Estimating lifetime risk of diabetes in the Chinese population

In this Perspective, Fiona Bragg and Zhengming Chen discuss the burden of diabetes in the Chinese Population.

The worldwide epidemic of diabetes continues to grow [1]. In China, the rise in prevalence has been notably rapid; about 12% of the adult population has diabetes [2], accounting for almost one quarter of cases worldwide [1] and representing a 10-fold increase over the last 3 to 4 decades. It is appropriate, therefore, that diabetes—both prevention and management—is a major focus of current health policy initiatives in China [3,4], and their success depends on reliable quantification of the burden of diabetes. Commonly used measures such as prevalence and incidence fail to capture excess mortality risks or differences in life expectancy in diabetes [5]. Moreover, they may be less easily interpreted by policy makers and affected individuals. Estimates of lifetime risks and life years spent living with diabetes in an accompanying study by Luk and colleagues provide a valuable new perspective on the burden of diabetes in the Chinese population [6].The study used Hong Kong territory-wide electronic health records data for 2.6 million adults. Using a Markov chain model and Monte-Carlo simulations, Luk and colleagues estimated age- and sex-specific lifetime risks of diabetes (incorporating both clinically diagnosed and undiagnosed diabetes) and remaining life years spent with diabetes. Their findings showed a lifetime risk of 65.9% and 12.7 years of life living with diabetes for an average 20-year old with normoglycaemia. For an average 20-year old with prediabetes the corresponding estimates were 88.0% and 32.5 years, respectively. In other words, 6 out of 10 20-year olds with normoglycaemia and 9 out of 10 with prediabetes would be expected to develop diabetes in their lifetime. The estimated lifetime risks declined with increasing age and were higher among women than men at all ages, likely reflecting women’s higher life expectancy.These estimated lifetime risks are striking and concerning. Moreover, they are notably higher than western population estimates [7–10], including those considering both diagnosed and undiagnosed diabetes [9,10]. An Australian study estimated that 38% of 25-year olds would develop diabetes in their lifetime [10]. Another study in the Netherlands reported 31.3% and 74.0% probabilities of developing diabetes in the remaining lifetime for individuals aged 45 years without diabetes and with prediabetes, respectively [9]. Diabetes incidence and overall mortality influence population lifetime risks. Differences in the glycaemic indicators used to identify undiagnosed diabetes may have contributed to differences between studies in diabetes incidence. In the study by Luk and colleagues, a combination of fasting plasma glucose (FPG), HbA1c levels and oral glucose tolerance testing (OGTT) was used, while in the Australian [10] and the Netherlands [9] studies, they used FPG/OGTT and mainly FPG, respectively. However, it is unlikely these differences would fully account for the large disparities seen in lifetime risk. Similarly, differences between life expectancy in Hong Kong (84.8 years), Australia (83.4 years), and the Netherlands (82.2 years) are too small to explain the differences. Interestingly, the high lifetime risks observed in Hong Kong were more comparable to those in the Indian population, estimated at 55.5% and 64.6%, respectively, among 20-year-old men and women [11]. The typical type 2 diabetes (T2D) phenotype in these Asian populations may partly explain their higher estimated lifetime risks. More specifically, T2D in both Chinese and Indian populations is characterised by onset among younger and less adipose individuals than typically observed in western populations, exacerbated by rapid urbanisation and associated unhealthy lifestyles [12].However, aspects of Luk and colleagues’ study design may have overestimated lifetime diabetes risks. Chief among these is the data source used and associated selection bias. The Hong Kong Diabetes Surveillance Database includes only individuals who have ever had a plasma glucose or HbA1c measurement undertaken in a local health authority facility. Since measurement of glycaemic indicators is more likely among individuals at greater current or future risk of dysglycaemic states, this will have inflated estimates of lifetime risk and life years spent with diabetes. Although replication was undertaken by the study authors to address this bias in the smaller China Health and Retirement Longitudinal Survey (CHARLS) cohort, it does not fully allay these concerns, with modestly lower estimated lifetime diabetes risks in the CHARLS cohort, even after accounting for its higher mortality. A further limitation is their consideration of transition to dysglycaemic states as irreversible. Although data on long-term transition between glycaemic states are lacking, reversion from prediabetes (and less commonly diabetes) to normoglycaemia is well recognised, e.g., through lifestyle interventions [13].Large-scale population-based cohort studies could valuably address many of the limitations described [14]. Furthermore, lifetime risks are, by definition, population-based and represent the risk of an average person in the population, limiting their value for communicating long-term disease risks to specific individuals. However, the extensive phenotyping (e.g., adiposity) characteristic of many large contemporary cohorts [14] would facilitate incorporation of risk factors into lifetime risk estimates, enhancing their relevance to individuals. Previous studies have found greater lifetime risks of diabetes associated with adiposity [9,11], and this approach could be extended to incorporate other established, as well as more novel (e.g., genetic), risk factors. This is arguably of particular relevance to later-onset chronic conditions, such as T2D, in which changes in risk factors during middle age can influence lifetime risks. A valuable extension of Luk and colleagues’ study will be estimation of risk factor specific lifetime diabetes risks for the Chinese population.Importantly, the limitations described do not detract from the enormity and importance of the challenge diabetes poses for China, including Hong Kong, and the estimates presented by Luk and colleagues provide valuable impetus for action. The disease burden insights can inform treatment programmes and enhance understanding of current and future impacts of diabetes and associated complications on the healthcare system. Moreover, T2D is preventable, and arguably, the greatest value of these estimated lifetime risks is in highlighting the need for, and informing the planning and provision of, diabetes primary prevention programmes. This includes identification of high-risk individuals, such as those with prediabetes, who are most likely to benefit from prevention interventions. However, the magnitude of the estimated lifetime diabetes risks, including among the large proportion of the population in a normoglycaemic state, additionally demonstrates the need for population-level prevention approaches, including environmental, structural, and fiscal strategies. Without such actions, the individual and societal consequences of diabetes for present and future generations in Hong Kong, as well as mainland China, will be immense.     

Urogenital schistosomiasis infection prevalence targets to determine elimination as a public health problem based on microhematuria prevalence in school-age children

BackgroundRecent research suggests that schistosomiasis targets for morbidity control and elimination as a public health problem could benefit from a reanalysis. These analyses would define evidence-based targets that control programs could use to confidently assert that they had controlled or eliminated schistosomiasis as a public health problem. We estimated how low Schistosoma haematobium infection levels diagnosed by urine filtration in school-age children should be decreased so that microhematuria prevalence was at, or below, a “background” level of morbidity.MethodologyData obtained from school-age children in Burkina Faso, Mali, Niger, Tanzania, and Zambia who participated in schistosomiasis monitoring and evaluation cohorts were reanalyzed before and after initiation of preventive chemotherapy. Bayesian models estimated the infection level prevalence probabilities associated with microhematuria thresholds ≤10%, 13%, or 15%.Principal findingsAn infection prevalence of 5% could be a sensible target for urogenital schistosomiasis morbidity control in children as microhematuria prevalence was highly likely to be below 10% in all surveys. Targets of 8% and 11% infection prevalence were highly likely to result in microhematuria levels less than 13% and 15%, respectively. By contrast, measuring heavy-intensity infections only achieves these thresholds at impractically low prevalence levels.Conclusions/significanceA target of 5%, 8%, or 11% urogenital schistosomiasis infection prevalence in school-age children could be used to determine whether a geographic area has controlled or eliminated schistosomiasis as a public health problem depending on the local background threshold of microhematuria.     

Serotonin paracrine signaling in tissue fibrosis

The molecule serotonin (5-hydroxytryptamine or 5-HT) is involved in numerous biological processes both inside and outside of the central nervous system. 5-HT signals through 5-HT receptors and it is the diversity of these receptors and their subtypes that give rise to the varied physiological responses. It is clear that platelet derived serotonin is critical for normal wound healing in multiple organs including, liver, lung heart and skin. 5-HT stimulates both vasoconstriction and vasodilation, influences inflammatory responses and promotes formation of a temporary scar which acts as a scaffold for normal tissue to be restored. However, in situations of chronic injury or damage 5-HT signaling can have deleterious effects and promote aberrant wound healing resulting in tissue fibrosis and impaired organ regeneration. This review highlights the diverse actions of serotonin signaling in the pathogenesis of fibrotic disease and explores how modulating the activity of specific 5-HT receptors, in particular the 5-HT2 subclass could have the potential to limit fibrosis and restore tissue regeneration. This article is part of a Special Issue entitled: Fibrosis: Translation of basic research to human disease.     

Regulation of endomembrane biogenesis in arabidopsis by phospatidic acid hydrolase

Coordination of membrane lipid biosynthesis is important for cell function during plant growth and development. Here we summarize our recent work on PHOSPHATIDIC ACID PHOSPHOHYDROLASE (PAH) which suggests that this enzyme is a key regulator of phosphaticylcholine (PC) biosynthesis in Arabidopsis thaliana. Disruption of PAH activity elevates phosphatidic acid (PA) levels and stimulates PC biosynthesis and biogenesis of the endoplasmic reticulum (ER). Furthermore, the activity of PHOSPHOCHOLINE CYTIDYLYLTRANSFERASE (CCT), which is the key enzyme controlling the rate of PC biosynthesis, is directly stimulated by PA and expression of a constitutively active version of CCT replicates the effects of PAH disruption. Hence PAH activity can control the abundance of PA, which in turn can modulate CCT activity to govern the rate of PC biosynthesis. Crucially it is not yet clear how PAH activity is regulated in Arabidopsis but there is evidence that PAH1 and PAH2 are both phosphorylated and further work will be required to investigate whether this is functionally significant.     

Seed storage: maintaining seed viability and vigor for restoration use

Effective seed storage after sourcing (harvesting or purchasing) is critical to restoration practitioners and native seed producers, as it is key to maintaining seed viability. Inadequate seed storage can lead to a waste of both natural and economic resources when seeds of poor quality are sown. When working with native species with unknown storage behavior, general assumptions can be made based on studies on related species, and standard practices may be applied with caution; however, an investigation should be conducted to understand if specific storage requirements are needed and for how long seeds can be stored before they lose significant viability. In this paper of the Special Issue Standards for Native Seeds in Ecological Restoration, we provide an overview of the key concepts in seed storage and the steps to take for effective storage of native seeds for restoration use.     

Breaking barriers? Ethnicity and socioeconomic background impact on early career progression in the fields of ecology and evolution

The academic disciplines of Science, Technology, Engineering and Mathematics (STEM) have long suffered from a lack of diversity. While in recent years there has been some progress in addressing the underrepresentation of women in STEM subjects, other characteristics that have the potential to impact on equality of opportunity have received less attention. In this study, we surveyed 188 early career scientists (ECRs), defined as within 10 years of completing their PhD, in the fields of ecology, evolutionary biology, behaviour, and related disciplines. We examined associations between ethnicity, age, sexual orientation, sex, socioeconomic background, and disability, with measures of career progression, namely publication record, number of applications made before obtaining a postdoc, type of contract, and number of grant applications made. We also queried respondents on perceived barriers to progression and potential ways of overcoming them. Our key finding was that socioeconomic background and ethnicity were associated with measures of career progression. While there was no difference in the number of reported first‐authored papers on PhD completion, ethnic minority respondents reported fewer other‐authored papers. In addition, ECRs from a lower socioeconomic background were more likely to report being in teaching and research positions, rather than research‐only positions, the latter being perceived as more prestigious by some institutions. We discuss our findings in the context of possible inequality of opportunity. We hope that this study will stimulate wider discussion and help to inform strategies to address the underrepresentation of minority groups in the fields of ecology and evolution, and STEM subjects more widely.     

Genetic and biological characterisation of three cryptic Eimeria operational taxonomic units that infect chickens (Gallus gallus domesticus)

More than 68 billion chickens were produced globally in 2018, emphasising their major contribution to the production of protein for human consumption and the importance of their pathogens. Protozoan Eimeria spp. are the most economically significant parasites of chickens, incurring global costs of more than UK £10.4 billion per annum. Seven Eimeria spp. have long been recognised to infect chickens, with three additional cryptic operational taxonomic units (OTUs) first described more than 10 years ago. As the world’s farmers attempt to reduce reliance on routine use of antimicrobials in livestock production, replacing drugs that target a wide range of microbes with precise species- and sometimes strain-specific vaccines, the breakthrough of cryptic genetic types can pose serious problems. Consideration of biological characteristics including oocyst morphology, pathology caused during infection and pre-patent periods, combined with gene-coding sequences predicted from draft genome sequence assemblies, suggest that all three of these cryptic Eimeria OTUs possess sufficient genetic and biological diversity to be considered as new and distinct species. The ability of these OTUs to compromise chicken bodyweight gain and escape immunity induced by current commercially available anticoccidial vaccines indicates that they could pose a notable threat to chicken health, welfare, and productivity. We suggest the names Eimeria lata n. sp., Eimeria nagambie n. sp. and Eimeria zaria n. sp. for OTUs x, y and z, respectively, reflecting their appearance (x) or the origins of the first isolates of these novel species (y, z).