Diabetes & Metabolism Journal

Original Article

Metabolic Risk/Epidemiology
Low Household Income Status and Death from Pneumonia in People with Type 2 Diabetes Mellitus: A Nationwide Study: You-Bin Lee, So Hee Park, Kyu-na Lee, Bongsung Kim, So Yoon Kwon, Jiyun Park, Gyuri Kim, Sang-Man Jin, Kyu Yeon Hur, Kyungdo Han, Jae Hyeon Kim; Diabetes Metab J. 2023;47(5):682-692. Published online June 22, 2023; DOI: https://doi.org/10.4093/dmj.2022.0184

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Abstract PDF Supplementary Material PubReader ePub: Background
We explored the risk of death from pneumonia according to cumulative duration in low household income state (LHIS) among adults with type 2 diabetes mellitus (T2DM).
Methods
Using Korean National Health Insurance Service data (2002 to 2018), the hazards of mortality from pneumonia were analyzed according to duration in LHIS (being registered to Medical Aid) during the 5 years before baseline (0, 1–4, and 5 years) among adults with T2DM who underwent health examinations between 2009 and 2012 (n=2,503,581). Hazards of outcomes were also compared in six groups categorized by insulin use and duration in LHIS.
Results
During a median 7.18 years, 12,245 deaths from pneumonia occurred. Individuals who had been exposed to LHIS had higher hazards of death from pneumonia in a dose-response manner (hazard ratio [HR], 1.726; 95% confidence interval [CI], 1.568 to 1.899 and HR, 4.686; 95% CI, 3.948 to 5.562 in those exposed for 1–4 and 5 years, respectively) compared to the non-exposed reference. Insulin users exposed for 5 years to LHIS exhibited the highest outcome hazard among six groups categorized by insulin use and duration in LHIS.
Conclusion
Among adults with T2DM, cumulative duration in LHIS may predict increased risks of mortality from pneumonia in a graded dose-response manner. Insulin users with the longest duration in LHIS might be the group most vulnerable to death from pneumonia among adults with T2DM.

Review

Cardiovascular Risk/Epidemiology
Intensified Multifactorial Intervention in Patients with Type 2 Diabetes Mellitus: Takayoshi Sasako, Toshimasa Yamauchi, Kohjiro Ueki; Diabetes Metab J. 2023;47(2):185-197. Published online January 12, 2023; DOI: https://doi.org/10.4093/dmj.2022.0325

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In the management of diabetes mellitus, one of the most important goals is to prevent its micro- and macrovascular complications, and to that end, multifactorial intervention is widely recommended. Intensified multifactorial intervention with pharmacotherapy for associated risk factors, alongside lifestyle modification, was first shown to be efficacious in patients with microalbuminuria (Steno-2 study), then in those with less advanced microvascular complications (the Anglo-Danish-Dutch Study of Intensive Treatment In People with Screen Detected Diabetes in Primary Care [ADDITION]-Europe and the Japan Diabetes Optimal Treatment study for 3 major risk factors of cardiovascular diseases [J-DOIT3]), and in those with advanced microvascular complications (the Nephropathy In Diabetes-Type 2 [NID-2] study and Diabetic Nephropathy Remission and Regression Team Trial in Japan [DNETT-Japan]). Thus far, multifactorial intervention led to a reduction in cardiovascular and renal events, albeit not necessarily significant. It should be noted that not only baseline characteristics but also the control status of the risk factors and event rates during intervention among the patients widely varied from one trial to the next. Further evidence is needed for the efficacy of multifactorial intervention in a longer duration and in younger or elderly patients. Moreover, now that new classes of antidiabetic drugs are available, it should be addressed whether strict and safe glycemic control, alongside control of other risk factors, could lead to further risk reductions in micro- and macrovascular complications, thereby decreasing all-cause mortality in patients with type 2 diabetes mellitus.

Citations

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Cardiovascular Risk Reduction in Type 2 Diabetes: Further Insights into the Power of Weight Loss and Exercise
Seung-Hwan Lee
Endocrinology and Metabolism.2023; 38(3): 302. CrossRef
Sarcopenia: Loss of mighty armor against frailty and aging
Takayoshi Sasako, Kohjiro Ueki
Journal of Diabetes Investigation.2023; 14(10): 1145. CrossRef

Original Articles

Metabolic Risk/Epidemiology
Metabolic Dysfunction-Associated Fatty Liver Disease and Mortality: A Population-Based Cohort Study: Kyung-Soo Kim, Sangmo Hong, Hong-Yup Ahn, Cheol-Young Park; Diabetes Metab J. 2023;47(2):220-231. Published online January 12, 2023; DOI: https://doi.org/10.4093/dmj.2021.0327

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Background
We investigated whether metabolic dysfunction-associated fatty liver disease (MAFLD) is associated with an elevated risk of all-cause and cardiovascular mortality using a large-scale health examination cohort.
Methods
A total of 394,835 subjects in the Kangbuk Samsung Health Study cohort were enrolled from 2002 to 2012. Participants were categorized by the presence of nonalcoholic fatty liver disease (NAFLD) and MAFLD as follows: normal subjects; patients with both NAFLD and MAFLD; patients with NAFLD only; and patients with MAFLD only. Cox proportional hazards models were used to analyze the risk of mortality.
Results
During a median 5.7 years of follow-up, 20.69% was patients with both NAFLD and MAFLD, 1.51% was patients with NAFLD only, and 4.29% was patients with MAFLD only. All-cause and cardiovascular death was higher in patients with MAFLD than those without MAFLD (P<0.001, respectively). In patients with MAFLD only, the hazard ratio (HR) of all-cause and cardiovascular death was 1.35 (95% confidence interval [CI], 1.13 to 1.60) and 1.90 (95% CI, 1.26 to 2.88) after adjusting for age, which lost its statistical significance by multivariable adjustments. Compared to patients with less than two components of metabolic dysfunction, patients with more than two components of metabolic dysfunction were a higher risk of cardiovascular death (HR, 2.05; 95% CI, 1.25 to 3.38) and only women with more than two components of metabolic dysfunction were a higher risk of all-cause death (HR, 1.44; 95% CI, 1.02 to 2.03).
Conclusion
MAFLD criteria could identify a high-risk group for all-cause and cardiovascular death.

Citations

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Comparison of Outcomes Between Metabolic Dysfunction-Associated Fatty Liver Disease and Non-alcoholic Fatty Liver Disease: A Meta-Analysis
Ghazala S Virk, Jaahnavi Vajje, Nausheen K Virk, Raam Mannam, Wajeeh Rehman, Naglaa G Ghobriel , Irfan-ud-din Mian, Muhammad Usama
Cureus.2023;[Epub] CrossRef
Trends in prevalence and all-cause mortality of metabolic dysfunction-associated fatty liver disease among adults in the past three decades: Results from the NHANES study
Zhi-Qin Xie, Hong-Xia Li, Bing-Kun Wang, Zhao-Ming Yang, Zi-Yu Zhang, Wen-Liang Tan, Wen-Xin Li, Qing-Bin Wang, Lei Yang, Hong-Kai Zhuang, Chen-Wei Tang, Chang-Zhen Shang, Ya-Jin Chen
European Journal of Internal Medicine.2023; 110: 62. CrossRef
Comparing the Mortality Risk between Metabolic Dysfunction-Associated Fatty Liver Disease and Non-Alcoholic Fatty Liver Disease
Han Na Jung, Chang Hee Jung
Diabetes & Metabolism Journal.2023; 47(2): 198. CrossRef
Increased expression of sodium-glucose cotransporter 2 and O-GlcNAcylation in hepatocytes drives non-alcoholic steatohepatitis
Hye Jin Chun, Eun Ran Kim, Minyoung Lee, Da Hyun Choi, Soo Hyun Kim, Eugene Shin, Jin-Hong Kim, Jin Won Cho, Dai Hoon Han, Bong-Soo Cha, Yong-ho Lee
Metabolism.2023; 145: 155612. CrossRef
Current understanding and future perspectives on the impact of changing NAFLD to MAFLD on global epidemiology and clinical outcomes
Karl Vaz, Daniel Clayton-Chubb, Ammar Majeed, John Lubel, David Simmons, William Kemp, Stuart K. Roberts
Hepatology International.2023; 17(5): 1082. CrossRef

Cardiovascular Risk/Epidemiology
Myocardial Infarction, Stroke, and All-Cause Mortality according to Low-Density Lipoprotein Cholesterol Level in the Elderly, a Nationwide Study: You-Bin Lee, Minji Koo, Eunjin Noh, Soon Young Hwang, Jung A Kim, Eun Roh, So-hyeon Hong, Kyung Mook Choi, Sei Hyun Baik, Geum Joon Cho, Hye Jin Yoo; Diabetes Metab J. 2022;46(5):722-732. Published online March 8, 2022; DOI: https://doi.org/10.4093/dmj.2021.0225

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Background
We assessed the myocardial infarction (MI), stroke, and all-cause death risks during follow-up according to the low-density lipoprotein cholesterol (LDL-C) levels among older adults.
Methods
The Korean National Health Insurance Service datasets (2002 to 2020) were used for this population-based cohort study. The hazards of MI, stroke, and all-cause mortality during follow-up were analyzed according to LDL-C level in individuals aged ≥65 years without baseline cardiovascular diseases (n=1,391,616).
Results
During a mean 7.55 years, 52,753 MIs developed; 84,224 strokes occurred over a mean 7.47 years. After a mean 8.50 years, 233,963 died. A decrease in LDL-C was associated with lower hazards of MI and stroke. The decreased hazard of stroke in lower LDL-C was more pronounced in statin users, and individuals with diabetes or obesity. The hazard of all-cause death during follow-up showed an inverted J-shaped pattern according to the LDL-C levels. However, the paradoxically increased hazard of mortality during follow-up in lower LDL-C was attenuated in statin users and individuals with diabetes, hypertension, or obesity. In statin users, lower LDL-C was associated with a decreased hazard of mortality during follow-up.
Conclusion
Among the elderly, lower LDL-C was associated with decreased risks of MI and stroke. Lower LDL-C achieved by statins in the elderly was associated with a decreased risk of all-cause death during follow-up, suggesting that LDL-C paradox for the premature death risk in the elderly should not be applied to statin users. Intensive statin therapy should not be hesitated for older adults with cardiovascular risk factors including diabetes.

Citations

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Chin-Huan Chang, Shu-Tin Yeh, Seng-Wei Ooi, Chung-Yi Li, Hua-Fen Chen
PeerJ.2023; 11: e14609. CrossRef
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Kyuho Kim, Henry N. Ginsberg, Sung Hee Choi
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Endocrinology and Metabolism.2022; 37(5): 759. CrossRef

Brief Reports

Complications
Trends in the Incidence, Prevalence, and Mortality of End-Stage Kidney Disease in South Korea: Min-Jeong Lee, Kyoung Hwa Ha, Dae Jung Kim, Inwhee Park; Diabetes Metab J. 2020;44(6):933-937. Published online December 23, 2020; DOI: https://doi.org/10.4093/dmj.2020.0156

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12 Citations

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Knowledge of the epidemiologic characteristics of end-stage kidney disease (ESKD) patients is essential. The trends in the prevalence, incidence, and mortality rates of ESKD were analyzed retrospectively using the Korean National Health Insurance ServiceNational Sample Cohort database between 2006 and 2015. From 2006 to 2015, the incidence of ESKD decreased from 28.6 to 24.0 per 100,000 people and showed a decreasing pattern with or without diabetes mellitus. However, the incidence of those aged ≥75 years increased, as did the mean age at the onset of ESKD. From 2007 to 2015, the prevalence of ESKD increased in all age groups, but particularly in those aged ≥75 years. The prevalence of ESKD differed by sex and diabetes mellitus status and this gap widened over time. Mortality rates in ESKD patients remained relatively constant throughout the study period. However, mortality rates in ESKD without diabetes decreased over the same period.

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Complications
Trends in Cardiovascular Complications and Mortality among Patients with Diabetes in South Korea: Jung Hwan Park, Kyoung Hwa Ha, Bo Yeon Kim, Jae Hyuk Lee, Dae Jung Kim; Diabetes Metab J. 2021;45(1):120-124. Published online December 9, 2020; DOI: https://doi.org/10.4093/dmj.2020.0175; Correction in: Diabetes Metab J 2021;45(2):283

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We investigated the cardiovascular complications and mortality rates of patients with diabetes in South Korea. The rates of hospitalization due to cardiovascular complications and mortality were analyzed using the Korean National Health Insurance Service-National Sample Cohort. From 2006 to 2015, the rates of hospitalization due to major cardiovascular complications decreased, while those due to heart failure (from 72 to 146 and 124 to 161 per 10,000 men and women, respectively) and peripheral artery disease (from 39 to 55 and 19 to 35 per 10,000 men and women, respectively) increased. In the period 2007 to 2015, the mortality rates for cancer, cerebrovascular disease, diabetes, heart disease, and hypertensive disease all decreased. However, the mortality rate for pneumonia increased. We observed a continuous reduction in cardiovascular complications and mortality in adults with diabetes. However, with the increase in some diabetes complications, more efforts are needed to prevent diabetes complications.

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The effect of metabolic dysfunction-associated fatty liver disease and diabetic kidney disease on the risk of hospitalization of heart failure in type 2 diabetes: a retrospective cohort study
Seung Eun Lee, Juhwan Yoo, Bong-Seong Kim, Han Seok Choi, Kyungdo Han, Kyoung-Ah Kim
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Original Articles

COVID-19
Independent Impact of Diabetes on the Severity of Coronavirus Disease 2019 in 5,307 Patients in South Korea: A Nationwide Cohort Study: Sun Joon Moon, Eun-Jung Rhee, Jin-Hyung Jung, Kyung-Do Han, Sung-Rae Kim, Won-Young Lee, Kun-Ho Yoon; Diabetes Metab J. 2020;44(5):737-746. Published online October 21, 2020; DOI: https://doi.org/10.4093/dmj.2020.0141

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Background
Inconsistent results have been observed regarding the independent effect of diabetes on the severity of coronavirus disease 2019 (COVID-19). We conducted a nationwide population-based cohort study to evaluate the relationship between diabetes and COVID-19 severity in South Korea.
Methods
Patients with laboratory-confirmed COVID-19 aged ≥30 years were enrolled and medical claims data were obtained from the Korean Health Insurance Review and Assessment Service. Hospitalization, oxygen treatment, ventilator application, and mortality were assessed as severity outcomes. Multivariate logistic regression analyses were performed after adjusting for age, sex, and comorbidities.
Results
Of 5,307 COVID-19 patients, the mean age was 56.0±14.4 years, 2,043 (38.5%) were male, and 770 (14.5%) had diabetes. The number of patients who were hospitalized, who received oxygen, who required ventilator support, and who died was 4,986 (94.0%), 884 (16.7%), 121 (2.3%), and 211 (4.0%), respectively. The proportion of patients with diabetes in the abovementioned outcome groups was 14.7%, 28.1%, 41.3%, 44.6%, showing an increasing trend according to outcome severity. In multivariate analyses, diabetes was associated with worse outcomes, with an adjusted odds ratio (aOR) of 1.349 (95% confidence interval [CI], 1.099 to 1.656; P=0.004) for oxygen treatment, an aOR of 1.930 (95% CI, 1.276 to 2.915; P<0.001) for ventilator use, and an aOR of 2.659 (95% CI, 1.896 to 3.729; P<0.001) for mortality.
Conclusion
Diabetes was associated with worse clinical outcomes in Korean patients with COVID-19, independent of other comorbidities. Therefore, patients with diabetes and COVID-19 should be treated with caution.

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Covid-19
The Clinical Characteristics and Outcomes of Patients with Moderate-to-Severe Coronavirus Disease 2019 Infection and Diabetes in Daegu, South Korea: Mi Kyung Kim, Jae-Han Jeon, Sung-Woo Kim, Jun Sung Moon, Nan Hee Cho, Eugene Han, Ji Hong You, Ji Yeon Lee, Miri Hyun, Jae Seok Park, Yong Shik Kwon, Yeon-Kyung Choi, Ki Tae Kwon, Shin Yup Lee, Eon Ju Jeon, Jin-Woo Kim, Hyo-Lim Hong, Hyun Hee Kwon, Chi Young Jung, Yin Young Lee, Eunyeoung Ha, Seung Min Chung, Jian Hur, June Hong Ahn, Na-young Kim, Shin-Woo Kim, Hyun Ha Chang, Yong Hoon Lee, Jaehee Lee, Keun-Gyu Park, Hyun Ah Kim, Ji-Hyun Lee; Diabetes Metab J. 2020;44(4):602-613. Published online August 12, 2020; DOI: https://doi.org/10.4093/dmj.2020.0146

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Background

Coronavirus disease 2019 (COVID-19) is a global pandemic that had affected more than eight million people worldwide by June 2020. Given the importance of the presence of diabetes mellitus (DM) for host immunity, we retrospectively evaluated the clinical characteristics and outcomes of moderate-to-severe COVID-19 in patients with diabetes.

Methods

We conducted a multi-center observational study of 1,082 adult inpatients (aged ≥18 years) who were admitted to one of five university hospitals in Daegu because of the severity of their COVID-19-related disease. The demographic, laboratory, and radiologic findings, and the mortality, prevalence of severe disease, and duration of quarantine were compared between patients with and without DM. In addition, 1:1 propensity score (PS)-matching was conducted with the DM group.

Results

Compared with the non-DM group (n=847), patients with DM (n=235) were older, exhibited higher mortality, and required more intensive care. Even after PS-matching, patients with DM exhibited more severe disease, and DM remained a prognostic factor for higher mortality (hazard ratio, 2.40; 95% confidence interval, 1.38 to 4.15). Subgroup analysis revealed that the presence of DM was associated with higher mortality, especially in older people (≥70 years old). Prior use of a dipeptidyl peptidase-4 inhibitor or a renin-angiotensin system inhibitor did not affect mortality or the clinical severity of the disease.

Conclusion

DM is a significant risk factor for COVID-19 severity and mortality. Our findings imply that COVID-19 patients with DM, especially if elderly, require special attention and prompt intensive care.

Citations

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Clinical Outcomes of COVID-19 Patients with Type 2 Diabetes: A Population-Based Study in Korea
Ji Hong You, Sang Ah Lee, Sung-Youn Chun, Sun Ok Song, Byung-Wan Lee, Dae Jung Kim, Edward J. Boyko
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Complications
Differences in Clinical Outcomes between Patients with and without Hypoglycemia during Hospitalization: A Retrospective Study Using Real-World Evidence: Jeongmin Lee, Tong Min Kim, Hyunah Kim, Seung-Hwan Lee, Jae Hyoung Cho, Hyunyong Lee, Hyeon Woo Yim, Kun-Ho Yoon, Hun-Sung Kim; Diabetes Metab J. 2020;44(4):555-565. Published online May 8, 2020; DOI: https://doi.org/10.4093/dmj.2019.0064

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Background

Some patients admitted to hospitals for glycemic control experience hypoglycemia despite regular meals and despite adhering to standard blood glucose control protocols. Different factors can have a negative impact on blood glucose control and prognosis after discharge. This study investigated risk factors for hypoglycemia and its effects on glycemic control during the hospitalization of patients in the general ward.

Methods

This retrospective study included patients who were admitted between 2009 and 2018. Patients were provided regular meals at fixed times according to ideal body weights during hospitalization. We categorized the patients into two groups: those with and those without hypoglycemia during hospitalization.

Results

Of the 3,031 patients, 379 experienced at least one episode of hypoglycemia during hospitalization (HYPO group). Hypoglycemia occurred more frequently particularly in cases of premixed insulin therapy. Compared with the control group, the HYPO group was older (61.0±16.8 years vs. 59.1±16.5 years, P=0.035), with more females (60.4% vs. 49.6%, P<0.001), lower body mass index (BMI) (23.5±4.2 kg/m² vs. 25.1±4.4 kg/m², P<0.001), and higher prevalence of type 1 diabetes mellitus (6.1% vs. 2.6%, P<0.001), They had longer hospital stay (11.1±13.5 days vs. 7.6±4.6 days, P<0.001). After discharge the HYPO group had lower glycosylated hemoglobin reduction rate (−2.0%±0.2% vs. −2.5%±0.1%, P=0.003) and tended to have more frequent cases of cardiovascular disease.

Conclusion

Hypoglycemia occurred more frequently in older female patients with lower BMI and was associated with longer hospital stay and poorer glycemic control after discharge. Therefore, clinicians must carefully ensure that patients do not experience hypoglycemia during hospitalization.

Citations

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Acute kidney injury: a strong risk factor for hypoglycaemia in hospitalized patients with type 2 diabetes
Ana Carreira, Pedro Castro, Filipe Mira, Miguel Melo, Pedro Ribeiro, Lèlita Santos
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Adherence to healthy lifestyle behaviors as a preventable risk factor for severe hypoglycemia in people with type 2 diabetes: A longitudinal nationwide cohort study
Jae‐Seung Yun, Kyungdo Han, Yong‐Moon Park, Eugene Han, Yong‐ho Lee, Seung‐Hyun Ko
Journal of Diabetes Investigation.2022; 13(9): 1533. CrossRef
Predicting hypoglycemia in hospitalized patients with diabetes: A derivation and validation study
Michal Elbaz, Jeries Nashashibi, Shiri Kushnir, Leonard Leibovici
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Letter: Differences in Clinical Outcomes between Patients with and without Hypoglycemia during Hospitalization: A Retrospective Study Using Real-World Evidence (Diabetes Metab J 2020;44:555-65)
Sung-Woo Kim
Diabetes & Metabolism Journal.2020; 44(5): 775. CrossRef
Response: Differences in Clinical Outcomes between Patients with and without Hypoglycemia during Hospitalization: A Retrospective Study Using Real-World Evidence (Diabetes Metab J 2020;44:555-65)
Jeongmin Lee, Hun-Sung Kim
Diabetes & Metabolism Journal.2020; 44(5): 779. CrossRef
Hypoglycaemia and Cardiovascular Disease Risk in Patients with Diabetes
Niki Katsiki, Kalliopi Kotsa, Anca P. Stoian, Dimitri P. Mikhailidis
Current Pharmaceutical Design.2020; 26(43): 5637. CrossRef

Brief Report

Cardiovascular risk/Epidemiology
Clinical Impact of Dysglycemia in Patients with an Acute Myocardial Infarction: Jae-Wook Chung, Yeong-Seon Park, Jeong-Eon Seo, Yeseul Son, Cheol-Woo Oh, Chan-Hee Lee, Jong-Ho Nam, Jung-Hee Lee, Jang-Won Son, Ung Kim, Jong-Seon Park, Kyu-Chang Won, Dong-Gu Shin; Diabetes Metab J. 2021;45(2):270-274. Published online April 16, 2020; DOI: https://doi.org/10.4093/dmj.2019.0164

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This study aimed to determine the impact of dysglycemia on myocardial injury and cardiac dysfunction in acute myocardial infarctions (AMIs). From 2005 to 2016, a total of 1,593 patients with AMIs who underwent percutaneous coronary intervention were enrolled. The patients were classified into five groups according to the admission glucose level: ≤80, 81 to 140, 141 to 200, 201 to 260, and ≥261 mg/dL. The clinical and echocardiographic parameters and 30-day mortality were analyzed. The peak troponin I and white blood cell levels had a positive linear relationship to the admission glucose level. The left ventricular ejection fraction had an inverted U-shape trend, and the E/E' ratio was U-shaped based on euglycemia. The 30-day mortality also increased as the admission glucose increased, and the cut-off value for predicting the mortality was 202.5 mg/dL. Dysglycemia, especially hyperglycemia, appears to be associated with myocardial injury and could be another adjunctive parameter for predicting mortality in patients with AMIs.

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Original Article

Epidemiology
Diabetes Mellitus and Cause-Specific Mortality: A Population-Based Study: Sen Li, Jiaxin Wang, Biao Zhang, Xinyi Li, Yuan Liu; Diabetes Metab J. 2019;43(3):319-341. Published online April 19, 2019; DOI: https://doi.org/10.4093/dmj.2018.0060

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Background

To investigate whether diabetes contributes to mortality for major types of diseases.

Methods

Six National Health and Nutrition Examination Survey data cycles (1999 to 2000, 2001 to 2002, 2003 to 2004, 2005 to 2006, 2007 to 2008, and 2009 to 2010) and their linked mortality files were used. A population of 15,513 participants was included according to the availability of diabetes and mortality status.

Results

Participants with diabetes tended to have higher all-cause mortality and mortality due to cardiovascular disease, cancer, chronic lower respiratory diseases, cerebrovascular disease, influenza and pneumonia, and kidney disease. Confounder-adjusted Cox proportional hazard models showed that both diagnosed diabetes category (yes or no) and diabetes status (diabetes, prediabetes, or no diabetes) were associated with all-cause mortality and with mortality due to cardiovascular disease, chronic lower respiratory diseases, influenza and pneumonia, and kidney disease. No associations were found for cancer-, accidents-, or Alzheimer's disease-related mortality.

Conclusion

The current study's findings provide epidemiological evidence that diagnosed diabetes at the baseline is associated with increased mortality risk due to cardiovascular disease, chronic lower respiratory diseases, influenza and pneumonia, and kidney disease, but not with cancer or Alzheimer's disease.

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Review

Epidemiology
The Evidence for an Obesity Paradox in Type 2 Diabetes Mellitus: Seung Jin Han, Edward J. Boyko; Diabetes Metab J. 2018;42(3):179-187. Published online May 31, 2018; DOI: https://doi.org/10.4093/dmj.2018.0055

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Abstract PDF PubReader

Although overweight/obesity is a major risk factor for the development of type 2 diabetes mellitus, there is increasing evidence that overweight or obese patients with type 2 diabetes mellitus experience lower mortality compared with patients of normal weight. This paradoxical finding, known as the “obesity paradox,” occurs in other chronic diseases, and in type 2 diabetes mellitus is particularly perplexing given that lifestyle intervention with one goal being weight reduction is an important feature of the management of this condition. We summarize in this review the findings from clinical and epidemiologic studies that have investigated the association between overweight and obesity (usually assessed using body mass index [BMI]) and mortality in type 2 diabetes mellitus and discuss potential causes of the obesity paradox. We conclude that most studies show evidence of an obesity paradox, but important conflicting findings still exist. We also evaluate if potential bias might explain the obesity paradox in diabetes, including, for example, the presence of confounding factors, measurement error due to use of BMI as an index of obesity, and reverse causation.

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Original Articles

Epidemiology
Ten-Year Mortality Trends for Adults with and without Diabetes Mellitus in South Korea, 2003 to 2013: Kyeong Jin Kim, Tae Yeon Kwon, Sungwook Yu, Ji A Seo, Nan Hee Kim, Kyung Mook Choi, Sei Hyun Baik, Dong Seop Choi, Sin Gon Kim, Yousung Park, Nam Hoon Kim; Diabetes Metab J. 2018;42(5):394-401. Published online April 26, 2018; DOI: https://doi.org/10.4093/dmj.2017.0088

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Background

To estimate and compare the trends of all-cause and cause-specific mortality rates for subjects with and without diabetes in South Korea, from 2003 to 2013.

Methods

Using a population-based cohort (2003 to 2013), we evaluated annual mortality rates in adults (≥30 years) with and without diabetes. The number of subjects in this analysis ranged from 585,795 in 2003 to 670,020 in 2013.

Results

Age- and sex-adjusted all-cause mortality rates decreased consistently in both groups from 2003 to 2013 (from 14.4 to 9.3/1,000 persons in subjects with diabetes and from 7.9 to 4.4/1,000 persons in those without diabetes). The difference in mortality rates between groups also decreased (6.61 per 1,000 persons in 2003 to 4.98 per 1,000 persons in 2013). The slope associated with the mortality rate exhibited a steeper decrease in subjects with diabetes than those without diabetes (regression coefficients of time: −0.50 and −0.33, respectively; P=0.004). In subjects with diabetes, the mortality rate from cardiovascular disease decreased by 53.5% (from 2.73 to 1.27 per 1,000 persons, P for trend <0.001). Notably, the decrease in mortality from ischemic stroke (79.2%, from 1.20 to 0.25 per 1,000 persowns) was more profound than that from ischemic heart disease (28.3%, from 0.60 to 0.43 per 1,000 persons).

Conclusion

All-cause and cardiovascular mortality rates decreased substantially from 2003 to 2013, and the decline in ischemic stroke mortality mainly contributed to the decreased cardiovascular mortality in Korean people with diabetes.

Citations

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Ye Seul Yang, Hack-Lyoung Kim, Sang-Hyun Kim, Min Kyong Moon
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Lipid Management in Korean People with Type 2 Diabetes Mellitus: Korean Diabetes Association and Korean Society of Lipid and Atherosclerosis Consensus Statement
Ye Seul Yang, Hack-Lyoung Kim, Sang-Hyun Kim, Min Kyong Moon
Diabetes & Metabolism Journal.2023; 47(1): 1. CrossRef
Letter: Triglyceride-Glucose Index Predicts Cardiovascular Outcome in Metabolically Unhealthy Obese Population: A Nationwide Population-Based Cohort Study (J Obes Metab Syndr 2022;31:178-86)
Gwanpyo Koh
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Jeong-Whun Kim, Tae-Bin Won, Chae-Seo Rhee, Young Mi Park, In-Young Yoon, Sung-Woo Cho
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Epidemiology
Depression and Mortality in People with Type 2 Diabetes Mellitus, 2003 to 2013: A Nationwide Population-Based Cohort Study: Jong-Hyun Jeong, Yoo Hyun Um, Seung-Hyun Ko, Jong-Heon Park, Joong-Yeol Park, Kyungdo Han, Kyung-Soo Ko; Diabetes Metab J. 2017;41(4):296-302. Published online August 3, 2017; DOI: https://doi.org/10.4093/dmj.2017.41.4.296

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Background

Previous reports have demonstrated a bidirectional relationship between depression and diabetes mellitus (DM), accentuating a need for more intensive depression screening in DM patients. There is a relative paucity of data on the mortality of depressed DM patients in Korea.

Methods

Retrospective data from January 2003 to December 2013 were collected for adult type 2 diabetes mellitus (T2DM) patients older than 30 years using the National Health Information database maintained by the Korean National Health Insurance Service (NHIS). Demographic characteristics were analyzed with descriptive statistics, and the annual prevalence of depression was estimated. Mortality rates and hazard ratios for each age group (stratified into six age groups) of patients diagnosed with T2DM in 2003 were estimated using a Cox proportional hazard method, with the Kaplan-Meier cumulative survival curve showing the overall survival rates according to the T2DM status until the given year of 2013.

Results

The annual prevalence of depression was consistently higher in T2DM group from 2003 to 2013. The mortality hazard ratio was higher in the depressed in all age groups, and the risk was higher in male groups and in younger-aged groups.

Conclusion

Depression was significantly associated with a high mortality risk in T2DM patients; hence, a more systematic surveillance of T2DM patients to identify risk factors for depression might contribute significantly to reducing mortality risk in this group of patients.

Citations

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You Lee Yang, Eun-Ok Im, Yunmi Kim
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Complications
Severe Hypoglycemia and Cardiovascular or All-Cause Mortality in Patients with Type 2 Diabetes: Seon-Ah Cha, Jae-Seung Yun, Tae-Seok Lim, Seawon Hwang, Eun-Jung Yim, Ki-Ho Song, Ki-Dong Yoo, Yong-Moon Park, Yu-Bae Ahn, Seung-Hyun Ko; Diabetes Metab J. 2016;40(3):202-210. Published online April 5, 2016; DOI: https://doi.org/10.4093/dmj.2016.40.3.202

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Background

We investigated the association between severe hypoglycemia (SH) and the risk of cardiovascular (CV) or all-cause mortality in patients with type 2 diabetes.

Methods

The study included 1,260 patients aged 25 to 75 years with type 2 diabetes from the Vincent Type 2 Diabetes Resgistry (VDR), who consecutively enrolled (n=1,260) from January 2000 to December 2010 and were followed up until May 2015 with a median follow-up time of 10.4 years. Primary outcomes were death from any cause or CV death. We investigated the association between the CV or all-cause mortality and various covariates using Cox proportional hazards regression analysis.

Results

Among the 906 participants (71.9%) who completed follow-up, 85 patients (9.4%) had at least one episode of SH, and 86 patients (9.5%) died (9.1 per 1,000 patient-years). Patients who had died were older, had a longer duration of diabetes and hypertension, received more insulin, and had more diabetic microvascular complications at baseline, as compared with surviving patients. The experience of SH was significantly associated with an increased risk of all-cause mortality (hazard ratio [HR], 2.64; 95% confidence interval [CI], 1.39 to 5.02; P=0.003) and CV mortality (HR, 6.34; 95% CI, 2.02 to 19.87; P=0.002) after adjusting for sex, age, diabetic duration, hypertension, mean glycosylated hemoglobin levels, diabetic nephropathy, lipid profiles, and insulin use.

Conclusion

We found a strong association between SH and increased risk of all-cause and CV mortality in patients with type 2 diabetes.

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