Young-onset type 2 diabetes and younger current age: increased susceptibility to retinopathy in contrast to other complications

Association between age at diabetes diagnosis and the development and progression of diabetic retinopathy

This study aimed to investigate the relationship between age at diabetes diagnosis (ADD) and the development and progression of diabetic retinopathy (DR). This study combined analysis of the National Health and Nutrition Examination Survey (NHANES) data with Mendelian randomization (MR). We employed regression models, propensity score matching, generalized additive model smoothing splines (GAM), random forest algorithms, and other analytical techniques. Cross-sectional analysis of NHANES data (n = 877) showed that the DR group had a significantly younger ADD compared to the DR-free group (P < 0.001). Regression analysis revealed a significant inverse association between ADD and DR prevalence (OR = 0.96, P < 0.001). MR analysis further supported this inverse relationship (OR = 0.42, P = 0.003). Two non-linear analytical approaches identified peak DR occurrence probability at ages 24.45 (GAM) and 24.2 (Shapley additive explanations dependence plots). Additionally, younger ADD was associated with increased DR severity across all categories (P < 0.05). In conclusion, older ADD was associated with a protective effect against the development and progression of DR, as supported by both analysis of NHANES data and MR. These findings underscore the importance of increased vigilance and more frequent screening for DR in patients diagnosed with diabetes at a young age.

Profiling of Macrovascular and Microvascular Complications in Young-Onset Type 2 Diabetes: A Scoping Review

Young-onset type 2 diabetes is defined as type 2 diabetes diagnosed before the age of 40 years. It is characterized by more aggressive pathology compared with type 2 diabetes diagnosed later in life, leading to earlier susceptibility to macrovascular and microvascular complications. This scoping review comprehensively profiles the complications associated with young-onset type 2 diabetes. Early detection of these complications, comprehensive risk assessment, and multifaceted glycemic management will improve quality of life and overall life expectancy in this population.

Age at onset of type 2 diabetes and prevalence of vascular disease and heart failure: Systematic review and dose-response meta-analysis

AIM

To investigate the relationship between age at diagnosis of type 2 diabetes and the risk of macrovascular disease, heart failure, and microvascular disease.

METHODS

In August 2022, PubMed/EMBASE were searched for articles reporting (i) coronary artery disease, cerebrovascular disease, peripheral vascular disease, amputation; (ii) heart failure; and (iii) retinopathy, neuropathy, nephropathy (albuminuria, chronic kidney disease [CKD], end-stage renal disease) by age at diagnosis of type 2 diabetes. Random effects, non-linear dose-response meta-analysis was undertaken for each outcome to assess the association with age at diagnosis (40 years = reference), using both crude and maximally adjusted odds ratios separately, with and without adjustment for current age (age at sampling).

RESULTS

We identified 42 articles (230,003 to 3,465,590 participants; 1035 to 391,140 events). Age at diagnosis was positively associated with the risk of macrovascular diseases, heart failure, and CKD, independent of current age, and negatively associated with retinopathy. For other microvascular outcomes, when adjusting for current age, a "reverse U" relationship was observed (peak risk = 55-60 years).

DISCUSSION

Retinopathy was negatively associated with age at diagnosis, highlighting the importance of retinopathy screening in early-onset type 2 diabetes. The implications of other associations were unclear due to the heterogeneity in methodologies and findings.

Association of age at diagnosis of diabetes with subsequent risk of age-related ocular diseases and vision acuity

BACKGROUND

The importance of age on the development of ocular conditions has been reported by numerous studies. Diabetes may have different associations with different stages of ocular conditions, and the duration of diabetes may affect the development of diabetic eye disease. While there is a dose-response relationship between the age at diagnosis of diabetes and the risk of cardiovascular disease and mortality, whether the age at diagnosis of diabetes is associated with incident ocular conditions remains to be explored. It is unclear which types of diabetes are more predictive of ocular conditions.

AIM

To examine associations between the age of diabetes diagnosis and the incidence of cataract, glaucoma, age-related macular degeneration (AMD), and vision acuity.

METHODS

Our analysis was using the UK Biobank. The cohort included 8709 diabetic participants and 17418 controls for ocular condition analysis, and 6689 diabetic participants and 13378 controls for vision analysis. Ocular diseases were identified using inpatient records until January 2021. Vision acuity was assessed using a chart.

RESULTS

During a median follow-up of 11.0 years, 3874, 665, and 616 new cases of cataract, glaucoma, and AMD, respectively, were identified. A stronger association between diabetes and incident ocular conditions was observed where diabetes was diagnosed at a younger age. Individuals with type 2 diabetes (T2D) diagnosed at < 45 years [HR (95%CI): 2.71 (1.49-4.93)], 45-49 years [2.57 (1.17-5.65)], 50-54 years [1.85 (1.13-3.04)], or 50-59 years of age [1.53 (1.00-2.34)] had a higher risk of AMD independent of glycated haemoglobin. T2D diagnosed < 45 years [HR (95%CI): 2.18 (1.71-2.79)], 45-49 years [1.54 (1.19-2.01)], 50-54 years [1.60 (1.31-1.96)], or 55-59 years of age [1.21 (1.02-1.43)] was associated with an increased cataract risk. T2D diagnosed < 45 years of age only was associated with an increased risk of glaucoma [HR (95%CI): 1.76 (1.00-3.12)]. HRs (95%CIs) for AMD, cataract, and glaucoma associated with type 1 diabetes (T1D) were 4.12 (1.99-8.53), 2.95 (2.17-4.02), and 2.40 (1.09-5.31), respectively. In multivariable-adjusted analysis, individuals with T2D diagnosed < 45 years of age [β 95%CI: 0.025 (0.009,0.040)] had a larger increase in LogMAR. The β (95%CI) for LogMAR associated with T1D was 0.044 (0.014, 0.073).

CONCLUSION

The younger age at the diagnosis of diabetes is associated with a larger relative risk of incident ocular diseases and greater vision loss.

Validation of the Chinese version of the diabetes health profile to predict the impact of mobile health education on quality of life in type 2 diabetes patients

Purpose

The Diabetes Health Profile (DHP18), initially created in the United Kingdom, currently lacks a Chinese version. This study endeavors to authenticate the Chinese adaptation of the DHP18 and assess the influence of mobile health (mHealth) education intervention on the quality of life of individuals living with diabetes.

Patients and methods

The study included 470 Type 2 diabetes Mellitus (T2DM) patients (204 men, 266 women), spanning an age range of 19-79 years, with an average age of 54 ± 12.40 years. Data analysis employed Jamovie and Mplus software. Moreover, test-retest reliability was evaluated in 52 hospitalized T2DM patients through two repeated measurements taken 4 weeks apart.

Results

The Chinese version DHP18 scale exhibited high reliability, evidenced by a Cronbach's alpha of 0.88, and coefficient of test-retest reliability of 0.84. Individual subscales also demonstrated strong reliability, ranging from 0.76 to 0.84, with test-retest reliability spanning from 0.71 to 0.74. Confirmatory Factor Analysis (CFA) employing a three-factor structure (χ2 = 294.69, GFI = 0.92, TLI = 0.91, RMSEA = 0.05, SRMR = 0.06) validated the scale's construct validity. Notably, there was a statistically significant difference (p < 0.05) in the quality of life between Type 2 diabetes patients using mHealth education intervention and those without mHealth education intervention. Mediation analysis revealed that Appraisal of Diabetes (ADS) and Self-Management Efficacy (SED) mediated the effects of Psychological Distress (PD) and Behavior Adherence (BA) on quality of life, both significant direct and indirect effects (p < 0.001). In addition, Dietary Abstinence (DE) displayed significant overall impact (β = -0.13, p < 0.001) and indirect influence (β = -0.10, p < 0.01) on diabetic patients' quality of life, though lacking a significant direct effect (β = -0.03, p = 0.38).

Conclusion

The Chinese version of the Diabetes Health Profile Scale meets stringent psychometric standards and stands as an appropriate measurement tool for Chinese T2DM patients, maintaining comparable results to the original scale's structure. The mHealth education intervention yielded a notably positive impact on the quality of life among T2DM patients. Mediation analysis revealed that the three dimensions of the DHP were mediated by Appraisal of Diabetes and Diabetes Self-Management Efficacy, partially mediated by Psychological Distress and Behavior Adherence, and fully mediated by Dietary Abstinence, providing insight into the positive effects of the mHealth model on the quality of life of diabetic patients.

Systemic and ocular outcomes in patients with young-onset type 2 diabetes

PURPOSE

To analyze the systemic and ocular outcomes in patients with young-onset type 2 diabetes (YO-DM2) based on grade of presenting diabetic retinopathy (DR).

METHODS

Retrospective cohort study analysis of empaneled patients with type 2 diabetes <40 years old with retinopathy screening within the Los Angeles Department of Health Services between 01/01/2017-07/01/2021 were included. Patients were stratified based on presenting severity of DR determined on fundus photographs or clinical examination. Patient's systemic co-morbidities and ocular outcomes were then compared across each group. Procedural (e.g. intravitreal injections) and surgical interventions (e.g. pars plana vitrectomy) were documented as performed by the treating physician.

RESULTS

2795 patients were screened from 12,456 patients diagnosed with diabetes younger than age 40 (22.4 %). Of these, 1496 patients were diagnosed with type 2 DM. 1084 (72.4 %) of patients presented without DR, 307 (20.5 %) presented with non-proliferative diabetic retinopathy (NPDR), and 105 (7.0 %) of patients presented with proliferative diabetic retinopathy (PDR). Increasing presenting diabetic retinopathy severity was associated with longer duration of diabetes, greater systemic comorbidities (e.g. diabetic foot disease, neuropathy, chronic kidney or end stage renal disease), worse baseline and final visual acuity, and required more procedural and surgical interventions.

CONCLUSIONS

Worse presenting DR severity in patients young-onset type 2 diabetes was associated with greater comorbid systemic and ocular disease with worse visual acuity outcomes. <1 % of patients without diabetic retinopathy or with mild NPDR were likely to progress to PDR. Diabetic kidney disease was an independent risk factor for developing neovascular glaucoma and retinal detachments. Prompt evaluation and intervention in patients with YO-DM2 may help reduce the associated systemic and ocular morbidity.

High prevalence of retinopathy in young-onset type 2 diabetes and possible sex differences: insights from Norwegian general practice

INTRODUCTION

People with young-onset type 2 diabetes (YOD), defined as diabetes diagnosis before age 40, have a high lifetime risk of vascular complications. We aimed to estimate the prevalence of YOD among adults with type 2 diabetes (T2D) in Norwegian general practice and explore associations between age at diabetes diagnosis and retinopathy overall and in men and women.

RESEARCH DESIGN AND METHODS

We collected cross-sectional data from general practice electronic medical records of 10 241 adults with T2D in 2014, and repeated measurements of hemoglobin A1c (HbA1c) from 2012 to 2014. Using multivariate logistic regression, we assessed associations between YOD and later-onset T2D, sex and retinopathy.

RESULTS

Of all individuals with T2D, 10% were diagnosed before 40 years of age in both sexes. Compared with later-onset T2D, HbA1c increased faster in YOD, and at the time of diagnosis HbA1c was higher in men, particularly in YOD. Retinopathy was found in 25% with YOD, twice as frequently as in later onset. After adjustments for confounders (age, country of origin, education, body mass index), OR of retinopathy was increased in both men with YOD (OR 2.6 (95% CI 2.0 to 3.5)) and women with YOD (OR 2.2 (1.5 to 3.0)). After further adjustments for potential mediators (diabetes duration and HbA1c), the higher OR persisted in men with YOD (OR 1.8 (1.3 to 2.4)) but was attenuated and no longer significant for women with YOD.

CONCLUSIONS

Retinopathy prevalence was more than twice as high in YOD as in later-onset T2D. The increased likelihood of retinopathy in YOD was partly mediated by higher HbA1c and longer T2D duration, but after accounting for these factors it remained higher in men with YOD.

Finnish diabetes risk score outperformed triglyceride-glucose index in diabetes risk prediction

Purpose

Triglyceride-Glucose (TyG) index is a surrogate marker of insulin resistance. This study compared the performance of TyG index and the Finnish diabetes risk score (FINDRISC) in diabetes risk prediction.

Methods

This cross-sectional study involved 122 young adults (aged 15-35 years) in Asaba, Delta State, Nigeria. Anthropometric measurements and biochemical analysis were done following standard protocols. Diabetes risk scoring was done using the FINDRISC questionnaire. TyG index was calculated logarithmically. Discrimination between TyG index and FINDRISC was done by plotting receiver operating characteristic (ROC) curves.

Results

High risk participants had significantly (p < 0.001) higher mean values of body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR) relative to the lower risk categories. Participants in TyG index Quartile 4 had significantly higher mean values of triglyceride (p < 0.001) and fasting plasma glucose (p < 0.05). BMI and triglyceride had the most significant (p < 0.001) positive correlation with FINDRISC and TyG index, respectively. A moderately elevated to high risk (FINDRISC ≥ 12) of developing diabetes was found in 14.8% of the participants; with a female preponderance (20.6%) relative to males (7.4%). More than half of the participants (52.5%) had slightly elevated risk and differences in diabetes risk susceptibility were significant (p < 0.001) across gender. FINDRISC had an AUC value of 0.826 while TyG index had an AUC value of 0.628 for diabetes risk prediction.

Conclusion

FINDRISC had a better performance than TyG index in the prediction of diabetes risk in this population. The use of other TyG-related parameters rather than TyG index is recommended in future studies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-023-01252-y.

Preliminary observational study of metabonomics in patients with early and late-onset type 2 diabetes mellitus based on UPLC-Q-TOF/MS

Non-targeted metabonomic techniques were used to explore changes in metabolic profiles of patients with early onset and late onset T2DM. Newly diagnosed early onset T2DM (EarT2DM) and late onset T2DM (LatT2DM) patients were recruited, and the matched age, sex, and low-risk population of diabetes mellitus were selected as the control group. 117 adults were recruited in the study, including 21 in EarT2DM group with 25 in corresponding control group (heaCG1), and 48 in LatT2DM group with 23 in corresponding control group (heaCG2). There were 15 relatively distinctive metabolic variants in EarT2DM group and 10 distinctive metabolic variants in LatT2DM group. The same changing pathways mainly involved protein, aminoacyl-tRNA biosynthesis, fatty acid biosynthesis, taurine metabolism, arginine biosynthesis, lysosome and mTOR signaling pathway. The independent disturbed pathways in EarT2DM included branched chain amino acids, alanine, aspartate and glutamate metabolism. The independent disturbed pathways in LatT2DM involved linoleic acid metabolism, biosynthesis of unsaturated fatty acids, arginine, proline metabolism and FoxO signaling pathway. T2DM patients at different diagnosed ages may have different metabolite profiles. These metabolic differences need to be further verified.

Complications and Treatment of Early-Onset Type 2 Diabetes

Context

Global reports have revealed a dramatic rise in the number of patients diagnosed with type 2 diabetes (T2DM) over the past three decades in all age groups, even in children and adolescents. The physiologic phenomenon of insulin resistance during puberty, as well as genetic and epigenetic factors, are implicated in this phenomenon. It seems that patients with early-onset T2DM experience a more aggressive clinical course; however, limited treatments available for these patients pose a challenge. This narrative review intends to scrutinize the micro- and macrovascular complications and treatments of patients with early-onset T2DM.

Methods

The literature search was conducted in the PubMed database to identify all relevant original English articles published from the beginning of 2018 until January 2023.

Results

Vascular complications, such as albuminuria, hypertension, cardiovascular diseases, and retinopathy, were seen to be more common in early-onset T2DM compared to type 1 diabetes. The odds ratio of vascular complications was higher in early-onset compared to late-onset T2DM. In children and adolescents with T2DM, the only approved medications included metformin, insulin, and glucagon-like peptide-1 agonists. Treatment of early-onset T2DM with metformin monotherapy cannot yield durable glycemic control, and most patients need early combination therapy.

Conclusions

During the past years, the frequency of early-onset T2DM has been growing at an alarming rate. Vascular complications in these patients seem more aggressive and more challenging to control. Hence, further clinical trials should be conducted to develop novel therapeutic approaches and evaluate their long-term benefits in terms of glycemic control and preventing future complications.

Development and validation of a diabetic retinopathy risk prediction model for middle-aged patients with type 2 diabetes mellitus

Objectives

The study aims to establish a predictive nomogram of diabetic retinopathy(DR) for the middle-aged population with type 2 diabetes mellitus (T2DM).

Methods

This retrospective study screened 931 patients with T2DM between 30 and 59 years of age from the 2011-2018 National Health and Nutrition Examination Survey database. The development group comprised 704 participants from the 2011-2016 survey, and the validation group included 227 participants from the 2017-2018 survey. The least absolute shrinkage and selection operator regression model was used to determine the best predictive variables. The logistic regression analysis built three models: the full model, the multiple fractional polynomial (MFP) model, and the stepwise (stepAIC) selected model. Then we decided optimal model based on the receiver operating characteristic curve (ROC). ROC, calibration curve, Hosmer-Lemeshow test, and decision curve analysis (DCA) were used to validate and assess the model. An online dynamic nomogram prediction tool was also constructed.

Results

The MFP model was selected to be the final model, including gender, the use of insulin, duration of diabetes, urinary albumin-to-creatinine ratio, and serum phosphorus. The AUC was 0.709 in the development set and 0.704 in the validation set. According to the ROC, calibration curves, and Hosmer-Lemeshow test, the nomogram demonstrated good coherence. The nomogram was clinically helpful, according to DCA.

Conclusion

This study established and validated a predictive model for DR in the mid-life T2DM population, which can assist clinicians quickly determining who is prone to develop DR.

Association between Age at Type 2 Diabetes Onset and Diabetic Retinopathy: A Double-Center Retrospective Study

BACKGROUND

With the decreasing age of type 2 diabetes mellitus (T2DM) onset, the incidence of diabetic complications is gradually increasing. We evaluated the independent effect of age at diabetes onset on diabetic retinopathy (DR) development.

METHODS

A total of 7472 patients with T2DM were enrolled in the National Metabolic Management Center from September 2017 to May 2022. Anthropometry data, laboratory reports, and medical history were collected. The independent association of DR with age at diabetes onset was analyzed using multivariable logistic regression models. In addition, a stratified analysis was performed to determine the effect of confounding variables.

RESULTS

Of the 7472 patients recruited, 1642 (21.98%) had DR. Patients with DR had considerably younger ages of diabetes onset than those without DR (45 (38-53) years vs. 50 (43-57) years, P < 0.001). The proportion of patients with T2DM onset at a younger age was higher in the DR group than that in the non-DR group. Participants were divided into four groups according to their age at diabetes onset, namely, ≥60, <40, 40-49, and 50-59 years. Compared with patients with diabetes onset at age ≥ 60 years, those with diabetes onset at <40 years (odds ratio (OR): 5.56, 95% confidence interval (CI): 3.731-8.285, P < 0.001), 40-49 years (OR: 2.751, 95% CI: 2.047-3.695, P < 0.001), and 50-59 years (OR: 1.606, 95% CI: 1.263-2.042, P < 0.001) were at an increased risk of DR after adjusting for potential confounding factors. Furthermore, stratification analyses demonstrated that young age at diabetes onset is an independent risk factor for DR.

CONCLUSIONS

Compared with diabetes onset at an older age, diabetes onset at a younger age is associated with a significantly increased DR risk.

Prevalence and risk of diabetic complications in young-onset versus late-onset type 2 diabetes mellitus

AIMS

To compare the prevalence and risk of diabetic complications between people with young-onset and late-onset type 2 diabetes mellitus (T2DM).

METHODS

In this observational study, 10,447 people with T2DM had at least one study of diabetic complications: retinopathy, neuropathy, chronic kidney disease (CKD), carotid artery plaque. We use odds ratios to compare complications between young-onset T2DM (YOD) and late-onset T2DM (LOD).

RESULTS

We compare 1,791 people with YOD (diagnosed < 40 years) and 8,656 with LOD (diagnosed ≥ 40 years). The YOD had a higher prevalence of these complications than the LOD (p < 0.011) after adjustment for confounding factors. Further adjustment for diabetes duration greatly attenuated the odds ratios however, neuropathy remained significantly more frequent in people with YOD (adjusted odds ratio: 1.39, 95% confidence interval: 1.13-1.71, p = 002). In cluster analysis on the 2,126 study participants who were diagnosed with T2DM within the previous two years, 47% of the YOD group were in the severe insulin-deficient diabetes cluster in comparison to 23% LOD; 28% and 44% respectively were in the mild age-related diabetes.

CONCLUSION

People with YOD had a higher prevalence of complications than those with LOD, but this was mostly attributed to a longer duration of diabetes. However, the prevalence of neuropathy remained significantly higher even after adjusting for factors including the duration of diabetes.

ISPAD Clinical Practice Consensus Guidelines 2022: Type 2 diabetes in children and adolescents

Since the 2018 ISPAD guidelines on this topic, follow-up of large cohorts from around the globe have continued informing the current incidence and prevalence of co-morbidities and complications in young adults with youth-onset type 2 diabetes (T2D). This chapter focuses on the risk factors, diagnosis and presentation of youth-onset T2D, the initial and subsequent management of youth-onset T2D, and management of co-morbidities and complications. We include key updates from the observational phase of the multi-center Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial, the SEARCH for Diabetes in Youth (SEARCH) study and new data from the Restoring Insulin Secretion (RISE) study, a head-to-head comparison of youth onset vs adult-onset T2D. We also include an expanded section on risk factors associated with T2D, algorithms and tables for treatment, management, and assessment of co-morbidities and complications, and sections on recently approved pharmacologic therapies for the treatment of youth-onset T2D, social determinants of health, and settings of care given COVID-19 pandemic.

Cytokine levels in the aqueous humor of young and senior patients with proliferative diabetic retinopathy

OBJECTIVE

To evaluate the aqueous humor levels of vascular endothelial growth factor (VEGF), connective tissue growth factor (CTGF), and tumor necrosis factor α (TNF-α) as biomarkers of the severity of proliferative diabetic retinopathy (PDR) in young and senior patients.

METHODS

This was a prospective clinical study. From October 2020 to June 2021, 37 patients (37 eyes) who were diagnosed with PDR and received pars plana vitrectomy (PPV) at Tianjin Medical University Eye Hospital were recruited and allocated to either the young (16 patients, 16 eyes) or senior subgroup (21 patients, 21 eyes). Twelve patients with cataracts (12 eyes) who underwent phacoemulsification combined with intraocular lens (IOL) implantation during the same period were recruited in the control group. The fibrovascular proliferation (FVP) grade and PDR severity scores were recorded during PPV. Enzyme-linked immunosorbent assay was used to detect the levels of VEGF, CTGF, and TNF-α in the aqueous humor.

RESULTS

(1) Young patients with PDR had a higher FVP grade and PDR severity score (P = 0.037, = 0.009); (2) The levels of the three cytokines in the study group were all significantly higher than in the control group (all P < 0.001); (3) The CTGF level in the young subgroup (2239.55 ± 167.32 pg/mL) was significantly higher than that in the senior subgroup (2114.49 ± 102.04 pg/mL) (P = 0.025). The VEGF level in the young subgroup (311.09 ± 10.74 pg/mL) was significantly lower than that in the senior subgroup (324.85 ± 14.97 pg/mL) (P = 0.004). The TNF-α level was not statistically different between the two subgroups (P = 0.382); (4) The CTGF/VEGF ratio in the young subgroup (7.20 ± 0.54) was significantly higher than in the senior subgroup (6.52 ± 0.39) (P < 0.001); (5) The CTGF/VEGF ratio was positively correlated with the FVP grades (R = 0.377, P = 0.022) and with the PDR severity scores (R = 0.354, P = 0.032) in patients with PDR.

CONCLUSION

The aqueous humor CTGF/VEGF ratio was positively correlated with the severity of PDR. A higher CTGF/VEGF ratio in the aqueous humor proved that neovascular fibrosis was more serious in young patients when they received PPV.

Prevalence of Diabetic Retinopathy in Undiagnosed Diabetic Patients: A Nationwide Population-Based Study

BACKGROUND

We investigated the prevalence of diabetic retinopathy (DR) in patients with undiagnosed diabetes through a nationwide survey, compared to those with known diabetes.

METHODS

Among the participants of the Korean National Health and Nutrition Examination Surveys (KNHANES) from 2017 to 2018, individuals aged ≥40 years with diabetes and fundus exam results were enrolled. Sampling weights were applied to represent the entire Korean population. Newly detected diabetes patients through KNHANES were classified under "undiagnosed diabetes."

RESULTS

Among a total of 9,108 participants aged ≥40 years, 951 were selected for analysis. Of them, 31.3% (standard error, ±2.0%) were classified under "undiagnosed diabetes." The prevalence of DR in patients with known and undiagnosed diabetes was 24.5%±2.0% and 10.7%±2.2%, respectively (P<0.001). The DR prevalence increased with rising glycosylated hemoglobin (HbA1c) levels in patients with known and undiagnosed diabetes (P for trend=0.001 in both). Among those with undiagnosed diabetes, the prevalence of DR was 6.9%±2.1%, 8.0%±3.4%, 5.6%±5.7%, 16.7%±9.4%, and 42.6%±14.8% for HbA1c levels of <7.0%, 7.0%-7.9%, 8.0%-8.9%, 9.0%-9.9%, and ≥10.0% respectively. There was no difference in the prevalence of hypertension, dyslipidemia, hypertriglyceridemia, or obesity according to the presence or absence of DR.

CONCLUSION

About one-third of patients with diabetes were unaware of their diabetes, and 10% of them have already developed DR. Considering increasing the prevalence of DR according to HbA1c level was found in patients with undiagnosed diabetes like those with known diabetes, screening and early detection of diabetes and DR are important.

Health consequences of early-onset compared with late-onset type 2 diabetes mellitus

Background

Although cumulating evidence has suggested that early-onset type 2 diabetes mellitus (T2DM) conferred on patients a broader tendency for complications beyond vascular ones, a comprehensive analysis of patterns of complications across all relevant systems is currently lacking.

Method

We prospectively studied 1 777 early-onset (age at diagnosis ≤ 45 years) and 35 889 late-onset (>45 years) T2DM patients with matched unexposed individuals from the UK Biobank. Diabetes-specific and -related complications were examined using phenome-wide association analysis, with patterns identified by comorbidity network analysis. We also evaluated the effect of lifestyle modifications and glycemic control on complication development.

Results

The median follow-up times for early-onset and late-onset T2DM patients were 17.83 and 9.39 years, respectively. Compared to late-onset T2DM patients, patients with early-onset T2DM faced a significantly higher relative risk of developing subsequent complications that primarily affected sense organs [hazard ratio (HR) 3.46 vs. 1.72], the endocrine/metabolic system (HR 3.08 vs. 2.01), and the neurological system (HR 2.70 vs. 1.81). Despite large similarities in comorbidity patterns, a more complex and well-connected network was observed for early-onset T2DM. Furthermore, while patients with early-onset T2DM got fewer benefits (12.67% reduction in pooled HR for all studied complications) through fair glycemic control (median HbA_1c ≤ 53 mmol/mol) compared to late-onset T2DM patients (18.01% reduction), they seemed to benefit more from favorable lifestyles, including weight control, healthy diet, and adequate physical activity.

Conclusions

Our analyses reveal that early-onset T2DM is an aggressive disease resulting in more complex complication networks than late-onset T2DM. Aggressive glucose-lowering intervention, complemented by lifestyle modifications, are feasible strategies for controlling early-onset T2DM-related complications.

Causes and Risk Factors of Repeated Hospitalization among Patients with Diabetic Retinopathy

Purpose

To identify the causes and risk factors of repeated hospitalization among patients with diabetic retinopathy (DR).

Methods

Our study retrospectively examined the data of DR patients who were readmitted for treatments to the Department of Ophthalmology, Guangdong Provincial People's Hospital between January 2012 and July 2021. We first analyzed the main causes of repeated admissions and then divided the patients into three groups according to the times of readmissions. Ordinal logistic regression was performed to determine the impact of patients' demographic and clinical characteristics. Moreover, comparisons of the length of stay and the hospitalization cost of DR patients with repeated admission causes were conducted.

Results

Among 2592 hospital discharges of 827 patients who experienced at least two hospitalizations, the major causes of repeated hospitalization were macular edema (30.83%), vitreous hemorrhage (29.09%), cataract (22.76%), proliferative membrane formation (6.91%), silicone oil removal (4.71%), retinal detachment (4.44%), and glaucoma (4.17%). The results of ordinal logistic regression showed that younger patients with medical insurance and local residence have a higher risk of repeated hospitalization (p < 0.05). Furthermore, patients readmitted for vitreous hemorrhage, proliferative membrane formation, and retinal detachment experienced longer length of hospital stay and higher hospitalization cost (p < 0.001).

Conclusions

Multiple causes and risk factors contribute to repeated hospitalization, imposing a substantial physical and economic burden on DR patients. A better understanding of these causes and risk factors of readmission may lead to lowering such risks and alleviating patients' burden.

Management of type 2 diabetes in young adults aged 18-30 years: ADS/ADEA/APEG consensus statement

INTRODUCTION

Type 2 diabetes in young adults (nominally, 18-30 years of age) is a more aggressive condition than that seen in older age, with a greater risk of major morbidity and early mortality. This first Australian consensus statement on the management of type 2 diabetes in young adults considers areas where existing type 2 diabetes guidance, directed mainly towards older adults, may not be appropriate or relevant for the young adult population. Where applicable, recommendations are harmonised with current national guidance for type 2 diabetes in children and adolescents (aged < 18 years). The full statement is available at https://www.diabetessociety.com.au, https://www.adea.com.au and https://www.apeg.org.au.

MAIN RECOMMENDATIONS

Advice is provided on important aspects of care including screening, diabetes type, psychological care, lifestyle, glycaemic targets, pharmacological agents, cardiovascular disease risk management, comorbidity assessment, contraception and pregnancy planning, and patient-centred education. Special considerations for Aboriginal and Torres Strait Islander Australians are highlighted separately.

CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT

Management recommendations for young adults, which differ from those for adults, include: ▪screening for diabetes in young adults with overweight or obesity and additional risk factors, including in utero exposure to type 2 diabetes or gestational diabetes mellitus; ▪more stringent glucose targets (glycated haemoglobin ≤ 6.5% [≤ 48 mmol/mol]); ▪in the context of obesity or higher cardio-renal risk, glucagon-like peptide 1 receptor agonists and sodium-glucose cotransporter 2 inhibitors are preferred second line agents; ▪β-cell decline is more rapid, so frequent review, early treatment intensification and avoidance of therapeutic inertia are indicated; ▪a blood pressure target of < 130/80 mmHg, as the adult target of ≤ 140/90 mmHg is too high; ▪absolute cardiovascular disease risk calculators are not likely to be accurate in this age group; early statin use should therefore be considered; and ▪a multidisciplinary model of care including an endocrinologist and a certified diabetes educator.

Barriers and enablers to diabetic eye screening attendance: An interview study with young adults with type 1 diabetes

AIM

The aim of this study was to identify barriers and enablers of diabetic eye screening (DES) attendance amongst young adults with diabetes living in the United Kingdom.

METHODS

Semistructured qualitative interviews with adults aged 18-34 years with diabetes. Participants were purposively sampled to aim for representation across gender, geographical locations, diabetes type, years since diabetes diagnosis and patterns of attendance (i.e. regular attenders, occasional non-attenders, regular non-attenders). Data were collected and analysed using the Theoretical Domains Framework (TDF) to explore potential individual, sociocultural and environmental influences on attendance. Data were analysed using a combined deductive and inductive thematic analysis approach. Barriers/enablers were mapped to behaviour change techniques (BCTs) to identify potential strategies to increase attendance.

RESULTS

Key barriers to attendance reported by the sample of 29 study participants with type 1 diabetes, fell within the TDF domains: [Knowledge] (e.g. not understanding reasons for attending DES or treatments available if diabetic retinopathy is detected), [Social Influences] (e.g. lack of support following DES results), [Social role and Identity] (e.g. not knowing other people their age with diabetes, feeling 'isolated' and being reluctant to disclose their diabetes) and [Environmental Context and Resources] (e.g. lack of appointment flexibility and options for rescheduling). Enablers included: [Social Influences] (e.g. support of family/diabetes team), [Goals] (e.g. DES regarded as 'high priority'). Many of the reported barriers/enablers were consistent across groups. Potential BCTs to support attendance include Instructions on how to perform the behaviour; Information about health consequences; Social support (practical) and Social comparison.

CONCLUSIONS

Attendance to diabetic eye screening in young adults is influenced by a complex set of interacting factors. Identification of potentially modifiable target behaviours provides a basis for designing more effective, tailored interventions to help young adults regularly attend eye screening and prevent avoidable vision loss.

Association Between Diabetic Retinopathy and Insomnia Risk: A Nationwide Population-Based Study

BACKGROUND

Previous studies have suggested a close link between sleep disturbances and diabetic retinopathy (DR). However, to date, no confirmatory findings have been reported. We aimed to explore the risk of insomnia in DR by considering demographic factors and diabetes mellitus (DM)-related variables.

METHODS

A nationwide population-based cohort of 2,206,619 patients with type 2 diabetes from the Korean National Insurance Service Database was followed up for insomnia incidence. DR, non-proliferative DR (NPDR), and proliferative DR (PDR) were defined according to ICD-10 codes. The interactive effects of sex, age, and DM-related variables were analyzed to evaluate their impact on insomnia risk in DR.

RESULTS

Compared with the non-DR group, insomnia risk was increased in the DR [(adjusted hazard ratio (aHR): 1.125, 95% confidence interval (CI):1.108-1.142), NPDR (aHR:1.117, 95% CI:1.099-1.134), and PDR (aHR:1.205, 95% CI: 1.156-1.256), even after controlling for comorbidities, lifestyle factors, and DM-related variables. The men and youngest age groups (<40 years) were most vulnerable to insomnia risk. Sex, age, DM duration, and chronic kidney disease (CKD) status exerted interactive effects with DR status in increasing the insomnia risk. In the PDR group, sex, age, DM duration, insulin therapy status, and CKD status exerted interactive effects that increased the risk of insomnia.

CONCLUSION

Insomnia risk is significantly higher in patients with DR, and clinical attention is warranted.

The association between age at diagnosis of type 2 diabetes and albuminuria in Chinese adults: A nationwide population study

BACKGROUND

Type 2 diabetes is increasingly diagnosed at a younger age worldwide and in China. Limited data are available regarding the association between age at diabetes diagnosis and risks of albuminuria. This study sought to examine the independent effect of age at diagnosis of type 2 diabetes on the risk of albuminuria.

METHODS

We used data from a nationwide multicenter study with 207 961 participants in mainland China. Age, sex, and study site were matched for 31 366 screen-detected type 2 diabetes cases and 31 366 normal controls. Age, sex, study site, and diabetes duration were matched for 7490 self-reported type 2 diabetes cases and 7490 normal controls. Risks of having albuminuria in matched type 2 diabetes vs controls were examined using multivariable logistic regression analysis in strata of age at diabetes diagnosis.

RESULTS

Although the absolute rate of albuminuria is higher in older adults, the odds ratio of albuminuria in type 2 diabetes vs matched controls decreased with increasing age at diagnosis. For participants with diabetes diagnosed at an age of <50, 50 to 59, 60 to 69, or ≥70 years, the multivariable adjusted risk of albuminuria increased by 81%, 60%, 45%, and 33% for screen-detected diabetes, and 135%, 121%, 90%, and 58% for self-reported diabetes compared with their normal controls, respectively.

CONCLUSIONS

A younger age at diagnosis of type 2 diabetes is associated with a more significantly elevated risk of albuminuria than an older age at diagnosis in Chinese adults.

Young adult onset type 2 diabetes versus type 1 diabetes: Progression to and survival on renal replacement therapy

BACKGROUND

Young-onset type 2 diabetes is an aggressive disease characterized by development of diabetic complications, including nephropathy, early in the disease course. However, within the cohort of young-onset type 1 and type 2 diabetes there are limited comparative data regarding progression to ESKD requiring renal replacement therapy or renal-related death (RRT/RRD).

METHODS

Probabilistic linkage of data from the RPAH Diabetes Centre, National Death Index and Australian and New Zealand Dialysis and Transplant Registry was undertaken. Cumulative Incidence Competing Risk and Cox Proportional Hazards Modelling approaches were utilized to examine progression to ESKD in young-onset type 1 and type 2 diabetes (age of diagnosis 15-35 years).

FINDINGS

Unadjusted incidence rates (95% CI) of RRT/RRD in young-onset type 1 and type 2 diabetes were 3.1 (2.3-4.0) and 4.6 (3.7-5.7) per 1000 person years respectively. After adjustment for gender, ethnicity and duration of diabetes, the HR (95% CI) of RRT/RRD in young-onset type 2 diabetes was 2.0 (1.4-2.9). The HR remained higher after further adjustment for first available cholesterol, HbA1c and systolic blood pressure but not BMI. For those who progressed to RRT, prognosis was similar irrespective of diabetes type; cumulative incidence of mortality was 40% in both young-onset type 1 and type 2 diabetes after 6 years of dialysis.

INTERPRETATION

Progression to RRT/RRD is greater in young-onset type 2 diabetes than in young-onset type 1 diabetes. The increased progression is associated with increased BMI. However, once ESKD is reached, individuals with young-onset type 1 and type 2 diabetes do equally poorly.

An Enhanced SMS Text Message-Based Support and Reminder Program for Young Adults With Type 2 Diabetes (TEXT2U): Randomized Controlled Trial

Background

Clinic attendance, metabolic control, engagement in self-management, and psychological health are suboptimal in young-onset (age of onset <40 years) type 2 diabetes.

Objective

We examined the effectiveness of an enhanced SMS text message–based support and reminder program in improving clinic attendance, metabolic control, engagement in self-management, and psychological health in young-onset type 2 diabetes.

Methods

A 12-month, parallel-arm, randomized controlled trial comparing an enhanced, semipersonalized SMS text message–based intervention (incorporating 1-8 supportive and/or informative text messages per month) against standard care was conducted in a specialized clinic for young adult type 2 diabetes. The primary outcome was maintenance of 100% attendance at scheduled quarterly clinical appointments. Secondary outcomes included (1) metabolic indices, (2) pathology and self-monitored blood glucose (SMBG) data availability, and (3) psychosocial well-being.

Results

A total of 40 participants were randomized, and 32 completed their 12-month study visit. The average participant age was 32.7 (SD 5.1) years, 50% (20/40) were male, and baseline glycated hemoglobin A_1c (HbA_1c) was 7.3% (SD 1.9%) (56 mmol/mol, SD 20). A higher proportion of the intervention group achieved 100% attendance (12/21, 57%, vs 5/19, 26%, for the control group); Kaplan-Meier analysis demonstrated significantly greater cumulative attendance in the intervention group (P=.04). There were no between-group differences in HbA_1c, BMI, lipids, or availability of pathology and SMBG data. Odds of recording an improvement in the Diabetes Empowerment Scale–Short Form score were higher in the intervention group at 6 months (odds ratio [OR] 4.3, 95% CI 1.1-17), with attenuation of this effect at study end (OR 3.1, 95% CI 0.9-11). Program acceptability was high; >90% of participants would recommend the program to new patients.

Conclusions

An enhanced SMS text message–based support and reminder program doubled scheduled clinic attendance rates for patients with young-onset type 2 diabetes. The program was highly acceptable and provided early support for patient empowerment but had no significant effect on measures of metabolic control or self-management.

Trial Registration

Australian and New Zealand Clinical Trials Registry (ACTRN12618000479202); https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373579

Nonalcoholic fatty liver disease increases the risk of diabetes in young adults: A nationwide population-based study in Korea

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of diabetes but has been rarely investigated in young adults. In this study, we investigated the relationship between NAFLD and incident diabetes risk in young adults using nationwide Korean population data.

METHODS

This population-based cohort study from the Korean National Health Insurance Service included adults aged 20 through 39 years who underwent a health examination from 2009 to 2012. NAFLD was defined as a fatty liver index (FLI) ≥60 in the absence of alcohol consumption of ≥30 g/day. Newly diagnosed diabetes during follow-up was identified using claims data. Cox regression was used to calculate the hazard ratio for incident diabetes after adjusting for classical confounders.

FINDINGS

Among the 5,254,786 participants, 9.3% had an FLI ≥60. During the median follow-up of 8.6 years, 91,885 cases of incident diabetes occurred. In multivariable analysis, the risk of incident diabetes was significantly higher in the NAFLD group than the control group (adjusted hazard ratio = 4.97, 95% confidence interval, 4.90-5.05). Stratified analyses showed higher associations in those who were ≥30 years, male, obese, smokers, alcohol consumers, and did not regularly exercise (all P < 0.001).

CONCLUSIONS

NAFLD is associated with a five-fold increased risk of incident diabetes in young adults. These results suggest an independent high risk for incident diabetes in young adults and underscore the importance of paying early attention to patients who develop NAFLD before middle age.

Transition of Youth With Type 2 Diabetes: Predictors of Health-Care Utilization After Transition to Adult Care From Population-Based Administrative Data

OBJECTIVES

In this study, we aimed to compare health-care visits pre- and posttransition from pediatric to adult care between youth with type 2 and type 1 diabetes.

METHODS

We linked a clinical database with the Manitoba Population Research Data Repository to compare health-care visits 2 years before and after transition, and investigated baseline factors influencing health-care engagement.

RESULTS

Youth with type 2 diabetes (n=196) vs type 1 diabetes (n=456) were more likely to be female (61% vs 44%), older at diagnosis (13.6 vs 10.6 years), live in northern regions and to be in the lowest socioeconomic status quartile (53% vs 5.4%). Seventy-six percent of youth with type 2 diabetes attended a follow-up visit within 2 years of transition compared to 97% of youth with type 1 diabetes. Youth with type 2 diabetes had higher rates of hospitalization pretransition (19.6 vs 11.6 admissions/100 patient years) and posttransition (24.7 vs 11.7 admissions/100 patient years) and fewer medical visits (pretransition: 2.4 vs 3.0 visits/person year [p<0.01]; posttransition: 1.6 vs 2.1 visits/person year [p<0.01]). Accounting for sex, geography, age, education, socioeconomic status and diabetes type, achieving 4 visits in 2 years posttransition was predicted by the number of visits pretransition (odds ratio, 1.35; 95% confidence interval, 1.23 to 1.49) and diabetes type (type 2 diabetes: odds ratio, 0.57; 95% confidence interval, 0.34 to 0.98).

CONCLUSIONS

Youth with type 2 diabetes attend fewer medical follow-up visits pre- and posttransition to adult care compared to youth with type 1 diabetes. Focused, informed, specific transition planning is needed that addresses the unique characteristics of this population.

Young-onset type 2 diabetes and younger current age: increased susceptibility to retinopathy in contrast to other complications

BACKGROUND

Type 2 diabetes diagnosed during youth and early adulthood is aggressive and associated with a high burden of vascular complications. The increase in complications is often attributed to long disease duration and poor metabolic control. Whether people with young-onset type 2 diabetes are inherently more susceptible to long-term complications than those diagnosed in later adulthood is unclear.

METHODS

Prospective data from 3322 individuals, diagnosed between the age of 15 and 70 years and collected 10-25 years after diabetes diagnosis, were analysed. The cross-sectional associations between age at diagnosis and microvascular and macrovascular complications were analysed using logistic regression models, adjusted for duration of diabetes exposure and metabolic risk factors including blood pressure, cholesterol and updated mean HbA_1c .

RESULTS

The prevalence of retinopathy was highest in those with young-onset type 2 diabetes (diagnosed at age 15 to <40 years). After 10-15 years' diabetes duration, the adjusted odds ratio for retinopathy in this population was 2.8 (95% CI 1.9-4.1; reference group those diagnosed at 60 to <70 years of age). The odds of retinopathy remained higher in people with young-onset type 2 diabetes after longer durations of diabetes exposure; the odds decreased with increasing age at diagnosis. This pattern was not observed in models of other complications: after 10-15 years' diabetes exposure, the adjusted odds ratios for albuminuria, peripheral neuropathy and macrovascular disease in people with young-onset type 2 diabetes were 0.5 (95% CI 0.4-0.8), 0.7 (95% CI 0.5-1.1) and 0.2 (95% CI 0.1-0.3), respectively.

CONCLUSION

After accounting for disease duration and other important confounders, people with type 2 diabetes diagnosed in youth and early adulthood (or with a younger current age) appeared to be inherently more susceptible to retinopathy. For other complications, adjusted risk appears highest in the oldest age of diagnosis group. These data have screening and treatment target implications.