Autoantibodies to glutamic acid decarboxylase in diabetic patients from a multi-ethnic Australian community: the Fremantle Diabetes Study

Prevalence of autoimmune diabetes among Aboriginal Australians: the Fremantle Diabetes Study Phase II

The prevalence of autoimmune diabetes was assessed in 113 indigenous and 1555 non-indigenous participants in the Fremantle Diabetes Study Phase II. Both type 1 diabetes (3.5% vs. 8.2%) and latent autoimmune diabetes of adults diagnosed based on glutamic acid decarboxylase antibody (GADA) positivity (1.0% vs. 5.7%) were lower in Aboriginal participants (P = 0.101 and 0.039 respectively). Six Aboriginals with GADA-negative type 2 diabetes were positive for tyrosine phosphatase-related islet antigen 2 antibodies but did not exhibit relative insulin deficiency.

Application of a validated prognostic plasma protein biomarker test for renal decline in type 2 diabetes to type 1 diabetes: the Fremantle Diabetes Study Phase II

BACKGROUND

There are scant data relating to prognostic biomarkers for chronic kidney disease (CKD) complicating type 1 diabetes. The aim of this study was to assess the performance of the plasma protein biomarker-based PromarkerD test developed and validated for predicting renal decline in type 2 diabetes in the context of type 1 diabetes.

METHODS

The baseline PromarkerD test score was determined in 91 community-based individuals (mean age 46.2 years, 56.5% males) with confirmed type 1 diabetes recruited to the longitudinal observational Fremantle Diabetes Study Phase II. The performance of the PromarkerD test in predicting the risk of incident CKD (estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73m2 in people without CKD at baseline) or an eGFR decline of ≥ 30% over the next four years was determined. The score can range from 0 to 100%, and is categorized as representing low (< 10%), moderate (10% to < 20%) or high (≥ 20%) risk.

RESULTS

The area under the receiver operating characteristic curve was 0.93 (95% confidence interval 0.87-0.99) for the composite renal endpoint, indicating strong predictive accuracy. The positive and negative predictive values at moderate (10% to < 20%) and high (≥ 20%) risk PromarkerD cut-offs were 46.7-50.0% and ≥ 92.0%, respectively.

CONCLUSIONS

These preliminary data suggest that PromarkerD is at least as good a prognostic test for renal decline in type 1 as type 2 diabetes.

Effect of prior gestational diabetes on the risk of cardiovascular disease and death in women with type 2 diabetes: The Fremantle Diabetes Study Phase II

BACKGROUND

To examine whether prior gestational diabetes mellitus (GDM) is associated with prevalent coronary heart disease (CHD), cerebrovascular disease (CeVD) and peripheral arterial disease (PAD), and all-cause mortality, in community-based women with type 2 diabetes.

METHODS

Baseline prevalences of CHD/CeVD/PAD/prior GDM were determined in 718 females (mean ± SD age 65.5 ± 11.9 years) from the Fremantle Diabetes Study Phase II. Deaths between baseline (2008-2011) and end-2016 were ascertained. Cox regression identified predictors of mortality with GDM as a candidate variable.

RESULTS

Compared to the 673 women without GDM, the 39 (5.4 %) with prior GDM were younger, more likely Aboriginal, smokers and obese, had longer diabetes duration and higher HbA1c levels, and were more dyslipidemic (P ≤ 0.046). Prevalences of CHD (24.6 versus 23.1 %), CeVD (7.5 % versus 2.6 %) and PAD (27.5 % versus 23.7 %) were not significantly different in those without versus with prior GDM (P ≥ 0.35). There were 116 deaths (16.2 %) during 6.8 ± 1.6 years of follow-up. Age, Aboriginal ethnicity, marital status, current smoking, heart rate, estimated glomerular filtration rate, CHD and PAD were independently associated with all-cause mortality (P ≤ 0.023); GDM status did not add to the most parsimonious model (P = 0.62).

CONCLUSIONS

Prior GDM does not increase CVD risk or all-cause mortality in women with type 2 diabetes.

Temporal trends in chronic complications of diabetes by sex in community-based people with type 2 diabetes: the Fremantle Diabetes Study

BACKGROUND

Whether recent reductions in cardiovascular disease (CVD) events and mortality in type 2 diabetes apply equally to both sexes is largely unknown. The aim of this study was to characterize temporal changes in CVD events and related outcomes in community-based male and female Australian adults with type 2 diabetes or without known diabetes.

METHODS

Participants from the longitudinal observational Fremantle Diabetes Study Phases I (FDS1; n = 1291 recruited 1993-1996) and II (FDS2; n = 1509 recruited 2008-2011) and four age-, sex- and postcode-matched individuals without diabetes (FDS1 n = 5159; FDS2 n = 6036) were followed for first myocardial infarction, stroke, heart failure hospitalization, lower extremity amputation, CVD death and all-cause mortality. Five-year incidence rates (IRs) for males versus females in FDS1 and FDS2 were calculated, and IR ratios (IRRs) derived.

RESULTS

The FD1 and FDS2 participants were of mean age 64.0 and 65.4 years, respectively, and 48.7% and 51.8% were males. For type 2 diabetes, IRRs for all endpoints were 11-62% lower in FDS2 than FDS1 for both sexes. For participants without diabetes, IRRs were 8-56% lower in FDS2 versus FDS1 apart from stroke in females (non-significantly 41% higher). IRRs for males versus females across FDS phases were not significantly different for participants with type 2 diabetes or those without diabetes (P-values for male * FDS2 interaction ≥ 0.0.083 adjusted for age). For risk factors in participants with type 2 diabetes, greater improvements between FDS1 and FDS2 in smoking rates in males were offset by a greater reduction in systolic blood pressure in females.

CONCLUSIONS

The incidence of chronic complications in Australians with type 2 diabetes and without diabetes has fallen similarly in both sexes over recent decades, consistent with comparably improved overall CVD risk factor management.

Comparative mortality and its determinants in community-based people with type 1 diabetes: the Fremantle Diabetes Study Phase I

INTRODUCTION

The aim of this study was to compare mortality in community-based Australians with type 1 diabetes (T1D), without diabetes, or with type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

The longitudinal observational Fremantle Diabetes Study Phase I (FDS1) T1D cohort, matched people without diabetes from the FDS1 catchment area, and matched FDS1 participants with T2D were followed up from entry (1993-1996) to death/end-2017. Mortality rates (MRs) and mortality rate ratios (MRRs) were calculated. Cox regression models identified independent determinants of death.

RESULTS

Of 121 participants with T1D and 484 age/sex/postcode-matched people without diabetes (pooled mean±SD age 43.1±15.3 years, 59.2% men), 55 (45.5%, MR 25.7 (95% CI 19.4 to 33.5)/1000 person-years) and 88 (18.2%, MR 8.5 (95% CI 6.8 to 10.4)/1000 person-years), respectively, died during 12 541 person-years of follow-up (MRR 3.04 (95% CI 2.13 to 4.31), p<0.001). Among participants with T1D, diagnosis at age 18-27 years and baseline HbA_1c, urinary albumin:creatinine ratio, and retinopathy were independent predictors of death (p≤0.011). Twenty-five FDS1 participants died from cardiovascular disease (MR 11.7 (95% CI 7.6 to 17.3)/1000 person-years) vs 28 residents without diabetes (MR 2.7 (95% CI 1.8 to 3.9)/1000 person-years; MRR (95% CI) 4.34 (2.43, 7.73) (p<0.001). There were 93 FDS1 participants with T1D who were age/sex matched with an FDS1 participant with T2D and 53 (57.0%) and 37 (39.8%), respectively, died (p=0.027). In pooled Cox regression analysis, T1D was not a determinant of mortality (HR 1.18 (95% CI 0.71 to 1.97), p=0.523).

CONCLUSIONS

T1D substantially increases the risk of death, especially when diagnosed in late adolescence/young adulthood. Diabetes type does not influence mortality after adjustment for key confounding variables.

Temporal trends in minor and major lower extremity amputation in people with type 2 diabetes: The Fremantle Diabetes Study

AIMS

To determine whether incident minor and major lower extremity amputations (LEAs) have declined in recent decades in type 2 diabetes.

METHODS

Participants with type 2 diabetes from the community-based Fremantle Diabetes Study Phases I (FDS1; n = 1,296, mean age 64.0 years, recruited 1993-1996) and II (FDS2; n = 1,509, mean age 65.4 years, recruited 2008-2011) were followed from entry to incident minor/major LEA, death or five years. Cox regression determined hazard ratios (HRs) for each outcome for FDS2 versus FDS1 and independent predictors of incident minor and major LEA in the combined cohort.

RESULTS

Age- and sex-adjusted HRs (95% CIs) in FDS2 versus FDS1 for incident minor and major LEA were, respectively, 0.60 (0.27, 1.35) and 0.59 (0.22, 1.59). Higher glycated haemoglobin, urine albumin: creatinine (uACR) ratio and peripheral sensory neuropathy (PSN) were independent predictors of incident minor LEA. Higher fasting serum glucose, peripheral arterial disease (PAD), end-stage kidney disease and prior diabetes-related minor LEA were associated with incident major LEA.

CONCLUSIONS

There were non-significant reductions of approximately 40% in incident minor and major LEA in community-based people with type 2 diabetes during the 15 years between FDS Phases. Predictors of minor/major LEA confirm distinct high-risk patient groups with implications for clinical management.

Temporal Trends in Mortality Associated with Comorbid Type 2 Diabetes and Schizophrenia: The Fremantle Diabetes Study

BACKGROUND

In Phase I of the community-based Fremantle Diabetes Study (FDS1), there was evidence of a deleterious interactive effect of schizophrenia and type 2 diabetes on mortality. Our aim was to investigate whether the mortality gap had improved in FDS Phase II (FDS2) conducted 15 years later.

METHODS

Participants with type 2 diabetes from FDS1 (n = 1291 recruited 1993-1996) and FDS2 (n = 1509 recruited 2008-2011) were age-, sex- and postcode-matched 1:4 to people without diabetes. Schizophrenia at entry and incident deaths were ascertained from validated administrative data.

RESULTS

Schizophrenia affected 50/11,195 (0.45%) of participants without diabetes and 17/2800 (0.61%) of those with type 2 diabetes (p = 0.284). During 142,304 person-years of follow-up, the mortality rate (95% CI) was lowest for the FDS2 subgroup without diabetes/schizophrenia (18.2 (16.9, 19.6)/1000 person-years) and highest in FDS2 and FDS1 subgroups with type 2 diabetes/schizophrenia (53.3 (14.5, 136.6) and 98.0 (31.8, 228.8)/1000 person-years, respectively). Compared to the respective FDS subgroup without diabetes/schizophrenia, the mortality rate ratio was approximately 50% higher in the type 2 diabetes subgroup, and three times higher in those with type 2 diabetes/schizophrenia. In Cox regression, unadjusted hazard ratios were highest in those with type 2 diabetes/schizophrenia in FDS1 (HR (95% CI): 3.71 (1.54, 8.93) and FDS2 (2.96 (1.11, 7.91)), increasing to 5.61 (2.33, 13.5) and 26.9 (9.94, 72.6), respectively, after adjustment for age.

CONCLUSIONS

Although limited by small numbers of schizophrenia cases, these data suggest that comorbid type 2 diabetes and schizophrenia remains associated with a substantial and possibly increasing mortality gap.

Latent autoimmune diabetes in adults in China

Latent autoimmune diabetes in adults (LADA) is a type of diabetes caused by slow progression of autoimmune damage to pancreatic beta cells. According to the etiological classification, LADA should belong to the autoimmune subtype of type 1 diabetes (T1D). Previous studies have found general immune genetic effects associated with LADA, but there are also some racial differences. Multicenter studies have been conducted in different countries worldwide, but it is still unclear how the Chinese and Caucasian populations differ. The epidemiology and phenotypic characteristics of LADA may vary between Caucasian and Chinese diabetic patients as lifestyle, food habits, and body mass index differ between these two populations. The prevalence of LADA in China has reached a high level compared to other countries. The prevalence of LADA in China has reached a high level compared to other countries, and the number of patients with LADA ranks first in the world. Previous studies have found general immune genetic effects associated with LADA, but some racial differences also exist. The prevalence of LADA among newly diagnosed type 2 diabetes patients over the age of 30 years in China is 5.9%, and LADA patients account for 65% of the newly diagnosed T1D patients in the country. As a country with a large population, China has many people with LADA. A summary and analysis of these studies will enhance further understanding of LADA in China. In addition, comparing the similarities and differences between the Chinese and the Caucasian population from the perspectives of epidemiology, clinical, immunology and genetics will help to improve the understanding of LADA, and then promote LADA studies in individual populations.

Restrictive Pulmonary Disease in Diabetes Mellitus Type II Patients

Background

The present study aimed to evaluate the proportion of restrictive pulmonary disease in individuals with diabetes mellitus type II patients.

Methodology

A cross-sectional study was performed at Liaquat University of Medical & Health Sciences between May 2020 and June 2021. All individuals aged between 40 and 65 years, irrespective of gender were included in the study. While those individuals with known obstructive lung diseases, blood disorders, or malignancy were excluded. Spirometry, total lung capacity (TLC), and carbon monoxide diffusing capacity (DLCO) measurements were conducted to obtain a pattern of restrictive disease in patients. Patients were divided into three main groups; i) prediabetes, ii) newly diagnosed cases of diabetes, iii) longstanding diabetes mellitus type II, and iv) control group. The parameters like the patients’ age, sex, medication, history of smoking, and cardiac diseases, among other demographics were recorded. The data collected was recorded on a predesigned proforma.

Results

The majority of the newly diagnosed cases, as well as long-standing diseases, were elderly males (p=0.014 and p<0.0001). Dyspnea was significantly correlated with longstanding diabetes mellitus type II as indicated by a higher mean score of 0.65 ± 0.10 (p=0.006). Smoking did not significantly correlate with diabetes mellitus type II. In patients with longstanding diabetes, 27 (14.4%) had a modified Medical Research Council (mMRC) score of greater than two while none of the controls had severe breathlessness. Reduced forced vital capacity (FVC) was detected in 16.0% of patients with longstanding diabetes and 12.8% in patients with newly diagnosed disease. Similar results were obtained for total lung capacity (TLC) and diffusing capacity (DLCO) (p=0.003 and p=0.02).

Conclusion

Diabetes mellitus type II is significantly associated with restrictive lung disease in patients as indicated by a high number of patients with longstanding diabetes in our study who were found to have restrictive lung disease and severe dyspnea. Screening for lung dysfunction could aid in optimum management of this debilitating disease.

Temporal Trends in Renal Replacement Therapy in Community-Based People with or without Type 2 Diabetes: The Fremantle Diabetes Study

Background: Although rates of cardiovascular disease complicating type 2 diabetes are declining, equivalent data for renal replacement therapy (RRT) are conflicting. The aim of this study was to characterize temporal changes in RRT incidence rates (IRs) in Australians with or without type 2 diabetes. Methods: Participants with type 2 diabetes from the Fremantle Diabetes Study Phases I (FDS1; n = 1291 recruited 1993–1996) and II (FDS2; n = 1509 recruited 2008–2011) were age-, sex- and postcode-matched 1:4 to people without diabetes and followed for first hospitalization for/with RRT. Five-year IRs, IR ratios (IRRs) for those with versus without diabetes in FDS1 and FDS2, and IR differences (IRDs), were calculated. Results: The 13,995 participants had a mean age of 64.8 years and 50.4% were males. For the type 2 diabetes cohorts, the 5-year RRT IR was nearly threefold higher in FDS2 versus FDS1 (IRR (95% CI): 2.85 (1.01–9.87)). Sixteen more participants with type 2 diabetes/10,000 person-years received RRT in FDS2 than FDS1 compared with an IRD of 2/10,000 person-years in those without diabetes. Type 2 diabetes increased RRT risk at least 5-fold. This increased risk was greater in Aboriginal participants who were relatively young when RRT was initiated and more prone to rapid progression to RRT. Multivariable analysis using the combined FDS type 2 diabetes cohorts confirmed albuminuria as a strong independent RRT risk factor. Conclusions: The incidence of RRT is increasing substantially in Australians with type 2 diabetes, especially in Aboriginals who progress to RRT more rapidly at a younger age than non-Aboriginals.

Latent Autoimmune Diabetes of Adults (LADA) Is Likely to Represent a Mixed Population of Autoimmune (Type 1) and Nonautoimmune (Type 2) Diabetes

Latent autoimmune diabetes of adults (LADA) is typically defined as a new diabetes diagnosis after 35 years of age, presenting with clinical features of type 2 diabetes, in whom a type 1 diabetes-associated islet autoantibody is detected. Identifying autoimmune diabetes is important since the prognosis and optimal therapy differ. However, the existing LADA definition identifies a group with clinical and genetic features intermediate between typical type 1 and type 2 diabetes. It is unclear whether this is due to 1) true autoimmune diabetes with a milder phenotype at older onset ages that initially appears similar to type 2 diabetes but later requires insulin, 2) a disease syndrome where the pathophysiologies of type 1 and type 2 diabetes are both present in each patient, or 3) a heterogeneous group resulting from difficulties in classification. Herein, we suggest that difficulties in classification are a major component resulting from defining LADA using a diagnostic test-islet autoantibody measurement-with imperfect specificity applied in low-prevalence populations. This yields a heterogeneous group of true positives (autoimmune type 1 diabetes) and false positives (nonautoimmune type 2 diabetes). For clinicians, this means that islet autoantibody testing should not be undertaken in patients who do not have clinical features suggestive of autoimmune diabetes: in an adult without clinical features of type 1 diabetes, it is likely that a single positive antibody will represent a false-positive result. This is in contrast to patients with features suggestive of type 1 diabetes, where false-positive results will be rare. For researchers, this means that current definitions of LADA are not appropriate for the study of autoimmune diabetes in later life. Approaches that increase test specificity, or prior likelihood of autoimmune diabetes, are needed to avoid inclusion of participants who have nonautoimmune (type 2) diabetes. Improved classification will allow improved assignment of prognosis and therapy as well as an improved cohort in which to analyze and better understand the detailed pathophysiological components acting at onset and during disease progression in late-onset autoimmune diabetes.

Temporal Trends in Incident Hospitalization for Diabetes-Related Foot Ulcer in Type 2 Diabetes: The Fremantle Diabetes Study

OBJECTIVE

To determine whether, reflecting trends in other chronic complications, incident hospitalization for diabetes-related foot ulcer (DFU) has declined over recent decades in type 2 diabetes.

RESEARCH DESIGN AND METHODS

Participants with type 2 diabetes from the community-based Fremantle Diabetes Study phases I (FDS1; 1,296 participants, mean age 64.0 years, 48.6% males, recruited 1993-1996) and II (FDS2; 1,509 participants, mean age 65.4 years, 51.8% males, recruited 2008-2011) were followed from entry to first hospitalization for/with DFU, death, or 5 years (whichever came first). Incident rate ratios (IRRs) and incident rate differences (IRDs) were calculated for FDS2 versus FDS1 overall and in 10-year age-groups. Cox proportional hazards modeling determined independent predictors of first DFU hospitalization in the combined cohort.

RESULTS

Incident DFU hospitalization (95% CI) was 1.9 (0.9-3.3)/1,000 person-years in FDS1 during 5,879 person-years of follow-up and 4.5 (3.0-6.4)/1,000 person-years in FDS2 during 6,915 person-years of follow-up. The crude IRR (95% CI) was 2.40 (1.17-5.28) (P = 0.013) and IRD 2.6 (0.7-4.5)/1,000 person-years (P = 0.010). The highest IR for any age-group was 23.6/1,000 person-years in FDS2 participants aged 31-40 years. Age at diabetes diagnosis (inverse), HbA_1c, insulin use, height, ln(urinary albumin/creatinine), absence of any foot pulse, previous peripheral revascularization, and peripheral sensory neuropathy (PSN) were independent predictors of incident hospitalization for/with DFU.

CONCLUSIONS

Incident DFU hospitalizations complicating type 2 diabetes increased between FDS phases, especially in younger participants, and were more likely in those with PSN, peripheral arterial disease, and suboptimal glycemic control at baseline.

Latent Autoimmune Diabetes in Adults (LADA) and its Metabolic Characteristics among Yemeni Type 2 Diabetes Mellitus Patients

PURPOSE

Although there is ample data about the prevalence of diabetes in the Middle East, little is known about the prevalence and features of autoimmune diabetes in this region. The aim of this study was to investigate the prevalence and metabolic characteristics of latent autoimmune diabetes in adults (LADA) amongst Yemeni Type 2 DM patients.

PATIENTS AND METHODS

In this cross-section study, 270 Type 2 DM patients aged 30-70 years were recruited from the National Diabetes Center, Al-Thowra Hospital, Sana'a city, during the period November 2015 to August 2016. All Type 2 DM patients were diagnosed within 5 years and who did not require insulin for a minimum of 6 months following diagnosis. Levels of glutamic acid decarboxylase autoantibodies (GADA) were measured in all patients, and LADA was diagnosed in patients testing positive for anti-GAD antibodies. Further, biochemical analysis was carried out including fasting blood glucose (FBG), glycated haemoglobin (HbA1c), insulin, and lipid profile. Insulin resistance (HOMA-IR) and β-cell function (HOMA-β) were calculated.

RESULTS

The prevalence of LADA, as defined by GADA-positive, amongst patient with Type 2 DM was 4.4%; with no significant difference in the prevalence between male (5.8%) and female (3.4%). LADA patients were younger than GADA-negative Type 2 DM. Body mass index, waist circumference, insulin and HOMA-β were significantly lower in LADA patients, whereas triglyceride, cholesterol, HDL-c and HOMA-IR were non-significantly lower with respect to Type 2 DM. In contrast, FBG and HbA1c were significantly higher in LADA patients. Moreover, the prevalence of metabolic syndrome was significantly lower in LADA as compared with Type 2 DM. Only 2 out of the 12 GADA-positive (16.7%) were on insulin treatment at the time of the study.

CONCLUSION

The prevalence of LADA in Yemeni Type 2 DM is lower than many of those reported in the literature, with no gender preference. Metabolic syndrome was significantly lower in LADA patients. Patients with LADA share insulin resistance with Type 2 DM but display a more severe defect in β-cell function, thus highlighting the importance of an early diagnosis of LADA, to correctly treat LADA patients, allowing safe and effective therapies.

Temporal Trends in Cardiovascular Complications in People With or Without Type 2 Diabetes: The Fremantle Diabetes Study

CONTEXT

There is evidence that diabetes-related complications are declining but most data sources have limitations.

OBJECTIVE

To characterize temporal changes in incidence rates (IRs) of chronic complications and mortality in well-characterized, community-based Australians.

DESIGN

Longitudinal observational study.

SETTING

Urban population.

PARTICIPANTS

Participants with type 2 diabetes from the Fremantle Diabetes Study phases I (FDS1; n = 1291 recruited 1993-1996) and II (FDS2; n = 1509 recruited 2008-2011) age-, sex,- and ZIP code-matched 1:4 to people without diabetes.

MAIN OUTCOME MEASURES

First hospitalizations for/with myocardial infarction (MI), stroke, heart failure (HF), lower extremity amputation, and cardiovascular disease (CVD) and all-cause mortality. Five-year IRs, IR ratios for those with versus without diabetes in FDS1 and FDS2, and IR differences (IRDs), were calculated.

RESULTS

The 13,995 participants had a mean age of 64.8 years and 50.4% were males. There were lower IR ratios for MI, stroke, HF, and CVD death in FDS2 versus FDS1. IRDs for people with versus without type 2 diabetes had reduced by >50% between phases for MI, stroke, HF, lower extremity amputation, and CVD death, with no change in IRD for all-cause mortality. Within the pooled type 2 diabetes cohort, FDS2 versus FDS1 participation was an independent inverse predictor of stroke, HF, CVD death, and all-cause mortality after adjustment in Cox proportional hazards models.

CONCLUSIONS

Cardiovascular outcomes in Australians have improved since the 1990s, especially in type 2 diabetes. The difference in all-cause mortality between those with and without type 2 diabetes has persisted despite longer survival.

Past, present and future of latent autoimmune diabetes in adults

Latent autoimmune diabetes in adults (LADA) is the most common form of autoimmune diabetes diagnosed in adults. Similar to type 1 diabetes, the prevalence of LADA is impacted by ethnicity and geography. LADA is characterized by β cell loss due to autoimmunity and insulin resistance and has highly heterogeneous clinical features, autoimmunity, and genetics in a glutamic acid decarboxylase antibody (GADA) titre-dependent manner, suggesting LADA is part of a continuum spectrum between type 1 and type 2 diabetes. Although LADA is the most frequent form of autoimmune diabetes diagnosed in adults, clinical trials involving LADA are scarce. Here we review the recent advancements in LADA epidemiology, clinical features, pathogenesis, and interventions. We also highlight the environmental factors that are thought to play an important role in addition to genetics in the pathogenesis of LADA. In the future, high-throughput molecular profiles might shed light on the nature of LADA among the wide spectrum of diabetes and offer new opportunities to identify novel LADA-specific biomarkers.

Temporal changes in the incidence and predictors of severe hypoglycaemia in type 2 diabetes: The Fremantle Diabetes Study

AIM

To determine the incidence of severe hypoglycaemia and its predictors in community-based patients with type 2 diabetes studied between 2008 and 2013 compared with those in a cohort of patients with type 2 diabetes from the same geographical area assessed a decade earlier.

METHODS

We studied 1551 participants (mean age 65.7 years, 51.9% men) with type 2 diabetes from the longitudinal observational Fremantle Diabetes Study Phase II (FDS2). Severe hypoglycaemia was ascertained as that requiring ambulance attendance, emergency department services and/or hospitalization. Cox proportional hazards modelling was used to determine predictors of a first episode of severe hypoglycaemia, and negative binomial regression was used to identify predictors of frequency.

RESULTS

Sixty-three participants (4.1%) experienced 83 episodes, representing an incidence of 1.34/100 participant-years (95% confidence interval [CI] 1.08 to 1.67; vs 1.67/100 participant-years [95% CI 1.31-2.13] in the Fremantle Diabetes Study Phase I [FDS1]; P = 0.18). Those experiencing severe hypoglycaemia experienced one to four episodes in both cohorts. The independent predictors of incident severe hypoglycaemia in the FDS2 were: older age; higher educational attainment; alcohol consumption; current smoking; sulphonylurea/insulin treatment; prior severe hypoglycaemia; renal impairment; and plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP). The same variables except smoking were associated with frequency of severe hypoglycaemia. Most of these risk factors paralleled those in the FDS1, but current smoking and plasma NT-proBNP were novel.

CONCLUSIONS

The incidence and frequency of severe hypoglycaemia did not change between the Fremantle Diabetes Study phases but novel risk factors, including plasma NT-proBNP, were observed in the FDS2.

Clinical risk factors for depressive syndrome in Type 2 diabetes: the Fremantle Diabetes Study

AIMS

To identify early clinical predictors of depressive syndrome in people with Type 2 diabetes.

METHODS

Depressive syndrome was assessed in 325 individuals with Type 2 diabetes 15 years after a baseline assessment, which included information on antidepressant use and depressive symptoms obtained using a quality-of-life scale. Follow-up current and lifetime depressive syndrome were assessed using the nine-item Patient Health Questionnaire and the Brief Lifetime Depression Scale and taking account of antidepressant use. Analyses were conducted inclusive and exclusive of antidepressant use where Patient Health Questionnaire criteria were not met.

RESULTS

At baseline, the participants were aged 57.2±9.3 years and the median (interquartile range) diabetes duration was 2.2 (0.6-6.0) years. After a mean of 14.7±1.1 years' follow-up, 81 participants (24.9%) had depressive syndrome (14.8% defined by the Patient Health Questionnaire, 10.2% defined by antidepressants) and 31.4% reported lifetime depression, and in 10.2% of participants this preceded diabetes onset. With logistic regression (inclusive of antidepressants), follow-up depressive syndrome was negatively associated with education level [odds ratio 0.39 (95% CI 0.20-0.75)] and antidepressant use [odds ratio 0.11 (95% CI 0.03-0.36)] and was positively associated with depression history before diabetes onset [odds ratio 2.79 (95% CI 1.24-6.27)]. In the model exclusive of antidepressants, depressive syndrome was positively associated with baseline depressive symptoms [odds ratio 2.57 (95% CI 1.32-5.03)] and antidepressant use [odds ratio 3.54 (95% CI 1.20-10.42)] and was negatively associated with education level [odds ratio 0.39 (95% CI 0.19-0.81)].

CONCLUSIONS

Risk factors for depressive syndrome can be identified early after the onset of Type 2 diabetes. The early presence of depressive symptoms or its treatment and/or history of depression are likely indicators of vulnerability. Early risk stratification for late depressive syndrome is feasible in people with Type 2 diabetes and could assist with depression treatment or prevention.

Monitoring Patients on Metformin: Recent Changes and Rationales

Objective: The Food and Drug Administration recently updated metformin prescribing recommendations for patients with diabetes and renal disease. The American Diabetes Association as well as the American Association of Clinical Endocrinologists and American Clinical Endocrinologists also recommend periodic monitoring of vitamin B12 levels for patients using metformin. A review of the literature was conducted to assess data to evaluate the recent updates to metformin usage and provide rationales for these recommendations. Data Sources: PubMed MESH terms "Diabetes Mellitus, Type 2" and "Renal Insufficiency, Chronic" and "Metformin" were searched with an English limitation from 1990 to May 2017. A MEDLINE search was conducted using the terms "metformin" and "renal disease" from 1990 to May 2017. A PubMed search was conducted using the MESH terms "vitamin b12 deficiency" and "metformin" from 1970 to May 2017. A MEDLINE search was conducted using terms "metformin" and "vitamin B12 deficiency" with an English limitation from 1970 to May 2017. Study Selection and Data Extraction: Retrospective and prospective clinical trials, meta-analyses, and systematic reviews were considered for inclusion. Citations from identified articles were also reviewed for inclusion. Data Synthesis: The incidence of metformin-associated lactic acidosis is minimal. Data indicate metformin-treated patients with an estimated glomerular filtration rate above 30 mL/min/1.73 m2 have a reduction in mortality. Additionally, data suggest metformin may lead to vitamin B12 deficiency. Conclusion: Data support recommendations for metformin use in patients with diabetes and renal insufficiency with an estimated glomerular filtration rate above 30 mL/min/1.73 m2. Data also suggest that baseline and periodic testing of vitamin B12 levels are warranted and supported by clinical guidelines due to the risk of vitamin B12 deficiency in metformin-treated patients.

Compliance with guidelines for disease management in diabetes: results from the SwissDiab Registry

OBJECTIVE

Tight glycemic control and aggressive treatment of additional cardiovascular risk factors can substantially reduce risk of diabetes-related complications. In 2013, the Swiss Society of Endocrinology and Diabetology (SSED) established national criteria on good disease management in diabetes, but little is known about compliance in clinical care. Here we assessed to what extent patients from two tertiary care centers in the German-speaking part of Switzerland enrolled in the Swiss Diabetes (SwissDiab) Registry adhere to the SSED criteria.

RESEARCH DESIGN AND METHODS

SwissDiab is a prospective observational cohort study of patients regularly treated at Swiss tertiary diabetes centers. Data were collected through standardized annual health examinations. Baseline participant descriptive statistics, stratified by diabetes mellitus type 1 (DM1) and type 2 (DM2), were compared with SSED targets for glycemic control, blood pressure, blood lipids, weight maintenance, and ophthalmic examination.

RESULTS

By the end of 2016, 604 participants with DM1 (40%) and DM2 (60%) had data available for analyses, 36% and 29% women, respectively. At baseline, all the SSED targets were met with two exceptions: a glycated hemoglobin A1c value <7% was measured in 32% of participants with DM1 (SSED target: ≥40%) and 47% and 56% of overweight or obese participants with DM1 and DM2, respectively, received nutritional counseling in the previous year (SSED target: ≥80%).

CONCLUSIONS

The SSED targets for good disease management in diabetes were achieved in the majority of participants at the time of enrollment, but results also highlight areas where disease management can be improved, particularly the role of nutrition counseling.

Risk and associates of incident hip fracture in type 1 diabetes: The Fremantle Diabetes Study

AIMS

To determine the relative risk of incident hip fracture in patients with type 1 diabetes and matched controls, to examine baseline associates of incident hip fracture in the patients with type 1 diabetes, and to compare hip fracture rates in age- and sex-matched patients with type 1 versus type 2 diabetes.

METHODS

Longitudinal observational study of 121 adults with type 1 diabetes (mean ± SD age 43.0 ± 15.5 years, 59.5% male) and 484 age- and sex-matched adults without diabetes. Age and sex matching was possible for 93 pairs of type 1 and type 2 participants. The main outcome measure was incident hip fracture hospitalisation.

RESULTS

During a mean ± SD 14.5 ± 5.8 years of follow-up, the incidence rate ratio for first hip fracture hospitalisation in type 1 participants versus residents without diabetes was 6.39 (95% CI 1.94-22.35, P < .001). In Cox proportional hazards modelling, type 1 diabetes was associated with cause-specific hazard ratio (csHR) for hip fracture of 7.11 (2.45-20.64, P < .001) after age and sex adjustment. Hip fracture in type 1 participants was associated with older age, osteoporosis treatment, depressive symptoms, ethnicity, systolic blood pressure, serum HDL-cholesterol, albuminuria and serum adiponectin (P ≤ 0.047); associations remained for the first three of these variables after adjustment for age and body mass index (P ≤ 0.025). The csHR for incident hip fracture was 5.32 (1.12-25.37, P = .036) for type 1 versus 2 diabetes.

CONCLUSIONS

Hip fracture risk is markedly elevated in type 1 diabetes compared with age and sex-matched individuals without diabetes and with type 2 diabetes from the same population.

Low serum HDL-cholesterol concentrations in mid-life predict late-life cognitive impairment in type 2 diabetes: The Fremantle diabetes study

In a study involving patients with type 2 diabetes assessed annually over 5years, serum HDL-cholesterol was the sole mid-life metabolic predictor of late-life cognitive impairment.

The relationship between estimated glomerular filtration rate trajectory and all-cause mortality in type 2 diabetes: the Fremantle Diabetes Study

OBJECTIVE

To investigate the association between estimated GFR (eGFR) and all-cause mortality, including the contribution of temporal eGFR changes, in well-characterised community-based patients with type 2 diabetes.

DESIGN

Longitudinal observational study.

METHODS

Participants from the Fremantle Diabetes Study Phase 1 were assessed between 1993 and 1996 and followed until end-December 2012. Cox proportional hazards modelling was used to assess the relationship between baseline eGFR category (Stage 1-5) and all-cause death, and between eGFR trajectories assigned by semiparametric group-based modelling (GBM) and all-cause death in patients with five post-baseline annual eGFR measurements.

RESULTS

In the full cohort (1296 patients; mean±s.d. age 64.1±11.3years, 48.6% males), 738 (56.9%) died during 12.9±6.1years of follow-up. There was a U-shaped relationship between all-cause death and eGFR category. With Stage 3 (45-59mL/min/1.73m(2)) as reference, the strongest association was for eGFR ≥90mL/min/1.73m(2) (hazard ratio (95% CI) 2.01 (1.52-2.66); P<0.001). GBM identified four linear trajectories ('low', 'medium', 'high', 'high/declining') in 532 patients with serial eGFR measurements. With medium trajectory as reference, eGFR trajectory displaced baseline eGFR category as an independent predictor of death, with low and high/declining trajectories associated with more than double the risk (2.03 (1.30-3.18) and 2.24 (1.31-3.83) respectively, P≤0.003) and associated median reductions in survival of 6.5 and 8.7years respectively.

CONCLUSION

There is a nonlinear relationship between eGFR and death in type 2 diabetes, which is at least partially explained by a sub-group of patients with an initially high but then rapidly declining eGFR.

The role of pharmaceutical care in diabetes management

Pharmaceutical care (PC) is a process through which a pharmacist works with other healthcare professionals and the patient to optimise pharmacotherapy. Early studies, carried out before PC was established, provided limited evidence of the benefits of pharmacist involvement in diabetes management. More recent research has examined the role of PC in a range of diabetic sub-groups. Although few of these studies were randomised, prospective and included clinically important end points such as HbA1C, some beneficial effects of PC were reported. In the most recent study, a 12-month randomised controlled trial of PC in community-based diabetic patients, regular face-to-face and telephone interviews with an experienced clinical pharmacist improved glycosylated haemoglobin while glycaemic control did not change in the controls. In addition, reductions in blood pressure, and in absolute vascular risk for patients with no history of coronary artery disease, were significantly greater in the PC group. Available evidence suggests that PC can prove a valuable component of community-based multi-disciplinary diabetes care.

Latent autoimmune diabetes amongst adults with type 2 diabetes in a Nigerian tertiary hospital

AIMS

The aim was to investigate the frequency and characteristics of persons with latent autoimmune diabetes in adults (LADA) amongst patients who had been clinically diagnosed as type 2 diabetes mellitus (CT2DM) in a tertiary care centre.

METHODOLOGY

One hundred and sixty patients with CT2DM participated in this cross-sectional study following selection by systematic random sampling. Demographic data, relevant clinical history and anthropometric measurements (weight, height, waist circumference and hip circumference) were taken and blood samples were obtained for analysis of fasting blood glucose, glycated haemoglobin (HbA1c) and glutamic acid decarboxylase antibodies (GADA). The results were analysed using SPSS version 16.

RESULTS

Nineteen (11.9%) out of 160 persons with CT2DM were positive for GADA. 95(59.4%) of the total study population were females. The mean (SD) age, BMI, waist circumference, were 60.49 (10.37) years, 26.47 (4.80) kg/m2, 92.16 (11.50)cm respectively. Subjects with CT2DM who were GADA positive had trend towards lower mean BMI (25.64 kg/m2 vs. 26.59 kg/m2) and waist circumference (89.80 kg/m2 vs. 92.47 kg/m2) than GADA negative subjects. GADA positive subjects also had a trend showing higher mean fasting blood glucose (144 mg/dl vs. 125 mg/dl, t=2.20, p=0.14), higher mean HbA1c (7% vs. 6.1%, t=3.19, p=0.077) and a higher proportion on insulin (31.6% vs. 22%, χ2=0.07, p=0.25) when compared with GADA negative patients.

CONCLUSION

The prevalence of LADA amongst a subset of Nigerians with CT2DM was 11.9%. There were no distinguishing clinical features to help characterize persons with LADA. The above finding emphasizes the importance of GADA testing for appropriate classification of persons with CT2DM. Early diagnosis of LADA would help direct appropriate therapy to optimize glycaemic control.

Higher ferritin levels, but not serum iron or transferrin saturation, are associated with Type 2 diabetes mellitus in adult men and women free of genetic haemochromatosis

CONTEXT

Iron overload predisposes to diabetes and higher ferritin levels have been associated with diabetes. However, it is unclear whether ferritin reflects differences in iron-related parameters between diabetic and nondiabetic persons. We examined associations of serum ferritin, iron and transferrin saturation with Type 2 diabetes in adults without genetic predisposition to iron overload.

DESIGN, PARTICIPANTS AND MEASUREMENTS

Cross-sectional analysis of community-dwelling men and women aged 17-97 years from the Busselton Health Survey, Western Australia. Men and women carrying genotypes associated with haemochromatosis (C282Y/C282Y or C282Y/H63D) were excluded. Serum ferritin, iron and transferrin saturation were assayed.

RESULTS

There were 1834 men (122 with diabetes, 6·6%) and 2351 women (141 with diabetes, 6%). In men, higher serum ferritin was associated with diabetes after adjusting for age, smoking, alcohol, cardiovascular history, body mass index (BMI), waist, blood pressure, lipids, C-reactive protein (CRP), adiponectin, alanine transaminase (ALT) and gamma-glutamyl transpeptidase (GGT) [odds ratio (OR): 1·29 per 1 unit increase log ferritin, 95% confidence interval (CI) = 1·01-1·65, P = 0·043]. In women, higher serum ferritin was associated with diabetes [fully adjusted OR: 1·31 per 1 unit increase log ferritin, 95% CI = 1·04-1·63, P = 0·020; 1·84 for tertile (T) 3 vs T1, 95% CI = 1·09-3·11]. Neither iron levels nor transferrin saturation were associated with diabetes risk in men or women. Higher ferritin was not associated with insulin resistance in nondiabetic adults.

CONCLUSIONS

In adults, higher ferritin levels are independently associated with prevalent diabetes while iron and transferrin saturation are not. Ferritin is a robust biomarker for diabetes risk, but further investigation is needed to clarify whether this relationship is mediated via iron metabolism.

High GADA titer increases the risk of insulin requirement in LADA patients: a 7-year follow-up (NIRAD study 7)

OBJECTIVE

The aim of this study was to determine whether glutamic acid decarboxylase antibody (GADA) titer and other clinical parameters could define the risk of progression to insulin therapy in latent autoimmune diabetes in adults (LADA) patients during a 7-year follow-up.

METHODS

This study involved 220 LADA and 430 type 2 diabetes subjects followed up for 7 years from the time of GADA screening to evaluate their progression toward insulin therapy. Kaplan-Meier curves and multivariate logistic regression analysis were performed to identify the markers capable of influencing this progression.

RESULTS

During the follow-up, the drop out was 4% in both groups. A total of 119 (56.1%) out of 212 LADA patients required insulin during the 7 years of follow-up. The Kaplan-Meier plots showed that 74/104 (71.1%) of high GADA titer required insulin compared with 45/108 (41.6%) of low GADA titer and with 86/412 (20.9%) of type 2 diabetes (P<0.0001 for both). A BMI of ≤25 kg/m2 and IA-2IC and zinc transporter 8 (ZnT8) positivity were also shown as the markers of faster progression (P<0.0001 for both). The proportion of LADA patients requiring insulin was significantly higher in the group of subjects treated also with sulfonylurea in the first year from diagnosis compared with those treated with diet and/or insulin sensitizers (P<0.001). The multivariate analysis confirmed that the presence of high GADA titer was a significant predictor of insulin requirement (P<0.0001, OR=6.95).

CONCLUSIONS

High GADA titer, BMI ≤ 25, ZnT8 and IA-2IC positivity and sulfonylurea treatment, in the first year from diagnosis, significantly increase the progression toward insulin requirement in LADA patients.

Higher body mass index in adults at diagnosis of the slowly progressive form of type 1 diabetes mellitus is associated with lower risk HLA genes

We hypothesised that higher body weight, a proposed risk factor for type 1 diabetes mellitus, would be associated with increased penetrance of lower risk genes. In adults at diagnosis of the slowly progressive form of type 1 diabetes mellitus we found that higher body mass index was associated with the absence of the highest risk HLA genes.

Clinical impact of the temporal relationship between depression and type 2 diabetes: the Fremantle diabetes study phase II

Background

The clinical features of type 2 diabetes may differ depending on whether first depression episode precedes or follows the diagnosis of diabetes.

Methods

Type 2 patients from the observational community-based Fremantle Diabetes Study Phase II underwent assessment of lifetime depression using the Brief Lifetime Depression Scale (developed and validated for this study) supplemented by information on current depression symptoms (Patient Health Questionnaire, 9-item version) and use of antidepressants. Patients were categorized as never depressed (Group 1), having had depression before diabetes diagnosis (Group 2), diagnosed with depression and diabetes within 2 years of each other (Group 3) and having depression after diabetes diagnosis (Group 4).

Results

Of 1391 patients, 20.8% were assigned to Group 2, 6.0% to Group 3 and 14.5% to Group 4. In Group 2, depression occurred a median 15.6 years before diabetes onset at age 37.2±14.7 years. These patients had similar clinical characteristics to never depressed patients except for reduced self-care behaviours and having more symptomatic peripheral arterial disease. In Group 4, depression occurred a median 9.9 years after diabetes onset at age 59.8±13.0 years. These patients had long duration diabetes, poor glycaemic control, more intensive management and more diabetic complications. Group 4 patients had more current depression than Group 2 but were less likely to be receiving antidepressants.

Conclusions/Interpretation

The clinical features of depression and type 2 diabetes are heterogeneous depending on their temporal relationship. There may be corresponding differences in the pathogenesis of depression in diabetes that have implications for diagnosis and management.

Adapting and validating diabetes simulation models across settings: accounting for mortality differences using administrative data

AIMS

To develop age and sex-specific risk equations for predicting mortality following major complications of diabetes, using a large linked administrative dataset from Western Australia (WA) and to incorporate these into an existing diabetes simulation model.

METHODS

The study uses linked hospital and mortality records on 13,884 patients following a major diabetes-related complication with a mean (SD) duration of 2.62 (2.25) years. Risk equations for predicting mortality were derived and integrated into the UKPDS Outcomes Model. Estimates of life expectancy and incremental QALYs gained as a result of two theoretical therapies (a reduction of HbA1c of 1%, and reduction of systolic blood pressure of 10 mmHg) were determined using the original and adapted models.

RESULTS

The two versions of the model generated differences in life expectancy following specific events; however there was little impact of using alternative mortality equations on incremental QALYs gained as a result of reducing HbA(1c) or systolic blood pressure, or on outcomes of life expectancy for a cohort initially free of complications.

CONCLUSIONS

Mortality following complications varies across diabetic populations and can impact on estimates of life expectancy, but appears to have less impact on incremental benefits of interventions that are commonly used in pharmoeconomic analyses.

Latent autoimmune diabetes in adults in Asians: similarities and differences between East and West

Latent autoimmune diabetes in adults (LADA) is a form of autoimmune diabetes with features of both type 1 and type 2 diabetes and in the middle of the diabetes spectrum. Scientists clash on the question of whether this type of diabetes is a unique diabetes subtype. Multicenter studies have been performed in different countries, including the Korea National Diabetes Program (KNDP) collaboratory group, the Ehime study in Japan, the Not Insulin-Requiring Autoimmune Diabetes (NIRAD) study in Italy, the Nord-Trøndelag Health (HUNT) study in Norway, the UK Prospective Diabetes Study (UKPDS) in the UK, the Action LADA study in Europe and the LADA China study in China. These studies found universal immunogenetic effects associated with LADA, but with some ethnic differences. Herein we summarize those multicenter studies and compare the ethnic similarities and differences between East and West from epidemiological, clinical, immune, and genetic viewpoints.

The prevalence and characteristics of latent autoimmune diabetes in adults (LADA) and its relation with chronic complications in a clinical department of a university hospital in Korea

Few studies were performed to evaluate the prevalence of latent autoimmune diabetes in adults (LADA) and the difference of chronic complications between LADA, T1DM, and T2DM in Korean. The aim of this study is to establish the prevalence of LADA in a diabetic clinic of Soonchunhyang University hospital and to compare the phenotypic characteristics according to DM classification based on positivity of glutamic acid decarboxylase antibodies (GADA). Also, another important point concerns the occurrence of diabetes chronic microvascular complications in LADA. 323 patients who were checked GADA among diabetic patients admitted at Soonchunhyang University hospital were recruited. Twenty-eight patients (8.7%) were identified as positive for GADA. 11.5% (n = 37) were diagnosed with T1DM and 5.3% (n = 17) were diagnosed with LADA. GADA titer showed significant negative correlation with age of onset, total cholesterol (TC), triglyceride (TG), fasting C-peptide, stimulated C-peptide, BMI, and positive correlation with HbA1C and HDL-C. Compared with those that tested negative for GADA, patients with GADA positive had lower values of onset age, BMI, TC, TG, LDL-C, fasting, and stimulated C-peptide levels and higher values of HbA1C. A significant gradual increase of values was observed for the onset age, BMI, SBP, DBP, fasting, and stimulated C-peptide across the T1DM, LADA, and T2DM subgroups. Concerning the chronic complications there was no difference in prevalence of retinopathy, neuropathy and nephropathy between three groups. Of LADA patients, 12 patients were receiving insulin treatment and mean time to insulin initiation was about 37 months. In conclusion, because our study suggests LADA subgroups in Korea appear to have a faster decline in C-peptide levels, it is worth detecting the patients with LADA early and effort to preserve beta cell function. Furthermore, our results showed that the prevalence of microvascular complication was comparable between the subgroups.

Incidence and predictors of hospitalization for bacterial infection in community-based patients with type 2 diabetes: the fremantle diabetes study

Background

The few studies that have examined the relationship between diabetes and bacterial infections have utilized administrative databases and/or have had limited/incomplete data including recognized infection risk factors. The aim of this study was to determine the incidence and associates of bacterial infection severe enough to require hospitalization in well-characterized community-based patients with type 2 diabetes.

Methods and Findings

We studied a cohort of 1,294 patients (mean±SD age 64.1±11.3 years) from the longitudinal observational Fremantle Diabetes Study Phase I (FDS1) and 5,156 age-, gender- and zip-code-matched non-diabetic controls. The main outcome measure was incident hospitalization for bacterial infection as principal diagnosis between 1993 and 2010. We also examined differences in statin use in 52 FDS1 pairs hospitalized with pneumonia (cases) or a contemporaneous non-infection-related cause (controls). During 12.0±5.4 years of follow-up, 251 (19.4%) patients were hospitalized on 368 occasions for infection (23.7/1,000 patient-years). This was more than double the rate in matched controls (incident rate ratio (IRR) (95% CI), 2.13 (1.88–2.42), P<0.001). IRRs for pneumonia, cellulitis, and septicemia/bacteremia were 1.86 (1.55–2.21), 2.45 (1.92–3.12), and 2.08 (1.41–3.04), respectively (P<0.001). Among the diabetic patients, older age, male sex, prior recent infection-related hospitalization, obesity, albuminuria, retinopathy and Aboriginal ethnicity were baseline variables independently associated with risk of first hospitalization with any infection (P≤0.005). After adjustment for these variables, baseline statin treatment was not significant (hazard ratio (95% CI), 0.70 (0.39–1.25), P = 0.22). Statin use at hospitalization for pneumonia among the case-control pairs was similar (23.1% vs. 13.5%, P = 0.27).

Conclusions

The risk of severe infection is increased among type 2 diabetic patients and is not reduced by statin therapy. There are a number of other easily-accessible sociodemographic and clinical variables that could be used to optimize infection-related education, prevention and management in type 2 diabetes.

Incidence and predictors of all-cause and site-specific cancer in type 2 diabetes: the Fremantle Diabetes Study

OBJECTIVE

To explore the relationship between diabetes and cancer.

DESIGN

The Fremantle Diabetes Study (FDS) was a community-based longitudinal observational study of 1426 subjects, 1294 of which had type 2 diabetes.

METHODS

The FDS type 2 cohort and four age-, sex- and postcode-matched controls per case were followed for cancer events from 1993 until mid-2010 and incidence rate ratios (IRRs) were calculated. Competing risks proportional hazards models generated risk factors for incident cancers in the diabetic group.

RESULTS

There were 309 first cancers over 13 051 patient-years, or 2368 (95% confidence interval (95% CI) 2111-2647)/100 000 patient-years in the diabetes patients vs 1131 over 60 324 patient-years (1875 (1769-1987)/100 000 patient-years) in the controls. For those aged ≥45 years, the risk of all-cause cancer was elevated in type 2 diabetic men (IRRs 1.23, 95% CI 1.04-1.45) and women (1.30, 1.06-1.59). The incidence of colorectal cancer was increased (1.36, 1.01-1.82), especially in diabetic men aged 75-84 years (2.14, 1.22-3.64). Age at diabetes diagnosis (sub-hazard ratio 1.05, 1.02-1.09), calcium channel blocker therapy (2.37, 1.39-4.06), recent exercise (2.11, 1.06-4.20) and serum total cholesterol (0.68, 0.52-0.88) increased colorectal cancer risk. Pancreatic cancer was also more frequent in the diabetic patients (IRR 2.26, 1.20-4.10). Diabetic men and women had similar risks of prostate and breast cancer to those of controls (0.83, 0.59-1.14 and 0.86, 0.52-1.36).

CONCLUSIONS

Type 2 diabetes is associated with a moderately increased cancer risk in well-characterised community-based patients, especially pancreatic cancer and colorectal cancer in older men. Recommended cancer screening should be considered as part of routine diabetes management.

Continuing disparities in cardiovascular risk factors and complications between aboriginal and Anglo-Celt Australians with type 2 diabetes: the Fremantle Diabetes Study

OBJECTIVE

To determine whether disparities in the nature and management of type 2 diabetes persist between Aboriginal and the majority Anglo-Celt patients in an urban Australian community.

RESEARCH DESIGN AND METHODS

Baseline data from the observational Fremantle Diabetes Study collected from 1993 to 1996 (phase I) and from 2008 to 2011 (phase II) were analyzed. Patients characterized as Aboriginal or Anglo-Celt by self-report and supporting data underwent comprehensive assessment, including questionnaires, examination, and biochemical testing in a single laboratory. Generalized linear modeling with age/sex adjustment was used to examine differences in changes in variables in the two groups between phases I and II.

RESULTS

The indigenous participants were younger at entry and at diabetes diagnosis than the Anglo-Celt participants in both phases. They were also less likely to be educated beyond primary level and were more likely to be smokers. HbA(1c) decreased in both groups over time (Aboriginal median 9.6% [interquartile range 7.8-10.7%] to 8.4% [6.6-10.6%] vs. Anglo-Celt median 7.1% [6.2-8.4%] to 6.7% [6.2-7.5%]), but the gap persisted (P = 0.65 for difference between phases I and II by ethnic group). Aboriginal patients were more likely to have microvascular disease in both phases. The prevalence of peripheral arterial disease (ankle-brachial index ≤0.90 or lower-extremity amputation) increased in Aboriginal but decreased in Anglo-Celt participants (15.8-29.7 vs. 30.7-21.5%; P = 0.055).

CONCLUSIONS

Diabetes management has improved for Aboriginal and Anglo-Celt Australian patients, but disparities in cardiovascular risk factors and complications persist.

The relationship between self-monitoring of blood glucose results and glycated haemoglobin in type 2 diabetes: the fremantle diabetes study

The benefits of self-monitoring of blood glucose (SMBG) in type 2 diabetes remain contentious. If SMBG data do not accurately reflect HbA(1c), attempts to modify lifestyle/pharmacotherapy will be ineffective. We aimed to determine how well SMBG correlates with HbA(1c) and fasting serum glucose (FSG). Community-based type 2 patients using SMBG provided their highest and lowest pre- and post-prandial glucose results in the week before detailed assessment. The ability of average pre- and post-prandial SMBG to predict HbA(1c)>7.0% was determined by linear regression and receiver operating characteristic (ROC) analyses. Of 1286 patients with known SMBG status, 70% reported using SMBG. Pre-prandial SMBG data were obtained from 554 participants and post-prandial SMBG data from 418. The mean SMBG result and HbA(1c) correlated significantly (pre-prandial r(s)=0.55, post-prandial r(s)=0.47; P<0.001). Areas under the ROC curve (95% confidence limits) were 0.78 (0.74-0.83) and 0.74 (0.69-0.78) for pre- and post-prandial SMBG (P<0.04). The optimal cut-point was 6.5 mmol/L for pre-prandial SMBG (sensitivity 79.3%, specificity 64.4%). Mean pre-prandial SMBG results correlated with FSG (r(s)=0.64, P<0.001) but were on average 1.4 mmol/L lower, consistent with known whole blood vs. plasma differences. Since SMBG values reflect prevailing glycaemia, refinements in their interpretation and application may improve SMBG effectiveness.

The epidemiology and characteristics of type 2 diabetes in urban, community-based young people

As little is known about the impact of type 2 diabetes amongst Australian youth despite international increases in childhood obesity, we aimed to identify and characterize people aged<25 years with type 2 diabetes in an urban community with 60,000 people aged 10-24 years. The estimated maximum prevalence (59/100,000 persons) was lower than US estimates but higher than in Asia and Europe. In eight patients assessed in detail, obesity and related comorbidities were common, and quality of life was low.

Economic impact of moderate weight loss in patients with Type 2 diabetes: the Fremantle Diabetes Study

AIM

To assess the change in the cost of diabetes medication attributable to moderate weight loss in patients with Type 2 diabetes.

METHODS

Longitudinal data collected annually from 590 patients participating in the observational, community-based Fremantle Diabetes Study were examined to determine whether moderate weight loss (≥ 5% of initial body weight) was independently associated with diabetes medication cost during 4 years' follow-up.

RESULTS

Overall, the weight of the cohort decreased significantly during 4.3 ± 0.4 years' follow-up by 1.3 ± 6.2 kg (-1.4 ± 7.9% baseline body weight; trend P < 0.001). Moderate weight loss was achieved by 31%. HbA(1c) improved significantly in the group with moderate weight loss compared with the group without moderate weight loss [-4 ± 16 mmol/mol (-0.3 ± 1.5%) vs. 0 ± 17 mmol/mol (0.0 ± 1.5%), P = 0.015]. Mean (bias-corrected 95% confidence intervals) diabetes medication costs were $A820 ($A744-907) during follow-up. As the cost distribution was highly right-skewed and contained zeros, it was square root (√) transformed before multiple linear regression analysis. The most parsimonious model of baseline associates of √(diabetes medication cost) included glycaemic control, diabetes treatment, diabetes duration, BMI, systolic blood pressure, serum HDL cholesterol (negative), taking lipid-lowering medication and age (negative) (adjusted R(2) = 73.6%). After adjusting for these variables, √(diabetes medication cost) was negatively associated with moderate weight loss (P = 0.026). After entering average values for the cohort into the model, the cost of diabetes medications between baseline and fourth review for an average patient with no weight loss was $A752 compared with $A652 for a patient who attained moderate weight loss, a saving of $A100 (-13.3%).

DISCUSSION

These data highlight the economic and clinical benefits of moderate weight loss in Type 2 diabetes.

Renin-angiotensin-aldosterone system blockade and urinary albumin excretion in community-based patients with Type 2 diabetes: the Fremantle Diabetes Study

AIMS

To determine whether the reduction in urinary albumin excretion through renin-angiotensin-aldosterone system blockade found in intervention trials extends to community-based patients with Type 2 diabetes.

METHODS

We analysed data from 302 participants in the longitudinal observational Fremantle Diabetes Study who commenced angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy during follow-up and who had an annual assessment on either side of this therapeutic change.

RESULTS

At baseline, the patients had a mean age of 63.8 years, a median diabetes duration of 4 years, a median HbA(1c) of 7.6% (60 mmol/mol) and a geometric mean (sd range) urinary albumin:creatinine ratio of 3.3 mg/mmol (0.8-13.1 mg/mmol). The percentages with normo-, micro- and macroalbuminuria were 49.0, 38.4 and 12.6%, respectively. During 6.1 ± 1.7 years of follow-up, initiation of renin-angiotensin-aldosterone system blockade was associated with a larger geometric mean (sd range) absolute albumin:creatinine ratio reduction in the patients with macroalbuminuria compared with those who had either normo- or microalbuminuria [-40.9 (-825.7 to 159.9) mg/mmol) vs. 1.7 (-1.6 to 20.0) mg/mmol and -0.5 (-23.0 to 39.5) mg/mmol, respectively; P < 0.001]. These changes remained significant after adjustment for changes in blood pressure and other potentially confounding variables, including drug dose and angiotensin-converting enzyme genotype. The post-treatment median albumin:creatinine ratios were 35.4 and 27.4% lower than before treatment in those with micro- or macroalbuminuria, respectively.

CONCLUSIONS

Usual-care initiation of renin-angiotensin-aldosterone system blockade confers a quantitatively similar renal benefit to that in intervention trials in Type 2 diabetes.

Angiotensin-converting enzyme insertion/deletion polymorphism and severe hypoglycemia complicating type 2 diabetes: the Fremantle Diabetes Study

AIMS/HYPOTHESES

The aim of this study was to determine whether the angiotensin-converting enzyme (ACE) gene I/D polymorphisms independently predict severe hypoglycemia in community-dwelling type 2 patients.

METHODS

Six hundred and two patients who were ACE genotyped at baseline and assessed in 1998 were followed up to the end of June 2006. Severe hypoglycemia was defined as that requiring documented health service use as the primary diagnosis. Cox proportional hazards modeling was used to determine the predictors of first episode and zero-inflated negative binomial regression modeling identified predictors of frequency.

RESULTS

Forty-nine patients (8.1%) experienced 63 episodes of severe hypoglycemia. After adjusting for previously identified significant independent predictors of time to first episode, both ACE DD genotype and ACE inhibitor therapy, but not their interaction, added to the model [hazard ratio (95% confidence interval): 2.34 (1.29-4.26), P = 0.006, and 1.77 (0.99-3.13), P = 0.052, respectively]. Similarly, after adjusting for previously identified risk factors for multiple episodes of severe hypoglycemia, ACE DD genotype was independently associated with increased risk [incidence relative risk (95% confidence interval): 1.80 (1.00-3.24), P = 0.050].

CONCLUSIONS/INTERPRETATION

ACE DD genotype was associated with an approximately 2-fold increased risk of the first episode of severe hypoglycemia and its subsequent frequency in well-characterized patients with type 2 diabetes. Consistent with previous case-control studies, ACE inhibitor therapy was a weak predictor of severe hypoglycemia. ACE I/D genotyping might provide useful adjunctive prognostic information when intensive glycemic control measures are contemplated.

Accuracy, determinants, and consequences of body weight self-perception in type 2 diabetes: the Fremantle Diabetes Study

OBJECTIVE

To assess the accuracy, determinants, and consequences of body weight self-perception in type 2 diabetes.

METHODS

We studied 1272 community-based patients and a 518-patient overweight/obese subset who returned for ≥4 annual reviews. Multiple logistic regression was used to identify baseline predictors of correct weight self-perception and to determine whether correct weight self-perception predicted future weight loss. Overweight and obesity were defined as body mass indices of 25.0-29.9 and ≥30.0 kg/m(2), respectively.

RESULTS

Of the patients who were overweight (40.0%) or obese (41.8%) at baseline, 52.8% and 83.7%, respectively, correctly self-identified their weight category. Overweight/obese participants who self-identified correctly were more likely to have been informed they were overweight (P<.001), predominantly by their general practitioner (80.1%). Overweight participants had less self-awareness if they were not abdominally obese, did not speak English fluently, were male, or had a low income. Obese participants were more likely to consider themselves overweight if they had better diabetes knowledge and higher educational attainment. Correct weight self-perception did not influence subsequent weight loss.

CONCLUSIONS

Health care professionals can facilitate body weight self-awareness in type 2 diabetes. Education programmes should recognise the impact of gender and socio-demographic variables on accurate weight self-perception.

Helicobacter pylori cytotoxin-associated gene-A antibodies do not predict complications or death in type 2 diabetes: the Fremantle Diabetes Study

OBJECTIVES

There is cross-sectional evidence that CagA antigen produced by Helicobacter pylori is associated with coronary heart disease, stroke, atrial fibrillation (AF) and microalbuminuria, but no large-scale longitudinal studies have been conducted in diabetic patients. We aimed to determine whether cytotoxin-associated gene-A (CagA) seropositivity is independently associated with important vascular outcomes in type 2 diabetes.

METHODS

We studied 1179 type 2 patients from a well characterized community-based cohort who had available sera from baseline assessment between 1993 and 1996, and follow-up for incident events to end-June 2007. H. pylori IgG and CagA antibodies at baseline were measured by validated ELISA. Multiple logistic/linear regression analysis and Cox proportional hazards modelling were used to determine independent baseline associates of prevalent and incident complications, respectively, including H. pylori/CagA serostatus.

RESULTS

At baseline, 62.0% of patients were H. pylori seropositive and 37.7% were both H. pylori and CagA seropositive. CagA seropositivity was not independently associated with prevalent coronary heart disease (CHD), cerebrovascular disease (CVD), peripheral arterial disease or AF at baseline (P > 0.41), but there was a significant inverse association with ln(urinary albumin:creatinine) (P = 0.033). There were no independent associations between CagA seropositivity and incident CHD/CVD or progression to microalbuminuria (P > 0.20). During follow-up, 480 patients (40.7%) died, 246 (50.2%) from cardiovascular causes. After adjustment for other variables,CagA seropositivity was weakly protective against cardiovascular death (P = 0.024).

CONCLUSION

CagA seropositivity is not a risk factor for chronic vascular complications of type 2 diabetes. Assay of CagA antibodies does not contribute significantly to clinical management outside gastroenterological indications.

Cardiovascular risk prediction in adults with type 1 diabetes: the Fremantle Diabetes Study

The performance of the Fremantle Diabetes Study cardiovascular risk equation, derived in 1240 individuals with type 2 diabetes, was assessed in a parallel cohort of 117 adults with type 1 diabetes. Despite significantly different phenotypic characteristics, the equation successfully identified adults with type 1 diabetes at increased cardiovascular risk.

Apolipoprotein E genotype and mortality in Southern European and Anglo-Celt patients with type 2 diabetes: the Fremantle Diabetes Study

OBJECTIVE

To determine whether cardiac and all-cause mortality are lower in Southern European (SE) patients than in Anglo-Celt (AC) patients with type 2 diabetes in an urban Australian setting, and, if so, whether ethnicity-specific differences in apolipoprotein E (APOE) genotypes are contributory.

DESIGN

Longitudinal observational cohort study.

METHODS

We analysed detailed data from 1057 patients from the community-based Fremantle Diabetes Study, 238 were of an SE migrant background and 819 of AC ethnicity. Cox proportional hazards modelling was used to identify independent predictors of cardiac and all-cause mortality.

RESULTS

During 9.8±3.5 years of follow-up, 411 (38.9%) participants died, 161 (39.2%) from cardiac causes. Significant positive baseline independent predictors of cardiac death were age, male gender, coronary heart disease, cerebrovascular disease, peripheral arterial disease, retinopathy and peripheral neuropathy (P≤0.004), while maternal history of diabetes was protective (P=0.014). After adjusting for these variables, APOE4 carriage was predictive (hazard ratio (95% confidence interval) 1.61 (1.01-2.58); P=0.048). SE ethnicity did not add significantly to the model either as a single variable or as an interaction term with APOE4 carriage (P≥0.86). Significant independent predictors of all-cause mortality were age, male gender, smoking, coronary heart disease, cerebrovascular disease, peripheral arterial disease, retinopathy, peripheral neuropathy and microalbuminuria (P≤0.047), while overweight/obesity, lipid-lowering therapy and recent exercise were protective (P≤0.008). APOE4 carriage, SE ethnicity and their interaction did not add to the model (P≥0.32).

CONCLUSIONS

SE ethnicity does not confer an independent survival advantage in community-based Australian type 2 diabetic patients, but APOE4 carriers are at higher risk of cardiac death.

Sulphonylurea-metformin combination therapy, cardiovascular disease and all-cause mortality: the Fremantle Diabetes Study

AIM

To determine whether combination of metformin-sulphonylurea is associated with an increased risk of cardiovascular disease (CVD) and mortality in an urban community-based cohort of type 2 patients.

METHODS

We studied 1271 (98.2%) of 1294 type 2 participants in the observational Fremantle Diabetes Study (mean age 64.2 years, 48.8% males) who had detailed diabetes-specific therapy recorded at baseline and complete follow-up data. Mortality and hospital discharge data were collected over 13 174 patient-years (mean +/- SD: 10.4 +/- 3.9 years). Cox proportional hazards modelling was used to determine whether baseline diabetes treatments were independently associated with cardiovascular mortality, hospitalization for/death from CVD or all-cause mortality after adjustment for other explanatory variables.

RESULTS

During follow-up, 523 deaths occurred (41.1%) of which 269 (51.4%) were attributed to CVD. Hospitalization for CVD as principal diagnosis occurred at least once for 481 (37.8%) participants. In Kaplan-Meier analyses, there were significant differences in cardiovascular mortality, hospitalization for/death from CVD and all-cause mortality between diabetes therapy groups (p < 0.001). Compared with diet and metformin monotherapy, those treated with metformin-sulphonylurea had higher cardiovascular and all-cause mortality (p < or = 0.024). Insulin users had significantly higher cardiovascular mortality, hospitalization for/death from CVD and all-cause mortality than those on combination therapy (p < or = 0.016). After adjustment for significant variables in the most parsimonious models, diabetes treatment was not independently associated with any of the three study endpoints (p > or = 0.49).

CONCLUSIONS

Combination metformin-sulphonylurea appears as safe as other blood glucose-lowering therapies used for type 2 diabetes.

Serum uric acid does not predict cardiovascular or all-cause mortality in type 2 diabetes: the Fremantle Diabetes Study

AIMS/HYPOTHESIS

To determine whether serum uric acid: (1) is associated with cardiovascular disease (CVD) death and/or all-cause mortality in type 2 diabetes; and (2) consistent with published data, predicts these outcomes in older patients and those of southern European ethnicity.

METHODS

We studied those 1,268 (98%) of 1,294 type 2 participants in the observational Fremantle Diabetes Study who had a fasting serum uric acid measured at baseline. Mortality data were collected over a mean (+/-SD) 10.3 +/- 3.9 years. Cox proportional hazards modelling was used to determine independent baseline predictors of CVD and all-cause death including fasting serum uric acid as a continuous variable and quartiles.

RESULTS

During follow up, 525 deaths occurred (41.4% of the cohort) of which 271 (51.6%) were attributed to CVD. In univariate analyses, patients in the highest uric acid quartile had the greatest CVD and all-cause mortality (p = 0.007 and p = 0.001). After adjustment for significant variables in the most parsimonious model, baseline serum uric acid was not an independent associate of CVD or all-cause mortality whether entered as a continuous variable (HR 1.11 [95% CI 0.96-1.27] and 1.10 [95% CI 0.98-1.22] for a 0.1 mmol/l increase, respectively) or as quartiles (p > 0.10). Analyses of 638 patients >65 years of age and 231 of southern European ethnicity produced similar results.

CONCLUSIONS/INTERPRETATION

Serum uric acid was not an independent predictor of CVD or all-cause mortality in our community-based type 2 patients. Fasting serum uric acid concentrations do not appear to be prognostically useful in type 2 diabetes.

Determinants of severe hypoglycemia complicating type 2 diabetes: the Fremantle diabetes study

CONTEXT

There are limited published data characterizing severe hypoglycemia complicating type 2 diabetes.

OBJECTIVE

The objective of the study was to determine the incidence and predictors of severe hypoglycemia in community-dwelling type 2 patients.

DESIGN

This was a longitudinal observational cohort study.

SETTING

This was a community-based study.

PATIENTS

There were 616 patients (mean age 67.0 yr, 52.3% males, median diabetes duration 7.7 yr) assessed in 1998 and followed up to the end of June 2006.

MAIN OUTCOME MEASURES

Severe hypoglycemia defined as that requiring ambulance attendance, emergency department services, and/or hospitalization. Cox proportional hazards modeling was used to determine predictors of first episode, and Poisson, negative binomial, zero-inflated Poisson, and zero-inflated negative binomial regression models identified predictors of frequency.

RESULTS

Fifty-two (8.4%) experienced 66 episodes during 3953 patient-years (incidence 1.7 per 100 patient-years). Those experiencing severe hypoglycemia had one to four episodes. Significant independent predictors of time to first episode were duration of insulin treatment, estimated glomerular filtration rate less than 60 ml/min per 1.73 m(2), peripheral neuropathy, education beyond primary level, and past severe hypoglycemia. The zero-inflated negative binomial provided the best model of severe hypoglycemia frequency. Lower fasting serum glucose and higher glycosylated hemoglobin were significantly associated with frequency, whereas patients at minimal risk of repeated severe hypoglycemia were unlikely to use insulin or to have short-duration insulin treatment, to have renal impairment or peripheral neuropathy, or to be educated beyond primary level.

CONCLUSIONS

Duration of insulin treatment was confirmed as an independent risk factor for severe hypoglycemia. The novel association with educational attainment suggests knowledge-driven intensive glycemic self-management. The positive relationship between frequency and glycosylated hemoglobin may identify patients with unstable glycemic control.

Aspirin is associated with reduced cardiovascular and all-cause mortality in type 2 diabetes in a primary prevention setting: the Fremantle Diabetes study

OBJECTIVE

To determine whether regular aspirin use (> or =75 mg/day) is independently associated with cardiovascular disease (CVD) and all-cause mortality in community-based patients with type 2 diabetes and no history of CVD.

RESEARCH DESIGN AND METHODS

Of the type 2 diabetic patients recruited to the longitudinal observational Fremantle Diabetes Study, 651 (50.3%) with no prior CVD history at entry between 1993 and 1996 were followed until death or the end of June 2007, representing a total of 7,537 patient-years (mean +/- SD 11.6 +/- 2.9 years). Cox proportional hazards modeling was used to determine independent baseline predictors of CVD and all-cause mortality including regular aspirin use.

RESULTS

There were 160 deaths (24.6%) during follow-up, with 70 (43.8%) due to CVD. In Kaplan-Meier survival analysis, there was no difference in either CVD or all-cause mortality in aspirin users versus nonusers (P = 0.52 and 0.94, respectively, by log-rank test). After adjustment for significant variables in the most parsimonious Cox models, regular aspirin use at baseline independently predicted reduced CVD and all-cause mortality (hazard ratio [HR] 0.30 [95% CI 0.09-0.95] and 0.53 [0.28-0.98[, respectively; P < or = 0.044). In subgroup analyses, aspirin use was independently associated with reduced all-cause mortality in those aged > or =65 years and men.

CONCLUSIONS

Regular low-dose aspirin may reduce all-cause and CVD mortality in a primary prevention setting in type 2 diabetes. All-cause mortality reductions are greatest in men and in those aged > or =65 years. The present observational data support recommendations that aspirin should be used in primary CVD prevention in all but the lowest risk patients.

GAD antibody positivity predicts type 2 diabetes in an adult population

OBJECTIVE

To evaluate the significance of GAD antibodies (GADAs) and family history for type 1 diabetes (FH(T1)) or type 2 diabetes (FH(T2)) in nondiabetic subjects.

RESEARCH DESIGN AND METHODS

GADAs were analyzed in 4,976 nondiabetic relatives of type 2 diabetic patients or control subjects from Finland. Altogether, 289 (5.9%) were GADA(+)-a total of 253 GADA(+) and 2,511 GADA(-) subjects participated in repeated oral glucose tolerance tests during a median time of 8.1 years. The risk of progression to diabetes was assessed using Cox regression analysis.

RESULTS

Subjects within the highest quartile of GADA(+) (GADA(+)(high)) had more often first-degree FH(T1) (29.2 vs. 7.9%, P < 0.00001) and GADA(+) type 2 diabetic (21.3 vs. 13.7%, P = 0.002) or nondiabetic (26.4 vs. 13.3%, P = 0.010) relatives than GADA(-) subjects. During the follow-up, the GADA(+) subjects developed diabetes significantly more often than the GADA(-) subjects (36/253 [14.2%] vs. 134/2,511 [5.3%], P < 0.00001). GADA(+)(high) conferred a 4.9-fold increased risk of diabetes (95% CI 2.8-8.5) compared with GADA(-)-seroconversion to positive during the follow-up was associated with 6.5-fold (2.8-15.2) and first-degree FH(T1) with 2.2-fold (1.2-4.1) risk of diabetes. Only three subjects developed type 1 diabetes, and others had a non-insulin-dependent phenotype 1 year after diagnosis. GADA(+) and GADA(-) subjects did not clinically differ at baseline, but they were leaner and less insulin resistant after the diagnosis of diabetes.

CONCLUSIONS

GADA positivity clusters in families with type 1 diabetes or latent autoimmune diabetes in adults. GADA positivity predicts diabetes independently of family history of diabetes, and this risk was further increased with high GADA concentrations.