Community Diabetes At High Risk Of Abnormal Glucose Metabolism And Associated Complications Of Screening And Risk Factors Analysis

PartⅠOutcomes of Screening for Abnormality of Glucose Metabolism,Insulin Resistance andβ-Cell Function Assessment,Metabolic Syndrome Prevalence in Subjects with High-risk for Diabetes in CommunityObjective:1.To investigate the abnormality of glucose metabolism in subjects with high-risk for diabetes in community,analysis the risk facotors for diabetes in them and to explore the strategy of diabete screening in subjects with high-risk for diabetes in community2.To assess the insulin resistance and isletβ-cell function of subjects with high-risk for diabetes in community and explore their correlative factors.3.To investigate the prevence of metablic syndrome(MS) in subjects with high-risk for diabetes in community and explore the optimal waist circumference(WC) cutoff point for identifying MS in middle and older subjects in community.Methods:It is a cross section study.From May 2005 to April 2007,1645 subjects age 40～80 years without diabetes history was recruited by a simple criterion from Changfeng community. Data of demological information,medical and family history was collected by questionnaire. Data of anthropometric parameters,blood pressure,fasting blood glucose,oral glucose tolerance test(OGTT) and lipid profiles were collected by physical examination and biochemical tests to confirm whether they have risk factors or not.Diabetes(DM),impaired glucose tolorence(IGT) and inpaired fasting glucose(IFG) were defined by criteria of America Diabetes Association 2003.IGT and IFG were called impaire glucose regulation (IGR),DM and IGR were called abnormaliy of glucose metabolism.Classification Tree Method was used to analyse the stratige of the screening for diabetes.Homeostasis model assessment(HOMA) was applied to assess the statusofβ-cell function(HOMA-β) and insulin resistance(HOMA-IR).Metabolic syndrome was defined by criteria of International Diabetes Federal(IDF).Multvariate Logistic regression model was applied to analysis the risk fators for diabete,insulin resistance &β-cell function decrease.The ROC curve was applied explore the optimal waist circumstance cutoff point for MS.Results:1.1654 screened subjuects were divided into high-risk group(n=1389,M/F:492/897) and non-risk group(n=256,M/F:70/186) according to whether thery met the criteria of risk for diabtes,the consistent rate was 84.4%.The prevalence of new diagnosed diabetes(NDM), IGR,isolated impaired glucose tolerance(I-IGT),isolated impaired fasting glucose(I-IFG) and combinded IGT and IFG(IGT/IFG) were higher in high-risk group than non-risk group (11.5%vs.2.0%,34.6%vs.14.1%,10.7%vs.3.1%,14.1%vs.9.0%,9.7%vs.2.0%, P＜0.001).Age increase,positive family history of diabetes,overweight & obesity and dyslipdemia were the main risk factors for diabete in the high-risk group.The diabetes creening strategy analysis showed that the dabetes as the screening target,age entered the Classification Tree first,the root node was separated into three child nodes(age≤55years,55～70 years,≥70 years).When the age was≤55 years,overweight and obesity entered the Tree first;when the age was 55～70 years,the diabetic family history entered the Tree first;when the age was≥70 years,dyslipdemia entered the Tree first;if without dyslipdemia,the gender(female) entered the Tree first.Of the high-risk group,the prevelance of NDM was highest in the subjects aged over 70 years with dyslipdemia (25.2%),the prevelance of NDM in subjects with age 55-70 years and family history of diabetes was 18.2%,subjects aged over 70 years was 17.2%,subjects with age 40-55 years and overweight & obesity was 7.5%.2.HOMA-IR was higher in high-risk group than non-risk group(1.22 vs.0.91P＜0.001), there was no significant difference of HOMA-βbetween high-risk and non-risk groups (4.96 vs.4.92,P＞0.05).In high-risk group,HOMA-IR increased from NGT,IGR to NDM (1.11 vs.1.28 vs.1.58,P＜0.001),while HOMA-βdecreased(5.14 vs.4.84 vs.4.50, P＜0.001).Both HOMA-IR and HOMA-βwere higher in NGT of high-risk group than NGT in non-risk group(1.11 vs.0.85;5.14 vs.14.97,P＜0.001).HOMA-IR(P＜0.001),but not HOMA-β(P＞0.05),increased with the increase of risk factors in high-risk group.For high-risk goup,both HOMA-IR and HOMA-βwere lower in males than in females(1.09 vs. 1.30;4.80 vs.5.05,P＜0.001).In high-risk group,female,overweith & obesity, hypertension and dyslipdemia were independent risk factor for insulin resistance;male and positive family histories were independent risk factor forβ-cell function decrease.3.The prevelance MS was 39.1%in high-risk group according to the criteria of IDF,the prevelance of males was lower than that of females(32.1%vs.42.9%,P＜0.001).According to ROC curve,the shortest distance of ROC curve for wasit circumstance to identify 2 or more MS components was 85.0cm for males and 80.0cm for female.Their sensitivity and speciality were 72%and 50%,76%and 59%,respectively.Base on this waist circumstance cutoff point,the rest criteria were the same as IDF,the prevelance of MS in high-risk group was 43.8%,male 45.5%and female 42.9%.There was no significant difference of the MS prevelance between males and females(P＞0.05).Conclusions:1.The prevelacne of abnormality of glucose metabolim was higher in the subjects with high-risk factors for diabetes in community.The main risk factors for diabetes in high-risk group were age increase,positive family history,overweight & obesity and dyslipdemia. Screening for diabetes in high-risk group was suggested to be focused on the people as follow:age 40-55 with overweight & obesity,age 55-70 with positive family history,age 70-80 with dyslipdemia or females.2.Compared with non-risk group,insulin resistance was severe and isletβ-cell function is decreased in the people with abnormal glucose metabolism,insletβ-cell function is compensately increased in the people with NGT in high-risk group.In high-risk group insulin resistance increased with the increase of risk factors,from NGT,IGR to NDM insulin resistace increased gradually,whileβ-cell function decreased..In high-risk group, female,overweith & obesity,hypertension and dyslipdemia were independent risk factor for insulin resistance;male and positive family histories were independent risk factor forβ-cell function decrease.4.People with high-risk factors for diabetes were also subjects with high-risk for MS.The optimal wasit circumstance cutoff point for MS in middle and older subjects in community was 85cm for males and 80cm for females. PartⅡThe Complications Screening in Subjects with high-ris for Diabete in the communityObjective:1.To evaluate the clinical application of urinary albumin-creatinine ratio(ACR) in subjects with high-risk factors for diabetes in community albuminuria screening by random spot and first morning urine.To investigate the prevalence of albuminuria in subjets with high-risk for diabetes in community and its correlative risk factors,analysis its relationship with insulin resistance.2.To investigate the prevelace of diabetic retinopathy in the subjets with high-risk for diabetes in community.To explore the relationship with the retinal vessel diameters and albuminuria.3.To investigate the prevalences of ECG findings and macrovascular disease in the subjets with high-risk for diabetes in community.Methods:1.443 subjects(M/F:234/209) with average age of 8.5±8.1 years were recruited in a screening for subjects with high-risk for diabetes in community.The random spot and first morning urine were collected on the same day,tow first morning urine were collected after that with at least two weeks interval.ACR was assessed.Two or more times of urinary ACR≥30mg/g in the three first morning urine was used as the "golden diagnostic standard" of albuminuria.2.The random spot urine was collected on the day of creening and urine ACR was assessed.Albuminuria was defined as urine ACR≥40(mg/g).The estimated glomerular filtration rate(eGFR) was caculated by MDRD formula.Multvariate Logistic regression model was applied to analysis the risk fators for albuminuria.Homeostasis model assessment(HOMA) was applied to assess the status of insulin resistance(HOMA-IR). Logistic regression applied to analysis the relationship with HOMA-IR and albuminuria.3.Retinal photographs were taken for subjects screened.Computer-assisted grading was used to determine the average caliber of retinal arterioles(central retinal arteriolar equivalent[CRAE]) and retinal venules(central retinal venular equivalent[CRVE]),the ratio of CRAE/CRVE(AVR) was caculated.Logistic regression applied to analysis the relationship with CRAE,CRVE,AVR and albuminuria. 4.A standard 12 leads electrocardiograph(ECG) was taken in the supine position for subjects screened.All ECGs were coded on the basis of the Minnesota coding criteria.The macrovascular diseases was defined as history of coronary heart disease,stroke or had ischaemic ECG.Results:1.443 subjects with average age of 58.5±8.1.The prevalence of albuminuria was 6.3% (28/443) according to the "golden diagnostic standard".The urinary ACR of random spot urine was higher than that of first morning urine(7.1 mg/g vs.3.2mg/g,P＜0.001).The positive rate of albuminuria screened by random spot urine was higher than that in first morning urine(14.9%vs.5.9%,P＜0.05).There was no significant difference between the random spot and first morning urine in the sensitivity and positive predict value(PPV) for the detection of albuminuria(96.4%vs.92.9%;99.73%vs.99.5%,P＞0.05).The specialty and negative predict value(NPV) of random spot urine was lower than those of first morning urine(90.6%vs.100.0%;40.9%vs.100.0%,P＜0.05).The optimal cutoff point of random urine to screening albuminuria was 40mg/g according to ROC,with sensitivity 96.4%and specialty 95.2%,PPV 57.45%and NPV 99.75%.The subjects with negative albuminuria of first morning urine but positive albuminuria of random spot urine had more cardiovascular disease and chronic kidney disease risk factors than those with negative albuminuria of both first morning urine and random spot urine.2.Albuminuria was defined as urine ACR≥40(mg/g) in a random spot urine.The prevelance of albuminuria was higher in high-risk group than in non-risk group(18.1%vs. 5.2%,P＜0.001).The prevelance of albuminuria was higher in females than in males(22.2% vs.10.7%,P＜0.001).The prevelance of albuminuria was increased with the decrease of eGFR(P＜0.05).In high-risk group,age increase,female,hypertension,abnormality of glucose metabolim,overweith & obesity,and decrease renal function were independent risk factor for albuminuria.After adjusted for age,sex,hypertension,abnormality of glucose metabolim,overweith & obesity,and decrease renal function,HOMA-IR was associated with albuminuria(odds ratio[OR],fourth vs.first quartiles,1.78;95%CI,1.1-2.9;P＜0.05). In female the OR was 2.1(95%CI,1.1-3.9;P＜0.05);in male the OR was 1.2(95%CI, 0.5-2.9;P＞0.05).3.The prevelance of DR was 6.5%in high-risk group and 5.5%in non-risk group,there was no significant difference between two group(P=0.838).Hbalc and sysdolic blood pressure were indepent risk factors for DR in high-risk group.There was no significant difference of average CRAE,CRVE and AVR between high-risk group and non-risk group (137.5±16.4μm vs.139.7±16.5μm;207.9±24.1μm vs.208.9±23.0μm;0.67±0.09 vs. 0.67±0.07,P＞0.05).4.After adjusted for age,sex,hypertension,abnormality of glucose metabolim,overweith & obesity,and decrease renal function,CRAE was not associated with albuminuria(OR, first vs.fourth quartiles,0.8;95%CI,0.4-1.5;P＞0.05);CRVE was not associated with albuminuria(OR,fourth vs.first quartiles,1.7;95%CI,0.8-3.5;P＞0.05);AVR was associated with albuminuria(OR,first vs.fourth quartiles,2.8;95%CI,1.3-6.3;P＜0.05). There was no significant relationship between CRAE,CRVE and AVR with albuminuria in male(P＞0.05);in females CRAE was not associated with albuminuria(OR,first vs.fourth quartiles,1.00;95%CI,0.42-2.42;P＞0.05),CRVE and AVR were associated with albuminuria(OR,fourth vs.first quartiles,2.4;95%CI,1.0-5.5;P＞0.05;OR,first vs.fourth quartiles 4.9;95%CI,1.9-12.9);P＜0.01).5.There were no significant difference of prevelance of major or minor ECGabnormalities and ischaemic ECG between high-risk and non-risk groups(11.3%vs.8.7%; 12.1%vs.11.4%;11.6%vs.10.6%,P＞0.05).In high-risk group,the prevelace minor ECG abnormalities and myocardic infarction ECG abnormalities were higher in males than those in females(14.9%vs.10.6;1.4%vs.0.3%,P＜0.05).The prevelance of macrovascular diseases was 20.5%in high-risk group.Conclusions:1.The urine ACR 40(mg/g) is suggested as an optimal cutoff point for random spot urine for albuminuria screening.The subjects with negative albuminuria of first morning urine but positive albuminuria of random spot urine had more cardiovascular disease and chronic kidney disease risk factors than those with negative albuminuria of both first morning urine and random spot urine.2.In high-risk group,the prevelance of albuminuria was high;age increase,female, hypertension,abnormality of glucose metabolim,overweith & obesity,and decrease renal function were independent risk factor for albuminuria.After adjusted for age,sex, hypertension,abnormality of glucose metabolim,overweith & obesity,and decrease renal function,insulin resistance was positively associated with albuminuria;the relationship was significant only in females.3.In high-risk group,the prevelance of DR in NDM was 12.9%.Hbalc and sysdolic blood pressure were indepent risk factors for DR in high-risk group.The prevelace of albuminuria was increased with the AVR decrease in high-risk group,in females the relationship between albuminuria and AVR was caused by venular dilatation rather than arteriolar narrowing.4.The prevelance of all ECG abnormalities were slightly higher in high-risk group than non-risk group,but not had statistic significance.The prevelance of minor ECG abnormalities and myocardic infarction ECG abnormalities were higher in males than those in females in high-risk group.The prevelance of macrovascular diseases was 20.5%in high-risk group.