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.

A multicentre demonstration project to evaluate the effectiveness and acceptability of the web-based Joint Asia Diabetes Evaluation (JADE) programme with or without nurse support in Chinese patients with Type 2 diabetes

AIMS

To test the hypothesis that delivery of integrated care augmented by a web-based disease management programme and nurse coordinator would improve treatment target attainment and health-related behaviour.

METHODS

The web-based Joint Asia Diabetes Evaluation (JADE) and Diabetes Monitoring Database (DIAMOND) portals contain identical built-in protocols to integrate structured assessment, risk stratification, personalized reporting and decision support. The JADE portal contains an additional module to facilitate structured follow-up visits. Between January 2009 and September 2010, 3586 Chinese patients with Type 2 diabetes from six sites in China were randomized to DIAMOND (n = 1728) or JADE, plus nurse-coordinated follow-up visits (n = 1858) with comprehensive assessments at baseline and 12 months. The primary outcome was proportion of patients achieving ≥ 2 treatment targets (HbA_1c < 53 mmol/mol (7%), blood pressure < 130/80 mmHg and LDL cholesterol < 2.6 mmol/l).

RESULTS

Of 3586 participants enrolled (mean age 57 years, 54% men, median disease duration 5 years), 2559 returned for repeat assessment after a median (interquartile range) follow-up of 12.5 (4.6) months. The proportion of participants attaining ≥ 2 treatment targets increased in both groups (JADE 40.6 to 50.0%; DIAMOND 38.2 to 50.8%) and there were similar absolute reductions in HbA_1c [DIAMOND -8 mmol/mol vs JADE -7 mmol/mol (-0.69 vs -0.62%)] and LDL cholesterol (DIAMOND -0.32 mmol/l vs JADE -0.28 mmol/l), with no between-group difference. The JADE group was more likely to self-monitor blood glucose (50.5 vs 44.2%; P = 0.005) and had fewer defaulters (25.6 vs 32.0%; P < 0.001).

CONCLUSIONS

Integrated care augmented by information technology improved cardiometabolic control, with additional nurse contacts reducing the default rate and enhancing self-care. (Clinical trials registry no.: NCT01274364).

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.

A randomized-controlled trial to investigate the effects of rivoglitazone, a novel PPAR gamma agonist on glucose-lipid control in type 2 diabetes

AIM

To examine the efficacy, safety and tolerability of rivoglitazone, a novel thiazolidinedione (TZD), and explore its effects on glucose and lipid control compared to placebo and pioglitazone in Chinese type 2 diabetic patients who are treatment naÏve or treated with a single oral blood glucose-lowering drug.

METHODS

This was a double-blind, randomized, placebo- and active-controlled study. A total of 287 Chinese type 2 diabetic patients with suboptimal glycaemic control (defined as HbA1c ≥6.5 to <10% and fasting plasma glucose ≥7 to ≤15 mmol/l) were enrolled. One hundred and seventy-four eligible patients were randomized into one of the five treatment arms for 12 weeks: placebo, pioglitazone 30 mg daily, rivoglitazone of dose 0.5, 1.0 or 1.5 mg daily. In a full set analysis, we used analysis of covariance to compare the primary endpoint defined as change in HbA1c from baseline to week 12/last observation carried forward in the rivoglitazone group at each dose level with the placebo group.

RESULTS

Changes in HbA1c were -0.11% in the 0.5-mg group; -0.22% in the 1-mg group and -0.17% in the 1.5-mg rivoglitazone group; -0.06% in the 30-mg pioglitazone group and 0.61% in the placebo group. Compared to placebo, changes were significant in all active treatment groups (all p < 0.05). Increase in high-density lipoprotein cholesterol and decrease in triglyceride were observed in the rivoglitazone 1 and 1.5 mg groups, respectively, compared to placebo from baseline to week 12 (p < 0.05). Drug-related oedema was reported in eight patients (7.7%) in all rivoglitazone groups compared to six patients (16.2%) in the pioglitazone group and one patient (3.0%) in the placebo group.

CONCLUSIONS

Rivoglitazone is an efficacious, safe and well-tolerated TZD which improved glycaemic control in Chinese type 2 diabetic patients up to 3 months.

Sonographic measurement of mesenteric fat predicts presence of fatty liver among subjects with polycystic ovary syndrome

OBJECTIVE

Visceral fat is believed to be important in the pathogenesis of metabolic syndrome and fatty liver. In this study, we examined the relationship between mesenteric fat thickness and other sonographic indices of adiposity and the presence of fatty liver among subjects with polycystic ovary syndrome (PCOS).

SUBJECTS AND METHODS

A total of 117 Chinese subjects with PCOS were evaluated (mean age, 28.6 ± 6.5 yr; mean body mass index, 24.3 ± 5.3 kg/m(2)). Anthropometric measurements and metabolic risk profile, including a standard oral glucose tolerance test, were assessed in all subjects. All subjects underwent an ultrasound examination for measurement of thickness of mesenteric, preperitoneal, and sc fat as well as evaluation for fatty liver.

RESULTS

Forty-six (39.3%) of the subjects had fatty liver. PCOS subjects with fatty liver had higher body mass index, waist circumference, waist-hip ratio, and systolic blood pressure; a more unfavorable lipid profile with higher triglyceride; lower high-density lipoprotein cholesterol; higher fasting glucose and insulin; higher 2-h glucose during oral glucose tolerance test; lower SHBG; and higher alanine aminotransferase. Subjects with fatty liver had increased thickness of preperitoneal, mesenteric, and sc fat, as well as increased carotid intima-media thickness. Abdominal fat thickness showed moderate correlation to alanine aminotransferase as well as fasting insulin. On multivariate logistic regression, fasting insulin and mesenteric fat thickness were identified as independent predictors of fatty liver among subjects with PCOS.

CONCLUSION

Fatty liver is present in a significant proportion of Chinese patients with PCOS. Sonographic measurement of mesenteric fat is an independent determinant of fatty liver among subjects with PCOS and identifies subjects at increased cardiovascular risk.

Metabolic syndrome, endothelial injury, and subclinical atherosclerosis in patients with systemic lupus erythematosus

OBJECTIVES

To study the link between metabolic syndrome (MetS), endothelial injury, and atherosclerosis in patients with systemic lupus erythematosus (SLE).

METHODS

Consecutive SLE patients without a history of arterial thrombosis were screened for atherosclerosis at the carotid and coronary arteries by B-mode ultrasound [intima-media thickness (IMT)] and multidetector computed tomography (MDCT) scan (Agatston calcium scores), respectively. Plasma levels of homocysteine, high-sensitivity C-reactive protein (hsCRP), soluble vascular cell adhesion molecule (sVCAM)-1, P-selectin, and soluble thrombomodulin (sTM) were assayed. Patients were stratified according to the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) criteria for MetS, using the Asian criteria for abdominal obesity. Risk factors for atherosclerosis were studied.

RESULTS

Of the 123 SLE patients (93% women; age 47.9+/-11 years; SLE duration 10.9+/-7.0 years) studied, 20 (16.3%) had MetS. The prevalence of MetS in the SLE patients was significantly higher than in 492 age- and sex-matched healthy controls (9.6%; p=0.03). Coronary calcification and abnormal carotid IMT were detected in 38 (31%) and 72 (59%) of SLE patients, respectively. Patients with MetS had a significantly higher Agatston score (69.5+/-95 vs. 16.4+/-57; p=0.03) and a numerically higher carotid IMT (p=0.43) than those without. In a logistic regression model, the MetS [odds ratio (OR) 3.11, 95% confidence interval (CI) 1.01-9.59, p=0.049] was associated with coronary atherosclerosis after adjustment for age and other risk factors. In addition, patients with MetS had significantly higher levels of hsCRP (p=0.002), homocysteine (p=0.03), and sTM (p=0.01).

CONCLUSIONS

The MetS is more prevalent in SLE patients than the general population and is associated with endothelial injury and coronary atherosclerosis. More aggressive control of risk factors is justified in these patients.

ABCG2 polymorphism is associated with the low-density lipoprotein cholesterol response to rosuvastatin

The ATP-binding cassette G2 (ABCG2) c.421C>A (rs2231142) polymorphism influences the pharmacokinetics of rosuvastatin. We examined whether this polymorphism influences the low-density lipoprotein cholesterol (LDL-C)-lowering efficacy of the drug. In 305 Chinese patients with hypercholesterolemia who were treated with rosuvastatin at a dosage of 10 mg daily, the c.421A variant was found to be significantly associated with greater reduction in LDL-C level, in a gene-dose-dependent manner. As compared with subjects with the c.421CC genotype, those with the c.421AA genotype showed a 6.9% greater reduction in LDL-C level, which would be equivalent to the effect obtained by doubling the dose of rosuvastatin.

The NCEP-ATPIII but not the IDF criteria for the metabolic syndrome identify Type 2 diabetic patients at increased risk of chronic kidney disease

AIM

To examine the association between chronic kidney disease (CKD) and the metabolic syndrome (MetS) using both International Diabetes Federation (IDF) and National Cholesterol Education Program's Adult Treatment Panel III (NCEP-ATPIII) definitions in Chinese subjects with Type 2 diabetes.

METHODS

Subjects with Type 2 diabetes were categorized according to the presence or absence of MetS by IDF or NCEP-ATPIII criteria. CKD was considered present if glomerular filtration rate, calculated using the abbreviated equation developed by the Modification of Diet in Renal Disease study with Chinese modification, was < 60 ml/min per 1.73 m2. Multivariate logistic regression analysis of the association between CKD and MetS by either definition was performed.

RESULTS

Of 6350 subjects (mean age 55.1 +/- 13.3 years), 3439 (54.2%) and 3204 (50.5%) had MetS by IDF and NCEP-ATPIII definitions, respectively. Using the IDF definition, the presence of MetS was not associated with CKD [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.71, 1.29, P = 0.784]. In contrast, the association with CKD was significant when MetS was defined by the NCEP-ATPIII definition (OR 1.75, 95% CI 1.37, 2.24, P < 0.001). In subjects who did not have MetS (n = 2911) as defined by IDF criteria, 997 fulfilled the MetS criteria of NCEP-ATP III. The association with CKD was stronger, after adjustment for covariates, in these subjects (OR 1.42, 95% CI 1.03, 1.97, P = 0.032) compared with subjects who met IDF criteria of MetS.

CONCLUSION

In Type 2 diabetes, NCEP-ATPIII, but not the IDF definition of MetS, identifies a subgroup of patients who have a higher risk of CKD.

Burden of obesity--lessons learnt from Hong Kong Chinese

There is now a pandemic of chronic diseases in Asian countries, driven mainly by obesity, diabetes and cardio-renal complications. In Hong Kong, the reported prevalence of obesity, defined as body mass index (BMI) > or = 25 kg m(-2), varied from one-quarter to one-third of the population. In a population-based survey conducted in 1995, 16.7% of Hong Kong adults had the metabolic syndrome (MES) (National Cholesterol Education Programme criterion). Obesity is now a global concern not only in adults but also among children and adolescents. In 2003, a territory-wide survey in Hong Kong reported the prevalence of central obesity and MES to be 9.0% and 2.4%, respectively, in Chinese adolescents. Overweight, positive family history of diabetes and studying at schools of lower academic grading were independent risk factors for the adolescent MES. Lifestyle modification with proper diet and exercise is essential for health protection. In accord with western data, a weight management programme in Hong Kong Chinese with a 4-6% reduction in body weight or waist circumference was associated with significant reductions in all cardiovascular risk factors. Psychosocial factors related to chronic diseases are also of growing concern. In Hong Kong Chinese, increasing BMI was associated with a lower number of sleeping hours and increasing working hours, suggesting an intimate relationship between physical health and psychosocial stress. Chronic non-communicable diseases are therefore major health threats in Hong Kong, with obesity as one of the major risk factors. A multidimensional and multidisciplinary health promotion and disease management plan is urgently needed to control these epidemics.

The cost of obesity in Hong Kong

Obesity is now being considered a rapid growing economic burden on the healthcare system of many countries. These costs should include expenditure on prevention, as well as the investigation and treatment of obesity and its related problems. Accurate information on the cost of obesity in Hong Kong is lacking so we analysed the annual hospital discharges in a representative district hospital in Hong Kong. The estimated hospitalization costs in Hong Kong' public hospitals were HK$ 2.29 billion (US$ 0.29 billion) in 1998 and HK$ 3.36 billion (US$ 0.43 billion) in 2002 accounting for 8.2-9.8% of total public expenditure on health in Hong Kong. Based on the likelihood ratio of diabetes, hypertension and dylsipidaemia related to obesity in Hong Kong Chinese (defined as body mass index > or = 25 kg m(-2)) the estimated proportion of these conditions attributable to obesity are 10-20%. In addition, significant amounts of money are being spent by the public on obesity self management schemes of no proven benefit. In 2005, 5.5% of Hong Kong's total population was consuming proprietary drugs for obesity or its related conditions. To properly assess the overall costs of obesity, other indirect costs should also be considered such as economic losses on sick leave because of obesity and its related conditions.

Burden of obesity--lessons learnt from Hong Kong Chinese

There is now a pandemic of chronic diseases in Asian countries, driven mainly by obesity, diabetes and cardio-renal complications. In Hong Kong, the reported prevalence of obesity, defined as body mass index (BMI) > or = 25 kg m(-2), varied from one-quarter to one-third of the population. In a population-based survey conducted in 1995, 16.7% of Hong Kong adults had the metabolic syndrome (MES) (National Cholesterol Education Programme criterion). Obesity is now a global concern not only in adults but also among children and adolescents. In 2003, a territory-wide survey in Hong Kong reported the prevalence of central obesity and MES to be 9.0% and 2.4%, respectively, in Chinese adolescents. Overweight, positive family history of diabetes and studying at schools of lower academic grading were independent risk factors for the adolescent MES. Lifestyle modification with proper diet and exercise is essential for health protection. In accord with western data, a weight management programme in Hong Kong Chinese with a 4-6% reduction in body weight or waist circumference was associated with significant reductions in all cardiovascular risk factors. Psychosocial factors related to chronic diseases are also of growing concern. In Hong Kong Chinese, increasing BMI was associated with a lower number of sleeping hours and increasing working hours, suggesting an intimate relationship between physical health and psychosocial stress. Chronic non-communicable diseases are therefore major health threats in Hong Kong, with obesity as one of the major risk factors. A multidimensional and multidisciplinary health promotion and disease management plan is urgently needed to control these epidemics.

Metabolic syndrome in the Hong Kong community: the United Christian Nethersole Community Health Service primary healthcare programme 2001-2002

INTRODUCTION

With recognition of the important role of central obesity in metabolic syndrome (MES), the International Diabetes Federation (IDF) has proposed a revised definition for MES in early 2005. Information of MES in Chinese by IDF criteria is limited.

METHODS

This was a cross-sectional observation survey. A sample of 7,473 subjects (2,660 men and 4,813 women) was examined. They presented voluntarily in the period between August 2001 and September 2002 for health assessment at the three health centres of the United Christian Nethersole Community Health Service.

RESULTS

The mean age and standard deviation was 50.4 +/- 10.6 years (range 19-93 years, median 48.0 years). Among them, 30 percent had central obesity, 34 percent had low high-density lipoprotein cholesterol, 20 percent had hypertriglyceridaemia, 47 percent had high blood pressure, and 23 percent had dysglycaemia. The age-standardised percentages of MES by National Cholesterol Education Programme and IDF criteria were 18.3 and 13.9 percent, respectively.

CONCLUSION

MES is not uncommon among the Hong Kong Chinese community. Further studies on the management and prevention of MES are indicated.

Autoimmune polyendocrinopathy type II in a Chinese patient

Autoimmune polyendocrinopathy type II is rarely reported in Chinese patients. A 42-year-old Chinese woman with a history of Hashimoto's thyroiditis and hypogonadotropic hypogonadism presented with pneumonia. During hospitalisation, she went into an adrenal crisis and diabetic ketoacidosis. Subsequent dynamic hormonal tests revealed primary and secondary adrenal insufficiency. She also had pernicious anaemia, possible alopecia areata, and myasthenia gravis. This constellation of multiple endocrine and non-endocrine disorders led to the diagnosis of autoimmune polyendocrinopathy type II. As the syndrome can be lethal, it is important to maintain a high index of suspicion, enabling early diagnosis and the appropriate replacement therapy, to ensure a successful outcome.

Hong Kong men with low incomes have worse health-related quality of life as judged by SF-36 scores

OBJECTIVE

To analyse the association between income and health-related quality of life using the Medical Outcome Study Short Form 36 (SF-36) Chinese version in Hong Kong Chinese working population.

DESIGN

Cross-sectional observation study.

SETTING

A commercial company in Hong Kong.

PARTICIPANTS

All clerical and administrative staff of a commercial company was invited to participate; 876 of the 1003 staff agreed. The subjects were categorised into three income groups according to monthly income in Hong Kong dollars (low, < or =10,000; middle, >10,000-25,000; high, >25,000). The mean age of the 288 men and 588 women was 34.9 (standard deviation, 7.9; median, 34.0; range, 18-71) years.

MAIN OUTCOME MEASURES

SF-36 scores on health-related quality of life.

RESULTS

The distribution of income was 30% in high-, 54.8% in middle-, and 15.2% in low-income groups. Women had similar SF-36 scores among different income groups. In men, for most variables there was a significant positive linear correlation between income and SF-36 scores.

CONCLUSION

Low income is associated with a worse health-related quality of life in Hong Kong Chinese men.

Metabolic syndrome by the international diabetes federation definition in Hong Kong Chinese

In this report, we aimed to examine the impact of the new International Diabetes Federation (IDF) definition on the prevalence and clinical characteristics of subjects with metabolic syndrome (MES). Data were obtained from a prevalence survey for cardiovascular risk factors in a Hong Kong Chinese working population. There were 1513 subjects well representing all occupational groups from managers to general laborers [910 (60.1%) men and 603 (39.9%) women (mean age 37.5+/-9.2, median 37.0, range 18-66 years)]. The crude prevalence of MES defined by the IDF criterion was 7.4% (compared to other criteria: NCEP, 9.6%; WHO, 13.4% and EGIR, 8.9%). The age-standardized prevalence of MES by the IDF criterion was 8.8% in women and 7.3% in men. Subjects with MES defined by IDF criterion had higher body mass index and waist compared to those with MES defined by NCEP or WHO criteria, and lower triglyceride compared to those with MES defined by NCEP criterion after adjustment for age, gender and smoking. Non-MES subjects defined by IDF criterion had higher 2h glucose and insulin resistance compared to non-MES subjects defined by WHO. In conclusion, the new IDF criterion for MES is easy to implement in clinical practice. It may be potentially more 'specific' in identifying subjects with MES although compared to the NCEP criterion, it may have missed a proportion of subjects, especially men, who have metabolic derangement. Prospective and interventional studies are needed to validate the prognostic values of this new definition in comparison with other existing definitions.

Association between sleeping hours, working hours and obesity in Hong Kong Chinese: the 'better health for better Hong Kong' health promotion campaign

OBJECTIVE

To study the inter-relationships between sleeping hours, working hours and obesity in subjects from a working population.

RESEARCH DESIGN

A cross-sectional observation study under the 'Better Health for Better Hong Kong' Campaign, which is a territory-wide health awareness and promotion program.

SUBJECTS

4793 subjects (2353 (49.1%) men and 2440 (50.9%) women). Their mean age (+/-s.d.) was 42.4+/-8.9 years (range 17-83 years, median 43.0 years). Subjects were randomly selected using computer-generated codes in accordance to the distribution of occupational groups in Hong Kong.

RESULTS

The mean daily sleeping time was 7.06+/-1.03 h (women vs men: 7.14+/-1.08 h vs 6.98+/-0.96 h, P<0.001). Increasing body mass index (BMI) was associated with reducing number of sleeping hours and increasing number of working hours reaching significance in the whole group as well as among male subjects. Those with short sleeping hour (6 h or less) and long working hours (>9 h) had the highest BMI and waist in both men and women. Based on multiple regression analysis with age, smoking, alcohol drinking, systolic and diastolic blood pressure, mean daily sleeping hours and working hours as independent variables, BMI was independently associated with age, systolic and diastolic blood pressure in women, whereas waist was associated with age, smoking and blood pressure. In men, blood pressure, sleeping hours and working hours were independently associated with BMI, whereas waist was independently associated with age, smoking, blood pressure, sleeping hours and working hours in men.

CONCLUSION

Obesity is associated with reduced sleeping hours and long working hours in men among Hong Kong Chinese working population. Further studies are needed to investigate the underlying mechanisms of this relationship and its potential implication on prevention and management of obesity.

The efficacy and tolerability of fosinopril in Chinese type 2 diabetic patients with moderate renal insufficiency

BACKGROUND

The renoprotective effect of angiotensin II antagonists has been demonstrated in type 2 diabetic patients with nephropathy but similar data on angiotensin-converting enzyme (ACE) inhibitors are limited. We examined the efficacy and tolerability of fosinopril, an ACE inhibitor with dual hepatic and renal clearance, in 38 type 2 diabetic patients with moderate renal impairment (plasma creatinine 130-300 micromol/l) over a 2-year period.

METHODS

This was a single-centre, randomized, double-blinded, placebo-controlled trial comparing fosinopril 20 mg daily vs. placebo in addition to conventional antihypertensive treatment over a 2-year period. The primary endpoints were the rate of change and the percentage change in both 24-h urinary albumin excretion (UAE) and creatinine clearance (CrCl).

RESULTS

The mean age of the patients was 65 +/- 6 years (range 47-76 years, median 66 years) and plasma creatinine 190 +/- 49 micromol/l. For similar blood pressure control, the percentage change of UAE in patients with microalbuminuria was greater in the fosinopril than the placebo group (-24.2 +/- 28.8 vs. 11.6 +/- 42.1%, p = 0.003 after adjustment for baseline covariates). In the fosinopril group, the rate of change of endogenous CrCl was slower than the placebo group (-0.07 +/- 0.19 vs. -0.24 +/- 0.35 ml/min/week, p = 0.026). The incidence of adverse events was similar between the two groups.

CONCLUSIONS

Fosinopril treatment reduced albuminuria and rate of decline in renal function in type 2 diabetic patients with moderate renal insufficiency and did not increase the incidence of adverse events.

Effects of a structured health education programme by a diabetic education nurse on cardiovascular risk factors in Chinese Type 2 diabetic patients: a 1-year prospective randomized study

AIMS

To assess the effect of regular diabetic health education on cardiovascular risk factors in Chinese Type 2 diabetic patients.

METHODS

This was a 1-year prospective randomized study. One hundred and eighty Type 2 diabetic subjects were recruited from three regional diabetic centres in Hong Kong. Ninety received additional structured reinforcement of diabetic health education by a trained nurse after the doctors' consultations every 3 months (intervention group). The others received the same medical care except no nursing reinforcement (control group). Outcome measures included fasting plasma glucose, HbA(1c), body mass index, waist circumference, blood pressure and lipid profiles, which were assessed before the study and after 1 year.

RESULTS

Two of the controls defaulted follow-up. The intervention group and controls had similar age and sex distribution. At the end of study, the intervention group had reducted their waist circumference, diastolic blood pressure, HbA(1c), total cholesterol and low-density lipoprotein cholesterol levels. The controls had reduced their total cholesterol and low-density lipoprotein cholesterol levels. Other cardiovascular risk factors were not significantly changed in the controls. Addition of drugs and/or dosage increment of anti-diabetic drugs, lipid-lowering agents and anti-hypertensive agents were similar between the two groups.

CONCLUSIONS

Regular structured reinforcement with diabetic health education is useful. It helps to control more successfully some of the cardiovascular risk factors in Chinese Type 2 diabetic patients.

Effects of gender, Helicobacter pylori and hepatitis B virus serology status on cardiovascular and renal complications in Chinese type 2 diabetic patients with overt nephropathy

BACKGROUND

The aim of this study was to investigate whether chronic infections with Helicobacter pylori and hepatitis B virus (HBV) might affect clinical outcomes in Chinese type 2 diabetic patients with advanced nephropathy.

METHODS

A prospective study of 97 type 2 diabetic patients with clinical proteinuria and renal insufficiency (median serum creatinine 200 micro mol/l).

RESULTS

During a median follow-up period of 2 years, 34 developed end-stage renal disease (ESRD), 28 had cardiovascular endpoints and 11 patients had died (seven men and four women), and 52.7% developed a combined endpoint. Female patients had longer disease duration, higher blood pressure, lower body weight but higher serum creatinine and spot urine albumin : creatinine ratio as well as lower haemoglobin than male patients. On logistic regression analysis, female gender (hazard ratio: 5.91, p = 0.02), negative H. pylori serology (8.39, p = 0.004), baseline serum creatinine (1.04, p = 0.001) and haemoglobin (1.86, p = 0.01) were independent predictors for ESRD. Systolic blood pressure (1.04, p = 0.003), prior treatment with angiotensin-converting enzyme inhibitors or angiotensin II receptor antagonists (3.41, p = 0.04) and positive hepatitis B surface antigen (4.88, p = 0.025) were independent predictors for cardiovascular endpoints. Female gender (7.89, p = 0.002) and baseline serum creatinine (1.05, p < 0.001) were independent predictors for combined death and cardio-renal endpoints.

CONCLUSIONS

In Chinese type 2 diabetic patients with clinical proteinuria renal insufficiency, there were high rates of death and cardio-renal outcomes. Female gender, low haemoglobin and negative H. pylori serology were important predictors for ESRD, whereas chronic HBV infection was associated with increased cardiovascular risks.

Short-term effects after a 3-month aerobic or anaerobic exercise programme in Hong Kong Chinese

Information on the beneficial effects of exercise in Chinese concerning weight reduction and fat loss is limited. We studied 18 young, healthy Chinese volunteers and assessed the short-term effects of exercise on their anthropometric and biochemical parameters. They had not done regular exercise before the study and were randomly assigned to aerobic or anaerobic exercise group (9 subjects in each group). Professional trainers on aerobic and anaerobic exercise were invited to teach and supervise the whole group on the exercise programme. The study lasted 3 months with exercise of at least 3 sessions per week of 30 min each. Of the 18 subjects, 7 (38.9%) were men and 11 (61.1%) women. Their mean age was 28.9 +/- 3.6 yr (men: 29.6 +/- 4.2 yr, women: 28.5 +/- 3.4 yr, p value: NS). After the 3-month exercise programme, body weight and body mass index reduction were significant only in the aerobic group but not in the anaerobic one, while body fat percentage was improved in both groups. This suggests anaerobic exercise may increase the lean to fat body mass ratio. Plasma glucose was reduced in the aerobic group but not in the anaerobic one. Plasma insulin level was, otherwise, similar before and after exercise in both groups. This is compatible with a blunted insulin hormonal response to endurance exercise and an improved tissue sensitivity to insulin.

Dexfenfluramine and heart-valve regurgitation in Chinese patients with type 2 diabetes

OBJECTIVE

To assess whether valvular lesions are associated with the use of dexfenfluramine in Chinese patients with type 2 diabetes.

DESIGN

Case-control study.

PATIENTS AND METHODS

Thirty-six obese Chinese patients with type 2 diabetes and a history of dexfenfluramine use during the period January 1992 and September 1997 were recruited into the study, while another 43 age- and sex-matched Chinese patients with type 2 diabetes were recruited as controls. The mean age for the cases was 44.1 years (standard deviation, 11.2 years; median, 42.5 years; range, 20-64 years). The 43 control subjects were age- and sex-matched, and had a mean age of 48.5 years (standard deviation, 10.9 years; median, 51.0 years; range, 16-63 years; P>0.05). The male-to-female ratio was confirmed as similar between the two groups (10:26 versus 12:31; P>0.05). All patients were clinically free from cardiovascular disease. Patients with a history of underlying valvular disease from any cause were excluded from the study. All patients underwent echocardiographic assessment, and the presence of any valvular lesions was documented.

RESULTS

The mean duration of dexfenfluramine use by the cases was 21.8 weeks (standard deviation, 29.0 weeks; median, 18.0 weeks; range, 1-160 weeks). Subjects with a history of dexfenfluramine use had higher rates of significant aortic regurgitation, tricuspid regurgitation of any severity, and of any valvular regurgitation, compared to controls (11.1% versus 0%, P<0.05; 30.6% versus 4.7%, P<0.01; and 61.1% versus 34.9%, P<0.05, respectively). Logistic stepwise regression analysis to predict the risk of valvular lesion was conducted, with age, sex, history of dexfenfluramine use, body mass index, waist-hip ratio, blood pressure, fasting plasma glucose, lipid profile, and duration of diabetes as independent variables. A history of dexfenfluramine use was the only significant parameter entered into the model (significant aortic regurgitation: beta=9.19, standard error=46.6, P<0.05; any tricuspid regurgitation: beta=2.76, standard error=10.8, P<0.05).

CONCLUSION

In Chinese patients with type 2 diabetes, a history of dexfenfluramine use is associated with heart-valve regurgitation, particularly aortic regurgitation.

Triglyceride, albuminuria and blood pressure are the major associations of non-fatal cardiovascular disease in Chinese type 2 diabetes

Diabetes is associated with an increased risk of cardiovascular disease (CVD). We studied risk factors for CVD in a cohort of Chinese type 2 diabetic patients recruited between July 1994 and August 1998. Ischemic heart disease (IHD) was defined as a history of: (i) confirmed coronary artery disease (with typical electrocardiographic changes or a positive exercise tolerance test) in patients under care of a cardiologist; (ii) documented myocardial infarction; or (iii) coronary interventions such as angioplasty or coronary artery bypass graft. Cerebrovascular accident (CVA) was defined as any definite cerebral vascular event with or without residual neurological deficit. CVD was defined as a history of IHD or CVA. The study enrolled 3333 patients, including 1370 men (41.1%) and 1963 women (58.9%) of mean age 55.9+/-13.3 years (range, 16-91 years; median, 57 years). A total of 279 patients (8.4%) had CVD (including 4.1% with CVA, 4.9% with IHD, and 0.6% with both CVA and IHD). Men had an overall higher rate of CVD than women (10.1% vs. 7.1%, p=0.002). All cardiovascular diseases showed a progressive increase in prevalence with increasing age with the peak among those aged </=60 years. Logistic regression analysis was used to examine the predictive value of age, body mass index, waist-to-hip ratio, blood pressure, fasting plasma glucose, glycated hemoglobin, lipid profiles, albuminuria, smoking and family history of diabetes on the risk of CVD. In women, age, systolic blood pressure and triglyceride level and in men, age and albuminuria, were predictive for CVD. In conclusion, 8.4% of Hong Kong Chinese type 2 diabetic patients being followed in a hospital out-patient setting have a history of established and confirmed cardiovascular disease. Age, systolic blood pressure, triglyceride and albuminuria were the major independent risk factors for non-fatal cardiovascular diseases.

Obesity and cardiovascular risk factors in Hong Kong Chinese

The purpose of this cross-sectional study was to examine the risk associations between obesity indexes [body mass index (BMI) and waist circumference (WC)], cardiovascular risk factors [plasma glucose and lipids, blood pressure and urinary albumin excretion (UAE)] and morbidity conditions (Type 2 diabetes mellitus, hypertension, dyslipidaemia and/or albuminuria) in Hong Kong Chinese. Seven-hundred and two Hong Kong Chinese subjects (18-65 years of age, 59.4% of whom had at least one morbidity condition) were recruited from the Prince of Wales Hospital, Hong Kong SAR. The measurements taken of the subjects included: height; weight; waist and hip circumferences; blood pressure; fasting plasma glucose and lipids; and 24-h UAE. The mean BMI was 22.4 and 25.7 kg m(-2) in healthy subjects and patients, respectively. The mean WC measurements of healthy subjects and patients were 77.1 and 86.4 cm in males and 71.0 and 81.8 cm in females, respectively. There were increasing trends between obesity indexes and the severity of cardiovascular risk factors and the prevalence of morbidity conditions (all P-values for trend <0.05). Using 19.0-20.9 kg m(-2) and <70 cm as a referent, subjects with a BMI of > or =25.0 kg m(-2) (in both sexes) and/or a WC of > or =85 cm in males and > or =75 cm in females had an age-adjusted odds ratio between 3.2 and 4.4 for the occurrence of at least one morbidity condition. Patients with a greater number of comorbidities also had higher BMI and WC measurements (all P-values for the trend were <0.05 with adjustment for age and gender). Hence, despite Hong Kong Chinese being less obese than Caucasians, the intimate relationships among obesity, cardiovascular risk factors and morbidity conditions remain. Our data support using lower BMI and WC levels to define obesity and its associated health risks rather than using the criteria established from Caucasians who generally have larger body frames.

The central roles of obesity-associated dyslipidaemia, endothelial activation and cytokines in the Metabolic Syndrome--an analysis by structural equation modelling

HYPOTHESIS

The multi-faceted components of the metabolic syndrome now include markers of inflammation and endothelial activation. Despite this growing body of epidemiological data, standard statistical methods fail to evaluate the nature of these associations adequately. In this pilot study, we hypothesize that obesity may lead to endothelial activation which is in part mediated by dyslipidaemia and proinflammatory cytokines. These factors interact to give rise to hyperinsulinaemia, hypertension and an anti-fibrinolytic state. To test this hypothesis, we used confirmatory factor analysis and structural equation modelling to fit these data to a model designed on theoretical grounds.

METHODS

Metabolic syndrome variables, cytokines (IL6 and TNFalpha), markers of inflammation and endothelial activation were measured in 107 Caucasian non-diabetic subjects aged 40-75 y. Using confirmatory factor analysis, we identified six factors to represent composite measurements of blood pressure, obesity, dyslipidaemia, hyperinsulinaemia, endothelial activation and the anti-fibrinolytic state. We fitted these variables to two separate models, one using IL-6 and the other TNFalpha as the cytokine, and examined the inter-relationships (path analysis) amongst these variables, based on the above hypothesis.

RESULTS

Men were centrally more obese and had increased markers of endothelial activation, inflammation and the anti-fibrinolytic state as well as hyperinsulinaemia and dyslipidaemia, compared with women. Obesity indexes (both body mass index and waist-hip ratio) were strongly associated with multiple cardiovascular risk factors. Both IL6 and TNFalpha were correlated with age, male gender, obesity indexes and markers of endothelial activation. Only IL-6 was associated with smoking while TNFalpha was correlated with hyperinsulinaemia. In the TNFalpha model, 61% of the obesity variance was explained by male gender, 36% of TNFalpha variance by age and dyslipidaemia, 43% of dyslipidaemia variance by age and obesity, 33% of hyperinsulinaemia variance by dyslipidaemia and a non-smoking state, 29% of anti-fibrinolytic state variance by hyperinsulinaemia, 65% of endothelial activation variance by TNFalpha, dyslipidaemia and hyperinsulinaemia, 34% of blood pressure variance by hyperinsulinaemia and endothelial activation. In the IL-6 model, we observed similar relationships except that 23% of IL6 variance was explained by smoking and age.

CONCLUSIONS

Using confirmatory factor analysis and structural equation modelling, we found that obesity, dyslipidemia and cytokines were the principal explanatory variables for the various components of the metabolic syndrome, with IL6 and TNFalpha having different explanatory variables and effects. These complex inter-relationships were in part mediated by hyperinsulinaemia and endothelial activation. While this hypothetical model was based on scientific evidence, supported by rigorous analysis, it requires further confirmation in large-scale prospective studies. Given the complexity of the biological system and its interactions with exogenous factors, structural equation modelling provides a useful scientific tool for hypothesis testing, complementary to the more traditional experimental and cohort studies.