| Objective1.To explore the relationship between Atherogenic index of plasma(AIP)and insulin resistance(IR),type 2 diabetes mellitus(T2DM)and its risk markers(fasting blood glucose,glycosylated hemoglobin,fasting insulin and insulin resistance index),so as to provide scientific basis for further research and application of AIP in IR and T2DM.2.Combined with AIP and other clinical indicators,a Nomogram predictive model of poor blood glucose control in overweight/obesity T2DM was constructed to provide clinical basis for blood glucose management of overweight/obese patients with T2DM,and it is helpful to take targeted intervention measures to control blood glucose.3.To explore the distribution characteristics of traditional Chinese medicine(TCM)syndromes of poor blood glucose control in overweight/obesity T2DM and its correlation with AIP and other clinical indexes,so as to provide syndrome support for the treatment of overweight/obesity T2DM with TCM.4.To systematically evaluate the role of clearing heat and removing dampness therapy of TCM in blood glucose control of overweight/obese T2DM.The effectiveness and safety of the prescription for Qingre Huashi Yunpi Formula based on the method of clearing heat and removing dampness were verified by real-world research.At the same time,the pharmacodynamic material basis and regulation mechanism of Qingre Huashi Yunpi Formula were predicted by network pharmacology and bioinformatics.The purpose of this study is to provide reference for the clinical practice and efficacy research of TCM in the intervention of overweight/obesity T2DM.Methods1.Study 1:the relationship between new lipid markers and insulin resistance and type 2 diabetes:a cross-sectional study.This part of the study adopts the method of cross-sectional study.The subjects were public data from five NHANES cycles(2009-2018).Weighted samples were used to analyze the relationship between AIP and T2DM risk markers by weighted multi-factor linear regression model.At the same time,the weighted multi-factor logistic regression model was used to analyze the relationship between AIP,T2DM and IR.Furthermore,the generalized additive model and smooth curve fitting are used to evaluate the nonlinear relationship between AIP,T2DM and IR.Analysis of threshold effect and saturation effect by using Two-part logistic regression model.2.Study 2:Nomogram prediction model of poor blood glucose control in overweight/obese T2DM based on new lipid markers and study on the characteristics of TCM Syndromes.This part of the study adopts the method of case series analysis.The subjects were overweight/obese patients with T2DM who were admitted to the Department of Endocrinology in four districts of Guangdong Hospital of traditional Chinese Medicine from January 2018 to December 2021.Linear trend test was used to analyze the relationship between AIP quartile and poor glycaemic control.Then Lasso regression analysis and multi-factor Logistic regression analysis was used to screen the risk factors.And construct the Nomogram risk assessment model of poor glycaemic control in overweight/obese T2DM.Finally,the performance and verification of the model are evaluated comprehensively from the degree of differentiation,calibration,decision curve analysis and Bootstrap self-sampling method.At the same time,the distribution of TCM syndromes in overweight/obese T2DM patients with poor glycaemic control was analyzed,and the relationship between TCM syndromes and AIP and other clinical indexes was explored.3.Study 3:Meta-analysis of clearing heat and removing dampness therapy of TCM on blood glucose control in overweight/obesity type 2 diabetes mellitus.This part of the study adopts systematic evaluation method.Computer retrieval of PubMed,Embase,SinoMed,CNKI,CQVIP,and Wanfang Database from the establishment of the database to March 11.2023 on randomized controlled trials of conventional Western medicine treatment combined with heat-clearing and dampness-clearing therapy of TCM for the treatment of overweight/obese T2DM.Then,the Cochrane bias risk assessment tool was used to evaluate the quality of the included literature.Finally,Stata and Revman software are used for statistical analysis,and GRADE tool is used to evaluate the quality of the evidence.4.Study 4:a real-world study on the efficacy of Qingre Huashi Yunpi Formula in the treatment of overweight/obesity T2DM based on propensity score.This part of the study adopts the prospective cohort study method of real-world study.The subjects were overweight/obese patients with type 2 diabetes who were treated in the Department of Endocrinology in four districts of Guangdong Hospital of traditional Chinese Medicine from May 2022 to February 2023.According to the exposure factors(whether to use Qingre Huashi Yunpi Formula),the subjects were naturally divided into two groups:integrated traditional Chinese and western medicine(ITCWM)group VS Western medicine(WM)group.The WM group was treated with conventional Western medicine,and the ITCWM group was treated with Qingre Huashi Yunpi Formula combined with conventional Western medicine treatment.The total course of treatment was 12 weeks.Using the propensity score matching method(PSM)to control and deal with the differences of baseline data and potential confounding factors between the two groups.To evaluate the effect of ITCWM treatment on glycosylated hemoglobin,obesity related index,glucose and lipid metabolism index,new lipid factor and inflammatory factor in the treatment of overweight/obesity T2DM.5.Study 5:study on the mechanism of Qingre Huashi Yunpi Formula in the treatment of type 2 diabetes based on network pharmacology and bioinformatics.This part of the study adopts the research methods of network pharmacology and bioinformatics.The active components and corresponding targets of Qingre Huashi Yunpi Formula were screened by searching TCMSP database.The action targets of type 2 diabetes were collected by Genecard,OMIM,TTD and Drugbank databases,and the drug-disease common targets were screened.Then,analyze and build the PPI network,and analyze the topology of PPI network and screen out the core targets.Then,GO function annotation analysis and KEGG path analysis are carried out.Finally,the core targets are verified by GEO database and attie laboratory diabetes database,and molecular docking was carried out to verify the binding ability of active compounds with core targets.Results1.Study 1:A total of 49,694 participants were screened and finally 9,245 participants were included for data analysis.(1)The results of weighted multi-factor linear regression model showed that in the fully adjusted model,the total population AIP was positively correlated with FBG(β=0.85.95%CI:0.66,1.05),HbA1c(β=0.48,95%CI:0.39.0.58),FS1(β=47.74,95%CI:41.42,54.07)and HOMA-IR(β=2.39,95%CI:1.97,2.82).The conversion of AIP from continuous variables to classified variables(grouped in quartiles)is still positively correlated.After excluding 1858 patients with diabetes mellitus,positive correlation was still observed by sensitivity analysis.(2)The results of weighted multivariate logistic regression model showed that there was a significant positive correlation between AIP and T2DM(OR=7.1 8,95%CI:5.21.9.91)and IR(OR=15.80,95%CI:11.44,21.80)in the fully adjusted model.The conversion of AIP from continuous variables to classified variables(grouped in quartiles)is still positively correlated.The results of subgroup analysis showed that the effect of AIP on the risk of T2DM and IR was stable in the sub-analysis(P<0.05).However,in the gender subgroup,there was a significant interaction(T2DM:P=0.0024;IR:P=0.0135).Female participants(OR=10.94)had a stronger association with AIP and T2DM risk than male participants(OR=4.78).Female participants(OR=17.03)had a stronger association with AIP and IR risk than male participants(OR=9.39).However,significant interactions were observed in subgroup analysis stratified by smoking(P=0.0130).Non-smoking participants(OR=17.98)had a stronger association with the risk of AIP and IR than those who smoked in the past(OR=8.27)and current smoking(OR=7.54).(3)The generalized additive model and smooth curve fitting reveal the nonlinear relationship between AIP,T2DM and IR.The inflection point of AIP calculated by Two-part logistic regression model is-0.47.There is a positive correlation between AIP and T2DM when AIP>-0.47.The inflection point of AIP calculated by Two-part logistic regression model is 0.45.There was a positive correlation between AIP and IR when AIP<0.45.2.Study 2:A total of 1061 overweight/obese T2DM patients were included in this study.Among them,there were 279 patients(26.30%)with blood glucose control and 782 patients(73.70%)with poor glycaemic control.The results of linear trend test showed that with the increase of HbAlc quartile,the proportion of poor glycaemic control(HbA1c≥7%)increased,which were 62.55%,73.03%,74.61%and 83.87%,respectively.The results of Lasso regression analysis and multivariate Logistic regression analysis showed that the course of diabetes≥10 years,use more than 2 kinds of oral hypoglycemic drugs,FBG,FCP,LDL-C,AIP,ALT and WBC were Independent influencing factors for poor glycaemic control in overweight/obese T2DM patients.The model equation for risk assessment of poor glycaemic control in overweight/obese T2DM patients is P=-4.74+0.53*the course of diabetes≥10 years-0.44*use more than 2 kinds of oral hypoglycemic drugs+0.55*FBG-2.93*FCP+0.33*LDL-C+0.02*ALT+0.19*WBC+1.48*AIP.After visualization,the Nomogram model is obtained.The AUC value of this prediction model is 0.872(95%CI:0.849-0.895),the best truncation value is 0.710,the specificity is 0.802,and the sensitivity is 0.814.The Bootstrap method is used for internal verification,and the AUC value of the corrected model is 0.865(95%CI:0.838-0.891).The calibration evaluation shows that the C-index value is 0.867.DCA results show that this model is more effective in predicting the risk of poor glycaemic control when the threshold probability is 20%-98%.There was significant difference in the distribution of TCM syndrome types between overweight/obese T2DM patients with qualified blood glucose control and patients with poor blood glucose control.The order of TCM syndrome types of 782 overweight/obese T2DM patients with poor glycaemic control was as follows:damp-heat trapping spleen syndrome(39.90%)>qi-yin deficiency syndrome(28.77%)>spleen deficiency phlegm-dampness syndrome(13.81%)>heat-excess injury syndrome(11.64%)>yin-yang deficiency syndrome(5.88%).The relationship between TCM syndrome types and clinical data showed that there were significant differences in gender,smoking history,drinking history,diet control,regular exercise and PAS distribution among different TCM syndrome types(P<0.05).The levels of BMI,FBG,HbA1c,HDL-C,ALB,Cr,WBC,NC,MC,AIP and FAR were significantly different among different TCM syndrome types(P<0.05).Among them,the BMI level of damp-heat trapped spleen syndrome,spleen deficiency phlegm-dampness syndrome and yin-yang deficiency syndrome was significantly higher than that of qi-yin deficiency syndrome.The BMI level of damp-heat trapped spleen syndrome and yin-yang deficiency syndrome was significantly higher than that of heat-excess injury syndrome.The FBG level of damp-heat trapped spleen syndrome and spleen deficiency phlegm-dampness syndrome was significantly higher than that of qi-yin deficiency syndrome.The level of HbAlc in the heat-excess injury syndrome and damp-heat trapped spleen syndrome was significantly higher than that of yin-yang deficiency syndrome.The HDL-C level of damp-heat trapped spleen syndrome was significantly lower than that of qi-yin deficiency syndrome.The ALB level of damp-heat trapped spleen syndrome and yin-yang deficiency syndrome was significantly lower than that of qi-yin deficiency syndrome.The Cr level of damp-heat trapped spleen syndrome was significantly higher than that of qi-yin deficiency syndrome and spleen deficiency phlegm-dampness syndrome.The NC level of damp-heat trapped spleen syndrome and spleen deficiency phlegm-dampness syndrome was significantly higher than that of heat-excess injury syndrome.The level of MC in the heat-excess injury syndrome was significantly lower than that of damp-heat trapped spleen syndrome,spleen deficiency phlegm-dampness syndrome,and yin-yang deficiency syndrome.The AIP level of damp-heat trapped spleen syndrome was significantly higher than that of qi-yin deficiency syndrome.3.Study 3:A total of 1511 patients were included in 20 studies.The improvement effect of clearing heat and removing dampness therapy of TCM combined with conventional Western medicine treatment on HbAlc[WMD=-0.55,95%CI(-0.70,-0.40),P<0.05],FBG[WMD=-0.74,95%CI(-0.90,-0,57),P<0.05],HOMA-IR[WMD=-0.61,95%CI(-0.87,-0.35),P<0.05],BMI[WMD=-0.95,95%CI(-1.15,-0.75),P<0.05],WHR[WMD=-0.02,95%CI(-0.03,0.01),P<0.05],TC[WMD=-0.48,95%CI(-0.83,-0.13),P<0.05],TG[WMD=-0.38,95%CI(-0.50,-0.26),P<0.05],LDL-C[WMD=-0.30,95%CI(-0.49,一0.10),P<0.05],HDL-C[WMD=-0.12,95%CI(-0.05,-0.19),P<0.05],IL-6[WMD=-1.54,95%CI(-2.44,-0.65),P<0.05]and TNF-α[WMD=-5.21,95%CI(6.67,-3.75),P<0.05]in patients with overweight or obese T2DM was better than that of conventional Western medicine treatment.And there was no statistically significant difference in the incidence of adverse reactions between the two groups.The results of the subgroup analysis showed that duration of treatment,class of hypoglycemic western medicine and risk of sequence generation may be the source of heterogeneity.The quality of the studies was generally low according to GRADE evidence.4.Study 4:A total of 111 subjects were included in this part of the study,including 39 cases in the ITCWM group and 72 cases in the WM group.A total of 7 cases fell off in the course of the study,with a drop rate of 6.31%.The results of PSM matching showed that 37 pairs were matched successfully by PSM 1:1 calipers.After matching,age,sex,course of diabetes,history of hypertension,history of hyperlipidemia,history of smoking,drinking,Metformin,AGI,SGLT-2i,GLP-1RA,statins lipid-lowering drugs,SBP,DBP,BMI,WC,WHR and HbA1c were balanced before treatment(P>0.05).The results of the intervention show that:(1)Main curative effect indicators:the level of HbAlc in ITCWM group and WM group after treatment were lower than those before treatment(P<0.001).Compared between the two groups,the improvement of HbAlc in the ITCWM group was better than that in the WM group(P=0.002).(2)Secondary curative effect indicators:After treatment,FBG,HOMA-IR,BMI,WC,HC,WHR,TC,AIP,hs-CRP,IL-6.TNF-α and total score of TCM syndrome in ITCWM group decreased(P<0.05),FBG,HOMA-IR,BMI,WC,HC,WHR,TC,TNF-α and total score of TCM syndrome decreased after treatment in WM group(P<0.05).Compared between the two groups,the improvement of FBG,HOMA-IR,BMI,WC,HC,WHR,AIP,hs-CRP,TNF-α and TCM syndrome score before and after treatment in the ITCWM group was better than that in the WM group(P<0.05).After treatment,the total effective rate of the ITCWM group was 94.6%,and that of the WM group was 81.1%.The comprehensive curative effect of the ITCWM group was more obvious than that of the WM group(P=0.010).In terms of safety indexes(ALT,AST,BUN.Cr),there was no significant difference between the two groups before and after treatment.5.Study 5:It is predicted that Qingre Huashi Yunpi Formula mainly acts on the core targets of MYC,AKT1,CDKN1A,EGFR,FOS,HIF1A,JUN,MAPK1,RB1,TP53 through active components such as quercetin,baicalein,β-sitosterol,formononetin,kaempferol,luteolin,naringenin,wogonin,licochalcone a,etc,interfering with lipid and atherosclerosis,AGE-RAGE,fluid shear stress and atherosclerosis,IL-17,TNF,Th17,PI3K-Akt,apoptosis and tumor related pathways(p53,chemical carcinogenesis-receptor activation,prostate cancer,bladder cancer,etc),which involves the response of cells to different stimuli,such as exogenous stimulation,oxidative stress,reactive oxygen species,nutritional level and so on.Through the analysis of differential gene expression in GSE29231 dataset,it was verified that core genes CDKN1A,FOS,JUN,TP53,RB1,STAT3,MAPK1,AKT1.EGFR,MYC and HIF1A were highly expressed in visceral fat samples of T2DM female patients,which were significantly higher than those of non-diabetic visceral tissue samples(adj.p<0.05).Compared with lean mice,the expressions of core targets RB1,MAPK3,MAPK1,MAPK14,AKT1 and HIF1A were significantly up-regulated in adipose tissue of obese diabetic mice in attie laboratory diabetes database(P<0.05).The results of molecular docking showed that the main active components had good binding effect with the above core targets.Conclusion1.There is a positive correlation between AIP and T2DM risk markers(FBG、HbA1c、FSI and HOMA-IR).AIP is associated with an increased risk of IR and T2DM,and this association is more pronounced among female participants..2.The course of diabetes≥10 years,use less than 2 kinds of oral hypoglycemic drugs,FBG,FCP,LDL-C,AIP,ALT and WBC are independent risk factors for poor glycaemic control in overweight/obese type 2 diabetes patients.The Nomogram prediction model based on the above risk factors can better predict the risk probability of blood glucose control in overweight/obese type 2 diabetes patients in the next 2 to 3 months.3.There are differences in the distribution of TCM syndrome types between overweight/obese type 2 diabetes patients with blood glucose control and patients with poor blood glucose control,suggesting that blood glucose control may be affected by TCM syndromes.The most common TCM syndrome in patients with overweight/obesity T2DM with poor glycaemic control is damp-heat trapped spleen syndrome.The damp-heat trapped spleen syndrome is associated with higher levels of BMI,HbAlc and AIP.4.The method of clearing heat and resolving dampness has certain advantages in improving blood glucose and weight control,lipid regulation and anti-inflammation in overweight/obese patients with type 2 diabetes,which is worth popularizing on the basis of clinical syndrome differentiation and treatment.5.For the overweight/obese type 2 diabetic patients with damp-heat trapped spleen syndrome with poor blood glucose control,the effect of using Qingre Huashi Yunpi Formula combined with conventional Western medicine in intervening blood glucose control and correcting obesity is better than that of western medicine alone.it can improve insulin resistance and clinical symptoms,and the safety is good,and its possible mechanism is related to the regulation of inflammatory factors and lipid metabolism.6.Qingre Huashi Yunpi Formula may act on the core targets such as JUN,AKTl,FOS,MAPK1,TP53 and CDKN1A through active components such as quercetin,baicalein,β-sitosterol,formononetin and kaempferol,and regulate lipid and atherosclerosis,PI3K-Akt and other signal pathways,participate in the regulation of inflammatory response and lipid metabolism to improve insulin resistance is one of its possible mechanisms. |
