The Association between Pulmonary Functions and Incident Diabetes: Longitudinal Analysis from the Ansung Cohort in Korea (Diabetes Metab J 2020;44: 699–710)

Article information

Diabetes Metab J. 2020;44(6):940-941
Publication date (electronic) : 2020 December 23
doi :
Department of Endocrinology and Metabolism, Chosun University Hospital, Gwangju, Korea
Corresponding author: Jin Hwa Kim,, Department of Endocrinology and Metabolism, Chosun University Hospital, 365 Pilmundaero, Dong-gu, Gwangju 61453, Korea, E-mail:

Diabetes is a chronic systematic metabolic disease that effects multiple organs and systems, including the lungs [1]. The pulmonary system has rich vascularity and abundant connective tissue [2]. Long-standing hyperglycemia can lead to microvascular damage, non-enzymatic glycation, and proliferation of extracellular connective tissue, which result in declining lung function [3,4]. Oxidative stress, endothelial micro-injuries, platelet activation, and inflammation also can affect diabetes-related lung dysfunction [5,6].

Several studies have suggested that impaired pulmonary function can predict the development of diabetes or insulin resistance [79]. Lazarus et al. [10] reported that forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and maximal mid-expiratory flow rate were associated with insulin resistance over a period of 20.9 years. Identifying individuals who are at risk of developing diabetes may allow for earlier precision interventions that would manage or prevent diabetes.

In the article entitled “The association between pulmonary functions and incident diabetes: longitudinal analysis from the Ansung cohort in Korea,” Choi et al. [11] evaluated the potential role of reduced pulmonary function as a risk factor for incident diabetes in Koreans. The authors clearly showed that FVC and FEV1 were independent risk factors for diabetes in Koreans aged 40 to 60 years. They proposed several potential possibilities, although determining the exact biologic mechanism underlying these findings was not possible. They suggested that pulmonary factors were possible risk factors for insulin resistance and diabetes. Considering the ethnic differences in diabetes pathogenesis, this study is highly relevant to Asians with diabetes. The strength of this study is that it was a prospective community-based cohort study of pulmonary function as a risk factor for incident diabetes using 10-year follow-up data and assessing diabetes incidence using both oral glucose tolerance tests and glycosylated hemoglobin levels in order to avoid misclassification of diabetes.

In my opinion, these finding may reflect early pulmonary functional change in the course of glucose intolerance before diabetes appears. Pulmonary function may be a marker reflecting subclinical glucose intolerance status leading to lung dysfunction, and not risk factor for developing diabetes. Although the authors sought to adjust for all confounding variables, this issue remains a concern. Extending this study to longer term follow-up and other age groups would also be useful. Lastly, evaluation of the association with other chronic diabetes complications including cardiovascular disease is needed. This study’s findings appear especially relevant during the current coronavirus disease 2019 pandemic. I hope the authors further explore the association between lung dysfunction and diabetes.



No potential conflict of interest relevant to this article was reported.


1. American Diabetes Association. 11. Microvascular complications and foot care: standards of medical care in diabetes-2020. Diabetes Care 2020;43(Suppl 1):S135–51.
2. Kolahian S, Leiss V, Nurnberg B. Diabetic lung disease: fact or fiction? Rev Endocr Metab Disord 2019;20:303–19.
3. Rajasurya V, Gunasekaran K, Surani S. Interstitial lung disease and diabetes. World J Diabetes 2020;11:351–7.
4. Chance WW, Rhee C, Yilmaz C, Dane DM, Pruneda ML, Raskin P, Hsia CC. Diminished alveolar microvascular reserves in type 2 diabetes reflect systemic microangiopathy. Diabetes Care 2008;31:1596–601.
5. Scano G, Seghieri G, Mancini M, Filippelli M, Duranti R, Fabbri A, Innocenti F, Iandelli I, Misuri G. Dyspnoea, peripheral airway involvement and respiratory muscle effort in patients with type I diabetes mellitus under good metabolic control. Clin Sci (Lond) 1999;96:499–506.
6. Forgiarini LA Jr, Kretzmann NA, Porawski M, Dias AS, Marroni NA. Experimental diabetes mellitus: oxidative stress and changes in lung structure. J Bras Pneumol 2009;35:788–91.
7. Engstrom G, Janzon L. Risk of developing diabetes is inversely related to lung function: a population-based cohort study. Diabet Med 2002;19:167–70.
8. Engstrom G, Hedblad B, Nilsson P, Wollmer P, Berglund G, Janzon L. Lung function, insulin resistance and incidence of cardiovascular disease: a longitudinal cohort study. J Intern Med 2003;253:574–81.
9. Ford ES, Mannino DM. National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. Prospective association between lung function and the incidence of diabetes: findings from the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. Diabetes Care 2004;27:2966–70.
10. Lazarus R, Sparrow D, Weiss ST. Baseline ventilatory function predicts the development of higher levels of fasting insulin and fasting insulin resistance index: the Normative Aging Study. Eur Respir J 1998;12:641–5.
11. Choi HS, Lee SW, Kim JT, Lee HK. The association between pulmonary functions and incident diabetes: longitudinal analysis from the Ansung cohort in Korea. Diabetes Metab J 2020;44:699–710.

Article information Continued