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Identifying risk of type 2 diabetes: epidemiologic perspectives from biomarkers to lifestyle
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.ORCID iD: 0000-0003-2475-7131
2006 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Type 2 diabetes is a significant health problem because of its high prevalence and strong association with cardiovascular morbidity and mortality. An increase of type 2 diabetes is predicted due to increasing obesity and sedentary lifestyle habits. The development from latent to diagnostic disease spans many years and during this time it is possible to prevent or postpone type 2 diabetes using lifestyle and pharmacological interventions.

The objective of this thesis is to investigate and describe early patterns and risk indicators of type 2 diabetes. The focus is on type 2 diabetes as one component in metabolic syndrome, i.e. the clustering of several cardiovascular risk markers.

Two studies based on the Västerbotten Intervention Programme (VIP) provided the data; one case-referent study nested within VIP which includes 237 diabetes cases that were clinically diagnosed 5.4 years after the health survey, each with two referents; and one panel study with 5 consecutive annual cohorts including subjects that participated in VIP between1990 and 1994 and returned to a follow-up after 10 years, a total of 16 492 individuals. Associations between risk markers and type 2 diabetes or metabolic syndrome are evaluated by several statistical techniques. A model of metabolic syndrome is hypothesized.

A prediction model for developing type 2 diabetes among middle-aged individuals is proposed, where high risk is defined as having at least two out of three risk criteria (fasting plasma glucose ≥6.1 mmol/L, HbA1c ≥4.7% (Swedish Mono-S standard) and BMI ≥27 in men and BMI ≥30 in women). With positive predictive values of 32% in men and 46% in women, this model performs at least as well as other published prediction models. Information on family history of diabetes does not improve the result and the cumbersome oral glucose tolerance test is not needed. Therefore this model should be feasible for use in routine care.

A model of metabolic syndrome with five composite factors, based on 14 variables including markers produced by adipose tissue and b-cells, suggest that obesity with insulin resistance and b-cell decompensation are the core perturbations in the early stages of type 2 diabetes, while inflammation and dyslipidemia could not be shown to be independent early risk indicators. The composite factors do not improve the prediction as compared to the single markers of fasting glucose, BMI and proinsulin and, possibly blood pressure values.

Stress (measured as passive or tense working conditions) and weak social support (measured as emotional support), are suggested to be strong risk indicators along with high BMI for type 2 diabetes in women. In men BMI is predictive, but the stress variables are not shown to be associated with future type 2 diabetes. A social gap is indicated by double risk of metabolic syndrome among subjects with low (≤ 9 years at school) compared to high education (≥ 13 years). High consumption of Swedish smokeless tobacco, snuff (>4 cans/week), is independently associated with metabolic syndrome, obesity and hypertriglyceridemia, but not with dysregulation of glucose.

To conclude, single markers, that are commonly used in daily practice, are useful and sufficient for identification of subjects that are in the early stages of type 2 diabetes. Obesity with insulin resistance and b-cell decompensation are the core perturbations in early development to T2DM. Lifestyle, socioeconomic and psychosocial markers, in addition to biomarkers, are important determinants of future type 2 diabetes and metabolic syndrome, albeit not similarly among men and women.

Place, publisher, year, edition, pages
Umeå: Folkhälsa och klinisk medicin , 2006. , 92 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1077
Keyword [en]
Type 2 diabetes mellitus, metabolic syndrome, prediction, stress, social support, smokeless tobacco, risk, obesity, lifestyle, psychosocial, clinical markers, case-referent study, cohort study
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-953ISBN: 978-91-7264-238-6 (print)OAI: oai:DiVA.org:umu-953DiVA: diva2:145175
Public defence
2007-01-12, Sal B, Byggnad 1 D, Tandläkarhögskolan, våning 9, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2006-12-20 Created: 2006-12-20 Last updated: 2015-04-29Bibliographically approved
List of papers
1. A combination of HbA1c, fasting glucose and BMI is effective in screening for individuals at risk of future type 2 diabetes: OGTT is not needed.
Open this publication in new window or tab >>A combination of HbA1c, fasting glucose and BMI is effective in screening for individuals at risk of future type 2 diabetes: OGTT is not needed.
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2006 (English)In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 260, no 3, 263-71 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To identify a screening model that predicts high risk of future type 2 diabetes and is useful in clinical practice. DESIGN AND METHODS: Incident case-referent study nested within a population-based health survey. We compared screening models with three risk criteria and calculated sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and attributable proportion. We used fasting plasma glucose (FPG) alone or with an oral glucose tolerance test (OGTT), glycosylated haemoglobin A (HbA1c) (normal range 3.6-5.3%), body mass index (BMI), triglycerides and family history of diabetes (FHD). SETTING: Participants in a health survey at all primary care centres (n=33,336) and subjects with diagnosed type 2 diabetes in primary and hospital care (n=6088) in Umeå during 1989-2001. SUBJECTS: Each of the 164 subjects who developed clinically diagnosed type 2 diabetes (median time to diagnosis of 5.4 years) and 304 sex- and age-matched referents without diabetes diagnosis. RESULTS: Screening models with at least one criterion present had sensitivities of 0.90-0.96, specificities of 0.43-0.57 and PPVs of 8-9%. Combinations of the criteria, FPG>or=6.1 mmol L-1 (capillary plasma), HbA1c>or=4.7% and BMI>or=27 in men and BMI>or=30 in women, had sensitivities, specificities and PPVs of 0.66%, 0.93% and 32%, and 0.52%, 0.97% and 46% respectively. Using FHD as one of three risk criteria showed comparable results. Addition of triglycerides or OGTT did not improve the prediction. CONCLUSIONS: The combination of HbA1c, FPG and BMI are effective in screening for individuals at risk of future clinical diagnosis of type 2 diabetes. OGTT or FHD is not necessary.

Keyword
Adult, Biological Markers/blood, Blood Glucose/*analysis, Body Mass Index, Case-Control Studies, Diabetes Mellitus; Type 2/*blood/diagnosis, Fasting/blood, Female, Glucose Tolerance Test, Health Surveys, Hemoglobin A; Glycosylated/*analysis, Humans, Logistic Models, Male, Middle Aged, Risk Assessment/methods, Sensitivity and Specificity, Sweden, Unnecessary Procedures
National Category
Environmental Health and Occupational Health
Identifiers
urn:nbn:se:umu:diva-14580 (URN)10.1111/j.1365-2796.2006.01689.x (DOI)16918824 (PubMedID)
Available from: 2008-06-25 Created: 2008-06-25 Last updated: 2015-04-29Bibliographically approved
2. Components of metabolic syndrome predicting diabetes: no role of inflammation or dyslipidemia.
Open this publication in new window or tab >>Components of metabolic syndrome predicting diabetes: no role of inflammation or dyslipidemia.
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2007 (English)In: Obesity (Silver Spring), ISSN 1930-7381, Vol. 15, no 7, 1875-1885 p.Article in journal (Refereed) Published
National Category
Environmental Health and Occupational Health
Identifiers
urn:nbn:se:umu:diva-16214 (URN)10.1038/oby.2007.222 (DOI)17636107 (PubMedID)
Available from: 2007-11-30 Created: 2007-11-30 Last updated: 2015-04-29Bibliographically approved
3. Work stress and low emotional support is associated with increased risk of future type 2 diabetes in women
Open this publication in new window or tab >>Work stress and low emotional support is associated with increased risk of future type 2 diabetes in women
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2007 (English)In: Diabetes Research and Clinical Practice, ISSN 0168-8227, E-ISSN 1872-8227, Vol. 76, no 3, 368-377 p.Article in journal (Refereed) Published
Abstract [en]

A case-referent study nested within a population-based health survey investigated the associations between psychosocial stress, such as work stress and low emotional support, and future development of type 2 diabetes among occupationally working middle-aged men and women. All participants in a health survey conducted during 1989-2000 (n=33,336) in Umeå in northern Sweden, were included. We identified 191 cases, who were not diabetic initially but were diagnosed with type 2 diabetes after 5.4+/-2.6 years. Two age- and sex-matched referents were selected for each case. Multivariate logistic regression analyses and interaction effects between variables were evaluated.

In women, passive or tense working situations were associated with future type 2 diabetes with odds ratios 3.6 (95% confidence interval 1.1-11.7) and 3.6 (1.0-13.3), respectively, and also low emotional support 3.0 (1.3-7.0). These associations were not seen in men. In women, they remained after adjustment for BMI, civil status and educational level, and there were also tendencies for interactions between work stress and low emotional support.

In conclusion, work stress and low emotional support may increase the risk of type 2 diabetes in women, but not in men. These findings contribute to our understanding of psychosocial stress as potential risk factors for type 2 diabetes in a Swedish population.

National Category
Family Medicine
Identifiers
urn:nbn:se:umu:diva-14584 (URN)10.1016/j.diabres.2006.09.002 (DOI)17034894 (PubMedID)
Available from: 2007-09-12 Created: 2007-09-12 Last updated: 2015-04-29Bibliographically approved
4. Contribution of Swedish moist snuff to the metabolic syndrome: a wolf in sheep's clothing?
Open this publication in new window or tab >>Contribution of Swedish moist snuff to the metabolic syndrome: a wolf in sheep's clothing?
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2006 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 34, no 6, 576-583 p.Article in journal (Refereed) Published
Abstract [en]

AIM: Combined effects of genetic and environmental factors underlie the clustering of cardiovascular risk factors in the metabolic syndrome (MetSy). The aim was to investigate associations between several lifestyle factors and MetSy, with a focus on the possible role of smokeless tobacco in the form of Swedish moist snuff (snus). METHODS: A population-based longitudinal cohort study within the Västerbotten Intervention Programme in Northern Sweden. All inhabitants at the ages of 30, 40, 50, and 60 are invited to participate in a health survey that includes a questionnaire on psychosocial conditions and lifestyle and measurement of biological variables. Individuals examined in 1990-94 (n = 24,230) and who also returned for follow-up after 10 years were included (total of 16,492 individuals: 46.6% men and 53.4% women). Regression analyses were performed. MetSy was the outcome and analyses were adjusted for age, sex, alcohol abuse, and family history of CVD and diabetes. RESULTS: Ten-year development of MetSy was associated with high-dose consumption of snus at baseline (OR 1.6 [95% CI 1.26-2.15]), low education (2.2 [1.92-2.63]), physical inactivity (1.5 [1.22-1.73]) and former smoking (1.2 [1.06-1.38]). Snus was associated with separate components of MetSy, including triglycerides (1.6, 1.30-1.95), obesity (1.7 [1.36-2.18]) but not hypertension, dysglycemia and low HDL cholesterol. CONCLUSIONS: MetSy is independently associated with high consumption of snus, even when controlling for smoking status. The finding is of public health interest in societies with widespread use of snus. More research is needed to better understand the mechanisms underlying this effect.

Keyword
Adult, Cohort Studies, Female, Follow-Up Studies, Health Surveys, Humans, Life Style, Longitudinal Studies, Male, Metabolic Syndrome X/blood/complications/*etiology, Middle Aged, Prospective Studies, Questionnaires, Risk Factors, Socioeconomic Factors, Sweden/epidemiology, Tobacco; Smokeless/*adverse effects
National Category
Environmental Health and Occupational Health
Identifiers
urn:nbn:se:umu:diva-14583 (URN)10.1080/14034940600665143 (DOI)17132590 (PubMedID)
Available from: 2007-08-28 Created: 2007-08-28 Last updated: 2015-04-29Bibliographically approved

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