: diabetes coronary heart disease: 1.59 [1.38-1.82]; diabetes peripheral artery disease: 1.60 [1.01-2.54]; diabetes stroke: 1.50 [1.13-1.99]; ≥2: 2.66 [1.92-3.68]). Subgroup analysis showed that strict glycemic (glycated hemoglobin <6.5%) and blood pressure (<140/90 mm Hg) control attenuated the association.

CONCLUSIONS

Individual and cumulative MacroVCs confer significant risk of incident microvascular complications in patients with T1D and type 2 diabetes. Our results may facilitate cost-effective high-risk population identification and development of precise prevention strategies.

Metabolic Score for Insulin Resistance and New-Onset Type 2 Diabetes in a Middle-Aged and Older Adult Population: Nationwide Prospective Cohort Study and Implications for Primary Care

BACKGROUND

The metabolic score for insulin resistance (METS-IR) has emerged as a noninsulin-based index for the approximation of insulin resistance (IR), yet longitudinal evidence supporting the utility of METS-IR in the primary prevention of type 2 diabetes mellitus (T2DM) remains limited.

OBJECTIVE

We aimed to investigate the longitudinal association between METS-IR, which combines fasting plasma glucose (FPG), lipid profiles, and anthropometrics that can be routinely obtained in resource-limited primary care settings, and the incidence of new-onset T2DM.

METHODS

We conducted a closed-cohort analysis of a nationwide, prospective cohort of 7583 Chinese middle-aged and older adults who were free of T2DM at baseline, sampled from 28 out of 31 provinces in China. We examined the characteristics of participants stratified by elevated blood pressure (BP) at baseline and new-onset T2DM at follow-up. We performed Cox proportional hazard regression analysis to explore associations of baseline METS-IR with incident T2DM in participants overall and in participants stratified by baseline BP. We also applied net reclassification improvement and integrated discrimination improvement to examine the incremental value of METS-IR.

RESULTS

During a mean follow-up period of 6.3 years, T2DM occurred in 527 participants, among which two-thirds (332/527, 62.9%; 95% CI 58.7%-67.1%) had baseline FPG<110 mg/dL. A SD unit increase in baseline METS-IR was associated with the first incidence of T2DM (adjusted hazard ratio [aHR] 1.33, 95% CI 1.22-1.45; P<.001) in all participants. We obtained similar results in participants with normal baseline BP (aHR 1.41, 95% CI 1.22-1.62; P<.001) and elevated baseline BP (aHR 1.29, 95% CI 1.16-1.44; P<.001). The predictive capability for incident T2DM was improved by adding METS-IR to FPG. In study participants with new-onset T2DM whose baseline FPG was <126 mg/dL and <110 mg/dL, 62.9% (332/527; 95% CI 60%-65.9%) and 58.1% (193/332; 95% CI 54.3%-61.9%) of participants had baseline METS-IR above the cutoff values, respectively.

CONCLUSIONS

METS-IR was significantly associated with new-onset T2DM, regardless of baseline BP level. Regular monitoring of METS-IR on top of routine blood glucose in clinical practice may add to the ability to enhance the early identification of primary care populations at risk for T2DM.

Higher dietary flavonol and isoflavonoid intakes are associated with lower incidence of type 2 diabetes

Background: Adequate evidence supports beneficial effects of plant-derived phytochemicals against type 2 diabetes (T2D). Among phytochemicals, dietary flavonoids is one of the superb candidates. The whole studies are carried out in Western populations, so it is needed to investigate the risk of T2D by dietary flavonoid intakes in ethnic origins and other regions to confirm these relations. This study was conducted to investigate whether the daily consumption of total flavonoid and its subclasses can affect the incidence of type 2 diabetes (T2D) in the Iranian population. Methods: Eligible adults (n=6547) were selected from among participants of the Tehran lipid and glucose study with an average follow-up of 3.0 years. Dietary intakes were assessed using a valid and reliable 168-item semi-quantitative food frequency questionnaire. Multivariate Cox proportional hazard regression models were used to estimate the development of T2D in relation to total intake of flavonoids. Results: This study was conducted on 2882 men and 3665 women, aged 41.3±14.6 and 39.0±13.4 years, respectively. After adjustment for several potential confounders (age, sex, diabetes risk score, physical activity, energy, fiber and total fat intakes), risk of T2D decreased from tertiles 1 to 3 for flavonols (HR (95% CI): 1.00, 0.86 (0.64-1.16), 0.87 (0.63-0.93), Ptrend=0.01) and isoflavonoids (HR (95% CI): 1.00, 0.84 (0.62-1.13), 0.64 (0.46-0.88), Ptrend=0.02), whereas non-significant results were found for total flavonoid and other subclasses of flavonoid. Conclusion: These results emphasize the potential protective role of flavonols and isoflavonoids rich food (e.g. apple, tea, soy, and dark chocolate) in the prevention of T2D.

SGLT-2 Inhibitor Use and Cause-Specific Hospitalization Rates: An Outcome-Wide Study to Identify Novel Associations of SGLT-2 Inhibitors

Sodium-glucose co-transporter 2 inhibitors (SGLT2is) have demonstrated multifaceted pharmacological effects. In addition to type 2 diabetes, they are now indicated for heart failure and chronic kidney disease. This study aimed to identify novel associations between SGLT2i use and health outcomes using real-world data. Using linked data from a nationwide diabetes registry in Australia, we compared hospitalization rates in people living with type 2 diabetes commencing treatment with SGLT2i and dipeptidyl peptidase-4 inhibitor (DPP4i) between December 1, 2013, and June 30, 2019. Cause-specific hospitalizations were categorized across three hierarchies of diagnoses (first, first three, and first four digits of International Classification of Diseases, Tenth Version, Australian Modification codes). Incidence rate ratio (IRR) and 95% confidence interval (95% CI) for each cause-specific hospitalization were estimated using negative binomial regression. In the first hierarchy, hospitalization rates were lower across most diagnosis groups among SGLT2i initiators (n = 99,569) compared with DPP4i initiators (n = 186,353). In the second and third hierarchies, there were lower hospitalization rates relating to infections, anemias, and obstructive airway diseases among SGLT2i initiators compared with DPP4i initiators. These included sepsis (IRR: 0.60, 95% CI: 0.51-0.72) anemia (IRR: 0.55, 95% CI: 0.46-0.66), and chronic obstructive pulmonary diseases (IRR: 0.52, 95% CI: 0.40-0.68), as well as for previously known associations (e.g., heart failure (IRR: 0.63, 95% CI: 0.56-0.70)). SGLT2is have previously uncharacterized associations on a range of important clinical outcomes; validation of these associations requires further study, some of which may suggest novel benefits or new indications for SGLT2is.

Effect of a multicomponent quality improvement strategy on sustained achievement of diabetes care goals and macrovascular and microvascular complications in South Asia at 6.5 years follow-up: Post hoc analyses of the CARRS randomized clinical trial

BACKGROUND

Diabetes control is poor globally and leads to burdensome microvascular and macrovascular complications. We aimed to assess post hoc between-group differences in sustained risk factor control and macrovascular and microvascular endpoints at 6.5 years in the Center for cArdiovascular Risk Reduction in South Asia (CARRS) randomized trial.

METHODS AND FINDINGS

This parallel group individual randomized clinical trial was performed at 10 outpatient diabetes clinics in India and Pakistan from January 2011 through September 2019. A total of 1,146 patients with poorly controlled type 2 diabetes (HbA1c ≥8% and systolic BP ≥140 mm Hg and/or LDL-cholesterol ≥130 mg/dL) were randomized to a multicomponent quality improvement (QI) strategy (trained nonphysician care coordinator to facilitate care for patients and clinical decision support system for physicians) or usual care. At 2.5 years, compared to usual care, those receiving the QI strategy were significantly more likely to achieve multiple risk factor control. Six clinics continued, while 4 clinics discontinued implementing the QI strategy for an additional 4-year follow-up (overall median 6.5 years follow-up). In this post hoc analysis, using intention-to-treat, we examined between-group differences in multiple risk factor control (HbA1c <7% plus BP <130/80 mm Hg and/or LDL-cholesterol <100 mg/dL) and first macrovascular endpoints (nonfatal myocardial infarction, nonfatal stroke, death, revascularization [angioplasty or coronary artery bypass graft]), which were co-primary outcomes. We also examined secondary outcomes, namely, single risk factor control, first microvascular endpoints (retinopathy, nephropathy, neuropathy), and composite first macrovascular plus microvascular events (which also included amputation and all-cause mortality) by treatment group and whether QI strategy implementation was continued over 6.5 years. At 6.5 years, assessment data were available for 854 participants (74.5%; n = 417 [intervention]; n = 437 [usual care]). In terms of sociodemographic and clinical characteristics, participants in the intervention and usual care groups were similar and participants at sites that continued were no different to participants at sites that discontinued intervention implementation. Patients in the intervention arm were more likely to exhibit sustained multiple risk factor control than usual care (relative risk: 1.77; 95% confidence interval [CI], 1.45, 2.16), p < 0.001. Cumulatively, there were 233 (40.5%) first microvascular and macrovascular events in intervention and 274 (48.0%) in usual care patients (absolute risk reduction: 7.5% [95% CI: -13.2, -1.7], p = 0.01; hazard ratio [HR] = 0.72 [95% CI: 0.61, 0.86]), p < 0.001. Patients in the intervention arm experienced lower incidence of first microvascular endpoints (HR = 0.68 [95% CI: 0.56, 0.83), p < 0.001, but there was no evidence of between-group differences in first macrovascular events. Beneficial effects on microvascular and composite vascular outcomes were observed in sites that continued, but not sites that discontinued the intervention.

CONCLUSIONS

In urban South Asian clinics, a multicomponent QI strategy led to sustained multiple risk factor control and between-group differences in microvascular, but not macrovascular, endpoints. Between-group reductions in vascular outcomes at 6.5 years were observed only at sites that continued the QI intervention, suggesting that practice change needs to be maintained for better population health of people with diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01212328.