Metabolic Factors Modulating the Connection Between Diabetes and Pulmonary Alterations

Type 1 and 2 diabetes have been variably associated with reduced forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC), but mechanisms remain unclear. This study examined the role of glucose and insulin metabolism for pulmonary function across diabetes (sub)types and normal glucose tolerance as the control (CON) in the German Diabetes Study (GDS) and assessed causality by Mendelian randomization (MR) analyses in independent cohorts.

In GDS, 426 spirometry measurements of participants with type 1 diabetes, 482 of participants with type 2 diabetes, and 244 of CON were cross-sectionally analyzed after phenotyping, including Botnia clamps for insulin sensitivity (M value), secretion, and clearance. Associations between metabolic measures and lung function were assessed using generalized linear models, adjusting for confounders. MR analysis used data from the MAGIC (Meta-Analyses of Glucose and Insulin-Related Traits Consortium) consortium (HOMA-insulin resistance [IR], n = 37,037) and the UK Household Longitudinal Study (pulmonary function, n = 321,047).

In GDS, higher M value (all β > 0.18, P < 0.0001) and insulin clearance (all β = 0.05, P < 0.050) were associated with higher FEV1 and FVC. Compared with type 1 diabetes and CON, type 2 diabetes had lower FEV1 and FVC, which associated with M value (all β > 0.17, P < 0.050). FEV1 was associated with daily insulin doses in type 1 diabetes (β = -0.21, P = 0.0006). FEV1 was associated with type 2 diabetes (β = -0.19, P = 0.0052), severe insulin resistant (β = -0.27, P = 0.039), and mild age-related diabetes (β = -0.23, P = 0.0033). MR supported a causal association between HOMA-IR and lower FEV1 (β = -0.13, P = 0.0018).

Lower FEV1 and FVC in diabetes are linked to insulin resistance, impaired clearance, and higher insulin doses, all of which result in higher insulinemia and likely represent underlying pathogenic mechanisms.