The effect of diabetes and prediabetes on the prevalence, complications and mortality in nonalcoholic fatty liver disease

Background/Aims@#Nonalcoholic fatty liver disease (NAFLD) is closely associated with diabetes. The cumulative impact of both diseases synergistically increases risk of adverse events. However, present population analysis is predominantly conducted with reference to non-NAFLD individuals and has not yet examined the impact of prediabetes. Hence, we sought to conduct a retrospective analysis on the impact of diabetic status in NAFLD patients, referencing non-diabetic NAFLD individuals. @*Methods@#Data from the National Health and Nutrition Examination Survey 1999–2018 was used. Hepatic steatosis was defined with United States Fatty Liver Index (US-FLI) and FLI at a cut-off of 30 and 60 respectively, in absence of substantial alcohol use. A multivariate generalized linear model was used for risk ratios of binary outcomes while survival analysis was conducted with Cox regression and Fine Gray model for competing risk. @*Results@#Of 32,234 patients, 28.92% were identified to have NAFLD. 36.04%, 38.32% and 25.63% were non-diabetic, prediabetic and diabetic respectively. Diabetic NAFLD significantly increased risk of cardiovascular disease (CVD), stroke, chronic kidney disease, all-cause and CVD mortality compared to non-diabetic NAFLD. However, prediabetic NAFLD only significantly increased the risk of CVD and did not result in a higher risk of mortality. @*Conclusions@#Given the increased risk of adverse outcomes, this study highlights the importance of regular diabetes screening in NAFLD and adoption of prompt lifestyle modifications to reduce disease progression. Facing high cardiovascular burden, prediabetic and diabetic NAFLD individuals can benefit from early cardiovascular referrals to reduce risk of CVD events and mortality.

Use of SGLT-2 Inhibitors in Patients with Type 2 Diabetes Mellitus and Abdominal Obesity: An Asian Perspective and Expert Recommendations

The prevalence of obesity in Asia is of epidemic proportions, with an estimated 1 billion overweight/obese individuals in the region. The majority of patients with type 2 diabetes mellitus (T2DM) are overweight/obese, which increases the risk of cardiorenal outcomes in these patients; hence, sustained reductions in body weight and visceral adiposity are important management goals. However, most of the glucose-lowering therapies such as insulin, sulfonylureas, glinides, and thiazolidinediones induce weight gain, which makes the management of overweight/obese T2DM patients challenging. Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are the only oral glucose-lowering agents that have been shown to reduce body weight and visceral adiposity. In addition, SGLT-2 inhibitors therapy reduces ectopic fat deposition and improves adipose tissue function and weight-related quality of life. In this article, we aim to consolidate the existing literature on the effects of SGLT-2 inhibitors in Asian patients with T2DM and to produce clinical recommendations on their use in overweight or obese patients with T2DM. Recommendations from international and regional guidelines, as well as published data from clinical trials in Asian populations and cardiovascular outcomes trials are reviewed. Based on the available data, SGLT-2 inhibitors represent an evidence-based therapeutic option for the management of overweight/obese patients with T2DM.

Treating Diabetes in Older Adults – Optimising Glycaemic Targets with Comorbidities in Mind

@#Ageing is associated with changes in the body composition, reduced insulin sensitivity and beta-cell function, which predispose the older adults to glucose intolerance and a higher risk of diabetes mellitus. The diabetes treatment for older adults is complicated by higher rates of coexisting illnesses, functional and physical disability, cognitive impairment, and more prone to injury. The treatment goal is less stringent, with a reasonable HbA1c between 7.0 to 8.0 percent, with the aim to minimise the risk of hypoglycaemia. Medical nutrition therapy and physical activity are the cornerstones in the management, failing so, pharmacotherapy with oral or injectable diabetes medication would be needed for diabetes control. The Appropriate Care Guidelines, Ministry of Health, on Oral Glucose-Lowering Agents, and Initiating Basal Insulin in type 2 diabetes mellitus, published in 2017, have provided the framework for the use of oral glucose-lowering agents and insulin therapy for diabetes management in the general population. The diabetes management plan includes a multidisciplinary team, a greater consideration of patient factors, aspiration and goals, and risk evaluation and mitigation strategy to prevent hypoglycaemia. Easy and early access to health care is critical as older adults are prone to rapid deterioration in the clinical condition.

SGLT2-inhibitor and its place in Contemporary Diabetes Management

@#The therapeutic approach for patients with type 2 diabetes is evolving rapidly. The recent published cardiovascular outcomes trials (EMPA-Reg, Canvas and DECLARE-TIMI 58), and DAPA-HF and CREDENCE studies demonstrated the benefits of Sodium-glucose transporter 2 inhibitors (SGLT2i) in improving the outcomes of diabetic patients with cardiovascular disease, heart failure and diabetic nephropathy. The cardiorenal benefits are seen beyond the glycaemic control. The treatment algorithm recommends early use of SGLT2i, especially among those with existing cardiovascular disease, heart failure or kidney disease. The side effects of SGLT2i are related to its underlying mechanisms of action, i.e. a higher incidence of genital yeast infections and urinary tract infections. SGLT2i can also cause euglycaemic ketoacidosis and is not currently indicated for use in patients with type 1 diabetes.

Diabetes Mellitus as a Cardiometabolic Disease

@#Diabetes mellitus is a global health crisis. It is associated with many disabling co-morbidities and could lead to premature cardiovascular disease and death. Chronic hyperglycaemia leads to many pathological changes that are atherogenic. Some studies have regarded diabetes mellitus as a coronary heart disease risk equivalent, especially patients with a long duration of disease. Diabetes mellitus is associated with other traditional cardiovascular risk factors such as hypertension and dyslipidaemia, which together they increase the risk of cardiovascular disease by many folds. There are several strategies to improve the cardiovascular outcomes among people with diabetes mellitus, including the following: 1) early intensive glycaemic control (UKPDS); 2) optimal treatment of traditional cardiovascular risk factors (STENO-2); and 3) use of novel glucose-lowering therapies (sodium-glucose transporter 2 inhibitors or glucagon-like peptide 1 agonist) that have benefits on cardiovascular events or mortality.

Attitudes and Concerns of Diabetic Patients towards Bariatric Surgery as Treatment of Diabetes

<p><b>INTRODUCTION</b>Bariatric surgery is increasingly recognised as an effective treatment for type 2 diabetes that significantly improves glycaemic control, even achieving remission. This study examined perceptions and concerns of diabetic patients towards bariatric surgery as a treatment option for diabetes.</p><p><b>MATERIALS AND METHODS</b>A total of 150 patients were recruited from a specialised diabetic outpatient clinic and completed a questionnaire (items were rated on a Likert scale from slightly important [lowest score of 1] to extremely important [maximum score of 5]). Logistic regression was performed to identify factors influencing decision for surgery.</p><p><b>RESULTS</b>The 74 males and 76 females had mean age of 50 (range 20 to 78) and body mass index (BMI) of 29.6 kg/m(range 18.1 to 51); 61% considered surgery favourably. Predictive factors for interest in surgery: higher educational levels (OR = 2.3; 95% CI, 1.2 to 4.4), duration of diabetes (OR = 0.4; 95% CI, 0.2 to 1.0) and use of insulin (OR = 2.1; 95% CI, 1.1 to 4.1). Reasons for surgery: desire for remission (Likert scale 4.7 ± 0.7), to prevent complications (Likert scale 4.5 ± 0.9) and to reduce medications (Likert scale 4.3 ± 1.1). For those not keen on surgery, main reasons were fear of surgery (Likert scale 4 ± 1.5) and satisfaction with current therapy (Likert scale 3.7 ± 1.6).</p><p><b>CONCLUSION</b>Many diabetic patients would consider surgery as an option to improve their metabolic disorder (greater interest in patients with higher educational levels, currently using insulin and with shorter duration of diabetes). Surgical complications, length of recovery and duration of benefits were the main concerns.</p>

Prevalence and control of hypercholesterolaemia as defined by NCEP-ATPIII guidelines and predictors of LDL-C goal attainment in a multi-ethnic Asian population

<p><b>INTRODUCTION</b>Few studies in Asia have assessed the burden of hypercholesterolaemia based on the global cardiovascular risk assessment. This study determines the burden of hypercholesterolaemia in an Asian population based on the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATPIII) guidelines, and examines predictors of low-density lipoprotein cholesterol (LDL-C) goal attainment.</p><p><b>MATERIALS AND METHODS</b>Five thousand and eighty-three Chinese, Malays and Asian-Indians living in Singapore were assigned to coronary heart disease (CHD)-risk category based on the NCEP-ATPIII guidelines. Awareness, treatment and control of hypercholesterolaemia based on risk- specific LDL-C goal were determined, including the use of lipid-lowering therapy (LLT). Cox-regression models were used to identify predictors of LDL-C above goal among those who were aware and unaware of hypercholesterolaemia.</p><p><b>RESULTS</b>One thousand five hundred and sixty-eight (30.8%) participants were aware of hypercholesterolaemia and 877 (17.3%) were newly diagnosed (unaware). For those who were aware, 39.3% participants received LLT. Among those with 2 risk factors, only 59.7% attained LDL-C goal. The majority of them were taking statin monotherapy, and the median dose of statins was similar across all CHD risk categories. Among participants with 2 risk factors and not receiving LLT, 34.1% would require LLT. Malays or Asian-Indians, higher CHD risk category, increasing body mass index (BMI), current smoking and lower education status were associated with higher risk of LDL-C above goal. Being on LLT reduced the risk of having LDL-C above goal.</p><p><b>CONCLUSION</b>The burden of hypercholesterolaemia is high in this multi-ethnic population especially those in the higher CHD risk categories, and might be partly contributed by inadequate titration of statins therapy. Raising awareness of hypercholesterolaemia, appropriate LLT initiation and titration, weight management and smoking cessation may improve LDL-C goal attainment in this population.</p>