Jonathan E. Shaw

Diabetes in Asia and the Pacific: Implications for the Global Epidemic.

The last three decades have witnessed an epidemic rise in the number of people with diabetes, especially type 2 diabetes, and particularly in developing countries, where more than 80% of the people with diabetes live. The rise of type 2 diabetes in South Asia is estimated to be more than 150% between 2000 and 2035. Although aging, urbanization, and associated lifestyle changes are the major determinants for the rapid increase, an adverse intrauterine environment and the resulting epigenetic changes could also contribute in many developing countries. The International Diabetes Federation estimated that there were 382 million people with diabetes in 2013, a number surpassing its earlier predictions. More than 60% of the people with diabetes live in Asia, with almost one-half in China and India combined. The Western Pacific, the world’s most populous region, has more than 138.2 million people with diabetes, and the number may rise to 201.8 million by 2035. The scenario poses huge social and economic problems to most nations in the region and could impede national and, indeed, global development. More action is required to understand the drivers of the epidemic to provide a rationale for prevention strategies to address the rising global public health “tsunami.” Unless drastic steps are taken through national prevention programs to curb the escalating trends in all of the countries, the social, economic, and health care challenges are likely to be insurmountable.

The Effect of Treatment of Obstructive Sleep Apnea on Glycemic Control in Type 2 Diabetes

RATIONALEnThere is uncertainty about the effects of treating obstructive sleep apnea on glycemic control in patients with type 2 diabetes.nnnOBJECTIVESnTo determine whether treatment of obstructive sleep apnea in patients with type 2 diabetes improves glycemic control.nnnMETHODSnIn this trial, we randomized patients with type 2 diabetes and no previous diagnosis of obstructive sleep apnea, with a glycated hemoglobin level of 6.5-8.5%, and an oxygen desaturation index of 15 or more events per hour to positive airway pressure therapy or to usual care.nnnMEASUREMENTS AND MAIN RESULTSnA total of 416 patients met the entry criteria as determined by each site and were randomized. Of the 298 participants who met centrally adjudicated entry criteria, no differences between the study groups were seen for change in glycated hemoglobin. Furthermore, there were no between-group differences when analyses were restricted to those with poorer baseline glycemic control, those with more severe sleep apnea, or those who were adherent to therapy. A greater fall in diastolic blood pressure occurred in the positive airway pressure group than in the usual care group (-3.5 mm Hg vs. -1.5 mm Hg; Pu2009=u20090.07). This difference was significant in those who were adherent to positive airway pressure therapy (-4.4 mm Hg vs. -1.6 mm Hg; Pu2009=u20090.02). There was a significant reduction in sleepiness in the positive airway pressure therapy group (Pu2009<u20090.0001). Quality of life assessment revealed improvements in vitality, mental health, and mental component summary scores in the positive airway pressure therapy group.nnnCONCLUSIONSnThis trial showed no effect of positive airway pressure therapy on glycemic control in patients with relatively well-controlled type 2 diabetes and obstructive sleep apnea. Clinical trial registered with www.clinicaltrials.gov (NCT00509223).

IDF Diabetes Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045

INTRODUCTIONnSince the year 2000, IDF has been measuring the prevalence of diabetes nationally, regionally and globally.nnnAIMnTo produce estimates of the global burden of diabetes and its impact for 2017 and projections for 2045.nnnMETHODSnA systematic literature review was conducted to identify published studies on the prevalence of diabetes, impaired glucose tolerance and hyperglycaemia in pregnancy in the period from 1990 to 2016. The highest quality studies on diabetes prevalence were selected for each country. A logistic regression model was used to generate age-specific prevalence estimates or each country. Estimates for countries without data were extrapolated from similar countries.nnnRESULTSnIt was estimated that in 2017 there are 451 million (age 18-99u202fyears) people with diabetes worldwide. These figures were expected to increase to 693 million) by 2045. It was estimated that almost half of all people (49.7%) living with diabetes are undiagnosed. Moreover, there was an estimated 374 million people with impaired glucose tolerance (IGT) and it was projected that almost 21.3 million live births to women were affected by some form of hyperglycaemia in pregnancy. In 2017, approximately 5 million deaths worldwide were attributable to diabetes in the 20-99u202fyears age range. The global healthcare expenditure on people with diabetes was estimated to be USD 850 billion in 2017.nnnCONCLUSIONnThe new estimates of diabetes prevalence, deaths attributable to diabetes and healthcare expenditure due to diabetes present a large social, financial and health system burden across the world.

Global Health Effects of Overweight and Obesity

The Global Burden of Disease (GBD) study that is now reported in the Journal offers a discouraging reminder that the global obesity epidemic is worsening in most parts of the world and that its implications regarding both physical health and economic health remain ominous.1 The study, in which researchers assembled data from 195 countries to model trends in overweight and obesity and related morbidity and mortality, showed that the prevalence of obesity has more than doubled since 1980 and is now 5% in children and 12% in adults — findings that mirror similar global trends in type 2 diabetes. Apart . . .

Design and baseline characteristics of participants in the Researching cardiovascular Events with a Weekly INcretin in Diabetes (REWIND) trial on the cardiovascular effects of dulaglutide

The aim was to determine the effects of dulaglutide, a synthetic once‐weekly, injectable human glucagon‐like peptide 1 analogue that lowers blood glucose, body weight, appetite and blood pressure, on cardiovascular outcomes. People with type 2 diabetes, aged ≥50u2009years, with glycated haemoglobin (HbA1c) ≤9.5%, and either a previous cardiovascular event, evidence of cardiovascular disease or ≥2 cardiovascular risk factors were randomly allocated to a weekly subcutaneous injection of either dulaglutide (1.5u2009mg) or placebo and followed within the ongoing Researching cardiovascular Events with a Weekly INcretin in Diabetes (REWIND) trial every 3 to 6u2009months. The primary cardiovascular outcome is the first occurrence of the composite of cardiovascular death or non‐fatal myocardial infarction or non‐fatal stroke. Secondary outcomes include each component of the primary composite cardiovascular outcome, a composite clinical microvascular outcome comprising retinal or renal disease, hospitalization for unstable angina, heart failure requiring hospitalization or an urgent heart failure visit, and all‐cause mortality. Follow‐up will continue until the accrual of 1200 confirmed primary outcomes. Recruitment of 9901 participants (mean age 66u2009years, 46% women) occurred in 370 sites located in 24 countries over a period of 2u2009years. The mean duration of diabetes was 10u2009years, mean baseline HbA1c was 7.3%, and 31% had prior cardiovascular disease. The REWIND trials international scope, high proportion of women, high proportion of people without prior cardiovascular disease and inclusion of participants whose mean baseline HbA1c was 7.3% suggests that its cardiovascular and safety findings will be directly relevant to the typical middle‐aged patient seen in general practice throughout the world.

Age-specific trends from 2000-2011 in all-cause and cause-specific mortality in type 1 and type 2 Diabetes: A cohort study of more than one million people

OBJECTIVE To analyze changes by age-group in all-cause and cause-specific mortality rates from 2000–2011 in people with diabetes. RESEARCH DESIGN AND METHODS A total of 1,189,079 (7.3% with type 1 diabetes) Australians with diabetes registered on the National Diabetes Service Scheme between 2000 and 2011 were linked to the National Death Index. Mortality rates in the total population were age standardized to the 2001 Australian population. Mortality rates were calculated for the following age-groups: 0 to <40 years, ≥ 40 to <60 years, and ≥60 to ≤85 years. Annual mortality rates were fitted using a Poisson regression model including calendar year as a covariate and age and sex where appropriate, with Ptrend reported. RESULTS For type 1 diabetes, all-cause, cardiovascular disease (CVD), and diabetes age-standardized mortality rates (ASMRs) decreased each year by 0.61, 0.35, and 0.14 per 1,000 person-years (PY), respectively, between 2000 and 2011, Ptrend < 0.05, while cancer mortality remained unchanged. By age, significant decreases in all-cause, CVD, and diabetes mortality rates were observed in all age-groups, excluding diabetes mortality in age-group 0–40 years. For type 2 diabetes, all-cause, CVD, and diabetes ASMRs decreased per year by 0.18, 0.15, and 0.03 per 1,000 PY, respectively, Ptrend < 0.001, while cancer remained unchanged. By age, these decreases were observed in all age-groups, excluding 0–40 years, where significant increases in all-cause and cancer mortality were noted and no change was seen for CVD and diabetes mortality. CONCLUSIONS All-cause, CVD, and diabetes ASMRs in type 1 and type 2 diabetes decreased between 2000 and 2011, while cancer ASMRs remained unchanged. However, younger populations are not benefiting from the same improvements as older populations. In addition, the absence of a decline in cancer mortality warrants urgent attention.

Life expectancy of type 1 diabetic patients during 1997–2010: a national Australian registry-based cohort study

Aims/hypothesisThere is limited information about the impact of type 1 diabetes on life expectancy in a contemporary population. We examined the life expectancy of type 1 diabetic patients and explored the contribution of mortality at different ages and of different causes of death to years of life lost (YLL) compared with the general population.MethodsWe derived mortality rates of Australians with type 1 diabetes listed on the National Diabetes Services Scheme (NDSS) between 1997 and 2010 (nu2009=u200985,547) by linking the NDSS to the National Death Index. The Chiang method was used to estimate life expectancy and Arriaga’s method was used to estimate the contributions of age-specific and cause-specific mortality to the YLL.ResultsA total of 5,981 deaths were identified during the 902,136 person-years of follow up. Type 1 diabetic patients had an estimated life expectancy at birth of 68.6xa0years (95% CI 68.1, 69.1), which was 12.2xa0years (95% CI 11.8, 12.7) less than that in the general population. The improvement in life expectancy at birth in 2004–2010 compared with 1997–2003 was similar for both type 1 diabetic patients (men, 1.9xa0years [95% CI 0.4, 3.3]; women, 1.5xa0years [95% CI 0.0, 3.2]) and the general population (men, 2.2xa0years; women, 1.4xa0years). Deaths at age <60xa0years accounted for 60% of the YLL from type 1 diabetes for men and 45% for women. The major contribution to YLL was mortality from endocrine and metabolic disease at age 10–39xa0years (men, 39–59%; women, 35–50%) and from circulatory disease at age ≥40xa0years (men, 43–75%; women, 34–75%).Conclusions/interpretationData from 1997 to 2010 showed that Australian type 1 diabetic patients had an estimated loss in life expectancy at birth of 12.2xa0years compared with the general population.

Associations between television viewing and physical activity and low back pain in community-based adults: A cohort study.

AbstractTwo systematic reviews concluded that there was limited evidence to support an association between physical activity and sedentary behavior and developing low back pain (LBP). The aim of this study was to examine the associations of physical activity and television viewing time with LBP intensity and disability in community-based adults.Five thousand fifty-eight participants (44% men) of the Australian Diabetes, Obesity and Lifestyle Study had physical activity and television viewing time measured in 1999 to 2000, 2004 to 2005, and 2011 to 2012, and LBP intensity and disability assessed in 2013 to 2014 using the Chronic Pain Grade Questionnaire. Multinomial logistic regressions were used to estimate the odds ratio for LBP intensity and disability associated with physical activity and television viewing time. Analyses were adjusted for age, education, smoking, dietary guideline index score, body mass index, and mental component summary score. To test whether associations of physical activity or television viewing time with LBP intensity and disability were modified by sex, obesity, or age, interactions were tested using the likelihood ratio test.As gender modified the associations between physical activity and television viewing time and LBP disability (Pu200a=u200a0.05), men and women were examined separately. A total of 81.7% men and 82.1% women had LBP. Most men (63.6%) and women (60.2%) had low intensity LBP with fewer having high intensity LBP (18.1% men, 21.5% women). Most participants had no LBP disability (74.5% men, 71.8% women) with the remainder reporting low (15.8% men, 15.3% women) or high (9.7% men, 12.9% women) LBP disability. Insufficient physical activity (<2.5 hours/week) was not associated with LBP intensity or disability. High television viewing time (≥2 hours/day) was associated with greater prevalence of LBP disability in women (low disability OR 1.35, 95% CI 1.04–1.73; high disability OR 1.29, 95% CI 1.01–1.72).Although it needs to be confirmed in RCTs our findings suggest that targeting time spent watching television and possibly other prolonged sedentary behaviors may have the potential to reduce LBP disability in community-based adults, particularly in women.

Burden of diabetes in Australia: life expectancy and disability-free life expectancy in adults with diabetes

Aims/hypothesisThe aim of this work was to estimate the life expectancy (LE) and disability-free life expectancy (DFLE) for adults with and without diabetes.MethodsThe Chiang method and the adapted Sullivan method were used to estimate LE and DFLE by age and sex. Mortality data in 2011 were available from the National Diabetes Services Scheme for diabetes and from standard national mortality datasets for the general population. Data on prevalence of disability and severe or profound core activity limitation were derived from the 2012 Australian Survey of Disability, Ageing and Carers (SDAC). The definitions of disability used in the SDAC followed the International Classification of Functioning, Disability and Health. Data on diabetes prevalence were derived from the Australian Diabetes, Obesity and Lifestyle study.ResultsThe estimated LE and DFLE (with 95% uncertainty interval [UI]) at age 50xa0years were 30.2 (30.0, 30.4) and 12.7 (11.5, 13.7) years, respectively, for men with diabetes, and the estimates were 33.9 (33.6, 34.1) and 13.1 (12.3, 13.9) years, respectively, for women with diabetes. The estimated loss of LE associated with diabetes at age 50xa0years was 3.2 (3.0, 3.4) years for men and 3.1 (2.9, 3.4) years for women, as compared with their counterparts without diabetes. The corresponding estimated loss of DFLE was 8.2 (6.7, 9.7) years for men and 9.1 (7.9, 10.4) years for women. Women with diabetes spent a greater number of absolute years and a greater proportion of their life with disability as compared with men with diabetes and women without diabetes. The gains in LE and DFLE across the whole population at age 50xa0years after hypothetically eliminating diagnosed diabetes were 0.6 (0.5, 0.6) years and 1.8 (1.0, 2.8) years.Conclusions/interpretationIn adults, diabetes results in a modest reduction in LE and a substantial reduction in DFLE. Efforts to identify the specific causes of disability and effective interventions are needed.

Hypertension, antihypertensive treatment and cancer incidence and mortality: a pooled collaborative analysis of 12 Australian and New Zealand cohorts

Background: Observational studies examining associations between hypertension and cancer are inconsistent. We explored the association of hypertension, graded hypertension and antihypertensive treatment with cancer incidence and mortality. Method: Eighty-six thousand five hundred and ninety-three participants from the Australian and New Zealand Diabetes and Cancer Collaboration were linked to the National Death Index and Australian Cancer Database. Cox proportional hazards models estimated hazard ratios and 95% confidence intervals (95% CI) for the association of treated and untreated hypertension with cancer incidence and mortality. Results: Over a median follow-up of 15.1 years, 12u200a070 incident and 4350 fatal cancers were identified. Untreated and treated hypertension, compared with normotension, were associated with an increased risk for cancer incidence [hazard ratio 1.06, 95% CI (1.00–1.11) and 1.09 (1.02–1.16) respectively], and cancer mortality (1.07, 0.98–1.18) and (1.15, 1.03–1.28), respectively. When compared with untreated hypertension, treated hypertension did not have a significantly greater risk for cancer incidence (1.03, 0.97–1.10) or mortality (1.07, 0.97–1.19). A significant dose–response relationship was observed between graded hypertension and cancer incidence and mortality; Ptrendu200a=u200a0.053 and Ptrendu200a=u200a0.001, respectively. When stratified by treatment status, these relationships remained significant in untreated, but not in treated, hypertension. Conclusion: Hypertension, both treated and untreated, is associated with a modest increased risk for cancer incidence and mortality. Similar risks in treated and untreated hypertension suggest that the increased cancer risk is not explained by the use of antihypertensive treatment.