Modifying Effect of Body Mass Index on Survival in Elderly Type 2 Diabetic Patients: Hong Kong Diabetes Registry.

OBJECTIVE: There are nonlinear risk associations of body mass index (BMI) with mortality in type 2 diabetes (T2D) and elderly populations although similar information in elderly individuals with T2D are lacking. RESEARCH DESIGN AND METHODS: We analyzed prospective data for 3186 Chinese patients with T2D with age 65 years or older. Baseline demographic data, risk factors, complications, and all-cause mortality were captured from the Hong Kong Diabetes Registry and the Hong Kong Hospital Authority Clinical Management System. RESULTS: Over a median follow-up period of 6.0 years (medium-term), 816 (25.6%) deaths occurred and at 9.4 years (long-term), 1557 (48.9%) patients had died. Men were more likely to die than women with increased mortality rate with increasing age (morality rates of men with normal BMI at 9-year follow-up in the 65 to 69, 70 to 74, and 75 years or older age groups were 41.8, 70.3, and 101.4 per 1000 person-years, whereas that for women were 35.5, 50.4, and 78.8 respectively). Within each age group, high BMI was associated with increased survival, especially in the 75 years and older age group and with prolonged follow-up period. Using Cox regression analysis, after adjustment for confounders, high BMI (≥ 25.0 kg/m(2)) was associated with reduced risk of death in all subgroups, reaching significance in men in the older age groups at 9-year follow-up (for men 70 to 74 years old, hazard ratio [HR] of mortality was 0.67, 95% confidence interval [CI] 0.48-0.95, for those ≥ 75, HR was 0.62, 95% CI 0.44-0.89) compared with 18.5 to 22.9 kg/m(2) as referent. CONCLUSIONS: In Chinese elderly patients with T2D, high BMI protected against mortality, calling for more attention to people with low BMI who might have unmet clinical needs.

Measuring depression with CES-D in Chinese patients with type 2 diabetes: the validity and its comparison to PHQ-9.

BACKGROUND: The validity of the 20-item Center for Epidemiological Studies Depression (CES-D) scale for depression screening in Hong Kong Chinese patients with type 2 diabetes remains unknown. We aimed to validate CES-D, compare its psychometric properties with the 9-item Patient Health Questionnaire (PHQ-9), and explore whether one of the two is more suitable for depression screening in Chinese patients with type 2 diabetes. METHODS: Between June 2010 and July 2011, 545 consecutive Chinese patients with type 2 diabetes who underwent structured comprehensive assessments completed the CES-D and PHQ-9. Forty patients were retested within 2-4 weeks by telephone interview and 97 patients were randomly selected to undergo the Mini International Neuropsychiatric Interview (MINI) by psychiatrists for clinical diagnosis of depression. RESULTS: The internal consistency (Cronbach's α) of CES-D was 0.85, with a test-retest correlation coefficient of 0.64. The area under the curve for CES-D compared to the clinical diagnosis of major depression was 0.85. A cut-off score of ≥21 for CES-D provided the optimal balance between sensitivity (78.3 %) and specificity (74.3 %) and identified 17.8 % (n = 97) of patients with depression. CES-D and PHQ-9 showed moderate agreement in depression screening (Cohen's Kappa: 0.45). Compared to non-depressed patients, those who screened positive by PHQ-9 had a higher HbA1c whereas the glycemic differences were not significant when using CES-D. CONCLUSION: The CES-D is a valid screening tool for depression in Chinese type 2 diabetic patients although the PHQ-9 was more discriminative in identifying those with suboptimal glycemic control.

High risk for cardiovascular disease in Chinese type 2 diabetic patients with major depression--a 7-year prospective analysis of the Hong Kong Diabetes Registry.

BACKGROUND: Depression is known to be associated with premature mortality and cardiovascular disease (CVD) in type 2 diabetes, although there is a paucity of similar data in Chinese population. In this study, we examined the risk association of major depression with premature mortality and CVD in a hospital clinic-based cohort. METHODS: In a prospective cohort of 7835 Hong Kong Chinese with type 2 diabetes but without CVD at baseline, 153 patients were diagnosed with major depression by psychiatrists in public hospitals. After a median follow-up period of 7.4 years, 827 patients died and 829 patients developed CVD mainly due to stroke (n=384). We used Cox proportional hazard regression to obtain the hazard ratio (HR, 95% confidence interval, CI) of depression for the risk of mortality and CVD. RESULTS: Depressed patients were younger (51.6 versus 56.6 years, p<0.001), more likely to be female (78.4% versus 53.0%, p<0.001), had higher LDL-cholesterol (3.2 versus 3.0 mmol/L, p=0.038) at baseline and longer hospitalization stays per year (median:0.8 nights per 100-person-years versus 0.1 nights per 100-person-years, p<0.001). After adjusting for conventional risk factors, depression independently predicted CVD [HR=2.18(95% CI=1.45-3.27)], mainly due to stroke [HR=3.55(95% CI=2.15-5.84)]. LIMITATIONS: The young age and small sample size of patients with depression did not give sufficient power to confirm risk association of depression with premature mortality and myocardial infarction. CONCLUSIONS: In Chinese type 2 diabetic patients, depression was associated with a 2-3 fold increase in the risk of incident CVD, especially stroke.

Treatment and landmark clinical trials for renoprotection.

During the last two decades, many large-scale randomized clinical trials have confirmed the importance of lowering blood pressure and inhibiting the renin-angiotensin-aldosterone system (RAAS) to preserve renal function in patients with chronic kidney disease due to different causes. With growing epidemic of type 2 diabetes, the burden of diabetic nephropathy (DN) will continue to grow. Based on a large body of epidemiological, experimental and interventional studies, strict glycemic control, blood pressure lowering and RAAS blockade are now the recommended strategies in the prevention and control of DN. Both angiotensin-converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) have been shown unequivocally to reduce proteinuria and preserve renal function in affected patients. Importantly, therapeutic responses are dose dependent, and these drugs should be given in maximal dosages as tolerated. Combined use of ACEI and ARB reduced proteinuria and rate of decline of renal function, although it did not appear to confer extra renoprotection over the use of either agent alone. Spironolactone and aliskiren are alternative drugs that block the RAAS and have been demonstrated to further reduce proteinuria when added to ACEI or ARB. In the absence of long-term data about their safety and efficacy on renal function, combined use of these agents must be administered with caution after careful consideration of risk-benefit ratio with close monitoring for adverse effects, notably hyperkalemia. Pending further evidence, the use of a team approach to attain multiple treatment goals will improve renal outcomes in these high risk subjects.

Diabetes-related distress and physical and psychological health in chinese type 2 diabetic patients.

OBJECTIVE: To validate a Chinese version of the Diabetes Distress Scale (CDDS). RESEARCH DESIGN AND METHODS: The CDDS was derived using forward-backward translation and administered in 189 Chinese type 2 diabetic patients with evaluation of its psychometric properties. RESULTS: On the basis of principal-component analysis, three factors of the 15-item version of the CDDS (CDDS-15) accounted for 63% of the variance. The correlation coefficient between the original 17-item and 15-item scales was 0.99. The Cronbach α for internal consistency was 0.90, and the test-retest reliability coefficient was 0.74. The CDDS-15 score was significantly associated with glycemic control, obesity, depressive symptoms, and quality of life. CONCLUSIONS: The CDDS-15 is a valid and reliable instrument to assess diabetes-related distress.

Lipid control and use of lipid-regulating drugs for prevention of cardiovascular events in Chinese type 2 diabetic patients: a prospective cohort study.

BACKGROUND: Dyslipidaemia is an important but modifiable risk factor of cardiovascular disease (CVD) in type 2 diabetes. Yet, the effectiveness of lipid regulating drugs in Asians is lacking. We examined the effects of lipid control and treatment with lipid regulating drugs on new onset of CVD in Chinese type 2 diabetic patients. METHODS: In this prospective cohort consisting of 4521 type 2 diabetic patients without history of CVD and naïve for lipid regulating treatment recruited consecutively from 1996 to 2005, 371 developed CVD after a median follow-up of 4.9 years. We used Cox proportional hazard regression to obtain the hazard ratios (HR) of lipids and use of lipid regulating drugs for risk of CVD. RESULTS: The multivariate-adjusted HR (95% confidence interval) of CVD in patients with high LDL-cholesterol (≥ 3.0 mmol/L) was 1.36 (1.08 - 1.71), compared with lower values. Using the whole range value of HDL-cholesterol, the risk of CVD was reduced by 41% with every 1 mmol/L increase in HDL-cholesterol. Plasma triglyceride did not predict CVD. Statins use was associated with lower CVD risk [HR = 0.66 (0.50 - 0.88)]. In sub-cohort analysis, statins use was associated with a HR of 0.60 (0.44 - 0.82) in patients with high LDL-cholesterol (≥ 3.0 mmol/L) and 0.49 (0.28 - 0.88) in patients with low HDL-cholesterol. In patients with LDL-cholesterol < 3.0 mmol/L, use of fibrate was associated with HR of 0.34 (0.12 - 1.00). Only statins were effective in reducing incident CVD in patients with metabolic syndrome [(HR = 0.58(0.42 - 0.80)]. CONCLUSIONS: In Chinese type 2 diabetic patients, high LDL-cholesterol and low HDL-cholesterol predicted incident CVD. Overall, patients treated with statins had 40-50% risk reduction in CVD compared to non-users.