Diabetes, Frequency of Exercise, and Mortality Over 12 Years: Analysis of the National Health Insurance Service-Health Screening (NHIS-HEALS) Database

Accelerometer-derived physical activity and mortality in individuals with type 2 diabetes

Physical activity (PA) has been shown to reduce diabetes mortality, but largely based on imprecise self-reported data, which may hinder the development of related recommendations. Here, we perform a prospective cohort study of 19,624 individuals with type 2 diabetes (T2D) from the UK Biobank with a median follow-up of 6.9 years. Duration and intensity of PA are measured by wrist-worn accelerometers over a 7-day period. We observe L-shaped associations of longer duration of PA, regardless of PA intensity, with risks of all-cause and cancer mortality, as well as a negatively linear association with cardiovascular disease mortality. 12.7%, 15.8%, and 22.3% of deaths are attributable to the lowest level of light-intensity, moderate-intensity PA, and vigorous-intensity PA, respectively. Collectively, our findings provide insights for clinical guidelines that should highlight the potential value of adherence to greater intensity and duration of PA for patients with T2D.

Association of aerobic and muscle-strengthening physical activity with all-cause and cardiovascular disease mortality among adults with type 2 diabetes: A prospective cohort of US adults

OBJECTIVE

To investigate the relationship of moderate physical activity (MPA), vigorous physical activity (VPA), and muscle strengthening activity (MSA), independently and jointly, with all-cause, cardiovascular disease (CVD), and non-CVD mortality in individuals with type 2 diabetes (T2D).

MATERIAL AND METHODS

This cohort study included 47,538 adults with T2D and 561,963 adults without T2D from the National Health Interview Survey 1997-2018 who provided data on self-reported physical activity (PA). Mortality data were obtained from the National Death Index through 2019. Cox regression was used to estimate hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

In analyses mutually adjusted, versus no MPA adults with T2D, performing the recommendations of MPA (150-299 min/week) associated with lower all-cause mortality (HR, 0.72; 95% CI, 0.66-0.78), CVD mortality (HR, 0.68; 95% CI, 0.58-0.79), and non-CVD mortality (HR, 0.72; 95% CI, 0.65-0.79). Similar benefits were observed in those meeting recommendations for VPA and MSA. Higher levels of PA beyond current recommendations may provide a few additional benefits without adverse effects on mortality risk, regardless of diabetes onset age, duration of diabetes, and medication status. The joint analysis indicates that combining MSA with aerobic PA could further lower mortality risk, and lowest all-cause mortality was observed among individuals engaging in either 75-150 min/week of VPA and 1 time/week of MSA (HR, 0.30; 95% CI, 0.13-0.70) or 150-299 min/week of MPA and 1 time/week of MSA (HR, 0.33; 95% CI, 0.20-0.55).

CONCLUSION

Our study supports the current PA guidelines and suggests that there may be limited benefits gained from exercising beyond recommended levels in adults with T2D, combining recommended levels of aerobic and resistance exercises could yield the greatest benefits.

Cost-effectiveness of the anti-vascular endothelial growth factor intravitreal injection and panretinal photocoagulation for patients with proliferative diabetic retinopathy in South Korea

BACKGROUND

We determined the cost-effectiveness of the anti-vascular endothelial growth factor (VEGF) intravitreal injection versus panretinal photocoagulation (PRP) for patients with proliferative diabetic retinopathy (PDR) in South Korea.

METHODS

We simulated four treatment strategies using PRP and the anti-VEGF injection by constructing a Markov model for a hypothetical cohort of 50-year-old PDR patients: (1) PRP only; (2) anti-VEGF injection only; (3) PRP first; and (4) anti-VEGF injection first.

RESULTS

In this cost-effectiveness analysis, compared with only-PRP, the incremental cost-effectiveness ratio was $95,456 per quality-adjusted life-year (QALY) for PRP first, $34,375 per QALY for anti-VEGF injection first, and $33,405 per QALY for anti-VEGF injection only from a healthcare perspective. From the societal and payer perspective, strategy (2) was more cost-saving and effective than (1). In the probabilistic sensitivity analysis, only-PRP was cost-effective up to the willingness-to-pay (WTP) of about $42,000, while anti-VEGF injection only was cost-effective from a healthcare perspective. From the societal and payer perspectives, regardless of the value of WTP, anti-VEGF injection only was the most cost-effective strategy.

CONCLUSION

In our study, the anti-VEGF injection for PDR was cost-effective from the payer and societal perspectives.

Behavioral and Psychological Factors in Buffering Diabetes-related Disability Development

BACKGROUND

Diabetes is associated with disability development. Healthy behaviors and psychosocial support can help patients manage their disease.

PURPOSE

To examine the role of various behavioral and psychological factors in buffering the effect of diabetes on disability development over time in Taiwanese adults.

METHODS

Data on 5,131 adults aged ≥50 years were obtained from the Taiwan Longitudinal Study on Aging. A cohort sequential multilevel design was employed to analyze the association between behavioral and psychosocial factors and the risk of disability over a 11-year period.

RESULTS

In patients with diabetes, having social support and exercising more than six times a week were associated with 4% and 49% reductions in the risk of disability, respectively (βdiabetes*socialsupport = -0.285, p = .006; βdiabetes*exercise3 = -2.612, p = .007). Exercising more than six times a week had an additional significant protective effect against disability development per year (βdiabetes*exercises3*age = -0.241, p = .038). Depression did not significantly interact with diabetes. However, a trajectory analysis revealed that individuals who had both diabetes and depression had the highest disability score from middle age among all participants.

CONCLUSIONS

Engaging in frequent exercise is the most influential factor for reducing the risk of disability in patients with diabetes. Social support provides an additional benefit for disability prevention in individuals with diabetes.

Exercise Frequency Reduction Is Associated With Higher Risk of Infection in Newly Diagnosed Diabetes: A Nationally Representative Cohort Study

BACKGROUND

Exercise is an important method to control the progression of diabetes. Since diabetes compromises immune function and increases the risk of infectious diseases, we hypothesized that exercise may affect the risk of infection by its immunoprotective effects. However, population-based cohort studies regarding the association between exercise and the risk of infection are limited, especially regarding changes in exercise frequency. The aim of this study was to determine the association between the change in exercise frequency and the risk of infection among patients with newly diagnosed diabetes.

METHODS

Data of 10,023 patients with newly diagnosed diabetes were extracted from the Korean National Health Insurance Service-Health Screening Cohort. Self-reported questionnaires for moderate-to-vigorous physical activity (MVPA) were used to classify changes in exercise frequency between two consecutive two-year periods of health screenings (2009-2010 and 2011-2012). The association between changes in exercise frequency and the risk of infection was evaluated using multivariable Cox proportional-hazards regression.

RESULTS

Compared with engaging in ≥ 5 times of MVPA/week during both periods, a radical decrease in MVPA (from ≥ 5 times of MVPA/week to physical inactivity) was associated with a higher risk of pneumonia (adjusted hazard ratio [aHR], 1.60; 95% confidence interval [CI], 1.03-2.48) and upper respiratory tract infection (aHR, 1.15; 95% CI, 1.01-1.31). In addition, a reduction of MVPA from ≥ 5 to < 5 times of MVPA/week was associated with a higher risk of pneumonia (aHR, 1.52; 95% CI, 1.02-2.27), whereas the risk of upper respiratory tract infection was not higher.

CONCLUSION

Among patients with newly diagnosed diabetes, a reduction in exercise frequency was related to an increase in the risk of pneumonia. For patients with diabetes, a modest level of physical activity may need to be maintained to reduce the risk of pneumonia.

Leisure-time physical activity and mortality risk in type 2 diabetes: A nationwide cohort study

AIM

Physical activity improves insulin resistance, inhibits inflammation, and decreases the incidence of cardiovascular disease. These are major causes of death in patients with diabetes.

METHODS

The Taiwan National Health Interview Survey collected baseline characteristics of socioeconomic level, education, marriage, and health behaviour, including leisure time physical activity in 2001, 2005, 2009, and 2013. The National Health Insurance research dataset 2000-2016 contained detailed information on medical conditions, including all comorbidities. All-cause and cardiovascular deaths were confirmed by the National Death Registry.

RESULTS

A total of 4859 adults with type 2 diabetes were included in the analysis; 2389 (49 %) were men and the mean±SD age was 60±13 years. Kaplan-Meier curve of all-cause (log-rank P<0.001) and cardiovascular death (log-rank P=0.038) categorized by leisure-time physical activity showed a significant difference. The multivariable Cox regression model showed that those who had more leisure time physical activity had a significantly lower risk of all-cause death than those with no physical activity (physical activity of 1-800 MET-min/week HR = 0.66, 95% CI: 0.54-0.81, physical activity of >800 MET-min/week HR = 0.67, 95% CI: 0.56-0.81). A significant trend was also observed (P <0.001). Similar results were also observed for cardiovascular mortality (physical activity of 1-800 MET-min/week HR = 0.54, 95% CI: 0.36-0.84, physical activity of >800 MET-min/week HR = 0.78, 95% CI: 0.55-1.13).

CONCLUSION

For those with diabetes, increased leisure-time physical activity significantly reduced risk of all-cause and cardiovascular death. Further research is warranted to determine the proper prescription for physical activity to prolong healthy life.

Effects of exercise initiation and smoking cessation after new-onset type 2 diabetes mellitus on risk of mortality and cardiovascular outcomes

Lifestyle changes after a diagnosis of type 2 diabetes mellitus (DM) can affect vascular health outcomes. The objective of this study was to investigate the effects of changes in smoking and exercise on the risk of cardiovascular disease (CVD) and mortality in patients with newly diagnosed DM. Data were analyzed for 181,591 people with newly diagnosed type 2 DM who underwent 2 serial health examinations within 2 years before and after DM diagnosis. The study population was followed from the baseline to the date of death or cardiovascular events, or until December 31, 2018 and median follow-up was 6.07 years. Based on the change in status from before to after the diagnosis, participants were grouped into smoking groups (continuous smokers, quitters, new smokers, and nonsmokers) and exercise groups (constant exercisers, new exercisers, exercise dropouts, and nonexercisers). Compared with the nonexercisers, those who initiated exercise after their DM diagnosis had a lower risk of myocardial infarction (MI), stroke, and all-cause mortality: the hazard ratio (HR; 95% confidence interval [CI]) was 0.85 (0.76–0.94) for MI, 0.86 (0.78–0.94) for stroke, and 0.84 (0.89–0.90) for all-cause mortality. Quitters had a higher risk of MI, stroke, and all-cause mortality than nonsmokers, but their risk level was much lower than that in continuous smokers. When the group of continuous smokers and nonexercisers was considered as the reference group, participants who quit smoking and remained nonexercisers had a 21% lower risk of CVD (HR 0.79; 95% CI 0.70–0.90). Those who quit smoking and started exercising had a 46% reduced risk of CVD (HR 0.54; 95% CI 0.41–0.71) and a 22% reduced risk in all-cause mortality (HR 0.78; 95% CI 0.63–0.96). Smoking cessation and exercise initiation after a diagnosis of new-onset type 2 DM was associated with a reduced risk of CVD and all-cause mortality.

Physical Activity Dimensions and Its Association with Risk of Diabetes in Middle and Older Aged Chinese People

Background: Diabetes and physical inactivity are prevalent worldwide. Risk of diabetes is known to be related with insufficient physical activity (PA), but associations with the respective dimensions of PA is unclear. Objective: To describe the patterns of physical activity among Chinese middle- and older-aged individuals and figure out their associations with diabetes risk in different dimensions. Methods: Extracting self-reported data from China Health and Retirement Longitudinal Study (CHARLS, 2015), this study included 6196 participants. Multivariate logistic regression was conducted to determine the association between diabetes risk and PA dimensions such as intensity, frequency, duration, and volume. Results: Concerning frequency, lower diabetes risk was associated with performing vigorous PA at any frequency overall. For duration, smaller odds of diabetes were observed in performing vigorous PA 2-4 h/day (OR 0.46, 95%CI 0.30 to 0.71), moderate PA ≥4 h/day (OR 0.59, 95%CI 0.42 to 0.82) and light PA ≥4 h/day (OR 0.59, 95%CI 0.41 to 0.85) overall. For volume, lower diabetes risk was associated with performing moderate-to-vigorous PA (MVPA) ≥2250 METs/week (OR 0.58, 95%CI 0.42 to 0.81) in middle-aged group (45-64 years), whereas no significant associations between MVPA and diabetes risk were found in older aged group (≥65 years). Conclusions: Our results revealed that physical inactivity is prevalent in China, with a greater proportion in the diabetes group. Lower risk of diabetes was associated with higher frequency, longer duration and longer volume of PA at higher intensity in middle-aged respondents and similar associations at lower intensity for the older adults. Additionally, further well-designed prospective studies are needed to confirm our findings.

The association between sialolithiasis and smoking, alcohol drinking and obesity in Korea: a nested case-control study

BACKGROUND

Smoking and alcohol consumption are the most common social habits in patients with sialolithiasis. Moreover, obesity has been reported to have a significant association with poor oral hygiene, one of the causes of sialolithiasis. The purpose of this study was to evaluate the relationships among tobacco smoking, drinking alcohol, obesity and sialolithiasis in a Korean population.

METHODS

The Korean National Health Insurance Service-Health Screening Cohort, which includes patients ≥40 years old, was assessed from 2002 to 2013. A total of 947 sialolithiasis participants were matched with 3788 control subjects at a ratio of 1:4 with respect to age group, sex, income group, region of residence, hypertension, diabetes, and dyslipidemia. We analyzed the participants' previous histories of smoking (current or past smokers compared to nonsmokers) and alcohol consumption (≥ 1 time per week compared to < 1 time per week) in the sialolithiasis and control groups. Obesity was measured using body mass index (BMI, kg/m²), which was categorized as < 18.5 (underweight), ≥ 18.5 and < 23 (normal), ≥ 23 and < 25 (overweight), ≥ 25 and < 30 (obese I), and ≥ 30 (obese II). Crude and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using conditional logistic regression analyses.

RESULTS

The rate of smoking was higher in the sialolithiasis group (32.4% [307/947]) than in the control group (29.1% [1103/3788], P = 0.047). The adjusted OR of smoking for the sialolithiasis group was 1.31 (95% CI = 1.08-1.59, P = 0.006). Alcohol consumption and obesity were not statistically significantly related to sialolithiasis.

CONCLUSION

The odds of smoking were increased in sialolithiasis patients compared with control subjects in the population ≥ 40 years of age.

Influence of Sodium Glucose Cotransporter 2 Inhibition on Physiological Adaptation to Endurance Exercise Training

CONTEXT

The combination of two beneficial antidiabetes interventions, regular exercise and pharmaceuticals, is intuitively appealing. However, metformin, the most commonly prescribed diabetes medication, attenuates the favorable physiological adaptations to exercise; in turn, exercise may impede the action of metformin.

OBJECTIVE

We sought to determine the influence of an alternative diabetes treatment, sodium glucose cotransporter 2 (SGLT2) inhibition, on the response to endurance exercise training.

DESIGN, PARTICIPANTS, AND INTERVENTION

In a randomized, double-blind, repeated measures parallel design, 30 sedentary overweight and obese men and women were assigned to 12 weeks of supervised endurance exercise training, with daily ingestion of either a placebo or SGLT2 inhibitor (dapagliflozin: ≤10 mg/day).

OUTCOME MEASUREMENTS AND RESULTS

Endurance exercise training favorably modified body mass, body composition (dual-energy x-ray absorptiometry), peak oxygen uptake (graded exercise with indirect calorimetry), responses to standardized submaximal exercise (indirect calorimetry, heart rate, and blood lactate), and skeletal muscle (vastus lateralis) citrate synthase activity (main effects of exercise training, all P < 0.05); SGLT2 inhibition did not influence any of these physiological adaptations (exercise training × treatment interaction, all P > 0.05). However, after endurance exercise training, fasting blood glucose was greater with SGLT2 inhibition, and increased insulin sensitivity (oral glucose tolerance test/Matsuda index) was abrogated with SGLT2 inhibition (exercise training × treatment interaction, P < 0.01).

CONCLUSION

The efficacy of combining two beneficial antidiabetes interventions, regular endurance exercise and SGLT2 inhibition, was not supported. SGLT2 inhibition blunted endurance exercise training-induced improvements in insulin sensitivity, independent of effects on aerobic fitness or body composition.

Associations of serum liver enzyme levels and their changes over time with all-cause and cause-specific mortality in the general population: a large-scale national health screening cohort study

OBJECTIVES

To investigate the associations of the levels of liver enzymes, such as alanine aminotransferase (ALT), aspartate aminotransferase (AST) and gamma glutamyltransferase (GGT), at baseline and their changes over time with mortality.

DESIGN

Cohort study.

SETTING, PARTICIPANTS AND OUTCOME MEASURES

We analysed the data of 484 472 individuals from the National Health Insurance Service-National Health Screening Cohort (2002-2013). We used two exposure indices: (1) deciles of baseline ALT, AST and GGT levels measured in 2002 or 2003 and (2) deciles of changes in ALT, AST and GGT levels over a 4 year period (2002-2006 or 2003-2007). We constructed Cox models to evaluate the associations of these exposure indices with mortality (2008-2013).

RESULTS

We found non-monotonic dose-response associations between the baseline levels of ALT and AST and all-cause mortality. We also found a monotonic non-linear association between the baseline levels of GGT and all-cause mortality (10th decile: HR=2.05, 95% CI: 1.93 to 2.18). Compared with the ninth, sixth and fourth deciles of changes in ALT (8-13 U/L), AST (1 U/L) and GGT (-3 to -2 U/L) over time, respectively, the risks of all-cause mortality increased in both the higher and lower deciles of changes in the corresponding liver enzyme levels (10th decile: HR=1.36, 95% CI 1.24 to 1.48; 1st decile: HR=1.46, 95% CI 1.34 to 1.59 for ALT; 10th decile: 1.55, 95% CI 1.40 to 1.71; 1st decile: HR=1.53, 95% CI 1.38 to 1.69 for AST; 10th decile: HR=1.71, 95% CI 1.56 to 1.88; 1st decile: HR=1.67, 95% CI 1.52 to 1.84 for GGT). These non-monotonic dose-response associations remained when analyses were stratified by the medians or quartiles of the baseline liver enzyme levels.

CONCLUSIONS

The levels of liver enzymes at baseline and over time showed non-linear associations with mortality.

Sleep-disordered breathing and Alzheimer's disease: A nationwide cohort study

Sleep-disordered breathing (SDB) is common and can lead to significant cognitive decline, such as Alzheimer's disease (AD). Therefore, the present study was conducted to investigate whether SDB is associated with AD onset. This study used the nationwide health check-up cohort data between 2002 and 2015. The study population comprised individuals who were diagnosed with SDB and those without SDB who were matched by using propensity score. The matched cohort was followed up until the onset of AD, death, or end of 2015. A multivariate Cox proportional hazard model was used in the analysis. There were 727 (16.7%) patients in the SDB group between 2002 and 2005 and 3635 subjects (83.3%) in the propensity score-matched non-SDB group. After adjusting for the possible confounding variables, patients with SDB were almost 1.58 times more likely to develop AD than those without SDB (hazard ratio [HR] = 1.575, 95% confidence interval [CI] = 1.013-2.448). The present study showed that SDB was associated with an onset of AD. The findings of this study highlight the importance of the interventions to raise awareness of SDB and the need for the government's support to reduce the barrier in accessing appropriate SDB treatment.

Prevalence and factors associated with type 2 diabetes mellitus and hypertension among the hill tribe elderly populations in northern Thailand

BACKGROUND

Type 2 diabetes mellitus (T2DM) and hypertension (HT) are major noncommunicable health problems in both developing and developed countries, including Thailand. Each year, a large amount of money is budgeted for treatment and care. Hill tribe people are a marginalized population in Thailand, and members of its elderly population are vulnerable to health problems due to language barriers, lifestyles, and daily dietary intake.

METHODS

An analytic cross-sectional study was conducted to estimate the prevalence of T2DM and HT and to assess the factors associated with T2DM and HT. The study populations were hill tribe elderly adults aged ≥  60 years living in Chiang Rai Province, Thailand. A simple random method was used to select the targeted hill tribe villages and participants into the study. A validated questionnaire, physical examination form, and 5-mL blood specimen were used as research instruments. Fasting plasma glucose and blood pressure were examined and used as outcome measurements. Chi-square tests and logistic regression were used for detecting the associations between variables at the significance level alpha=0.05.

RESULTS

In total, 793 participants participated in the study; 49.6% were male, and 51.7% were aged 60-69 years. A total of 71.5% were Buddhist, 93.8% were uneducated, 62.9% were unemployed, and 89 % earned an income of < 5,000 baht/month. The overall prevalence of T2DM and HT was 16.8% and 45.5%, respectively. Approximately 9.0% individuals had comorbidity of T2DM and HT. Members of the Lahu, Yao, Karen, and Lisu tribes had a greater odds of developing T2DM than did those of the Akha tribe. Being overweight, having a parental history of T2DM, and having high cholesterol were associated with T2DM development. In contrast, those who engaged in highly physical activities and exercise had lower odds of developing T2DM than did those who did not. Regarding HT, being female, having a high dietary salt intake, being overweight, and having a parental history of HT were associated with HT development among the hill tribe elderly populations.

CONCLUSIONS

The prevalence of T2DH and HT among the hill tribe elderly populations is higher than that among the general Thai population. Public health interventions should focus on encouraging physical activity and reducing personal weight, dietary salt intake, and greasy food consumption among the hill tribe elderly.