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Vergès B. Cardiovascular disease in type 1 diabetes, an underestimated danger: Epidemiological and pathophysiological data. Atherosclerosis 2023:S0021-9150(23)00244-7. [PMID: 37369617 DOI: 10.1016/j.atherosclerosis.2023.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023]
Abstract
Cardiovascular disease (CV) is a common complication of type 1 diabetes (T1D) and a leading cause of death. T1D patients are more likely to develop CV disease (CVD) early in life and show a reduction of life expectancy of at least 11 years. Patients with a young age of T1D onset have a substantially higher CV risk. The reasons for increased atherosclerosis in T1D patients are not entirely explained. In addition to the typical CV risk factors, long-term hyperglycemia has a significant impact by inducing oxidative stress, vascular inflammation, monocyte adhesion, arterial wall thickening and endothelial dysfunction. Additionally, CVD in T1D is also associated with nephropathy. However, CVD risk is still significantly increased in T1D patients, in good glycemic control without additional CV risk factors, indicating the involvement of supplementary potential factors. By increasing oxidative stress, vascular inflammation, and endothelial dysfunction, hypoglycemia and glucose variability may exacerbate CVD. Moreover, significant qualitative and functional abnormalities of lipoproteins are present in even well-controlled T1D patients and are likely to play a role in the development of atherosclerosis and the promotion of CVD. According to recent research, immune system dysfunction, which is typical of auto-immune T1D, may also promote CVD, likely via inflammatory pathways. In addition, T1D patients who are overweight or obese exhibit an additional CV risk due to pathophysiological mechanisms that are similar to those seen in T2D.
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Affiliation(s)
- Bruno Vergès
- Endocrinology-Diabetology Department, University-Hospital of Dijon, Dijon, France; INSERM LNC-UMR1231, Medicine University, 21000 Dijon, France; Service Endocrinologie, Diabétologie et Maladies Métaboliques, CHU-Dijon, 14 rue Gaffarel, F-21000 Dijon, France.
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Gomes MB, Santos DC, Drummond K, Pinheiro A, Muniz LH, Leal F, Negrato CA. Prevalence of overweight/obesity and its relationship with metabolic syndrome and fatty liver index in adult patients with type 1 diabetes. A Brazilian multicenter study. Diabetol Metab Syndr 2023; 15:28. [PMID: 36823646 PMCID: PMC9948365 DOI: 10.1186/s13098-023-00996-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/11/2023] [Indexed: 02/25/2023] Open
Abstract
AIMS To determine the prevalence of overweight/obesity and its relationship with metabolic syndrome (MS), fatty liver index (FLI), cardiovascular risk factors (CVRF), and diabetes-related chronic complications (DRCC) in adult patients with type 1 diabetes (T1D). METHODS This study was conducted in 14 Brazilian public clinics in ten cities, with 1,390 patients: 802 females (57.7%), 779 (56.0%) Caucasians, aged 33.6 ± 10.8 years, age at diagnosis, 16.2 ± 9.2 years, diabetes duration, 17.4 ± 9.2 years, and HbA1c 8.8 ± 2.0%. RESULTS Overall, 825 patients (59.4%) had normal weight, and 565 had overweight/obesity; ( 429 (30.9%) presented overweight and 136 (9.8%) presented obesity). After adjustments, overweight/obesity was associated with age, family history of overweight/obesity, total daily insulin dose, hypertension, adherence to diet, type of health care insurance, use of metformin, levels of C-reactive protein, triglycerides, uric acid and HDL-cholesterol. These patients also presented a higher prevalence of MS, FLI ≥ 60, and CVRF than patients without overweight/obesity. Overweight/obesity was not associated with DRCC and with HbA1c levels. CONCLUSIONS Patients with T1D with overweight/obesity presented traditional risk factors for DRCC, cardiovascular diseases, MS, and non-alcoholic fatty liver disease; most of these risk factors are modifiable and can be avoided with interventions that prevent overweight/obesity.
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Affiliation(s)
- Marilia Brito Gomes
- Department of Internal Medicine, State University of Rio de Janeiro, Blv. 28 de Setembro, 77, Rio de Janeiro, 20551-030, Brazil.
| | - Deborah Conte Santos
- Department of Internal Medicine, State University of Rio de Janeiro, Blv. 28 de Setembro, 77, Rio de Janeiro, 20551-030, Brazil
| | - Karla Drummond
- Department of Ophthalmology, Sao Paulo Federal University, Av. Dr. Arnaldo, 455, Cerqueira César, São Paulo, SP, Brasil
| | - André Pinheiro
- Department of Ophthalmology, Regional Hospital of Taguatinga. QNC, Área Especial nº 24, Taguatinga Norte/DF, Brasília, Brazil
| | - Luiza Harcar Muniz
- Department of Internal Medicine, State University of Rio de Janeiro, Blv. 28 de Setembro, 77, Rio de Janeiro, 20551-030, Brazil
| | - Franz Leal
- Department of Ophthalmology, University of Campinas, Rua Tessália Vieira de Camargo, 126, Campinas, São Paulo, Brazil
| | - Carlos Antonio Negrato
- Medical Doctor Program, University of São Paulo-School of Dentistry, Alameda Dr. Octávio Pinheiro Brisolla, 9-75, Jardim Brasil, Bauru, São Paulo, Brazil
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Hernández M, Nóvoa-Medina Y, Faner R, Palou E, Esquerda A, Castelblanco E, Wägner AM, Mauricio D. Genetics: Is LADA just late onset type 1 diabetes? Front Endocrinol (Lausanne) 2022; 13:916698. [PMID: 36034444 PMCID: PMC9404871 DOI: 10.3389/fendo.2022.916698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is a controversy regarding Latent Autoimmune Diabetes in Adults (LADA) classification and whether it should be considered a slowly progressing form of type 1 (T1) diabetes (DM) or a distinct type of DM altogether. METHODS This cross-sectional study assessed major genes associated with T1DM (class II HLA, PTPN22 [rs2476601] and INS [rs689]) in patients with LADA, as compared with participants with T1DM (stratified according to age of diagnosis before or after 30) and T2DM. HLA genotyping of the DRB1, DQA1 and DQB1 loci was performed by reverse PCR sequence-specific oligonucleotides. HLA haplotypes were assigned according to those most frequently described in the European population. INS and PTPN22 SNPs were genotyped by real-time PCR. RESULTS A total of 578 participants were included: 248 with T1DM (70 diagnosed after the age of 30), 256 with T2DM and 74 with LADA. High risk HLA alleles were significantly more frequent in LADA than in T2DM, whereas the opposite was true for protective alleles. We found a lower frequency of the high-risk DRB1*04-DQB1*03:02-DQA1*03:01 haplotype in LADA (21.1%) than in the overall T1DM (34.7%) (p<0.05), whereas no differences were found between these groups for DRB1*03-DQB1*02:01-DQA1*05:01 or for protective alleles. Only 12% the overall T1DM group had no risk alleles vs 30% of LADA (p<0.0005). However, HLA allele distribution was similar in LADA and T1DM diagnosed after the age of 30. A total of 506 individuals (195 with T1DM [21 diagnosed after age 30] 253 with T2DM and 58 with LADA) were genotyped for the PTPN22 and INS SNPs. The G/A genotype of the PTPN22 rs2476601 was more frequent and the T/T genotype of the INS SNP rs689 was less frequent in T1DM compared to LADA. We did not find any significant differences in the frequency of the mentioned SNPs between LADA and T2DM, or between LADA and T1DM diagnosed after the age of 30. CONCLUSION In this relatively small cross-sectional study, the genetic profile of subjects with LADA showed a similar T1DM-related risk allele distribution as in participants with T1DM diagnosed after the age of 30, but fewer risk alleles than those diagnosed before 30. Differences were present for HLA, as well as PTPN22 and INS genes.
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Affiliation(s)
- M. Hernández
- Department of Endocrinology and Nutrition, University Hospital Arnau de Vilanova, Lleida, Spain
- Lleida Biomedical Research Institute (IRB Lleida), University of Lleida (UdL), Lleida, Spain
| | - Y. Nóvoa-Medina
- Department of Pediatrics, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, Spain
- Research Institute in Biomedical and Health Sciences (IUIBS), University of Las Palmas de Gran Canaria (ULPGC), Las Palmas de Gran Canaria, Spain
| | - R. Faner
- Histocompatibility and Immunogenetics Laboratory, Blood and Tissue Bank, Barcelona, Spain
| | - E. Palou
- Histocompatibility and Immunogenetics Laboratory, Blood and Tissue Bank, Barcelona, Spain
| | - A. Esquerda
- Department of Laboratory Medicine, University Hospital Arnau de Vilanova, Lleida, Spain
| | - E. Castelblanco
- Diabetis en Atenció Primària - Catalunya (DAP-Cat) Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina, Barcelona, Spain
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - A. M. Wägner
- Research Institute in Biomedical and Health Sciences (IUIBS), University of Las Palmas de Gran Canaria (ULPGC), Las Palmas de Gran Canaria, Spain
- Department of Endocrinology and Nutrition, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, Spain
- *Correspondence: A. M. Wägner, ; D. Mauricio,
| | - D. Mauricio
- Department of Endocrinology, Hospital de la Santa Creu i Sant Pau & Institut d’Investigació Biomèdica (IIB) Sant Pau, Barcelona, Spain
- Consorcio Centro de Investigación Biomédica en Red (CIBER) of Diabetes and Associated Metabolic Diseases, Instituto de Salud Carlos III, Barcelona, Spain
- Faculty of Medicine, University of Vic & Central University of Catalonia, Vic, Spain
- *Correspondence: A. M. Wägner, ; D. Mauricio,
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Wada E, Onoue T, Kinoshita T, Hayase A, Handa T, Ito M, Furukawa M, Okuji T, Kobayashi T, Iwama S, Sugiyama M, Takagi H, Hagiwara D, Suga H, Banno R, Goto M, Arima H. Adult-onset autoimmune diabetes identified by glutamic acid decarboxylase autoantibodies: a retrospective cohort study. Diabetologia 2021; 64:2183-2192. [PMID: 34268631 DOI: 10.1007/s00125-021-05516-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/05/2021] [Indexed: 12/26/2022]
Abstract
AIMS/HYPOTHESIS Patients with GAD antibodies (GADAb) showing clinical features of type 2 diabetes typically exhibit progression to an insulin-dependent state in several months or years. This condition is diagnosed as slowly progressive insulin-dependent (type 1) diabetes mellitus (SPIDDM) or latent autoimmune diabetes in adults, a subtype of adult-onset autoimmune diabetes. However, some patients diagnosed with adult-onset autoimmune diabetes do not progress to an insulin-dependent state. We conducted a retrospective cohort study to identify patients with non-insulin-dependent diabetes among those diagnosed with adult-onset autoimmune diabetes using measurable indicators in routine clinical practice. METHODS We surveyed data from the electronic medical records of all patients with GADAb from eight medical centres in Japan for selecting and analysing patients who matched the diagnostic criteria of SPIDDM. RESULTS Overall, 345 patients were analysed; of these, 162 initiated insulin therapy (insulin therapy group), whereas 183 did not (non-insulin therapy group) during the follow-up period (median 3.0 years). Patients in the non-insulin therapy group were more likely to be male and presented a later diabetes onset, shorter duration of diabetes, higher BMI, higher blood pressure levels, lower HbA1c levels, lower GADAb levels and lesser antidiabetic agent use than those in the insulin therapy group when GADAb was first identified as positive. A Cox proportional hazards model showed that BMI, HbA1c levels and GADAb levels were independent factors for progression to insulin therapy. Kaplan-Meier analyses revealed that 86.0% of the patients with diabetes having GADAb who presented all three factors (BMI ≥ 22 kg/m2, HbA1c < 75 mmol/mol [9.0%] and GADAb <10.0 U/ml) did not require insulin therapy for 4 years. CONCLUSIONS/INTERPRETATION Higher BMI (≥22 kg/m2), lower HbA1c (<75 mmol/mol [9.0%]) and lower GADAb levels (<10.0 U/ml) can predict a non-insulin-dependent state for at least several years in Japanese patients with diabetes having GADAb.
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Affiliation(s)
- Eri Wada
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takeshi Onoue
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Tamaki Kinoshita
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ayaka Hayase
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoko Handa
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masaaki Ito
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mariko Furukawa
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takayuki Okuji
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoko Kobayashi
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shintaro Iwama
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mariko Sugiyama
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Takagi
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daisuke Hagiwara
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidetaka Suga
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryoichi Banno
- Research Center of Health, Physical Fitness and Sports, Nagoya University, Nagoya, Japan
| | - Motomitsu Goto
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Arima
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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Karatas S, Beysel S. Visceral Adiposity Index, Triglyceride/High-Density Lipoprotein Ratio, and Lipid Accumulation Product Index to Discriminate Metabolic Syndrome Among Adult Type 1 Diabetes Patients. Metab Syndr Relat Disord 2021; 19:507-512. [PMID: 34283922 DOI: 10.1089/met.2021.0047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: Obesity and metabolic syndrome (MetS) are growing problems in type 1 diabetic patients; these can influence clinical complications and also treatment regimens. Visceral adipose tissue inflammation plays an important role in cardiovascular complications. Visceral adiposity index (VAI), lipid accumulation product index (LAP), and triglyceride (TG)/high-density lipoprotein (HDL) ratio have been strongly correlated with insulin resistance and visceral adipose tissue amount in previous studies. Therefore, this study aimed to investigate and compare the usefulness of these indices to detect MetS in patients with type 1 diabetes mellitus (T1DM). Materials and Methods: Patients with T1DM and gender- and age-matched controls were included in this cross-sectional study. MetS was defined using both International Diabetes Federation (IDF), World Health Organization (WHO), and National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria. T1DM patients were divided into two groups according to the IDF criteria. VAI, LAP, and TG/HDL ratio were calculated for all patients. Groups were compared accordingly. Results: One hundred twenty-six patients with T1DM were included in the study. Increased VAI was observed in association with MetS. Patients with MetS (32.2%) had the highest VAI than healthy controls (8.21 ± 8.86; 3.49 ± 2.73, respectively, P < 0.01). For determining MetS in type 1 diabetes, the cutoff value of VAI was 2.65 [area under the curve (AUC) = 0.837, sensitivity 80.0%, specificity 72.8%], LAP was 27.57 (AUC = 0.842, sensitivity 80.0%, specificity74.0%), TG/HDL ratio was 2.18 (AUC = 0.826, sensitivity 75.0%, specificity 74.0%), each P < 0.001. Conclusions: MetS becomes increasingly common in T1DM. VAI, LAP, and TG/HDL ratio were useful for predicting MetS in patients with T1DM.
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Affiliation(s)
- Savas Karatas
- Endocrinology and Metabolism Department, Istanbul Research and Education Hospital, Istanbul, Turkey
| | - Selvihan Beysel
- Endocrinology and Metabolism Department, Afyonkarahisar Saglik Bilimleri University, Afyonkarahisar, Turkey
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Vilarrasa N, San Jose P, Rubio MÁ, Lecube A. Obesity in Patients with Type 1 Diabetes: Links, Risks and Management Challenges. Diabetes Metab Syndr Obes 2021; 14:2807-2827. [PMID: 34188505 PMCID: PMC8232956 DOI: 10.2147/dmso.s223618] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/19/2021] [Indexed: 12/15/2022] Open
Abstract
Obesity affects large numbers of patients with type 1 diabetes (T1D) across their lifetime, with rates ranging between 2.8% and 37.1%. Patients with T1D and obesity are characterized by the presence of insulin resistance, of high insulin requirements, have a greater cardiometabolic risk and an enhanced risk of developing chronic complications when compared to normal-weight persons with T1D. Dual treatment of obesity and T1D is challenging and no specific guidelines for improving outcomes of both glycemic control and weight management have been established for this population. Nevertheless, although evidence is scarce, a comprehensive approach based on a balanced hypocaloric diet, physical activity and cognitive behavioral therapy by a multidisciplinary team, expert in both obesity and diabetes, remains as the best clinical practice. However, weight loss responses with lifestyle changes alone are limited, so in the "roadmap" of the treatment of obesity in T1D, it will be helpful to include anti-obesity pharmacotherapy despite at present there is a lack of evidence since T1D patients have been excluded from anti-obesity drug clinical trials. In case of severe obesity, bariatric surgery has proven to be of benefit in obtaining a substantial and long-term weight loss and reduction in cardiovascular risk. The near future looks promising with the development of new and more effective anti-obesity treatments and strategies to improve insulin resistance and oxidative stress. Advances in precision medicine may help individualize and optimize the medical management and care of these patients. This review, by gathering current evidence, highlights the need of solid knowledge in all facets of the treatment of patients with obesity and T1D that can only be obtained through high quality well-designed studies.
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Affiliation(s)
- Nuria Vilarrasa
- Department of Endocrinology and Nutrition, Hospital Universitario de Bellvitge-IDIBELL, Barcelona, Spain
- CIBERDEM-CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, Madrid, Spain
- Correspondence: Nuria Vilarrasa Hospital Universitario de Bellvitge-IDIBELL, C/Feixa Llarga s/n, 08907 L´Hospitalet de Llobregat, Barcelona, SpainTel +34 93-5338511Fax +34 933375248 Email
| | - Patricia San Jose
- Department of Endocrinology and Nutrition, Hospital Universitario de Bellvitge-IDIBELL, Barcelona, Spain
| | - Miguel Ángel Rubio
- Department of Endocrinology & Nutrition, Hospital Clínico San Carlos, IDISSC, Madrid, 28040, Spain
| | - Albert Lecube
- CIBERDEM-CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, Madrid, Spain
- Endocrinology and Nutrition Department, Hospital Universitari Arnau de Vilanova, Lleida, 25198, Spain
- Obesity, Diabetes and Metabolism (ODIM) Research Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), University of Lleida, Lleida, Spain
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Vergès B. Cardiovascular disease in type 1 diabetes: A review of epidemiological data and underlying mechanisms. Diabetes Metab 2020; 46:442-9. [PMID: 32998054 DOI: 10.1016/j.diabet.2020.09.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/27/2020] [Accepted: 09/05/2020] [Indexed: 12/15/2022]
Abstract
Cardiovascular disease (CVD) is highly prevalent in patients with type 1 diabetes (T1D) and a major cause of mortality. CVD arises earlier in life in T1D patients and is responsible for a significant reduction of at least 11 years' life expectancy. Also, the incidence of CVD is much more pronounced in patients with T1D onset at an earlier age. However, the factors responsible for increased atherosclerosis and CVD in T1D are not yet totally clarified. In addition to the usual cardiovascular (CV) risk factors, chronic hyperglycaemia plays an important role by promoting oxidative stress, vascular inflammation, monocyte adhesion, arterial wall thickening and endothelial dysfunction. Diabetic nephropathy and cardiac autonomic neuropathy are also associated with increased CVD in T1D. In fact, the CVD risk remains significantly increased even in well-controlled T1D patients who have no additional CV risk factors, indicating that other potential factors are likely to be involved. Hypoglycemia and glucose variability could enhance CV disease by promoting oxidative stress, vascular inflammation and endothelial dysfunction. Furthermore, even well-controlled T1D patients show significant qualitative and functional abnormalities of lipoproteins that are likely to be implicated in the development of atherosclerosis and premature CVD. In addition, recent data suggest that a dysfunctional immune system, which is typical of autoimmune T1D, might also promote CVD possibly through inflammatory pathways. Moreover, overweight and obese T1D patients can manifest additional CV risk through pathophysiological mechanisms resembling those observed in type 2 diabetes (T2D).
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Wang H, Zhang Z, Liu Y, Yang J, Zhang J, Clark C, Rodriguez DA, Amirthalingam P, Guo Y. Pre-pregnancy body mass index in mothers, birth weight and the risk of type I diabetes in their offspring: A dose-response meta-analysis of cohort studies. J Gynecol Obstet Hum Reprod 2020; 50:101921. [PMID: 32992035 DOI: 10.1016/j.jogoh.2020.101921] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 09/18/2020] [Accepted: 09/19/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND The incidence of type I diabetes among children has increased significantly and the relationship between maternal pre-pregnancy Body Mass Index (BMI), Birth weight and risk of Type 1 diabetes in children (T1DMC) is controversial. OBJECTIVE This dose-response meta-analysis was performed to investigate the association between maternal Pre-Pregnancy Body-Mass Index, Birth Weight and the Risk of Childhood Type I Diabetes. SEARCH STRATEGY A comprehensive systematic search was conducted in MEDLINE/PubMed, SCOPUS, Cochrane, and Web of Science databases from inception to April 2019. Key search terms included "body mass index" OR "Birth weight" AND "Type 1 diabetes". SELECTION CRITERIA Peer-reviewed studies that reporting association between BMI or birth weight and type I diabetes in a retrospective or prospective study by appropriate estimates such as the hazard ratio (HR), risk ratio (RR), or odds ratio (OR) and the corresponding 95 % confidence intervals (CI). DATA COLLECTION AND ANALYSIS MOOSE guidelines were followed. Data were extracted by 2 researchers, independently. Combined hazard ratios (HRs) was evaluated by DerSimonian and Laird Random-effects model. RESULTS Two studies continuing four arms with 1,209,122 participants were eligible for pre-pregnancy BMI section meta-analysis and six studies were eligible for inclusion, providing 10,340,036 participants for birth weight section meta-analysis. Pooled results demonstrated a significant association between obesity and risk of T1DMC (HR: 1.30, 95 % CI: 1.16-1.46, I2 = 7%). The combined HR (95 % CI) showed lower risk of T1DMC in low birth weight infants (HR: 0.78, 95 % CI: 0.69-0.88, I2 = 0%) and higher risk of T1DMC in the high birth weight infants versus the normal category of birth weight (HR: 1.08, 95 % CI: 1.00-1.17, I2 = 31 %). There was a significant non-linear association between birth weight and risk of T1DMC in children (Coef =-0.00032, p = 0.001). CONCLUSIONS AND RELEVANCE This systematic review and meta-analysis identified high maternal BMI and High birth weight (HBW) increase risk of childhood T1DMC.
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Affiliation(s)
- Haiyan Wang
- Obstetrics Department, Affiliated Hospital of Chengde Medical College, Chengde City, 067100, China
| | - Zhongmin Zhang
- Clinical Laboratory, Staff Hospital of Chengde Iron & Steel Group Co., LTD., Chengde City, 067102, China
| | - Yanfang Liu
- Obstetrics Department, Affiliated Hospital of Chengde Medical College, Chengde City, 067100, China
| | - Jiaqi Yang
- Department of Preventive Medicine, Chengde Medical College, Chengde City, 067100, China
| | - Jinhuan Zhang
- Obstetrics Department, Affiliated Hospital of Chengde Medical College, Chengde City, 067100, China
| | - Cain Clark
- Centre for Sport, Exercise and Life Sciences, Coventry University, Coventry, CV1 5FB, United Kingdom
| | - David Avelar Rodriguez
- Pediatric Gastroenterology and Nutrition Unit, Instituto Nacional De Pediatria, Coyoacan, Mexico
| | - Palanisamy Amirthalingam
- Department of Pharmacy Practice, Faculty of Pharmacy, University of Tabuk, P.O. Box 741, Tabuk 71491, Saudi Arabia
| | - Yanwei Guo
- Obstetrics Department, Affiliated Hospital of Chengde Medical College, Chengde City, 067100, China.
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Nishimura A, Matsumura K, Kikuno S, Nagasawa K, Okubo M, Mori Y, Kobayashi T. Slowly Progressive Type 1 Diabetes Mellitus: Current Knowledge And Future Perspectives. Diabetes Metab Syndr Obes 2019; 12:2461-2477. [PMID: 31819572 PMCID: PMC6886592 DOI: 10.2147/dmso.s191007] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 10/18/2019] [Indexed: 12/21/2022] Open
Abstract
Slowly progressive type 1 insulin-dependent diabetes mellitus (SPIDDM), sometimes referred to as latent autoimmune diabetes in adults (LADA), is a heterogeneous disease that is often confused with type 1 and type 2 diabetes. As a result, there were few diagnostic criteria for this disorder until 2012, when the Japan Diabetes Society established criteria that could be used in clinical practice. A primary question is whether pathologic markers for type 1 or type 2 diabetes are present in the pancreas of patients with SPIDDM, because the phenotype of SPIDDM is similar to both type 1 and type 2 diabetes. Recent studies clarified pathologic findings in the pancreas of patients with SPIDDM, which included T-cell-mediated insulitis, a marker of type 1 diabetes; pseudoatrophic islets (islets specifically devoid of beta cells), another hallmark of type 1 diabetes; and a lack of amylin (ie, islet amyloid polypeptide) deposition to the islet cells, a pathologic marker of type 2 diabetes. In terms of preventing the loss of beta-cell function in patients with SPIDDM, several studies have shown that some drugs, including dipeptidyl peptidase-4 inhibitors, are effective. There is an increased need for early diagnosis of SPIDDM to preserve beta-cell function. This review presents updated findings on the pathogenesis and immunologic findings of the affected pancreas, diagnostic markers, risk factors for progression of beta-cell dysfunction, epidemiology, clinical features, diagnostic strategies, prevention strategies, and clinical options for patients with SPIDDM.
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Affiliation(s)
- Akihiro Nishimura
- Department of Endocrinology and Metabolism, Toranomon Hospital, Tokyo, Japan
| | - Kimio Matsumura
- Department of Endocrinology and Metabolism, Toranomon Hospital, Tokyo, Japan
| | - Shota Kikuno
- Department of Endocrinology and Metabolism, Toranomon Hospital, Tokyo, Japan
| | - Kaoru Nagasawa
- Department of Endocrinology and Metabolism, Toranomon Hospital, Tokyo, Japan
| | - Minoru Okubo
- Department of Endocrinology and Metabolism, Toranomon Hospital, Tokyo, Japan
| | - Yasumichi Mori
- Department of Endocrinology and Metabolism, Toranomon Hospital, Tokyo, Japan
| | - Tetsuro Kobayashi
- Division of Immunology and Molecular Medicine, Okinaka Memorial Institute for Medical Research, Tokyo, Japan
- Correspondence: Tetsuro Kobayashi Okinaka Memorial Institute for Medical Research, 2-2-2 Toranomon, Minato-Ku, Tokyo, JapanTel +81-3-3588-1111Fax +81-3-3582-7068 Email
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10
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Bjornstad P, Donaghue KC, Maahs DM. Macrovascular disease and risk factors in youth with type 1 diabetes: time to be more attentive to treatment? Lancet Diabetes Endocrinol 2018; 6:809-820. [PMID: 29475800 PMCID: PMC6102087 DOI: 10.1016/s2213-8587(18)30035-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 12/03/2017] [Accepted: 12/05/2017] [Indexed: 02/08/2023]
Abstract
Cardiovascular disease remains the leading cause of mortality in patients with type 1 diabetes. Although cardiovascular disease complications are rare until adulthood, pathology and early markers can manifest in adolescence. Whereas advances have been made in the management of microvascular complications of type 1 diabetes, similar progress in reducing macrovascular complications has not been made. The reasons for the absence of progress remain incompletely understood, but most likely relate to the long time needed for cardiovascular disease to manifest clinically and hence for risk factor management to show a clinical benefit, thus allowing inertia to prevail for diagnosis and particularly for targeting risk factors. In this Review, we summarise paediatric data on traditional and novel risk factors of cardiovascular disease, provide an overview of data from previous and current clinical trials, discuss future directions in cardiovascular disease research for paediatric patients with type 1 diabetes, and advocate for the early identification and treatment of cardiovascular disease risk factors as recommended in multiple guidelines.
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Affiliation(s)
- Petter Bjornstad
- Department of Pediatric Endocrinology, University of Colorado School of Medicine, Aurora, CO, USA; Barbara Davis Center for Diabetes, University of Colorado Denver, Aurora, CO, USA.
| | - Kim C Donaghue
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, University of Sydney, NSW, Australia
| | - David M Maahs
- Department of Pediatric Endocrinology, Stanford University School of Medicine, Palo Alto, CA, USA
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11
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Magnus MC, Olsen SF, Granstrom C, Lund-Blix NA, Svensson J, Johannesen J, Fraser A, Skrivarhaug T, Joner G, Njølstad PR, Størdal K, Stene LC. Paternal and maternal obesity but not gestational weight gain is associated with type 1 diabetes. Int J Epidemiol 2018; 47:417-426. [PMID: 29415279 PMCID: PMC5913633 DOI: 10.1093/ije/dyx266] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/23/2017] [Accepted: 12/06/2017] [Indexed: 01/10/2023] Open
Abstract
Background Our objective was to examine the associations of parental body mass index (BMI) and maternal gestational weight gain with childhood-onset type 1 diabetes. Comparing the associations of maternal and paternal BMI with type 1 diabetes in the offspring will provide further insight into the role of unmeasured confounding by characteristics linked to BMI in both parents. Methods We studied 132 331 children participating in the Norwegian Mother and Child Cohort Study (MoBa) and the Danish National Birth Cohort (DNBC) who were born between February 1998 and July 2009. Exposures of interest included parental BMI and maternal gestational weight gain obtained by maternal report. We used Cox-proportional hazards regression to examine the risk of type 1 diabetes (n=499 cases), which was ascertained by national childhood diabetes registers. Results The incidence of type 1 diabetes was 32.7 per 100 000 person-years in MoBa and 28.5 per 100 000 person-years in DNBC. Both maternal pre-pregnancy obesity, adjusted hazard ratio (HR) 1.41 [95% confidence interval (CI): 1.06, 1.89] and paternal obesity, adjusted HR 1.51 (95% CI: 1.11, 2.04), were associated with childhood-onset type 1 diabetes. The associations were similar after mutual adjustment. In contrast, maternal total gestational weight gain was not associated with childhood-onset type 1 diabetes, adjusted HR 1.00 (95% CI: 0.99, 1.02) per kilogram increase. Conclusions Our study suggests that the association between maternal obesity and childhood-onset type 1 diabetes is not likely explained by intrauterine mechanisms, but possibly rather by unknown environmental factors influencing BMI in the family.
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Affiliation(s)
- Maria C Magnus
- Division for Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
- MRC Integrative Epidemiology Unit at University of Bristol, Bristol, UK
- Department of Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Sjurdur F Olsen
- Centre for Fetal Programming, Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Charlotta Granstrom
- Centre for Fetal Programming, Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Nicolai A Lund-Blix
- Division for Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
- Department of Pediatrics, Oslo University Hospital, Oslo, Norway
| | - Jannet Svensson
- Department of Pediatrics, Copenhagen University Hospital, Herlev, Denmark
| | - Jesper Johannesen
- Department of Pediatrics, Copenhagen University Hospital, Herlev, Denmark
| | - Abigail Fraser
- MRC Integrative Epidemiology Unit at University of Bristol, Bristol, UK
- Department of Population Health Sciences, Bristol Medical School, Bristol, UK
- NIHR Bristol Biomedical Research Centre at the University Hospitals Bristol, NHS Foundation Trust and the University of Bristol, Bristol, UK
| | | | - Geir Joner
- Department of Pediatrics, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Pål R Njølstad
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
- KG Jebsen Center for Diabetes Research, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Ketil Størdal
- Division for Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
- Department of Pediatrics, Ostfold Hospital Trust, Fredrikstad, Norway
| | - Lars C Stene
- Division for Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
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12
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Bjornstad P, Lovshin JA, Lytvyn Y, Boulet G, Lovblom LE, Alhuzaim ON, Farooqi MA, Lai V, Tse J, Cham L, Orszag A, Scarr D, Weisman A, Keenan HA, Brent MH, Paul N, Bril V, Perkins BA, Cherney DZI. Adiposity Impacts Intrarenal Hemodynamic Function in Adults With Long-standing Type 1 Diabetes With and Without Diabetic Nephropathy: Results From the Canadian Study of Longevity in Type 1 Diabetes. Diabetes Care 2018; 41:831-839. [PMID: 29437821 PMCID: PMC5860840 DOI: 10.2337/dc17-2475] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 01/09/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Central adiposity is considered to be an important cardiorenal risk factor in the general population and in type 1 diabetes. We sought to determine the relationship between central adiposity and intrarenal hemodynamic function in adults with long-standing type 1 diabetes with and without diabetic nephropathy (DN). RESEARCH DESIGN AND METHODS Patients with type 1 diabetes (n = 66, duration ≥50 years) and age-/sex-matched control subjects (n = 73) were studied. The cohort was stratified into 44 DN Resistors (estimated glomerular filtration rate [eGFR] >60 mL/min/1.73 m2 and <30 mg/day urine albumin) and 22 patients with DN (eGFR ≤60 mL/min/1.73 m2 or ≥30 mg/day urine albumin). Intrarenal hemodynamic function (glomerular filtration rate for inulin [GFRINULIN], effective renal plasma flow for p-aminohippuric acid [ERPFPAH]) was measured. Afferent arteriolar resistance, efferent arteriolar resistance, renal blood flow, renal vascular resistance [RVR], filtration fraction, and glomerular pressure were derived from the Gomez equations. Fat and lean mass were quantified by DXA. RESULTS Whereas measures of adiposity did not associate with GFRINULIN or ERPFPAH in healthy control subjects, trunk fat mass inversely correlated with GFRINULIN (r = -0.46, P < 0.0001) and ERPFPAH (r = -0.31, P = 0.01) and positively correlated with RVR (r = 0.53, P = 0.0003) in type 1 diabetes. In analyses stratified by DN status, greater central adiposity related to lower GFRINULIN values in DN and DN Resistors, but the relationships between central adiposity and ERPFPAH and RVR were attenuated and/or reversed in patients with DN compared with DN Resistors. CONCLUSIONS The adiposity-intrarenal hemodynamic function relationship may be modified by the presence of type 1 diabetes and DN, requiring further study of the mechanisms by which adiposity influences renal hemodynamic function.
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Affiliation(s)
- Petter Bjornstad
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada .,Division of Endocrinology, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Julie A Lovshin
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yuliya Lytvyn
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Genevieve Boulet
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Leif E Lovblom
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Omar N Alhuzaim
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Mohammed A Farooqi
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Vesta Lai
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Josephine Tse
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Leslie Cham
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrej Orszag
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Daniel Scarr
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Alanna Weisman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | - Michael H Brent
- Department of Ophthalmology and Vision Sciences and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Narinder Paul
- Division of Cardiothoracic Radiology, Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Vera Bril
- The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Krembil Neuroscience Centre, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada
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13
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Hoshina S, Miura J, Uchigata Y. Relationship between HLA haplotype and BMI change in Japanese slowly progressive type 1 diabetes patients. Diabetes Res Clin Pract 2017; 124:81-83. [PMID: 28110239 DOI: 10.1016/j.diabres.2016.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 12/07/2016] [Accepted: 12/10/2016] [Indexed: 10/20/2022]
Abstract
We investigated the association between susceptible HLA and BMI change rate from diagnosis of diabetes to diagnosis of slowly progressive type 1 diabetes in Japanese diabetic patients. Subjects with the HLA DRB1*04:05-DQB1*04:01 haplotype were more likely to show weight loss than those without. This HLA haplotype might affect weight loss.
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Affiliation(s)
- Sari Hoshina
- Diabetes Center, Tokyo Women's Medical University School of Medicine, Japan
| | - Junnosuke Miura
- Diabetes Center, Tokyo Women's Medical University School of Medicine, Japan.
| | - Yasuko Uchigata
- Diabetes Center, Tokyo Women's Medical University School of Medicine, Japan
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14
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Abstract
PURPOSE OF REVIEW To summarize recent studies about obesity, insulin resistance, and type 1 diabetes mellitus (T1DM). RECENT FINDINGS Overweight and obesity continue to be prevalent among individuals with T1DM. Obesity rates appear to have reached a plateau among children with T1DM in some parts of the world. The risk for development of T1DM is increased by obesity and may occur at an earlier age among obese individuals with a predisposition. Obesity increases the risk for comorbidities among individuals with T1DM, especially metabolic syndrome, and microvascular and macrovascular diseases. Metformin, glucagon-like peptide-1 agonist therapy, sodium glucose cotransporter-2 inhibitor therapy, and bariatric surgery may be beneficial therapies for glucose control, comorbidity management, and obesity among adults with T1DM. Insulin resistance may be improved among obese individuals with T1DM by biguanides (metformin) and glucagon-like peptide-1 agonists (exenatide). SUMMARY We review the last 18 months of literature on obesity, insulin resistance, and T1DM to highlight new epidemiologic results and treatments.
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Affiliation(s)
- Sarit Polsky
- aBarbara Davis Center for Diabetes, Division of Endocrinology, Metabolism and Diabetes bDepartment of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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15
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Peet A, Hämäläinen AM, Kool P, Ilonen J, Knip M, Tillmann V. Circulating IGF1 and IGFBP3 in relation to the development of β-cell autoimmunity in young children. Eur J Endocrinol 2015; 173:129-37. [PMID: 25947142 DOI: 10.1530/eje-14-1078] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 05/05/2015] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This study aimed at investigating the role of IGF1 and IGF binding protein 3 (IGFBP3) in the development of β-cell autoimmunity. METHODS Five hundred and sixty-three subjects with HLA-conferred susceptibility to type 1 diabetes (T1D) were monitored for signs of seroconversion to positivity for insulin and/or GAD, IA2, and zinc transporter 8 autoantibodies by the age of 3 years. In 40 subjects who developed at least one autoantibody, IGF1 and IGFBP3 plasma concentrations were measured and compared with 80 control subjects who remained negative for autoantibodies, and were matched for age, sex, country of origin, and HLA genotype. The increments of IGF1, IGFBP3, and IGF1/IGFBP3 molar ratio before and after seroconverison were compared with corresponding time intervals in controls. RESULTS The IGF1 concentrations at the age of 12 months and the IGF1/IGFBP3 ratio at the age of 24 months were lower in the autoantibody-positive children (P<0.05). The increase in circulating IGFBP3 was significantly higher in the autoantibody-positive children before seroconversion than in the corresponding time intervals in controls (0.43 mg/l; 95% CI 0.29-0.56 vs 0.22 mg/l; 95% CI 0.10-0.34 mg/l; P<0.01). Children carrying the high-risk HLA genotype had lower plasma IGF1 and IGFBP3 concentrations at the age of 24 months than those with low-risk genotypes (P<0.05 and < 0.01 respectively). CONCLUSIONS Circulating IGF1 and IGFBP3 appear to have a role in early development of β-cell autoimmunity. The decreased IGF1 concentrations in children with the high-risk HLA genotype may contribute to the reduced growth previously described in such children.
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Affiliation(s)
- Aleksandr Peet
- Department of PediatricsUniversity of Tartu, N. Lunini 6 51014 Tartu, EstoniaChildren's Clinic of Tartu University HospitalN. Lunini 6, Tartu, EstoniaChildren's Hospital and Jorvi HospitalUniversity of Helsinki and Helsinki University Central Hospital, Helsinki, FinlandImmunogenetics LaboratoryUniversity of Turku, Turku, FinlandDepartment of Clinical MicrobiologyUniversity of Eastern Finland, Kuopio, FinlandDiabetes and Obesity Research ProgramUniversity of Helsinki, Helsinki, FinlandFolkhälsan Research CenterHelsinki, Finland andDepartment of PediatricsTampere University Hospital, Tampere, Finland Department of PediatricsUniversity of Tartu, N. Lunini 6 51014 Tartu, EstoniaChildren's Clinic of Tartu University HospitalN. Lunini 6, Tartu, EstoniaChildren's Hospital and Jorvi HospitalUniversity of Helsinki and Helsinki University Central Hospital, Helsinki, FinlandImmunogenetics LaboratoryUniversity of Turku, Turku, FinlandDepartment of Clinical MicrobiologyUniversity of Eastern Finland, Kuopio, FinlandDiabetes and Obesity Research ProgramUniversity of Helsinki, Helsinki, FinlandFolkhälsan Research CenterHelsinki, Finland andDepartment of PediatricsTampere University Hospital, Tampere, Finland
| | - Anu-Maaria Hämäläinen
- Department of PediatricsUniversity of Tartu, N. Lunini 6 51014 Tartu, EstoniaChildren's Clinic of Tartu University HospitalN. Lunini 6, Tartu, EstoniaChildren's Hospital and Jorvi HospitalUniversity of Helsinki and Helsinki University Central Hospital, Helsinki, FinlandImmunogenetics LaboratoryUniversity of Turku, Turku, FinlandDepartment of Clinical MicrobiologyUniversity of Eastern Finland, Kuopio, FinlandDiabetes and Obesity Research ProgramUniversity of Helsinki, Helsinki, FinlandFolkhälsan Research CenterHelsinki, Finland andDepartment of PediatricsTampere University Hospital, Tampere, Finland
| | - Pille Kool
- Department of PediatricsUniversity of Tartu, N. Lunini 6 51014 Tartu, EstoniaChildren's Clinic of Tartu University HospitalN. Lunini 6, Tartu, EstoniaChildren's Hospital and Jorvi HospitalUniversity of Helsinki and Helsinki University Central Hospital, Helsinki, FinlandImmunogenetics LaboratoryUniversity of Turku, Turku, FinlandDepartment of Clinical MicrobiologyUniversity of Eastern Finland, Kuopio, FinlandDiabetes and Obesity Research ProgramUniversity of Helsinki, Helsinki, FinlandFolkhälsan Research CenterHelsinki, Finland andDepartment of PediatricsTampere University Hospital, Tampere, Finland
| | - Jorma Ilonen
- Department of PediatricsUniversity of Tartu, N. Lunini 6 51014 Tartu, EstoniaChildren's Clinic of Tartu University HospitalN. Lunini 6, Tartu, EstoniaChildren's Hospital and Jorvi HospitalUniversity of Helsinki and Helsinki University Central Hospital, Helsinki, FinlandImmunogenetics LaboratoryUniversity of Turku, Turku, FinlandDepartment of Clinical MicrobiologyUniversity of Eastern Finland, Kuopio, FinlandDiabetes and Obesity Research ProgramUniversity of Helsinki, Helsinki, FinlandFolkhälsan Research CenterHelsinki, Finland andDepartment of PediatricsTampere University Hospital, Tampere, Finland Department of PediatricsUniversity of Tartu, N. Lunini 6 51014 Tartu, EstoniaChildren's Clinic of Tartu University HospitalN. Lunini 6, Tartu, EstoniaChildren's Hospital and Jorvi HospitalUniversity of Helsinki and Helsinki University Central Hospital, Helsinki, FinlandImmunogenetics LaboratoryUniversity of Turku, Turku, FinlandDepartment of Clinical MicrobiologyUniversity of Eastern Finland, Kuopio, FinlandDiabetes and Obesity Research ProgramUniversity of Helsinki, Helsinki, FinlandFolkhälsan Research CenterHelsinki, Finland andDepartment of PediatricsTampere University Hospital, Tampere, Finland
| | - Mikael Knip
- Department of PediatricsUniversity of Tartu, N. Lunini 6 51014 Tartu, EstoniaChildren's Clinic of Tartu University HospitalN. Lunini 6, Tartu, EstoniaChildren's Hospital and Jorvi HospitalUniversity of Helsinki and Helsinki University Central Hospital, Helsinki, FinlandImmunogenetics LaboratoryUniversity of Turku, Turku, FinlandDepartment of Clinical MicrobiologyUniversity of Eastern Finland, Kuopio, FinlandDiabetes and Obesity Research ProgramUniversity of Helsinki, Helsinki, FinlandFolkhälsan Research CenterHelsinki, Finland andDepartment of PediatricsTampere University Hospital, Tampere, Finland Department of PediatricsUniversity of Tartu, N. Lunini 6 51014 Tartu, EstoniaChildren's Clinic of Tartu University HospitalN. Lunini 6, Tartu, EstoniaChildren's Hospital and Jorvi HospitalUniversity of Helsinki and Helsinki University Central Hospital, Helsinki, FinlandImmunogenetics LaboratoryUniversity of Turku, Turku, FinlandDepartment of Clinical MicrobiologyUniversity of Eastern Finland, Kuopio, FinlandDiabetes and Obesity Research ProgramUniversity of Helsinki, Helsinki, FinlandFolkhälsan Research CenterHelsinki, Finland andDepartment of PediatricsTampere University Hospital, Tampere, Finland Department of PediatricsUniversity of Tartu, N. Lunini 6 51014 Tartu, EstoniaChildren's Clinic of Tartu University HospitalN. Lunini 6, Tartu, EstoniaChildren's Hospital and Jorvi HospitalUniversity of Helsinki and Helsinki University Central Hospital, Helsinki, FinlandImmunogenetics LaboratoryUniversity of Turku, Turku, FinlandDepartment of Clinical MicrobiologyUniversity of Eastern Finland, Kuopio, FinlandDiabetes and Obesity Research ProgramUniversity of Helsinki, Helsinki, FinlandFolkhälsan Research CenterHelsinki, Finland andDepartment of PediatricsTampere University Hospital, Tampere, Finland Department of PediatricsUniversity of Tartu, N. Lunini 6 51014 Tartu, EstoniaChildren's Clinic of Tartu University HospitalN. Lunini 6, Tartu, EstoniaChildren's Hospital and Jorvi
| | - Vallo Tillmann
- Department of PediatricsUniversity of Tartu, N. Lunini 6 51014 Tartu, EstoniaChildren's Clinic of Tartu University HospitalN. Lunini 6, Tartu, EstoniaChildren's Hospital and Jorvi HospitalUniversity of Helsinki and Helsinki University Central Hospital, Helsinki, FinlandImmunogenetics LaboratoryUniversity of Turku, Turku, FinlandDepartment of Clinical MicrobiologyUniversity of Eastern Finland, Kuopio, FinlandDiabetes and Obesity Research ProgramUniversity of Helsinki, Helsinki, FinlandFolkhälsan Research CenterHelsinki, Finland andDepartment of PediatricsTampere University Hospital, Tampere, Finland Department of PediatricsUniversity of Tartu, N. Lunini 6 51014 Tartu, EstoniaChildren's Clinic of Tartu University HospitalN. Lunini 6, Tartu, EstoniaChildren's Hospital and Jorvi HospitalUniversity of Helsinki and Helsinki University Central Hospital, Helsinki, FinlandImmunogenetics LaboratoryUniversity of Turku, Turku, FinlandDepartment of Clinical MicrobiologyUniversity of Eastern Finland, Kuopio, FinlandDiabetes and Obesity Research ProgramUniversity of Helsinki, Helsinki, FinlandFolkhälsan Research CenterHelsinki, Finland andDepartment of PediatricsTampere University Hospital, Tampere, Finland
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