Effect of a Comprehensive Training Programme for Tuberculosis Health Care Providers and Tuberculosis Patients on Diabetes – A Report from South India.

Aims: High prevalence of diabetes mellitus (DM) in TB patients demands that TB health care providers are sensitized and updated on risk factors, screening, diagnosis and management of DM. This study was designed to assess the impact of one day training programme on screening, detection and management of DM. Study Design: One group – pre and post test design. Place and Duration of Study: The one day training session with an inbuilt awareness programme was conducted for TB health care providers and TB patients with diabetes, over a period of 3 years, from since November 2010 involving 22 tuberculosis units of 3 districts in Tamil Nadu, India. Methodology: The impact was assessed using a pretested questionnaire pre and post training, based on the improvement in knowledge among physicians and other health care providers and awareness among patients. Similarly, using a separate questionnaire before and six months after the training programme, improvement in practice was assessed based on an increase in the proportion of staff involved in screening, educating and referring TB patients with diabetes. Appropriate statistical analysis was done using SPSS version 16. Results: There was a significant increase in the knowledge of physicians and other health care providers and in patient’s awareness on all components covered under the training and awareness session respectively. No significant improvement was noted in the knowledge of other TB health care providers, in diet category on the questionnaire. There was a significant improvement in practice based on the substantial increase in the proportion of tuberculosis unit staff conducting DM screening for TB patients using appropriate methods and in referrals for proper management of DM. Conclusion: The training session on DM with an inbuilt awareness campaign for TB patients had a significant impact on the knowledge and practice of TB health care providers.

Risk of future diabetes is as high with abnormal intermediate post-glucose response as with impaired glucose tolerance.

AIMS: This analysis was done to compare the risk of development of diabetes among subjects with impaired glucose tolerance (IGT) and early glucose intolerance (EGI; intermediary post glucose level > or = 160 mg/dl) when compared with normal (NGT). Profile of insulin secretion and insulin resistance was compared in a subgroup of subjects with EGI, IGT and diabetes. PATIENTS AND METHODS: A program on 'primary prevention of diabetes' was initiated and high risk subjects were encouraged to join the program and were followed up. Out of 4084 (M:F 2344:1740) subjects enrolled in the program, a total of 1659 (M:F 1044:615) subjects with mean age 41.3 +/- 10.2 years who had at least two follow up visits were selected for this analysis. OGTTs were performed once in every 6 months. The median follow up duration was 5 years. The conversion rate to diabetes in subjects with persistent IGT or EGI was determined. In a subgroup of subjects, NGT (n = 118), IGT (n = 68), EGI (n = 106) and new DM (n = 126), plasma insulin at fasting, 30 min and 2 hr were measured and insulin resistance (HOMA-IR) was calculated by HOMA method. Insulinogenic index (DeltaI/G) was also calculated. RESULTS: The rate of conversion of IGT 251 (40.5%) and EGI 210 (36.5%) subjects to diabetes was similar and significantly higher when compared with the NGT subjects 99 (21.3%). Similar results were noted both in men and women. By using ROC procedure, a cut - off value of one hour post glucose of > or = 160 mg/dl gave a sensitivity of 80% and specificity of 70% to detect abnormal glucose tolerance. In a subset of subjects studied, it was noted that subjects with EGI had significantly higher fasting insulin values than NGT. Insulin resistance (IR) was the highest in DM [Geometric mean (SD)] 6.6 (1.9)), followed by EGI (4.5 (2.3)) (p < 0.0001 vs NGT, 2.9 (2.4)) and IGT (3.9 (2.2)). Insulinogenic index was normal in EGI, NGT and IGT, and it was lower in DM in comparison with other groups. The multiple logistic regression analysis showed that EGI (odds ratio (OR) 2.11) and development of diabetes was strongly associated. The survival curve (time free from diabetes) showed that the median survival time for NGT, EGI and IGT were 18.7, 11.6 and 9.6 yrs respectively. CONCLUSION: EGI which is a distinct entity with abnormal intermediate glucose response in glucose tolerance test (GTT) appears to be a risk factor similar to IGT in the development of diabetes. They had higher insulin resistance with normal insulin secretion. Therefore, it is important to determine the intermediate value also during the GTT in addition to fasting and 2 hr post glucose values.

Plasma homocysteine concentration and coronary artery disease in Asian Indians.

OBJECTIVE: This study was done (a) to evaluate the relationship between the plasma total homocysteine (tHcy) levels and coronary artery disease (CAD) in Asian Indians and (b) to see the relationship between tHcy and glucose intolerance. METHODS: Fasting concentrations of plasma tHcy was measured in 137 men, aged > or = 25 years who underwent coronary angiography while investigating for chest pain. Among them 71 had no CAD and 66 had CAD. Fasting plasma glucose (FPG) and glycosylated haemoglobin (HbA1c) were estimated. Total Hcy was measured using the Elisa method (Axis Biochemicals ASA-Oslo, Norway) in fasting EDTA plasma. RESULTS: The subjects with CAD were significantly older but had similar body mass index (BMI), waist-hip ratio (WHR), FPG and HbA1c values compared with the non-CAD subjects (P < 0.001). The median tHcy and the percentages of abnormal values were similar in non-CAD and CAD groups. No significant differences were seen in the four subgroups with respect to the mean tHcy or the percentage of abnormal values. The highest tHcy values were seen in the non-diabetic, non-CAD group (group 1--control). CONCLUSION: This preliminary data indicates that tHcy concentrations are not elevated in subjects with CAD and probably there is no association between total homocysteine and CAD in Indians. Homocysteine values were not influenced by the glucose tolerance status. Measurement of homocysteine concentrations may be more appropriate when the blood levels of vitamin B12 and folate are also measured.

Is increased apolipoprotein B-A major factor enhancing the risk of coronary artery disease in type 2 diabetes?

OBJECTIVES: An association of Apolipoprotein B (Apo B) with coronary artery disease (CAD) independent of LDL cholesterol (LDLc) concentrations has been reported in white population. This analysis was taken up to study whether the higher CAD risk in Asian Indians with diabetes could be explained by possible alterations in Apo B and Apolipoprotein A1 (Apo A1) concentrations. METHODS: The study group consisted of four hundred and forty seven men aged > or = 25 years, 167 with CAD and 280 with no CAD, classified by coronary angiography. Plasma lipid profile including total cholesterol, LDLc, Apo A1 and Apo B were done. Glucose tolerance was evaluated in all. RESULTS: Age, BMI, Apo B, and Apo A1 were significantly associated with CAD in a multiple regression analysis. Hyper Apo B was more common than hyper LDLc in CAD (73.6% vs 20.4%, chi2 = 157, P < 0.001). Apo B concentrations were increased in diabetic subjects even in the presence of normal levels of LDLc and in the absence of CAD. CONCLUSIONS: The study has shown that the apolipoproteins B and A1 provide better information regarding the risk of CAD. Apo B abnormalities exist in large percentages of CAD subjects despite having normal levels of LDLc. Diabetes per se enhances the Apo B concentrations and this could probably be one of the mechanisms of accelerated CAD in diabetes. Hyper Apo B may be an index of CAD risk.

Prevalence of vascular complications and their risk factors in type 2 diabetes.

OBJECTIVE: a) To determine the prevalence of microvascular and macrovascular complications in Type 2 diabetes in India and b) to identify the major factors for the complications. METHODS: A study was done in 3010 subjects (M:F 1892:1118, Mean age 52 +/- 9.7 years) attending a diabetic clinic. The study sample resembled the population sample in anthropometry, age and socioeconomic factors. All patients had undergone the tests for retinopathy, nephropathy, neuropathy, peripheral vascular disease (PVD) and cardiovascular disease by ECG. RESULTS: Retinopathy was diagnosed in 23.7% (background retinopathy in 20.0% and proliferative in 3.7%), proteinuria was present in 19.7% and persistant proteinuria of > or = 500 mg/dl was seen in 5.5% of them, CHD was present in 11.4% and PVD was present in 4.0%. Of the total 119 cases with PVD, 18 had gangrene and 21 had undergone amputations. Peripheral neuropathy was present in 27.5%. Cerebrovascular accidents were reported in 26 cases (0.9%). Hypertension was present in 38% of the cases. Multiple logistic regression analyses showed that age had a significant association with retinopathy, neuropathy, CHD and PVD. Duration of diabetes had significant association with the complications other than CHD. Higher HbA1 increased the risk of retinopathy, neuropathy and nephropathy. Hypertension was associated with the complications except PVD and neuropathy. The strongest association was between hypertension and nephropathy. CONCLUSION: The study highlights the high prevalence of vascular complications in Type 2 diabetes in India. Retinopathy and neuropathy were the commonest complications of diabetes.

Difference in body fat percentage does not explain the gender dimorphism in leptin in Asian Indians.

OBJECTIVE: Leptin is a hormone probably having regulatory function on energy intake and metabolic activities in humans. The study was done: (a) To determine the relation of leptin with the body fat% in Indians, (b) To see whether the differences in body fat accounted for the gender differences in the concentration of leptin and (c) to look for the effect of diabetes on the levels of leptin. METHODS: Glucose tolerance was determined by oral glucose tolerance test (GTT) in 87 subjects with no known history of diabetes. Leptin was estimated by radio immuno assay. Age, height, weight, waist and hip circumferences were noted. Body mass index (BMI, weight kg/height m2) and waist:hip ratio (WHR) were calculated. The body fat % was estimated by bioelectrical impedance analysis. RESULTS: Leptin correlated with log fat % and BMI, body weight and waist circumference in different categories of glucose tolerance (Pearson's correlation test). Leptin values were higher in women than in men even after correcting for the body fat % indicating that the gender dimorphism was not explained by the higher fat % in women. The geometric mean of leptin concentration in men was 3.6 ng/ml and in women 10.9 ng/ml (P < 0.0001). Leptin level were not influenced by the status of glucose tolerance. Gender showed a significant effect on leptin concentration (F = 11.0, df = 1.39, P = 0.002) after adjusting for the effect of covariates i.e. percentage of fat (log), BMI, age, WHR and 2 h plasma glucose by ANCOVA. None of the covariates except BMI (P < 0.0001) showed significant correlation with leptin. The total variance explained was 68.4%. CONCLUSION: We conclude that (1) Plasma leptin is strongly correlated to the body fat content (2) the gender dimorphism of leptin is not explained by the differences in fat percentage and (3) hyperglycemia does not influence plasma leptin levels.