The role of triglyceride-glucose index in the prediction of the development of hypertension – findings from a community cohort in Singapore / Journal of the ASEAN Federation of Endocrine Societies

Objectives@#Triglyceride-glucose index (TyGI) is an emerging surrogate marker of insulin resistance. We aim to explore the role of triglyceride-glucose index in the prediction of the development of hypertension.@*Methodology@#nducted a retrospective cohort study that included 3,183 study participants identified from a community health screening programme who had no baseline hypertension and were then followed up after an average of 1.7 years. Cox proportional-hazard model was used to assess the association between risk of incident hypertension and TyGI in quartiles, while adjusting for demographics and clinical characteristics.@*Results@#Hypertension occurred in 363 study participants (11.4%). Those who developed hypertension had higher TyGI [8.6 (IQR 8.2-9.0)] than those who did not [8.2 (IQR 8.0-8.7)] (p<0.001). Significant association between TyGI and hypertension was observed in both the unadjusted and proportional hazard model [Quartile (Q)2, p=0.010; Q3, p<0.001 and Q4, p<0.001] and the model that adjusted for demographics (Q2, p=0.016; Q3, p=0.003; Q4, p<0.001). In the model adjusted for clinical covariates, the hazard of developing hypertension remained higher in TyGI Q4 compared to TyGI Q1(Hazard Ratio=2.57; 95% Confidence Interval: 1.71, 3.87). Increasing triglyceride-glucose index accounted for 16.4% of the association between increasing BMI and incident hypertension, after adjusting for age, gender, ethnicity and baseline HDL cholesterol (p<0.001).@*Conclusion@#Triglyceride-glucose index was an independent predictor of the development of hypertension. It may potentially be used as an inexpensive indicator to predict the development of hypertension and risk-stratify individuals to aid management in clinical practice.

Clinical Determinants of Diabetes Progression in Multiethnic Asians with Type 2 Diabetes - A 3-Year Prospective Cohort Study

INTRODUCTION@#The risk for diabetes progression varies greatly in individuals with type 2 diabetes mellitus (T2DM). We aimed to study the clinical determinants of diabetes progression in multiethnic Asians with T2DM.@*MATERIALS AND METHODS@#A total of 2057 outpatients with T2DM from a secondary-level Singapore hospital were recruited for the study. Diabetes progression was defined as transition from non-insulin use to requiring sustained insulin treatment or glycated haemoglobin (HbA1c) ≥8.5% when treated with 2 or more oral hypoglycaemic medications. Multivariable logistic regression (LR) was used to study the clinical and biochemical variables that were independently associated with diabetes progression. Forward LR was then used to select variables for a parsimonious model.@*RESULTS@#A total of 940 participants with no insulin use or indication for insulin treatment were analysed. In 3.2 ± 0.4 (mean ± SD) years' follow-up, 163 (17%) participants experienced diabetes progression. Multivariable LR revealed that age at T2DM diagnosis (odds ratio [95% confidence interval], 0.96 [0.94-0.98]), Malay ethnicity (1.94 [1.19-3.19]), baseline HbA1c (2.22 [1.80-2.72]), body mass index (0.96 [0.92-1.00]) and number of oral glucose-lowering medications (1.87 [1.39-2.51]) were independently associated with diabetes progression. Area under receiver operating characteristic curve of the parsimonious model selected by forward LR (age at T2DM diagnosis, Malay ethnicity, HbA1c and number of glucose-lowering medication) was 0.76 (95% CI, 0.72-0.80).@*CONCLUSION@#Young age at T2DM diagnosis, high baseline HbA1c and Malay ethnicity are independent determinants of diabetes progression in Asians with T2DM. Further mechanistic studies are needed to elucidate the pathophysiology underpinning progressive loss of glycaemic control in patients with T2DM.

Ethnic disparity in inter-arm systolic blood pressure difference and its determinants among Asians with type 2 diabetes: A cross-sectional study / Journal of the ASEAN Federation of Endocrine Societies

@#<p><strong>OBJECTIVES:</strong> An inter-arm difference in systolic blood pressure (IADSBP) of 10 mmHg or more has been associated with cardiovascular disease (CVD) and increased mortality in T2DM patients. We aim to study ethnic disparity in IADSBP and its determinants in a multi-ethnic T2DM Asian cohort.<br /><strong>METHODOLOGY:</strong> Bilateral blood pressures were collected sequentially in Chinese (n=654), Malays (n=266) and Indians (n=313). IADSBP was analyzed as categories (<br /><strong>RESULTS:</strong> Malays (27.4%) and Indians (22.4%) had higher prevalence of IADSBP ?10 mmHg than Chinese (17.4%) (p=0.002). After adjustment for age, gender, duration of diabetes, hemoglobin A1c, body mass index (BMI), heart rate, pulse wave velocity (PWV), estimated glomerular filtration rate (eGFR), albumin-to-creatinine ratio (ACR), smoking, hypertension, soluble receptor for advanced glycation end products (sRAGE), and usage of hypertension medications, ethnicity remained associated with IADSBP. While Malays were more likely to have IADSBP ?10 mmHg than Chinese (OR=1.648, 95%CI: 1.138-2.400, p=0.009), Indians had comparable odds with the Chinese. BMI (OR=1.054, 95%CI: 1.022-1.087, p=0.001) and hypertension (OR=2.529, 95%CI: 1.811-3.533, p<0.001) were also associated with IADSBP ?10 mmHg.<br /><strong>CONCLUSION:</strong> IADSBP in Malays were more likely to be ?10 mmHg than the Chinese which may explain their higher risk for CVD and mortality. Measuring bilateral blood pressures may identify high-risk T2DM individuals for intensive risk factor-management.</p>

Prevalence of Chronic Kidney Disease in Adults with Type 2 Diabetes Mellitus

<p><b>INTRODUCTION</b>Diabetes mellitus (DM) is a major cause of chronic kidney disease (CKD). The epidemiology of CKD secondary to type 2 DM (T2DM) (i.e. diabetic nephropathy (DN)) has not been well studied in Singapore, a multi-ethnic Asian population. We aimed to determine the prevalence of CKD in adult patients with T2DM.</p><p><b>MATERIALS AND METHODS</b>We conducted a cross-sectional study on patients (n = 1861) aged 21 to 89 years with T2DM who had attended the DM centre of a single acute care public hospital or a primary care polyclinic between August 2011 and November 2013. Demographic and clinical data were obtained from patients using a standard questionnaire. Spot urine and fasting blood samples were sent to an accredited hospital laboratory for urinary albumin, serum creatinine, HbA1c and lipid measurement. CKD was defined and classified using the 2012 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines and classification.</p><p><b>RESULTS</b>The distribution by risk of adverse CKD outcomes was: low risk, 47%; moderate risk, 27.2%; high risk, 12.8%; and very high risk, 13%. The prevalence of CKD in patients with T2DM was 53%. Variables significantly associated with CKD include neuropathy, blood pressure ≥140/80 mmHg, triglycerides ≥1.7 mmol, body mass index, duration of diabetes, HbA1c ≥8%, age, cardiovascular disease, and proliferative retinopathy.</p><p><b>CONCLUSION</b>CKD was highly prevalent among patients with T2DM in Singapore. Several risk factors for CKD are well recognised and amenable to intervention. Routine rigorous screening for DN and enhanced programme for global risk factors reduction will be critical to stem the tide of DN.</p>

Fasting during Ramadan and Associated Changes in Glycaemia, Caloric Intake and Body Composition with Gender Differences in Singapore

<p><b>INTRODUCTION</b>Millions of Muslim patients with diabetes mellitus (DM) fast during Ramadan. However, little is known about the metabolic impact of Ramadan fasting. We aimed to study the changes in body composition and metabolic profile in this group of patients.</p><p><b>MATERIALS AND METHODS</b>We studied 29 Southeast Asian Muslim patients with type 2 diabetes; all underwent pre-Ramadan education. Study variables were weight change, body composition (using multifrequency bioimpedance method, InBody S20®, Biospace, South Korea), blood pressure (BP), glycated haemoglobin (HbA1c), fasting lipid profile, and caloric intake assessment using FoodWorks® nutrient analysis software.</p><p><b>RESULTS</b>Twenty-three subjects fasted ≥15 days; mean ± SD: 57 ± 11 years; 52% were males. HbA1c improved significantly (8.6 ± 2.4% pre-Ramadan vs 8.0 ± 2.3% end-Ramadan, P = 0.017). Despite similar body weight, there was reduction in body fat mass (BFM) (30.9 ± 11 kg vs 29.2 ± 12.2 kg, P = 0.013). Multivariate analysis suggested that the reduction in HbA1c was attributed by reduction in BFM (β = -0.196, P = 0.034). There was no change in visceral adiposity (visceral fat area (VFA)) but stratification by gender showed a reduction amongst females (137.6 ± 24.5 cm2 to 132.5 ± 25.7 cm2, P = 0.017). These changes occurred despite similar total caloric intake (1473.9 ± 565.4 kcal vs 1473.1 ± 460.4 kcal, P = 0.995), and proportion of carbohydrate (55.4 ± 6.3% vs 53.3 ± 7.5%, P = 0.25) and protein intake (17.6 ± 4.1% vs 17.3 ± 5.4%, P = 0.792), before and during Ramadan respectively, but with increased proportion of fat intake (11.9 ± 2.4% vs 13 ± 11.7%, P = 0.04). Seven out of 23 patients had medications adjusted to avert symptomatic hypoglycaemia but none of the patients developed severe hypoglycaemia.</p><p><b>CONCLUSION</b>Ramadan fasting can be practiced safely with prior patient education and medication adjustment. It also confers modest benefits on metabolic profile and body composition, especially among females.</p>

Risk factor profile and treatment patterns of patients with atherothrombosis in Singapore: insight from the REACH Registry

<p><b>INTRODUCTION</b>Atherothrombosis is the leading cause of cardiovascular mortality. The Reduction of Atherothrombosis for Continued Health (REACH) Registry provided information on atherosclerosis risk factors and treatment. Singapore was one of the 44 participating countries in the REACH Registry. The objective of this study was to determine the atherosclerosis risk factor profile and treatment patterns in Singapore patients enrolled in the REACH Registry.</p><p><b>MATERIALS AND METHODS</b>The REACH Registry is an international prospective observational registry of subjects with or at risk for atherothrombosis. Patients aged 45 years or older with established vascular disease [coronary artery disease (CAD), cerebrovascular disease (CVD), peripheral arterial disease (PAD)] or 3 or more atherosclerosis risk factors were recruited between 2003 and 2004.</p><p><b>RESULTS</b>A total of 881 patients (64.4% male) were recruited in Singapore by 63 physicians. The mean age was 64 +/- 9.8 years (range, 45 to 95). Seven hundred and one (79.6%) patients were symptomatic (CAD 430, CVD 321, PAD 72) while 180 (20.4%) patients had > or =3 risk factors. Approximately 13% of symptomatic patients had symptomatic polyvascular disease. There was a high proportion of diabetes mellitus (57%), hypertension (80.6%) and hypercholesterolemia (80.1%). A substantial proportion of symptomatic patients were current smokers (14.1%). Approximately half of the patients were either overweight or obese [abdominal obesity, 54.3%; body mass index (BMI) 23-27.5, 45.9%; BMI > or =27.5, 23.3%]. Patients were undertreated with antiplatelet agents (71.9% overall; range, 23.9% for > or =3 risk factors to 84.7% for PAD) and statins (76.2% overall; range, 73.6% for PAD to 82.1% for CAD). Risk factors remained suboptimally controlled with a significant proportion of patients with elevated blood pressure (59.4% for > or =3 risk factors and 48.6% for symptomatic patients), elevated cholesterol (40% for > or =3 risk factors and 24.4% for symptomatic patients) and elevated blood glucose (45% for > or =3 risk factors and 19.8% for symptomatic patients).</p><p><b>CONCLUSION</b>Established atherosclerosis risk factors are common in Singapore patients in the REACH Registry; and obesity is a major problem. Most of these risk factors remained suboptimally controlled.</p>