Incidence rates and predictors of microvascular and macrovascular complications in patients with type 2 diabetes: Results from the longitudinal global discover study

The role of peripheral white blood cell counts in the association between central adiposity and glycemic status

AIMS

Although central adiposity is a well-known risk factor for diabetes, the underlying mechanism remains unclear. The aim of this study was to explore the potential mediation role of circulating WBC counts in the association between central adiposity and the risk of diabetes.

MATERIALS AND METHODS

A cross-sectional study was conducted using data from the Fuqing cohort study, which included 6,613 participants aged 35-75 years. Logistic regression analysis and Spearman's rank correlation analysis were used to examine the relationships between waist-to-hip ratio, WBC counts and glycemic status. Both simple and parallel multiple mediation models were used to explore the potential mediation effects of WBCs on the association of waist-to-hip ratio with diabetes.

RESULTS

The study revealed a positive relationship between waist-to-hip ratio and risk of prediabetes (OR = 1.53; 95% CI, 1.35 to 1.74) and diabetes (OR = 2.89; 95% CI, 2.45 to 3.40). Moreover, elevated peripheral WBC counts were associated with both central adiposity and worsening glycemic status (P < 0.05). The mediation analysis with single mediators demonstrated that there is a significant indirect effect of central adiposity on prediabetes risk through total WBC count, neutrophil count, lymphocyte count, and monocyte count; the proportions mediated were 9.92%, 6.98%, 6.07%, and 3.84%, respectively. Additionally, total WBC count, neutrophil count, lymphocyte count, monocyte count and basophil count mediated 11.79%, 11.51%, 6.29%, 4.78%, and 1.76%, respectively, of the association between central adiposity and diabetes. In the parallel multiple mediation model using all five types of WBC as mediators simultaneously, a significant indirect effect (OR = 1.09; 95% CI, 1.06 to 1.14) were observed, with a mediated proportion of 12.77%.

CONCLUSIONS

Central adiposity was independently associated with an elevated risk of diabetes in a Chinese adult population; levels of circulating WBC may contribute to its underlying mechanisms.

Predictors of microvascular complications in patients with type 2 diabetes mellitus at regional referral hospitals in the central zone, Tanzania: a cross-sectional study

Microvascular complications encompass a group of diseases which result from long-standing chronic effect of diabetes mellitus (DM). We aimed to determine the prevalence of microvascular complications and associated risk factors among patients with type 2 diabetes mellitus (T2DM). A cross-sectional analytical hospital-based study was conducted at Singida and Dodoma regional referral hospitals in Tanzania from December 2021 to September 2022. A total of 422 patients with T2DM were included in the analysis by determining the prevalence of microvascular complications and their predictors using multivariable logistic regression analysis. A two-tailed p value less than 0.05 was considered statistically significant. The prevalence of microvascular complications was 57.6% (n = 243) and diabetic retinopathy was the most common microvascular complication which accounted for 21.1% (n = 89). Having irregular physical activity (AOR = 7.27, 95% CI = 2.98-17.71, p < 0.001), never having physical activity (AOR = 2.38, 95% CI = 1.4-4.01, p = 0.013), being hypertensive (AOR = 5.0, 95% CI = 2.14-11.68, p = 0.030), having T2DM for more than 5 years (AOR = 2.74, 95% CI = 1.42-5.26, p = 0.025), being obese (AOR = 2.63, 95% CI = 1.22-5.68, p = 0.010), and taking anti-diabetic drugs irregularly (AOR = 1.94, 95% CI = 0.15-0.77, p < 0.001) were the predictors of microvascular complications. This study has revealed a significant proportion of microvascular complications in a cohort of patients with T2DM. Lack of regular physical activity, being obese, taking anti-diabetic drugs irregularly, presence of hypertension, and long-standing duration of the disease, were significantly associated with microvascular complications.

Relationships of multidimensional factors to self-management in patients with diabetes: A Cross-sectional, correlational study

Poor self-management in patients with diabetes is a consistent issue, leading to diabetes complications. The purpose of this study was to examine the relationships of demographic, cognitive, psychological, social, and physiological factors to self-management in patients with diabetes. In this cross-sectional, correlational study, data were collected from 98 patients through REDCap in 2023. Multiple regression analysis was used to address the study purpose. In the sample, adherence to adequate self-management was poor. Knowledge, self-efficacy, and body mass index (BMI) were associated with overall diabetes self-management. Self-efficacy and BMI were associated with diet and exercise. Knowledge and self-efficacy were associated with blood glucose testing. No factors were associated with smoking and foot care. In conclusion, different factors were associated with different types of self-management, but BMI and self-efficacy were associated with most types of self-management. Clinicians and researchers can target BMI, self-efficacy, and knowledge to improve self-management in patients with diabetes.

Effects of Meditation Intervention on Self-management in Adult Patients With Type 2 Diabetes: A Systematic Literature Review and Meta-analysis

BACKGROUND

Diabetes complications are prevalent and cause adverse effects on the physical, psychological, and economic status of adult patients with type 2 diabetes. Meditation may positively affect self-management and, in turn, reduce diabetes complications. However, the systematic examination of the effects of meditation without additional components on self-management in this population have been rarely examined.

PURPOSE

The aim of this study was to examine the effects of meditation interventions on self-management (ie, control of glucose, blood pressure, cholesterol, and obesity and self-management) among adult patients with type 2 diabetes in randomized controlled trials.

METHODS

In this systematic review and meta-analysis, 6 electronic databases were searched using major keywords of meditation , diabetes , and self-management during March 2022.

RESULTS

Eight studies (9 articles) using mindfulness-based meditation were included. The meta-analysis showed that meditation improved hemoglobin A 1c (effect size = -0.75; 95% confidence interval, -1.30 to -0.21; P = .007) but not fasting blood glucose. Only a few studies examined meditation effects on other types of self-management (eg, blood pressure, body mass index, cholesterol, diet, exercise, foot care, and monitoring of blood glucose), and the effects were inconsistent. In 1 study, meditation improved diabetes self-management.

CONCLUSIONS

Mindfulness-based meditation reduced hemoglobin A 1c levels in adult patients with type 2 diabetes but did not consistently improve other types of self-management in a few studies examined. This may imply the need for additional intervention components to improve different types of self-management. Further studies are needed to examine the effects of different types of meditations with additional components on different types of self-management.

Prevalence of impaired awareness of hypoglycaemia in people with diabetes mellitus: A systematic review and meta-analysis from 21 countries and regions

AIMS

Impaired awareness of hypoglycaemia (IAH) is a complication of glucose-lowering therapies for diabetes. The purpose of this review was to estimate the pooled prevalence of IAH and unawareness of hypoglycaemia (UAH).

METHODS

We searched the major databases from inception to 8 August 2022 and included all cross-sectional and cohort studies reporting IAH prevalence in people with diabetes. A random-effects model was used to pool effect values. Subgroup analysis and meta-regression were used to identify study-level characteristics affecting prevalence.

RESULTS

Sixty-two studies from 21 countries published between 2000 and 2022 were included, with 39,180 participants (type 1 diabetes: 19,304 vs. Type 2 diabetes: 14,650). The pooled prevalence was 23.2% (95% CI: 18.4%-29.3%) via the Clarke questionnaire, 26.2% (95% CI: 22.9%-29.9%) via the Gold score, and 58.5% (95% CI: 53.0%-64.6%) via the Pedersen-Bjergaard method, all from studies classified as presenting a moderate and low risk of bias. The prevalence of IAH was generally higher in people with type 1 diabetes than in those with type 2 diabetes and lowest in Europe. Meta-regression results show that the duration of diabetes was a factor influencing the prevalence of IAH. The prevalence of UAH by the Pedersen-Bjergaard method was 17.6 (95% CI: 14.9%-20.3%).

CONCLUSIONS

IAH is a prevalent risk event among people with type 1 and type 2 diabetes, showing clinical heterogeneity and regional variability. UAH, an adverse progression of IAH, is also a serious burden. More primary research on the prevalence of IAH is needed in areas with a high diabetes burden.

Impact of diabetes duration on left ventricular mass regression with empagliflozin

AIMS

The duration of type 2 diabetes mellitus (T2DM) is an important determinant of diabetes severity. The EMPA-HEART CardioLink-6 trial reported significant left ventricular (LV) mass indexed to body surface area (LVMi) regression in patients treated with the sodium-glucose cotransporter 2 inhibitor (SGLT2i) empagliflozin for 6 months. This exploratory sub-analysis of the same trial investigated the association between T2DM duration and LVMi regression.

METHODS AND RESULTS

A total of 97 individuals with T2DM and coronary artery disease (CAD) were randomly assigned to receive empagliflozin 10 mg daily or placebo. LVMi was measured at the baseline and 6 month visit using cardiac magnetic resonance imaging. The study population was divided into those with a baseline T2DM duration <10 years (n = 40) or ≥10 years (n = 57). A linear model adjusting for baseline values in each of the subgroups (ANCOVA) was used to assess the treatment effect of 6 month change in LVMi, LV end systolic volume indexed to body surface area, LV end diastolic volume indexed to body surface area and LV ejection fraction. Patients in the T2DM duration <10 years group (38 males [95.0%], median age 63 [IQR: 55 years to 70 years]) had a median T2DM duration of 4 years (IQR: 2.0 years to 7.0 years). Those in the T2DM duration ≥10 years group (52 males [91.2%], median age 65 [IQR: 57 years to 71 years]) had a median duration of 15 years (IQR: 12 years to 20 years). There was no significant difference in baseline LVMi according to T2DM duration (median 62 g/m² [IQR: 53.1 g/m² to 70.0 g/m² ] for T2DM duration <10 years; median 57.5 g/m² [IQR: 52.1 g/m² to 66.2 g/m² ] for T2DM duration ≥10 years; P = 0.11). Empagliflozin was associated with reductions in LVMi irrespective of duration of T2DM above and below 10 years (T2DM duration <10 years group, mean adjusted difference -2.90 g/m² [95% CI: -6.64 g/m² to 0.84 g/m² ]; T2DM duration ≥10 years group, mean adjusted difference -3.69 g/m² [95% CI: -0.14 g/m² to -7.24 g/m² ]; P_interaction  = 0.07).

CONCLUSIONS

In the EMPA-HEART CardioLink-6 trial, empagliflozin treatment was associated with reductions in LVMi in people with T2DM and CAD irrespective of the duration of diabetes assessed categorically above and below 10 years.

Relationships between Physical Activity Frequency and Self-Perceived Health, Self-Reported Depression, and Depressive Symptoms in Spanish Older Adults with Diabetes: A Cross-Sectional Study

Diabetes is one of the most prevalent noncommunicable diseases in the world. This disease can affect both physical and mental health in the population. This study analyzed the prevalence of Self-Perceived Health (SPH), self-reported depression, and depressive symptoms in comparison with the Physical Activity Frequency (PAF) reported by Spanish older adults with diabetes. A cross-sectional study was carried out with data from 2799 self-reported diabetic participants, all of whom were residents of Spain, aged 50-79 years, and included in the European Health Surveys carried out in Spain (EHIS) both in 2014 and 2020. The relationships between the variables were analysed with a chi-squared test. A z-test for independent proportions was performed to analyze differences in proportions between the sexes. A multiple binary logistic regression was carried out on the prevalence of depression. Linear regressions were performed on depressive symptoms and SPH. Dependent relationships were found between the SPH, self-reported depression, and depressive symptoms with PAF. Most of the very active participants reported a higher prevalence of self-reported depression. Physical inactivity increased the risk of depression, major depressive symptoms, and negative SPH.

Ambient air pollution and hospitalization for type 2 diabetes in China: A nationwide, individual-level case-crossover study

Scarce evidence is available on the short-term association between air pollution and type 2 diabetes (T2D). We aimed to evaluate the associations between short-term exposure to six criteria air pollutants and hospitalization for T2D based on a national registry. We conducted an individual-level, time-stratified case-crossover study among inpatients with a primary diagnosis of T2D from 153 hospitals across 20 provincial regions in China (2013-2021). Daily concentrations of fine particulate matter (PM_2.5), inhalable particle (PM₁₀), nitrogen dioxide (NO₂), sulfur dioxide (SO₂) and carbon monoxide (CO), and ozone were collected from the nearest monitoring stations. T2D patients were separated into those admission for T2D with and without complications. Distributed lag non-linear models combined with conditional logistic regressions were used to estimate the associations. A total of 88,904 patients were hospitalized for T2D. Short-term exposures to all six air pollutants above except for ozone were significantly associated with the risk of hospitalization for T2D and both subclasses. An interquartile range increase in the concentrations of PM_2.5, PM₁₀, NO₂, SO₂, and CO at lag 0-2 d was associated with higher hospitalization risk of T2D by 1.71% (95%CI: 0.56%, 2.87%), 2.08% (0.88%, 3.29%), 4.85% (3.29%, 6.44%), 2.44% (1.22%, 3.67%) and 2.55% (1.24%, 3.88%), respectively. The associations of T2D hospitalizations were stronger in cold season than in warm season. Air pollutants had more acute and stronger associations with T2D with complications. The exposure-response relationship curves showed no thresholds, and the slopes were larger for T2D with complications. This nationwide individual-level, case-crossover study provides the first comprehensive evidence that short-term exposure to multiple criteria air pollutants may increase the risk of hospitalizations for T2D, especially for T2D with complications.

Association of Bone Turnover Markers with Type 2 Diabetes Mellitus and Microvascular Complications: A Matched Case-Control Study

Purpose

The aim of this study was to evaluate the association of bone turnover markers (BTMs) with type 2 diabetes mellitus (T2DM) and microvascular complications.

Methods

A total of 166 T2DM patients and 166 non-diabetic controls matched by gender and age were enrolled. T2DM patients were sub-classified into groups based on whether they had diabetic peripheral neuropathy (DPN), diabetic retinopathy (DR), and diabetic kidney disease (DKD). Clinical data including demographic characteristics and blood test results [serum levels of osteocalcin (OC), N-terminal propeptide of type 1 procollagen (P1NP), and β-crosslaps (β-CTX)] were collected. Logistic regression and restrictive cubic spline curves were performed to examine the association of BTMs with the risk of T2DM and microvascular complications.

Results

After adjusting for family history of diabetes, sex and age, an inverse association was observed between elevated serum OC levels [O, p < 0.001] and increased serum P1NP levels , p < 0.001] with the risk of T2DM. Moreover, there was an inverse linear association of serum OC and P1NP levels with the risk of T2DM. However, β-CTX was not associated with T2DM. Further analysis showed a nonlinear association between OC and the risk of DR, while P1NP and β-CTX were not correlated with DR. Serum concentrations of BTMs were not associated with the risks of DPN and DKD.

Conclusion

Serum OC and P1NP levels were negatively correlated with T2DM risk. Particularly, serum OC levels were associated with DR risk. Given that BTMs are widely used as markers of bone remodeling, the present finding provides a new perspective for estimating the risk of diabetic microvascular complications.

Association of Serum Bilirubin Levels with Macro- and Microvascular Complications in Chinese People with Type 2 Diabetes Mellitus: New Insight on Gender Differences

BACKGROUND

Previous studies suggested protective effects of bilirubin against cardiovascular disease, with a possible gender difference. However, the relationship between serum total bilirubin (TBIL) with diabetic macro- and microvascular complications remains unknown. We aimed to examine the association of macro- and microvascular complications with serum TBIL levels.

METHODS

Serum TBIL was measured in 648 patients with T2DM. Demographic and clinical data were obtained from the inpatient medical record system. Serum TBIL was measured with an automatic biochemistry analyzer according to routine protocols. Parameters of vascular complications, including ankle-brachial index, carotid intima-media thickness, estimated glomerular filtration rate and the urinary albumin to creatinine ratio, were measured and calculated. The association between TBIL and diabetic macro- and microvascular complications was analyzed.

RESULTS

In multivariable logistic regression, after adjustment for age, sex, body mass index and diabetic duration, higher serum TBIL levels were significantly associated with decreased odds of microalbuminuria (OR = 0.31, [95% CI] 0.16-0.61, P = 0.003) and chronic kidney disease (OR = 0.19, [95% CI] 0.09-0.41, P < 0.001). These associations were only found in male but not in female patients. However, no significant relationship was found between TBIL and peripheral arterial disease or carotid hypertrophy.

CONCLUSION

Our findings suggest that physiological higher TBIL level might be a protective factor for diabetic microvascular complications.

Cost-Utility Analysis of Once-Weekly Semaglutide, Dulaglutide, and Exenatide for Type 2 Diabetes Patients Receiving Metformin-Based Background Therapy in China

Introduction: The substantial financial burden associated with type 2 diabetes (T2D) over a lifetime cannot be neglected. Therefore, the objective of this study was to evaluate the pharmacoeconomic value of three once-weekly GLP-1 RAs, namely subcutaneous semaglutide (sc. SEMA), dulaglutide (DULA), and extended-release exenatide (e-r EXEN), in treating patients with T2D that cannot be controlled with metformin-based background therapy, and to find a suitable price reduction for non-cost-effective medications, to provide reasonable recommendations to the administration for adjusting drug prices.

Methods: The baseline characteristics of the simulation patient cohort were sourced from a comprehensive meta-analysis synthesizing 453 trials evaluating 21 hypoglycemic agents from nine categories of drugs. The UKPDS OM2 was applied to project the long-term effectiveness and costs from a Chinese health care provider’s perspective. After cost-utility analysis, the reasonable price adjustment of non-cost-effective options was explored via binary search. Uncertainty was measured by means of sensitivity analysis.

Results: After a 40-year simulation, the sc. SEMA, DULA, and e-r EXEN groups yielded 9.6315, 9.5968, and 9.5895 quality-adjusted life years (QALYs), respectively. In terms of expenditure, the total costs for the sc. SEMA, DULA, and e-r EXEN groups were $42012.47, $24931.27, and $40264.80, respectively. DULA was dominant over e-r EXEN due to the higher QALYs and lower total costs. The ICURs of sc. SEMA vs. DULA and sc. SEMA vs. e-r EXEN were $492994.72/QALY and $41622.69/QALY (ICUR > λ), respectively, indicating that sc. SEMA was not more cost-effective than DULA or e-r EXEN. The INMB and absolute NMB yielded the same conclusions which were robust to one-way, scenario, and probabilistic sensitivity analyses. After several assumptions in the binary search, sc. SEMA and e-r EXEN appear to become cost-effective when their annual costs are decreased by 57.67% and 70.34%, respectively, with DULA as a counterpart.

Conclusion: From the cost-utility analysis, DULA appears to be the most cost-effective option among sc. SEMA, DULA, and e-r EXEN for the treatment of patients with T2D receiving metformin-based background therapy. With a 57.67% or 70.34% reduction in cost, sc. SEMA or e-r EXEN, respectively, would become as cost-effective as DULA in China.

Diabetes and restenosis

Restenosis, defined as the re-narrowing of an arterial lumen after revascularization, represents an increasingly important issue in clinical practice. Indeed, as the number of stent placements has risen to an estimate that exceeds 3 million annually worldwide, revascularization procedures have become much more common. Several investigators have demonstrated that vessels in patients with diabetes mellitus have an increased risk restenosis. Here we present a systematic overview of the effects of diabetes on in-stent restenosis. Current classification and updated epidemiology of restenosis are discussed, alongside the main mechanisms underlying the pathophysiology of this event. Then, we summarize the clinical presentation of restenosis, emphasizing the importance of glycemic control in diabetic patients. Indeed, in diabetic patients who underwent revascularization procedures a proper glycemic control remains imperative.