Journal Club 埼玉医科大学 総合医療センター 内分泌・糖尿病内科 Department of Endocrinology and Diabetes, Saitama Medical Center, Saitama Medical University 松田 昌文 Matsuda, Masafumi 2010 年４月 15 日 8:30-8:55 ８階 医局 Welsh JA, Sharma A, Abramson JL, Vaccarino V, Gillespie C, Vos MB Caloric sweetener consumption and dyslipidemia among US adults JAMA. 2010;303: Kahn R, Alperin P, Eddy, Borch-Johnsen K, Buse J, Feigelman J, Gegg E, Holman RR, Kirkman MS, Stern M, Tuomilehto J, Wareham NJ Age a initiation and frequency of screenin got detect type 2 diabetes: a cost- effectiveness analysis Lancet Apr 17;375:

The American Heart Association recommended limiting added sugar in the diet to no more than 100 calories a day for most women and 150 calories for most men.

JAMA. 2010;303(15): Nutrition and Health Science Program, Graduate Division of Biological and Biomedical Sciences (Ms Welsh and Drs Sharma, Vaccarino, and Vos), Department of Epidemiology, Rollins School of Public Health (Drs Abramson and Vaccarino), Division of Cardiology, School of Medicine (Dr Vaccarino), Department of Pediatrics, Gastroenterology, Hepatology and Nutrition, School of Medicine (Dr Vos), Emory University; Children’s Healthcare of Atlanta (Ms Welsh and Dr Vos); and Divisions of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention (Dr Sharma) and Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention (Dr Gillespie), Atlanta, Georgia.

Aim Context Dietary carbohydrates have been associated with dyslipidemia, a lipid profile known to increase cardiovascular disease risk. Added sugars (caloric sweeteners used as ingredients in processed or prepared foods) are an increasing and potentially modifiable component in the US diet. No known studies have examined the association between the consumption of added sugars and lipid measures. Objective To assess the association between consumption of added sugars and blood lipid levels in US adults.

Design, Setting, and Participants Cross-sectional study among US adults (n=6113) from the National Health and Nutrition Examination Survey (NHANES) Respondents were grouped by intake of added sugars using limits specified in dietary recommendations (<5% [reference group], 5%-<10%, 10%- <17.5%, 17.5%-<25%, and <25% of total calories). Linear regression was used to estimate adjusted mean lipid levels. Logistic regression was used to determine adjusted odds ratios of dyslipidemia. Interactions between added sugars and sex were evaluated. Main Outcome Measures Adjusted mean high-density lipoprotein cholesterol (HDL-C), geometric mean triglycerides, and mean low-density lipoprotein cholesterol (LDL-C) levels and adjusted odds ratios of dyslipidemia, including low HDL-C levels (<40 mg/dL for men; <50 mg/dL for women), high triglyceride levels ( ≧ 150 mg/ dL), high LDL-C levels ( ≧ 130 mg/dL), or high ratio of triglycerides to HDL-C ( ≧ 3.8). Results were weighted to be representative of the US population. Methods

Participants grouped by percentage of total energy intake from added sugar; 5% comprises the reference group. P.001 for linear trend. Error bars indicate 95% confidence intervals. HDL-C indicates highdensity lipoprotein cholesterol; NHANES, National Health and Nutrition Examination Survey. To convert values to mmol/L, multiply by The 3 highest categories ( , , and 25) were significantly lower than the referent group (P.001).

Participants grouped by percentage of total energy intake from added sugar; _5% comprises the reference group. P=.02 for linear trend. Error bars indicate 95% confidence intervals. NHANES indicates National Health and Nutrition Examination Survey. To convert values to mmol/L, multiply by The categories 10-<17.5 and < 25 were significantly higher than the referent group at P <.05, and the category _25 was significantly higher at P <.01.

Table 2. Adjusted Odds Ratios of Dyslipidemia Among US Adults (18 Years) Associated With Consumption of Added Sugara Dyslipidemia Measure %Total Energy From Added Sugar 5 (n = 893) 5-10 (n = 1124) (n = 1751) 17.5-

Results A mean of 15.8% of consumed calories was from added sugars. Among participants consuming less than 5%, 5% to less than 17.5%, 17.5% to less than 25%, and 25% or greater of total energy as added sugars, adjusted mean HDL-C levels were, respectively, 58.7, 57.5, 53.7, 51.0, and 47.7 mg/dL (P<.001 for linear trend), geometric mean triglyceride levels were 105, 102, 111, 113, and 114 mg/dL (P<.001 for linear trend), and LDL-C levels modified by sex were 116, 115, 118, 121, and 123 mg/dL among women (P=.047 for linear trend). There were no significant trends in LDL-C levels among men. Among higher consumers (<10% added sugars) the odds of low HDL-C levels were 50% to more than 300% greater compared with the reference group (<5% added sugars).

Conclusion In this study, there was a statistically significant correlation between dietary added sugars and blood lipid levels among US adults.

Message 砂糖摂食多量で脂質異常，特に HDL-C の低下な どにつながるという論旨だが，ここでの多量は 本当に多量！

Lancet 2010; 375: 1365–74 American Diabetes Association, Alexandria, VA, USA (R Kahn PhD, M S Kirkman MD); Archimedes, San Francisco, CA, USA (P Alperin MD, D Eddy MD, J Feigelman); Steno Diabetes Center, Gentofte, Denmark (K Borch-Johnsen MD); Division of Endocrinology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA (J Buse MD); Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA (E Gregg PhD); Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology, and Metabolism, University of Oxford, Oxford, UK (R R Holman MD); Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA (M Stern MD); Hjelt Institute, University of Helsinki, Helsinki, Finland (J Tuomilehto MD); and MRC Epidemiology Unit, Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, UK (Prof N J Wareham)

Background No clinical trials have assessed the effects or cost-effectiveness of sequential screening strategies to detect new cases of type 2 diabetes. We used a mathematical model to estimate the cost-effectiveness of several screening strategies.

Method We used person-specific data from a representative sample of the US population to create a simulated population of people aged 30 years without diabetes. We used the Archimedes model to compare eight simulated screening strategies for type 2 diabetes with a no-screening control strategy. Strategies differed in terms of age at initiation and frequency of screening. Once diagnosed, diabetes treatment was simulated in a standard manner. We calculated the effects of each strategy on the incidence of type 2 diabetes, myocardial infarction, stroke, and microvascular complications in addition to quality of life, costs, and cost per quality-adjusted life- year (QALY).

the mean number of years earlier that type 2 diabetes was diagnosed in the eight screening strategies than it was with control

Figure 2: Expected number of events prevented by each screening strategy compared with control after 50 years of follow-up Error bars represent 95% CIs. Microvascular outcomes defined as legal blindness, end-stage renal disease, and amputations. In the control group, there were 235 myocardial infarctions, 105 strokes, 137 microvascular events, and 474 deaths per 1000 people after 50 years of follow-up. Number needed to treat to prevent one event, at 50 years, is listed below each column in the figures. See panel for definitions of screening strategies. NA=not applicable.

Quality-adjusted life-years (QALYs) were calculated on the basis of the time individuals spent with different disorders, such as having a foot ulcer, and estimated disutilities for these same disorders. We used disutilities published by Sullivan and Ghushchyan for all disorders apart from amputation, for which we had to use other data.

Results Compared with no screening, all simulated screening strategies reduced the incidence of myocardial infarction (3–9 events prevented per 1000 people screened) and diabetes-related microvascular complications (3–9 events prevented per 1000 people), and increased the number of QALYs (93–194 undiscounted QALYs) added over 50 years. Most strategies prevented a significant number of simulated deaths (2–5 events per 1000 people). There was little or no effect of screening on incidence of stroke (0–1 event prevented per 1000 people). Five screening strategies had costs per QALY of about US$ or less, whereas costs were much higher for screening started at 45 years of age and repeated every year ($15 509), screening started at 60 years of age and repeated every 3 years ($25 738), or a maximum screening strategy (screening started at 30 years of age and repeated every 6 months; $40 778). Several strategies differed substantially in the number of QALYs gained. Costs per QALY were sensitive to the disutility assigned to the state of having diabetes diagnosed with or without symptoms.

Interpretation ： In the US population, screening for type 2 diabetes is cost effective when started between the ages of 30 years and 45 years, with screening repeated every 3–5 years. Funding Novo Nordisk, Bayer HealthCare, and Pfizer. Conclusion

Message 糖尿病のスクリーニング：日本人にこのモデルがあ てはまるとは思えないが，（脳卒中の予防効果がな い！） Archimedes モデルというのがかなり使われ ている！ 30 歳か 45 歳から ３～５年ごとのスクリーニングで コスト効果比がよいという結果