Associations of comorbid depression with cardiovascular-renal events and all-cause mortality accounting for patient reported outcomes in individuals with type 2 diabetes: a 6-year prospective analysis of the Hong Kong Diabetes Register.

Background: Psychosocial status and patient reported outcomes (PRO) [depression and health-related quality-of-life (HRQoL)] are major health determinants. We investigated the association between depression and clinical outcomes in Chinese patients with type 2 diabetes (T2D), adjusted for PRO. Methods: Using prospective data from Hong Kong Diabetes Register (2013-2019), we estimated the hazard-ratio (HR, 95%CI) of depression (validated Patient Health Questionnaire 9 (PHQ-9) score≥7) with incident cardiovascular disease (CVD), ischemic heart disease (IHD), chronic kidney disease (CKD: eGFR<60 ml/min/1.73m2) and all-cause mortality in 4525 Chinese patients with T2D adjusted for patient characteristics, renal function, medications, self-care and HRQoL domains (mobility, self-care, usual activities, pain/discomfort, anxiety/depression measured by EQ-5D-3L) in linear-regression models. Results: In this cohort without prior events [mean ± SD age:55.7 ± 10.6, 43.7% women, median (IQR) disease duration of 7.0 (2.0-13.0) years, HbA1c, 7.2% (6.6%-8.20%), 26.4% insulin-treated], 537(11.9%) patients had depressive symptoms and 1923 (42.5%) patients had some problems with HRQoL at baseline. After 5.6(IQR: 4.4-6.2) years, 141 patients (3.1%) died, 533(11.8%) developed CKD and 164(3.6%) developed CVD. In a fully-adjusted model (model 4) including self-care and HRQoL, the aHR of depression was 1.99 (95% confidence interval CI):1.25-3.18) for CVD, 2.29 (1.25-4.21) for IHD. Depression was associated with all-cause mortality in models 1-3 adjusted for demographics, clinical characteristics and self-care, but was attenuated after adjusting for HRQoL (model 4- 1.54; 95%CI: 0.91-2.60), though HR still indicated same direction with important magnitude. Patients who reported having regular exercise (3-4 times per week) had reduced aHR of CKD [0.61 (0.41-0.89)]. Item 4 of PHQ-9 (feeling tired, little energy) was independently associated with all-cause mortality with aHR of 1.66 (1.30-2.12). Conclusion: Depression exhibits significant association with CVD, IHD, and all-cause mortality in patients with diabetes, adjusting for their HRQoL and health behaviors. Despite the association between depression and all-cause mortality attenuated after adjusting for HRQoL, the effect size remains substantial. The feeling of tiredness or having little energy, as assessed by item Q4 of the PHQ-9 questionnaire, was found to be significantly associated with an increased risk of all-cause mortality after covariate adjustments. Our findings emphasize the importance of incorporating psychiatric evaluations into holistic diabetes management.

Association between dietary supplement use and mortality among US adults with diabetes: a longitudinal cohort study.

BACKGROUND: Despite the popularity of dietary supplements, their effectiveness and safety in patients with diabetes remain controversial. Furthermore, evidence from clinical trials may not be generalizable to real-world settings. This study examined the association between dietary supplement use and mortality outcomes among patients with diabetes based on a nationally representative sample of US adults. METHODS: This study analyzed data from National Health and Nutrition Examination Survey (NHANES) 1999-2018. Supplement users referred to adults with diabetes who reported the use of any dietary supplements in the last 30 days, and with a cumulative duration of ≥ 90 days. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the associations between supplement use and all-cause mortality, and mortality from cardiovascular diseases (CVD), diabetes, and cancer. Subgroup analysis of different supplement classes (vitamins, minerals, botanicals, amino acids, fatty acids, probiotics and glucosamine) were also conducted. RESULTS: We included 8,122 adults with diabetes (mean age: 59.4 years; 48.7% female), of whom 3,997 (54.0%) reported using supplements regularly. Vitamins (87.3%), minerals (75.3%) and botanicals (51.8%) were the most popular supplements. At a median follow-up of 6.9 years, 2447 all-cause deaths had occurred. Overall supplement use was not associated with risk of all-cause mortality among patients with diabetes (HR = 0.97, 95% CI: 0.87 to 1.08, P = 0.56). Subgroup analyses suggested that amino acid use was associated with a lower all-cause mortality (HR = 0.66, 95% CI: 0.46 to 0.96, P = 0.028), while the use of fatty acids (HR = 0.62, 95% CI: 0.42 to 0.92, P = 0.018) and glucosamine (HR = 0.69, 95% CI: 0.51 to 0.95, P = 0.022) supplements were significantly associated with lower CVD mortality. CONCLUSIONS: Our results derived from real-world data suggested that overall supplement use was not associated with any mortality benefit in patients with diabetes. However, there is preliminary evidence that suggests a protective effect of amino acid use on all-cause mortality, and a benefit of fatty acids and glucosamine supplement use on CVD mortality. Future large-scale longitudinal studies are needed to investigate the association between dietary supplement use and other intermediate diabetes-related outcomes, such as glucose control and reducing diabetes-related complications.

Pharmacomicrobiomics in Western Medicine and Traditional Chinese Medicine in Type 2 Diabetes.

Pharmacomicrobiomics refers to the interactions between foreign compounds and the gut microbiome resulting in heterogeneous efficacy, side effects, and toxicity of the compound concerned. Glucose lowering drugs reduce blood glucose by modulating insulin secretion and its actions as well as redistributing energy disposal. Apart from genetic, ecological, and lifestyle factors, maintaining an equilibrium of the whole gut microbiome has been shown to improve human health. Microbial fingerprinting using faecal samples indicated an 'invisible phenotype' due to different compositions of microbiota which might orchestrate the interactions between patients' phenotypes and their responses to glucose-lowering drugs. In this article, we summarize the current evidence on differences in composition of gut microbiota between individuals with type 2 diabetes (T2D) and healthy individuals, the disruption of the balance of beneficial and pathogenic microbiota was shown in patients with T2D and how Western Medicine (WM) and Traditional Chinese Medicine (TCM) might re-shape the gut microbiota with benefits to the host immunity and metabolic health. We particularly highlighted the effects of both WM and TCM increase the relative abundance of health promoting bacteria, such as, Akkermansia muciniphila, Blautia, and Bifidobacterium adolescentis, and which have been implicated in type 2 diabetes (T2D). Several lines of evidence suggested that TCM might complement the efficacy of WM through alteration of microbiota which warrants further investigation in our pursuit of prevention and control of T2D.

Association of technologically assisted integrated care with clinical outcomes in type 2 diabetes in Hong Kong using the prospective JADE Program: A retrospective cohort analysis.

BACKGROUND: Diabetes outcomes are influenced by host factors, settings, and care processes. We examined the association of data-driven integrated care assisted by information and communications technology (ICT) with clinical outcomes in type 2 diabetes in public and private healthcare settings. METHODS AND FINDINGS: The web-based Joint Asia Diabetes Evaluation (JADE) platform provides a protocol to guide data collection for issuing a personalized JADE report including risk categories (1-4, low-high), 5-year probabilities of cardiovascular-renal events, and trends and targets of 4 risk factors with tailored decision support. The JADE program is a prospective cohort study implemented in a naturalistic environment where patients underwent nurse-led structured evaluation (blood/urine/eye/feet) in public and private outpatient clinics and diabetes centers in Hong Kong. We retrospectively analyzed the data of 16,624 Han Chinese patients with type 2 diabetes who were enrolled in 2007-2015. In the public setting, the non-JADE group (n = 3,587) underwent structured evaluation for risk factors and complications only, while the JADE (n = 9,601) group received a JADE report with group empowerment by nurses. In a community-based, nurse-led, university-affiliated diabetes center (UDC), the JADE-Personalized (JADE-P) group (n = 3,436) received a JADE report, personalized empowerment, and annual telephone reminder for reevaluation and engagement. The primary composite outcome was time to the first occurrence of cardiovascular-renal diseases, all-site cancer, and/or death, based on hospitalization data censored on 30 June 2017. During 94,311 person-years of follow-up in 2007-2017, 7,779 primary events occurred. Compared with the JADE group (136.22 cases per 1,000 patient-years [95% CI 132.35-140.18]), the non-JADE group had higher (145.32 [95% CI 138.68-152.20]; P = 0.020) while the JADE-P group had lower event rates (70.94 [95% CI 67.12-74.91]; P < 0.001). The adjusted hazard ratios (aHRs) for the primary composite outcome were 1.22 (95% CI 1.15-1.30) and 0.70 (95% CI 0.66-0.75), respectively, independent of risk profiles, education levels, drug usage, self-care, and comorbidities at baseline. We reported consistent results in propensity-score-matched analyses and after accounting for loss to follow-up. Potential limitations include its nonrandomized design that precludes causal inference, residual confounding, and participation bias. CONCLUSIONS: ICT-assisted integrated care was associated with a reduction in clinical events, including death in type 2 diabetes in public and private healthcare settings.

A polysaccharide extract from the medicinal plant Maidong inhibits the IKK-NF-κB pathway and IL-1ß-induced islet inflammation and increases insulin secretion.

The herb dwarf lilyturf tuber (Maidong, Ophiopogonis Radix) is widely used in Chinese traditional medicine to manage diabetes and its complications. However, the role of Maidong polysaccharide extract (MPE) in pancreatic ß-cell function is unclear. Here, we investigated whether MPE protects ß-cell function and studied the underlying mechanisms. We treated db/db and high-fat diet (HFD)-induced obese mice with 800 or 400 mg/kg MPE or water for 4 weeks, followed by an oral glucose tolerance test. Pancreas and blood were collected for molecular analyses, and clonal MIN6 ß-cells and primary islets from HFD-induced obese mice and normal chow diet-fed mice were used in additional analyses. In vivo, MPE both increased insulin secretion and reduced blood glucose in the db/db mice but increased only insulin secretion in the HFD-induced obese mice. MPE substantially increased the ß-cell area in both models (3-fold and 2-fold, p < 0.01, for db/db and HFD mice, respectively). We observed reduced nuclear translocation of the p65 subunit of NF-κB in islets of MPE-treated db/db mice, coinciding with enhanced glucose-stimulated insulin secretion (GSIS). In vitro, MPE potentiated GSIS and decreased interleukin 1ß (IL-1ß) secretion in MIN6 ß-cells. Incubation of MIN6 cells with tumor necrosis factor α (TNFα), interferon-γ, and IL-1ß amplified IL-1ß secretion and inhibited GSIS. These effects were partially reversed with MPE or the IκB kinase ß inhibitor PS1145, coinciding with reduced activation of p65 and p-IκB in the NF-κB pathway. We conclude that MPE may have potential for therapeutic development for ß-cell protection.

Depressive Symptoms, Co-Morbidities, and Glycemic Control in Hong Kong Chinese Elderly Patients With Type 2 Diabetes Mellitus.

BACKGROUND AND OBJECTIVES: Undiagnosed depression is an important comorbidity in type 2 diabetes (T2D) which can be detected using the Geriatric Depression Scale (GDS-15) questionnaire. In this cross-sectional study, we examined the associations of depression using GDS score with control of cardiometabolic risk factors and health status in elderly patients with T2D. SETTING AND PARTICIPANTS: Between February and December 2013, patients aged ≥65 years who underwent structured comprehensive assessment as a quality improvement program at the Diabetes Center of a teaching hospital were invited to complete the GDS-15 questionnaire. MAIN OUTCOME MEASURES: Depression was defined as a GDS score ≥7. Demographic data, prior history of co-morbidities, frequency of self-reported hypoglycemia, and attainment of treatment targets defined as HbA1c, <7%, blood pressure <130/80 mmHg, and LDL-C <2.6 mmol/L were documented. RESULTS: Among 325 participants (65% male, median [interquartile range] age: 69 [8] years), 42 (13%) had depression. Patients with depression had longer disease durations (mean ± SD: 15.1 ± 9.1 vs. 11.6 ± 8.1 years, P = 0.02), more frequent self-reported hypoglycemic events (17 vs. 6%, P = 0.03) and were less likely to attain all three treatment targets (0 vs. 16%, P = 0.004) than those without depression. On multivariable analysis, patients with depression had an odds ratio of 2.84 (95% confidence intervals: 1.35-6.00, P = 0.006) of reporting prior history of co-morbidities. CONCLUSION: In elderly patients with T2D, depression was not uncommon especially in those with poor control of risk factors, hypoglycemia, and co-morbidities. Inclusion of GDS-15 questionnaire during structured assessment for complications and risk factors can identify these high-risk patients for more holistic management of their physical and mental health.

Engaging traditional medicine providers in colorectal cancer screening education in a chinese american community: a pilot study.

INTRODUCTION: Although colorectal cancer (CRC) screening is effective in preventing colon cancer, it remains underused by Asian Americans. Because Chinese Americans often use traditional Chinese medicine (TCM), we conducted a pilot study to explore the feasibility and acceptability of having TCM providers deliver education about CRC screening. METHODS: Four TCM providers (2 herbalists and 2 acupuncturists) were trained to deliver small-group educational sessions to promote CRC screening. Each provider recruited 15 participants aged 50 to 75. Participants completed a baseline survey on CRC-related knowledge, attitudes, and behaviors and then attended one 2-hour educational session delivered by the providers in Cantonese or Mandarin. Three months later, participants completed a postintervention survey. RESULTS: Sixty participants were recruited from the San Francisco Chinatown neighborhood. The average age was 62.4 years. Most participants had limited English proficiency (96.7%), annual household income less than $20,000 per year (60%), and low educational attainment (65.1% < high school education). At postintervention (n = 57), significant increases were found in having heard of CRC (from 52.6% to 79.0%, P < .001) and colon polyps (from 64.9% to 84.2%, P < .001). Knowledge regarding screening frequency recommendations also increased significantly. The rate of ever having received any CRC screening test increased from 71.9% to 82.5% (P <.001). The rate of up-to-date screening increased from 70.2% to 79.0% (P = .04). CONCLUSION: The findings suggest that TCM providers can be trained to deliver culturally and linguistically appropriate outreach on CRC screening within their community. Participants reached by TCM providers increased CRC knowledge and self-reported CRC screening.

Exploring a Culturally Relevant Model of Cancer Prevention Involving Traditional Chinese Medicine Providers in a Chinese American Community.

INTRODUCTION: Colorectal cancer (CRC) is the third most commonly diagnosed cancer in all racial and ethnic groups. Although CRC screening is very cost-effective, screening rates are low among most ethnic groups, including Asian Americans. Given the high use of traditional Chinese medicine (TCM) among Chinese Americans one potentially useful approach to promote CRC screening in these communities could involve TCM providers in outreach efforts. METHODS: A two-phase study was conducted. The perceived suitability of TCM providers in CRC prevention was explored in Phase 1. Guided by Phase 1 findings, in Phase 2, a 38-page integrative educational flipchart was developed and tested. Focus groups and observations were conducted with TCM providers (acupuncturists and herbalists) and with limited English proficient Chinese American immigrants living in San Francisco, California. RESULTS: In Phase 1, the role of TCM providers as CRC screening educators was deemed acceptable by both providers and community members, although some providers had reservations about engaging in CRC outreach activities due to lack of expertise. The majority of providers were not aware of regular CRC screening as a preventive measure, and most were not up-to-date in their own screening. In Phase 2, the integrative CRC education flipchart was perceived as culturally appropriate based on stakeholder input and feedback. CONCLUSION: This study shows that TCM providers have the potential to be a valuable and culturally appropriate community resource for providing information on CRC screening. It suggests a potential role for traditional healers as change agents in the immigrant community health network.