Secular trends in sleep and circadian problems among adolescents in Hong Kong: From 2011-2012 to 2017-2019

OBJECTIVE

The study aimed to investigate secular trends in sleep and circadian problems in Hong Kong Chinese adolescents.

METHODS

This study analyzed cross-sectional data from two large-scale school-based sleep surveys conducted in 2011-2012 and 2017-2019. Sleep and circadian problems, including sleep-wake pattern, insomnia, chronotype, social jetlag, daytime sleepiness, and other sleep-related factors, were compared between two survey years.

RESULTS

A total of 8082 adolescents (5639 students in 2011-2012 [Mean age: 14.4 years, 50.9% boys] and 2443 students in 2017-2019 [Mean age: 14.7 years, 54.0% boys]) were included in this 7-year study. The average time in bed of Hong Kong adolescents decreased from 8.38 hours to 8.08 hours from 2011-2012 to 2017-2019. There was a 0.28-hour delay in weekday bedtime, 0.54-hour advance in weekend wake-up time, and a 0.36-hour decline in average time in bed, resulting in increased trends of sleep loss (Time in bed <8h: OR = 2.06, 95%CI: 1.44-2.93, p < 0.01; Time in bed <7h: OR = 2.73, 95%CI: 1.92-3.89, p < 0.01), daytime sleepiness (OR = 1.70, 95%CI: 1.34-2.16, p < 0.01), and evening chronotype (OR = 1.26, 95%CI: 1.08-1.48, p < 0.01). The increased trend in insomnia disorder, however, was insignificant when covariates were adjusted.

CONCLUSION

A secular trend of reduced time in bed, delay in weekday bedtime, advance in weekend wake-up time, increase in evening chronotype and daytime sleepiness from 2011-2012 to 2017-2019 were observed. There is a timely need for systematic intervention to promote sleep health in adolescents.

"Shame on Me": Exploring the Role of Self-Stigma in Psychological Outcomes Among Type 2 Diabetes Patients in Hong Kong

BACKGROUND

Studies have suggested that type 2 diabetes mellitus (T2DM) are at risk of self-stigmatization (i.e., internalized sense of shame about having diabetes). Self-stigma has been found to be associated with poorer psychological outcomes among chronic disease patients; relevant studies examining such an association and its psychosocial mechanisms are scarce among Chinese T2DM patients. This study aimed to examine the association between self-stigma and psychological outcomes among T2DM patients in Hong Kong. Self-stigma was hypothesized to be associated with higher psychological distress and lower quality of life (QoL). Such associations were also hypothesized to be mediated by lower perceived social support, lower self-care self-efficacy, plus higher self-perceived burden to significant others.

METHODS

T2DM patients (N = 206) recruited from hospitals and clinics in Hong Kong were invited to complete a cross-sectional survey measuring the aforementioned variables.

RESULTS

After controlling for covariates, multiple mediation analysis results indicated the indirect effects from self-stigma to psychological distress via increased self-perceived burden (β = 0.07; 95% CI = 0.02, 0.15) and decreased self-care self-efficacy (β = 0.05; 95% CI = 0.01, 0.11) were significant. Moreover, the indirect effect from self-stigma to QoL via decreased self-care self-efficacy was also significant (β = -0.07; 95% CI = -0.14, -0.02). After considering the mediators, the direct effects from self-stigma to higher psychological distress and lower QoL remained significant (βs = 0.15 and -0.15 respectively, ps < .05).

CONCLUSIONS

Self-stigma could be linked to poorer psychological outcomes through increased self-perceived burden and decreased self-care self-efficacy among T2DM patients. Targeting those variables when designing interventions might facilitate those patients' psychological adjustments.

Changes in mesenteric fat thickness and its clinical impact in bariatric surgery

Obesity, especially central obesity is associated with increased risk of metabolic syndrome, non-alcoholic fatty liver disease (NAFLD) and type 2 diabetes mellitus. The study aimed to investigate the associations of the changes of abdominal fat thicknesses with changes of anthropometric indexes and improvements of metabolic phenotypes in patients with obesity and T2DM before and after bariatric surgery. Between April 2016 and January 2017, 34 adult patients with concurrent obesity and T2DM scheduled for different bariatric surgeries were prospectively evaluated by ultrasound before and 1-year after bariatric surgery to determine abdominal fat thicknesses (mesenteric fat, preperitoneal fat and subcutaneous fat) and NAFLD. At 1 year, of the 25 patients that finished the study, significant decrease in mesenteric-fat-thickness was associated with significant reduction of obesity, that is, BMI (-24%, p < .001), remission of metabolic syndrome (32%, p = .008), NAFLD (60%, p < .001) and T2DM (44%, p < .001). Lower baseline mesenteric fat thickness was associated with remission of metabolic syndrome. Lower baseline mesenteric-fat-thickness may have the potential to predict metabolic syndrome remission after bariatric surgery.

Association of accelerometer-measured sleep duration and different intensities of physical activity with incident type 2 diabetes in a population-based cohort study

PURPOSE

The aim of the current study was to investigate the association of accelerometer-measured sleep duration and different intensities of physical activity (PA) with the risk of incident type 2 diabetes in a population-based prospective cohort study.

METHODS

Altogether, 88,000 participants (mean age = 62.2 ± 7.9 years, mean ± SD) were included from the UK Biobank. Sleep duration (short: <6 h/day; normal: 6-8 h/day; long: >8 h/day) and PA of different intensities were measured using a wrist-worn accelerometer over a 7-day period between 2013 and 2015. PA was classified according to the median or World Health Organization-recommendation: total volume of PA (high, low), moderate-to-vigorous PA (MVPA) (recommended, not recommended), and light-intensity PA (high, low). Incidence of type 2 diabetes was ascertained using hospital records or death registries.

RESULTS

During a median follow-up of 7.0 years, 1615 incident type 2 diabetes cases were documented. Compared with normal sleep duration, short (hazard ratio (HR) = 1.21, 95% confidence interval (95%CI): 1.03-1.41) but not long sleep duration (HR = 1.01, 95%CI: 0.89-1.15) was associated with excessive type 2 diabetes risk. This increased risk among short sleepers seems to be protected against by PA. Compared with normal sleepers with high or recommended PA, short sleepers with low volume of PA (HR = 1.81, 95%CI: 1.46-2.25), not recommended (below the World Health Organization-recommended level of) MVPA (HR = 1.92, 95%CI: 1.55-2.36), or low light-intensity PA (HR = 1.49, 95%CI: 1.13-1.90) had a higher risk of type 2 diabetes, while short sleepers with a high volume of PA (HR = 1.14, 95%CI: 0.88-1.49), recommended MVPA (HR = 1.02, 95%CI: 0.71-1.48), or high light-intensity PA (HR = 1.14, 95%CI: 0.92-1.41) did not.

CONCLUSION

Accelerometer-measured short but not long sleep duration was associated with a higher risk of incident type 2 diabetes. A higher level of PA, regardless of intensity, potentially ameliorates this excessive risk.

Role of Argininosuccinate Synthase 1 -Dependent L-Arginine Biosynthesis in the Protective Effect of Endothelial Sirtuin 3 Against Atherosclerosis

Atherosclerosis is initiated with endothelial cell (EC) dysfunction and vascular inflammation under hyperlipidemia. Sirtuin 3 (SIRT3) is a mitochondrial deacetylase. However, the specific role of endothelial SIRT3 during atherosclerosis remains poorly understood. The present study aims to study the role and mechanism of SIRT3 in EC function during atherosclerosis. Wild-type Sirt3f/f mice and endothelium-selective SIRT3 knockout Sirt3f/f; Cdh5Cre/+ (Sirt3EC-KO) mice are injected with adeno-associated virus (AAV) to overexpress PCSK9 and fed with high-cholesterol diet (HCD) for 12 weeks to induce atherosclerosis. Sirt3EC-KO mice exhibit increased atherosclerotic plaque formation, along with elevated macrophage infiltration, vascular inflammation, and reduced circulating L-arginine levels. In human ECs, SIRT3 inhibition resulted in heightened vascular inflammation, reduced nitric oxide (NO) production, increased reactive oxygen species (ROS), and diminished L-arginine levels. Silencing of SIRT3 results in hyperacetylation and deactivation of Argininosuccinate Synthase 1 (ASS1), a rate-limiting enzyme involved in L-arginine biosynthesis, and this effect is abolished in mutant ASS1. Furthermore, L-arginine supplementation attenuates enhanced plaque formation and vascular inflammation in Sirt3EC-KO mice. This study provides compelling evidence supporting the protective role of endothelial SIRT3 in atherosclerosis and also suggests a critical role of SIRT3-induced deacetylation of ASS1 by ECs for arginine synthesis.

Enhanced prediction of abnormal glucose tolerance using an extended non-invasive risk score incorporating routine renal biochemistry

INTRODUCTION

Type 2 diabetes is preventable in subjects with impaired glucose tolerance based on 2-hour plasma glucose (2hPG) during 75 g oral glucose tolerance test (OGTT). We incorporated routine biochemistry to improve the performance of a non-invasive diabetes risk score to identify individuals with abnormal glucose tolerance (AGT) defined by 2hPG≥7.8 mmol/L during OGTT.

RESEARCH DESIGN AND METHODS

We used baseline data of 1938 individuals from the community-based "Better Health for Better Hong Kong - Hong Kong Family Diabetes Study (BHBHK-HKFDS) Cohort" recruited in 1998-2003. We incorporated routine biochemistry in a validated non-invasive diabetes risk score, and evaluated its performance using area under receiver operating characteristics (AUROC) with internal and external validation.

RESULTS

The AUROC of the original non-invasive risk score to predict AGT was 0.698 (95% CI, 0.662 to 0.733). Following additional inclusion of fasting plasma glucose, serum potassium, creatinine, and urea, the AUROC increased to 0.778 (95% CI, 0.744 to 0.809, p<0.001). Net reclassification improved by 31.9% (p<0.001) overall, by 30.8% among people with AGT and 1.1% among people without AGT. The extended model showed good calibration (χ2=11.315, p=0.1845) and performance on external validation using an independent data set (AUROC=0.722, 95% CI, 0.680 to 0.764).

CONCLUSIONS

The extended risk score incorporating clinical and routine biochemistry can be integrated into an electronic health records system to select high-risk subjects for evaluation of AGT using OGTT for prevention of diabetes.

School-Based Sleep Education Program for Children: A Cluster Randomized Controlled Trial

Insufficient sleep contributes negatively to child developmental processes and neurocognitive abilities, which argues the need for implementing interventions to promote sleep health in children. In this study, we evaluated the effectiveness of a multimodal and multilevel school-based sleep education program in primary school children using a cluster randomized controlled design. Twelve schools were randomly assigned to either the sleep education or nonactive control groups. The sleep education group included a town hall seminar, small class teaching, leaflets, brochures, and a painting competition for children. Parents and teachers were invited to participate in a one-off sleep health workshop. Parental/caregiver-reported questionnaires were collected at baseline and 1-month follow-up. A total of 3769 children were included in the final analysis. There were no significant improvements observed in the sleep-wake patterns, daytime functioning, and insomnia symptoms between the two groups at follow-up, whereas the intervention group had significantly improved parental sleep knowledge than the controls (paternal: adjusted mean difference: 0.95 [95% confidence interval (CI): 0.18 to 1.71]; maternal: adjusted mean difference: 0.87 [95% CI: 0.17 to 1.57]). In addition, children receiving the intervention had a lower persistence rate of excessive beverage intake (adjusted odds ratio: 0.49 [95% CI: 0.33 to 0.73]), and experienced greater reductions in conduct problems (adjusted mean difference: 0.12 [95% CI: 0.01 to 0.24]) compared with the controls at 1-month of follow-up. Moreover, a marginally significant reduction for emotional problems in the intervention group was also observed (adjusted mean difference: 0.16 [95% CI: -0.00 to 0.32]). These findings demonstrated that school-based sleep education was effective in enhancing parental sleep knowledge and improving behavioral outcomes in children, but not sufficient in altering the children's sleep-wake patterns and sleep problems.

Device-supported automated basal insulin titration in adults with type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials

Background

Technological advances make it possible to use device-supported, automated algorithms to aid basal insulin (BI) dosing titration in patients with type 2 diabetes.

Methods

A systematic review and meta-analysis of randomized controlled trials were performed to evaluate the efficacy, safety, and quality of life of automated BI titration versus conventional care. The literature in Medline, Embase, Web of Science, and the Cochrane databases from January 2000 to February 2022 were searched to identify relevant studies. Risk ratios (RRs), mean differences (MDs), and their 95% confidence intervals (CIs) were calculated using random-effect meta-analyses. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

Findings

Six of the 7 eligible studies (889 patients) were included in meta-analyses. Low- to moderate-quality evidence suggests that patients who use automated BI titration versus conventional care may have a higher probability of reaching a target of HbA_1c <7.0% (RR, 1.82 [95% CI, 1.16-2.86]); and a lower level of HbA_1c (MD, -0.25% [95% CI, -0.43 to -0.06%]). No statistically significant differences were detected between the two groups in fasting glucose results, incidences of hypoglycemia, severe or nocturnal hypoglycemia, and quality of life, with low to very low certainty for all the evidence.

Interpretation

Automated BI titration is associated with small benefits in reducing HbA_1c without increasing the risk of hypoglycemia. Future studies should explore patient attitudes and the cost-effectiveness of this approach.

Funding

Sponsored by the Chinese Geriatric Endocrine Society.

Use of basal insulin in the management of adults with type 2 diabetes: An Asia-Pacific evidence-based clinical practice guideline

The objective of this study was to provide recommendations regarding effectiveness, safety, optimal starting dose, optimal maintenance dose range, and target fasting plasma glucose of five basal insulins (glargine U-300, degludec U-100, glargine U-100, detemir, and insulin protamine Hagedorn) in insulin-naïve adult patients with type 2 diabetes in the Asia-Pacific region. Based on evidence from a systematic review, we developed an Asia-Pacific clinical practice guideline through comprehensive internal review and external review processes. We set up and used clinical thresholds of trivial, small, moderate, and large effects for different critical and important outcomes in the overall certainty of evidence assessment and balancing the magnitude of intervention effects when making recommendations, following GRADE methods (Grading of Recommendations, Assessment, Development, and Evaluation). The AGREE (Appraisal of Guidelines, Research and Evaluation) and RIGHT (Reporting Items for practice Guidelines in HealThcare) guideline reporting checklists were complied with. After the second-round vote by the working group members, all the recommendations and qualifying statements reached over 75% agreement rates. Among 44 contacted external reviewers, we received 33 clinicians' and one patient's comments. The overall response rate was 77%. To solve the four research questions, we made two strong recommendations, six conditional recommendations, and two qualifying statements. Although the intended users of this guideline focused on clinicians in the Asia-Pacific region, the eligible evidence was based on recent English publications. We believe that the recommendations and the clinical thresholds set up in the guideline can be references for clinicians who take care of patients with type 2 diabetes worldwide.

Effectiveness, safety, initial optimal dose, and optimal maintenance dose range of basal insulin regimens for type 2 diabetes: A systematic review with meta-analysis

AIMS

To investigate the effectiveness, safety, optimal starting dose, optimal maintenance dose range, and target fasting plasma glucose of five basal insulins in insulin-naïve patients with type 2 diabetes mellitus.

METHODS

MEDLINE, EMBASE, Web of Science, and the Cochrane Library were searched from January 2000 to February 2022. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was adopted. The registration ID is CRD42022319078 in PROSPERO.

RESULTS

Among 11 163 citations retrieved, 35 publications met the planned criteria. From meta-analyses and network meta-analyses, we found that when injecting basal insulin regimens at bedtime, the optimal choice in order of most to least effective might be glargine U-300 or degludec U-100, glargine U-100 or detemir, followed by neutral protamine hagedorn (NPH). Injecting glargine U-100 in the morning may be more effective (ie, more patients archiving glycated hemoglobin < 7.0%) and lead to fewer hypoglycemic events than injecting it at bedtime. The optimal starting dose for the initiation of any basal insulins can be 0.10-0.20 U/kg/day. There is no eligible evidence to investigate the optimal maintenance dose for basal insulins.

CONCLUSIONS

The five basal insulins are effective for the target population. Glargine U-300, degludec U-100, glargine U-100, and detemir lead to fewer hypoglycemic events than NPH without compromising glycemic control.

Sonographic Measurement of Mesenteric Fat Thickness Is a Better Predictor of Aortic Stiffness Compared With Conventional Obesity Indexes

Increased aortic stiffness is closely associated with central obesity whereas mesenteric fat is the key adipose tissue in central obesity. We investigated the associations of mesenteric fat thickness with aortic stiffness, with comparison to conventional obesity measures. We used ultrasound to measure mesenteric, pre-peritoneal and subcutaneous fat thickness, carotid intima-media thickness (CIMT) and carotid-femoral pulse wave velocity (c-f PWV), an index of central aortic stiffness. Anthropometric indexes, blood pressure, fasting plasma glucose and lipid profile were measured. One hundred forty-seven healthy volunteers (age [mean ± standard deviation]: 43.2 ± 13.3 y; 41.5% men) were assessed. On univariate analysis, mesenteric, preperitoneal and subcutaneous fat thickness, body mass index (BMI), waist circumference (WC), waist/hip ratio (WHR) and waist/height ratio (WHtR) were associated with c-f PWV with or without adjustment for age. The mesenteric fat thickness had the highest correlation coefficient (r = 0.48, p < 0.001) with c-f PWV among all the investigated obesity indexes. Using multiple linear regression analysis, only mesenteric fat thickness remained to be an independent determinant of c-f PWV after adjustments for other abdominal fat thickness, anthropometric and metabolic indexes and CIMT. In conclusion, mesenteric fat thickness is an independent risk factor for aortic stiffness and has a stronger association with aortic stiffness compared with conventional obesity indexes.

The impact of sleep-corrected social jetlag on mental health, behavioral problems, and daytime sleepiness in adolescents

STUDY OBJECTIVES

This study aimed to examine the effect of sleep-corrected social jetlag (SJLsc) on mental health, behavioral problems, and daytime sleepiness in adolescents.

METHODS

This was a cross-sectional study which included 4787 adolescents (Mean age: 14.83±1.6y, 56.0% girls) recruited from 15 secondary schools in Hong Kong. SJLsc was defined as the absolute difference between sleep-corrected midsleep on weekdays and weekends, at which the sleep debt has been considered. It was classified into three groups: low-level ("LSJLsc", <1h), mid-level ("MSJLsc", ≥1h and <2h), and high-level of SJLsc ("HSJLsc", ≥2h). Adolescents' mental health, behavioral problems and daytime sleepiness were measured by the General Health Questionnaire (GHQ-12), the Strengths and Difficulties Questionnaire (SDQ) and the Pediatric Daytime Sleepiness Scale (PDSS). Logistic regression analysis and restricted cubic spline regression (RCS) analysis were applied with consideration of confounders including age, gender, puberty and sleep problems.

RESULTS

Nearly half (46.9%) of adolescents had SJLsc for at least 1 h. Greater SJLsc was associated with more behavioral difficulties (MSJLsc: OR: 1.20, p = 0.03; HSJLsc: OR: 1.34, p = 0.02) when controlling for age, sex, puberty, chronotype, insomnia, and time in bed. There was a dose-response relationship in which higher SJLsc had an increased risk of conduct problems and hyperactivity, while only high-level SJLsc was associated with a peer relationship problem. In RCS analysis, SJLsc was associated with a higher likelihood of behavioral difficulties (p = 0.03) but not poor mental health or daytime sleepiness.

CONCLUSIONS

Sleep-corrected social jetlag was a unique risk factor for behavioral problems in adolescents. Our findings highlighted the need for interventions to promote healthy sleep-wake patterns in school adolescents.

Effects of combination treatment with metformin and berberine on hypoglycemic activity and gut microbiota modulation in db/db mice

BACKGROUND

Gut microbiota alterations could influence the metabolism of administered drugs, leading to their altered pharmacokinetics and pharmacodynamics. Despite that metformin and berberine has individually demonstrated their impacts on hypoglycemic activities and gut microbiota alterations in diabetic mice, investigation regarding the impact of their combination treatment in diabetic treatment has never been conducted.

PURPOSE

Our current study was proposed aiming to investigate the effect of combination use of metformin with berberine on hypoglycemic activity and identify the possible intestinal bacteria involved in their microbiota-medicated drug-drug interactions in db/db mice.

STUDY DESIGN

Pharmacodynamics interactions between metformin and berberine were evaluated in six groups of db/db mice (db, M250, B250, B125, B250+M250, and B125+M250) with its wild type (WT) as control to receive 14 days treatment of vehicle, metformin at 250 mg/kg, berberine at 250/125 mg/kg, and metformin (250 mg/kg) 2 h after dosing berberine (250/125 mg/kg).

METHODS

On day 13, insulin tolerance test (ITT) was conducted. On day 15, fasting serum samples were obtained for insulin concentration determination followed by intraperitoneal glucose tolerance test (ipGTT), homeostatic model assessment for insulin resistance (HOMA-IR) calculation, and feces collection for microbial 16S rRNA sequencing analyses. In addition, metformin steady state plasma concentrations on day 15 were measured by validated LC-MS/MS method.

RESULTS

Combination treatment of metformin with berberine could further reduce in blood glucose in comparison to that of db/db diabetic control. Further microbial 16S rRNA sequencing analyses revealed that gut microbiota compositions were significantly changed with the abundance of Proteobacteria and Verrucomicrobia altered the most after metformin and berberine co-treatment compared to their monotherapy. In addition, steady state metformin concentrations in their combination treatment were significantly higher than that from metformin monotherapy.

CONCLUSION

Co-administration of metformin (250 mg/kg) with berberine (125 mg/kg) could not only further improve insulin sensitivity, but also demonstrate different alterations on gut microbial communities than that of their individual treatment in db/db mice.

Decreased cortical bone density and mechanical strength with associated elevated bone turnover markers at peri-pubertal peak height velocity: a cross-sectional and longitudinal cohort study of 396 girls with adolescent idiopathic scoliosis

Decreased cortical bone density and bone strength at peak height velocity (PHV) were noted in girls with adolescent idiopathic scoliosis (AIS). These findings could provide the link to the previously reported observation that low bone mineral density (BMD) could contribute as one of the prognostic factors for curve progression that mostly occurs during PHV in AIS.

INTRODUCTION

As part of the studies related to aetiopathogenesis of AIS, we assessed bone qualities, bone mechanical strength and bone turnover markers (BTMs) focusing at the peri-pubertal period and PHV in AIS girls.

METHODS

396 AIS girls in two separate cohorts were studied. Skeletal maturity was assessed using the validated thumb ossification composite index (TOCI). Bone qualities and strength were evaluated with high-resolution peripheral quantitative computed tomography (HR-pQCT) and finite element analysis (FEA).

RESULTS

Cohort-A included 179 girls (11.95 ± 0.95 years old). Girls at TOCI-4 had numerically the highest height velocity (0.71 ± 0.24 cm/month) corresponding to the PHV. Subjects at TOCI-4 had lower cortical volumetric BMD (672.36 ± 39.07 mg/mm³), cortical thickness (0.68 ± 0.08 mm) and apparent modulus (1601.54 ± 243.75 N/mm²) than: (a) those at TOCI-1-3 (724.99 ± 32.09 mg/mm³ (p < 0.001), 0.79 ± 0.11 mm (p < 0.001) and 1910.88 ± 374.75 N/mm² (p < 0.001), respectively) and (b) those at TOCI-8 (732.28 ± 53.75 mg/mm³ (p < 0.001), 0.84 ± 0.14 mm (p < 0.001), 1889.11 ± 419.37 N/mm² (p < 0.001), respectively). Cohort-B included 217 girls (12.22 ± 0.89 years old). Subjects at TOCI-4 had higher levels of C-terminal telopeptide of type 1 collagen (1524.70 ± 271.10 pg/L) and procollagen type 1 N-terminal propeptide (941.12 ± 161.39 µg/L) than those at TOCI-8 (845.71 ± 478.55 pg/L (p < 0.001) and 370.08 ± 197.04 µg/L (p < 0.001), respectively).

CONCLUSION

AIS girls had decreased cortical bone density and bone mechanical strength with elevated BTMs at PHV. Coupling of PHV with decreased cortical and FEA parameters could provide the link to the previously reported observation that low BMD could contribute as one of the prognostic factors for curve progression that mostly occurs during PHV in AIS.

Legacy effect of high glucose on promoting survival of HCT116 colorectal cancer cells by reducing endoplasmic reticulum stress response

Patients with diabetes have increased risk of cancer and poor response to anti-cancer treatment. Increased protein synthesis is associated with endoplasmic reticulum (ER) stress which can trigger the unfolded protein response (UPR) to restore homeostasis, failure of which can lead to dysregulated cellular growth. We hypothesize that hyperglycemia may have legacy effect in promoting survival of cancer cells through dysregulation of UPR. Using HCT116 colorectal cancer cells as a model, we demonstrated the effects of high glucose (25 mM) on promoting cell growth which persisted despite return to normal glucose medium (5.6 mM). Using the Affymetrix gene expression microarray in HCT116 cells programmed by high glucose, we observed activation of genes related to cell proliferation and cell cycle progression and suppression of genes implicated in UPR including BiP and CHOP. These gene expression changes were validated in HCT116 cancer cells using quantitative real-time PCR and Western blot analysis. We further examined the effects of thapsigargin, an anti-cancer prodrug, which utilized ER stress pathway to induce apoptosis. High glucose attenuated thapsigargin-induced UPR and growth inhibition in HCT116 cells, which persisted despite return to normal glucose medium. Western blot analysis showed activation of caspase-3 in thapsigargin-treated cells in both normal and high glucose medium, albeit with lower levels of cleaved caspase-3 in cells exposed to high glucose, suggesting reduced apoptosis. Flow cytometry analysis confirmed fewer apoptotic cells under thapsigargin treatment in cells exposed to high glucose. Our results suggested that hyperglycemia altered gene expression involved in UPR with increased cell proliferation and facilitated survival of HCT116 cells under thapsigargin-induced ER stress by reducing the apoptotic response.

Detection of increased serum miR-122-5p and miR-455-3p levels before the clinical diagnosis of liver cancer in people with type 2 diabetes

People with type 2 diabetes (T2D) have increased cancer risk. Liver cancer (LC) has a high prevalence in East Asia and is one of the leading causes of cancer death globally. Diagnosis of LC at early stage carries good prognosis. We used stored serum from patients of Hong Kong Diabetes Register before cancer diagnosis to extract RNA to screen for microRNA markers for early detection of LC in T2D. After screening with Affymetrix GeneChip microarray with serum RNA from 19 incident T2D LC (T2D-LC), 20 T2D cancer free (T2D-CF) and 20 non-T2D non-cancer patients, top signals were validated in a 3-group comparison including 1888 T2D-CF, 127 T2D-LC, and 487 T2D patients with non-liver cancer patients using qPCR. We detected 2.55-fold increase in miR-122-5p and 9.21-fold increase in miR-455-3p in the T2D-LC group. Using ROC analysis, miR-122-5p and miR-455-3p jointly predicted LC with an area under the curve of 0.770. After adjustment for confounders, each unit increase of miR-455-3p increased the odds ratio for liver cancer by 1.022. Increased serum levels of miR-122-5p and miR-455-3p were independently associated with increased risk of incident LC in T2D and may serve as potential biomarkers for early detection of LC in T2D.

The trajectories and associations of eveningness and insomnia with daytime sleepiness, depression and suicidal ideation in adolescents: A 3-year longitudinal study

BACKGROUND

Eveningness and insomnia are highly comorbid and closely related to psychopathology in adolescents. We aimed to prospectively investigate the trajectories and associations of eveningness and insomnia with daytime functioning, depression and suicidal risk in adolescents.

METHODS

A 3-year longitudinal study was conducted among 414 Chinese adolescents. The associations of eveningness and insomnia with daytime functioning, depression and suicidal ideation were analyzed using logistic regressions.

RESULTS

The prevalence rates of eveningness were similar at baseline and follow-up (19.3% vs 22.5%; p = 0.27), while the prevalence of insomnia increased at follow-up (29.2% vs 40.8%; p < 0.001). Among those eveningness adolescents (n=80) at baseline, 46.2% remained as stable evening-type at follow-up, and among those insomnia adolescents (n=121) at baseline, 64.5% had persistent insomnia at follow-up. Logistic regressions showed that stable, incident, and resolved eveningness were associated with excessive daytime sleepiness (EDS) at follow-up, while only persistent and incident insomnia increased the risk of EDS. Persistent and incident insomnia, as well as stable eveningness were independently associated with depression at follow-up. Persistent and incident insomnia, but not eveningness, were associated with suicidal ideation.

LIMITATIONS

The outcome assessments were based on self-reported questionnaires and the sample size is modest.

CONCLUSIONS

Persistent eveningness and insomnia are significantly associated with greater risks of EDS and depression in adolescents, while both persistent and incident insomnia, but not eveningness, increased the risk of suicidal ideation. These findings underscore the importance of addressing sleep and circadian factors in the management of adolescent mood and daytime functioning.

Glucose-lowering drugs and outcome from COVID-19 among patients with type 2 diabetes mellitus: a population-wide analysis in Hong Kong

OBJECTIVES

To investigate the association between baseline use of glucose-lowering drugs and serious clinical outcome among patients with type 2 diabetes.

DESIGN

Territory-wide retrospective cohort of confirmed cases of COVID-19 between January 2020 and February 2021.

SETTING

All public health facilities in Hong Kong.

PARTICIPANTS

1220 patients with diabetes who were admitted for confirmed COVID-19.

PRIMARY AND SECONDARY OUTCOME MEASURES

Composite clinical endpoint of intensive care unit admission, requirement of invasive mechanical ventilation and/or in-hospital death.

RESULTS

In this cohort (median age 65.3 years, 54.3% men), 737 (60.4%) patients were treated with metformin, 385 (31.6%) with sulphonylureas, 199 (16.3%) with dipeptidyl peptidase-4 (DPP-4) inhibitors and 273 (22.4%) with insulin prior to admission. In multivariate Cox regression, use of metformin and DPP-4 inhibitors was associated with reduced incidence of the composite endpoint relative to non-use, with respective HRs of 0.51 (95% CI 0.34 to 0.77, p=0.001) and 0.46 (95% CI 0.29 to 0.71, p<0.001), adjusted for age, sex, diabetes duration, glycated haemoglobin (HbA1c), smoking, comorbidities and drugs. Use of sulphonylureas (HR 1.55, 95% CI 1.07 to 2.24, p=0.022) and insulin (HR 6.34, 95% CI 3.72 to 10.78, p<0.001) were both associated with increased hazards of the composite endpoint.

CONCLUSIONS

Users of metformin and DPP-4 inhibitors had fewer adverse outcomes from COVID-19 compared with non-users, whereas insulin and sulphonylurea might predict a worse prognosis.

Association of serum 25(OH)Vit-D levels with risk of pediatric fractures: a systematic review and meta-analysis

The association between the risk of fractures and suboptimal vitamin D (Vit-D) status remains controversial in children. This meta-analysis suggested that serum 25(OH)Vit-D levels were lower in pediatric cases with fractures. 25-hydroxyvitamin D (25(OH)Vit-D) levels less than 50 nmol/L were associated with increased fracture risk in children.

INTRODUCTION

This study aimed to assess the association between serum 25(OH)Vit-D and the risk of fractures in children, and to explore the sources of heterogeneity and investigate their impact on results.

METHODS

Systematic review and meta-analysis were conducted for observational studies comparing serum 25(OH)Vit-D levels between fracture and non-fracture pediatric cases. The quality of the included studies was assessed using the Newcastle-Ottawa Scale (NOS).

RESULTS

Analysis on 17 case-control and 6 cross-sectional studies (2929 fracture cases and 5000 controls) suggested that 25(OH)Vit-D was lower in fracture cases than in controls (pooled mean difference (MD) = - 3.51 nmol/L; 95% confidence interval (CI): - 5.60 to - 1.42) with a heterogeneity (I²) of 73.9%. The sensitivity analysis which merged the case-control studies that had a NOS score ≥ 4 showed a pooled MD of - 4.35 nmol/L (95% CI: - 6.64 to - 2.06) with a heterogeneity (I²) of 35.9%. Pooled odds ratio of fracture in subjects with 25(OH)Vit-D ≤ 50 nmol/L compared to subjects with 25(OH)Vit-D > 50 nmol/L was 1.29 (95% CI: 1.10 to 1.53; I² < 1%).

CONCLUSION

This study indicated that serum 25(OH)Vit-D levels were lower in pediatric patients with fractures. 25(OH)Vit-D ≤ 50 nmol/L was associated with increased fracture risk in children.

Blood-Glucose-Lowering Effect of Coptidis Rhizoma Extracts From Different Origins via Gut Microbiota Modulation in db/db Mice

Background:Coptidis rhizoma extracts (CREs) have been used widely for their anti-diabetic and anti-microbial activities, and berberine/jatrorrhizine/coptisine/palmatine are the primary bioactive components. Although guidelines have adopted content analyses of these components as a quality control method for CREs, it is difficult to differentiate the CREs from different sources using this method because of the lack of indications for their related pharmacological activities.

Purpose: To explore the effect of CREs (CREA/CREB/CREC) with different compositions of major components on the gut microbiota and blood glucose levels in db/db mice.

Methods: Degradation of berberine/jatrorrhizine/coptisine/palmatine from CREA/CREB/CREC in rat/mouse intestinal contents and their impact on nine common gastrointestinal bacteria were investigated. In addition, the effects of oral administration of CREA/CREB/CREC for 2 weeks on the gut microbiota and blood glucose levels in db/db mice were monitored via insulin/glucose tolerance test (ITT/GTT), insulin concentration, homeostatic model assessment of insulin resistance and fecal 16S rRNA sequencing.

Results and Conclusion: The total amount of berberine/jatrorrhizine/coptisine/palmatine was highest in CREA. Clostridium perfringens was strongly inhibited by all three CREs, with CREA demonstrating the most significant inhibitory effects on minimum inhibitory concentration, time-kill kinetics, and ATP production. In db/db mice, CREA resulted in the most significant decrease in ITT/GTT and depicted different changes in the microbiota from CREB/CREC. Thus, CREs with different compositions of berberine/jatrorrhizine/coptisine/palmatine differed in terms of time-kill kinetics and ATP production assays on C. perfringens. CREA revealed the potent bacterial inhibitory effects and glucose-lowering activity.

Associations of Renal Augmented Velocity Index with Arterial Stiffness, Carotid Intima-Media Thickness and Blood Pressure, in Comparison with Renal Resistive Index

The augmented velocity index (Avi) is a new Doppler index associated with arterial stiffness. We examined associations of renal Avi with blood pressure (BP), aortic stiffness and carotid intima-media thickness (IMT), and compared its performance with that of resistive index (RI). One hundred forty-seven volunteers were recruited. Renal Avi had significant positive correlations with systolic BP (r = 0.37, p < 0.001), diastolic BP (r = 0.2, p = 0.016), mean arterial pressure (r = 0.29, p < 0.001), pulse pressure (r = 0.31, p < 0.001), carotid-femoral pulse wave velocity (r = 0.49, p < 0.001) and carotid IMT (r = 0.23, p = 0.005). RI correlated positively with pulse pressure (r = 0.3, p < 0.001) only. After adjustments for co-variables, the associations remained similar. Patients with abnormal BP values (≥130/80 mm Hg), IMT and aortic stiffness (≥1 standard deviation of mean value) had higher Avi than those with normal values, but not RI. In conclusion, renal Avi had stronger associations with BP, arterial stiffness and carotid IMT than RI in apparently healthy volunteers, and was significantly increased in abnormal patients.

Increased co-expression of PSMA2 and GLP-1 receptor in cervical cancer models in type 2 diabetes attenuated by Exendin-4: A translational case-control study

BACKGROUND

Type 2 diabetes (T2D) increases the risk of many types of cancer. Dysregulation of proteasome-related protein degradation leads to tumorigenesis, while Exendin-4, a glucagon-like peptide 1 receptor (GLP-1R) agonist, possesses anti-cancer effects.

METHODS

We explored the co-expression of proteasome alpha 2 subunit (PSMA2) and GLP-1R in the Cancer Genome Atlas (TCGA) database and human cervical cancer specimens, supplemented by in vivo and in vitro studies using multiple cervical cancer cell lines.

FINDINGS

PSMA2 expression was increased in 12 cancer types in TCGA database and cervical cancer specimens from patients with T2D (T2D vs non-T2D: 3.22 (95% confidence interval CI: 1.38, 5.05) vs 1.00 (0.66, 1.34) fold change, P = 0.01). psma2-shRNA decreased cell proliferation in vitro, and tumour volume and Ki67 expression in vivo. Exendin-4 decreased psma2 expression, tumour volume and Ki67 expression in vivo. There was no change in GLP-1R expression in 12 cancer types in TCGA database. However, GLP-1R expression (T2D vs non-T2D: 5.49 (3.0, 8.1) vs 1.00 (0.5, 1.5) fold change, P < 0.001) was increased and positively correlated with PSMA2 expression in T2D-related (r = 0.68)  but not in non-T2D-related cervical cancer specimens. This correlation was corroborated by in vitro experiments where silencing glp-1r decreased psma2 expression. Exendin-4 attenuated phospho-p65 and -IκB expression in the NF-κB pathway.

INTERPRETATION

PSMA2 and GLP-1R expression in T2D-related cervical cancer specimens was increased and positively correlated, suggesting hyperglycaemia might promote cancer growth by increasing PSMA2 expression which could be attenuated by Exendin-4.

FUNDING

This project was supported by Postdoctoral Fellowship Scheme, Direct Grant, Diabetes Research and Education Fund from the Chinese University of Hong Kong (CUHK).

Young-onset diabetes, nutritional therapy and novel insulin delivery systems: a report from the 21st Hong Kong Diabetes and Cardiovascular Risk Factors - East Meets West Symposium

The prevalence and incidence of young-onset diabetes are increasing in many parts of the world, with the most rapid increase occurring in Asia, where one in five people with diabetes are diagnosed below the age of 40 years. Accumulation of glycaemic burden from an early age significantly increases the lifetime risks of developing complications from diabetes. Despite impending health threats, young people fare worse in the control of blood glucose and other metabolic risk factors. Challenges in the management of young-onset diabetes are compounded by heterogeneity of the underlying causes, pathophysiology and clinical phenotypes in this group. Effective characterization of people with diabetes has implications in steering the choice of glucose-lowering drugs, which, in turn, determines the clinical outcome. Medical nutritional therapy is key to effective management of people with diabetes but dietary adherence is often suboptimal among younger individuals. A recently published consensus report on nutritional therapy addresses dietary management in people with prediabetes as well as diabetes, and summarizes clinical evidence regarding macronutrient and micronutrient composition as well as eating patterns in people with diabetes. For people with type 1 diabetes, automated insulin delivery systems have rapidly evolved since the concept was first introduced at the National Institute of Health and the Juvenile Diabetes Research Foundation in 2005. The subsequent development of a type 1 diabetes simulator, developed using detailed human physiology data on carbohydrate metabolism replaced the need for pre-clinical animal studies and facilitated the seamless progression to artificial pancreas human clinical trials.

Cadherin-related family member 3 gene impacts childhood asthma in Chinese children

BACKGROUND

A missense variant (rs6967330) of the gene encoding cadherin-related family member 3 (CDHR3) was associated with recurrent severe exacerbations in pre-schoolers. However, there were limited data on its relationship with pre-school lung function and school-age asthma. This study replicated the association between polymorphic markers at the region of CDHR3 around rs6967330 and wheezing phenotypes in two independent cohorts of Chinese children.

METHODS

Ten tagging SNPs located 10 kb around rs6967330 were selected by HaploView 5.0 based on 1000 Genomes database for Southern Han Chinese. Their associations with wheezing and lung function were examined in 1341 Chinese pre-school children, while those for asthma phenotypes were examined in an independent group of 2079 school-age children. Genotypic and haplotypic associations were analyzed by multivariate regression, and generalized multifactor dimensionality reduction was used to examine epistatic interactions for wheezing traits.

RESULTS

The mean (SD) age of pre-school cohort was 4.7 (1.0) years. Rs6967330 was associated with current wheeze (odds ratio [OR] 1.63, 95% confidence interval [CI] 1.09-2.43) and its severity (OR 1.64, 95% CI 1.10-2.44) among pre-school children. This SNP was also associated with school-age asthma (OR 1.32, 95% CI 1.04-1.69). The minor allele of rs408223 was associated with lower FEV_0.5 (β = -2.411, P = .004) and FEV_0.5 /FVC (β = -1.292, P = .015). Lower spirometric indices were also associated with minor allele of rs140154310. GAC haplotype from rs4730125, rs6967330, and rs408223 was associated with pre-school current wheeze and school-age asthma. Epistatic interaction was found between unrelated CDHR3 SNPs for FEV_0.5 among pre-schoolers.

CONCLUSION

CDHR3 is a candidate gene for early-life wheezing, school-age asthma, and lung function in Chinese children.

Ten-Year Secular Trends in Sleep/Wake Patterns in Shanghai and Hong Kong School-Aged Children: A Tale of Two Cities

STUDY OBJECTIVES

To compare the secular trends of sleep/wake patterns in school-aged children in Hong Kong and Shanghai, two major metropolitan cities in China with two different policies that school start time was delayed in Shanghai, but advanced in Hong Kong in 10 years' time.

METHODS

Participants were from two waves of cross-sectional school-based surveys of children aged 6 to 11 years. In Shanghai, 4,339 and 13,795 children participated in the 2005 and 2014 surveys, respectively. In Hong Kong, 6,231 and 4,585 children participated in the 2003 and 2012 surveys, respectively. Parents reported their children's bedtime and wakeup time, and thus sleep duration, short sleep (≤ 9 hours) and weekend oversleep (difference in sleep duration between weekday and weekend > 2 hours) were determined.

RESULTS

Hong Kong children had later bedtime and wakeup time and slept consistently less than their Shanghai counterparts at both survey time points. The shorter sleep duration was particularly marked during weekdays. Over the interval period, weekday sleep duration significantly decreased from 9.2 to 8.9 hours as wakeup time became earlier for Hong Kong children, but increased from 9.4 to 9.6 hours as wakeup time became later for children in Shanghai. Children from both cities slept longer on the weekends. Prevalence of weekend oversleep significantly increased in Hong Kong children, but no interval change was found in Shanghai children.

CONCLUSIONS

The findings indicate subcultural differences in sleep/wake patterns in Shanghai and Hong Kong school-aged children. In particular, sleep duration had increased for Shanghai children, but decreased for Hong Kong children over 10 years. The benefits and barriers of delaying school start time for optimizing sleep health in school-aged children should be further explored.

Augmented Velocity Index: A New Doppler Index Associated with Arterial Stiffness

Augmented Velocity Index (Avi) is a new Doppler index developed to quantify velocity changes at the late systolic peak. We examined its reliability, association with arterial stiffness and cardiovascular risk factors. The Avi is calculated as (late systolic peak velocity - early systolic peak velocity)/(highest peak systolic velocity - end-diastolic velocity). Fifty volunteers (mean age ± standard deviation: 43.5 ± 14.2 y, men: 52%) without known medical illnesses or drug use were recruited. Carotid Doppler waveforms with measurements of Avi were recorded. Carotid pressure waveforms were obtained by applanation tonometry for measurement of the Augmentation Index (AI). Clinical measurements including body mass index (BMI) and blood pressure (BP) were assessed, and fasting blood was taken for measurement of glycemia and lipid profile. Another 15 volunteers (age range: 22-60 y, men: 33.3%) were recruited to study the reliability of Avi measurement. The results revealed that carotid Avi closely correlated with the index of arterial stiffness, AI (r = 0.76, p < 0.001) on Pearson correlation. On multiple linear regression analysis, Avi remained a significant independent determinant of AI after adjustments for clinical variables. The Avi had significant associations with cardiovascular risk factors (age, BMI, total cholesterol, low-density lipoprotein cholesterol, systolic and diastolic BP). The intra-class correlation coefficients for inter-observer and intra-observer reliability of Avi measurements were 0.93 (95% confidence interval [CI]: 0.8-0.98) and 0.97 (95% CI: 0.92-0.99) respectively. In conclusion, the Avi is a reproducible new Doppler index, independently associated with arterial stiffness in terms of the AI, which initially correlated with cardiovascular risk factors.

Gender differences in the associations between insomnia and glycemic control in patients with type 2 diabetes: a cross-sectional study

STUDY OBJECTIVES

Insomnia is associated with insulin resistance and type 2 diabetes (T2D) in the general population. However, the associations between insomnia and glycemic control in T2D population are not consistently reported. In this study, we aimed to examine the associations between insomnia and glycemic control, and gender differences in these associations among Hong Kong Chinese patients with T2D.

METHODS

This was a cross-sectional study involving T2D patients recruited from the Hong Kong Diabetes Registry between July 2010 and June 2015. Glycemic control was estimated by fasting plasma glucose (FPG) and glycated hemoglobin (HbA1c). Participants with the Insomnia Severity Index score > 14 were considered as having insomnia.

RESULTS

A total of 3753 patients were recruited. Compared with patients without insomnia, patients with insomnia had higher levels of FPG and HbA1c. After adjustment for potential confounding factors, insomnia was associated with higher FPG and HbA1c in the entire cohort. There were significant interactions between insomnia and gender for FPG (p = 0.001) and HbA1c (p = 0.025) in the full model. Subgroup analyses found that men with insomnia had higher FPG [8.23 (7.85-8.61) mmol/L versus 7.50 (7.39-7.61) mmol/L, p < 0.001] and HbA1c [7.79 (7.57-8.02)% versus 7.45 (7.39-7.52)%, p = 0.005] than men without insomnia after adjusted for confounding factors, whereas such difference was not observed in women.

CONCLUSIONS

T2D patients with insomnia had worse glycemic control than the patients without insomnia. The associations were particularly pronounced in men.

Early-life exposure to endocrine disrupting chemicals associates with childhood obesity

Increasing prevalence of childhood obesity poses threats to the global health burden. Because this rising prevalence cannot be fully explained by traditional risk factors such as unhealthy diet and physical inactivity, early-life exposure to endocrine disrupting chemicals (EDCs) is recognized as emerging novel risk factors for childhood obesity. EDCs can disrupt the hormone-mediated metabolic pathways, affect children's growth and mediate the development of childhood obesity. Many organic pollutants are recently classified to be EDCs. In this review, we summarized the epidemiological and laboratory evidence related to EDCs and childhood obesity, and discussed the possible mechanisms underpinning childhood obesity and early-life exposure to non-persistent organic pollutants (phthalates, bisphenol A, triclosan) and persistent organic pollutants (dichlorodiphenyltrichloroethane, polychlorinated biphenyls, polybrominated diphenyl ethers, per- and polyfluoroalkyl substances). Understanding the relationship between EDCs and childhood obesity helps to raise public awareness and formulate public health policy to protect the youth from exposure to the harmful effects of EDCs.

Association between hedonic hunger and glycemic control in non-obese and obese patients with type 2 diabetes

AIMS/INTRODUCTION

Higher hedonic hunger has been observed in obese individuals compared with those without obesity, but little is known about its association with glycemic management. We aimed to examine the association between hedonic hunger and glycemic control in non-obese and obese patients with type 2 diabetes.

MATERIALS AND METHODS

Between April and November 2016, a total of 211 type 2 diabetes patients who underwent comprehensive diabetes assessments at a university-affiliated hospital were recruited into two groups according to body mass index: non-obese (body mass index 18.5-24.9 kg/m2 ) and obese (body mass index ≥30 kg/m2 ) groups. All participants completed the Chinese version of the Power of Food Scale (PFS) for assessment of hedonic hunger. Good glycemic control was defined as glycated hemoglobin <7.0%.

RESULTS

Compared with the non-obese group, the obese group showed higher PFS aggregated and subscale 'food available' scores (both P < 0.05). After adjustment for age, sex, disease duration of diabetes and insulin use, there were positive associations of glycated hemoglobin with PFS aggregated, subscale 'food available' and 'food present' scores in the obese group (all P for trend <0.05). The PFS aggregated score was negatively associated with good glycemic control in obese type 2 diabetes patients after adjustment using logistic regression analysis (adjusted odds ratio 0.42, 95% confidence interval 0.20-0.91, P = 0.027). By contrast, such associations were not observed in non-obese type 2 diabetes patients.

CONCLUSIONS

Hedonic hunger had an independent and inverse association with good glycemic control in obese Chinese patients with type 2 diabetes, but not in their counterparts without obesity.

Sleep and Obesity

Rising global prevalence and incidence of obesity lead to increased cardiovascular-renal complications and cancers. Epidemiological studies reported a worldwide trend towards suboptimal sleep duration and poor sleep quality in parallel with this obesity epidemic. From rodents and human models, it is highly plausible that abnormalities in sleep, both quantity and quality, impact negatively on energy metabolism. While excess dietary intake and physical inactivity are the known drivers of the obesity epidemic, promotion of healthy sleep habits has emerged as a new target to combat obesity. In this light, present review focuses on the existing literature examining the relationship between sleep physiology and energy homeostasis. Notably, sleep dysregulation perturbs the metabolic milieu via alterations in hormones such as leptin and ghrelin, eating behavior, neuroendocrine and autonomic nervous systems. In addition, shift work and trans-meridian air travel may exert a negative influence on the hypothalamic-pituitary-adrenal axis and trigger circadian misalignment, leading to impaired glucose tolerance and increased fat accumulation. Amassing evidence has also suggested that uncoupling of the circadian clock can increase the risk of adverse metabolic health. Given the importance of sleep in maintaining energy homeostasis and that it is potentially modifiable, promoting good sleep hygiene may create new avenues for obesity prevention and treatment.

High risk of conversion to diabetes in first-degree relatives of individuals with young-onset type 2 diabetes: a 12-year follow-up analysis

AIM

Family history of diabetes is an established risk factor for Type 2 diabetes, but the impact of a family history of young-onset diabetes (onset < 40 years) on future risk of diabetes among first-degree relatives is unclear. In this prospective study, we examined the influence of family history of late- versus young-onset diabetes on the development of diabetes in a young to middle-aged Chinese population.

METHODS

Some 365 siblings identified through probands with Type 2 diabetes and 452 participants from a community-based health awareness project (aged 18-55 years) who underwent metabolic assessment during the period 1998-2002 were followed to 2012-2013 to determine their glycaemic status. Multivariate logistic regression was performed to investigate the association of family history of diabetes presented at different age categories with development of diabetes.

RESULTS

In this cohort, 53.4% (n = 167) of participants with a family history of young-onset diabetes, 30.1% (n = 68) of those with a family history of late-onset diabetes and 14.4% (n = 40) of those without a family history developed diabetes. Using logistic regression, family history of diabetes presented at ages ≥ 50, 40-49, 30-39 and < 30 years, increased conversion to diabetes with respective odds ratios of 2.4, 5.8, 9.4 and 7.0 (P < 0.001 for all), after adjustment for socio-economic status, smoking, obesity, hypertension and dyslipidaemia. Among participants without diabetes at baseline, risk association of family history of late-onset diabetes with incident diabetes was not sustained, whereas that of family history of young-onset diabetes remained robust on further adjustment for baseline glycaemic measurements.

CONCLUSIONS

First-degree relatives of people with Type 2 diabetes, especially relatives of those with young-onset diabetes, are at high risk for diabetes.

Persistent Organic Pollutants as Risk Factors for Obesity and Diabetes

PURPOSE OF REVIEW

The rising prevalence of obesity and diabetes cannot be fully explained by known risk factors, such as unhealthy diet, a sedentary lifestyle, and family history. This review summarizes the available studies linking persistent organic pollutants (POPs) to obesity and diabetes and discusses plausible underlying mechanisms.

RECENT FINDINGS

Increasing evidence suggest that POPs may act as obesogens and diabetogens to promote the development of obesity and diabetes and induce metabolic dysfunction. POPs are synthesized chemicals and are used widely in our daily life. These chemicals are resistant to degradation in chemical or biological processes, which enable them to exist in the environment persistently and to be bio-accumulated in animal and human tissue through the food chain. Increasingly, epidemiologic studies suggest a positive association between POPs and risk of developing diabetes. Understanding the relationship of POPs with obesity and diabetes may shed light on preventive strategies for obesity and diabetes.

Impact of a modest delay in school start time in Hong Kong school adolescents

OBJECTIVE

To examine the effects of a modest delay (15 min) in school start time (SST) on adolescent sleep patterns, mood, and behaviors.

METHODS

Two secondary schools in Hong Kong with a total of 1173 students (intervention: n = 617; comparison school n = 556) completed both baseline and follow-up questionnaires. School start time was delayed by 15 min, from 7:45 a.m. to 8:00 a.m., in the intervention school. The comparison school maintained their regular SST at 7:55 a.m. Students' sleep-wake patterns, daytime sleepiness, and mental and behavioral aspects were assessed by validated questionnaires before and after the intervention.

RESULTS

Students in the intervention school significantly delayed their weekday wake-up time (p < 0.001) and increased their total time in bed (p < 0.001) when compared to students in the comparison school. Both groups experienced a delay in their weekday bedtime. The students in the intervention school showed improved mental health [General Health Questionnaire (GHQ) score, p = 0.015], better prosocial behaviors (p = 0.009), better peer relationships (p < 0.001), greater attentiveness (p < 0.001), less emotional problems (p = 0.002), and less behavioral difficulties (p < 0.001) as measured by Strengths and Difficulties Questionnaire (SDQ).

CONCLUSIONS

A modest delay (15 min) in school start time can increase adolescent sleep with corresponding improvement in mood and behaviors. Current findings have significant implications for education policy, suggesting that school administrators and policy makers should systematically consider delaying school start time to promote sleep and health among school-aged adolescents.

CLINICAL TRIAL REGISTRATION

ChiCTR-TRC-12002798. The trial protocol can be accessed at: http://www.chictr.org/en/proj/show.aspx?proj=3955.

Emergence of Sex Differences in Insomnia Symptoms in Adolescents: A Large-Scale School-Based Study

STUDY OBJECTIVES

This study aimed to explore the moderation of pubertal status on the onset of sex differences in the prevalence of insomnia symptoms and their health correlates.

METHODS

A total of 7,507 children and adolescents (weighted percentage of female: 48.5%) aged between 6-17 y were recruited from thirty-one primary and secondary schools. Participants with difficulty initiating sleep (DIS), difficulty maintaining sleep (DMS), and/or early morning awakening (EMA) ≥ 3 times/week in the past month were considered as having insomnia symptoms. The severity of insomnia was measured by the Insomnia Severity Index (ISI).

RESULTS

The prevalence of insomnia symptoms increased from 3.4% to 12.2% in girls (3.6-fold) and from 4.3% to 9.1% in boys (2.1-fold) from Tanner stage 1 to 5. There was a significant interaction between sex and Tanner stage in the prevalence of insomnia (P < 0.001) with an emergence of female preponderance at Tanner stage 4 even after controlling for age, family income, and school start time. Similar sex-Tanner stage interactions were found in DIS, DMS, and ISI total score but not EMA. Insomnia symptoms were strongly associated with behavioral problems, poor mental health, and poor general health in both sexes. Boys with insomnia would report more maladaptive lifestyles (smoking, alcohol, and energy drinks) whereas girls with insomnia were more susceptible to emotional and relationship difficulties.

CONCLUSIONS

Pubertal maturation was associated with a progressive increase in the prevalence of insomnia symptoms with the emergence of female preponderance in both the prevalence and severity of insomnia symptoms at late puberty.

CLINICAL TRIALS REGISTRATION

Chinese Clinical Trial Register, http://www.chictr.org.cn, ID: ChiCTR-TRC-12002798.

Early gene-diet interaction between glucokinase regulatory protein (GCKR) polymorphism, vegetable and fish intakes in modulating triglyceride levels in healthy adolescents

BACKGROUND AND AIMS

The benefits of dietary vegetable and fish consumptions on improving glucose and lipid metabolism have been well established. Recently, the T-allele of a common genetic variant rs780094 at glucokinase regulatory protein (GCKR) was reported to be associated with elevated triglyceride (TG) levels but reduced fasting plasma glucose (FPG) and type 2 diabetes risk. However, the dietary modulation on genetic risk is not clearly understood.

METHODS AND RESULTS

A cohort of 2095 Chinese adolescents (mean age 15.6 ± 2.0 years, 45.3% male) recruited from a population-based school survey for cardiovascular risk factor assessment, with dietary data including weekly vegetable and fish consumptions as well as clinical data were genotyped for the GCKR rs780094 polymorphism. In the linear regression analysis with adjustment for sex, age, body mass index, and socioeconomic status (school banding, paternal and maternal education levels), the frequency of vegetable intake per week was inversely associated with FPG (P = 0.044). Individuals with low fish intake generally had elevated TG levels but reduced TC, HDL-C and LDL-C (0.006 < P < 0.029). We also observed significant associations of the minor T-allele of GCKR rs780094 with decreased FPG (P = 0.013) and increased TG levels (P = 2.7 × 10(-8)). There were significant gene-diet interactions between rs780094 and vegetable consumption (P(interaction) = 0.009), and between rs780094 and fish consumption (P(interaction) = 0.031) in modulating TG levels. The T-allele of GCKR locus was associated with higher TG levels amongst individuals with ≥7 vegetable meals per week (P = 6.4 × 10(-9)), and among individuals with <7 fish meals per week (P = 0.020 and 7.0 × 10(-7) for 4-6 and ≤3 meals per week, respectively). High intake of vegetable exerted a reduction in TG levels only among CC genotype carriers (Ptrend = 0.020), while high intake of fish was associated with reduced TG levels only among TT genotype carriers (Ptrend = 0.026).

CONCLUSIONS

In summary, our data indicated that the favorable associations of higher vegetable and fish intakes on TG levels are dependent on the genetic background of an individual. In particular, at-risk TT- genotype carriers of the GCKR variant may derive more benefits from a high fish intake, while the CC-genotype carriers may find further benefits from a high consumption of vegetable.

A school-based sleep education program for adolescents: a cluster randomized trial

OBJECTIVES

To evaluate the effectiveness of a multilevel and multimodal school-based education program.

METHODS

A cluster randomized controlled trial with 14 secondary schools in Hong Kong and a total of 3713 students (intervention: 1545 vs control: 2168; 40.2% boys; mean age ± SD: 14.72 ± 1.53 years) were included in the final analysis. The intervention included a town hall seminar, small class workshops, a slogan competition, a brochure, and an educational Web site. Their parents and teachers were offered sleep education seminars. The control schools did not receive any sleep program. Data were collected before and 5 weeks after the intervention.

RESULTS

The students in the intervention group had significantly improved sleep knowledge compared with the control group (mean difference: 3.64 [95% confidence interval (CI): 3.21 to 4.07]; Cohen's d = 0.51) as measured by using a sleep knowledge questionnaire. Weekday sleep duration was reduced in both groups, and the significant difference in weekday sleep duration was lost in the intention-to-treat analysis (mean difference: 0:01 [95% CI: -0:00 to 0:04]). In addition, the intervention group had a lower incidence of consuming caffeine-containing energy drinks (adjusted odds ratio: 0.46 [95% CI: 0.22 to 0.99]) and had better behavioral (mean difference: -0.56 [95% CI: -1.02 to -0.10]; Cohen's d = 0.13) and mental health (mean difference: -0.30 [95% CI: -0.15 to -0.46]; Cohen's d = 0.11) outcomes.

CONCLUSIONS

A school-based sleep education program was effective in enhancing sleep knowledge and improving behavioral and mental health, but it had no significant impact on sleep duration or pattern among adolescents.

Non-linear relationship between birthweight and cardiometabolic risk factors in Chinese adolescents and adults

AIM

To investigate the relationship between birthweight and cardiometabolic traits in two cohorts: one of Chinese adolescents and one of Chinese adults.

METHODS

Birthweight and clinical data, including anthropometric traits, fasting plasma glucose and fasting plasma insulin levels, blood pressure and lipid profiles were collected from 2035 adolescents and 456 adults. A subset of 735 subjects underwent an oral glucose tolerance test to measure the glucose and insulin concentrations at 0, 15, 30, 60 and 120 min.

RESULTS

Among adolescents, birthweight showed U-shaped relationships with larger body size, obesity, abdominal obesity in girls, insulin resistance and worse lipid profiles (0.0013 < P(quadratic) < 0.0499), as well as an inverse association with fasting plasma glucose (P(linear) = 0.0368). After further adjustment for adiposity, decreasing birthweight was associated with elevated fasting plasma glucose levels, greater insulin resistance and worse lipid profiles (3.1 × 10⁻⁵ < P(linear) < 0.0058). Among adults, high birthweight was associated with larger body size and abdominal obesity in men, while low birthweight was associated with elevated glucose levels at 15, 30, 60 and 120 min and a greater area under the curve at 0-120 min, as well as with β-cell dysfunction (6.5 × 10⁻⁵ < P(linear) < 0.0437). Adjustment for adult adiposity did not substantially change the relationships. There was significant interaction between birthweight and abdominal obesity in elevating fasting plasma insulin and homeostasis model assessment of insulin resistance (P > 0.05), with abdominally obese adolescents in the lowest birthweight category (≤ 2.5 kg) having the highest risk of insulin resistance.

CONCLUSIONS

Both high and low birthweights are associated with an increased risk of cardiometabolic abnormalities including obesity, abdominal obesity, hyperglycaemia, dyslipidaemia and insulin resistance, as well as with β-cell dysfunction.

Association between sleep architecture and glucose tolerance in children and adolescents

BACKGROUND

Short sleep duration is a contributing factor for decreased insulin sensitivity and hyperglycemia. Sleep architecture represents a cyclical pattern of sleep that shifts between sleep Stages N1, N2, N3 (slow wave sleep) and Stage R (rapid eye movement sleep). The aim of the present study was to examine the association between sleep architecture and glucose and insulin metabolism in both normal weight and overweight/obese children and adolescents.

METHODS

A total of 118 subjects participated in the study. Subjects under-went overnight polysomnography (PSG) when the percentage of total sleep time (% TST) spent at each sleep stage was recorded and an oral glucose tolerance test together was performed the next morning. We assessed glucose tolerance, insulin sensitivity and pancreatic β-cell function using 2-h glucose levels, the Matsuda index (IS(OGTT)), and insulin secretion-sensitivity index-2 (ISSI-2), respectively.

RESULTS

After adjustment for age, gender, body mass index z-score, pubertal status, and obstructive apnea hypopnea index, Stage N3 (% TST) was positively associated with IS(OGTT), whereas Stage N1 (%TST) exerted an opposite effect on IS(OGTT). Higher sleep efficiency and longer TST were independently associated with lower 2-h glucose levels, higher ISSI-2 and/or higher IS(OGTT).

CONCLUSIONS

Stage N3, sleep efficiency and TST were protective factors in maintaining glucose and insulin homeostasis; however, Stage N1 functioned in the opposite direction.

Testosterone level in men with type 2 diabetes mellitus and related metabolic effects: A review of current evidence

A significant proportion of patients with type 2 diabetes mellitus have a low testosterone level relative to reference ranges based on healthy young men. Only a small number of these patients suffer from classical hypogonadism as a result of recognizable hypothalamic-pituitary-gonadal axis pathology. The cut-off value of the serum testosterone level in men without obvious hypothalamic-pituitary-gonadal axis pathology is controversial. It is unclear to what extent a low serum testosterone level causally leads to type 2 diabetes and/or the metabolic syndrome. From a theoretical standpoint, there can be complex interactions among the hypothalamic-pituitary-gonadal axis, body composition and insulin resistance, which can be further influenced by intrinsic and extrinsic factors to give rise to metabolic syndrome, glucose intolerance, and low-grade inflammation to increase the risk of cardiovascular disease. Although a low serum testosterone level frequently coexists with cardiometabolic risk factors and might serve as a biomarker, more studies are required to clarify the causal, mediating or modifying roles of low serum testosterone level in the development of adverse clinical outcomes. Currently, there are insufficient randomized clinical trial data to evaluate the effects of testosterone replacement therapy on meaningful clinical outcomes. The risk-to-benefit ratio of testosterone therapy in high-risk subjects, such as those with type 2 diabetes, also requires elucidation. The present article aims to review the current evidence on low serum testosterone levels in patients with type 2 diabetes, and its implications on cardiovascular risk factors, metabolic syndrome and adverse clinical outcomes.

Maternal history of diabetes is associated with increased cardiometabolic risk in Chinese

OBJECTIVE

Positive family history is associated with increased type 2 diabetes (T2D) risk, and reflects both genetic and environmental risks. Several studies have suggested an excess maternal transmission of T2D, although the underlying mechanism is unknown. We aimed to examine the association between maternal diabetes and cardiometabolic risk in the offspring.

METHODS

Parental history of diabetes and clinical data including anthropometric traits, fasting plasma glucose and insulin (FPG, FPI), blood pressure and lipid profile were collected from 2581 unrelated Chinese offspring (2026 adolescents from a population-based school survey and 555 adults from a community-based health screening programme). A subset of subjects (n=834) underwent oral glucose tolerance test to measure the glucose and insulin concentrations at 0, 15, 30, 60 and 120 min for evaluation of the areas under the curve (AUC) of glucose and insulin at 0-120 min, homoeostasis model assessment of insulin resistance (HOMA-IR) and bell-cell function, insulinogenic index, insulin sensitivity index (ISI) and oral disposition index (DI).

RESULTS

A positive parental history of diabetes was associated with increased risk of obesity (odd ratios (OR) (95% confidence interval (CI))=1.48 (1.10-2.00)), central obesity (OR (95% CI)=1.67 (1.21-2.32)), higher FPI, HOMA-IR, 2-h insulin, AUC of glucose at 0-120 min, triglycerides, reduced ISI and DI. Compared with individuals without parental diabetes, offspring with diabetic mother had significantly increased risk of obesity (OR (95% CI)=1.59 (1.07-2.35)), central obesity (OR (95% CI)=1.88 (1.23-2.88)), higher glucose levels and BP, were more insulin resistant but also had impaired first-phase insulin response and worse lipid profile. However, paternal history of diabetes had no effect on any of the studied traits, except higher body mass index, waist circumference in females and FPG.

CONCLUSIONS

Our findings suggested that maternal history of diabetes conferred increased risk of cardiometabolic abnormalities, and was associated with both insulin resistance and impaired first-phase insulin secretion. Further investigation into the mechanism of transgenerational diabetes is warranted.

Familial young-onset diabetes, pre-diabetes and cardiovascular disease are associated with genetic variants of DACH1 in Chinese

In Asia, young-onset type 2 diabetes (YOD) is characterized by obesity and increased risk for cardiovascular disease (CVD). In a genome-wide association study (GWAS) of 99 Chinese obese subjects with familial YOD diagnosed before 40-year-old and 101 controls, the T allele of rs1408888 in intron 1 of DACH1(Dachshund homolog 1) was associated with an odds ratio (OR) of 2.49(95% confidence intervals:1.57-3.96, P = 8.4 × 10(-5)). Amongst these subjects, we found reduced expression of DACH1 in peripheral blood mononuclear cells (PBMC) from 63 cases compared to 65 controls (P = 0.02). In a random cohort of 1468 cases and 1485 controls, amongst top 19 SNPs from GWAS, rs1408888 was associated with type 2 diabetes with a global P value of 0.0176 and confirmation in a multiethnic Asian case-control cohort (7370/7802) with an OR of 1.07(1.02-1.12, P(meta)  = 0.012). In 599 Chinese non-diabetic subjects, rs1408888 was linearly associated with systolic blood pressure and insulin resistance. In a case-control cohort (n = 953/953), rs1408888 was associated with an OR of 1.54(1.07-2.22, P = 0.019) for CVD in type 2 diabetes. In an autopsy series of 173 non-diabetic cases, TT genotype of rs1408888 was associated with an OR of 3.31(1.19-9.19, P = 0.0214) and 3.27(1.25-11.07, P = 0.0184) for coronary heart disease (CHD) and coronary arteriosclerosis. Bioinformatics analysis revealed that rs1408888 lies within regulatory elements of DACH1 implicated in islet development and insulin secretion. The T allele of rs1408888 of DACH1 was associated with YOD, prediabetes and CVD in Chinese.

Associations of uric acid and gamma-glutamyltransferase (GGT) with obesity and components of metabolic syndrome in children and adolescents

BACKGROUND

The combined effect of uric acid, gamma-glutamyltransferase (GGT) and cardiovascular risk factors clustering in the youth remains under-explored.

OBJECTIVE

The objective of this study was to examine the association between uric acid, GGT, obesity and the individual components of metabolic syndrome in children and adolescents.

METHODS

We performed a cross-sectional observational study of 2067 children and adolescents (875 boys and 1192 girls) aged 6-20 years who were healthy volunteers and were recruited from primary and secondary schools in Hong Kong between 2007 and 2008. Subjects were divided into two strata (75th percentile as cut-off) for comparison between odds of cardiovascular risk factors.

RESULTS

After adjustment by multivariable logistic regression, subjects in upper stratum, i.e., >75th percentile, of either serum uric acid or GGT levels were associated with obesity, low high-density lipoprotein cholesterol (HDL-C) level and high blood pressure (adjusted odds ratios [AOR] ranged from 1.63 to 5.82, all P < 0.005) compared with those in the lower stratum. There were combined effect for upper stratum of both uric acid and GGT in the association with obesity, low HDL-C and high blood pressure (AOR ranged from 2.60 to 10.69, all P < 0.05) after adjustment for age, sex and body mass index z-score (except for obesity status) as well as body height (for high blood pressure).

CONCLUSION

Uric acid and GGT have combined effect in association with obesity and other cardiovascular risk factors in children and adolescents.

Genetic associations of type 2 diabetes with islet amyloid polypeptide processing and degrading pathways in asian populations

Type 2 diabetes (T2D) is a complex disease characterized by beta cell dysfunctions. Islet amyloid polypeptide (IAPP) is highly conserved and co-secreted with insulin with over 40% of autopsy cases of T2D showing islet amyloid formation due to IAPP aggregation. Dysregulation in IAPP processing, stabilization and degradation can cause excessive oligomerization with beta cell toxicity. Previous studies examining genetic associations of pathways implicated in IAPP metabolism have yielded conflicting results due to small sample size, insufficient interrogation of gene structure and gene-gene interactions. In this multi-staged study, we screened 89 tag single nucleotide polymorphisms (SNPs) in 6 candidate genes implicated in IAPP metabolism and tested for independent and joint associations with T2D and beta cell dysfunctions. Positive signals in the stage-1 were confirmed by de novo and in silico analysis in a multi-centre unrelated case-control cohort. We examined the association of significant SNPs with quantitative traits in a subset of controls and performed bioinformatics and relevant functional analyses. Amongst the tag SNPs, rs1583645 in carboxypeptidase E (CPE) and rs6583813 in insulin degrading enzyme (IDE) were associated with 1.09 to 1.28 fold increased risk of T2D (P_Meta = 9.4×10⁻³ and 0.02 respectively) in a meta-analysis of East Asians. Using genetic risk scores (GRS) with each risk variant scoring 1, subjects with GRS≥3 (8.2% of the cohort) had 56% higher risk of T2D than those with GRS = 0 (P = 0.01). In a subcohort of control subjects, plasma IAPP increased and beta cell function index declined with GRS (P = 0.008 and 0.03 respectively). Bioinformatics and functional analyses of CPE rs1583645 predicted regulatory elements for chromatin modification and transcription factors, suggesting differential DNA-protein interactions and gene expression. Taken together, these results support the importance of dysregulation of IAPP metabolism in T2D in East Asians.

Intrarenal arterial resistance is associated with microvascular complications in Chinese type 2 diabetic patients

BACKGROUND

Increased renal arterial resistance is associated with various types of chronic renal parenchymal diseases. A resistance index (RI) > 0.8 predicts deterioration in renal function in diabetic subjects. However, the association between renal RI and other diabetic complications has not been investigated. In this study, we examined the association between intrarenal arterial RI and diabetic complications in Chinese type 2 diabetic subjects.

METHODS

Three hundred and eighty-seven Chinese type 2 diabetic patients were recruited from a structured assessment programme to evaluate their risk factors and complications as a part of the quality improvement programme at the Prince of Wales Hospital. All subjects underwent ultrasound examinations for the assessment of intrarenal arterial RI of both kidneys. Clinical and biochemical parameters, including diabetes-related microvascular complications (nephropathy, retinopathy and sensory neuropathy) and macrovascular diseases, were examined.

RESULTS

The mean RI of patients with any microvascular complications (0.70 ± 0.09 versus 0.65 ± 0.06) such as nephropathy (0.71 ± 0.09 versus 0.66 ± 0.06), retinopathy (0.71 ± 0.08 versus 0.67 ± 0.08) and sensory neuropathy (0.75 ± 0.07 versus 0.68 ± 0.08) and with any macrovascular complications (0.71 ± 0.09 versus 0.68 ± 0.08) was higher than those without (P < 0.05). On multivariate analysis, after controlling for confounding variables, an RI ≥0.75 was associated with microvascular complications, nephropathy, retinopathy and sensory neuropathy, with odds ratio of 4.02 [95% confidence interval (CI) 1.72-9.4], 4.99 (2.61-9.56), 2.78 (1.52-5.09) and 5.74 (1.8-18.3), respectively. The association of RI with macrovascular complications was not significant in multivariate analysis.

CONCLUSION

Increased intrarenal arterial resistance was independently associated with an increased risk of microvascular complications including diabetic nephropathy, diabetic retinopathy and diabetic sensory neuropathy in Chinese type 2 diabetic patients.