Association of Cardiometabolic Multimorbidity and Depression With Cardiovascular Events in Early-Onset Adult Type 2 Diabetes: A Multiethnic Study in the U.S

The association between ethnicity and complications in individuals with early-onset type 2 diabetes: A systematic review

It remains unclear whether the prevalence and incidence of complications varies with ethnicity in individuals with early-onset type 2 diabetes. We undertook a systematic review to investigate. We identified sparse published data, with no clear findings. More prospective studies are needed. Epidemiological studies should routinely stratify by ethnicity.

Young adults with type 2 diabetes experience high rates of Level 3 Hypoglycemia: A subgroup analysis of the Real-World iNPHORM cohort

AIMS

This study evaluated the incidence of self-reported Level 3 hypoglycemia and explored associated risk factors in young adults with type 2 diabetes (T2D).

METHODS

Subgroup analyses with a one-year U.S.-wide T2D dataset were performed. Retrospective and prospective data on Level 3 hypoglycemia and participant characteristics were analyzed for 207 young adults (18-39 years old) and 436 middle-aged adults (40-64 years old). Age group-stratified multivariable negative binomial regression was used to identify factors associated with Level 3 hypoglycemia.

RESULTS

Young adults exhibited a threefold higher prevalence of Level 3 hypoglycemia events requiring medical assistance compared to the middle-aged cohort at baseline (p < 0.001). During follow-up, the young adults experienced a twofold higher prevalence of Level 3 hypoglycemia (p < 0.001), resulting in a fivefold higher rate of Level 3 hypoglycemia (p < 0.001) and greater hypoglycemia fear (p < 0.001). Distinct sociodemographics, general health and lifestyle factors, diabetes medical history, and diabetes therapy and technology use characteristics were observed in the young-adult group, as were unique risk factors for Level 3 hypoglycemia.

CONCLUSION

Our findings suggest that young adults with T2D are at particularly high risk of Level 3 hypoglycemia, with attributes that differ from those of the traditional middle-aged cohort.

Elevated plasma concentrations of lipoprotein (a) are associated with cardiovascular diseases in patients with early-onset type 2 diabetes mellitus

Objective

To ascertain whether vascular complications and high lipoprotein (a) [Lp(a)] concentrations are related in individuals with early-onset type 2 diabetes mellitus (T2DM).

Methods

This observational cross-sectional study included 591 individuals with early-onset T2DM who were divided into four groups based on Lp(a) values which was measured using immunoturbidimetry and presented as mg/dL: high, >50; intermediate, 30≤Lp(a)<50; low, 10≤Lp(a)<30; and very low, <10. The relationship between the risk of vascular complications and Lp(a) level was examined using a logistic regression model.

Results

The median age of onset for individuals with early-onset T2DM (n=591) was 37 years, duration of diabetes was 12 years, and glycated hemoglobin (HbA1c) level was 8.8%. The median Lp(a) was 10.40 (4.80-21.80) mg/dL, and Lp(a) concentration did not correlate with age, sex, or glycemic control (P>0.05). Individuals in the low Lp(a) (OR=2.12, 95% CI 1.17-3.84, P<0.05), intermediate Lp(a) (OR=2.76, 95% CI 1.10-6.98, P<0.05) and high Lp(a) (OR=4.79, 95% CI 2.03-11.31, P<0.01) groups had an increased risk of coronary heart disease (CHD) compared with those in the very low Lp(a) group after adjustment. Nevertheless, among individuals with early-onset T2DM, there was no correlation between Lp(a) concentration and the risk of cerebrovascular disease (CVL) and microvascular complications (P>0.05).

Conclusions

In patients with early-onset T2DM, Lp(a) concentration was independently associated with CHD. Lp(a) testing is essential to determine who has a latent high risk of CHD among patients with early-onset T2DM.

The Relationship between Visceral Fat Accumulation and Risk of Cardiometabolic Multimorbidity: The Roles of Accelerated Biological Aging

OBJECTIVES

To investigate the association between visceral fat accumulation and the risk of cardiometabolic multimorbidity (CMM) and the potential roles of accelerated biological aging in this relationship.

METHODS

Using data from the UK Biobank, a nationwide cohort study was conducted using the available baseline body roundness index (BRI) measurement. Biological aging was assessed using the Klemera-Doubal method for biological age and the phenotypic age algorithms. The association between the BRI and CMM was estimated using the Cox proportional hazards regression model, while the roles of biological aging were examined through interaction and mediation analyses.

RESULTS

During a median follow-up of 14.52 years, 6156 cases of CMM were identified. A significant association was observed between the BRI and CMM. The hazard ratio (HR) for CMM was 3.72 (95% confidence interval [CI]: 3.35-4.13) for individuals in the highest quartile compared with those in the lowest quartile of the BRI. More importantly, the BRI (AUC, 0.701; 95% CI, 0.694-0.707) demonstrated superior predictive performance relative to body mass index (AUC, 0.657; 95% CI, 0.650-0.664). Furthermore, the BRI exhibited additive interactions with accelerated biological aging on the risk of CMM, and accelerated biological aging partially mediated the association between the BRI and CMM.

CONCLUSIONS

These findings provide evidence for the application of the BRI as a novel and readily accessible screening tool associated with CMM, suggesting that the effective management of visceral fat and biological aging deceleration may hold promise for reducing CMM risk.

Identifying impaired mental health in patients with type 2 diabetes: a cross-sectional study in general practice

BACKGROUND

Type two diabetes (T2D) is linked to impaired mental health. International guidelines emphasise the importance of including psychological aspects in diabetes care. Yet, no systematic approach has been implemented to assess mental health in patients with T2D in general practice.

AIM

To evaluate the mental health of patients with T2D in general practice, and to investigate the effectiveness of asking patients about their wellbeing by using a single-item question compared with the five-item World Health Organization-Five Wellbeing Index (WHO-5).

DESIGN & SETTING

A cross-sectional study was undertaken, which included 230 patients with T2D in Danish general practice, from 1 May 2023-31 January 2024.

METHOD

Eligible patients were recruited at the annual chronic care consultation. They answered a single-item question on wellbeing and four validated measures of general wellbeing (WHO-5), depression (Patient Health Questionnaire-9; PHQ-9), anxiety (Generalised Anxiety Disorder-7; GAD-7), and diabetes distress (Problem Areas in Diabetes-5; PAID-5).

RESULTS

Overall, 32% of patients expressed symptoms of impaired mental health. Notably, the WHO-5 identified 53% of these patients, whereas only 12% of patients were identified through the single-item question. Importantly, among the patients exhibiting symptoms of impaired mental health, those identified by the WHO-5 displayed statistically significantly lower mental health scores across all measures (except PAID-5) compared with those not identified by the WHO-5.

CONCLUSION

A significant proportion of patients with T2D in general practice are affected by mental health issues. Our findings indicate that a single-item question may not sufficiently detect these issues, highlighting the importance of incorporating tools, such as the WHO-5, to offer a more comprehensive approach in diabetes care.

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

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

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The relationship between life's essential 8 score and depression symptom severity: evidence from a nationally representative sample of U.S. adults

BACKGROUND

Many studies have indicated that adverse cardiovascular health (CVH) behaviors are associated with an elevated risk of depression. However, the dose-response relationship between the two and the relative contributions of individual CVH components to depression risk remain unclear.

METHODS

We utilized data from the National Health and Nutrition Examination Survey (NHANES) conducted between 2015 and 2018. Quantified CVH was assessed using the Life's Simple 8 (LE8) instrument, depression symptoms were measured through the Patient Health Questionnaire-9 (PHQ-9), and a weighted logistic regression, restrictive cubic splines (RCS), subgroup analyses on sociodemographic factors, weighted quantile sum (WQS) regression were employed to evaluate the association between CVH and depression.

RESULTS

In a fully adjusted logistic regression model, for each unit increase in LE8 score, there was a corresponding decrease of 0.07 in depression score (β=-0.07, 95%CI -0.07 to -0.06, p < 0.001). The RCS model indicated a significant non-linear relationship between CVH and depression. Subgroup analyses revealed that the association between CVH and depression was strongest among women, ethnic minorities, individuals with low education levels, and those living in poverty. WQS regression analysis indicated that tobacco exposure and sleep health accounted for more than 60% of the cumulative effects of CVH indicators on depression.

CONCLUSION

This study indicates a significant negative correlation between overall cardiovascular health measured by LE8 scores and depression. Prioritizing interventions targeting lifestyle modifications to alleviate the burden of depression in public health initiatives is crucial.

Multimorbidity in elderly patients with or without T2DM: A real-world cross-sectional analysis based on primary care and hospitalisation data

Background

Shanghai's high level of ageing has given rise to a considerable number of elderly patients with type 2 diabetes mellitus (T2DM) who are confronted with the challenge of managing multimorbidity. We aimed to determine the prevalence of multimorbidity in elderly T2DM patients in a representative Pudong New Area community and critically evaluate current guidelines' inclusiveness in addressing major comorbidities.

Methods

Through the Shanghai Health Cloud platform, we extracted medical records of residents in the Huamu community (Pudong New Area, Shanghai) to screen elderly patients with at least three outpatient visits or one hospitalisation per year between 2019 and 2022. According to International Classification of Disease, 10th edition codes and personal identification number, we identified the status of T2DM and 12 other common chronic diseases, matched T2DM patients and non-T2DM patients 1:1 by age and gender, and then calculated the prevalence of multimorbidity status and annual prevalence of each comorbidity. We analysed associations between T2DM and specific chronic diseases using logistic regression models.

Results

More than 90% of elderly T2DM patients had at least one additional chronic disease. Multimorbidity was more frequent in women and older patients. Hyperlipidemia, hypertension, and ischaemic heart disease were the most prevalent comorbidities. The diagnosis of T2DM was significantly associated with both cardiovascular-kidney-metabolic and neuropsychiatric diseases. In addition, a higher prevalence and risk of chronic obstructive pulmonary disease (COPD) were consistently detected in elderly patients with T2DM, regardless of age and gender.

Conclusions

Multimorbidity in elderly patients with T2DM needs broader acknowledgement. Current guidelines focus more on cardiovascular-kidney-metabolic and neuropsychiatric diseases with inadequate guidance on COPD management. Hence, the pleiotropic effects of glucose-lowering drugs on COPD should be further investigated to optimise the comprehensive management strategy for this population.

Estimated glucose disposal rate, high sensitivity C-reactive protein and cardiometabolic multimorbidity in middle-aged and older Chinese adults: A nationwide prospective cohort study

AIM

To explore the separate and joint association of estimated glucose disposal rate (eGDR) and high-sensitivity C-reactive protein (hsCRP) with cardiometabolic multimorbidity (CMM).

METHODS

A total of 6900 participants aged 45 years or older with available data on eGDR and hsCRP and without cardiometabolic diseases at baseline from the China Health and Retirement Longitudinal Study were included. CMM was defined as the coexistence of two or more cardiometabolic diseases, including heart diseases, stroke, and diabetes.

RESULTS

During a median follow-up of 9.0 years, 464 (6.7 %) participants developed CMM. Low eGDR and high hsCRP separately and jointly increased the risk of CMM. The adjusted hazard ratio (HR) was 1.67 (95 % confidence interval [CI] 1.33-2.09) for low eGDR versus high eGDR, 1.43 (95 % CI 1.12-1.82) for high hsCRP versus low hsCRP) and 2.40 (95 % CI 1.77-3.27) for low eGDR plus high hsCRP versus high eGDR plus low hsCRP. The C-statistic, discriminatory power and risk reclassification significantly improved with the addition of combined eGDR and hsCRP for CMM (P < 0.001).

CONCLUSIONS

Low eGDR and high hsCRP were individually and jointly associated with increased risk of incident CMM. The findings highlighted the importance of joint evaluation of eGDR and hsCRP for primary prevention of CMM.

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

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

Cardiometabolic Disease Staging and Major Adverse Cardiovascular Event Prediction in 2 Prospective Cohorts

BACKGROUND

Cardiometabolic risk prediction models that incorporate metabolic syndrome traits to predict cardiovascular outcomes may help identify high-risk populations early in the progression of cardiometabolic disease.

OBJECTIVES

The purpose of this study was to examine whether a modified cardiometabolic disease staging (CMDS) system, a validated diabetes prediction model, predicts major adverse cardiovascular events (MACE).

METHODS

We developed a predictive model using data accessible in clinical practice [fasting glucose, blood pressure, body mass index, cholesterol, triglycerides, smoking status, diabetes status, hypertension medication use] from the REGARDS (REasons for Geographic And Racial Differences in Stroke) study to predict MACE [cardiovascular death, nonfatal myocardial infarction, and/or nonfatal stroke]. Predictive performance was assessed using receiver operating characteristic curves, mean squared errors, misclassification, and area under the curve (AUC) statistics.

RESULTS

Among 20,234 REGARDS participants with no history of stroke or myocardial infarction (mean age 64 ± 9.3 years, 58% female, 41% non-Hispanic Black, and 18% diabetes), 2,695 developed incident MACE (13.3%) during a median 10-year follow-up. The CMDS development model in REGARDS for MACE had an AUC of 0.721. Our CMDS model performed similarly to both the ACC/AHA 10-year risk estimate (AUC 0.721 vs 0.716) and the Framingham risk score (AUC 0.673).

CONCLUSIONS

The CMDS predicted the onset of MACE with good predictive ability and performed similarly or better than 2 commonly known cardiovascular disease prediction risk tools. These data underscore the importance of insulin resistance as a cardiovascular disease risk factor and that CMDS can be used to identify individuals at high risk for progression to cardiovascular disease.

Progress in Cardiac Magnetic Resonance Feature Tracking for Evaluating Myocardial Strain in Type-2 Diabetes Mellitus

The global prevalence of type-2 diabetes mellitus (T2DM) has caused harm to human health and economies. Cardiovascular disease is one main cause of T2DM mortality. Increased prevalence of diabetes and associated heart failure (HF) is common in older populations, so accurately evaluating heart-related injury and T2DM risk factors and conducting early intervention are important. Quantitative cardiovascular system imaging assessments, including functional imaging during cardiovascular disease treatment, are also important. The left-ventricular ejection fraction (LVEF) has been traditionally used to monitor cardiac function; it is often preserved or increased in early T2DM, but subclinical heart deformation and dysfunction can occur. Myocardial strains are sensitive to global and regional heart dysfunction in subclinical T2DM. Cardiac magnetic resonance feature-tracking technology (CMR-FT) can visualize and quantify strain and identify subclinical myocardial injury for early management, especially with preserved LVEF. Meanwhile, CMR-FT can be used to evaluate the multiple cardiac chambers involvement mediated by T2DM and the coexistence of complications. This review discusses CMR-FT principles, clinical applications, and research progress in the evaluation of myocardial strain in T2DM.

Multimorbidity in African ancestry populations: a scoping review

OBJECTIVES

Multimorbidity (MM) is a growing concern linked to poor outcomes and higher healthcare costs. While most MM research targets European ancestry populations, the prevalence and patterns in African ancestry groups remain underexplored. This study aimed to identify and summarise the available literature on MM in populations with African ancestry, on the continent, and in the diaspora.

DESIGN

A scoping review was conducted in five databases (PubMed, Web of Science, Scopus, Science Direct and JSTOR) in July 2022. Studies were selected based on predefined criteria, with data extraction focusing on methodology and findings. Descriptive statistics summarised the data, and a narrative synthesis highlighted key themes.

RESULTS

Of the 232 publications on MM in African-ancestry groups from 2010 to June 2022-113 examined continental African populations, 100 the diaspora and 19 both. Findings revealed diverse MM patterns within and beyond continental Africa. Cardiovascular and metabolic diseases are predominant in both groups (80% continental and 70% diaspora). Infectious diseases featured more in continental studies (58% continental and 16% diaspora). Although many papers did not specifically address these features, as in previous studies, older age, being women and having a lower socioeconomic status were associated with a higher prevalence of MM, with important exceptions. Research gaps identified included limited data on African-ancestry individuals, inadequate representation, under-represented disease groups, non-standardised methodologies, the need for innovative data strategies, and insufficient translational research.

CONCLUSION

The growing global MM prevalence is mirrored in African-ancestry populations. Recognising the unique contexts of African-ancestry populations is essential when addressing the burden of MM. This review emphasises the need for additional research to guide and enhance healthcare approaches for African-ancestry populations, regardless of their geographic location.

Diabetes and Multiple Long-term Conditions: A Review of Our Current Global Health Challenge

Use of effective treatments and management programs is leading to longer survival of people with diabetes. This, in combination with obesity, is thus contributing to a rise in people living with more than one condition, known as multiple long-term conditions (MLTC or multimorbidity). MLTC is defined as the presence of two or more long-term conditions, with possible combinations of physical, infectious, or mental health conditions, where no one condition is considered as the index. These include a range of conditions such as cardiovascular diseases, cancer, chronic kidney disease, arthritis, depression, dementia, and severe mental health illnesses. MLTC has major implications for the individual such as poor quality of life, worse health outcomes, fragmented care, polypharmacy, poor treatment adherence, mortality, and a significant impact on health care services. MLTC is a challenge, where interventions for prevention and management are lacking a robust evidence base. The key research directions for diabetes and MLTC from a global perspective include system delivery and care coordination, lifestyle interventions and therapeutic interventions.

Risk factors for multimorbidity in adulthood: A systematic review

BACKGROUND

Multimorbidity, the coexistence of multiple chronic diseases in an individual, is highly prevalent and challenging for healthcare systems. However, its risk factors remain poorly understood.

OBJECTIVE

To systematically review studies reporting multimorbidity risk factors.

METHODS

A PRISMA-compliant systematic review was conducted, searching electronic databases (MEDLINE, EMBASE, Web of Science, Scopus). Inclusion criteria were studies addressing multimorbidity transitions, trajectories, continuous disease counts, and specific patterns. Non-human studies and participants under 18 were excluded. Associations between risk factors and multimorbidity onset were reported.

RESULTS

Of 20,806 identified studies, 68 were included, with participants aged 18-105 from 23 countries. Nine risk factor categories were identified, including demographic, socioeconomic, and behavioral factors. Older age, low education, obesity, hypertension, depression, low pysical function were generally positively associated with multimorbidity. Results for factors like smoking, alcohol consumption, and dietary patterns were inconsistent. Study quality was moderate, with 16.2% having low risk of bias.

CONCLUSIONS

Several risk factors seem to be consistently associated with an increased risk of accumulating chronic diseases over time. However, heterogeneity in settings, exposure and outcome, and baseline health of participants hampers robust conclusions.

Prospective study of depressive symptoms and incident cardiovascular diseases in people with type 2 diabetes

BACKGROUND

To prospectively examine whether depressive symptoms were associated with higher risks of incident cardiovascular diseases (CVD) in individuals with type 2 diabetes.

METHODS

Included were 17,031 participants from UK Biobank with type 2 diabetes who were free of depression (identified by self-reported medical history, hospital record, and antidepressant use), and composite CVD, including atherosclerotic cardiovascular disease (ASCVD) and heart failure (HF). Cox proportional hazards models were applied to examine the association between depressive symptoms measured by Patient Health Questionaire-2 (PHQ-2) and incident composite CVD and its subtypes, adjusting for potential confounders.

RESULTS

During a median follow-up of 12.3 years, we documented 2875 incident composite CVD cases (including 1303 coronary artery disease, 531 ischemic stroke, 530 peripheral arterial disease, and 1142 HF cases). The presence of depressive symptoms had higher risks of composite CVD (adjusted HR, 1.34; 95 % CI, 1.17-1.54) among individuals with type 2 diabetes. Dose-response relationships were observed between depressive symptoms and the composite CVD, ASCVD, and three individual CVD outcomes (P-trend <0.05 for all).

CONCLUSIONS

Depressive symptoms were associated with a higher risk of CVD events across all degrees of metabolic control and diabetes severity. Dose-response associations were also found between depressive symptoms score and all incident CVD outcomes, except for ischemic stroke, after adjustment for cardiovascular and diabetes-related risk factors. Therefore, simple screening questions regarding depressive symptoms might be applied to people with type 2 diabetes to predict CVD outcomes.

A network-based study reveals multimorbidity patterns in people with type 2 diabetes

Patients with type 2 diabetes mellitus (T2DM) are at a heightened risk of living with multiple comorbidities. However, the comprehension of the multimorbidity characteristics of T2DM is still scarce. This study aims to illuminate T2DM's prevalent comorbidities and their interrelationships using network analysis. Using electronic medical records (EMRs) from 496,408 Chinese patients with T2DM, we constructed male and female global multimorbidity networks and age- and sex-specific networks. Employing diverse network metrics, we assessed the structural properties of these networks. Furthermore, we identified hub, root, and burst diseases within these networks while scrutinizing their temporal trends. Our findings uncover interconnected T2DM comorbidities manifesting as emergence in clusters or age-specific outbreaks and core diseases in each sex that necessitate timely detection and intervention. This data-driven methodology offers a comprehensive comprehension of T2DM's multimorbidity, providing hypotheses for clinical considerations in the prevention and therapeutic strategies.

Precision subclassification of type 2 diabetes: a systematic review

BACKGROUND

Heterogeneity in type 2 diabetes presentation and progression suggests that precision medicine interventions could improve clinical outcomes. We undertook a systematic review to determine whether strategies to subclassify type 2 diabetes were associated with high quality evidence, reproducible results and improved outcomes for patients.

METHODS

We searched PubMed and Embase for publications that used 'simple subclassification' approaches using simple categorisation of clinical characteristics, or 'complex subclassification' approaches which used machine learning or 'omics approaches in people with established type 2 diabetes. We excluded other diabetes subtypes and those predicting incident type 2 diabetes. We assessed quality, reproducibility and clinical relevance of extracted full-text articles and qualitatively synthesised a summary of subclassification approaches.

RESULTS

Here we show data from 51 studies that demonstrate many simple stratification approaches, but none have been replicated and many are not associated with meaningful clinical outcomes. Complex stratification was reviewed in 62 studies and produced reproducible subtypes of type 2 diabetes that are associated with outcomes. Both approaches require a higher grade of evidence but support the premise that type 2 diabetes can be subclassified into clinically meaningful subtypes.

CONCLUSION

Critical next steps toward clinical implementation are to test whether subtypes exist in more diverse ancestries and whether tailoring interventions to subtypes will improve outcomes.

Current insights and emerging trends in early-onset type 2 diabetes

Type 2 diabetes diagnosed in childhood or early adulthood is termed early-onset type 2 diabetes. Cases of early-onset type 2 diabetes are increasing rapidly globally, alongside rising obesity. Compared with a diagnosis later in life, an earlier-onset diagnosis carries an unexplained excess risk of microvascular complications, adverse cardiovascular outcomes, and earlier death. Women with early-onset type 2 diabetes also have a higher risk of adverse pregnancy outcomes. The high burden of complications renders individuals with early-onset type 2 diabetes at future risk of multimorbidity and interventions to reverse these concerning trends should be a priority. Within the early-onset cohort, disease pathophysiology and interventions have been better studied in paediatric-onset (<19 years) type 2 diabetes compared to adults; however, young adults aged 19-39 years (a larger number proportionally) are not well characterised and are also invisible in the current evidence base supporting management, which is derived from trials in later-onset type 2 diabetes. Young adults with type 2 diabetes face challenges in self-management that older individuals are less likely to experience (being in education or of working age, higher diabetes distress, and possible obesity-related stigma and diabetes-related stigma). There is a major research gap as to the optimal strategies to deploy in managing type 2 diabetes in adolescents and young adults, given that current models of care appear to not work as well in this age group. In the face of manifold risk factors (obesity, female sex, social deprivation, non-White European ethnicity, and genetic risk factors) prevention strategies with tailored lifestyle interventions, where needed, are likely to have greater success, but more evidence is needed. In this Review, we draw on evidence from both adolescents and young adults to provide a contemporary update on the current insights and emerging trends in early-onset type 2 diabetes.

Systematic review of precision subclassification of type 2 diabetes

Heterogeneity in type 2 diabetes presentation, progression and treatment has the potential for precision medicine interventions that can enhance care and outcomes for affected individuals. We undertook a systematic review to ascertain whether strategies to subclassify type 2 diabetes are associated with improved clinical outcomes, show reproducibility and have high quality evidence. We reviewed publications that deployed 'simple subclassification' using clinical features, biomarkers, imaging or other routinely available parameters or 'complex subclassification' approaches that used machine learning and/or genomic data. We found that simple stratification approaches, for example, stratification based on age, body mass index or lipid profiles, had been widely used, but no strategy had been replicated and many lacked association with meaningful outcomes. Complex stratification using clustering of simple clinical data with and without genetic data did show reproducible subtypes of diabetes that had been associated with outcomes such as cardiovascular disease and/or mortality. Both approaches require a higher grade of evidence but support the premise that type 2 diabetes can be subclassified into meaningful groups. More studies are needed to test these subclassifications in more diverse ancestries and prove that they are amenable to interventions.

Temporal trends in the prevalence and incidence of depression and the interplay of comorbidities in patients with young- and usual-onset type 2 diabetes from the USA and the UK

AIMS/HYPOTHESIS

We aimed to investigate the prevalence and incidence of depression, and the interplay of cardiometabolic comorbidities, in the differentiation of depression risk between young-onset diabetes (diagnosis at age <40 years) and usual-onset diabetes (diagnosis at age ≥40 years).

METHODS

Using electronic medical records from the UK and USA, retrospective cohorts of adults with incident type 2 diabetes diagnosed between 2006 and 2017 were examined. Trends in the prevalence and incidence of depression, and risk of developing depression, in participants with young-onset type 2 diabetes compared with usual-onset type 2 diabetes were assessed separately by sex and comorbidity status.

RESULTS

In total 230,932/1,143,122 people with type 2 diabetes from the UK/USA (mean age 58/60 years, proportion of men 57%/46%) were examined. The prevalence of depression in the UK/USA increased from 29% (95% CI 28, 30)/22% (95% CI 21, 23) in 2006 to 43% (95% CI 42, 44)/29% (95% CI 28, 29) in 2017, with the prevalence being similar across all age groups. A similar increasing trend was observed for incidence rates. In the UK, compared with people aged ≥50 years with or without comorbidity, 18-39-year-old men and women had 23-57% and 20-55% significantly higher risks of depression, respectively. In the USA, compared with those aged ≥60 years with or without comorbidity, 18-39-year-old men and women had 5-17% and 8-37% significantly higher risks of depression, respectively.

CONCLUSIONS/INTERPRETATION

Depression risk has been increasing in people with incident type 2 diabetes in the UK and USA, particularly among those with young-onset type 2 diabetes, irrespective of other comorbidities. This suggests that proactive mental health assessment from the time of type 2 diabetes diagnosis in primary care is essential for effective clinical management of people with type 2 diabetes.

Robustness of Multiple Imputation Methods for Missing Risk Factor Data from Electronic Medical Records for Observational Studies

Evaluating appropriate methodologies for imputation of missing outcome data from electronic medical records (EMRs) is crucial but lacking for observational studies. Using US EMR in people with type 2 diabetes treated over 12 and 24 months with dipeptidyl peptidase 4 inhibitors (DPP-4i, n = 38,483) and glucagon-like peptide 1 receptor agonists (GLP-1RA, n = 8,977), predictors of missingness of disease biomarker (HbA1c) were explored. Robustness of multiple imputation (MI) by chained equations, two-fold MI (MI-2F) and MI with Monte Carlo Markov Chain were compared to complete case analyses for drawing inferences. Compared to younger people (age quartile Q1), those in age quartile Q3 and Q4 were less likely to have missing HbA1c by 25-32% (range of OR CI: 0.55-0.88) at 6-month follow-up and by 26-39% (range of OR CI: 0.50-0.80) at 12-month follow-up. People with HbA1c ≥ 7.5% at baseline were 12% (OR CI: 0.83, 0.93) and 14% (OR CI: 0.77, 0.97) less likely to have missing data at 6-month follow-up in the DPP-4i and GLP-1RA groups, respectively. All imputation methods provided similar HbA1c distributions during follow-up as observed with complete case analyses. The clinical inferences based on absolute change in HbA1c and by proportion of people reducing HbA1c to a clinically acceptable level (≤ 7%) were also similar between imputed data and complete case analyses. MI-2F method provided marginally smaller mean difference between observed and imputed data with relatively smaller standard error of difference, compared to other methods, while evaluating for consistency through artificial within-sample analyses. The established MI techniques can be reliably employed for missing outcome data imputations in large EMR-based relational databases, leading to efficiently designing and drawing robust clinical inferences in pharmaco-epidemiological studies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41666-022-00119-w.

Gut microbiome metabolites as key actors in atherosclerosis co-depression disease

Cardiovascular diseases, mainly characterized by atherosclerosis (AS), and depression have a high comorbidity rate. However, previous studies have been conducted under a single disease, and there is a lack of studies in comorbid states to explore the commonalities in the pathogenesis of both diseases. Modern high-throughput technologies have made it clear that the gut microbiome can affect the development of the host's own disorders and have shown that their metabolites are crucial to the pathophysiology of AS and depression. The aim of this review is to summarize the current important findings on the role of gut microbiome metabolites such as pathogen-associated molecular patterns, bile acids, tryptophan metabolites, short-chain fatty acids, and trimethylamine N -oxide in depression and AS disease, with the aim of identifying potential biological targets for the early diagnosis and treatment of AS co-depression disorders.

Antidepressant prescriptions and therapy intensification in men and women newly diagnosed with depression in the UK

BACKGROUND

Evidence on therapeutic interventions and factors driving treatment intensification (TI) in people with incident depression in UK are scarce.

AIMS

To explore antidepressant prescribing patterns and factors influencing TI.

DESIGN

and setting: Retrospective cohort study of adults with incident depression diagnosed between 2006 and 2017 using UK primary care database.

METHODS

Patterns of antidepressant prescriptions, and factors influencing TI were evaluated by sex.

RESULTS

In 931,302 people with depression (90% initiating antidepressants), mean age was 39 years, 41% were male, 14% had cardiometabolic multimorbidity (CMM), and 54% were diagnosed at &lt; 40 years. Being the most prescribed first-line antidepressant (62%), SSRI prescribing rate increased from 66 per 1000 person-years to 170 per 1000 person-years; 24% (2% dose escalation, 4% adding, 18% switching) of first-line antidepressant initiators intensified with 13 months median time to TI. Compared to 60-70 years, younger adults had significantly higher TI risk (range of hazards ratio, HR: 1.08-1.42). CMM and anxiety were associated with 15-24% and 39-49% significantly higher TI risks respectively. First-line antidepressant and deprivation status influenced TI differently by gender.

CONCLUSIONS

Men and women with depression in UK have different antidepressant prescription patterns in real-world. Age at diagnosis, deprivation status and cardiometabolic multimorbidity are the major sociodemographic and non-psychiatric risk factors for therapeutic changes.

Cardiorenal Complications in Young-Onset Type 2 Diabetes Compared Between White Americans and African Americans

OBJECTIVE

To explore risks and associated mediation effects of developing chronic kidney disease (CKD) and heart failure (HF) in young- and usual-onset type 2 diabetes (T2D) between White Americans (WAs) and African Americans (AAs).

RESEARCH DESIGN AND METHODS

From U.S. medical records, 1,491,672 WAs and 31,133 AAs were identified and stratified by T2D age of onset (18-39, 40-49, 50-59, 60-70 years). Risks, mediation effects, and time to CKD and HF were evaluated, adjusting for time-varying confounders.

RESULTS

In the 18-39, 40-49, 50-59, 60-70 age-groups, the hazard ratios (of developing CKD and HF in AAs versus WAs were 1.21 (95% CI 1.17-1.26) and 2.21 (1.98-2.45), 1.25 (1.22-1.28) and 1.86 (1.75-1.97), 1.21 (1.19-1.24) and 1.54 (1.48-1.60), and 1.10 (1.08-1.12) and 1.11 (1.07-1.15), respectively. In AAs and WAs aged 18-39 years, time in years to CKD (8.7 [95% CI 8.2-9.1] and 9.7 [9.2-10.2]) and HF (10.3 [9.3-11.2] and 12.1 [10.6-13.5]) were, on average, 3.6 and 4.0 and 3.1 and 4.1 years longer compared with those diagnosed at age 60-70 years. Compared with females, AA males aged <60 years had an 11-49% higher CKD risk, while WA males aged <40 years had a 23% higher and those aged ≥50 years a 7-14% lower CKD risk, respectively. The mediation effects of CKD on the HF risk difference between ethnicities across age-groups (range 54-91%) were higher compared with those of HF on CKD risk difference between ethnicities across age-groups (13-39%).

CONCLUSIONS

Developing cardiorenal complications within an average of 10 years of young-onset T2DM and high mediation effects of CKD on HF call for revisiting guidelines on early diagnosis and proactive treatment strategies for effective management of cardiometabolic risk.

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.

Trend in Blood Pressure Control Post Antihypertensive Drug Initiation in the U.S

INTRODUCTION

The aim of this study is to evaluate the temporal trends in systolic blood pressure control over 18 months after blood pressure‒lowering drug initiation in the U.S.

METHODS

From U.S. nationally representative electronic health records, 1,036,775 adults initiating and continuing blood pressure‒lowering drugs for ≥18 months during 2006-2018 were identified (January 2021). Prevalence trends of cardiovascular disease, diabetes, and depression at blood pressure‒lowering drug initiation, blood pressure‒lowering drug therapy intensification over 18 months, and the adjusted probability of achieving systolic blood pressure control 6 months after baseline and sustaining the control for over 18 months were evaluated.

RESULTS

At blood pressure‒lowering drug initiation, the prevalence of diabetes and depression consistently increased during the study period across all age groups, particularly in those aged 18-49 years, whereas the prevalence of cardiovascular disease was stable. Adjusted probabilities of achieving sustainable systolic blood pressure control by age group were 0.62 (95% CI=0.61, 0.63) for ages 18-39 years, 0.55 (95% CI=0.55, 0.56) for ages 40-49 years, 0.50 (95% CI=0.49, 0.50) for ages 50-59 years, 0.43 (95% CI=0.42, 0.43) for ages 60-69 years, and 0.37 (95% CI=0.37, 0.38) for ages 70-80 years. Those with cardiovascular disease or cardiovascular disease and diabetes had approximately 20% lower adjusted probability of achieving systolic blood pressure control (31%/29%) than those without these conditions (52%, p<0.01). Those with depression had a 4% higher probability of systolic blood pressure control than those without the condition (49% vs 45%, p<0.01).

CONCLUSIONS

In the U.S., only 30%-50% of the population are achieving sustainable blood pressure control over 18 months after blood pressure‒lowering drug initiation, with no indication of improvement in control over the last decade.

Comorbidity of Type 2 Diabetes Mellitus and Depression: Clinical Evidence and Rationale for the Exacerbation of Cardiovascular Disease

Depression is a common comorbidity of type 2 diabetes mellitus (T2DM). T2DM with comorbid depression increases the risk of cardiovascular events and death. Depression and T2DM and its macrovascular complications exhibited a two-way relationship. Regarding treatment, antidepressants can affect the development of T2DM and cardiovascular events, and hypoglycemic drugs can also affect the development of depression and cardiovascular events. The combination of these two types of medications may increase the risk of the first myocardial infarction. Herein, we review the latest research progress in the exacerbation of cardiovascular disease due to T2DM with comorbid depression and provide a rationale and an outlook for the prevention and treatment of cardiovascular disease in T2DM with comorbid depression.

Association between single and multiple cardiometabolic diseases and depression: A cross-sectional study of 391,083 participants from the UK biobank

Background

Individual cardiometabolic diseases (CMDs) are associated with an increased risk of depression, but it's unclear whether having more than one CMD is associated with accumulative effects on depression. We aimed to assess the associations between CMDs and depression and determine the accumulative extent.

Methods

In this cross-sectional study based on UK Biobank, participants with available information on CMDs and depression were enrolled. The history of CMDs was derived from self-reported medical history and electrical health-related records. Depression status was assessed by the aggregation of self-reported history and antidepressant use, depression (Smith), and hospital inpatient diagnoses. Logistic regression models were fitted to assess the association between the number or specific patterns of CMDs and depression and to test the accumulative effect of CMD number, adjusting for confounding factors.

Results

391,083 participants were enrolled in our analyses. After multivariable adjustments, CMDs of different number or patterns were associated with a higher risk of depression compared with the reference group (all P < 0.001). In the full-adjusted model, participants with one [odds ratio (OR) 1.26, 95% confidence interval (CI) 1.23-1.29], two (OR 1.50, 95% CI 1.44-1.56), and three or more (OR 2.13, 95% CI 1.97-2.30) CMD(s) had an increased risk of depression. A significant, accumulative dose-related relationship between the number of CMDs and depression was observed (OR 1.25, 95% CI 1.24-1.27). The dose-dependent accumulative relationship was consistent in stratified analyses and sensitivity analyses.

Conclusions

CMDs were associated with a higher risk of depression, and there was an accumulative relationship between CMD number and depression.

Characteristics associated with early- vs. later-onset adult diabetes: The CARDIA study

AIMS

Differences in risk profiles for individuals with early- (<40 years old) vs. later-onset (≥40 years old) diabetes were examined.

METHODS

A nested case-comparison study design using 30-year longitudinal data from the Coronary Artery Risk Development in Young Adults (CARDIA) study was used. Survey data (socio-demographics, family history, medical records, and lifestyle behaviors), obesity-related measures (body mass index, weight), blood pressure, and laboratory data (insulin, fasting glucose, 2-h glucose, and lipids) were used to examine progression patterns of diabetes development in those with early-onset vs. later-onset diabetes.

RESULTS

Of 605 participants, 120 were in early-onset group while 485 were in later-onset group. Early-onset group had a lower A Priori Diet Quality Score, but not statistically significant at baseline; however, the between-group difference became significant at the time that diabetes was first detected (p = 0.026). The physical activity intensity score consistently decreased from baseline to the development of diabetes in both the early- and later-onset groups. Early-onset group showed more dyslipidemia at baseline and at the time that diabetes was first detected, and rapid weight gain from baseline to the development of diabetes.

CONCLUSIONS

Emphases on lifestyle modification and risk-based diabetes screening in asymptomatic young adults are necessary for early detection and prevention.

Temporal trends in co-morbidities and cardiometabolic risk factors at the time of type 2 diabetes diagnosis in the UK

AIM

To evaluate temporal patterns in co-morbidities, cardiometabolic risk factors and a high atherosclerotic cardiovascular disease (ASCVD) risk population at type 2 diabetes (T2D) diagnosis by age groups and sex.

MATERIALS AND METHODS

From the UK primary care database, 248,619 people with a new diagnosis of T2D during 2005-2016 were identified. Among people without ASCVD, high ASCVD risk was defined as two or more of current smoker, grade 2+ obesity, hypertension, dyslipidaemia or microvascular disease. Cardiometabolic multimorbidity (CMM) was defined as two or more of cardiovascular disease, microvascular disease, hypertension, dyslipidaemia, grade 2+ obesity or cancer. Temporal patterns in the distribution of cardiometabolic risk factors were evaluated.

RESULTS

While the prevalence of ASCVD was stable over time (approximately 18%), 50% were identified to have a high ASCVD risk (26% and 38% in the 18-39 and 40-49 years age groups, respectively), with an increasing trend across all age groups. Overall, 51% had CMM at diagnosis, increasing during 2005-2016 for the 18-39 years age group by 14%-17%, for the 40-49 years age group by 27%-33%, for the 50-59 years age group by 41%-50%, for the 60-69 years age group by 56%-65%, and for the 70-79 years age group by 65%-80%. People with young-onset T2D had significantly higher HbA1c, body mass index and lipids at diagnosis (all p < .01). The proportions with an HbA1c of 7.5% or higher in the 18-39 and 40-49 years age groups were 58% and 54%, respectively, significantly and consistently higher over the last decade compared with those aged 50 years or older, with males having higher proportions of 15-26 and 10-18 percentage points, respectively, compared with females.

CONCLUSIONS

CMM and high ASCVD risk have been increasing consistently across all age groups and in both sex, in particular CMM in those aged younger than 50 years. Our findings indicate that the European Society of Cardiology-European Association for the Study of Diabetes recommendations need to change to consider people with young-onset T2D as a high-risk group, as recommended in the Primary Care Diabetes Europe position statement.