Detection,management,and prevention of diabetes-related foot disease in the Australian context

Diabetes-related foot disease(DFD)is a widely feared complication among people who live with diabetes.In Australia and globally,rates of disability,cardiovascular disease,lower extremity amputation,and mortality are significantly increased in patients with DFD.In order to understand and prevent these outcomes,we analyse the common pathogenetic processes of neuropathy,arterial disease,and infection.The review then summarises important management considerations through the interdisciplinary lens.Using Australian and international guidelines,we offer a stepwise,evidence-based practical approach to the care of patients with DFD.

State of Knowledge on the Metabolic Syndrome and NASH in the Ivorian Population: Case of People Attending the Diabetology Endocrinology Service of the University Hospital Center (CHU) of Yopougon (Abidjan, Côte d’Ivoire)

Non-alcoholic hepatic steatosis (NASH), characterized by an excessive accumulation of lipids in the liver, is strongly associated with Metabolic Syndrome, which groups together a constellation of cardiovascular risk factors that make it an emerging public health problem on a global scale. The objective of this study was to review the state of knowledge on Metabolic Syndrome and NASH in the Ivorian population. It was a retrospective study conducted over a period of 2 months at the Diabetes Endocrinology Department of the University Hospital Centre (CHU) of Yopougon. It included all patients of any age and sex who were hospitalized or received consultation. The criteria of the Metabolic Syndrome defined by the International Diabetes Federation (IDF) were used to define and calculate the prevalence of the Metabolic Syndrome. Our study found a prevalence of 18.66% of Metabolic Syndrome according to the IDF criteria and a prevalence of 3.33% of NASH in a population of 150 patients hospitalized or received in consultation. There was a predominance of women and older subjects, so the current level of knowledge about Metabolic Syndrome and NASH was low in our study population with only 12%. Indeed, patients over 50 years of age were at higher risk of developing Metabolic Syndrome and NASH. Apart from hyperglycemia, abdominal obesity and arterial hypertension were the most common criteria. Finally, age and body mass index (BMI) were significantly associated with the presence of metabolic syndrome and non-alcoholic fatty liver disease (NASH). However, the awareness of the population, the respect of food hygiene and the implementation of recommended strategies are essential elements in the eradication of these different pathologies.

Gut microbiota and Ma-Pi 2 macrobiotic diet in the treatment of type 2 diabetes

In the past 10 years the prevalence of type 2 diabetes mel itus(T2DM) has increased hugely worldwide,driven by a rise in the numbers of overweight and obese individuals.A number of diets have been shown to be effective for the management of T2DM:the Mediterranean diet,the vegetarian diet and the low-calorie diet.Results of studies clearly indicate,however,that the efficacy of these diets is not solely related to the biochemical structure of the individual nutrients they contain.This review discusses this point with reference to the potential role of the intestinal microbiota in diabetes.The macrobiotic Ma-Pi 2 diet is rich in carbohydrates,whole grains and vegetables,with no animal fat or protein or added sugar.In shortand medium-term trials conducted in patients with T2 DM,the Ma-Pi 2 diet has been found to significantly improve indicators of metabolic control,including fasting blood glucose,glycosylated hemoglobin,the serum lipid profile,body mass index,body weight and blood pressure.The diet may also alter the gut microbiota composition,which could additionally affect glycemic control.As a result,the Ma-Pi 2 diet could be considered a valid additional shortto medium-term treatment for T2 DM.

Novel insights regarding the role of noncoding RNAs in diabetes

Diabetes mellitus(DM)is a group of metabolic disorders defined by hyperglycemia induced by insulin resistance,inadequate insulin secretion,or excessive glucagon secretion.In 2021,the global prevalence of diabetes is anticipated to be 10.7%(537 million people).Noncoding RNAs(ncRNAs)appear to have an important role in the initiation and progression of DM,according to a growing body of research.The two major groups of ncRNAs implicated in diabetic disorders are miRNAs and long noncoding RNAs.miRNAs are singlestranded,short(17–25 nucleotides),ncRNAs that influence gene expression at the post-transcriptional level.Because DM has reached epidemic proportions worldwide,it appears that novel diagnostic and therapeutic strategies are required to identify and treat complications associated with these diseases efficiently.miRNAs are gaining attention as biomarkers for DM diagnosis and potential treatment due to their function in maintaining physiological homeostasis via gene expression regulation.In this review,we address the issue of the gradually expanding global prevalence of DM by presenting a complete and upto-date synopsis of various regulatory miRNAs involved in these disorders.We hope this review will spark discussion about ncRNAs as prognostic biomarkers and therapeutic tools for DM.We examine and synthesize recent research that used novel,high-throughput technologies to uncover ncRNAs involved in DM,necessitating a systematic approach to examining and summarizing their roles and possible diagnostic and therapeutic uses.

Emerging significance of butyrylcholinesterase

Butyrylcholinesterase(BChE;EC 3.1.1.8),an enzyme structurally related to acetylcholinesterase,is widely distributed in the human body.It plays a role in the detoxification of chemicals such as succinylcholine,a muscle relaxant used in anesthetic practice.BChE is well-known due to variant forms of the enzyme with little or no hydrolytic activity which exist in some endogamous communities and result in prolonged apnea following the administration of succinylcholine.Its other functions include the ability to hydrolyze acetylcholine,the cholinergic neurotransmitter in the brain,when its primary hydrolytic enzyme,acetylcholinesterase,is absent.To assess its potential roles,BChE was studied in relation to insulin resistance,type 2 diabetes mellitus,cognition,hepatic disorders,cardiovascular and cerebrovascular diseases,and inflammatory conditions.Individuals who lack the enzyme activity of BChE are otherwise healthy,until they are given drugs hydrolyzed by this enzyme.Therefore,BChE is a candidate for the study of loss-of-function mutations in humans.Studying individuals with variant forms of BChE can provide insights into whether they are protected against metabolic diseases.The potential utility of the enzyme as a biomarker for Alzheimer’s disease and the response to its drug treatment can also be assessed.

Scope and caveats:Artificial intelligence in gastroenterology

The use of Artificial intelligence(AI)has evolved from its mid-20th century origins to playing a pivotal tool in modern medicine.It leverages digital data and computational hardware for diverse applications,including diagnosis,prognosis,and treatment responses in gastrointestinal and hepatic conditions.AI has had an impact in diagnostic techniques,particularly endoscopy,ultrasound,and histopathology.AI encompasses machine learning,natural language processing,and robotics,with machine learning being central.This involves sophisticated algorithms capable of managing complex datasets,far surpassing traditional statistical methods.These algorithms,both supervised and unsupervised,are integral for interpreting large datasets.In liver diseases,AI's non-invasive diagnostic applications,particularly in non-alcoholic fatty liver disease,and its role in characterizing hepatic lesions is promising.AI aids in distinguishing between normal and cirrhotic livers and improves the accuracy of lesion characterization and prognostication of hepatocellular carcinoma.AI enhances lesion identification during endoscopy,showing potential in the diagnosis and management of early-stage esophageal carcinoma.In peptic ulcer disease,AI technologies influence patient management strategies.AI is useful in colonoscopy,particularly in detecting smaller colonic polyps.However,its applicability in nonacademic settings requires further validation.Addressing these issues is vital for harnessing the potential of AI.In conclusion,while AI offers transformative possibilities in gastroenterology,careful integration and balancing of technical possibilities with ethical and practical application,is essential for optimal use.

Type 2 diabetes mellitus affects eradication rate of Helicobacter pylori

AIM: To study the eradication rate of Helicobacter pylori (Hp) in a group of type 2 diabetes and compared it with an age and sex matched non-diabetic group.METHODS: 40 diabetic patients (21 females, 19 males;56±7 years) and 40 non-diabetic dyspeptic patients (20females, 20 males; 54±9 years) were evaluated. Diabetic patients with dyspeptic complaints were referred for upper gastrointestinal endoscopies; 2 corpus and 2 antral gastric biopsy specimens were performed on each patient. Patients with positive Hp results on histopathological examination comprised the study group. Non-diabetic dyspeptic patients seen at the Gastroenterology Outpatient Clinic and with the same biopsy and treatment protocol formed the control group.A triple therapy with amoxycillin (1 g b.i.d), clarithromycin (500 mg b.i.d) and omeprazole (20 mg b.i.d.) was given to both groups for 10 days. Cure was defined as the absence of Hp infection assessed by corpus and antrum biopsies in control upper gastrointestinal endoscopies performed 6weeks after completing the antimicrobial therapy.RESULTS: The eradication rate was 50 % in the diabetic group versus 85 % in the non-diabetic control group (P＜0.001).CONCLUSION: Type 2 diabetic patients showed a significantly lower eradication rate than controls which may be due to changes in microvasculature of the stomach and to frequent antibiotic usage because of recurrent bacterial infections with the development of resistant strains.

Diabetes mellitus and stroke: A clinical update

Cardiovascular disease including stroke is a major complication that tremendously increases the morbidity and mortality in patients with diabetes mellitus(DM). DM poses about four times higher risk for stroke. Cardiometabolic risk factors including obesity, hypertension, and dyslipidaemia often co-exist in patients with DM that add on to stroke risk. Because of the strong association between DM and other stroke risk factors, physicians and diabetologists managing patients should have thorough understanding of these risk factors and management. This review is an evidence-based approach to the epidemiological aspects, pathophysiology, diagnostic work up and management algorithms for patients with diabetes and stroke.

Coexistence of ovarian serous papillary cystadenofibroma and type A insulin resistance syndrome in a 14-year-old girl: A case report

BACKGROUND Type A insulin resistance syndrome is a rare disorder caused by mutations in the gene encoding the insulin receptor.Its coexistence with ovarian serous papillary cystadenofibroma is even rarer.CASE SUMMARY A 14-year-old girl developed type A insulin resistance syndrome and showed high fasting insulin,glucose,and hemoglobin A1c(HbA1c)levels.The girl suffered from ovarian serous papillary cystadenofibroma.The laboratory results were as follows:fasting insulin was 2624.90 pmol/L and HbA1c was 8.5%.A heterozygous missense mutation on exon 20 of the insulin receptor gene(c.3601C>T,Arg1201Trp)was observed.The histopathological diagnosis was a cystic lesion that extended to the upper right uterus,indicating a right ovarian serous papillary cystadefibroma accompanied by focal interstitial hyperplasia.The patient was treated with metformin for over 6 mo.Additionally,laparoscopic resection(bilateral)of the ovarian lesion and laparoscopic intestinal adhesiolysis were performed under general anesthesia.Diet therapy combined with exercise was then initiated.The patient had an uneventful recovery.The patient also showed improved blood glucose control,with reduced levels of fasting insulin(857.84 pmol/L)and HbA1c(7.0%).CONCLUSION Insulin resistance may play a significant role in the induction of tumors.It is important to investigate further the association between insulin resistance and tumors and the underlying mechanism.

Reproductive disturbances among Saudi adolescent girls and young women with type 1 diabetes mellitus

AIM To identify reproductive disturbances among adolescent girls and young women with type 1 diabetes mellitus(T1 DM) in Saudi Arabia.METHODS This cross sectional study was conducted among 102 female with T1 DM,(aged 13-29 years) who attended the Diabetes Clinic at Diabetes Treatment Center, Prince Sultan Military Medical City, Saudi Arabia between April 2015 to March 2016. Clinical history, anthropometric characteristics and reproductive disturbance were collected through a questionnaire.RESULTS Of 102 patients included in this analysis, 26.5%(27/102) were reported that they experienced an irregular menses. Of these patients, when compared to whose diabetes was diagnosed before menarche(35.4%, 17/48), patients diagnosed with diabetes after menarche(18.5%, 10/54) showed significantly less irregular menses(difference 16.9%, P = 0.04). Similarly, compared to patients diagnosed with diabetes prior to menarche(mean age 12.9 years; n = 48), patients diagnosed with diabetes after menarche(meanage 12.26 years; n = 54) were found to have 0.64 years delay in the age of menarche(P = 0.04). Among the studied patients, 15.7%(16/102) had polycystic ovary syndrome(PCOS). Of these PCOS patients, 37.5%(6/16) had irregular menses, 6.3%(1/16) had Celiac disease, 37.5%(6/16) had Hashimoto thyroiditis and 18.7%(3/16) had acne.CONCLUSION More than one fourth of the study population with T1 DM experiencing an irregular menses. Adolescent girls and young women diagnosed with diabetes prior to menarche showed higher menstrual irregularity and a delay in the age of menarche.

Fasting biochemical hypoglycemia and related-factors in nondiabetic population: Kanagawa Investigation of Total Check-up Data from National Database-8

BACKGROUND In healthy people,the lowest daily blood glucose concentration is usually observed in the early morning,after overnight fasting.However,the clinical relevance and the prevalence of fasting biochemical hypoglycemia(FBH)are poorly understood in people who do not have diabetes,although the clinical implications of such hypoglycemia have been extensively studied in patients with diabetes.FBH can be influenced by many factors,including age,sex,body mass,smoking,alcohol drinking,exercise levels,medications,and eating behaviors,such as breakfast skipping and late-night eating.AIM To determine the prevalence of FBH and investigated its association with potential risk factors in a population without diabetes.METHODS Clinical parameters and lifestyle-related factors were assessed in a cross-sectional study of 695613 people aged 40-74 years who had undergone a health check-up(390282 men and 305331 women).FBH was defined as fasting plasma glucose<70 mg/dL(3.9 mmol/L)after overnight fasting,regardless of any symptoms.The absence of diabetes was defined as HbA1c<6.5%,fasting plasma glucose<126 mg/dL(7.0 mmol/L),and no pharmacotherapy for diabetes.Multivariate logistic regression analysis,with adjustment for confounding factors,was used to identify associations.RESULTS FBH was present in 1842 participants(0.26%).There were significantly more women in the FBH group(59.1%)than in the non-FBH group(43.9%).Values of most of the clinical parameters,but not age,were significantly lower in the FBH group than in the non-FBH group.Logistic regression analysis showed that a body mass index of≤20.9 kg/m2(reference:21-22.9 kg/m2)and current smoking were significantly associated with FBH,and this was not altered by adjustment for age,sex,and pharmacotherapy for hypertension or dyslipidemia.Female sex was associated with FBH.When the data were analyzed according to sex,men in their 60s or 70s appeared more likely to experience FBH compared with their 40s,whereas men in their 50s and women aged≥50 years appeared less likely to experience FBH.The relationships of FBH with other factors including alcohol drinking and pharmacotherapies for hypertension and dyslipidemia also differed between men and women.CONCLUSION FBH occurs even in non-diabetic people,albeit at a very low frequency.FBH is robustly associated with low body mass and smoking,and its relationship with lifestyle factors varies according to sex.

Prehabilitation of overweight and obese patients with dysglycemia awaiting bariatric surgery: Predicting the success of obesity treatment

Bariatric surgery offers the best health results in overweight and obese patients but is not a risk and/or complication-free treatment.In cases with additional hyperglycemia,the burden of surgery can be even higher and alter both shortterm and long-term outcomes.Although bariatric surgery offers glycemic improvements and in the case of early onset diabetes disease remission,weight loss results are lower than for obese patients without diabetes.Different multimodal programs,usually including interventions related to patients’performance,nutritional and psychological status as well as currently available pharmacotherapy before the surgery itself might considerably improve the immediate and late postoperative course.However,there are still no clear guidelines addressing the prehabilitation of obese patients with dysglycemia undergoing bariatric surgery and therefore no unique protocols to improve patients’health.In this minireview,we summarize the current knowledge on prehabilitation before bariatric surgery procedures in patients with obesity and dysglycemia.

Dose Adjustment for Normal Eating: Longer Term Perspectives of Adults with Type 1 Diabetes

Aim:?To explore the longer term blood glucose self-monitoring outcomes and frequency of monitoring for outpatients with diabetes type 1 after completion of the Dose Adjustment for Normal Eating (DAFNE) course. The hypothesis was that DAFNE outcomes would differ according to frequency of glucose monitoring.Methods:?A?sequential data-triangulation design using existing?baseline (T0) and 12-months (T12)?DAFNE course data and interview data from 12 randomly selected participants who had completed the course two years ago.?Results: Age range was 23 to 70 years with HbA1c 6.1% to 12.6% at T0?and 6.1% to 11.4% at T12. Comparisons of HbA1c, PAID, HAD subscales?anxiety?and?depression,?and covariate data between T0?and T12indicatedsignificant reductions in the mean depression and PAID scores (both?P?< 0.001) for the whole group. For the two groups who recorded their blood glucose less than three times or three or more times per day, changes were not significantly different. For both groups, the trend between T0?and T12?was downwards for change in mean blood glucose level and all survey scales. The proportion of all participants with T12?HbA1c at or below their T0?value was greater than 50% (Proportion = 69%, 95% CI: 56% - 79%) but only the highest HbA1c tertile group showed a significant difference (P?= 0.003). There was an average decrease in the incidence of hypoglycaemic events of 0.6 overall: The greatest change was for the high HbA1c tertile with a mean decrease of 0.8. The interview data suggested that DAFNE graduates experimented more with food, exercise, and insulin;gained knowledge;learnt personal body needs;increased awareness of blood glucose level;gained confidence and improved their quality of life. Conclusions: There was insufficient evidence to conclude that frequency of blood glucose monitoring influenced metabolic control. However, people with type 1 diabetes who undertake the less restricted DAFNE approach to diabetes self-management can improve their quality of life and glycaemic control.

enriched diets and the growth, development and survival of litoria moorei (anura) tadpoles reared in captivity at low density

Increasing numbers of amphibian species require conservation breeding programs for their survival.A major challenge is the efficient rearing of tadpoles,many of which require complex habitats and specialised diets.Aquatic tadpoles of the West Australian frog Litoria moorei were kept at low density(1 tadpole per 1.95 litres water) in aquaria at 25℃.Fed on a staple diet of boiled lettuce and leaf litter,group of diets were supplemented with either control,Wardley Premium Spirulina Discs,Sera~(TM) GVG-mix tropical fish food,or a combination of Wardley Premium Spirulina discs and Sera~(TM) GVG-mix fish food.There was a relatively high loss(i.e.,found dead,euthanized due to scoliosis,or not found) of tadpoles fed with the lettuce/leaf litter alone,but this was increased significantly when supplemented with Wardley Premium Spirulina discs,either alone or with Sera~(TM) GVG-mix fish food,and Sera~(TM) GVG fish food alone.However,the survived tadpoles fed on the three supplements were all heavier after three weeks and at metamorphosis than those fed with lettuce/leaf litter alone,and reached metamorphosis quicker.It is concluded that any benefit of the food supplements in terms of increasing the rate of growth and development of the tadpoles is outweighed by greater mortality.There is now a need for the efficient rearing of tadpoles,many from novel species that need complex habitats.Further studies of diet are required due to the current conservation crisis of amphibians.

Incretin manipulation in diabetes management

Incretin-based therapies have revolutionized the medical management of type 2 diabetes mellitus(T2DM) in the 21 st century. Glucagon-like peptide-1(GLP-1) suppresses appetite and gastric motility, and has trophic effects on pancreas, cardio-protective and renal effects. GLP-1 analogues and dipeptidyl peptidase-4 inhibitors form the incretin-based therapies. Significant reduction of hemoglobin A1 c when used as monotherapy and in combination regimens, favorable effects on body weight, and low risk of hypoglycemia are their unique therapeutic benefits. Their safety and tolerability are comparable to other anti-diabetic medications. Concern about elevated risk of pancreatitis has been discarded by two recent meta-analyses. This article discusses the therapeutic manipulation of incretin system for the management of T2 DM.

Effects of glycaemic management on diabetic kidney disease

Hyperglycaemia contributes to the onset and progression of diabetic kidney disease(DKD). Observational studies have not consistently demonstrated a glucose threshold, in terms of HbA1c levels, for the onset of DKD. Tight glucose control has clearly been shown to reduce the incidence of micro-or macroalbuminuria. However, evidence is now also emerging to suggest that intensive glucose control can slow glomerular filtration rate loss and possibly progression to end stage kidney disease. Achieving tight glucose control needs to be balanced against the increasing appreciation that glucose targets for the prevention of diabetes related complications need be individualised for each patient. Recently, empagliflozin which is an oral glucose lowering agent of the sodium glucose cotransporter-2 inhibitor class has been shown to have renal protective effects. However, the magnitude of empagliflozin's reno-protective properties are over and above that expected from its glucose lowering effects and most likely largely result from mechanisms involving alterations in intra-renal haemodynamics. Liraglutide and semaglutide, both injectable glucose lowering agents which are analogues of human glucagon like peptide-1 have also been shown to reduce progression to macroalbuminuria through mechanisms that remain to be fully elucidated. Here we review the evidence from observational and interventional studies that link good glucose control with improved renal outcomes. We also briefly review the potential reno-protective effects ofnewer glucose lowering agents.

Diabetes epidemic in the Asia pacific region:has hemoglobin A1C finally earned its place as a diagnostic tool?

Two-third of the world's population lives in the Asia Pacific region where prevalence of diabetes has reached epidemic proportion.With China and India being the most populous nations on the globe,it is believed that over 150 million diabetes reside in the region with more than 95%being of type 2 diabetes mellitus(T2DM).Furthermore,other Pacific islands in the region have high rales of T2DM including Tonga.Fiji.French Polynesia,and Nauru.The latter has the highest prevalence of T2DM per population in the world.Over the past two decades,in Australia and New Zealand,the prevalence of T2DM has more than doubled,mainly amongst the Aboriginal and Torres Strait Islander and Maori peoples respectively.With the increasing prevalence of dialietes in the Asia Pacific region coupled with the limited number of resources,use of a reliable and effective mode of diagnosis for T3DVI is warranted.Yet to date,only New Zealand has adopted the American Diabetes Association recommendation of using hemoglobin A1C in the diagnosis of the disease.The aim of this review is to discuss the clinical usefulness of hemoglobin A1C and highlight its diagnostic role in the Asia Pacific region where T2DM is increasingly encountered.

Is adiponectin level a predictor of nonalcoholic fatty liver disease in nondiabetic male patients?

AIM: To study the levels of adiponectin in nondiabetic patients with nonalcoholic fatty liver disease (NAFLD) in comparison with control group.METHODS: Thirty-five patients who had elevated serum aminotransferase levels with bright liver and 34 healthy volunteers without liver disease were evaluated. Age,gender and body mass index (BMI) were recorded. Fasting plasma glucose, insulin, adiponectin, proinsulin and lipid profile were measured. A standard oral glucose tolerance test (OGTT) with insulin response was performed and the index of insulin resistance was calculated according to the homeostasis model assessment (HOMA) method.RESULTS: According to the OGTT results, none of the participants had diabetes. Serum adiponectin levels were statistically significantly lower in patients with NAFLD than in control group (8.14±3.4 μg/mL vs12.4±9.4 μg/mL,respectively, P＜0.01). A statistically significant correlation was found between adiponectin and BMI (r: -0.33, P＜0.01),HOMA (r: -0.26, P＜0.05), proinsulin (r: -0.32, P＜0.01),AST (r: -0.25, P＜0.05), ALT (r: -0.26, P＜0.05) or GGT (r: -0.22, P＜0.05). In multiple regression analysis models,adiponectin levels were the only predictor of NAFLD in males, whereas in female group it was the BMI.CONCLUSION: Low adiponectin level might be a predictor of NAFLD especially in male nondiabetics.

Metabolic surgery: A paradigm shift in type 2 diabetes management

Obesity and type 2 diabetes mellitus(T2DM) are major public health issues globally over the past few decades. Despite dietary interventions, lifestyle modifications and the availability of several pharmaceutical agents, management of T2 DM with obesity is a major challenge to clinicians. Metabolic surgery is emerging as a promising treatment option for the management of T2 DM in the obese population in recent years. Several observational studies and a few randomised controlled trials have shown clear benefits of various bariatric procedures in obese individuals in terms of improvement or remission of T2 DM and multiple other health benefits such as improvement of hypertension, obstructive sleep apnoea, osteoarthritis and non-alcoholic fatty liver disease. Uncertainties about the long-term implications of metabolic surgery such as relapse of T2 DM after initial remission, nutritional and psychosocial complications and the optimal body mass index for different ethnic groups exist. The article discusses the major paradigm shift in recent years in the management of T2 DM after the introduction of metabolic surgery.

Unhealthy eating habits around sleep and sleep duration: To eat or fast?

Traditionally, breakfast skipping(BS), and recently latenight dinner eating(LNDE), have attracted attention in public health because they can predispose to cardiometabolic conditions such as obesity and type 2 diabetes. Intriguingly, it has become evident that short duration of sleep elicits similar health risks. As LNDE, BS, and short sleep can be closely related and can aggravate each other, these three should not be considered separately. In this context, LNDE(or its equivalents, snacking or heavy alcohol consumption after dinner) and BS may be representative unhealthy eating habits around sleep(UEHAS). While it is important to take energy in the early morning for physical and intellectual activities, attaining a fasting state is essential for metabolic homeostasis. Our previous UEHAS studies have shown that BS without LNDE, i.e., BS alone, is not associated with obesity and diabetes, suggesting the possibility that BS or taking a very low energy breakfast, which could yield fasting for a while, may prevent obesity and diabetes in people with inevitable LNDE. Further studies considering UEHAS and short sleep simultaneously are needed to elucidate the effects of these unhealthy lifestyles on cardiometabolic diseases.