Population based study of quality of diabetes care in southern India.

OBJECTIVES: To analyse and compare the clinical profile and glycaemic outcome in known diabetic cases in South Indian urban and periurban populations. MATERIAL AND METHODS: Details of known type 2 diabetic cases identified in a population survey of diabetes in Chennai city, Kanchipuram town and Periurban Villages (PUV) of Panruti in Tamil Nadu were analyzed (n=524, M:F, 256:268). Glycaemic outcome, prevalence of hypertension, dyslipidaemia and obesity, and treatment details were studied and compared between the areas. RESULTS: Mean age at diagnosis was 45.3 +/- 10.1 years, prevalence of hypertension was 57.4% (32% known), 48% were obese and a larger percentage (63.3%) had abdominal obesity Dyslipidaemia was present in nearly 50%. Abnormalities were more in urban areas than in PUV. Glycaemic target (post prandial glucose < or =160 mg/dl) was met by 28.8% only; better results were seen in PUV. In PUV 46% were not taking any diabetic treatment. As expected, majority of patients in all areas were treated with oral drugs. CONCLUSIONS: This population-based data indicated that the clinical outcome in known diabetic cases was far from satisfactory even in the city, where specialized diabetes care was available.

High prevalence of cardiometabolic risk factors among young physicians in India.

AIM: To assess the health status of young Indian doctors engaged in clinical practice compared with the general population. MATERIALS AND METHODS: During a continuing medical education programme on diabetes, data from 2499 doctors from urban and semiurban areas, (mean age 39.0 + 9.0 yrs), were collected and was compared with 3278 subjects from general population (mean age 37.0 +/- 8.0 yrs). Prevalence of diabetes, hypertension, obesity, dyslipidaemia, metabolic syndrome, smoking and alcohol consumption were analysed. RESULTS: Doctors had significantly higher (p<0.001) prevalence of all abnormalities except diabetes, compared with the general population (diabetes 13.3 Vs 14.8%, impaired glucose tolerance 10.7 Vs 7.4%, hypertension 35.6% Vs 27.0%, obesity 55.5% Vs 35.8%, metabolic syndrome 29.0% Vs 24.8%). Undetected cases of diabetes and hypertension were similar in both groups. Use of alcohol was more common among doctors. Other illness was less common among doctors (13.2% Vs 21.8%, p < 0.001). CONCLUSIONS: In India, doctors had high prevalence of metabolic disorders showing that they had not taken good care of their health. Doctors need to be motivated to practise good healthcare habits that they advocate to their clients.

Parental influence on the spectrum of type 2 diabetes in the offspring among Indians.

AIM: Familial aggregation of type 2 diabetes and its vascular complications is strong in Indians. In this study, we have analysed whether the age of the parent at birth of the offspring had any influence on the age at diagnosis of diabetes and age at onset of microvascular complications in the diabetic offspring. METHODS: Families with either a type 2 diabetic father or mother and a type 2 diabetic offspring, all of whom had been tested at our centre were included in this study (n = 300, father--122, mother--178, offspring male --201, female--99). Anthropometric details, age at diagnosis of diabetes, age at onset of complications and duration of diabetes were recorded. All relevant clinical and investigatory tests were done and appropriate statistical analyses were done. RESULTS: Age at onset of diabetes was lower in the offspring than in their parents at least by a decade. The age at diagnosis of diabetes in the offspring was determined inversely by the age of the parent at childbirth (p<0.001) and positively by the age of onset of diabetes and the presence of complications in the parents (both p<0.0001). Moreover, the age at diagnosis of complications in the offspring were determined inversely by the age of the parent at childbirth (p=0.0001) and positively by the age of onset of complications in the parents (p=0.0009). DISCUSSION: A younger parental age at childbirth was protective to the offspring in that the offspring developed diabetes and the complications at an older age.

Stress and undetected hyperglycemia in southern Indian coastal population affected by tsunami.

AIM: Natural calamities are known to result in higher stress conditions and also result in adverse health outcomes including development of non-communicable diseases. The impact of tsunami on mental stress and prevalence of hyperglycemic conditions was assessed in a population affected by the calamity in coastal populations of southern India. METHODS: Two populations similar in demography and physical characteristics, but, one affected by tsunami were selected for a comparative study. Subjects aged 20 years or above were randomly selected (control population n = 1176; tsunami population n = 1184). Details of stress were assessed using Harvard trauma questionnaire and scores were assigned. Glucose tolerance was assessed using 2h capillary blood glucose (75gms glucose load) and diagnosis was made using WHO criteria. RESULTS: Stress score was significantly higher in tsunami population. Although the total prevalence of diabetes was similar (control - 10.0 %; tsunami population - 10.5 %) prevalence of undetected diabetes (5.7 % vs. 3.8 %; Z = 9.54, P < 0.001) and impaired glucose tolerance (9.8 % vs. 8.3 %; Z = 12.83, P < 0.001) higher in the tsunami area. Stress score was higher in women and in the young in the tsunami area. CONCLUSION: Population affected by tsunami was under high stress and also showed a high prevalence of undetected diabetes and impaired glucose tolerance.

Impact of Joint National Committee VII recommendations on diabetic microvascular complications.

AIMS AND OBJECTIVE: To determine the impact of the Seventh Report of the Joint National Committee recommendations on microvascular complications in South Indian type 2 diabetic patients. MATERIAL AND METHODS: In this study, 457 type 2 diabetic patients and 500 age-matched healthy control subjects, with no history of hypertension were enrolled. Based on blood pressure measurements, they were assigned as Group I: Normal (SBP < 120 and DBP < 80 mmHg); Group II: Prehypertension (SBP 120-139 or DBP 80-89 mmHg); Group III: Stage I hypertension (SBP 140-159 or DBP 90-99 mmHg) and Group IV: Stage II hypertension (SBP > or = 160 or DBP > or = 100). RESULTS: Blood pressure readings in controls and diabetics were: normal in 46.8% and 16.2% (chi2 = 101.1, p < 0.0001), prehypertension in 33.2% and 52.5% (chi2 = 35.7, p < 0.0001), stage I hypertension in 15.2% and 26.3% (chi2 = 17.3, p < 0.0001), stage II hypertension in 4.8% and 5% respectively. Prevalence of retinopathy increased with increasing incidence of hypertension (trend chi2 = 10.7, p < 0.01). In the multivariate analysis, cholesterol was associated with prehypertension, and cholesterol and family history of hypertension were associated with stage I hypertension. Albuminuria, family history of hypertension and serum triglycerides were associated with stage II hypertension. CONCLUSION: More than half of the diabetic subjects were prehypertensives. As expected prevalence of other complications increased with increasing levels of blood pressure. This emphasizes the need to have regular check up for hypertension to reduce the morbidity from other complications.

Detecting undiagnosed diabetes in urban Asian Indians--role of opportunistic screening.

BACKGROUND: The aim of the study was to determine the proportion of incidental to symptomatic diagnosis of diabetes and to compare the profile of symptomatic and incidentally diagnosed diabetic subjects. METHODS: One thousand newly diagnosed diabetic subjects (WHO criteria) were studied. Clinical, demographic, anthropometric details, blood pressure, glycaemic and lipid parameters were recorded. Reasons for medical check up were noted. RESULTS: Among the 1000 subjects, 29% were symptomatic for diabetes and 71% were incidentally diagnosed to have diabetes. Symptomatic subjects were younger, had higher glycaemia and prevalence of hypertension. CONCLUSION: The results show that majority of type 2 diabetic subjects remain asymptomatic and opportunistic screening for diabetes would be required for the early diagnosis of the disorder.

Use of glimepiride and insulin sensitizers in the treatment of type 2 diabetes--a study in Indians.

AIM: Short-term efficacy of glimepiride, metformin and pioglitazone in newly diagnosed type 2 diabetes was compared with a group treated with diet and exercise. Effects on insulin secretion and sensitivity were also assessed. METHODS: New type 2 diabetic subjects, aged 30-60 years with BMI < 30 kg/m2 were selected. Subjects having glycosylated haemoglobin (HbA1c) of < 8.5% were advised diet and exercise (control group). Others having HbA1c > or = 8.5 to 11.0% were randomized to receive glimepiride (group 2), metformin (group 3) and pioglitazone (group 4). At the final review between 12-14 weeks, changes in plasma glucose, HbA1c, lipid profile, HOMA insulin resistance (HOMA-IR), beta cell function (HOMA-BF) and insulinogenic index (delta I/G) were measured. Comparisons were made using appropriate statistical analyses. RESULTS: Seventy-seven of the 97 subjects randomized equally into four groups, were available for review. Glycaemic parameters improved in all groups. Mean cholesterol decreased significantly in groups treated with metformin and pioglitazone. HDL-cholesterol increased with pioglitazone. Insulin resistance decreased significantly with metformin and pioglitazone, beta cell fuhction also showed improvement CONCLUSIONS: Glycaemic control was seen in all study groups, the improvement was better in drug treated groups than in the control group. Glimepiride improved insulin secretion including the early phase secretion and reduced plasma triglycerides. Metformin and pioglitazone had beneficial effects on lipid levels, improved insulin sensitivity and improved insulin secretion also.

Age-specific prevalence and risk associations for impaired glucose tolerance in urban southern Indian population.

OBJECTIVES: A national survey of diabetes and impaired glucose tolerance (IGT) conducted in 2000 AD in six major cities of India showed a high prevalence of diabetes (12.1%) and IGT (14%). Prevalence of IGT was higher than that of diabetes in subjects with less than 40 years when compared with older subjects. This analysis was done to look for differences in the risk factors associated with IGT in the younger and older subjects. METHODS: Associations of body mass index (BMI), waist : hip ratio, physical activity, family history of diabetes and monthly income with IGT and with diabetes were tested in the age groups of < 40 and > or = 40 years separately. Multiple logistic regression analyses were done to test the associations. RESULTS: Prevalence of IGT was higher than diabetes in the younger group (13.1% Vs 5%, P < 0.001). Prevalence of obesity was higher in the older IGT subjects (38% Vs 30.5%, p < 0.003). Presence of positive family history of diabetes was similar in both the groups. In the > or = 40 year group age, BMI and family history of diabetes were common risk factors for diabetes and IGT. In the younger group, only BMI showed an association with IGT. The association of family history of diabetes with IGT was weaker than for diabetes even in the older subjects (Odds Ratio (OR) = 3.5 for diabetes, 1.33 for IGT). CONCLUSIONS: Prevalence of IGT was higher than diabetes in the age group < 40 years. Only BMI showed an association with IGT in them while the risk associations were similar to diabetes in the older group. Prospective studies will throw more light on the implications of these findings.

Persistent microalbuminuria in type 1 diabetic subjects in South India.

AIM: There are only a few reports on the prevalence of microalbuminuria (MAU) in type 1 diabetic subjects in India. This study was done to assess the prevalence of MAU in South Indian diabetic subjects. MATERIAL AND METHODS: MAU was estimated by measuring albumin/creatinine ratio in an early morning urine sample on three occasions using immunoturbidimetry (> 30 microg albumin/mg creatinine) in South Indian patients. Kidney function tests were done in 95 type 1 DM, (M:F, 56:39). Persistent proteinuria was detected in 17 (17.9%) and they were excluded from the study. Further details were taken only in the remaining 78 subjects. Persistent MAU was seen in 22 (28.2%) and other 56 subjects had normoalbuminuria (NAU) (71.8%). RESULTS: There was no significant difference in the age, duration of DM and the average HbAlc between MAU and NAU. MAU developed at the age of > or = 20 years, even in subjects with onset of diabetes at a younger age. Diabetic retinopathy was present in 3 (13.6%) and ECG abnormalities were seen in one patient with MAU. None of the subjects in NAU group had these abnormalities. Prevalence of MAU increased with increasing duration of diabetes, MAU was present in 3 patients (10.3%) with duration of diabetes < or = 5 years, in five patients (23.8%) with duration of diabetes> 5 to < or = 10 years and in 14 (50%) patients with duration of diabetes > 10 years. Hypertension was present in 5 (22.7%) of MAU and only in one subject with NAU. CONCLUSION: It is observed that MAU occurs in type 1 diabetes after the age of 20 years and it is present in a large proportion of the study subjects.

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.

Prevalence of pathogens in diabetic foot infection in South Indian type 2 diabetic patients.

AIM: To determine the prevalence of pathogens in diabetic foot infections, in relation to parameters like Wagner's grading, duration of diabetes and healing time. MATERIAL AND METHODS: A group of 654 (M:F, 433:221) type 2 diabetic patients with foot ulcers were studied. Specimens like pus, wound exudate and tissue were processed for smear for Gram's staining, aerobic and anaerobic culture, and biochemical identifications. RESULTS: In 654 diabetic patients, 728 pathogens were isolated. Aerobic pathogens were isolated in 437 (66.8%) patients and anaerobic pathogens were isolated in 217 (33.2%). As Wagner's grading increased, the prevalence of anaerobic pathogens also increased. Neuropathy was common in diabetic patients infected with both aerobic and anaerobic pathogens. Ulcers infected with anaerobic pathogens showed a longer healing time than ulcers infected with aerobic pathogens. There was no significant difference in peripheral vascular disease (PVD) in patients selected for the study. Among aerobic pathogens, Enterobacteriaceae family (48%), Staphylococcus species (spp) (18.2%), Streptococcus spp (16.8%) and Pseudomonas spp (17%) were seen frequently. Among anaerobes Peptostreptococcus spp and Clostridium spp formed 69.4%. Gram-negative anaerobes like Bacteroides spp and Fusobacterium spp were present in 30.6%. Healing time was longer when strict aerobic pathogen Pseudomonas spp and strict anaerobic pathogens were present (136.1 +/- 28.6 and 136.4 +/- 34.7 days, respectively). CONCLUSIONS: Diabetic foot infection is polymicrobial in nature. The healing time of wound infected with anaerobic pathogens was higher than those infected with aerobic pathogens. Anaerobic pathogens increased with the Wagner's grading. Presence of neuropathy increased the risk of foot infection.

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.

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.

Patients' adherence to diabetes treatment.

OBJECTIVES: a) To evaluate the patients' adherence to the treatment prescriptions and b) to analyse the reasons for non adherence. METHODS: A random sample of 386--type 2 diabetic subjects (M:F 223:163) were studied. Each subject was personally interviewed using a computerised proforma. The mean age of the study group was 52 +/- 10 years and 53% were treated with oral hypolycenic agent (OHA) and the rest with a combination of insulin and OHA. The mean duration of diabetes was 11.0 +/- 6.9 yrs. The overall adherence to the treatment regimen, diet and drug prescriptions and also regularity of home glucose monitoring by blood or urine tests were assessed. RESULTS: It was noted that only 25% of the study group were adhering to the treatment regularly. Dietary prescriptions were followed regularly only by thirty seven percent. Home glucose monitoring was being done only by twenty three percent. Non adherence was not related either to the age or duration of diabetes. Non adherence was more in the lower socio-economic group and was inversely related to the educational status. It was noted that approximately 20% of the subjects had an indifferent attitude to the advice given. CONCLUSIONS: The results showed that the rate of non adherence of treatment prescriptions was high. It stresses the need for constant motivation and one to one level education at frequent intervals to ensure better compliance to the treatment.

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.

Need for education on footcare in diabetic patients in India.

OBJECTIVES: The patient himself plays the crucial role in the prevention of diabetic foot disease and therefore education on foot care is important. In this study, we have evaluated the knowledge of the diabetic subjects regarding the foot problems and the care of feet in order to identify areas that require stress in the education programme. PATIENTS AND METHODS: Two hundred and fifty, consecutive cases of Type 2 diabetes (M:F, 176:74, age 57.2 +/- 9.7 yrs, duration 12.9 +/- 7.9 yrs) were selected for this study from the out-patient department of our hospital. A questionnaire was filled up for each patient by personal interview. The total score was 100 and a score of < 50 was considered as a low score for foot care knowledge. RESULTS: A score of < 50 was obtained in 67.2%. Low score was more common in women (78.5%) than in men (62.5%) (chi 2 = 5.26, P = 0.022). Low scores (< 50) were more common among those with lower level of formal education (chi 2 = 70.0, P < 0.0001), there were more women with low educational status. Significant foot problems like gangrene, foot ulcers were present in 27.2% and low scores were more common among those with these complications (82% vs 62%) (chi 2 = 8.3, P = 0.004). In general the scores on awareness of general foot care principles and basic facts about the foot complications were poor. Most of them (72%) had good knowledge about the right usage of foot wear. There was a trend to have lower scores with poor formal education (chi 2 = 51.1, P < 0.0001) and also with increasing age. There was no correlation between the scores and the number of hospital visits. Multiple linear regression analyses showed that 31.2% of the variations in the scores were explained by the level of education. CONCLUSIONS: This study underscores the importance of patient education on foot care principles, especially so, considering the magnitude of the problem of diabetes and the lower levels of literacy and poor socio economic status of many patients in this country.

Influence of life style factors in development of diabetes in Indians--scope for primary prevention.

OBJECTIVE: The objective of the study was to evaluate the influence of physical activity and stress factors on the development of diabetes mellitus (DM). METHODS: One hundred and eighty-seven adult subjects (M:F 112:75), registered in the primary prevention of diabetes programme for 2 or more years were studied prospectively. The study was done only in those who had either normal glucose tolerance (NGT) or diabetes at the time of review (tR). At entry (tE), 121 (64.7%) had normal glucose tolerance (NGT) and 66 (34.3%) had impaired glucose tolerance (IGT) by the WHO criteria. Dietary modifications and regular exercise programme were advised. Dietary modifications and regular exercise programme were advised. Study subjects were reviewed during August 1997 to October 1998. At review (TR) none had known history of diabetes. At TR, the status of glucose tolerance was assessed by oral GTT and influence of intervention measures and evaluation of the role of physical and psychological stress on glucose tolerance were assessed by a questionnaire method. RESULTS: At tR, 100 (53.5%) had NGT, and 87 (46.5%) had developed diabetes (DM). Adherence to exercise and other preventive measures was poor in the DM compared to nondiabetic group (NGT) (P < 0.0012). They showed lower dietary adherence (P = 0.042) and scores on mental stress was higher than in NGT group (P < 0.001). After controlling for age, gender and the initial 2 h plasma glucose, non-adherence to exercise and high scores of psychological stress showed strong association with diabetes. CONCLUSION: In this study, significant and independent roles of physical inactivity and psychological stress factors are demonstrated in the development of diabetes.