Body Roundness Index Is Better Correlated with Insulin Sensitivity than Body Shape Index in Young and Middle-Aged Japanese Persons

Aims: The present study aimed to clarify the relationships between novel and traditional anthropometric indices and insulin sensitivity (SI) in young and middle-aged Japanese persons with normal glucose tolerance (NGT), and middle-aged Japanese persons with NGT and glucose intolerance. Methods: Plasma glucose and insulin levels were measured in 1270 young (age <40 years) and 2153 middle-aged persons with NGT (n = 1531) and glucose intolerance (n = 622) during a 75-g oral glucose tolerance test. Height (Ht), weight, and waist circumference (WC) were measured. The body mass index (BMI), WC, and the WC/Ht ratio were used as traditional anthropometric indices. A body shape index (ABSI) and the body roundness index (BRI) were calculated as novel indices. Indices of SI (Matsuda index and 1/homeostasis model assessment of insulin resistance) were calculated and compared with anthropometric indices. Results: The ABSI showed a weak correlation with SI indices in all groups. The BRI showed almost the same correlation with SI indices as the BMI, WC, and WC/Ht in all groups. The inverse correlation between each of the anthropometric indices other than ABSI and SI indices was weak in young persons, at 0.16-0.27 (Spearman's ρ values), but strong in middle-aged persons, at 0.38-1.00. On receiver-operating characteristic (ROC) curve analysis for detection of insulin resistance, the ABSI had a lower area under the ROC curve (AUC) than the other anthropometric indices, and the BRI and the WC/Ht ratio showed similar AUCs. The AUCs for the BRI and WC/Ht ratio were the highest in middle-aged men with NGT and glucose intolerance. Conclusions: The BRI, not the ABSI, was better correlated with SI in young and middle-aged Japanese persons. The BRI and WC/Ht ratio were comparable in their correlations with SI and the detection of insulin resistance in the participants of the present study.

LBODP051 Relation Of The Quadrumvirate ― Hepatic Steatosis, High Normal Fasting Glucose, And Attenuated Whole Body-insulin Sensitivity And Glucose-stimulated Acute Insulin Secretion ― To Incident Prediabetes, The Beginning Of Type 2 Diabetes

Type 2 diabetes begins as conversion of normal glucose metabolism (NGM) to prediabetes, and 5-10% per year of people with prediabetes progress to diabetes. Therefore, understanding evolution of prediabetes is mandatory to know how type 2 diabetes starts. However, the process of conversion of NGM to prediabetes, which may be ethnicity-specific, has poorly been investigated. We analyzed 599 Japanese adults with NGM (fasting plasma glucose (FPG) <100 mg·dL-1 and 2-h PG at 75 g oral glucose tolerance (OGTT) <140 mg·dL-1) (male 62%, the mean age, body mass index (BMI), fasting IRI/FPG and 2-h IRI/PG, 52 years, 23.1 kg·m-2, 4.1 μU·mL-1/92 mg·dL-1 and 24.5 μU·mL-1/104 mg·dL-1, respectively). They received follow-up OGTTs at a mean of 3.7 years later (2,061 person-years observation). Prediabetes developed in 179 (impaired fasting glucose 102, impaired glucose tolerance 39, and impaired fasting glucose/impaired glucose tolerance 28). By the screening univariate analysis, Fatty Liver Index (FLI), FPG, ISIMATSUDA (index of basal and post-glucose whole body insulin sensitivity (Si) and Stumvoll's first phase (Stumvoll-1, an index of glucose-stimulated acute (∼10 min) insulin secretion (Isec) were robust risk factors for incident prediabetes. In contrast, indices of basal Si such as HOMA-IR, and basal, 30 min, or later phase index of Isec such as HOMAbeta and insulinogenic index, respectively, were not significant risk for prediabetes. In multivariate Cox model adjusted for age and sex, HR (95%CI) per 1 IQR increase were FLI 1.303 (1. 063-1.586), P <0. 01; FPG 1.400 (1. 076-1.840), P <0. 01; ISIMATSUDA 0.841 (0.712-0.963), P = 0. 03; Stumvoll-1 0.764 (0.622-0.935) P <0. 01. Note that FLI and FPG are risk factors and ISIMATSUDA and Stumvoll-1 are protective factors. Notably, FLI was a risk even after adjustment for BMI. The best cutoff values differentiating prediabetes Progressors from Nonprogressors obtained by the ROC curve using entire range of each risk factor was ≥12.4 for FLI, ≥95 mg·dL-1 for FPG, ≤11.99 for ISIMATSUDA and ≤486.3 for Stumvoll-1, and incidence of prediabetes was progressively high as 10/127 (6%), 34/153 (22%), 56/189 (30%), 53/106 (50%) and 16/24 (67%) among the participants with no, one, two, three and four unfavorable discriminating values for progression, respectively. AUC of ROC curve (AUROC) for the combination of the quadrumvirate was as large as 0.729 (0.661-0.788) with high precision as sensitivity 73.4% and specificity 63.8%. In conclusion, at the beginning of type 2 diabetes in the Japanese population who are non-obese and insulin-sensitive as shown, hepatic steatosis, the high normal FPG, attenuation of whole-body insulin sensitivity, lowered acute phase glucose-induced insulin release (the quadrumvirate) are synergistically and independently, with comparable strength each other, related to the development of prediabetes.

Presentation: No date and time listed

Hepatic Steatosis and High-normal Fasting Glucose as Risk Factors for Incident Prediabetes

Context

The role of hepatic steatosis (HS) in the initial stages of developing type 2 diabetes remains unclear.

Objective

We aimed to clarify the impact of HS indexed by Fatty Liver Index (FLI) and high-normal fasting plasma glucose (FPG) as risk factors for incident prediabetes in a nonobese cohort.

Methods

Data from 1125 participants with ADA-defined normal glucose metabolism (median age 52 years; BMI 23.1 kg/m²) were used for retrospective analysis. In the entire population, correlation between normal FPG and FLI was evaluated by multiple regression adjusted for age and sex. Follow-up data from 599 participants in whom 75-g OGTT was repeated 3.7 years later showed that 169 developed prediabetes. This was analyzed by the multivariate Cox proportional hazards model.

Results

In the entire population, FLI was positively correlated with FPG (P < 0.01): mean FLI increased from 15.8 at FPG 4.2 mmol/L to 31.6 at FPG 5.5 mmol/L. Analysis of the 599 participants (2061 person-years) by Cox model, adjusted for sex, age, family history of diabetes, ISI_MATSUDA, and Stumvoll-1, clarified an increased risk of prediabetes with high-normal FPG and FLI. Risk was increased 2.2 times with FLI ≥ 16.5 vs FLI < 16.5, P < 0.001, and increased 2.1 times in participants with FPG ≥ 5.3 mmol/L, P < 0.001. Cutoff values (unadjusted) were obtained by ROC at the point of the largest Youden’s index using the entire range of the variables.

Conclusion

Even among nonobese individuals, HS indexed by FLI and a high-normal FPG (≥ 5.3 mmol/L) are risk factors for prediabetes, independently from insulin.

Accuracy of 1-Hour Plasma Glucose During the Oral Glucose Tolerance Test in Diagnosis of Type 2 Diabetes in Adults: A Meta-analysis

OBJECTIVE

One-hour plasma glucose (1-h PG) during the oral glucose tolerance test (OGTT) is an accurate predictor of type 2 diabetes. We performed a meta-analysis to determine the optimum cutoff of 1-h PG for detection of type 2 diabetes using 2-h PG as the gold standard.

RESEARCH DESIGN AND METHODS

We included 15 studies with 35,551 participants from multiple ethnic groups (53.8% Caucasian) and 2,705 newly detected cases of diabetes based on 2-h PG during OGTT. We excluded cases identified only by elevated fasting plasma glucose and/or HbA_1c. We determined the optimal 1-h PG threshold and its accuracy at this cutoff for detection of diabetes (2-h PG ≥11.1 mmol/L) using a mixed linear effects regression model with different weights to sensitivity/specificity (2/3, 1/2, and 1/3).

RESULTS

Three cutoffs of 1-h PG, at 10.6 mmol/L, 11.6 mmol/L, and 12.5 mmol/L, had sensitivities of 0.95, 0.92, and 0.87 and specificities of 0.86, 0.91, and 0.94 at weights 2/3, 1/2, and 1/3, respectively. The cutoff of 11.6 mmol/L (95% CI 10.6, 12.6) had a sensitivity of 0.92 (0.87, 0.95), specificity of 0.91 (0.88, 0.93), area under the curve 0.939 (95% confidence region for sensitivity at a given specificity: 0.904, 0.946), and a positive predictive value of 45%.

CONCLUSIONS

The 1-h PG of ≥11.6 mmol/L during OGTT has a good sensitivity and specificity for detecting type 2 diabetes. Prescreening with a diabetes-specific risk calculator to identify high-risk individuals is suggested to decrease the proportion of false-positive cases. Studies including other ethnic groups and assessing complication risk are warranted.

A case of renovascular hypertension with incidental primary bilateral macronodular adrenocortical hyperplasia

SUMMARY

Renovascular hypertension (RVHT) is an important and potentially treatable form of resistant hypertension. Hypercortisolemia could also cause hypertension and diabetes mellitus. We experienced a case wherein adrenalectomy markedly improved blood pressure and plasma glucose levels in a patient with RVHT and low-level autonomous cortisol secretion. A 62-year-old Japanese man had been treated for hypertension and diabetes mellitus for 10 years. He was hospitalized because of a disturbance in consciousness. His blood pressure (BP) was 236/118 mmHg, pulse rate was 132 beats/min, and plasma glucose level was 712 mg/dL. Abdominal CT scanning revealed the presence of bilateral adrenal masses and left atrophic kidney. Abdominal magnetic resonance angiography demonstrated marked stenosis of the left main renal artery. The patient was subsequently diagnosed with atherosclerotic RVHT with left renal artery stenosis. His left adrenal lobular mass was over 40 mm and it was clinically suspected the potential for cortisol overproduction. Therefore, laparoscopic left nephrectomy and adrenalectomy were simultaneously performed, resulting in improved BP and glucose levels. Pathological studies revealed the presence of multiple cortisol-producing adrenal nodules and aldosterone-producing cell clusters in the adjacent left adrenal cortex. In the present case, the activated renin-angiotensin-aldosterone system and cortisol overproduction resulted in severe hypertension, which was managed with simultaneous unilateral nephrectomy and adrenalectomy.

LEARNING POINTS

Concomitant activation of the renin-angiotensin-aldosterone system and cortisol overproduction may contribute to the development of severe hypertension and lead to lethal cardiovascular complications. Treatment with simultaneous unilateral nephrectomy and adrenalectomy markedly improves BP and blood glucose levels. CYP11B2 immunohistochemistry staining revealed the existence of aldosterone-producing cell clusters (APCCs) in the adjacent non-nodular adrenal gland, suggesting that APCCs may contribute to aldosterone overproduction in patients with RVHT.

SUN-LB110 The Nutrition Education Using a Health Care Application With Artificial Intelligence in Patients With Diabetes Mellitus

Background: Diet control is the basis of the treatment of type 2 diabetes. However, the education and practice of diet control for the patients with type 2 diabetes mellitus (T2DM) need a lot of manpower and time. In 2009, we have developed a telemedicine model that nutritionists analyze photos of T2DM patients’ meal and supervise them remotely. Our system resulted in the improvement of glycemic control of T2DM patients. Recently, the image analysis technology using the artificial intelligence (AI) progresses rapidly. The smart device application “Asken” has an AI-powered photo analysis system which analyzes the photo of the entire meal and identifies the frame of each item as well as its menu and serving amount. In addition, this application delivers individualized dietary messages and feedbacks. Case reports: We report two T2DM cases who conducted nutrient intervention by this application. One case was a 72-year-old man whose HbA1c decreased from 7.2% to 6.6% and weighed from 58.7kg to 57.5kg in 4 months. However, his total cholesterol increased from 119mg/dl to 200mg/dl, and low-density lipoprotein cholesterol (LDL) also increased from 47mg/dl to 106mg/dl. Another case is a 60-year-old man whose HbA1c improved from 7.0% to 6.6% and his weight decreased from 78.0kg to 76.0kg in 3 months. Total cholesterol was 140mg/dl to 128mg/dl, and LDL-cholesterol was from 65mg/dl to 54mg/dl. Conclusion: Using this application might be useful for diet control of T2DM patients. The effects of AI-supported nutrient intervention using application like this should be further clarified in the large number of patients.

MON-LB304 The Construction of the Online Health Guidance Service for Life-Style Related Diseases (Kanazawa Slim Study)

Background: Metabolic syndrome is a cluster of metabolic disorders including elevated blood pressure, high plasma glucose, excess body fat around the waist, and abnormal cholesterol or triglyceride levels. These conditions cause serious complications such as heart disease, stroke and type 2 diabetes. In Japan, specific health checkups and specific health guidance which focused on metabolic syndrome has been performed since 2008. Those who fall under certain criteria need to receive a medical treatment guidance from doctor, public health nurse or dietitian. Those who received health guidance receives a reassessment of improvement of their life-style 3-6 months later. However, the efficacy of this approach has not been elucidated. In addition, many persons who have metabolic syndrome do not receive this instruction. Recently, the image analysis technology using the artificial intelligence (AI) progresses rapidly. The smart device application “Asken” has an AI-powered photo analysis system which analyzes the photo of the entire meal, and delivers individualized messages and dietary feedbacks. In this study, we utilized the Internet of Things (IoT) device which includes Asken app, body composition analyzer and sphygmomanometer that can connect wirelessly. Objective: Our aim is to assess the efficacy of specific health guidance adding on IoT device. This is a multicenter, unblinded, non-randomized controlled study. Results: At the end of January 2020, we recruited 219 participants including 105 participants with IoT devices. We used 48 participants (32 with IoT and 16 without IoT) who had finished a reassessment 3 to 6 months after initial guidance. Results: Age, body weight (BW), body mass index (BMI), blood pressure (BP), fasting plasma glucose (FPG), hemoglobin A1c (HbA1c), total cholesterol (T-Chol), high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), non-HDL cholesterol (n-HDL), and triglyceride (TG), did not differ between IoT-use and control group. 6 months after initial guidance, the quantity of decrease of BW in IoT-use group was significantly larger than control (-2.5 ± 4.1 kg vs. 0.6±4.4, p = 0.03). In addition, the quantities of decrease of both T-Chol and n-HDL in IoT-use group were also significantly larger than control (T-Chol, -5.9 ± 32.0 vs. 14.3 ± 31.6, p = 0.02; n-HDL, -7.6 ± 29.0 vs. 9.4 ± 27.5, p = 0.01). Conclusion: Using IoT device might be useful for body weight loss and the improvement of mild hypercholesterolemia in those with metabolic syndrome.

[Actual state of injection techniques and effect of medical treatment instructions in elderly patients with diabetes using insulin]

AIM

Support for elderly patients using insulin to continue self-injection safely is required for clinical settings. The aim of this study was 1) to clarify the actual state of self-injection procedures for elderly people injecting insulin and 2) to verify whether or not the injection procedures can be improved by nurses' medical treatment instructions.

SUBJECTS AND METHODS

The subjects were outpatients at an educational facility certified by the Japan Diabetes Society. Basic clinical characteristics, the Mini-Cog cognitive function test, basic ADL and instrumental ADL, and 24 items of the self-injection procedure were evaluated by nurses. After receiving a 30-minute face-to-face session of individual instructions from trained nurses two or more times, the injection procedure was re-evaluated.

RESULTS

Of the 63 study subjects, 10 were injecting insulin with the support of others (supported injection group). The median age in the self-injection group was 72 years old, while that in the supported injection group was 82 years old. The supported injection group was older, the female ratio higher, and the Mini-Cog and ADL indices lower than in the self-injection group (p <0.05). The median history of the use of insulin was over 10 years in both groups. In the self-injection group, the degree of proficiency with the injection technique was significantly improved after receiving the instructions (p <0.05). The biggest improvement was in response to the question, "Do you know that you need to shift the site of injections?", which doubled (p <0.05). The correct answer rate for "Do you know the name of your insulin formulation?" was less than half, and it remained unchanged even after receiving instructions. In the supported injection group, 90% had a Mini-Cog of ≤2 points, but 6 subjects (60%) were able to perform an injection by themselves with others supporting the adjustments made to the amount of insulin.

CONCLUSIONS

The self-injection technique improved significantly, even in elderly people, following the delivery of medical treatment instructions by nurses, and the item with the highest improvement effect was subjects' understanding of the need to shift the injection site. Our study showed that even in elderly people with cognitive dysfunction who are performing injections with the support of others, some of the injection procedures were retained by relying on procedural memory acquired in the past.

[Successful treatment of severe sulfonylurea-induced hypoglycemia by the subcutaneous administration of octreotide in an elderly patient with diabetes: A case report]

Sulfonylureas, a potent stimulator of insulin release from pancreatic β cells, can cause hypoglycemia, which is apt to recur with a prolonged duration in elderly patients. Octreotide acetate, a long-acting somatostatin analogue, suppresses the secretion of insulin and is recognized as a possible treatment for sulfonylurea-induced hypoglycemia. However, there are few reports on its use in an actual clinical setting, especially in the elderly. We herein report a case in which subcutaneous injection of octreotide was effective for treating prolonged and recurrent hypoglycemia caused by sulfonylureas in an elderly man. An 89-year-old man was transported to the emergency department of our hospital for disturbance of consciousness in the morning. He had been treated for type 2 diabetes with 0.5 mg glimepiride, with the most recent HbA1c measurement being 5.7%. His plasma glucose level was low (22 mg/dL), and he was in a coma (Japan Coma Scale: 300). Under a diagnosis of hypoglycemic coma caused by sulfonylurea, we dripped 10% glucose solution and administered 50% glucose solution every 1 to 2 h through a peripheral vein, but his hypoglycemia recurred several times. Finally, 50 μg octreotide was subcutaneously injected. Thereafter, hypoglycemia did not recur, and additional injections of 50% glucose solution were not required. The same dose of octreotide was additionally administered after 8 h. In conclusion, the subcutaneous injection of octreotide can be an effective and safe method of treating prolonged hypoglycemia caused by sulfonylureas in the elderly.

Study Protocol for the Effects of Artificial Intelligence (AI)-Supported Automated Nutritional Intervention on Glycemic Control in Patients with Type 2 Diabetes Mellitus

INTRODUCTION

Nutritional intervention is effective in improving glycemic control in patients with type 2 diabetes but requires large inputs of manpower. Recent improvements in photo analysis technology facilitated by artificial intelligence (AI) and remote communication technologies have enabled automated evaluations of nutrient intakes. AI- and mobile-supported nutritional intervention is expected to be an alternative approach to conventional in-person nutritional intervention, but with less human resources, although supporting evidence is not yet complete. The aim of this study is to test the hypothesis that AI-supported nutritional intervention is as efficacious as the in-person, face-to-face method in terms of improving glycemic control in patients with type 2 diabetes.

METHODS

This is a multicenter, unblinded, parallel, randomized controlled study comparing the efficacy of AI-supported automated nutrition therapy with that of conventional human nutrition therapy in patients with type 2 diabetes. Patients with type 2 diabetes mainly controlled with diet are to be recruited and randomly assigned to AI-supported nutrition therapy (n = 50) and to human nutrition therapy (n = 50). Asken, a mobile application whose nutritional evaluation has been already validated to that by the classical method of weighted dietary records, has been specially modified for this study so that it follows the recommendations of Japan Diabetes Society (total energy restriction with proportion of carbohydrates to fat to protein of 50-60, 20, and 20-30%, respectively).

PLANNED OUTCOMES

The primary outcome is the change in glycated hemoglobin levels from baseline to 12 months, and this outcome is to be compared between the two groups. The secondary outcomes are changes in fasting plasma glucose, plasma lipid profile, body weight, body mass index, waist circumference, blood pressures, and urinary albumin excretion. The results of this randomized controlled trial will fill the gap between the demand for support of AI in nutritional interventions and the scientific evidence on its efficacy.

TRIAL REGISTRATION

UMIN000032231.

Severe Mitral Regurgitation As a Result of Rupture of Mitral Valve Chordae Tendineae in a Patient With Graves Disease

Mitral valve prolapse is a common disorder, but severe mitral regurgitation (MR) as a result of rupture of mitral valve chordae tendineae is a rare manifestation of thyrotoxic heart disease. There are limited reports with respect to the onset of severe MR as a complication of Graves disease. We report a case of a 60-year-old woman with Graves disease and thyroid-associated ophthalmopathy as her past history. She had signs of congestive heart failure, a loud murmur as a result of MR, clinical cardiomegaly, and peripheral edema. Echocardiographic and angiographic data were consistent with moderate to severe MR. She also had thyrotoxicosis caused by the recurrence of Graves disease. She was taking methiamazole, a beta-blocker, hydrocortisone, and potassium iodide. Ultimately, thyroidectomy was performed to improve her hyperthyroid state. After normalization of her thyroid status, she continued to have moderate to severe MR, and mitral valve repair was performed. The present case had severe MR as a result of rupture of mitral valve chordae tendineae, which is considered rare in a patient with Graves disease.

[The status of glycemic control and hypoglycemia in elderly patients visiting the outpatient department specializing in diabetes]

AIM

The Japan Diabetes Society (JDS)/Japan Geriatrics Society (JGS) Joint Committee reported 'Glycemic Targets for Elderly Patients with Diabetes' in 2016. Based on this recommendation, we aimed to clarify 1) the achievement status of glycemic targets in the elderly and 2) the presence of hypoglycemia in real life among elderly individuals with an HbA1c below the lower limit.

SUBJECTS AND METHODS

[Analysis I] In 326 elderly with diabetes ≥65 years of age visiting the outpatient department specializing in diabetes, the proportions of patients with HbA1c values below the lower limit and the use of drugs potentially associated with severe hypoglycemia (e.g. insulin formulations, sulfonylureas, glinides) were investigated. [Analysis II] Of the patients with HbA1c values below the lower limit, seven were tested for hypoglycemia in real life using a continuous glucose monitoring system (CGM).

RESULTS

[Analysis I] Among the 326 subjects, 235 (72.1%) were using drugs potentially associated with severe hypoglycemia, and 63 (19.3%) had an HbA1c value below the lower limit. [Analysis II] In the seven patients examined using CGM, hypoglycemia was detected in five, all of whom were unaware.

CONCLUSIONS

A considerable number of elderly patients were taking drugs associated with hypoglycemic risks and had an HbA1c value below the lower limit, some of whom actually had hypoglycemia as detected by CGM. Using tools such as CGM, preventive measures against hypoglycemia should be taken.

Effect of sodium glucose cotransporter 2 inhibitors on obstructive sleep apnea in patients with type 2 diabetes

Obstructive sleep apnea syndrome (OSAS) is often associated with metabolic disorders such as obesity and type 2 diabetes and may contribute to cardiovascular events. A novel class of antidiabetic drugs, the sodium glucose cotransporter 2 inhibitors (SGLT2i) reduce body weight (BW), although there is limited data on their impact on OSAS. We therefore evaluated the effect of SGLT2i on OSAS in patients with type 2 diabetes. The presented study was a retrospective design in 18 patients with type 2 diabetes with OSAS (4 males, age range 39-81 yr) administrated a SGLT2i. HbA1c, BW, body mass index (BMI), blood pressure (BP) and apnea hypopnea index (AHI) were evaluated before and after SGLT2i administration. The relationships between the reduction in AHI and the other variables were examined using Pearson correlation analysis. We have got result that SGLT2i reduced AHI from 31.9 ± 18.0 to 18.8 ± 11.5 events per hr (p = 0.003). HbA1c, BW and BMI decreased significantly, whereas BP did not. The Pearson correlation analysis showed a significant relationship between the reduction in AHI and pre-administration of AHI. In conclusion, SGLT2i reduced not only HbA1c, BW and BMI but also AHI significantly and therefore has potential as an effective treatment of OSAS.

Insulin Secretion and Risk for Future Diabetes in Subjects with a Nonpositive Insulinogenic Index

AIM

To characterize subjects with a nonpositive insulinogenic index and longitudinally observe changes in their glucose tolerance.

SUBJECTS AND METHODS

A historical cohort study was conducted using data from the medical checkups of public school workers. Indices of insulin secretion and insulin sensitivity derived from oral glucose tolerance test (OGTT) and the incidences of diabetes and impaired glucose tolerance (IGT) were compared among subgroups of subjects with different insulinogenic index (change in insulin/change in glucose over the first 30 min on the OGTT).

RESULTS

Of the 1464 nondiabetic subjects at baseline, 72 (4.9%) subjects had a nonpositive insulinogenic index: 42 of those subjects had a nonpositive glucose response (ΔGlu_0-30 ≤ 0) and 30 had a nonpositive insulin response (ΔIns_0-30 ≤ 0). Compared with subjects who had normal glucose tolerance (NGT) with insulinogenic index ≥ 0.4, subjects with a nonpositive glucose response had a higher first-phase Stumvoll and lower incidences of diabetes and IGT based on a log-rank test (p < 0.05), whereas subjects with a nonpositive insulin response had lower indices of insulin secretion and a higher incidence of diabetes (p < 0.05).

CONCLUSIONS

These results demonstrate that in the first 30 min on the OGTT, subjects with a nonpositive insulinogenic index due to a nonpositive glucose response (ΔGlu_0-30 ≤ 0) had a lower risk for future diabetes and that subjects with nonpositive insulin response (ΔIns_0-30 ≤ 0) had a higher risk for future one.

Associations between Sleep-Disordered Breathing and Metabolic Risk Factors beyond Obesity

OBJECTIVE

Individuals with multiple metabolic risk factors often experience concomitant sleep-disordered breathing (SDB). We aimed to determine the associations of SDB with individual components of metabolic syndrome independent of obesity.

METHODS

A cross-sectional study was conducted in 1137 employees aged 30-64 years. Apnea-hypopnea index (AHI) was assessed using a portable monitor for obstructive sleep apnea by admission. Of these, 451 participants took an oral glucose tolerance test to assess homeostatic model assessment of insulin resistance (HOMA-IR) and Matsuda insulin sensitivity index (ISI).

RESULTS

The odds ratio (OR) of the highest category of the AHI (≥15 episodes per hour) compared to the lowest one (<5 episodes per hour) was significantly elevated for hypertension, for hypertriglyceridemia, and for low HDL-cholesterolemia when adjusted for age, sex, and alcohol and smoking status (p < 0.05). After further adjustment for body mass index (BMI) or waist circumference, the associations for hypertension still remained statistically significant (p < 0.05) while those for hypertriglyceridemia and low HDL-cholesterolemia were no longer significant. The association between higher insulin resistance as assessed by HOMA-IR and Matsuda ISI and higher categories of the AHI was also lost after adjustment for BMI.

CONCLUSION

Obesity was a strong confounding factor in the association between SDB and most metabolic risk factors including insulin resistance, except for hypertension. Further longitudinal study is needed to examine the temporal or causal relationships between SDB and metabolic risk factors. This trial is registered with UMIN-CTR UMIN000028067.

Trajectories of Postload Plasma Glucose in the Development of Type 2 Diabetes in Japanese Adults

We aimed to clarify how the trajectories of 1-hour postload plasma glucose (PG) and 2-hour PG were different in the development of type 2 diabetes. Using data of repeated health checkups in Japanese workers from April 2006 to March 2016, longitudinal changes of fasting, 1-hour, and 2-hour PG on the oral glucose tolerance test were analyzed with a linear mixed effects model. Of the 1464 nondiabetic subjects at baseline, 112 subjects progressed to type 2 diabetes during the observation period (progressors). In progressors, 1-hour PG and 2-hour PG showed gradual increases with slopes of 1.33 ± 0.2 and 0.58 ± 0.2 mg/dL/year, respectively, followed by a steep increase by which they attained diabetes. Until immediately before the diabetes transition, age- and sex-adjusted mean level of 2-hour PG was 149 ± 2.7 mg/dL, 34 ± 2.7 (30%) higher compared to nonprogressors, while that of 1-hour PG was 206 ± 4.1 mg/dL, 60 ± 4.3 mg/dL (41%) higher compared to nonprogressors. In conclusion, diabetes transition was preceded by a mild elevation of 2-hour PG for several years or more. The elevation in 1-hour PG was larger than that of 2-hour PG until immediately before the transition to diabetes.

One-hour plasma glucose as a predictor of the development of Type 2 diabetes in Japanese adults

AIMS

To test the hypothesis that 1-h plasma glucose in an oral glucose tolerance test is a better predictor of the development of diabetes than 2-h plasma glucose, independently of indices of insulin secretion or action in Japanese adults.

METHODS

A historical cohort study was conducted in 1445 Japanese workers who did not have diabetes. The association between 1-h plasma glucose and the development of Type 2 diabetes was analysed.

RESULTS

Overall, 95 of the study participants developed Type 2 diabetes during a mean follow-up of 4.5 years. The area under the receiver-operating characteristic curve for 1-h plasma glucose for future diabetes [0.88 (95% CI 0.84-0.91)] was greater than that for 2-h plasma glucose [0.79 (95% CI 0.74-0.84)], and for insulinogenic [0.73 (95% CI 0.68-0.78)] and disposition indices [0.79 (95% CI 0.74-0.84); P < 0.05]. Compared with the first quartile, the hazard ratio for future diabetes in the fourth quartile of 1-h plasma glucose was 42.5 [95% CI 5.7-315.2 (P < 0.05)] and the hazard ratio in the fourth quartile of 2-h plasma glucose was 4.4 [95% CI 1.8-10.8 (P < 0.05)], after adjustments for covariates including fasting plasma glucose. The significance of the elevated hazard ratio in the fourth quartile of 1-h plasma glucose was maintained after adjustments for 2-h plasma glucose, insulinogenic index or disposition index, whereas the elevation of the hazard ratio in the fourth quartile of 2-h plasma glucose was diminished and was no longer significant after adjustments for 1-h plasma glucose.

CONCLUSIONS

One-hour plasma glucose had a greater association with the future development of Type 2 diabetes than did 2-h plasma glucose, independently of oral glucose tolerance test-derived indices of insulin action in a Japanese population.

Development of new diabetes risk scores on the basis of the current definition of diabetes in Japanese subjects [Rapid Communication]

To develop diabetes risk score (RS) based on the current definition of diabetes, we retrospectively analyzed consecutive 4,159 health examinees who were non-diabetic at baseline. Diabetes, diagnosed by fasting plasma glucose (FPG) ≥7.0 mmol/L, 2hPG ≥11.1 mmol/L and/or HbA1c ≥6.5% (48 mmol/mol), developed in 279 of them during the mean period of 4.9 years. A full RS (RS_Full), a RS without 2hPG (RS_-2hPG) and a non-invasive RS (RS_NI) were created on the basis of multivariate Cox proportional model by weighted grading based on hazard ratio in half the persons assigned. The RSs were verified in the remaining half of the participants. Positive family history (FH), male sex, smoking and higher age, systolic blood pressure (SBP), FPG, 2hPG and HbA1c were independent predictors for RS_Full. For RS_-2hPG, 7 independent predictors, exclusive of 2hPG and smoking but inclusive of elevated triglycerides (TG) comparing to RS_Full, were selected. FH, male sex, and higher age, SBP and HbA1c were independent predictors in RS_NI. In the validation cohort, C-statistic (95%CI) of RS_Full, RS_-2hPG and RS_NI were 0.80 (0.76-0.84), 0.75 (0.70-0.78) and 0.68 (0.63-0.72), respectively, which were significantly different from each other (P <0.01). Absolute percentage difference between predicted probability and observed diabetes were 1.9%, 0.7% and 0.9%, by the three scores, respectively, and not significantly different from each other. In conclusion, diabetes defined by the current criteria was predicted by the new diabetes risk scores with reasonable accuracy. Nonetheless, RS_Full with a postchallenge glucose value performed superior to RS_-2hPG and RS_NI.

Impact of one-hour postchallenge glucose on the relationship between insulin sensitivity and secretion

The impact of postchallenge glucose on the relationship between insulin sensitivity (SI) and secretion (β) is unknown. We analyzed data from 2,264 health examinees (male/female 1,524/740, median age 54 yrs) with normal glucose tolerance (NGT, n = 1,623), non-diabetic hyperglycemia (NDH, n = 555), or diabetes (DM, n = 86) using OGTT-derived indices of SI (insulin sensitivity index [ISI]-Matsuda, 1/HOMA-IR, and 1/fasting IRI) and β (δIRI0-30/δPG0-30, and Stumvoll 1st [Stumvoll-1] and 2nd [Stumvoll-2] phases). The combination of 1/HOMA-IR and Stumvoll-1 recapitulated the hyperbolic SI-β relationship with the slope of the fitted line -1.000 in NGT subjects, and therefore it was utilized in the following analysis of the SI-β correlation. In multiple regression analysis of the relationship between SI and β, an independent correlation was found for 1 h-plasma glucose (PG; PG60) but not for 2 h-PG. When the NGT subjects were grouped by PG60 quartile (Q), the fitted line was flat in Q1 but progressively steeper from Q2 to Q4, with a slope (95%CI) of -0.663 (-0.726~-0.605), -0.680 (-0.745~-0.622), -0.847 (-0.922~-0.779), and -1.259 (-1.370~-1.158) (P for trend < 0.05). The fitted line steepened further in the NDH and DM groups, with a slope of -1.545 and -1.915, respectively (P < 0.01 for the difference). The intercept of the fitted line for SI-β correlation was also progressively lower across the PG60 Q for NGT, NDH, and DM. In conclusion, using the 1/HOMA-IR-Stumvoll-1 pair for an analysis of the SI-β relationship, elevated PG60 was associated with steepening and downward shifting of the fitted line for the SI-β correlation. The finding suggests impaired beta cell function.

Impact of gastrectomy on high-density lipoprotein cholesterol elevation in nonobese patients during a 10-year follow-up

AIM

The role of gastrectomy in glycemic control has been established in the current era of bariatric surgery for obesity. Gastrectomy in obese patients is associated with increased levels of high-density lipoprotein cholesterol (HDL-C). However, limited data on the effects of gastrectomy in nonobese patients are available. We herein investigated the long-term plasma lipid changes in nonobese patients who had undergone gastrectomy.

METHODS

Patients were enrolled as part of routine healthcare examinations from 1984 to 2003. Preoperative and postoperative data from patients who had undergone curative gastrectomy were analyzed for up to 10 years postoperatively. Three age- and sex-matched controls were assigned to each case.

RESULTS

Sixty-four nonobese patients without diabetes mellitus or a history of having taken lipid-lowering drugs who underwent curative gastrectomy during the study period were enrolled (60 subtotal gastrectomies, four total gastrectomies). The median follow-up period was 7.6 years. The mean body mass index was 9.6% lower one year after gastrectomy (p < 0.01), then plateaued with a slight recovery. Intriguingly, the preoperative HDL-C level was 21% higher one year after gastrectomy (p < 0.01), increased by another 30% six years after gastrectomy and remained at this level for the rest of the follow-up period. No significant changes in the HDL-C level were observed in the controls. The degree of HDL-C elevation was consistently significant, irrespective of the baseline triglyceride level, HDL-C level or body weight.

CONCLUSIONS

Gastrectomy in nonobese patients was associated with consistent and distinct long-term HDL-C elevations and body mass index reductions.

Endoscopic assessment of reflux esophagitis concurrent with hiatal hernia in male Japanese patients with obstructive sleep apnea

OBJECTIVE

The pathogenetic relationship underlying the high prevalence of gastroesophageal reflux disease (GERD) in patients with obstructive sleep apnea (OSA) remains unclear. In addition, GERD has not been adequately assessed by endoscopy in patients with OSA. The purpose of this study was to use endoscopy to investigate potential interactions among reflux esophagitis, hiatal hernia (HH) and OSA.

MATERIAL AND METHODS

A total of 243 consecutive male Japanese participants who underwent both overnight ambulatory polygraphic monitoring and esophagogastroduodenoscopy were retrospectively evaluated in a cross-sectional study. The prevalence and severity of HH and reflux esophagitis were assessed according to the Los Angeles classification and the Makuuchi classification, respectively. Associations among reflux esophagitis, HH and OSA were examined by univariate and multivariate analyses.

RESULTS

OSA was diagnosed in 98 individuals (40.3%). Endoscopy-confirmed esophagitis (p = 0.027) and HH (p < 0.001) were significantly more prevalent among patients with OSA. Multivariate regression model analysis adjusted for age, body mass index, visceral obesity represented by waist circumference, presence of OSA, concurrence of OSA and HH, smoking, and alcohol consumption yielded OSA as the only variable significantly associated with HH (odds ratio [OR], 2.60; 95% confidence interval [CI], 1.35-4.99; p = 0.004), while concurrence of OSA and HH was related to reflux esophagitis (OR, 3.59; CI, 1.87-6.92; p < 0.001).

CONCLUSIONS

OSA was associated with HH and concurrent OSA and HH with reflux esophagitis in male Japanese patients with OSA. Our results support the hypothesis that complicating HH may link reflux esophagitis to OSA.

Elevated liver enzymes are related to progression to impaired glucose tolerance in Japanese men

AIMS

To investigate whether the elevation of liver enzymes is associated with the progression from normal to impaired glucose tolerance.

METHODS

A historical cohort study was conducted in 594 male workers at public schools, who had normal glucose tolerance at baseline. The progression to impaired glucose tolerance and impaired fasting glycaemia during a mean follow-up of 3.1 years was measured using an oral glucose tolerance test.

RESULTS

Overall, 141 (23.7%) subjects developed impaired glucose tolerance and 68 (11.4%) subjects developed impaired fasting glycaemia, 23 of whom had combined impaired fasting glycaemia/impaired glucose tolerance. The incidence of impaired glucose tolerance increased significantly with increasing quartiles of serum aspartate aminotransferase, alanine aminotransferase and γ-glutamyltransferase (P for trend <0.01). In Cox proportional hazards regression analysis, after adjusting for comprehensive risk factors, including plasma glucose levels, BMI and homeostatic model assessment of insulin resistance, the risk of progression to impaired glucose tolerance was significantly higher in the highest quartile of alanine aminotransferase than in the lowest quartile (hazard ratio 2.5; 95% CI 1.1-5.7). A significant association between alanine aminotransferase and the progression to impaired glucose tolerance was found after further adjustments for other liver enzymes or after the sample was limited to those with BMI < 25.0 kg/m(2) or with fasting plasma glucose < 5.5 mmol/l.

CONCLUSIONS

A higher level of alanine aminotransferase was independently associated with progression from normal to impaired glucose tolerance in Japanese men. The elevation of alanine aminotransferase may be a change that occurs early in the evolution of diabetes.

cAMP signaling affects irreversible attachment during biofilm formation by Pseudomonas aeruginosa PAO1

Pseudomonas aeruginosa responds to environmental changes and regulates its life cycle from planktonic to biofilm modes of growth. The control of cell attachment to surfaces is one of the critical processes that determine this transition. Environmental signals are typically relayed to the cytoplasm by second messenger systems. We here demonstrated that the second messenger, cAMP, regulated the attachment of cells. Our results suggest cAMP inhibited the transition from reversible to irreversible attachment. Further analyses revealed that cell surface hydrophobicity, one of the key factors in cell attachment, was altered by cAMP.

Relationships between alanine aminotransferase (ALT), visceral adipose tissue (AT) and metabolic risk factors in a middle-aged Japanese population

AIM

The commonly observed relationship between increased visceral adiposity and metabolic abnormalities may be partly mediated by a concomitant increase in liver fat content. We evaluated the independent association between the level of alanine aminotransferase (ALT) as a surrogate marker of the liver fat content and the incidence of metabolic abnormalities after adjusting for the amount of visceral adipose tissue (AT).

METHODS

The subjects included 1,118 Japanese individuals (44% women) who underwent computed tomography to assess the amount of visceral AT on medical checkups. Cross-sectional associations between the serum ALT, visceral AT and metabolic risk factors were examined.

RESULTS

The ALT level and visceral AT were found to show a significant correlation(r=0.41 in men and r=0.36 in women, p＜0.001). In a multivariable linear regression analysis, the ALT level and visceral AT were found to be independently associated with blood pressure in men and triglycerides and 2-hour post-challenge glucose in both genders(p＜0.01), whereas only visceral AT was found to be associated with HDL-cholesterol(p＜0.01). When the participants were classified into four subgroups based on the 75th percentiles of ALT and visceral AT, the low ALT/high-visceral AT group, but not the high-ALT/low-visceral AT group, had a significantly higher odds ratio for low HDL-cholesterol among both genders(p＜0.05) and for hypertriglyceridemia in men only(p＜0.05). Meanwhile, the high-ALT/low-visceral AT group, but ot the low-ALT/high-visceral AT group, had a significantly higher odds ratio for IGT among women(p＜0.05).

CONCLUSIONS

Although the ALT level and visceral AT were found to be independently associated with most metabolic risk factors, visceral AT had a dominant association with dyslipidemia in both genders, while the ALT level appeared to have a closer association with IGT in women.

The evolution of non-diabetic hyperglycemia: a longitudinal study

The risk factors for impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) have yet to be established. Our aim was to elucidate the predisposing factors for IFG and IGT in Japanese subjects with normal glucose tolerance (NGT). Using a 75 g oral glucose tolerance test (OGTT), we analyzed 604 adults with the ADA-defined NGT. Follow-up glucose tolerance status was determined by 75 g OGTT performed 3.7 yrs later. Glucose-stimulated insulin secretion (GSIS), whole body insulin sensitivity (SI) and beta cell function (BCF) were estimated by Stumvoll indices, ISI(Matsuda), and a product of Stumvoll 1(st) and ISI(Matsuda), respectively, and hepatic SI by quantitative insulin sensitivity check index. Logistic regression analysis revealed that attenuated BCF due to low GSIS was an independent risk factor for IFG. Low whole body SI was an additional risk for IGT. Male gender and high BMI were independently related to the progression to both IFG and IGT, whereas a positive diabetes family history was independently related to IGT. The worsening of glucose tolerance at large was predicted with 66% sensitivity by risk engine with GSIS, whole body SI, gender, BMI and glucose. This finding may help when implementing early intervention strategies for diabetes.

Population impact of increased body mass index and attenuated beta-cell function on worsening of glucose metabolism in subjects with normal glucose tolerance: a pilot study

The population attributable fraction (PAF) of risk factors for the worsening of glucose metabolism in subjects with normal glucose tolerance (NGT) has not been calculated. Our aim was to obtain the PAF of increased body mass index (BMI) and attenuated beta-cell function (BCF) on worsening of glucose metabolism in subjects with NGT. We longitudinally analyzed 604 Japanese adults. The follow-up glucose tolerance status was determined 3.7 years later: 430 participants remained in the NGT category and 102 had progressed to impaired fasting glucose, 67 to impaired glucose tolerance, and 5 to diabetes mellitus. A product of ISIMatsuda and Stumvoll-1, i.e., oral disposition index (DIO), was used as a measure of BCF. The optimal cutoff baseline BMI and DIO values for the prediction of the worsening of glucose metabolism were > 23.1 and < 7.299 kg/m(2), respectively. Isolated increased BMI (iBMIHIGH), isolated low DI (iDIOLOW), and "BMIHIGH and DIOLOW (BMIHIGH/DIOLOW)" were all independently related to the worsening, and the PAF values (95 % CI) for worsening due to iBMIHIGH, iDIOLOW, and BMIHIGH/DIOLOW were 12.9 (3.2-18.4) %, 10.9 (5.0-13.9) %, and 31.4 (22.7-36.3) %, respectively. As much as 55 % of the worsening of glucose metabolism in the NGT subjects was attributable to increased BMI and/or attenuated BCF. The optimal cutoff for BMI was as low as 23.1 kg/m(2) in this population. We believe that these data should form the basis of future public health strategies for the prevention of diabetes in Japan.

Impact of visceral adipose tissue and subcutaneous adipose tissue on insulin resistance in middle-aged Japanese

AIM

The enlargement of visceral adipose tissue (VAT) is considered to mediate the close relationship between obesity and insulin resistance. We aimed to determine whether a stronger association of VAT compared to subcutaneous adipose tissue (SAT) with insulin resistance could be confirmed and generalized in non-diabetic Japanese men and women.

METHODS

Participants were 912 non-diabetic Japanese (636 men and 276 women, mean age 52.4±7.0 years, and mean BMI 24.9±3.1 kg/m(2)). VAT and SAT were measured through the use of computed tomography scanning. Homeostatic model for the assessment of insulin resistance (HOMA-IR) and Matsuda insulin sensitivity index (ISI) were calculated based on results from the oral glucose tolerance test.

RESULTS

For both genders, subjects in higher tertiles of SAT as well as VAT showed significantly higher levels of HOMA-IR and lower levels of Matsuda ISI (p<0.001). In multiple regression analyses with VAT and SAT included in the model, only VAT, but not SAT, was independently associated with Matsuda ISI in women (p<0.001), whereas both SAT and VAT were independently associated with HOMA-IR and with Matsuda ISI in men (p<0.001). When VAT and waist circumference were jointly included in the model, only VAT, but not waist circumference, was independently associated with Matsuda ISI in women (p<0.001) but not in men.

CONCLUSION

VAT had a stronger association with insulin resistance than SAT or waist circumference in women but not in men. BMI showed a comparable association with insulin resistance to VAT in this population.

Reduction of visceral fat correlates with the decrease in the number of obesity-related cardiovascular risk factors in Japanese with Abdominal Obesity (VACATION-J Study)

AIM

Visceral fat accumulation is associated with obesity-related cardiovascular risk factor accumulation and atherosclerosis. The present study investigated whether one-year reduction of the visceral fat area (VFA) correlates with a decrease in the number of such factors in Japanese with or without visceral fat accumulation.

METHODS

The study subjects comprised 5,347 Japanese, who underwent health check-ups in 2007 and 2008, including measurements of VFA and subcutaneous fat area (SFA) by computed tomography at 9 centers in Japan. Subjects with one or more such factor(s) were categorized into tertiles based on the one-year change in VFA. We investigated the multivariate age, sex, and one-year change in SFA-adjusted odds ratios (ORs) and 95% confidence intervals (CI) for reductions in the number of risk factors in each of the three categories based on the one-year change in VFA, in subjects with one or more such factors (n= 3,648).

RESULTS

In the entire group (n=3,648), the OR and 95%CI for reductions in the number of risk factors in the first tertile were 0.804 (0.673-0.962, p=0.0172), compared with the second tertile set at 1.0. Subjects with VFA <100cm(2) showed no reduction in the number of risk factors. In subjects with VFA≥100 cm(2), OR in the first tertile was 0.788 (0.639-0.972, p=0.0257) relative to the second tertile set at 1.0.

CONCLUSIONS

In subjects with multiple cardiovascular risk factors, visceral fat reduction correlated with a decrease in the number of such factors in subjects with VFA≥100cm(2), but not in those with VFA<100cm(2).

Absolute value of visceral fat area measured on computed tomography scans and obesity-related cardiovascular risk factors in large-scale Japanese general population (the VACATION-J study)

BACKGROUND

The management of cardiovascular risk factors is important for prevention of atherosclerotic cardiovascular diseases (ACVD). Visceral fat accumulation plays an important role in the clustering of cardiovascular risk factors, leading to ACVD. The present study investigated the gender- and age-specific relationship between obesity-related cardiovascular risk factor accumulation and computed tomography (CT)-measured fat distribution in a large-scale Japanese general population.

METHODS AND RESULTS

Fat distribution was measured on CT scans in 12,443 subjects (males/females = 10,080/2,363), who underwent medical health check-up at 9 centers in Japan. The investigated obesity-related cardiovascular risk factors were hyperglycemia, dyslipidemia, and elevated blood pressure. Visceral fat area (VFA) for all males and old females showed almost symmetric distribution, while that of young females showed skewed distribution with a marked left shift. Only a small proportion of young females had large visceral fat and cardiovascular risk accumulation. The mean number of risk factors exceeded 1.0 at around 100 cm(2) for VFA in all groups, irrespective of gender, age (cut-off age 55), and BMI (cut-off BMI 25 kg/m(2)).

CONCLUSIONS

In this large-scale Japan-wide general population study, an absolute VFA value of about 100 cm(2) equated with obesity-related cardiovascular risk factor accumulation, irrespective of gender, age, and BMI.

Insulin secretion and insulin sensitivity on the oral glucose tolerance test (OGTT) in middle-aged Japanese

The aim of this study was to assess the changes in insulin secretion and insulin sensitivity in relation to fasting and 2-hour plasma glucose (PG) levels and to assess the independent contributions of their impairments to non-diabetic hyperglycemia. A total of 2157 Japanese workers (mean age 52.6±7.3 years and mean BMI 23.9±3.2 kg/m(2)) underwent an oral glucose tolerance test (OGTT). Of these subjects, 1125 had normal glucose tolerance (NGT), 525 subjects had isolated impaired fasting glucose (IFG), 159 subjects had isolated impaired glucose tolerance (IGT), 263 subjects had combined IFG and IGT, and 85 subjects had newly diagnosed type 2 diabetes. Insulinogenic index and Matsuda insulin sensitivity index (ISI) were significantly attenuated in subjects with normal but slightly elevated fasting PG, or in subjects with normal but slightly elevated 2-hour PG. Whereas, InsAUC(120)/GluAUC(120) was not significantly decreased in those subjects, and significant decrease of it was observed exclusively in subjects with abnormal fasting PG (≥ 106 mg/dL) or abnormal 2-hour PG (≥ 221 mg/dL). Using multiple regression analyses, both Matsuda ISI and insulinogenic index were independently correlated with PG concentrations in subjects with IFG and/or IGT, while Matsuda ISI alone was independently correlated with fasting PG concentrations in normoglycemic subjects. In conclusion, both insulinogenic index and Matsuda ISI were significantly attenuated in subjects with normal but slightly elevated PG. Lowering of Matsuda ISI was likely to be a strong contributor to 'elevation of fasting PG within the normal range' in this population.

Age-related changes in abdominal fat distribution in Japanese adults in the general population

OBJECTIVE

Early studies have indicated that body fat shifts from peripheral stores to central stores with aging. The objective of this study was to investigate age-related changes in abdominal fat distribution of Japanese men and women of the general population over a wide range of body mass indices (BMI).

METHODS

A total of 2,220 non-diabetic, apparently healthy Japanese adults (1,240 men and 980 women; age range 40-69 years) were included in the study sample. All subjects underwent a CT scan at the level of the umbilicus, and the areas of visceral adipose tissue (AT) and subcutaneous AT were quantified.

RESULTS

When the subjects were stratified by BMI into 18.5-23.0 kg/m(2), 23.0-27.5 kg/m(2), and 27.5 kg/m(2) or higher, visceral AT was positively correlated with age in all of the BMI strata in both genders (p<0.01). In contrast, subcutaneous AT was negatively correlated with age in men with BMIs in excess of 23.0 kg/m(2) (p<0.01) and not at all in women. The mean levels of subcutaneous AT were over 2-fold greater than visceral AT in women aged 60-69 years in any BMI stratum.

CONCLUSION

In Japanese men and women, visceral AT was increased with age in all BMI strata in both genders, whereas subcutaneous AT was decreased with age in men with BMIs in excess of 23.0 kg/m(2) and not at all in women. Even with these age-related changes in abdominal fat distribution, women retained the subcutaneous-dominant type of fat distribution up to 70 years.

Contribution of visceral adiposity and insulin resistance to metabolic risk factors in Japanese men

We investigated the relative impacts of visceral adiposity and insulin resistance on the metabolic risk profile in middle-aged Japanese men. A cross-sectional study was conducted in 636 nondiabetic Japanese men with a mean age of 51.6 years. Visceral adipose tissue (AT) was assessed using computed tomography, and insulin resistance was determined by the homeostasis model assessment of insulin resistance (HOMA-IR). Metabolic risk factors were diagnosed according to the National Cholesterol Education Program Adult Treatment Panel III metabolic syndrome criteria: (1) hypertriglyceridemia, (2) low high-density lipoprotein cholesterol, (3) hypertension, (4) impaired fasting glucose, and (5) impaired glucose tolerance. Visceral AT and HOMA-IR were significantly and positively correlated with each other (r = 0.41, P < .001). Using the 75th percentile value as a cut point, those with isolated large visceral AT showed significantly greater odds ratios for each of the 5 risk factors measured except impaired fasting glucose, whereas those with isolated high HOMA-IR showed significantly greater odds ratios for each of the 5 risk factors except hypertriglyceridemia and impaired glucose tolerance, compared with the control group. The combined group (increased visceral AT and HOMA-IR) had the highest odds ratios for all studied risk factors. On logistic regression analysis using visceral AT and HOMA-IR as continuous independent variables, they were each independently associated with most of the metabolic risk factors and their clustering. In conclusion, neither visceral AT nor HOMA-IR stands out as the sole driving force of the risk profile; each makes a significant contribution to metabolic abnormalities in Japanese men.

Impacts of visceral adipose tissue and subcutaneous adipose tissue on metabolic risk factors in middle-aged Japanese

Regional fat distribution rather than overall fat volume has been considered to be important to understanding the link between obesity and metabolic disorders. We aimed to evaluate the independent associations of visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) with metabolic risk factors in apparently healthy middle-aged Japanese. Participants were 1,119 men and 854 women aged 38-60 years who were not taking medications for diabetes, hypertension, or dyslipidemia. VAT and SAT were measured by use of computed tomography (CT) scanning. VAT and SAT were significantly and positively correlated with each other in men (r = 0.531, P < 0.001) and women (r = 0.589, P < 0.001). In multiple regression analyses, either measure of abdominal adiposity (VAT or SAT) was positively associated with blood pressure, fasting plasma glucose, and log triglyceride (P < 0.001) and inversely with high-density lipoprotein (HDL)-cholesterol (P < 0.001). When VAT and SAT were simultaneously included in the model, the association of VAT with triglycerides was maintained (P < 0.001) but that of SAT was lost. The same was true for HDL-cholesterol in women. For fasting plasma glucose, the association with VAT was strong (P < 0.001) and the borderline association with SAT was maintained (P = 0.060 in men and P = 0.020 in women). Both VAT and SAT were independently associated with blood pressure (P < 0.001). Further adjustment for anthropometric indices resulted in the independent association only with VAT for all risk factors. In conclusion, impacts of VAT and SAT differed among risk factors. VAT showed dominant impacts on triglyceride concentrations in both genders and on HDL-cholesterol in women, while SAT also had an independent association with blood pressure.

Diabetes progression from "high-normal" glucose in school teachers

OBJECTIVE

High-normal, the intermediate category between normal fasting glucose (NFG) and impaired fasting glucose (IFG), was introduced in the criteria of the disordered glucose metabolism in 2008. The aim of this study was to investigate the risk for future incidence of type 2 diabetes of the subjects with high-normal and to examine how other metabolic variables could be useful for their risk stratification.

METHODS

A historical cohort study was conducted from 2001 to 2008, inclusive, in 4,165 non-diabetic employees at public schools (2,229 men and 1,936 women; age 45.8+/-5.9 years, range 25-55 years). They were classified at baseline as NFG with fasting plasma glucose (FPG)<100 mg/dL, high-normal with FPG 100-109 mg/dL, and IFG with FPG 110-125 mg/dL. The incidence of type 2 diabetes (defined either by FPG > or = 126 mg/dL or by receiving treatments) was measured.

RESULTS

The cumulative incidence during a mean follow-up of 5.1 years were 16/3,364 (0.5%), 40/613 (6.5%), and 53/188 (28.2%) in subjects with NFG, high-normal, and IFG, respectively. Multivariate-adjusted odds ratios for the incidence were still significant both in high-normal and IFG compared to NFG. Body mass index (BMI) and alanine aminotransaminase (ALT) were associated with the incidence of type 2 diabetes independently of FPG categories (p<0.05).

CONCLUSION

The future incidence of type 2 diabetes in subjects with high-normal was significantly higher than in those with NFG in this population. BMI and ALT can improve risk stratification in high-normal subjects.

Difference between fasting and nonfasting triglyceridemia; the influence of waist circumference

AIM

Postprandial hypertriglyceridemia is recognized as an independent risk factor for cardiovascular disease. The aim of this study was to identify differences between fasting and postprandial TG levels, focusing on the influence of waist circumference.

METHODS

Subjects included 1,505 men and 798 women aged 3865 years who were not taking medications for diabetes or dyslipidemia. Fasting TG levels were measured after an overnight fast, and postprandial TG levels were measured 2 hours after a standardized rice-based lunch (total 740 kcal, 20 g fat, 30 g protein, and 110 g carbohydrates) in the afternoon on the same day.

RESULTS

Fasting and postprandial TG levels were highly correlated in both men (r=0.86, p<0.001) and women (r=0.84, p<0.001). Waist circumference was positively correlated with fasting TG (r=0.38 in men and r=0.36 in women) and postprandial TG (r=0.42 in men and r=0.45 in women), respectively. On multiple regression analyses, the association of waist circumference with postprandial TG was still significant (standardized beta=0.10 in men and standardized beta=0.15 in women, p<0.001) after the inclusion of HbA1c, age, high-density-lipoprotein (HDL)-cholesterol, alcohol consumption, and fasting TG in the regression model.

CONCLUSION

Postprandial TG has a better relation with waist circumference than fasting TG.

Comparison of waist circumference with body mass index for predicting abdominal adipose tissue

AIMS

To compare waist circumference (WC) with body mass index (BMI) for the prediction of abdominal adipose tissues in Japanese men and women.

METHODS

1432 men and 1038 women aged 38-60 years were recruited. WC, BMI, visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) using CT scans were measured.

RESULTS

Women had a lower mean VAT than men (79.3 cm(2) vs. 132.3 cm(2); p<0.001) and a higher mean SAT (196.2 cm(2) vs. 139.7 cm(2); p<0.001). The correlation with WC or BMI was greatest for total adipose tissue (TAT), followed by SAT, and least for VAT. The correlation coefficients were not significantly different between WC and BMI for any adipose tissue except for VAT in men (p<0.05). Age was positively correlated with VAT in both genders (p<0.001). Using multiple regression analyses on VAT, R(2) values using WC and age were 0.45 in men and 0.48 in women. For SAT, the values were 0.57 in men and 0.59 in women.

CONCLUSIONS

The relationship with WC or BMI was greatest for TAT and SAT, and least for VAT. WC and BMI provided essentially similar estimates of TAT, VAT, and SAT in both genders.

Reassessment of the cutoff values of waist circumference and visceral fat area for identifying Japanese subjects at risk for the metabolic syndrome

In the new world-wide criteria for metabolic syndrome (MetS) by the International Diabetes Federation (IDF) in 2006, the Japanese is the only ethnicity in which the recommended waist circumference (WC) cutoff value is higher in women (>or=90cm) than in men (>or=85cm), and its validity appears to be controversial. We investigated the optimal cutoff points for the diagnosis of central obesity in Japanese men and women, using the receiver operating characteristic (ROC) curve analysis for both of WC and visceral fat area (VFA) in 1870 middle-aged Japanese. VFA was superior to WC and Body mass index (BMI) for discriminating the subjects with two or more nonadipose components of MetS. The optimal cutoff points of VFA and WC were 132.6cm(2) and 89.8cm for men and 91.5cm(2) and 82.3cm for women. The stratifications of MetS components more than 1.0 in average occurred more steeply by the accumulation of VFA in women than in men. In conclusion, setting the cutoff points of WC and VFA lower values in women than in men for the definition of central obesity is needed to identify the subjects with MetS in Japanese, as in other Asian populations.

The relationship between post-prandial plasma glucose and post-challenge plasma glucose in Japanese population

The relationship between post-prandial plasma glucose (PPG) and post-challenge plasma glucose (PCG) within individuals was investigated in Japanese population. The oral glucose tolerance test (OGTT) and measurements of PPG 2h after ingestion of a standardized rice-based meal (PPG2h), were performed in 4471 middle-aged Japanese subjects (2774 men and 1697 women, 50.7+/-8.5 years). There was a loose correlation between PPG2h and PCG2h (r=0.327, p<0.001). The diabetes group (n=170) showed the highest PPG2h, followed by the IGT group (n=786) and the NGT group (n=3414) (p<0.05). At the cutoff point of 140 mg/dl (7.8 mmol/l) for PPG2h, specificities were 94.9% for IGT plus diabetes and 92.9% for diabetes, but sensitivities were as low as 23.2% for IGT plus diabetes and 44.7% for diabetes. The correlation of PPG2h with PCG2h was stronger in the obese group (BMI>or=25 kg/m2) than in the lean group (BMI<20 kg/m2). We conclude that the correlation between PPG2h and PCG2h was significant but not very tight. In evaluating PPG2h, if the cutoff point of 140 mg/dl (7.8 mmol/l) for PCG2h is extrapolated, the majority of subjects with dysglycemia could be overlooked.

Large decreases in insulin requirement occurred repeatedly in two pregnancies in a type 1 diabetic woman

Whereas the increase in insulin requirement in late gestation is well described in diabetic pregnancy, a decrease in insulin dosage in the end of the third trimester has also been noted in clinical experience and the prevention of hypoglycaemia is important. Here we report a large decrease (over 50%) in the final few weeks of her two gestations in a woman with type 1 diabetes mellitus.

Legionella pneumonia associated with adult respiratory distress syndrome caused by Legionella pneumophila serogroup 3

A 68-year-old man developed pneumonia 2 days after nearly drowning in a bathtub of a hot spring spa. Chest radiography revealed bilateral consolidation shadows associated with adult respiratory distress syndrome. Initial treatment with antibiotics and pulse therapy with methylprednisolone was not effective. The patient died on the 4th hospital day. A urinary antigen test for Legionella was positive. Legionella pneumophila serogroup 3 was recovered from an intratracheal specimen. The same serotype of Legionella was isolated from the hot spring water. Restriction enzyme analysis by pulse-field gel electrophoresis revealed identical restriction fragments. We conclude that the water at the hot spring spa could have been the source of infection.