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Aim To determine whether intermediate hyperglycaemia, defined by fasting plasma glucose and HbA1c criteria, is associated with mortality in a 10‐year cohort of people in a Latin American country. Methods Analysis of the PERU MIGRANT Study was conducted in three different population groups (rural, rural‐to‐urban migrant, and urban). The baseline assessment was conducted in 2007/2008, with follow‐up assessment in 2018. The outcome was all‐cause mortality, and the exposure was intermediate hyperglycaemia, using three definitions: (1) impaired fasting glucose, defined according to American Diabetes Association criteria [fasting plasma glucose 5.6–6.9 mmol/l (100–125 mg/dl)]; (2) intermediate hyperglycaemia defined according to American Diabetes Association criteria [HbA1c levels 39–46 mmol/mol (5.7–6.4%)]; and (3) intermediate hyperglycaemia defined according to the International Expert Committee criteria [HbA1c levels 42–46 mmol/mol (6.0–6.4%)]. Crude and adjusted hazard ratios and 95% CIs were estimated using Cox proportional hazard models. Results At baseline, the mean (sd) age of the study population was 47.8 (11.9) years and 52.5% of the cohort were women. The study cohort was divided into population groups as follows: 207 people (20.0%) in the rural population group, 583 (59.7%) in the rural‐to‐urban migrant group and 198 (20.3%) in the urban population group. The prevalence of intermediate hyperglycaemia was: 6%, 12.9% and 38.5% according to the American Diabetes Association impaired fasting glucose definition, the International Expert Committee HbA1c‐based definition and the American Diabetes Association HbA1c‐based definition, respectively, and the mortality rate after 10 years was 63/976 (7%). Intermediate hyperglycaemia was associated with all‐cause mortality using the HbA1c‐based definitions in the crude models [hazard ratios 2.82 (95% CI 1.59–4.99) according to the American Diabetes Association and 2.92 (95% CI 1.62–5.28) according to the International Expert Committee], whereas American Diabetes Association‐defined impaired fasting glucose was not [hazard ratio 0.84 (95% CI 0.26–2.68)]. In the adjusted model, however, only the American Diabetes Association HbA1c‐based definition was associated with all‐cause mortality [hazard ratio 1.91 (95% CI 1.03–3.53)], whereas the International Expert Committee HbA1c‐based and American Diabetes Association impaired fasting glucose‐based definitions were not [hazard ratios 1.42 (95% CI 0.75–2.68) and 1.09 (95% CI 0.33–3.63), respectively]. Conclusions Intermediate hyperglycaemia defined using the American Diabetes Association HbA1c criteria was associated with an elevated mortality rate after 10 years in a cohort from Peru. HbA1c appears to be a factor associated with mortality in this Peruvian population., What's new? Intermediate hyperglycaemia is an important risk factor for diabetes, but the proportion of people with this condition varies according to the definition used.The extent to which impaired fasting glucose, impaired glucose tolerance and/or HbA1c criteria are associated with mortality remains unclear.Intermediate hyperglycaemia assessed using the HbA1c‐based American Diabetes Association definition was associated with increased mortality rate in a 10‐year cohort from a Latin American country.HbA1c appeared to be a measurement associated with mortality in this Peruvian population.

Aims To explore whether there is a different strength of association between self‐rated health and all‐cause mortality in people with type 2 diabetes across three country groupings: nine countries grouped together as 'established market economies'; Asia; and Eastern Europe. Methods The ADVANCE trial and its post‐trial follow‐up were used in this study, which included 11 140 people with type 2 diabetes from 20 countries, with a median follow‐up of 9.9 years. Self‐rated health was reported on a 0–100 visual analogue scale. Cox proportional hazard models were fitted to estimate the relationship between the visual analogue scale score and all‐cause mortality, controlling for a range of demographic and clinical risk factors. Interaction terms were used to assess whether the association between the visual analogue scale score and mortality varied across country groupings. Results The visual analogue scale score had different strengths of association with mortality in the three country groupings. A 10‐point increase in visual analogue scale score was associated with a 15% (95% CI 12–18) lower mortality hazard in the established market economies, a 25% (95% CI 21–28) lower hazard in Asia, and an 8% (95% CI 3–13) lower hazard in Eastern Europe. Conclusions Self‐rated health appears to predict 10‐year all‐cause mortality for people with type 2 diabetes worldwide, but this relationship varies across groups of countries., What's new? Self‐rated health is an independent predictor of mortality in people with diabetes.The visual analogue scale (VAS) score has a stronger association with mortality in Asia and a weaker association in Eastern Europe than in the 'established market economies' included in our study among people with type 2 diabetes.People with type 2 diabetes in different countries reporting the same VAS score can face different mortality risks.The VAS score can be a useful global health measure in clinical practice for people with type 2 diabetes, but adjustment would be required before it can be directly compared across countries and regions.

Aims To determine obstructive sleep apnoea prevalence in people with Type 2 or Type 1 diabetes in a national primary care setting, stratified by BMI category, and to explore the relationship between patient characteristics and obstructive sleep apnoea. Methods Using the Royal College of General Practitioners Research and Surveillance Centre database, a cross‐sectional analysis was conducted. Diabetes type was identified using a seven‐step algorithm and was grouped by Type 2 diabetes, Type 1 diabetes and no diabetes. The clinical characteristics of these groups were analysed, BMI‐stratified obstructive sleep apnoea prevalence rates were calculated, and a multilevel logistic regression analysis was completed on the Type 2 diabetes group. Results Analysis of 1 275 461 adult records in the Royal College of General Practitioners Research and Surveillance Centre network showed that obstructive sleep apnoea was prevalent in 0.7%. In people with Type 2 diabetes, obstructive sleep apnoea prevalence increased with each increasing BMI category, from 0.5% in those of normal weight to 9.6% in those in the highest obesity class. By comparison, obstructive sleep apnoea prevalence rates for these BMI categories in Type 1 diabetes were 0.3% and 4.3%, and in those without diabetes 1.2% and 3.9%, respectively. Obstructive sleep apnoea was more prevalent in men than women in both diabetes types. When known risk factors were adjusted for, there were increased odds ratios for obstructive sleep apnoea in people with Type 2 diabetes in the overweight and higher BMI categories. Conclusions Obstructive sleep apnoea was reported in people with both types of diabetes across the range of overweight categories and not simply in the highest obesity class., What's new? Links among Type 2 diabetes mellitus, obesity and obstructive sleep apnoea (OSA) have been established in secondary care clinic studies, but primary care population data are limited.From a national primary care network, we ascertained that people with Type 2 diabetes had an increased OSA prevalence in every excessive weight category, from overweight to obesity class 3. People with Type 1 diabetes had similar OSA prevalence rates as those without diabetes.Strategies to diagnose and manage OSA need to consider its increased prevalence in people with Type 2 diabetes who are overweight as well as those with obesity.

Contains fulltext : 232027.pdf (Publisher’s version ) (Open Access) AIM: To describe the prevalence and characteristics of polypharmacy in a Dutch cohort of individuals with type 2 diabetes. METHODS: We included people with type 2 diabetes from the Diabetes Pearl cohort, of whom 3886 were treated in primary care and 2873 in academic care (secondary/tertiary). With multivariable multinomial logistic regression analyses stratified for line of care, we assessed which sociodemographic, lifestyle and cardiometabolic characteristics were associated with moderate (5-9 medications) and severe polypharmacy (≥10 medications) compared with no polypharmacy (0-4 medications). RESULTS: Mean age was 63 ± 10 years, and 40% were women. The median number of daily medications was 5 (IQR 3-7) in primary care and 7 (IQR 5-10) in academic care. The prevalence of moderate and severe polypharmacy was 44% and 10% in primary care, and 53% and 29% in academic care respectively. Glucose-lowering and lipid-modifying medications were most prevalent. People with severe polypharmacy used a relatively large amount of other (i.e. non-cardiovascular and non-glucose-lowering) medication. Moderate and severe polypharmacy across all lines of care were associated with higher age, low educational level, more smoking, longer diabetes duration, higher BMI and more cardiovascular disease. CONCLUSIONS: Severe and moderate polypharmacy are prevalent in over half of people with type 2 diabetes in primary care, and even more in academic care. People with polypharmacy are characterized by poorer cardiometabolic status. These results highlight the significance of polypharmacy in type 2 diabetes.

Aims: Restrictions during the COVID-19 crisis will have impacted on opportunities to be active. We aimed to (a) quantify the impact of COVID-19 restrictions on accelerometer-assessed physical activity and sleep in people with type 2 diabetes and (b) identify predictors of physical activity during COVID-19 restrictions. Methods: Participants were from the UK Chronotype of Patients with type 2 diabetes and Effect on Glycaemic Control (CODEC) observational study. Participants wore an accelerometer on their wrist for 8 days before and during COVID-19 restrictions. Accelerometer outcomes included the following: overall physical activity, moderate-to-vigorous physical activity (MVPA), time spent inactive, days/week with ≥30-minute continuous MVPA and sleep. Predictors of change in physical activity taken pre-COVID included the following: age, sex, ethnicity, body mass index (BMI), socio-economic status and medical history. Results: In all, 165 participants (age (mean±S.D = 64.2 ± 8.3 years, BMI=31.4 ± 5.4 kg/m2, 45% women) were included. During restrictions, overall physical activity was lower by 1.7 mg (~800 steps/day) and inactive time 21.9 minutes/day higher, but time in MVPA and sleep did not statistically significantly change. In contrast, the percentage of people with ≥1 day/week with ≥30-minute continuous MVPA was higher (34% cf. 24%). Consistent predictors of lower physical activity and/or higher inactive time were higher BMI and/or being a woman. Being older and/or from ethnic minorities groups was associated with higher inactive time. Conclusions: Overall physical activity, but not MVPA, was lower in adults with type 2 diabetes during COVID-19 restrictions. Women and individuals who were heavier, older, inactive and/or from ethnic minority groups were most at risk of lower physical activity during restrictions Refereed/Peer-reviewed

Background Increased malnutrition risk has been observed in more than 40% people on haemodialysis in Israel. It is not clear that this risk is homogeneously distributed among people with versus without diabetes. Objectives To examine the influence of diabetes on malnutrition risk among people on haemodialysis. Methods This cross‐sectional study included a representative sample of 375 individuals on haemodialysis treated in hospital dialysis centres throughout Israel. Of these, 126 had diabetes. Dietary intake, biochemistry, anthropometric and hemodynamic measures were recorded. Malnutrition risk categories were defined: “minimal”: body mass index (BMI) ≥23 kg/m2 and serum albumin ≥38 mmol/L; “mild”: BMI

Aims Microalbuminuria is an indicator of adverse cardiovascular events and chronic kidney disease. Studies have described an elevated resting heart rate as a risk factor for microalbuminuria in people with cardiovascular disease, but none have clarified its role in microalbuminuria development in people with type 2 diabetes. Therefore, this study investigated the relationship between resting heart rate and new‐onset microalbuminuria in type 2 diabetes. Methods A total of 788 people from a glycaemic control trial in Taiwan were enrolled. Microalbuminuria was defined as a fasting urine albumin‐to‐creatinine ratio ≥30 mg/g in two consecutive urine tests. Resting heart rate and other covariates were measured at baseline. The quartile of resting heart rates, categorized as 80 beats/min, was used for analysis. Cox proportional hazard models were used to evaluate the association between resting heart rate and risk of microalbuminuria. Results During the follow‐up period, 244 people (31%) developed microalbuminuria. Those who developed microalbuminuria had a longer diabetes duration (median = 3.0 vs. 2.0 years, p 80 beats/min (with hazard ratios [95% CI] of 2.05 [1.32, 3.18], 2.10 [1.32, 3.32] and 1.62 [1.01, 2.59], respectively) compared to resting heart rates

Aims Depression is more prevalent in people with diabetes, and is associated with worse diabetes outcomes. Depression in diabetes is more treatment resistant, and as underlying mechanisms are unknown, development of more effective treatment strategies is complicated. A biopsychosocial model may improve our understanding of the pathophysiology, and therewith help improving treatment options. Methods Diabetes was diagnosed according to American Diabetes Association (ADA) criteria and a current depressive episode according to the International Classification of Diseases (ICD‐10), based on the Clinical Interview Schedule Revised (CIS‐R). From the Brazilian Longitudinal Study of Adult Health (ELSA‐Brasil), we included 455 participants without diabetes with a current depressive episode and 10 900 without either diabetes or a current depressive episode. Furthermore, 2183 participants had diabetes alone and 106 had both diabetes and a current depressive episode. Variable selection was based on their relationship with depression and/or diabetes. Multinomial multivariate logistic regression was used to determine how the models differed between participants with and without diabetes. Results A current depressive episode in diabetes was related to being older and female, having poorer education, financial problems, experiencing discrimination at work, home and school, higher waist circumference, albumin to creatinine ratio and insulin resistance, and the presence of hypertension and cardiovascular disease. In non‐diabetes, a current depressive disorder was related to being female, not being black, low income, psychological and social factors, non‐current alcohol use, lower HDL cholesterol, higher insulin resistance and the presence of cardiovascular disease. Conclusions A current depressive episode in the presence compared with the absence of diabetes was related more to biological than to psychosocial factors., What’s new? Diabetes is related to a higher prevalence of depression, which is more treatment resistant, and to angiopathy and morbidity.In individuals with diabetes, a current depressive episode was related to cardiovascular disease, hypertension, insulin resistance, higher waist circumference, triglyceride levels and albumin to creatinine ratio, being older and female, having lower education, financial problems in the past year, and experiencing discrimination at work, home and school.In participants without diabetes, a current depressive disorder was related to being female, not being of black race/ethnicity, having lower income, experiencing life events in the past year (assault/robbery, hospitalization, financial problems, divorce), discrimination at work, public places and at school, being an ex‐smoker, non‐current alcohol user, lower HDL cholesterol, higher γ‐glutamyltransferase, insulin resistance, and presence of cardiovascular disease.The biopsychosocial model increases our understanding of the complex pathophysiology of depression in diabetes.

Aim To quantify the association between behaviour change and weight loss after diagnosis of Type 2 diabetes, and the likelihood of remission of diabetes at 5‐year follow‐up. Method We conducted a prospective cohort study in 867 people with newly diagnosed diabetes aged 40–69 years from the ADDITION‐Cambridge trial. Participants were identified via stepwise screening between 2002 and 2006, and underwent assessment of weight change, physical activity (EPAQ2 questionnaire), diet (plasma vitamin C and self‐report), and alcohol consumption (self‐report) at baseline and 1 year after diagnosis. Remission was examined at 5 years after diabetes diagnosis via HbA1c level. We constructed log binomial regression models to quantify the association between change in behaviour and weight over both the first year after diagnosis and the subsequent 1–5 years, as well as remission at 5‐year follow‐up. Results Diabetes remission was achieved in 257 participants (30%) at 5‐year follow‐up. Compared with people who maintained the same weight, those who achieved ≥ 10% weight loss in the first year after diagnosis had a significantly higher likelihood of remission [risk ratio 1.77 (95% CI 1.32 to 2.38; p, What's new? Biochemical remission of Type 2 diabetes in the absence of pharmacological or surgical intervention has been shown to be achievable.This has been previously demonstrated in short‐term studies and only in selected populations through intensive weight loss programmes.We found that weight loss of ≥10% in the first few years after diagnosis was strongly associated with remission of Type 2 diabetes at 5 years.This was achieved without intensive lifestyle interventions or extreme calorie restrictions.Our findings should inform discussions with people who have newly diagnosed Type 2 diabetes as a motivation towards remission of the disease without restrictive and sometimes unachievable calorie restrictions.

Aims To estimate the incidence of Type 2 diabetes in children aged, What's new? The 2015/2016 UK incidence of Type 2 diabetes in children aged

Aim Higher haemoglobin levels and differences in glucose metabolism have been reported among high‐altitude residents, which may influence the diagnostic performance of HbA1c. This study explores the relationship between HbA1c and fasting plasma glucose (FPG) in populations living at sea level and at an altitude of > 3000 m. Methods Data from 3613 Peruvian adults without a known diagnosis of diabetes from sea‐level and high‐altitude settings were evaluated. Linear, quadratic and cubic regression models were performed adjusting for potential confounders. Receiver operating characteristic (ROC) curves were constructed and concordance between HbA1c and FPG was assessed using a Kappa index. Results At sea level and high altitude, means were 13.5 and 16.7 g/dl (P > 0.05) for haemoglobin level; 41 and 40 mmol/mol (5.9% and 5.8%; P, What's new? Haemoglobin levels and differences in glucose metabolism at high altitude may influence the diagnostic performance of testing for diabetes using HbA1c.We found that the relationship between HbA1c and fasting plasma glucose (FPG) differed markedly between high‐altitude and sea‐level areas.The relationship between HbA1c and FPG was quadratic at sea level and linear at high altitude.Corresponding FPG values for an HbA1c ≥ 48 mmol/mol (≥ 6.5%) cut‐off point, used for the diagnosis of diabetes, were 6.6 and 14.8 mmol/l (120 and 266 mg/dl) at sea level and high altitude, respectively.The sensitivity of HbA1c to detect abnormal FPG was 87.3% at sea level and 40.9% at high altitude. This suggests a limitation in the performance of HbA1c to diagnose diabetes at altitude.

Aims Population surveys of Type 2 diabetes mellitus and obesity conducted in Samoa over three decades have used varying methodologies and definitions. This study standardizes measures, and trends of Type 2 diabetes mellitus and obesity for 1978–2013 are projected to 2020 for adults aged 25–64 years. Methods Unit records from eight surveys (n = 12 516) were adjusted to the previous census for Division of residence, sex and age to improve national representativeness. Type 2 diabetes mellitus is defined as a fasting plasma glucose ≥ 7.0 mmol/l and/or on medication. Obesity is defined as BMI ≥ 30 kg/m2. Random effects meta‐regression was employed to assess time trends following logit transformation. Poisson regression from strata was used to assess the effects of mean BMI changes on Type 2 diabetes mellitus period trends. Results Over 1978–2013, Type 2 diabetes mellitus prevalence increased from 1.2% to 19.6% in men (2.3% per 5 years), and from 2.2% to 19.5% in women (2.2% per 5 years). Obesity prevalence increased from 27.7% to 53.1% in men (3.6% per 5 years) and from 44.4% to 76.7% (4.5% per 5 years) in women. Type 2 diabetes mellitus and obesity prevalences increased in all age groups. From period trends, Type 2 diabetes mellitus prevalence in 2020 is projected to be 26% in men and women. Projected obesity prevalence is projected to be 59% in men and 81% in women. Type 2 diabetes mellitus period trends attributable to BMI increase are estimated as 31% (men) and 16% (women), after adjusting for age. Conclusion This is the first study to produce trends of Type 2 diabetes mellitus and obesity in Samoa based on standardized data from population surveys. Type 2 diabetes mellitus is equally prevalent in both sexes, and obesity is widespread. Type 2 diabetes mellitus prevalence in Samoa is likely to continue to increase in the near future., What's new? This is the first study to standardize previously conducted, disparate population‐based measures of Type 2 diabetes mellitus and obesity from unit records of empirical surveys to produce period trends in Samoa.Prevalences of Type 2 diabetes mellitus and obesity have increased over 35 years (1978–2013), and are projected to continue to increase in the near future.The increase in Type 2 diabetes mellitus is partially attributed to the rise in obesity and effective interventions to reduce obesity are urgently required.

Aim: Optimal treatment of cardiovascular disease is essential to decrease mortality among people with diabetes, but information is limited on how actual treatment relates to guidelines. We analysed changes in therapeutic approaches to anti-hypertensive and lipid-lowering medications in people with Type 2 diabetes from 2006 and 2015. Methods: Summary data from clinical services in seven countries outside North America and Western Europe were collected for 39 684 people. Each site summarized individual-level data from outpatient medical records for 2006 and 2015. Data included: demographic information, blood pressure (BP), total cholesterol levels and percentage of people taking statins, anti-hypertensive medication (angiotensin-converting enzyme inhibitors, calcium channel blockers, angiotensin II receptor blockers, thiazide diuretics) and antiplatelet drugs. Results: From 2006 to 2015, mean cholesterol levels decreased in six of eight sites (range: −0.5 to −0.2), whereas the proportion with BP levels > 140/90 mmHg increased in seven of eight sites. Decreases in cholesterol paralleled increases in statin use (range: 3.1 to 47.0 percentage points). Overall, utilization of anti-hypertensive medication did not change. However, there was an increase in the use of angiotensin II receptor blockers and a decrease in angiotensin-converting enzyme inhibitors. The percentage of individuals receiving calcium channel blockers and aspirin remained unchanged. Conclusions: Our findings indicate that control of cholesterol levels improved and coincided with increased use of statins. The percentage of people with BP > 140/90 mmHg was higher in 2015 than in 2006. Hypertension treatment shifted from using angiotensin-converting enzyme inhibitors to angiotensin II receptor blockers. Despite the potentially greater tolerability of angiotensin II receptor blockers, there was no associated improvement in BP levels., Centro de Endocrinología Experimental y Aplicada

Aims To explore the gender- and age-specific risk of developing a first myocardial infarction in people treated with antidiabetic and/or antidepressant drugs compared with people with no pharmaceutical treatment for diabetes or depression. Methods A cohort of all Swedish residents aged 45–84 years (n = 4 083 719) was followed for a period of 3 years. Data were derived from three nationwide registers. The prescription and dispensing of antidiabetic and antidepressant drugs were used as markers of disease. All study subjects were reallocated according to treatment and the treatment categories were updated every year. Data were analysed using a Cox regression model with a time-dependent variable. The outcome of interest was first fatal or non-fatal myocardial infarction. Results During follow-up, 42 840 people had a first myocardial infarction, 3511 of which were fatal. Women aged 45–64 years, receiving both antidiabetic and antidepressant drugs had a hazard ratio for myocardial infarction of 7.4 (95% CI 6.3–8.6) compared with women receiving neither. The corresponding hazard ratio for men was 3.1 (95% CI 2.8–3.6). Conclusions The combined use of antidiabetic and antidepressant drugs was associated with a higher risk of myocardial infarction compared with use of either group of drugs alone. The increase in relative risk was greater in middle-aged women than in middle-aged men. Funding agencies: King Gustaf V and Queen Victoria Freemason Foundation

Aims To examine work disability trajectories among employees with and without diabetes and identify lifestyle‐related factors associated with these trajectories. Methods We assessed work disability using records of sickness absence and disability pension among participants with diabetes and age‐ sex‐, socio‐economic status‐ and marital status‐matched controls in the Finnish Public Sector Study (1102 cases; 2204 controls) and the French GAZEL study (500 cases; 1000 controls), followed up for 5 years. Obesity, physical activity, smoking and alcohol consumption were assessed at baseline and the data analysed using group‐based trajectory modelling. Results Five trajectories described work disability: ‘no/very low disability’ (41.1% among cases and 48.0% among controls); ‘low–steady’ (35.4 and 34.7%, respectively); ‘high–steady’ (13.6 and 12.1%, respectively); and two ‘high–increasing’ trajectories (10.0 and 5.2%, respectively). Diabetes was associated with a ‘high–increasing’ trajectory only (odds ratio 1.90, 95% CI 1.47–2.46). Obesity and low physical activity were similarly associated with high work disability in people with and without diabetes. Smoking was associated with ‘high–increasing’ trajectory in employees with diabetes (odds ratio 1.88, 95% CI 1.21–2.93) but not in those without diabetes (odds ratio 1.32, 95% CI 0.87–2.00). Diabetes was associated with having multiple ( ≥ 2) risk factors (21.1 vs. 11.4%) but the association between multiple risk factors and the ‘high–increasing’ trajectory was similar in both groups. Conclusions The majority of employees with diabetes have low disability rates, although 10% are on a high and increasing disability trajectory. Lifestyle‐related risk factors have similar associations with disability among employees with and without diabetes, except smoking which was only associated with poorer prognosis in diabetes., What's new? We examined trajectories of work disability among people with and without diabetes.Five trajectories describing disability level at the beginning of follow‐up and its development over 5 years were identified: ‘no/very low disability’, ‘low–steady’, ‘high–steady’ and two ‘high–increasing’ trajectories.The majority of employees with and without diabetes had low‐disability trajectories.Diabetes was associated with ‘high–increasing’ disability trajectories, although this affected only 10% of the population with diabetes.Obesity and physical inactivity, irrespective of diabetes, and smoking among employees with diabetes were associated with adverse disability trajectories.

Aims Increased visit‐to‐visit glycaemic variability is independently associated with adverse outcomes in Type 2 diabetes. Our aim was to identify the patient characteristics associated with raised visit‐to‐visit glycaemic variability in people with Type 2 diabetes. Methods A case–control study was conducted to establish associations between HbA1c variability and clinical covariates in 10 130 people with Type 2 diabetes. Variability was calculated by two metrics [sd and coefficient of variation (CV)] from a minimum of four HbA1c readings obtained over a 4‐year period. High and low variability groups were defined as the top and bottom tertile of the sd or CV, and used in logistic regression analyses including a number of clinical and biochemical covariates. The analyses were stratified into low mean (< 53 mmol/mol; 7%) and high mean (≥ 53 mmol/mol; 7%) HbA1c groups. Results Findings were consistent across both HbA1c groups and variability metrics. Treatment, independent of other factors, was the most strongly associated covariate for the risk of high HbA1c variability. A six‐fold increased risk was observed in the low HbA1c group, between the most and least intense treatment regimens (P < 0.001). Similar findings were present in the high HbA1c group with a three‐fold increase in risk (P < 0.001). In addition, male gender, younger age, reduced HDL‐cholesterol and increased BMI were all found to be independently associated with raised visit‐to‐visit glycaemic variability. Conclusions Intensive treatment resulting in low mean HbA1c was associated with marked increase in HbA1c variability. Irrespective of diabetes control, the greatest visit‐to‐visit variability was observed in young, insulin resistant men., What's new? Increased visit‐to‐visit HbA1c variability has previously been associated with increased risk of adverse outcomes, including microvascular and macrovascular disease.We determined the patient characteristics associated with raised visit‐to‐visit glycaemic variability, independent of the mean HbA1c level and established that these people with highly variable Type 2 diabetes have increased cardiovascular disease risk factors including male gender, raised BMI and reduced HDL‐cholesterol compared with those with low variability.People with Type 2 diabetes receiving greater intensity of treatment (e.g. insulin treatment or triple oral therapy) have greater visit‐to‐visit variability than those who are diet or monotherapy treated.

Aims To investigate whether the association of severe mental illness with Type 2 diabetes varies by ethnicity and age. Methods We conducted a cross‐sectional analysis of data from an ethnically diverse sample of 588 408 individuals aged ≥18 years, registered to 98% of general practices (primary care) in London, UK. The outcome of interest was prevalent Type 2 diabetes. Results Relative to people without severe mental illness, the relative risk of Type 2 diabetes in people with severe mental illness was greatest in the youngest age groups. In the white British group the relative risks were 9.99 (95% CI 5.34, 18.69) in those aged 18–34 years, 2.89 (95% CI 2.43, 3.45) in those aged 35–54 years and 1.16 (95% CI 1.04, 1.30) in those aged ≥55 years, with similar trends across all ethnic minority groups. Additional adjustment for anti‐psychotic prescriptions only marginally attenuated the associations. Assessment of estimated prevalence of Type 2 diabetes in severe mental illness by ethnicity (absolute measures of effect) indicated that the association between severe mental illness and Type 2 diabetes was more marked in ethnic minorities than in the white British group with severe mental illness, especially for Indian, Pakistani and Bangladeshi individuals with severe mental illness. Conclusions The relative risk of Type 2 diabetes is elevated in younger populations. Most associations persisted despite adjustment for anti‐psychotic prescriptions. Ethnic minority groups had a higher prevalence of Type 2 diabetes in the presence of severe mental illness. Future research and policy, particularly with respect to screening and clinical care for Type 2 diabetes in populations with severe mental illness, should take these findings into account., What's new? There is limited evidence of the association of severe mental illness with Type 2 diabetes mellitus in ethnic minorities.Using data from >500 000 people, we established that: (1) risk of Type 2 diabetes was increased up to 10‐fold in people with severe mental illness compared with groups without severe mental illness, irrespective of ethnicity, and was greatest in the youngest age groups; (2) prevalence of Type 2 diabetes was highest in Bangladeshi people with severe mental illness but was also high in all other South Asian, black African and black Caribbean groups; and (3) most associations persisted despite adjustment for anti‐psychotic prescriptions.

Aims To examine the relationship of self-reported diabetes, and of random blood glucose levels among individuals without known diabetes, with the prevalence of cardiovascular disease in Chinese adults. Methods We examined cross-sectional data from the China Kadoorie Biobank of 0.5 million people aged 30–79 years recruited from 10 diverse regions of China in the period 2004–2008. Logistic regression was used to estimate the odds ratios of prevalent cardiovascular disease associated with self-reported diabetes, and with measured random blood glucose levels among participants with no history of diabetes, adjusting simultaneously for age, sex, area, education, smoking, alcohol, blood pressure and physical activity. Results A total of 3.2% of participants had self-reported diabetes (men 2.9%; women 3.3%) and 2.8% had screen-detected diabetes (men 2.6%; women 2.8%), i.e. they had no self-reported history of diabetes but a blood glucose level suggestive of a diagnosis of diabetes. Compared with individuals without a history of diabetes, the odds ratios associated with self-reported diabetes were 2.18 (95% CI 2.06–2.30) and 1.88 (95% CI 1.75–2.01) for prevalent ischaemic heart disease and stroke/transient ischaemic attack, respectively. Among participants without self-reported diabetes there was a positive association between random blood glucose and ischaemic heart disease and stroke/transient ischaemic attack prevalence (P for trend

Aims To determine the prevalence and clinical characteristics of absolute insulin deficiency in long‐standing Type 2 diabetes, using a strategy based on home urinary C‐peptide creatinine ratio measurement. Methods We assessed the urinary C‐peptide creatinine ratios, from urine samples taken at home 2 h after the largest meal of the day, in 191 insulin‐treated subjects with Type 2 diabetes (diagnosis age ≥45 years, no insulin in the first year). If the initial urinary C‐peptide creatinine ratio was ≤0.2 nmol/mmol (representing absolute insulin deficiency), the assessment was repeated. A standardized mixed‐meal tolerance test with 90‐min stimulated serum C‐peptide measurement was performed in nine subjects with a urinary C‐peptide creatinine ratio ≤ 0.2 nmol/mmol (and in nine controls with a urinary C‐peptide creatinine ratio >0.2 nmol/mmol) to confirm absolute insulin deficiency. Results A total of 2.7% of participants had absolute insulin deficiency confirmed by a mixed‐meal tolerance test. They were identified initially using urinary C‐peptide creatinine ratio: 11/191 subjects (5.8%) had two consistent urinary C‐peptide creatinine ratios ≤ 0.2 nmol/mmol; 9 of these 11 subjects completed a mixed‐meal tolerance test and had a median stimulated serum C‐peptide of 0.18 nmol/l. Five of these 9 had stimulated serum C‐peptide 0.2 had endogenous insulin secretion confirmed by the mixed‐meal tolerance test. Compared with subjects with a urinary C‐peptide creatinine ratio >0.2 nmol/mmol, those with confirmed absolute insulin deficiency had a shorter time to insulin treatment (median 2.5 vs. 6 years, P=0.005) and lower BMI (25.1 vs. 29.1 kg/m2, P=0.04). Two out of the five patients with absolute insulin deficiency were glutamic acid decarboxylase autoantibody‐positive. Conclusions Absolute insulin deficiency may occur in long‐standing Type 2 diabetes, and cannot be reliably predicted by clinical features or autoantibodies. Absolute insulin deficiency in Type 2 diabetes may increase the risk of hypoglycaemia and ketoacidosis, as in Type 1 diabetes. Its recognition should help guide treatment, education and management. The urinary C‐peptide creatinine ratio is a practical non‐invasive method to aid detection of absolute insulin deficiency, with a urinary C‐peptide creatinine ratio > 0.2 nmol/mmol being a reliable indicator of retained endogenous insulin secretion.

Aims To estimate the risk of stroke in people with Type 2 diabetes with different blood pressure levels compared with the risk in the general population in Sweden. Methods This prospective case–control study included 408 076 people with Type 2 diabetes, aged ≥ 18 years, and free of prior stroke, registered in the Swedish National Diabetes Register 1998–2011. Age‐ and sex‐matched control subjects (n = 1 913 507) without stroke from the general population were included. Stroke diagnoses were retrieved using International Classification of Disease codes from the Swedish patient and death registers. Cox hazard ratios and 95% confidence intervals (CIs) were estimated at six different blood pressure levels. Results During a median follow‐up of 4 years, 19 548 (4.8%) people with Type 2 diabetes and 61 690 (3.2%) without diabetes were diagnosed with stroke, corresponding to an adjusted hazard ratio of 1.43 (95% CI 1.41–1.46) for people with Type 2 diabetes as a group. Compared with people without diabetes, the risk of stroke for people with Type 2 diabetes with different blood pressure levels was significantly higher, starting at blood pressure levels > 130/80 mmHg. Hazard ratios for stroke were 1.20 (95% CI 1.16–1.24), 1.47 (95% CI 1.43–1.50), and 1.97 (95% CI 1.90–2.03) for blood pressure categories of 130–139/80–89 mmHg, 140–159/90–99 mmHg and ≥ 160/≥ 100 mmHg, respectively, after adjustment for age, sex, diabetes duration, being born in Sweden, maximum education level and baseline comorbidities. Conclusions People with Type 2 diabetes and blood pressure < 130/80 mmHg had a risk of stroke similar to that of the general population., What's new? Type 2 diabetes and blood pressure level are well known predictors of stroke, but the risk of stroke for people with Type 2 diabetes at different blood pressure levels compared with the risk for the general population is not known.We found that people with Type 2 diabetes and blood pressure < 130/80 mmHg had a risk of any stroke similar to that of the general population.People with Type 2 diabetes and blood pressure in the range of 120–139/70–89 mmHg had a significantly lower risk of haemorrhagic stroke compared with the general population.

Aims To describe factors associated with prevalence or absence of microvascular and macrovascular complications in people with Type 1 diabetes of very long duration and to investigate the risk factors associated with the incidence of such complications. Methods We included individuals with Type 1 diabetes who had been entered in the Swedish National Diabetes Register between 2002 and 2004 (n = 18 450). First, risk factor distribution in people with diabetes duration of ≥ 50 years was compared between people with and without complications. Second, the incidence of complications during a 10‐year follow‐up period was studied in all individuals who had no complications at baseline. Results Among people with a diabetes duration of ≥ 50 years (n = 1023), 453 (44%) had macrovascular disease, 534 (52%) had microvascular disease and 319 (31%) did not have either of the diagnoses. Factors that differed significantly between people with and without macrovascular disease were gender, age, HbA1c, BMI, LDL cholesterol, HDL cholesterol, triglycerides, systolic blood pressure, albuminuria, antihypertensive medication and lipid‐lowering medication. The same factors differed significantly between people with and without microvascular disease, with the exception of gender and HDL cholesterol. During the follow‐up period, 6.1% of the study cohort were diagnosed with macrovascular disease and 19.6% with microvascular disease. Incidence of macrovascular disease was significantly associated with HbA1c levels. Hazard ratios decreased with longer diabetes duration. Conclusions People with Type 1 diabetes who have survived ≥ 50 years without complications are significantly younger, and have significantly lower HbA1c levels, BMI and triglyceride levels than survivors with complications. HbA1c level is a predictor of macrovascular disease, independently of diabetes duration., What's new? Previous studies in long‐term survivors of Type 1 diabetes have mainly been cross‐sectional, relying on self‐reported data, and the results have been inconsistent.This register‐based study of 18 450 people with Type 1 diabetes shows that those who have survived ≥ 50 years without complications are significantly younger and have significantly lower HbA1c levels, BMI and triglyceride levels than survivors with complications.HbA1c is a predictor of macrovascular disease, independently of diabetes duration, even after 50 years’ duration of Type 1 diabetes.It is important to identify factors that may protect individuals with Type 1 diabetes from major complications.

Aims To determine the cultural competence of diabetes services delivered to minority ethnic groups in a multicultural UK city with a diabetes prevalence of 4.3%. Methods A semi‐structured survey comprising 35 questions was carried out across all 66 general practices in Coventry between November 2011 and January 2012. Data were analysed using descriptive statistics. The cultural competence of diabetes services reported in the survey was assessed using a culturally competent assessment tool (CCAT). Results Thirty‐four general practices (52%) responded and six important findings emerged across those practices. (1) Ninety‐four per cent of general practices reported the ethnicity of their populations. (2) One in three people with diabetes was from a minority ethnic group. (3) Nine (26.5%) practices reported a diabetes prevalence of between 55% and 96% in minority ethnic groups. (4) The cultural competences of diabetes services were assessed using CCAT; 56% of practices were found to be highly culturally competent and 26% were found to be moderately culturally competent. (5) Ten practices (29%) reported higher proportionate attendance at diabetes annual checks in the majority white British population compared with minority ethnic groups. (6) Cultural diversity in relation to language and strong cultural traditions around food were most commonly reported as barriers to culturally competent service delivery. Conclusions Seven of the eight cultural barriers identified in the global evidence were present in the city. Use of the CCAT to assess existing service provision and the good baseline recording of ethnicity provide a sound basis for commissioning culturally competent interventions in the future., What's new? Ninety‐four per cent of general practices numerically reported the ethnicity of their populations, which compares favourably with previous surveys.One in three people with diabetes was from an minority ethnic group compared with one in ten of Coventry's population.Seven of the eight cultural barriers to effective diabetes care and management identified in the literature were present in the city.Fifty‐six per cent of the responding general practices provided highly culturally competent diabetes services to their patients.

Aim To analyse the impact of overweight and obesity on the risk of adverse maternal outcomes and fetal macrosomia in pregnancies of women treated for severe gestational diabetes. Methods This was a population‐based cohort study including all singleton pregnancies in Sweden without pre‐existing diabetes in the period 1998–2012. Only mothers with an early‐ pregnancy BMI of ≥ 18.5 kg/m² were included. Logistic regression analysis was used to determine odds ratios with 95% CIs for maternal outcomes and fetal growth. Analyses were stratified by maternal gestational diabetes/non‐gestational diabetes to investigate the impact of overweight/obesity in each group. Results Of 1 249 908 singleton births, 13 057 were diagnosed with gestational diabetes (1.0%). Overweight/obesity had the same impact on the risks of caesarean section and fetal macrosomia in pregnancies with and without gestational diabetes, but the impact of maternal BMI on the risk of preeclampsia was less pronounced in women with gestational diabetes. Normal‐weight women with gestational diabetes had an increased risk of caesarean section [odds ratio 1.26 (95% CI 1.16–1.37)], preeclampsia [odds ratio 2.03 (95% CI 1.71–2.41)] and large‐for‐gestational‐age infants [odds ratio 2.25 (95% CI 2.06–2.46)]. Risks were similar in the overweight group without gestational diabetes, caesarean section [odds ratio 1.34 (1.33–1.36)], preeclampsia odds ratio [1.76 (95% CI 1.72–1.81)], large‐for‐gestational‐age [odds ratio 1.76 (95% CI 1.74–1.79)]. Conclusions Maternal overweight and obesity is associated with similar increments in risks of adverse maternal outcomes and delivery of large‐for‐gestational‐age infants in women with and without gestational diabetes. Obese women with gestational diabetes are defined as a high‐risk group. Normal‐weight women with gestational diabetes have similar risks of adverse outcomes to overweight women without gestational diabetes., What's new? Maternal overweight and obesity is associated with similar increments in risks of adverse outcomes and delivery of large‐for‐gestational‐age infants in women with and without gestational diabetes.Overweight without gestational diabetes has a similar impact on the risk of maternal outcomes, such as preeclampsia, caesarean section and fetal macrosomia, as does gestational diabetes in women of normal weight.Obese women without gestational diabetes have higher rates of caesarean section, preeclampsia and macrosomia than normal‐weight women with gestational diabetes.Despite treatment, women with gestational diabetes still face excess risks of adverse pregnancy outcomes.

Aim To examine whether low circulating vitamin C concentrations and low fruit and vegetable intakes were associated with insulin resistance and other Type 2 diabetes risk markers in childhood. Methods We conducted a cross‐sectional, school‐based study in 2025 UK children aged 9–10 years, predominantly of white European, South‐Asian and black African origin. A 24‐h dietary recall was used to assess fruit, vegetable and vitamin C intakes. Height, weight and fat mass were measured and a fasting blood sample collected to measure plasma vitamin C concentrations and Type 2 diabetes risk markers. Results In analyses adjusting for confounding variables (including socio‐economic status), a one interquartile range higher plasma vitamin C concentration (30.9 μmol/l) was associated with a 9.6% (95% CI 6.5, 12.6%) lower homeostatic model assessment of insulin resistance value, 0.8% (95% CI 0.4, 1.2%) lower fasting glucose, 4.5% (95% CI 3.2, 5.9%) lower urate and 2.2% (95% CI 0.9, 3.4%) higher HDL cholesterol. HbA1c concentration was 0.6% (95% CI 0.2, 1.0%) higher. Dietary fruit, vegetable and total vitamin C intakes were not associated with any Type 2 diabetes risk markers. Lower plasma vitamin C concentrations in South‐Asian and black African‐Caribbean children could partly explain their higher insulin resistance. Conclusions Lower plasma vitamin C concentrations are associated with insulin resistance and could partly explain ethnic differences in insulin resistance. Experimental studies are needed to establish whether increasing plasma vitamin C can help prevent Type 2 diabetes at an early stage., What's new? We examined the cross‐sectional associations between intakes of fruit, vegetables and vitamin C, circulating vitamin C concentrations and insulin resistance in UK children.Circulating vitamin C concentration was inversely associated with insulin resistance, while intakes of fruit, vegetable and vitamin C were unrelated to insulin resistance.Low levels of circulating vitamin C concentrations in UK South‐Asian children could contribute to their higher insulin resistance.Further studies (including trials) are needed to examine the association of vitamin C with insulin resistance and its potential implications for Type 2 diabetes prevention.

Aims We contrasted impaired glucose regulation (prediabetes) prevalence, defined according to oral glucose tolerance test or HbA1c values, and studied cross‐sectional associations between prediabetes and subclinical/clinical cardiovascular disease (CVD) in a cohort of European and South Asian origin. Methods For 682 European and 520 South Asian men and women, aged 58–85 years, glycaemic status was determined by oral glucose tolerance test or HbA1c thresholds. Questionnaires, record review, coronary artery calcification scores and cerebral magnetic resonance imaging established clinical plus subclinical coronary heart and cerebrovascular disease. Results Prediabetes was more prevalent in South Asian participants when defined by HbA1c rather than by oral glucose tolerance test criteria. Accounting for age, sex, smoking, systolic blood pressure, triglycerides and waist–hip ratio, prediabetes was associated with coronary heart disease and cerebrovascular disease in European participants, most obviously when defined by HbA1c rather than by oral glucose tolerance test [odds ratios for HbA1c‐defined prediabetes 1.60 (95% CI 1.07, 2.39) for coronary heart disease and 1.57 (95% CI 1.00, 2.51) for cerebrovascular disease]. By contrast, non‐significant associations were present between oral glucose tolerance test‐defined prediabetes only and coronary heart disease [odds ratio 1.41 (95% CI 0.84, 2.36)] and HbA1c‐defined prediabetes only and cerebrovascular disease [odds ratio 1.39 (95% CI 0.69, 2.78)] in South Asian participants. Prediabetes defined by HbA1c or oral glucose tolerance test criteria was associated with cardiovascular disease (defined as coronary heart and/or cerebrovascular disease) in Europeans [odds ratio 1.95 (95% CI 1.31, 2.91) for HbA1c prediabetes criteria] but not in South Asian participants [odds ratio 1.00 (95% CI 0.62, 2.66); ethnicity interaction P = 0.04]. Conclusions Prediabetes appeared to be less associated with cardiovascular disease in the South Asian than in the European group. These findings have implications for screening, and early cardiovascular prevention strategies in South Asian populations., What's new? For participants of European origin, HbA1c values defined as impaired glucose regulation (prediabetes) were cross‐sectionally associated with coronary heart disease, cerebrovascular disease and the composite outcome of cardiovascular disease.By contrast, in South Asian participants prediabetes defined according to HbA1c concentration was non‐significantly associated with cerebrovascular disease only, and associations between HbA1c concentration‐defined prediabetes and overall cardiovascular disease were absent and, thus significantly weaker, than those seen in the European participants.This suggests that current prediabetes HbA1c thresholds may be inappropriate in South Asian groups as prediabetes defined in this way did not appear to confer excess cardiovascular risk in this ethnic group.

Aims:\ud Conventional definitions of obesity, e.g. body mass index (BMI) ≥ 30 kg/m2 or waist circumference cut-points of 102 cm (men) and 88 cm (women), may underestimate metabolic risk in non-Europeans. We prospectively identified equivalent ethnicity-specific obesity cut-points for the estimation of diabetes risk in British South Asians, African-Caribbeans and Europeans.\ud \ud Methods:\ud We studied a population-based cohort from London, UK (1356 Europeans, 842 South Asians, 335 African-Caribbeans) who were aged 40–69 years at baseline (1988–1991), when they underwent anthropometry, fasting and post-load (75 g oral glucose tolerance test) blood tests. Incident Type 2 diabetes was identified from primary care records, participant recall and/or follow-up biochemistry. Ethnicity-specific obesity cut-points in association with diabetes incidence were estimated using negative binomial regression.\ud \ud Results:\ud Diabetes incidence rates (per 1000 person years) at a median follow-up of 19 years were 20.8 (95% CI: 18.4, 23.6) and 12.0 (8.3, 17.2) in South Asian men and women, 16.5 (12.7, 21.4) and 17.5 (13.0, 23.7) in African-Caribbean men and women, and 7.4 (6.3, 8.7), and 7.2 (5.3, 9.8) in European men and women. For incidence rates equivalent to those at a BMI of 30 kg/m2 in European men and women, age- and sex-adjusted cut-points were: South Asians, 25.2 (23.4, 26.6) kg/m2; and African-Caribbeans, 27.2 (25.2, 28.6) kg/m2. For South Asian and African-Caribbean men, respectively, waist circumference cut-points of 90.4 (85.0, 94.5) and 90.6 (85.0, 94.5) cm were equivalent to a value of 102 cm in European men. Waist circumference cut-points of 84.0 (74.0, 90.0) cm in South Asian women and 81.2 (71.4, 87.4) cm in African-Caribbean women were equivalent to a value of 88 cm in European women.\ud \ud Conclusions:\ud In prospective analyses, British South Asians and African-Caribbeans had equivalent diabetes incidence rates at substantially lower obesity levels than the conventional European cut-points.

Aims To describe the burden of diabetes mellitus and impaired fasting glucose in middle-aged residents (35–64 years) in an urban area of Sri Lanka. Methods A cross-sectional survey was conducted in the Ragama Medical Officer of Health area, from which 2986 participants (1349 men and 1637 women) were randomly selected from the electoral registry between January and December 2007. The participants underwent a physical examination and had their height, weight, waist and hip circumferences and blood pressure measured by trained personnel. Fasting blood samples were taken for measurement of glucose, HbA1c and lipids. The prevalence of diabetes (fasting plasma glucose > 7 mmol/l) and impaired fasting glycaemia (fasting plasma glucose 5.6–6.9 mmol/l) and major predictors of diabetes in Sri Lanka were estimated from the population-based data. Results Age-adjusted prevalence of diabetes mellitus in this urban population was 20.3% in men and 19.8% in women. Through the present screening, 263 patients with diabetes and 1262 with impaired fasting glucose levels were identified. The prevalence of newly detected diabetes was 35.7% of all patients with diabetes. Among patients with diabetes, only 23.8% were optimally controlled. In the regression models, high BMI, high waist circumference, high blood pressure and hypercholesterolaemia increased the fasting plasma glucose concentration, independent of age, sex and a family history of diabetes. Conclusions Our data demonstrate the heavy burden of diabetes in this urban population. Short- and long-term control strategies are required, not only for optimal therapy among those affected, but also for nationwide primary prevention of diabetes.