Diabesity in Elderly Cardiovascular Disease Patients: Mechanisms and Regulators

The dual challenge of diabesity: pathophysiology, management, and future directions

Diabesity, the concurrent occurrence of obesity and type-2 diabetes mellitus (T2DM), represents a pressing global health challenge characterized by intricate pathophysiological mechanisms and a wide range of associated comorbidities. Central to its development are insulin resistance, metabolic syndrome, and chronic low-grade inflammation mediated by dysregulated adipokine secretion and systemic metabolic dysfunction. These mechanisms underpin the progression of diabesity and its complications, including cardiovascular disease and hypertension. Management strategies encompass lifestyle interventions focusing on tailored dietary modifications and structured physical activity, pharmacological treatments targeting both glycemic control and weight loss, and surgical interventions such as bariatric surgery, which have demonstrated efficacy in achieving durable outcomes. Clinical trials and meta-analyses underscore the comparative advantages of different treatment modalities in terms of efficacy, safety, and sustainability. Moreover, long-term follow-up studies emphasize the critical need for sustained multidisciplinary interventions to prevent relapse and enhance patient outcomes. Future advancements in management include exploring precision medicine approaches that integrate individual metabolic profiles, lifestyle factors, and emerging therapeutic innovations. A multidisciplinary approach combining advanced therapeutic strategies and patient-centered care remains pivotal for optimizing management and improving prognoses for individuals with diabesity. This review highlights the complex interplay between obesity and T2DM, offering comprehensive insights into their pathophysiology, clinical presentation, and management paradigms.

The Association between Lipoprotein(a) and Coronary Artery Calcification in Elderly Patients with Diabetes: A Cross-Sectional Study

Background

Lipoprotein(a) [Lp(a)] is associated with the development of coronary artery calcification (CAC), yet its exact function is not fully understood. This study sought to assess the relationship between Lp(a) levels and the risk of CAC in elderly diabetic patients.

Methods

This cross-sectional study included 486 elderly diabetic patients. The exposure factor was Lp(a) levels, categorized into three groups (T1, T2, T3). The outcome was the presence of CAC. The relationship between Lp(a) levels and CAC was evaluated using several statistical methods, including univariate and multivariate logistic regression, multivariable stratified analysis, receiver operating characteristic (ROC) curve analysis, and restricted cubic spline (RCS) analysis.

Results

The highest Lp(a) group (T3) showed significantly higher prevalence of CAC compared to the T1 and T2 groups. Univariate logistic regression indicated a significant link between Lp(a) and CAC. Furthermore, multivariate logistic regression supported the finding that elevated Lp(a) levels correlated with a heightened risk of CAC in all models. Specifically, each unit rise in Lp(a) was associated with a notable increase in CAC risk, and Log10Lp(a) and each 1 standard deviation increase in Lp(a) also significantly elevated CAC risk. Multivariable stratified analysis demonstrated significant differences in CAC risk across various subgroups, including age ≤70 years, males, females, smokers, hypertensive, non-hypertensive, hyperlipidemic, non-hyperlipidemic, non-stroke, and non-chronic kidney disease patients. ROC curve analysis showed that adding Lp(a) to the baseline model improved the area under the curve from 0.741 to 0.755. RCS analysis indicated a significant, approximately linear association between Log10Lp(a) and CAC risk (p nonlinear = 0.115).

Conclusions

In an elderly diabetic population, elevated levels of Lp(a) were strongly linked to a greater risk of CAC. Integrating Lp(a) measurements with conventional risk factors improves the predictive accuracy for CAC.

Sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide 1 receptor agonists and cancer mortality. A real-world registry

INTRODUCTION AND OBJECTIVES

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1ra) reduce cardiovascular events through different mechanisms, but their association with cancer remains unclear. The aim of this study was to compare the effect of combined treatment (SGLT2i and GLP1ra) and monotherapy (SGLT2i or GLP1ra) on hospitalization and/or death from cancer in a general population and a subgroup of patients with cardiovascular disease (CVD).

METHODS

We conducted a nonconcurrent observational prospective study of patients prescribed SGLT2i, GLP1ra, or both. Multinomial propensity scores were performed in the entire population and in a subgroup of patients with CVD. A multivariate Cox regression analysis was used to determine the hazard ratio (HR) for age, sex, risk factors, and treatment for each outcome.

RESULTS

We included 14 709 patients (11366 with SGLT2i, 1016 with GLP1ra, and 2327 with both treatments) from treatment initiation. Diabetes was present in 97% of the patients. The subgroup with CVD included 4957 (33.7%) patients. After a median of 33 months of follow-up, the risk of adverse cancer events was similar between patients with and without CVD (3.4% or 3.7%, respectively). The main risk factors for cancer mortality were male sex and age. Combined treatment and its duration reduced the risk of cancer mortality compared with monotherapy with SGLT2i or GLP1ra in the overall population (HR, 0.2216; 95%CI, 0.1106-0.4659; P<.001; and HR, 0.1928; 95%CI, 0.071-0.5219; P=.001, respectively) and in the subgroup of patients with CVD (HR, 0.2879; 95%CI, 0.0878-0.994; P<.049; and HR, 0.1329; 95%CI, 0.024-0.6768; P=.014, respectively).

CONCLUSIONS

Initiation of combined therapy (SGLT2i and GLP1ra) vs monotherapy with SGLT2i or GLP1ra was associated with a lower risk of cancer mortality, mostly in diabetic patients with or without CVD. Although clinical trials are needed, these results might be explained by the complementary mechanisms of these drugs, including their antiproliferative, anti-inflammatory, and metabolic effects. Future clinical trials and mechanistic studies will clarify the possible role of these drugs in carcinogenesis.

Sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide 1 receptor agonists and cancer mortality. A real-world registry

INTRODUCTION AND OBJECTIVES

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1ra) reduce cardiovascular events through different mechanisms, but their association with cancer remains unclear. The aim of this study was to compare the effect of combined treatment (SGLT2i and GLP1ra) and monotherapy (SGLT2i or GLP1ra) on hospitalization and/or death from cancer in a general population and a subgroup of patients with cardiovascular disease (CVD).

METHODS

We conducted a nonconcurrent observational prospective study of patients prescribed SGLT2i, GLP1ra, or both. Multinomial propensity scores were performed in the entire population and in a subgroup of patients with CVD. A multivariate Cox regression analysis was used to determine the hazard ratio (HR) for age, sex, risk factors, and treatment for each outcome.

RESULTS

We included 14 709 patients (11366 with SGLT2i, 1016 with GLP1ra, and 2327 with both treatments) from treatment initiation. Diabetes was present in 97% of the patients. The subgroup with CVD included 4957 (33.7%) patients. After a median of 33 months of follow-up, the risk of adverse cancer events was similar between patients with and without CVD (3.4% or 3.7%, respectively). The main risk factors for cancer mortality were male sex and age. Combined treatment and its duration reduced the risk of cancer mortality compared with monotherapy with SGLT2i or GLP1ra in the overall population (HR, 0.2216; 95%CI, 0.1106-0.4659; P<.001; and HR, 0.1928; 95%CI, 0.071-0.5219; P=.001, respectively) and in the subgroup of patients with CVD (HR, 0.2879; 95%CI, 0.0878-0.994; P<.049; and HR, 0.1329; 95%CI, 0.024-0.6768; P=.014, respectively).

CONCLUSIONS

Initiation of combined therapy (SGLT2i and GLP1ra) vs monotherapy with SGLT2i or GLP1ra was associated with a lower risk of cancer mortality, mostly in diabetic patients with or without CVD. Although clinical trials are needed, these results might be explained by the complementary mechanisms of these drugs, including their antiproliferative, anti-inflammatory, and metabolic effects. Future clinical trials and mechanistic studies will clarify the possible role of these drugs in carcinogenesis.

Diabesity and cardiovascular mortality in a prospective population cohort followed for more than 20 years

INTRODUCTION

Control of the main cardiovascular risk factors had succeeded in reducing cardiovascular diseases (CVD). However, the general increase in the prevalence of type 2 diabetes mellitus (DM2) and obesity has slowed this decline. Both CVRFs are strongly associated, and the term diabesity has been coined to refer to this relationship. The main objective of this study was to assess the influence of diabesity on cardiovascular mortality.

METHODS

Prospective cohort study involving 1246 individuals (54.3% women) followed for 20.9 years (SD=7.31) and selected by random two-stage sampling in a province in southeastern Spain. Diabesity was defined as the combination of DM2 with overweight and obesity. Survival curves (Kaplan-Meier) were calculated and two Cox regression models were used, one unadjusted and the other adjusted by the main explanatory variables in which the diabesity variable consisted of 6 categories (normal weight, overweight, obesity, normal weight+DM2, overweight+DM2 and obesity+DM2).

RESULTS

There were 95 deaths due to CV causes (7.6% of the total; 6.2% women and 9.3% men; p=0.01). After adjustment, the combination of DM2 and overweight increased the incidence of cardiovascular mortality by 133% (HR=2.33; 95% CI: 1.18-4.58; p=0.014) and the combination of DM2 and obesity by 49% (HR=1.49; 95% CI: 0.64-3.45; p=0.351), not reaching statistical significance in the latter case.

CONCLUSIONS

In the general population, the results of our study show that the combination of overweight and DM2 is associated with higher CV mortality. It seems a priority to intervene intensively in the control of both overweight and DM2.

Association between sociodemographic variables, healthy habits and stress with diabesity

INTRODUCTION

Diabesity is a pathological condition that combines obesity and type 2 diabetes in the same individual. Due to the current rise in both conditions, the prevalence of diabesity is increasing worldwide. Its etiology is known to be multifactorial; therefore, the aim of this study is to understand how diabesity is associated with various sociodemographic variables, healthy habits, and stress.

MATERIALS AND METHODS

A descriptive, cross-sectional study was conducted on 24,224 Spanish workers to evaluate the association between diabesity and various factors such as age, gender, socioeconomic status, smoking, alcohol consumption, physical activity, adherence to the Mediterranean diet, and stress. The criteria used to define diabesity included body mass index (BMI), body fat (BF), and visceral fat (VF).

RESULTS

All the aforementioned variables were found to be associated with diabesity. The highest odds ratios (OR) were observed for age, with values ranging from 5.57 (95% CI: 4.48-6.67) when BF was used as the diabesity criterion to 6.89 (95% CI: 5.60-8.19) when VF was the criterion. Similarly, elevated ORs were observed for male gender, with ORs of 6.77 (95% CI: 5.31-8.24) for VF and 3.34 (95% CI: 2.77-3.94) for BF.

CONCLUSIONS

In our study, the profile of a person at highest risk of diabesity is a man over 50 years old from a lower socioeconomic status, who is a smoker, regular alcohol consumer, sedentary, with low adherence to the Mediterranean diet, and experiencing high stress levels.

Long-term weight change, incident cardiovascular disease and all-cause mortality among diabetic adults

We aimed to explore the impact of weight change from young to middle adulthood on incident cardiovascular disease (CVD) and all-cause mortality in US diabetic adults. All study subjects aged 40-79 years were from the US National Health and Nutrition Examination Survey (NHANES) 1988-2018, and they were non-pregnant and had complete data on self-reported weight at age 25 and 10 years before baseline enrollment over average 29.4 years. CVD events occurring from 10 years ago to baseline enrollment were recorded. Relative to stable non-obesity group, the strongest association was noted for the weight-losing group, followed by the stable-obesity group and weight-gaining group over following 10 years. Referring to the stable-obesity group identified significance for the stable non-obesity group. If total population had maintained non-obese from young to middle adulthood, 12 % of CVD cases could have been averted. Relative to the stable non-obesity group, subjects who maintained obese between young and middle adulthood had an increased risk of all-cause mortality. Our findings indicated that the risk for incident CVD and all-cause mortality was potentially reinforced in diabetic adults who were obese at age 25 but non-obese at midlife and who remained stable obese vis-à-vis those with stable non-obesity.

Exploring diabesity pathophysiology through proteomic analysis using Caenorhabditis elegans

Introduction

Diabesity, characterized by obesity-driven Type 2 diabetes mellitus (T2DM), arises from intricate genetic and environmental interplays that induce various metabolic disorders. The systemic lipid and glucose homeostasis is controlled by an intricate cross-talk of internal glucose/insulin and fatty acid molecules to maintain a steady state of internal environment.

Methods

In this study, Caenorhabditis elegans were maintained to achieve glucose concentrations resembling the hyperglycemic conditions in diabetic patients to delve into the mechanistic foundations of diabesity. Various assays were conducted to measure intracellular triglyceride levels, lifespan, pharyngeal pumping rate, oxidative stress indicators, locomotor behavior, and dopamine signaling. Proteomic analysis was also performed to identify differentially regulated proteins and dysregulated KEGG pathways, and microscopy and immunofluorescence staining were employed to assess collagen production and anatomical integrity.

Results

Worms raised on diets high in glucose and cholesterol exhibited notably increased intracellular triglyceride levels, a decrease in both mean and maximum lifespan, and reduced pharyngeal pumping. The diabesity condition induced oxidative stress, evident from heightened ROS levels and distinct FT-IR spectroscopy patterns revealing lipid and protein alterations. Furthermore, impaired dopamine signaling and diminished locomotors behavior in diabesity-afflicted worms correlated with reduced motility. Through proteomic analysis, differentially regulated proteins encompassing dysregulated KEGG pathways included insulin signaling, Alzheimer's disease, and nicotinic acetylcholine receptor signaling pathways were observed. Moreover, diabesity led to decreased collagen production, resulting in anatomical disruptions validated through microscopy and immunofluorescence staining.

Discussion

This underscores the impact of diabesity on cellular components and structural integrity in C. elegans, providing insights into diabesity-associated mechanisms.

Combined Sodium-Glucose-Transporters Inhibitors and Glucagon-Like-Peptide Receptor Agonist Compared With Monotherapy Improves Long-Term Survival: A Real-World Registry

BACKGROUND

The benefits of new glucose-lowering agents on cardiovascular disease have been demonstrated in randomized clinical trials. However, more evidence is required to assess the additive value of a combined therapy based on sodium-glucose transporter inhibitors (SGLT2i) and glucagon-like peptide receptor agonists (GLP1ra) in a real-world population.

METHODS

A nonconcurrent prospective study was conducted using integrated electronic medical records from primary care and hospitals obtained through "big data" technologies in a healthy area in Galicia. The study involved patients who were given SGLT2i, GLP1ra, or both treatments between January 2018 and June 2022 and were categorized as either mono- or combined therapy (SGLT2i, GLP1ra, or both). The cumulative risk for different events: hospitalization or mortality, or both, for 1) coronary artery disease, 2) heart failure, 3) cerebrovascular accident, and all-cause mortality were represented by Kaplan-Meier curves and multivariate Cox regression analysis to obtain the hazard ratio (HR) and (95% confidence interval [CI]). Validation was performed in a subpopulation with propensity score matching.

RESULTS

The patients (15,549) who were included were median (standard deviation) 68 (12) years old, with 41% of them being female and 46% experiencing obesity. The median (interquartile range) of follow-up was 19 (8-33) months. The Kaplan-Meier analysis determined that the cumulative risk for coronary artery disease and cerebrovascular accident events was similar among the 3 different therapy groups. However, the combined therapy vs SGLT2i reduced the risk of heart failure events (HR 0.69; 95% CI, 0.56-0.87) or all-cause mortality (HR 0.68; 95% CI, 0.54-0.86). Multivariate Cox regression analysis, after matching with a propensity score, confirmed the benefits of combined therapy regarding SGLT2i or GLP1ra monotherapy.

CONCLUSION

Compared with SGLT2i or GLP1ra alone, combined therapy SGLT2i + GLP1ra reduces heart failure risk and all-cause mortality in a real-world population.

The roles of B cells in cardiovascular diseases

Damage to the heart can start the repair process and cause cardiac remodeling. B cells play an important role in this process. B cells are recruited to the injured place and activate cardiac remodeling through secreting antibodies and cytokines. Different types of B cells showed specific functions in the heart. Among all types of B cells, heart-associated B cells play a vital role in the heart by secreting TGFβ1. B cells participate in the activation of fibroblasts and promote cardiac fibrosis. Four subtypes of B cells in the heart revealed the relationship between the B cells' heterogeneity and cardiac remodeling. Many cardiovascular diseases like atherosclerosis, heart failure (HF), hypertension, myocardial infarction (MI), and dilated cardiomyopathy (DCM) are related to B cells. The primary mechanisms of these B cell-related activities will be discussed in this review, which may also suggest potential novel therapeutic targets.

Comprehensive Strategies for Metabolic Syndrome: How Nutrition, Dietary Polyphenols, Physical Activity, and Lifestyle Modifications Address Diabesity, Cardiovascular Diseases, and Neurodegenerative Conditions

Several hallmarks of metabolic syndrome, such as dysregulation in the glucose and lipid metabolism, endothelial dysfunction, insulin resistance, low-to-medium systemic inflammation, and intestinal microbiota dysbiosis, represent a pathological bridge between metabolic syndrome and diabesity, cardiovascular, and neurodegenerative disorders. This review aims to highlight some therapeutic strategies against metabolic syndrome involving integrative approaches to improve lifestyle and daily diet. The beneficial effects of foods containing antioxidant polyphenols, intestinal microbiota control, and physical activity were also considered. We comprehensively examined a large body of published articles involving basic, animal, and human studie, as well as recent guidelines. As a result, dietary polyphenols from natural plant-based antioxidants and adherence to the Mediterranean diet, along with physical exercise, are promising complementary therapies to delay or prevent the onset of metabolic syndrome and counteract diabesity and cardiovascular diseases, as well as to protect against neurodegenerative disorders and cognitive decline. Modulation of the intestinal microbiota reduces the risks associated with MS, improves diabetes and cardiovascular diseases (CVD), and exerts neuroprotective action. Despite several studies, the estimation of dietary polyphenol intake is inconclusive and requires further evidence. Lifestyle interventions involving physical activity and reduced calorie intake can improve metabolic outcomes.

Associations of diabesity with all-cause and cardiovascular disease mortality: Findings from the Mexico City Prospective Study

AIM

To investigate the joint associations of diabetes and obesity with all-cause and cardiovascular disease (CVD) mortality in the Mexico City Prospective Study.

MATERIALS AND METHODS

In total, 154 128 participants (67.2% women) were included in this prospective analysis. Diabetes was self-reported, while body mass index was used to calculate obesity. Using diabetes and obesity classifications, six groups were created: (a) normal (no diabetes and normal weight); (b) normal weight and diabetes; (c) overweight but not diabetes (overweight); (d) overweight and diabetes (prediabesity); (e) obesity but not diabetes (obesity); and (f) obesity and diabetes (diabesity). Associations between these categories and outcomes were investigated using Cox proportional hazard models adjusted for confounder factors.

RESULTS

During 18.3 years of follow-up, 27 197 (17.6%) participants died (28.5% because of CV causes). In the maximally adjusted model, participants those with the highest risk {hazard ratio (HR): 2.37 [95% confidence interval (CI): 2.24-2.51]}, followed by those with diabesity [HR: 2.04 (95% CI: 1.94-2.15)]. Similar trends of associations were observed for CVD mortality. The highest CV mortality risk was observed in individuals with diabesity [HR: 1.80 (95% CI: 1.63-1.99)], followed by normal weight and diabetic individuals [HR: 1.78 (95% CI: 1.60-1.98)].

CONCLUSION

This large prospective study identified that diabetes was the main driver of all-cause and CVD mortality in all the categories studied, with diabesity being the riskiest. Given the high prevalence of both conditions in Mexico, our results reinforce the importance of initiating prevention strategies from an early age.

Enhanced Levels of Adiposity, Stretch and Fibrosis Markers in Patients with Coexistent Heart Failure and Atrial Fibrillation

The coexistence of heart failure (HF) and atrial fibrillation (AF) worsens the prognosis of patients. We aimed to study the inflammation, metabolism, adiposity, and fibrosis markers on epicardial and subcutaneous fat and blood, and their relationship with HF and AF. Samples from 185 patients undergoing cardiac surgery were collected. Levels of multi-markers on fat biopsies and plasma were analyzed. Patients were grouped by HF or AF presence. Plasma adiposity markers were increased in AF patients, while increased stretch markers correlated with HF. Patients with both AF and HF had higher ANP and GDF-15 levels. After excluding AF patients, plasma FABP4 was identified as the main HF predictor. Fat biopsies from AF patients showed an enhanced inflammatory profile. Higher levels of adiposity markers are associated with AF or HF, and higher stretch and fibrosis markers with combined AF and HF, suggesting a role of adiposity-fibrosis pathway in HF and AF coexistence.

Impact of diabesity phenotype on cardiovascular diseases, major cardiovascular events and all-cause mortality

To investigate the longitudinal association of different phenotypes of diabetes and obesity with the incidence of cardiovascular disease (CVD), CVD- and all-cause mortality. A total of 5432 adults, aged ≥ 35 years and free of CVD were included in this cohort study. Diabesity phenotypes were defined in six categories based on the presence of diabetes (normal (NG), prediabetes and diabetes) and obesity (obese, non-obese). Fasting blood sugar, 2-h post prandial glucose, or using anti-diabetic medicines were used to define diabetes, and body mass index and waist circumference were used to define obesity. Cox proportional hazards models were used to estimate hazard ratios (HRs) for incident CVD, CVD- and all-cause mortality across these categories. After a median follow-up of 11.25 years, 819 CVD cases, 181 CVD deaths and 488 all-cause deaths occurred. In multivariable-adjusted models and irrespective of obesity definition, the phenotypes of normal glucose-obese, prediabetes-obese and pre-diabetes-non obese were not associated with CVD incidence in comparison with NG-non obese phenotype, however, the phenotypes of diabesity, either defined by general or abdominal obesity, were associated with increased risk of incident CVD events (HR = 1.42, 95% CI 1.01, 1.99, and HR = 1.46, 95% CI 1.07, 1.98, respectively). These findings were sex-specific and only in men with a phenotype of abdominal obesity-diabetes, a positive link was observed for CVD incidence (HR = 1.60, 95% CI 1.01, 2.52). No significant association was found between diabesity and death from CVD or all causes. Diabesity is a predictor of CVD and stroke incidence, but not CVD or all-cause mortality, among Iranians. This association is more pronounced amongst men than women.

Mediterranean diet and health in the elderly

The Mediterranean diet has probably been the most studied diet since the early 1950s. American physiologist Ancel Keys coined the term since it was based on the dietary habits of those populations bordering the Mediterranean basin, particularly the island of Crete and southern Italy. The motivation for the early studies lay in understanding why these populations had greater longevity and lower occurrence of chronic-degenerative diseases and forms of cancer when compared with the peoples of Northern Europe and North America. Traditionally, this dietary regimen was based on the seasonality of foods and the consumption of unrefined grains, legumes, fish, vegetables, fruits, little meat and use of olive oil as a condiment. The purpose of this paper is to understand, based on current scientific knowledge, how the different nutrients present in such a diet can play a preventive role in the onset of today's most frequent diseases.

New Insights into Adipose Tissue Metabolic Function and Dysfunction

Currently, one-third of people worldwide are overweight or obese, with a higher prevalence in women than in men and in the elderly than in the young [...].

Insights into Exosome in the Intervertebral Disc: Emerging Role for Disc Homeostasis and Normal Function

Low back pain (LBP) is a chronic condition that causes great individual suffering and economic burden. The major contributor of LBP is intervertebral disc degeneration (IDD), which is caused by a spectrum of homeostasis alteration, including the apoptosis of nucleus pulposus (NP) and annulus fibrosus (AF) cells, degradation of extracellular matrix (ECM), calcification of cartilaginous endplates (CEP) and so on. Currently, the therapeutic strategy for IDD includes conservative and surgery treatment. Nevertheless, none of them could reverse the progressive destruction of the intervertebral disc. Hence, it is pivotal to pursue a new therapeutic approach. Exosomes, nano-sized substances with diameters of 30-150 nm, can be synthesized and secreted by various types of cells. They play an important role in intercellular communication. Increasing evidence implicates that exosomes could impact the intracellular transcription activities, thereby inhibiting or accelerating the proliferation and apoptosis of cells. Thus, it is a new therapeutic source for IDD. This review chiefly focuses on generalizing and clarifying the roles of exosomes in the onset and deterioration of IDD, and their therapeutic potential.