Usluogullari et al. BMC Endocrine Disorders (2015) 15:33 DOI 10.1186/s12902-015-0029-y
RESEARCH ARTICLE
Open Access
The relationship between microvascular complications and vitamin D deficiency in type 2 diabetes mellitus Celil Alper Usluogullari*, Fevzi Balkan, Sedat Caner, Rifki Ucler, Cafer Kaya, Reyhan Ersoy and Bekir Cakir
Abstract Background: Vitamin D deficiency is reported as a possible risk factor for the development of diabetes in several epidemiologic studies. In this study, we investigated the frequency of 25-OH vitamin D deficiency in type 2 diabetes mellitus and the relationship between 25-OH vitamin D deficiency and the prevalence of microvascular complications. Methods: In this retrospective study, we evaluated the medical records of 557 patients with type 2 diabetes admitted to the Endocrinology Outpatient Clinic from January to March 2010 and 112 healthy controls randomly selected from individuals admitted to the hospital for a check-up and who had a laboratory result for serum 25-OH vitamin D concentrations at screening. The levels of 25-OH vitamin D in patients with type 2 diabetes and the relationship between 25-OH vitamin D deficiency and microvascular complications were investigated. Results: No significant difference in serum 25-OH vitamin D concentrations was observed between the diabetic and control groups. No correlation was observed between HbA1C and serum 25-OH vitamin D levels. Serum 25-OH vitamin D levels were lower in diabetic patients with nephropathy, and patients not using any medication, i.e., those treated with dietary changes alone, had a higher prevalence of nephropathy. Conclusion: Vitamin D deficiency is more common in diabetic patients with nephropathy. When microvascular complications were evaluated, vitamin D levels were found to be lower in patients in whom these complications were more severe. Vitamin D deficiency is therefore associated with microvascular complications in diabetic patients. Keywords: Type 2 diabetes mellitus, 25-hydroxyvitamin D, Microvascular complications
Background Vitamin D deficiency is an important risk factor for glucose intolerance [1]. Studies have shown impaired insulin synthesis and secretion in animal models with vitamin D deficiency; diabetes onset can be delayed with 1–25-OH vitamin D intake, and some specific studies have reported that vitamin D deficiency contributes to the etiology and progression of type 2 diabetes [2, 3]. 25OH vitamin D concentrations were found to be lower in patients with type 2 diabetes with impaired glucose tolerance than in controls [4]. Vitamin D is a known suppressor of renin biosynthesis, and vitamin D deficiency has been associated with progression of chronic kidney disease (CKD). Patients with type 2 diabetes and CKD * Correspondence: [email protected] Clinic of Endocrinology and Metabolism, Atatürk Training and Research Hospital, Ankara, Turkey
have an exceptionally high rate of severe 25-OH vitamin D deficiency. This study investigates a possible relationship between vitamin D status and microvascular complications in patients with type 2 diabetes.
Methods Patients with type 2 diabetes admitted to the Endocrinology Outpatient Clinic from January to March 2010 owing to dietary or medication needs were included in the study group, and healthy nondiabetic individuals admitted to the hospital for a general check-up and whose serum 25-OH vitamin D concentrations had been requested formed the control group. The vitamin D status of patients and controls was screened retrospectively. Due to seasonal changes, only patients whose vitamin D status was assessed during the January to March period were included in the study. The
© 2015 Usluogullari et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Usluogullari et al. BMC Endocrine Disorders (2015) 15:33
25-0H vitamin D data were evaluated retrospectively, so measurements for the other months could not be retrieved. Data were obtained from their medical records and included detailed histories, physical examination records, and laboratory findings (gender, age, height, weight, body mass index (BMI), waist circumference, fasting blood glucose, creatinine, HbA1c, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, and microalbumin levels in 24-h urine). Glomerular filtration rate (GFR) is the best overall index of kidney function. Normal GFR varies according to age, sex, and body size, and declines with age. The National Kidney Foundation recommends using the CKD Epidemiology Collaboration (CKD-EPI) Creatinine Equation (2009) to estimate GFR. The medications received were stratified as diet alone, oral hypoglycemic agents, or insulin. The relationships between 25-OH vitamin D, HbA1c, microvascular complications of diabetes (nephropathy, retinopathy, and neuropathy), and type of treatment were investigated. Patients with CKD, active infection, liver disease, primary hyperparathyroidism, macroalbuminuria, osteoporosis, serum creatinine level > 2 mg/dL, or those receiving vitamin D or calcium supplements were excluded from the study. For a diagnosis of nephropathy, patients were defined as having microalbuminuria with 24-h urine albumin content of 30–300 mg/day. For diagnosing diabetic retinopathy (DR), all participants underwent an ophthalmic examination by an experienced ophthalmologist. This examination consisted of funduscopy by slit-lamp with 90 D lenses and indirect ophthalmoscopy. DR was defined as the presence of one or more of the following lesions: microaneurysms, blot or flame-shaped hemorrhages, hard exudates, cotton-wool spots, or evidence of laser treatment for DR at baseline. DR was categorized as nonproliferative (NPDR) or proliferative (PDR), determined by the presence of retinal neovascularization. Peripheral neuropathy was defined by abnormalities in monofilament testing, performed with a SemmesWeinstein monofilament of 5.07/10 g, three times at each site (dorsal between the base of digits 1–2; ventral digits 1, 3, 5; metatarsal heads 1, 3, 5; medial and lateral midfoot; and heel). If the patient missed perceiving the filament more than once at one site, the test was considered abnormal at that site. If a subject did not perceive the filament at two or more of the 10 sites, the test was reported as abnormal. Vibration sensation was examined using a diapason on the dorsum of the big toe. A 128Hz tuning fork was used to examine vibration perception at the dorsum of the interphalangeal joint of the right hallux. The vibrating tuning fork was placed on the interphalangeal joint and if nothing was felt, the score was two points. When some vibration was sensed, the
Page 2 of 7
still-vibrating tuning fork was immediately placed at the dorsal wrist. When the vibration felt the same as that at the hallux, the score was zero points, and when it felt stronger, the score was one point. The study group consisted of 557 patients who were receiving dietary or medical treatment for confirmed type 2 diabetes. The control group consisted of 112 healthy subjects who were admitted for check-up. The study was conducted in accordance with International Conference on Harmonization Good Clinical Practice (ICH-GCP) guidelines, and the Declaration of Helsinki, and approval for the study was granted by the Ethical Committee of Ataturk Training and Research Hospital. Laboratory analysis
Owing to hospital regulations, antecubital vein blood sampling was performed between 8:00 and 10:00 a.m. on all subjects, healthy or with diabetes, after a 12-h fast. Fasting blood glucose was measured using a glucose oxidase method (Roche Diagnostic GmbH). Total cholesterol, HDL cholesterol, and triglycerides were measured by enzymatic methods (Boehringer, Mannheim, Germany). LDL concentrations were calculated via the Friedewald formula. 25-OH vitamin D concentration and HbA1c were measured by a high-performance liquid chromatography (HPLC) method and by HPLC-ultraviolet (UV) detection, respectively. Statistical analysis
Statistical Package for Social Sciences (SPSS) 17.0 for Windows software (SPSS Inc, Chicago, IL, USA) was used for the data analysis. Continuous variables with a normal distribution are presented as mean ± standard deviation; non-normally distributed continuous variables are presented as median (minimum to maximum); ordinal variables are presented as median and mode; and nominal variables are presented as number and percentage. The normality of the distribution of the continuous variables was evaluated using histograms and the onesample Kolmogorov-Smirnov test; distributions with p > 0.05 were accepted as normally distributed. The differences between normally distributed continuous independent variables were evaluated with the independent samples t test, and those without a normal distribution were evaluated with the Mann–Whitney U test. All hypotheses were examined using two-tailed tests and p < 0.05 was used as the significance level. The relationships between nominal variables were evaluated using the Pearson chi-squared test and the Fisher exact test; p < 0.05 was used as the significance level. Statistical significance of risk factors for complications in diabetic patients, the results obtained via univariate analysis were subjected to multivariate logistic regression.
Usluogullari et al. BMC Endocrine Disorders (2015) 15:33
Page 3 of 7
Results The demographic characteristics of the subjects in the study are shown in Table 1. There were 296 men in the diabetic group and 45 in the control group. There were 261 women in the diabetic group and 67 in the control group. Mean (±SD) age in the diabetic and control groups was 55.2 ± 10.9 and 53.1 ± 12.5 years, respectively; a statistically significant difference between the groups was not observed (p = 0.07). Mean BMI in the diabetic and control groups was 30.3 ± 5.5 and 29.8 ± 5.7 kg/m2, respectively. The average duration of diabetes in the diabetic group was 5 years (0–20 years). The two groups were similar in terms of age, height, weight, and BMI (Table 1). HbA1c levels were higher in the diabetic group than in controls, as expected (p < 0.001), and 25-OH vitamin D concentrations did not differ between the two groups (p = 0.302). Mean serum 25-OH vitamin D concentrations were higher in men than in women (21.89 ± 8.74 vs 20.24 ± 8.53 ng/mL, respectively; p = 0.025). Table 2 summarizes the prevalence of various microvascular complications observed in both groups. Microvascular complications were present in 172 of 555 patients (30.9 %). The mean 25-OH vitamin D concentrations in the groups with or without microvascular complications were estimated to be 19.1 ± 8.1 and 22.0 ± 8.7 ng/mL, respectively; this difference was statistically significant (p < 0.001). In the diabetic group, nephropathy was observed in 91 patients (16.3 %). The mean 25-OH vitamin D concentrations in the groups with or without nephropathy were estimated to be 18.52 ± 8.2 and 21.6 ± 8.6 ng/mL, respectively. Patients with type 2 diabetes had lower total 25-OH vitamin D concentrations than patients with any of the microvascular complications (p < 0.001) or patients with nephropathy (p = 0.002). In the diabetic group, retinopathy was observed in 73 of 311 patients (23.4 %). Similar 25OH vitamin D levels were observed in both groups, with Table 1 Patient characteristics Control group
(n = 557)
(n = 112)
Gender (female/male), n
261/296
67/45
0.008
Age (years), mean ± SD
55.2 ± 10.9
53.09 ± 12.5
0.07
Height (m), mean ± SD
163.5 ± 9.7
163.1 ± 9.7
0.712
Weight (kg), mean ± SD
81.1 ± 15.1
78.8 ± 14.2
0.209
BMI (kg/m2), mean ± SD
30.3 ± 5.5
29.8 ± 5.7
0.381
HbA1c (%), mean ± SD
7.7 ± 1.7
5.6 ± 0.3
RESEARCH ARTICLE
Open Access
The relationship between microvascular complications and vitamin D deficiency in type 2 diabetes mellitus Celil Alper Usluogullari*, Fevzi Balkan, Sedat Caner, Rifki Ucler, Cafer Kaya, Reyhan Ersoy and Bekir Cakir
Abstract Background: Vitamin D deficiency is reported as a possible risk factor for the development of diabetes in several epidemiologic studies. In this study, we investigated the frequency of 25-OH vitamin D deficiency in type 2 diabetes mellitus and the relationship between 25-OH vitamin D deficiency and the prevalence of microvascular complications. Methods: In this retrospective study, we evaluated the medical records of 557 patients with type 2 diabetes admitted to the Endocrinology Outpatient Clinic from January to March 2010 and 112 healthy controls randomly selected from individuals admitted to the hospital for a check-up and who had a laboratory result for serum 25-OH vitamin D concentrations at screening. The levels of 25-OH vitamin D in patients with type 2 diabetes and the relationship between 25-OH vitamin D deficiency and microvascular complications were investigated. Results: No significant difference in serum 25-OH vitamin D concentrations was observed between the diabetic and control groups. No correlation was observed between HbA1C and serum 25-OH vitamin D levels. Serum 25-OH vitamin D levels were lower in diabetic patients with nephropathy, and patients not using any medication, i.e., those treated with dietary changes alone, had a higher prevalence of nephropathy. Conclusion: Vitamin D deficiency is more common in diabetic patients with nephropathy. When microvascular complications were evaluated, vitamin D levels were found to be lower in patients in whom these complications were more severe. Vitamin D deficiency is therefore associated with microvascular complications in diabetic patients. Keywords: Type 2 diabetes mellitus, 25-hydroxyvitamin D, Microvascular complications
Background Vitamin D deficiency is an important risk factor for glucose intolerance [1]. Studies have shown impaired insulin synthesis and secretion in animal models with vitamin D deficiency; diabetes onset can be delayed with 1–25-OH vitamin D intake, and some specific studies have reported that vitamin D deficiency contributes to the etiology and progression of type 2 diabetes [2, 3]. 25OH vitamin D concentrations were found to be lower in patients with type 2 diabetes with impaired glucose tolerance than in controls [4]. Vitamin D is a known suppressor of renin biosynthesis, and vitamin D deficiency has been associated with progression of chronic kidney disease (CKD). Patients with type 2 diabetes and CKD * Correspondence: [email protected] Clinic of Endocrinology and Metabolism, Atatürk Training and Research Hospital, Ankara, Turkey
have an exceptionally high rate of severe 25-OH vitamin D deficiency. This study investigates a possible relationship between vitamin D status and microvascular complications in patients with type 2 diabetes.
Methods Patients with type 2 diabetes admitted to the Endocrinology Outpatient Clinic from January to March 2010 owing to dietary or medication needs were included in the study group, and healthy nondiabetic individuals admitted to the hospital for a general check-up and whose serum 25-OH vitamin D concentrations had been requested formed the control group. The vitamin D status of patients and controls was screened retrospectively. Due to seasonal changes, only patients whose vitamin D status was assessed during the January to March period were included in the study. The
© 2015 Usluogullari et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http:// creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Usluogullari et al. BMC Endocrine Disorders (2015) 15:33
25-0H vitamin D data were evaluated retrospectively, so measurements for the other months could not be retrieved. Data were obtained from their medical records and included detailed histories, physical examination records, and laboratory findings (gender, age, height, weight, body mass index (BMI), waist circumference, fasting blood glucose, creatinine, HbA1c, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, and microalbumin levels in 24-h urine). Glomerular filtration rate (GFR) is the best overall index of kidney function. Normal GFR varies according to age, sex, and body size, and declines with age. The National Kidney Foundation recommends using the CKD Epidemiology Collaboration (CKD-EPI) Creatinine Equation (2009) to estimate GFR. The medications received were stratified as diet alone, oral hypoglycemic agents, or insulin. The relationships between 25-OH vitamin D, HbA1c, microvascular complications of diabetes (nephropathy, retinopathy, and neuropathy), and type of treatment were investigated. Patients with CKD, active infection, liver disease, primary hyperparathyroidism, macroalbuminuria, osteoporosis, serum creatinine level > 2 mg/dL, or those receiving vitamin D or calcium supplements were excluded from the study. For a diagnosis of nephropathy, patients were defined as having microalbuminuria with 24-h urine albumin content of 30–300 mg/day. For diagnosing diabetic retinopathy (DR), all participants underwent an ophthalmic examination by an experienced ophthalmologist. This examination consisted of funduscopy by slit-lamp with 90 D lenses and indirect ophthalmoscopy. DR was defined as the presence of one or more of the following lesions: microaneurysms, blot or flame-shaped hemorrhages, hard exudates, cotton-wool spots, or evidence of laser treatment for DR at baseline. DR was categorized as nonproliferative (NPDR) or proliferative (PDR), determined by the presence of retinal neovascularization. Peripheral neuropathy was defined by abnormalities in monofilament testing, performed with a SemmesWeinstein monofilament of 5.07/10 g, three times at each site (dorsal between the base of digits 1–2; ventral digits 1, 3, 5; metatarsal heads 1, 3, 5; medial and lateral midfoot; and heel). If the patient missed perceiving the filament more than once at one site, the test was considered abnormal at that site. If a subject did not perceive the filament at two or more of the 10 sites, the test was reported as abnormal. Vibration sensation was examined using a diapason on the dorsum of the big toe. A 128Hz tuning fork was used to examine vibration perception at the dorsum of the interphalangeal joint of the right hallux. The vibrating tuning fork was placed on the interphalangeal joint and if nothing was felt, the score was two points. When some vibration was sensed, the
Page 2 of 7
still-vibrating tuning fork was immediately placed at the dorsal wrist. When the vibration felt the same as that at the hallux, the score was zero points, and when it felt stronger, the score was one point. The study group consisted of 557 patients who were receiving dietary or medical treatment for confirmed type 2 diabetes. The control group consisted of 112 healthy subjects who were admitted for check-up. The study was conducted in accordance with International Conference on Harmonization Good Clinical Practice (ICH-GCP) guidelines, and the Declaration of Helsinki, and approval for the study was granted by the Ethical Committee of Ataturk Training and Research Hospital. Laboratory analysis
Owing to hospital regulations, antecubital vein blood sampling was performed between 8:00 and 10:00 a.m. on all subjects, healthy or with diabetes, after a 12-h fast. Fasting blood glucose was measured using a glucose oxidase method (Roche Diagnostic GmbH). Total cholesterol, HDL cholesterol, and triglycerides were measured by enzymatic methods (Boehringer, Mannheim, Germany). LDL concentrations were calculated via the Friedewald formula. 25-OH vitamin D concentration and HbA1c were measured by a high-performance liquid chromatography (HPLC) method and by HPLC-ultraviolet (UV) detection, respectively. Statistical analysis
Statistical Package for Social Sciences (SPSS) 17.0 for Windows software (SPSS Inc, Chicago, IL, USA) was used for the data analysis. Continuous variables with a normal distribution are presented as mean ± standard deviation; non-normally distributed continuous variables are presented as median (minimum to maximum); ordinal variables are presented as median and mode; and nominal variables are presented as number and percentage. The normality of the distribution of the continuous variables was evaluated using histograms and the onesample Kolmogorov-Smirnov test; distributions with p > 0.05 were accepted as normally distributed. The differences between normally distributed continuous independent variables were evaluated with the independent samples t test, and those without a normal distribution were evaluated with the Mann–Whitney U test. All hypotheses were examined using two-tailed tests and p < 0.05 was used as the significance level. The relationships between nominal variables were evaluated using the Pearson chi-squared test and the Fisher exact test; p < 0.05 was used as the significance level. Statistical significance of risk factors for complications in diabetic patients, the results obtained via univariate analysis were subjected to multivariate logistic regression.
Usluogullari et al. BMC Endocrine Disorders (2015) 15:33
Page 3 of 7
Results The demographic characteristics of the subjects in the study are shown in Table 1. There were 296 men in the diabetic group and 45 in the control group. There were 261 women in the diabetic group and 67 in the control group. Mean (±SD) age in the diabetic and control groups was 55.2 ± 10.9 and 53.1 ± 12.5 years, respectively; a statistically significant difference between the groups was not observed (p = 0.07). Mean BMI in the diabetic and control groups was 30.3 ± 5.5 and 29.8 ± 5.7 kg/m2, respectively. The average duration of diabetes in the diabetic group was 5 years (0–20 years). The two groups were similar in terms of age, height, weight, and BMI (Table 1). HbA1c levels were higher in the diabetic group than in controls, as expected (p < 0.001), and 25-OH vitamin D concentrations did not differ between the two groups (p = 0.302). Mean serum 25-OH vitamin D concentrations were higher in men than in women (21.89 ± 8.74 vs 20.24 ± 8.53 ng/mL, respectively; p = 0.025). Table 2 summarizes the prevalence of various microvascular complications observed in both groups. Microvascular complications were present in 172 of 555 patients (30.9 %). The mean 25-OH vitamin D concentrations in the groups with or without microvascular complications were estimated to be 19.1 ± 8.1 and 22.0 ± 8.7 ng/mL, respectively; this difference was statistically significant (p < 0.001). In the diabetic group, nephropathy was observed in 91 patients (16.3 %). The mean 25-OH vitamin D concentrations in the groups with or without nephropathy were estimated to be 18.52 ± 8.2 and 21.6 ± 8.6 ng/mL, respectively. Patients with type 2 diabetes had lower total 25-OH vitamin D concentrations than patients with any of the microvascular complications (p < 0.001) or patients with nephropathy (p = 0.002). In the diabetic group, retinopathy was observed in 73 of 311 patients (23.4 %). Similar 25OH vitamin D levels were observed in both groups, with Table 1 Patient characteristics Control group
(n = 557)
(n = 112)
Gender (female/male), n
261/296
67/45
0.008
Age (years), mean ± SD
55.2 ± 10.9
53.09 ± 12.5
0.07
Height (m), mean ± SD
163.5 ± 9.7
163.1 ± 9.7
0.712
Weight (kg), mean ± SD
81.1 ± 15.1
78.8 ± 14.2
0.209
BMI (kg/m2), mean ± SD
30.3 ± 5.5
29.8 ± 5.7
0.381
HbA1c (%), mean ± SD
7.7 ± 1.7
5.6 ± 0.3
