a systematic review and meta-analysis

This is the first report on the relationship between clustered lifestyle, not a single aspect of lifestyle, and cardio-renal-metabolic parameters in patients with T2DM. Using factor analysis, lifestyle patterns in real daily life can be classified into three factors; morningness-eveningness, sleep quality and depressive state (type 1 pattern), consumption of food, alcohol and cigarettes (type 2 pattern), and physical activity (type 3 pattern). Interestingly, each lifestyle is associated with distinct cardio-renal -metabolic parameters.

Subjects with a higher score of type 1 pattern characterized by evening type, poor sleep quality and depressive status showed poor glycemic control and higher ALT and UAE levels in this study. It may be reasonable that these characteristics correlated well with each other because previous reports showed a tendency for such association[14] [15]. These individuals tend to have later dinners, frequent late evening snacks, and less frequent breakfast and consume more food. They were considered to consume a greater amount of their daily energy intake at late time of the day. A previous study demonstrated that late dinnertime increases in postprandial glucose levels after breakfast in the following morning compared to usual dinner time condition through a higher effect of late dinners on carbohydrate digestion and absorption of dietary carbohydrates [30]. Therefore, it seems that late eating could result in worsening of glycaemic control. In addition, consistent with our findings, evening type was shown to be related to more depressive symptoms [31]. Depressive status may also negatively affect glucose metabolism through increased counter-regulatory hormones [19].

Subjects with a higher score of type 1 pattern were more likely to be employed as workers, with higher frequency of overtime work beyond 21:00 PM (data not shown). Such workers may be often forced to stay awake through social cues against their preference. This may lead to disruption of the circadian system. A previous study demonstrated that forced circadian misalignment developed insulin resistance [32]. Therefore, circadian misalignment by environmental elements may contribute to worsening of glycemic control in those patients.

Patients with T2DM are known to have sleep abnormalities compared with healthy subjects [33]. In the present study, subjects with a higher score of type 1 pattern had poor sleep quality and short sleep duration. Recent studies reported both sleep quality and/or duration have negative influence on glucose and lipid metabolism in T2DM patients [911]. Sleep has major regulatory effects on metabolic function, hormone release and sympathovagal activity. Indeed, sleep deprivation is reported to be associated with low levels of circulating satiety hormone leptin, high levels of appetite stimulating hormone ghrelin [34] and high sympathetic activity [35]. These changes are expected to be deleterious for glycaemic control. Taken together, our findings suggest the synergistic deleterious effects of these unfavourable traits on glycemic control in patients with T2DM. In fact, our multivariate regression analysis suggested that type 1 pattern was associated with higher HbA1c levels even considering other lifestyle patterns. Thus, optimizing these unfavourable habits should be investigated as an intervention to improve glucose control in patients with T2DM.

Subjects with a higher score of type 1 pattern had high UAE levels. The high levels of UAE could be due to poor glycemic control and potentially high sympathetic activity. Due to the presence of accumulated risk factors for atherosclerosis, type 1 pattern was associated with increased atrial stiffness in the multivariate regression model.

Subjects with a high score of type 2 pattern reported high cons