Plant-Based Diets and All-cause and Cardiovascular Mortality in a Nationwide Cohort in Spain: The ENRICA Study

ObjectiveTo investigate the associations of a healthful plant-based diet index (hPDI) and an unhealthful plant-based diet index (uPDI) with all-cause and cardiovascular disease (CVD) mortality in Spanish adults.Patients and MethodsWe analyzed data from 11,825 individuals 18 years of age or older, representative of the Spanish population, recruited between 2008 and 2010 and followed-up to 2020. Food consumption was collected at baseline using a validated dietary history, which served to calculate two plant-based diet indices based on 18 major food groups (range, 18-90 points). For (1) hPDI only the consumption of healthy plant foods (whole grains, fruits, vegetables, nuts, legumes, vegetable oils, and tea/coffee) received positive scores; whereas for (2) uPDI, only the consumption of less healthy plant foods (fruit juices, sugar-sweetened beverages, refined grains, potatoes, and sweets/desserts) received positive scores. Multivariable-adjusted Cox models were used to estimate HRs and their 95% CIs.ResultsAfter a median follow-up of 10.9 and 9.8 years, 699 all-cause and 157 CVD deaths were ascertained, respectively. Each 10-point increase in hPDI was associated with 14% lower risk of all-cause death (HR, 0.86; 95% CI, 0.74 to 0.99), and 37% lower risk of CVD death (HR, 0.63; 95% CI, 0.46 to 0.85). No significant associations were found for uPDI.ConclusionHigher adherence to an hPDI diet, but not to a uPDI, was associated with lower all-cause and CVD mortality. This suggests that the quality of the plant food consumed is paramount to achieve diet-related benefits in mortality.Trial registrationclinicaltrials.gov Identifier: NCT02804672     

The association of plant-based dietary patterns with visceral adiposity,lipid accumulation product,and triglyceride-glucose index in Iranian adults

BackgroundWe sought to investigate whether adherence to a more plant-based, and less animal-based, diet is associated with visceral adiposity, lipid accumulation product (LAP), and triglyceride-glucose index (TyG) in Iranian adults.MethodsThis cross-sectional study was conducted on 270 adults aged between 18–75 years old. We created three plant-based diets. including an overall plant-based diet index (PDI), hPDI, and uPDI based on tertiles regarding the intake of animal- or plant-based food items obtained from a semi quantitative food-frequency questionnaire.ResultsHigher hPDI was significantly associated with lower body mass index (BMI) (P-value = 0.01), lower waist circumference (P-value<0.001), and lower waist-hip ratio (P-value<0.001). A significant increase was found for high density lipoproteins (HDL) (P-trend <0.001) with a significant decrease for LAP (P-value = 0.03) in those with higher adherence to hPDI. Moreover, greater adherence to PDI was associated with a significant increase in diastolic blood pressure (DBP) (p-value = 0.01) and fat free mass (FFM) (p-value = 0.01). There were no significant associations between PDIs and TyG and VFA.ConclusionWe found that a higher hPDI score was significantly associated with better anthropometric measurements. A significant increase was found for HDL and a significant decrease was found for LAP on hPDI. However, a higher PDI score was significantly associated with higher DBP and higher FFM.     

Comparing Type 2 Diabetes,Prediabetes, and Their Associated Risk Factors in Asian Indians in India and in the U.S.: The CARRS and MASALA Studies

OBJECTIVE

To assess the prevalence of diabetes and prediabetes and the associated risk factors in two Asian Indian populations living in different environments.

RESEARCH DESIGN AND METHODS

We performed cross-sectional analyses, using representative samples of 2,305 Asian Indians aged 40–84 years living in Chennai, India, from the Centre for cArdiometabolic Risk Reduction in South-Asia study (CARRS) (2010–2011), and 757 Asian Indians aged 40–84 years living in the greater San Francisco and Chicago areas from the U.S. Mediators of Atherosclerosis in South Asians Living in America (MASALA) study (2010–2013). Diabetes was defined as self-reported use of glucose-lowering medication, fasting glucose ≥126 mg/dL, or 2-h glucose ≥200 mg/dL. Prediabetes was defined as fasting glucose 100–125 mg/dL and/or 2-h glucose 140–199 mg/dL.

RESULTS

Age-adjusted diabetes prevalence was higher in India (38% [95% CI 36–40]) than in the U.S. (24% [95% CI 21–27]). Age-adjusted prediabetes prevalence was lower in India (24% [95% CI 22–26]) than in the U.S. (33% [95% CI 30–36]). After adjustment for age, sex, waist circumference, and systolic blood pressure, living in the U.S. was associated with an increased odds for prediabetes (odds ratio 1.2 [95% CI 0.9–1.5]) and a decreased odds for diabetes (odds ratio 0.5 [95% CI 0.4–0.6]).

CONCLUSIONS

These findings indicate possible changes in the relationship between migration and diabetes risk and highlight the growing burden of disease in urban India. Additionally, these results call for longitudinal studies to better identify the gene-environment-lifestyle exposures that underlie the elevated risk for type 2 diabetes development in Asian Indians.     

Factors influencing lower respiratory tract infection in older patients after general anesthesia

ObjectivePulmonary complication is common in older patients after surgery. We analyzed risk factors of lower respiratory tract infection after general anesthesia among older patients.MethodsIn this retrospective investigation, we included older patients who underwent surgery with general anesthesia. Logistic regression analyses were performed to determine risk factors of lower respiratory tract infection.ResultsA total 418 postoperative patients with general anesthesia were included; the incidence of lower respiratory tract infection was 9.33%. Ten cases were caused by gram-positive bacteria, 26 cases by gram-negative bacteria, and 2 cases by fungus. We found significant differences in age, smoking, diabetes, oral/nasal tracheal intubation, and surgery duration. Logistic regression analysis indicated that age ≥70 years (odds ratio [OR] 2.028, 95% confidence interval [CI] 1.115–3.646), smoking (OR 2.314, 95% CI 1.073–4.229), diabetes (OR 2.185, 95% CI 1.166–4.435), nasotracheal intubation (OR 3.528, 95% CI 1.104–5.074), and duration of surgery ≥180 minutes (OR 1.334, 95% CI 1.015–1.923) were independent risk factors of lower respiratory tract infections.ConclusionsOlder patients undergoing general anesthesia after tracheal intubation have a high risk of lower respiratory tract infections. Clinical interventions should be provided to prevent pulmonary infections in patients with relevant risk factors.     

Association and Familial Coaggregation of Type 1 Diabetes and Eating Disorders: A Register-Based Cohort Study in Denmark and Sweden

OBJECTIVETo ascertain the association and coaggregation of eating disorders and childhood-onset type 1 diabetes in families.RESEARCH DESIGN AND METHODSUsing population samples from national registers in Sweden (n = 2,517,277) and Demark (n = 1,825,920), we investigated the within-individual association between type 1 diabetes and eating disorders and their familial coaggregation among full siblings, half siblings, full cousins, and half cousins. On the basis of clinical diagnoses, we classified eating disorders into any eating disorder (AED), anorexia nervosa (AN) and atypical AN, and other eating disorder (OED). Associations were determined with hazard ratios (HRs) with 95% CIs from Cox regressions.RESULTSSwedish and Danish individuals with a type 1 diabetes diagnosis had a greater risk of receiving an eating disorder diagnosis (HR [95% CI] Sweden: AED 2.02 [1.80–2.27], AN 1.63 [1.36–1.96], OED 2.34 [2.07–2.63]; Denmark: AED 2.19 [1.84–2.61], AN 1.78 [1.36–2.33], OED 2.65 [2.20–3.21]). We also meta-analyzed the results: AED 2.07 (1.88–2.28), AN 1.68 (1.44–1.95), OED 2.44 (2.17–2.72). There was an increased risk of receiving an eating disorder diagnosis in full siblings in the Swedish cohort (AED 1.25 [1.07–1.46], AN 1.28 [1.04–1.57], OED 1.28 [1.07–1.52]); these results were nonsignificant in the Danish cohort.CONCLUSIONSPatients with type 1 diabetes are at a higher risk of subsequent eating disorders; however, there is conflicting support for the relationship between having a sibling with type 1 diabetes and an eating disorder diagnosis. Diabetes health care teams should be vigilant about disordered eating behaviors in children and adolescents with type 1 diabetes.     

Serum Galectin-3 and Subsequent Risk of Coronary Heart Disease in Subjects With Childhood-Onset Type 1 Diabetes: A Cohort Study

OBJECTIVETo study whether serum galectin-3 and other biomarkers of inflammation predict coronary heart disease (CHD) in subjects with long-standing childhood-onset type 1 diabetes.RESEARCH DESIGN AND METHODSA population-based nationwide cohort of 299 subjects with type 1 diabetes diagnosed in Norway at <15 years of age during 1973–1982 was examined in 2002–2003 at a mean age of 33 years (range 21–44), with mean diabetes duration of 24 years (range 19–30). Subjects were followed through 31 December 2017 for their first CHD event registered by a hospitalization or cause of death using nationwide registries. Stored serum samples were available for 296 subjects and analyzed for interleukin-6 (IL-6), IL-6 receptor, IL-18, hs-CRP, matrix metalloproteinase-9, tissue inhibitor of metalloproteinase-1 (TIMP-1), galectin-3, and high-sensitivity troponin T. Adjusted hazard ratios (aHRs) for CHD per SD increase in biomarker were estimated using Cox regression.RESULTSOf 295 subjects, 40 (13.6%) had a documented CHD event during a mean follow-up of 14.4 years (range 0.5–16). IL-6 (aHR 1.32 [95% CI 1.07–1.63]), galectin-3 (aHR 1.44 [95% CI 1.09–1.80]), and TIMP-1 (aHR 1.37 [95% CI 1.04–1.81]) were significant predictors of CHD after adjustment for conventional risk factors.CONCLUSIONSGalectin-3 was significantly associated with future CHD in subjects with type 1 diabetes, and if the results are replicated in larger studies, it may aid in prediction together with conventional risk factors for CHD.     

Association of Bariatric Surgery With Cancer Incidence in Patients With Obesity and Diabetes: Long-term Results From the Swedish Obese Subjects Study

OBJECTIVEObesity and type 2 diabetes are associated with serious adverse health effects, including cancer. Although bariatric surgery has been shown to reduce cancer risk in patients with obesity, the effect of bariatric surgery on cancer risk in patients with obesity and diabetes is less studied. We therefore examined the long-term incidence of cancer after bariatric surgery and usual care in patients with obesity and diabetes in the matched prospective Swedish Obese Subjects (SOS) study.RESEARCH DESIGN AND METHODSThe SOS study examines long-term outcomes following bariatric surgery or usual care. The current analysis includes 701 patients with obesity and type 2 diabetes at baseline, 393 of whom underwent bariatric surgery and 308 who received conventional obesity treatment. Information on cancer events was obtained from the Swedish National Cancer Register. Median follow-up time was 21.3 years (interquartile range 17.6–24.8 years, maximum 30.7 years).RESULTSDuring follow-up, the incidence rate for first-time cancer was 9.1 per 1,000 person-years (95% CI 7.2–11.5) in patients with obesity and diabetes treated with bariatric surgery and 14.1 per 1,000 person-years (95% CI 11.2–17.7) in patients treated with usual obesity care (adjusted hazard ratio 0.63 [95% CI 0.44–0.89], P = 0.008). Moreover, surgery was associated with reduced cancer incidence in women (0.58 [0.38–0.90], P = 0.016), although the sex-treatment interaction was nonsignificant (P = 0.630). In addition, diabetes remission at the 10-year follow-up was associated with reduced cancer incidence (0.40 [0.22–0.74], P = 0.003).CONCLUSIONSThese results suggest that bariatric surgery prevents cancer in patients with obesity and diabetes and that durable diabetes remission is associated with reduced cancer risk.     

Sedentary Behavior and Diabetes Risk Among Women Over the Age of 65 Years: The OPACH Study

OBJECTIVETo evaluate whether sedentary time (ST) and/or sedentary behavior patterns are related to incident diabetes in the U.S.’s oldest age-groups.RESEARCH DESIGN AND METHODSWomen without physician-diagnosed diabetes (n = 4,839, mean ± SD age = 79 ± 7 years) wore accelerometers for ≥4 days and were followed up to 6 years for self-reported newly diagnosed diabetes requiring treatment with medications. Hazard ratios (HRs) for incident diabetes were estimated across quartiles of accelerometer-measured ST and mean bout duration with use of Cox proportional hazards models. We conducted isotemporal substitution analyses using Cox regression and tested associations with risk for diabetes after statistically replacing ST with light physical activity (PA) or moderate-to-vigorous PA (MVPA) and after replacing light PA with MVPA.RESULTSDuring 20,949 person-years, 342 diabetes cases were identified. Women in ST quartile (Q)2, Q3, and Q4 (vs. Q1) had incident diabetes HR 1.20 (95% CI 0.87–1.65), 1.33 (0.97–1.82), and 1.21 (0.86–1.70); P_trend = 0.04. Respective HRs following additional adjustment for BMI and MVPA were 1.04 (95% CI 0.74–1.47), 1.04 (0.72–1.50), and 0.85 (0.56–1.29); P_trend = 0.90. Fully adjusted isotemporal substitution results indicated that each 30 min of ST replaced with MVPA (but not light PA) was associated with 15% lower risk for diabetes (HR 0.85 [95% CI 0.75–0.96]; P = 0.01); the HR for replacing 30 min of light PA with MVPA was 0.85 (95% CI 0.73–0.98); P = 0.03. Mean bout duration was not associated with incident diabetes.CONCLUSIONSStatistically replacing ST or light PA with MVPA was associated with lower diabetes risk in older women. While reducing ST is important for several health outcomes, results indicate that to reduce diabetes risk among older adults, the primary public health focus should be on increasing MVPA.     

Prior Glucose-Lowering Medication Use and 30-Day Outcomes Among 64,892 Veterans With Diabetes and COVID-19

OBJECTIVETo identify preinfection risk factors for adverse outcomes among veterans with diabetes and coronavirus disease 2019 (COVID-19) infection.RESEARCH DESIGN AND METHODSWe identified all Veterans Health Administration patients with diabetes and one or more positive nasal swab(s) for severe acute respiratory syndrome coronavirus 2 (1 March 2020–10 March 2021) (n = 64,892). We examined associations of HbA_1c and glucose-lowering medication use with hospitalization, intensive care unit (ICU) admission, and mortality at 30 days using logistic regression models and during 4.4 months of follow-up (range <1–13.1) using proportional hazards models.RESULTSCompared with HbA_1c <7.0%, HbA_1c ≥9.0% was associated with higher odds of hospitalization, ICU admission, and death at 30 days (odds ratio [OR] 1.27 [95% CI 1.19–1.35], 1.28 [95% CI 1.15–1.42], 1.30 [95% CI 1.17–1.44], respectively) as well as higher risk of death over 4.4 months (hazard ratio [HR] 1.22 [95% CI 1.12–1.32]). Insulin use was associated with higher odds of hospitalization, ICU admission, and death (OR 1.12 [95% CI 1.07–1.18], 1.12 [95% CI 1.04–1.22], and 1.18 [95% CI 1.09–1.27], respectively) and higher risk of death (HR 1.12 [95% CI 1.07–1.18]). Sodium–glucose cotransporter 2 inhibitor (SGLT2i), glucagon-like peptide-1 receptor agonist (GLP1-RA), or angiotensin receptor blocker use were associated with lower odds of hospitalization (OR 0.92 [95% CI 0.85–0.99], 0.88 [95% CI 0.81–0.96], and 0.94 [95% CI 0.89–0.99], respectively). Metformin and SGLT2i use were associated with lower odds (OR 0.84 [95% CI 0.78–0.91], 0.82 [95% CI 0.72–0.94], respectively) and risk of death (HR 0.84 [95% CI 0.79–0.89], 0.82 [95% CI 0.74–0.92], respectively).CONCLUSIONSAmong veterans with diabetes and COVID-19, higher HbA_1c and insulin use were directly associated with adverse outcomes, while use of a GLP1-RA, metformin, and SGLT2i was inversely associated.     

Increased Hemoglobin A1c Time in Range Reduces Adverse Health Outcomes in Older Adults With Diabetes

OBJECTIVEShort- and long-term glycemic variability are risk factors for diabetes complications. However, there are no validated A1C target ranges or measures of A1C stability in older adults. We evaluated the association of a patient-specific A1C variability measure, A1C time in range (A1C TIR), on major adverse outcomes.RESEARCH DESIGN AND METHODSWe conducted a retrospective observational study using administrative data from the Department of Veterans Affairs and Medicare from 2004 to 2016. Patients were ≥65 years old, had diabetes, and had at least four A1C tests during a 3-year baseline period. A1C TIR was the percentage of days during the baseline in which A1C was in an individualized target range (6.0–7.0% up to 8.0–9.0%) on the basis of clinical characteristics and predicted life expectancy. Increasing A1C TIR was divided into categories of 20% increments and linked to mortality and cardiovascular disease (CVD) (i.e., myocardial infarction, stroke).RESULTSThe study included 402,043 veterans (mean [SD] age 76.9 [5.7] years, 98.8% male). During an average of 5.5 years of follow-up, A1C TIR had a graded relationship with mortality and CVD. Cox proportional hazards models showed that lower A1C TIR was associated with increased mortality (A1C TIR 0 to <20%: hazard ratio [HR] 1.22 [95% CI 1.20–1.25]) and CVD (A1C TIR 0 to <20%: HR 1.14 [95% CI 1.11–1.19]) compared with A1C TIR 80–100%. Competing risk models and shorter follow-up (e.g., 24 months) showed similar results.CONCLUSIONSIn older adults with diabetes, maintaining A1C levels within individualized target ranges is associated with lower risk of mortality and CVD.     

Time in Range in Relation to All-Cause and Cardiovascular Mortality in Patients With Type 2 Diabetes: A Prospective Cohort Study

OBJECTIVEThere is growing evidence linking time in range (TIR), an emerging metric for assessing glycemic control, to diabetes-related outcomes. We aimed to investigate the association between TIR and mortality in patients with type 2 diabetes.RESEARCH DESIGN AND METHODSA total of 6,225 adult patients with type 2 diabetes were included from January 2005 to December 2015 from a single center in Shanghai, China. TIR was measured with continuous glucose monitoring at baseline, and the participants were stratified into four groups by TIR: >85%, 71–85%, 51–70%, and ≤50%. Cox proportional hazards regression models were used to estimate the association between different levels of TIR and the risks of all-cause and cardiovascular disease (CVD) mortality.RESULTSThe mean age of the participants was 61.7 years at baseline. During a median follow-up of 6.9 years, 838 deaths were identified, 287 of which were due to CVD. The multivariable-adjusted hazard ratios associated with different levels of TIR (>85% [reference group], 71–85%, 51–70%, and ≤50%) were 1.00, 1.23 (95% CI 0.98–1.55), 1.30 (95% CI 1.04–1.63), and 1.83 (95% CI 1.48–2.28) for all-cause mortality (P for trend <0.001) and 1.00, 1.35 (95% CI 0.90–2.04), 1.47 (95% CI 0.99–2.19), and 1.85 (95% CI 1.25–2.72) for CVD mortality (P for trend = 0.015), respectively.CONCLUSIONSThe current study indicated an association of lower TIR with an increased risk of all-cause and CVD mortality among patients with type 2 diabetes, supporting the validity of TIR as a surrogate marker of long-term adverse clinical outcomes.     

Osteocalcin and Risks of Incident Diabetes and Diabetic Kidney Disease: A 4.6-Year Prospective Cohort Study

OBJECTIVEWe aimed to examine the relationship between osteocalcin (OC) and the risk of incident diabetes and the risk of incident diabetic kidney disease (DKD).RESEARCH DESIGN AND METHODSWe followed 5,396 participants without diabetes (nondiabetes subcohort) and 1,174 participants with diabetes and normal kidney function (diabetes subcohort) at baseline. Logistic regression and modified Poisson regression models were used to estimate the relative risk (RR) of baseline OC levels with incident diabetes and DKD.RESULTSDuring a mean 4.6-year follow-up period, 296 cases of incident diabetes and 184 cases of incident DKD were identified. In the nondiabetes subcohort, higher OC levels were linearly associated with a decreased risk of diabetes (RR for 1-unit increase of log_e-transformed OC 0.51 [95% CI 0.35–0.76]; RR for highest vs. lowest quartile 0.65 [95% CI 0.44–0.95]; P for trend < 0.05). In the diabetes subcohort, OC levels were linearly inversely associated with incident DKD (RR for 1-unit increase of log_e-transformed OC 0.49 [95% CI 0.33–0.74]; RR for highest vs. lowest quartile 0.56 [95% CI 0.38–0.83]; P for trend < 0.05), even independent of baseline estimated glomerular filtration rate and urinary albumin-to-creatinine ratio. No significant interactions between OC and various subgroups on incident diabetes or DKD were observed.CONCLUSIONSLower OC levels were associated with an increased risk of incident diabetes and DKD.     

Risk Factors for Incident Fracture in Older Adults With Type 2 Diabetes: The Framingham Heart Study

OBJECTIVETo identify risk factors for fracture in type 2 diabetes.RESEARCH DESIGN AND METHODSThis prospective study included members of the Framingham Original and Offspring Cohorts. Type 2 diabetes was defined as fasting plasma glucose >125 mg/dL or use of type 2 diabetes therapy. We used repeated-measures Cox proportional hazards regression to calculate hazard ratios (HRs) and 95% CIs for associations between potential predictors and incidence of fragility fracture.RESULTSParticipants included 793 individuals with type 2 diabetes. Mean ± SD age was 70 ± 10 years; 45% were women. A total of 106 incident fractures occurred over 1,437 observation follow-up intervals. Fracture incidence increased with age (adjusted HRs 1.00, 1.44 [95% CI 0.65, 3.16], and 2.40 [1.14, 5.04] for <60, 60–70, and >70 years, respectively; P_trend = 0.02), female sex (2.23 [1.26, 3.95]), HbA_1c (1.00, 2.10 [1.17, 3.75], and 1.29 [0.69, 2.41] for 4.45–6.46% [25–47 mmol/mol], 6.50–7.49% [48–58 mmol/mol], and 7.50–13.86% [58–128 mmol/mol]; P_trend =0.03), falls in past year (1.00, 1.87 [0.82, 4.28], and 3.29 [1.34, 8.09] for no falls, one fall, and two or more falls; P_trend =0.03), fracture history (2.05 [1.34, 3.12]), and lower grip strength (0.82 [0.69, 0.99] per 5-kg increase). Femoral neck bone mineral density, BMI, smoking, physical function, chronic diseases, medications, and physical function were not associated with fracture incidence.CONCLUSIONSPrior falls, fractures, low grip strength, and elevated HbA_1c are risk factors for fractures in older adults with type 2 diabetes. Evaluation of these factors may improve opportunities for early intervention and reduce fractures in this high-risk group.     

Thirty-Year Trends in Complications in U.S. Adults With Newly Diagnosed Type 2 Diabetes

OBJECTIVETo assess the prevalence of and trends in complications among U.S. adults with newly diagnosed diabetes.RESEARCH DESIGN AND METHODSWe included 1,486 nonpregnant adults (aged ≥20 years) with newly diagnosed diabetes (diagnosed within the past 2 years) from the 1988–1994 and 1999–2018 National Health and Nutrition Examination Survey. We estimated trends in albuminuria (albumin-to-creatinine ratio ≥30 mg/g), reduced estimated glomerular filtration rate (eGFR <60 mL/min/1.73 m²), retinopathy (any retinal microaneurysms or blot hemorrhages), and self-reported cardiovascular disease (history of congestive heart failure, heart attack, or stroke).RESULTSFrom 1988–1994 to 2011–2018, there was a significant decrease in the prevalence of albuminuria (38.9 to 18.7%, P for trend <0.001) but no change in the prevalence of reduced eGFR (7.5 to 9.9%, P for trend = 0.30), retinopathy (1988–1994 to 1999–2008 only; 13.2 to 12.1%, P for trend = 0.86), or self-reported cardiovascular disease (19.0 to 16.5%, P for trend = 0.64). There were improvements in glycemic, blood pressure, and lipid control in the population, and these partially explained the decline in albuminuria. Complications were more common at the time of diabetes diagnosis for adults who were older, lower income, less educated, and obese.CONCLUSIONSOver the past three decades, there have been encouraging reductions in albuminuria and risk factor control in adults with newly diagnosed diabetes. However, the overall burden of complications around the time of the diagnosis remains high.     

Metabolic Syndrome and COVID-19 Mortality Among Adult Black Patients in New Orleans

OBJECTIVECoronavirus disease 2019 (COVID-19) mortality is high in patients with hypertension, obesity, and diabetes. We examined the association between hypertension, obesity, and diabetes, individually and clustered as metabolic syndrome (MetS), and COVID-19 outcomes in patients hospitalized in New Orleans during the peak of the outbreak.RESEARCH DESIGN AND METHODSData were collected from 287 consecutive patients with COVID-19 hospitalized at two hospitals in New Orleans, LA, from 30 March to 5 April 2020. MetS was identified per World Health Organization criteria.RESULTSAmong 287 patients (mean age 61.5 years; female, 56.8%; non-Hispanic Black, 85.4%), MetS was present in 188 (66%). MetS was significantly associated with mortality (adjusted odds ratio [aOR] 3.42 [95% CI 1.52–7.69]), intensive care unit requirement (ICU) (aOR 4.59 [CI 2.53–8.32]), invasive mechanical ventilation (IMV) (aOR 4.71 [95% CI 2.50–8.87]), and acute respiratory distress syndrome (ARDS) (aOR 4.70 [95% CI 2.25–9.82]) compared with non-MetS. Multivariable analyses of hypertension, obesity, and diabetes individually showed no association with mortality. Obesity was associated with ICU (aOR 2.18 [95% CI 1.25–3.81]), ARDS (aOR 2.44 [95% CI 1.28–4.65]), and IMV (aOR 2.36 [95% CI 1.33–4.21]). Diabetes was associated with ICU (aOR 2.22 [95% CI 1.24–3.98]) and IMV (aOR 2.12 [95% CI 1.16–3.89]). Hypertension was not significantly associated with any outcome. Inflammatory biomarkers associated with MetS, CRP and lactate dehydrogenase (LDH), were associated with mortality (CRP [aOR 3.66] [95% CI 1.22–10.97] and LDH [aOR 3.49] [95% CI 1.78–6.83]).CONCLUSIONSIn predominantly Black patients hospitalized for COVID-19, the clustering of hypertension, obesity, and diabetes as MetS increased the odds of mortality compared with these comorbidities individually.     

The Incidence of Diabetes Among 2,777,768 Veterans With and Without Recent SARS-CoV-2 Infection

OBJECTIVETo examine associations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection/coronavirus disease 2019 with incident diabetes.RESEARCH DESIGN AND METHODSWe conducted a retrospective cohort study using Veterans Health Administration data. We defined all patients without preexisting diabetes with one or more nasal swabs positive for SARS-CoV-2 (1 March 2020–10 March 2021; n = 126,710) as exposed and those with no positive swab and one or more laboratory tests (1 March 2020–31 March 2021; n = 2,651,058) as unexposed. The index date for patients exposed was the date of first positive swab and for patients unexposed a random date during the month of the qualifying laboratory test. We fit sex-stratified logistic regression models examining associations of SARS-CoV-2 with incident diabetes within 120 days and all follow-up time through 1 June 2021. A subgroup analysis was performed among hospitalized subjects only to help equalize laboratory surveillance.RESULTSSARS-CoV-2 was associated with higher risk of incident diabetes, compared with no positive tests, among men (120 days, odds ratio [OR] 2.56 [95% CI 2.32–2.83]; all time, 1.95 [1.80–2.12]) but not women (120 days, 1.21 [0.88–1.68]; all time, 1.04 [0.82–1.31]). Among hospitalized participants, SARS-CoV-2 was associated with higher risk of diabetes at 120 days and at the end of follow-up in men (OR 1.42 [95% CI 1.22–1.65] and 1.32 [1.16–1.50], respectively) but not women (0.72 [0.34–1.52] and 0.80 [0.44–1.45]). Sex ∗ SARS-CoV-2 interaction P values were all <0.1.CONCLUSIONSSARS-CoV-2 is associated with higher risk of incident diabetes in men but not in women even after greater surveillance related to hospitalization is accounted for.     

Shortened Leukocyte Telomere Length Is Associated With Glycemic Progression in Type 2 Diabetes: A Prospective and Mendelian Randomization Analysis

OBJECTIVESeveral studies support associations between relative leukocyte telomere length (rLTL), a biomarker of biological aging and type 2 diabetes. This study investigates the relationship between rLTL and the risk of glycemic progression in patients with type 2 diabetes.RESEARCH DESIGN AND METHODSIn this cohort study, consecutive Chinese patients with type 2 diabetes (N = 5,506) from the Hong Kong Diabetes Register with stored baseline DNA and available follow-up data were studied. rLTL was measured using quantitative PCR. Glycemic progression was defined as the new need for exogenous insulin.RESULTSThe mean (SD) age of the 5,349 subjects was 57.0 (13.3) years, and mean (SD) follow-up was 8.8 (5.4) years. Baseline rLTL was significantly shorter in the 1,803 subjects who progressed to insulin requirement compared with the remaining subjects (4.43 ± 1.16 vs. 4.69 ± 1.20). Shorter rLTL was associated with a higher risk of glycemic progression (hazard ratio [95% CI] for each unit decrease [to ∼0.2 kilobases]: 1.10 [1.06–1.14]), which remained significant after adjusting for confounders. Baseline rLTL was independently associated with glycemic exposure during follow-up (β = −0.05 [−0.06 to −0.04]). Each 1-kilobase decrease in absolute LTL was on average associated with a 1.69-fold higher risk of diabetes progression (95% CI 1.35–2.11). Two-sample Mendelian randomization analysis showed per 1-unit genetically decreased rLTL was associated with a 1.38-fold higher risk of diabetes progression (95% CI 1.12–1.70).CONCLUSIONSShorter rLTL was significantly associated with an increased risk of glycemic progression in individuals with type 2 diabetes, independent of established risk factors. Telomere length may be a useful biomarker for glycemic progression in people with type 2 diabetes.     

Type 2 Diabetes and COVID-19–Related Mortality in the Critical Care Setting: A National Cohort Study in England,March–July 2020

OBJECTIVETo describe the relationship between type 2 diabetes and all-cause mortality among adults with coronavirus disease 2019 (COVID-19) in the critical care setting.RESEARCH DESIGN AND METHODSThis was a nationwide retrospective cohort study in people admitted to hospital in England with COVID-19 requiring admission to a high dependency unit (HDU) or intensive care unit (ICU) between 1 March 2020 and 27 July 2020. Cox proportional hazards models were used to estimate 30-day in-hospital all-cause mortality associated with type 2 diabetes, with adjustment for age, sex, ethnicity, obesity, and other major comorbidities (chronic respiratory disease, asthma, chronic heart disease, hypertension, immunosuppression, chronic neurological disease, chronic renal disease, and chronic liver disease).RESULTSA total of 19,256 COVID-19–related HDU and ICU admissions were included in the primary analysis, including 13,809 HDU (mean age 70 years) and 5,447 ICU (mean age 58 years) admissions. Of those admitted, 3,524 (18.3%) had type 2 diabetes and 5,077 (26.4%) died during the study period. Patients with type 2 diabetes were at increased risk of death (adjusted hazard ratio [aHR] 1.23 [95% CI 1.14, 1.32]), and this result was consistent in HDU and ICU subsets. The relative mortality risk associated with type 2 diabetes decreased with higher age (age 18–49 years aHR 1.50 [95% CI 1.05, 2.15], age 50–64 years 1.29 [1.10, 1.51], and age ≥65 years 1.18 [1.09, 1.29]; P value for age–type 2 diabetes interaction = 0.002).CONCLUSIONSType 2 diabetes may be an independent prognostic factor for survival in people with severe COVID-19 requiring critical care treatment, and in this setting the risk increase associated with type 2 diabetes is greatest in younger people.     

American Diabetes Association Framework for Glycemic Control in Older Adults: Implications for Risk of Hospitalization and Mortality

OBJECTIVEThe 2021 American Diabetes Association (ADA) guidelines recommend different A1C targets in older adults that are based on comorbid health status. We assessed risk of mortality and hospitalizations in older adults with diabetes across glycemic control (A1C <7%, 7 to <8%, ≥8%) and ADA-defined health status (healthy, complex/intermediate, very complex/poor) categories.RESEARCH DESIGN AND METHODSProspective cohort analysis of older adults aged 66–90 years with diagnosed diabetes in the Atherosclerosis Risk in Communities (ARIC) study.RESULTSOf the 1,841 participants (56% women, 29% Black), 32% were classified as healthy, 42% as complex/intermediate, and 27% as very complex/poor health. Over a median 6-year follow-up, there were 409 (22%) deaths and 4,130 hospitalizations (median [25th–75th percentile] 1 per person [0–3]). In the very complex/poor category, individuals with A1C ≥8% (vs. <7%) had higher mortality risk (hazard ratio 1.76 [95% CI 1.15–2.71]), even after adjustment for glucose-lowering medication use. Within the very complex/poor health category, individuals with A1C ≥8% (vs. <7%) had more hospitalizations (incidence rate ratio [IRR] 1.41 [95% CI 1.03–1.94]). In the complex/intermediate group, individuals with A1C ≥8% (vs. <7%) had more hospitalizations, even with adjustment for glucose-lowering medication use (IRR 1.64 [1.21–2.24]). Results were similar, but imprecise, when the analysis was restricted to insulin or sulfonylurea users (n = 663).CONCLUSIONSThere were substantial differences in mortality and hospitalizations across ADA health status categories, but older adults with A1C <7% were not at elevated risk, regardless of health status. Our results support the 2021 ADA guidelines and indicate that <7% is a reasonable treatment goal in some older adults with diabetes.     

Trends in Receipt of American Diabetes Association Guideline-Recommended Care Among U.S. Adults With Diabetes: NHANES 2005–2018

OBJECTIVETo characterize national trends and characteristics of adults with diabetes receiving American Diabetes Association (ADA) guideline-recommended care.RESEARCH DESIGN AND METHODSWe performed serial cross-sectional analyses of 4,069 adults aged ≥20 years with diabetes who participated in the 2005–2018 National Health and Nutrition Examination Survey (NHANES).RESULTSOverall, the proportion of U.S. adults with diabetes receiving ADA guideline-recommended care meeting all five criteria by self-report in the past year (having a primary doctor for diabetes and one or more visits for this doctor, HbA_1c testing, an eye examination, a foot examination, and cholesterol testing) increased from 25.0% in 2005–2006 to 34.1% in 2017–2018 (P-trend = 0.004). For participants with age ≥65 years, it increased from 29.3% in 2005–2006 to 44.2% in 2017–2018 (P-trend = 0.001), whereas for participants with age 40–64 and 20–39 years, it did not change significantly during the same time period: 25.2% to 25.8% (P-trend = 0.457) and 9.9% to 26.0% (P-trend = 0.401), respectively. Those who were not receiving ADA guideline-recommended care were more likely to be younger, of lower socioeconomic status, uninsured, newly diagnosed with diabetes, not on diabetes medication, and free of hypercholesterolemia.CONCLUSIONSReceipt of ADA guideline-recommended care increased only among adults with diabetes aged ≥65 years in the past decade. In 2017–2018, only one of three U.S. adults with diabetes reported receiving ADA guideline-recommended care, with even a lower receipt of care among those <65 years of age. Efforts are needed to improve health care delivery and equity in diabetes care. Insurance status is an important modifiable determinant of receiving ADA guideline-recommended care.