A quantitative assessment of patient barriers to insulin

AIM

To assess diabetes treatment preferences with a focus on patient barriers to insulin treatment.

MATERIALS AND METHODS

A questionnaire using indirect and direct methods was administered as part of the International Diabetes Management Practices Study (IDMPS). Discrete choice modelling was used to assess how product attributes influence patients' preferences for diabetes treatment. A multinomial logit model was used to find the odds ratio for each parameter, representing the probability of selecting a chosen alternative given a choice set. This allowed for the derivation of relative attribute importance, an indication of how influential product attributes are in the respondents' choices.

RESULTS

The IDMPS questionnaire was administered to 14,033 individuals with diabetes in 18 countries. The majority of respondents were women (53%) and had Type 2 diabetes mellitus (T2DM; 85%). Across subgroups, administration (i.e. oral vs. injection) was a driver of preference. Patient preferences varied according to diabetes type; individuals with T2DM assigned much higher relative importance to administration than those with Type 1 diabetes mellitus (T1DM; 30.86% vs. 4.99%; p<0.0001). Individuals with T2DM treated with insulin placed less importance on administration than insulin-naïve T2DM patients (3.09% vs. 47.48%; p<0.0001). Diabetes education also had a significant effect on the priority given to administration between T2DM patients who received diabetes training and those who did not (28.21% vs. 33.68%, respectively; p<0.0001).

CONCLUSION

The insulin barriers perceived by patients with diabetes evolved with their disease experience. While administration was the primary preference driver for insulin-naïve patients, patients were increasingly concerned with more clinically relevant barriers as they gained experience with insulin. This finding suggests that patients using insulin understand the importance of achieving an optimal balance between safety and efficacy.

Diabetes prevention programs

Primary prevention of type 2 diabetes is effective for curbing its epidemic. Lifestyle intervention has been found to be a highly effective, safe, and cost-effective method for the prevention of diabetes in high-risk persons, the benefit of which can extend for many years. Among the pharmacologic agents studied for prevention of diabetes, metformin has been found to be the safest. Interventions using drugs are less preferred because the drugs' effects tend to dissipate after their use is stopped and adverse effects may also result. The major challenge is to translate current knowledge into prevention programs at the national level.

Role of industries in the care of diabetic foot

Diabetic foot disease is a dreaded complication causing severe economic and social burden, mental and physical agony, and severe morbidity and mortality. This complication is largely preventable if the risk factors such as peripheral neuropathy and peripheral arterial disease are detected early and appropriate measures are taken to control glycemia, foot pressure, and chances of foot injury. In the case of ulceration, proper microbial control, pressure offloading by debridement, and use of appropriate footwear are mandatory to save the foot. This article focuses on the need for preventive care for diabetic complications demonstrating potentially helpful roles for industry in India.

Does abnormal insulin action or insulin secretion explain the increase in prevalence of impaired glucose metabolism with age in populations of different ethnicities?

BACKGROUND

Age is associated with both impaired glucose and insulin metabolism. To what extent the age-related changes in insulin resistance (IR) and beta-cell function contribute to the increase in prevalence of impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) is less known, and this is investigated in this study.

METHODS

This study included 6610 men and 7664 women of different ethnic groups aged 30-69 years. IR and beta-cell function were examined by the homeostasis model assessment of insulin resistance (HOMA-IR) and homeostasis model assessment of beta-cell function (HOMA-B). Odds ratios (ORs) and 95% confidence intervals (95% CIs) were estimated using logistic regression analysis adjusting for body mass index and study.

RESULTS

In Chinese men, the ORs (95% CIs) for IFG were 2.69 (1.70, 4.26), 2.51 (1.49, 4.21) and 2.89 (1.68, 4.97), respectively, in age groups of 40-49, 50-59 and 60-69 years compared with 30-39 years (p < 0.001 for trend); the corresponding figures for IGT were 1.73 (1.25, 2.38), 2.54 (1.78, 3.63) and 3.57 (2.46, 5.19) (p < 0.001 for trend). Similar trends for IGT were observed also in Chinese women and other ethnic groups, but not for IFG in Mauritius Indian and Creole men. Adjustment for HOMA-IR and HOMA-B reduced the ORs in all age groups of all ethnicities for both IFG and IGT, but the risk gradient between age groups remained particularly for the IGT.

CONCLUSIONS

The age-related increase in glucose intolerance may not be fully explained by the defect in HOMA-IR and HOMA-B. As HOMA-IR and HOMA-B are only surrogate measures of insulin sensitivity and insulin secretion, the results need to be further investigated.

The metabolic syndrome: useful concept or clinical tool? Report of a WHO Expert Consultation

This article presents the conclusions of a WHO Expert Consultation that evaluated the utility of the 'metabolic syndrome' concept in relation to four key areas: pathophysiology, epidemiology, clinical work and public health. The metabolic syndrome is a concept that focuses attention on complex multifactorial health problems. While it may be considered useful as an educational concept, it has limited practical utility as a diagnostic or management tool. Further efforts to redefine it are inappropriate in the light of current knowledge and understanding, and there is limited utility in epidemiological studies in which different definitions of the metabolic syndrome are compared. Metabolic syndrome is a pre-morbid condition rather than a clinical diagnosis, and should thus exclude individuals with established diabetes or known cardiovascular disease (CVD). Future research should focus on: (1) further elucidation of common metabolic pathways underlying the development of diabetes and CVD, including those clustering within the metabolic syndrome; (2) early-life determinants of metabolic risk; (3) developing and evaluating context-specific strategies for identifying and reducing CVD and diabetes risk, based on available resources; and (4) developing and evaluating population-based prevention strategies.

Mitochondrial ATP synthase inhibition and nitric oxide are involved in muscle weakness that occurs in acute exposure of rats to monocrotophos

Organophosphate poisoning in the context of self-harm is a common medical emergency in Asia. Prolonged muscle weakness is an important but poorly understood cause of morbidity and mortality of the poisoning. This study examined mitochondrial function and its modulation by nitric oxide in muscle weakness of rats exposed to an acute, oral (0.8LD(50)) dose of monocrotophos. Muscle mitochondrial ATP synthase activity was inhibited in the rat in acute exposure to monocrotophos while respiration per se was not affected. This was accompanied by decreased mitochondrial uptake of calcium and increased levels of nitric oxide. Reactive cysteine groups of ATP synthase subunits were reduced in number, which may contribute to decreased enzyme activity. The decrease in ATP synthase activity and reactive cysteine groups of ATP synthase subunits was prevented by treatment of animals with the nitric oxide synthase inhibitor, L-N(G) Nitroarginine methyl ester, at 12 mg/kg body weight for 9 days in drinking water, prior to monocrotophos exposure. This indicated a role for nitric oxide in the process. The alterations in mitochondrial calcium uptake may influence cytosolic calcium levels and contribute to muscle weakness of acute organophosphate exposure.

Blood lipid levels in relation to glucose status in seven populations of Asian origin without a prior history of diabetes: the DECODA study

BACKGROUND

Dyslipidaemia commonly coexists with diabetes. We investigated the association of lipid profiles with glucose levels in populations of Asian origin without a prior history of diabetes.

METHODS

Cross-sectional data of 10,374 men and 12,552 women aged 30-74 years from 14 cohorts, representing seven populations of Asian origin were jointly analysed. Multivariable adjusted linear regression analyses with standardized regression coefficients (beta) were performed to estimate relationships between lipids and plasma glucose.

RESULTS

Within each glucose category, fasting plasma glucose (FPG) levels were correlated with increasing levels of triglycerides (TGs), total cholesterol (TC), TC to high-density lipoprotein (HDL) ratio and non-HDL cholesterol (non-HDL-C) (p < 0.05 in most of the ethnic groups) and inversely associated with HDL-C (p < 0.05 in some, but not all, of the populations). The association of lipids with 2-h plasma glucose (2hPG) followed a similar pattern as that for the FPG, except that an inverse relationship between HDL-C and glucose was more commonly observed for 2hPG than for FPG among different ethnic groups.

CONCLUSIONS

Hyperglycaemia is associated with adverse lipid profiles in Asians without a prior history of diabetes. The 2hPG appears to be more closely associated with lipid profiles than does FPG. When assessing the risk of cardiovascular disease, the association of the dyslipidaemia with intermediate hyperglycaemia needs to be considered.

Resource use associated with type 2 diabetes in Asia, Latin America, the Middle East and Africa: results from the International Diabetes Management Practices Study (IDMPS)

AIMS

To estimate diabetes-related resource use and investigate its predictors among individuals with type 2 diabetes in 24 countries in Asia, Latin America, the Middle East and Africa.

METHODS

Cross-sectional observational data on diabetes-related resource use were collected from 15,016 individuals with type 2 diabetes within the second wave of International Diabetes Management Practices Study. Mean (SD) annual quantities were determined and predictors of diabetes-related hospitalisations, inpatient days, emergency room visits and absenteeism were investigated using negative binomial regression.

RESULTS

Patients in Asia (n = 4678), Latin America (n = 6090) and the Middle East and Africa (n = 4248) made a mean (SD) of 3.4 (6.9), 5.4 (6.7) and 2.5 (4.4) General Practitioner visits per year. The mean (SD) number of inpatient days amounted to 3.8 (18.1), 2.2 (13.9) and 2.6 (13.5) per year. Results of the regression analysis showed the major influence of diabetes-related complications and inadequate glycaemic control on resource use. The expected annual rate of hospitalisation of patients with macrovascular complications compared with those without was 4.7 times greater in Asia [incidence rate ratio (IRR) = 4.7, 95% CI: 2.8-7.8, n = 2551], 5.4 times greater in Latin America (IRR = 5.4, 95% CI: 3.0-9.8, n = 3228) and 4.4 times greater in the Middle East and Africa (IRR = 4.4, 95% CI: 2.8-6.9, n = 2630).

CONCLUSIONS

Micro- and macrovascular complications and inadequate glycaemic control are significant predictors of resource use in people with type 2 diabetes of developing countries. This knowledge confirms the health economic importance of early diagnosis of diabetes, education of patients and glycaemic control.

Pioglitazone does not enhance the effectiveness of lifestyle modification in preventing conversion of impaired glucose tolerance to diabetes in Asian Indians: results of the Indian Diabetes Prevention Programme-2 (IDPP-2)

AIMS/HYPOTHESIS

The objective of this prevention programme was to study whether combining pioglitazone with lifestyle modification would enhance the efficacy of lifestyle modification in preventing type 2 diabetes in Asian Indians with impaired glucose tolerance.

METHODS

In a community-based, placebo-controlled 3 year prospective study, 407 participants with impaired glucose tolerance (mean age 45.3 +/- 6.2 years, mean BMI 25.9 +/- 3.3 kg/m(2)) were sequentially grouped to receive either: lifestyle modification plus pioglitazone, 30 mg (n = 204) or lifestyle modification plus placebo (n = 203). The participants and investigators were blinded to the assignment. The primary outcome was development of diabetes.

RESULTS

At baseline, both groups had similar demographic, anthropometric and biochemical characteristics. At year 3, the response rate was 90.2%. The cumulative incidence of diabetes was 29.8% with pioglitazone and 31.6% with placebo (unadjusted HR 1.084 [95% CI 0.753-1.560], p = 0.665). Normoglycaemia was achieved in 40.9% and 32.3% of participants receiving pioglitazone and placebo, respectively (p = 0.109). In pioglitazone group, two deaths and two non-fatal hospitalisations occurred due to cardiac problems; in the placebo group there were two occurrences of cardiac disease.

CONCLUSIONS/INTERPRETATION

Despite good adherence to lifestyle modification and drug therapy, no additional effect of pioglitazone was seen above that achieved with placebo. The effectiveness of the intervention in both groups was comparable with that of lifestyle modification alone, as reported from the Indian Diabetes Prevention Programme-1. The results are at variance with studies that showed significant relative risk reduction in conversion to diabetes with pioglitazone in Americans with IGT. An ethnicity-related difference in the action of pioglitazone in non-diabetic participants may be one explanation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00276497 FUNDING: This study was funded by the India Diabetes Research Foundation.

Cardiovascular risk factors in the normoglycaemic Asian-Indian population--influence of urbanisation

AIMS/HYPOTHESIS

The aim of this study was to investigate the prevalence of cardiovascular risk factors in normoglycaemic Asian-Indians and its association with urbanisation and plasma glucose.

METHODS

Data on 5,517 normoglycaemic individuals aged >/=20 years (1,521, 1,851 and 2,145 inhabitants of a city, a town and villages, respectively), from a 2006 diabetes survey, were used. The presence of single and multiple abnormalities, including obesity, abdominal obesity, hypertension and dyslipidaemia, was analysed. Risk associations for hypertension and dyslipidaemia were analysed using multivariate analysis after adjusting for confounding variables.

RESULTS

Both the prevalence and clustering of cardiovascular risk variables were higher in urban areas than in villages, and were higher in the city than in the town. Nearly half (47%) of the normoglycaemic individuals from villages had at least one risk factor. Age, male sex, BMI, waist circumference, lack of physical activity and living in an urban environment were associated with hypertension and dyslipidaemia; postprandial glucose level showed no association with hypertension or dyslipidaemia after adjusting for these risk factors. Fasting plasma glucose level showed an independent association with dyslipidaemia.

CONCLUSIONS/INTERPRETATION

There is a high prevalence of cardiovascular risk factors even among normoglycaemic individuals, and this is highest in urban areas. Fasting plasma glucose level showed an association with dyslipidaemia but not hypertension.

Forest dynamics in the Eastern Ghats of Tamil Nadu, India

The primary deciduous forests in the Eastern Ghats (EG) of Tamil Nadu (TN) India have undergone many changes owing to various need-based forest managements, such as timber extraction for industry, railway sleepers, charcoal, and forest clearance for hydroelectric projects and agriculture, during preindependence and postindependence periods (i.e., from 1800 to 1980). The enactment of a forest conservation act during the 1980s changed the perception of forest managers from utilization to conservation. This study was taken up to assess the forests dynamics in the EG of TN spatially between 1990 and 2003 and nonspatially between 1900 and the 1980s. Landsat Thematic Mapper (TM) and Indian Remote Sensing satellite (IRS) 1D Linear Imaging and Self Scanning (LISS III) data were used to assess forests during 1990 and 2003, respectively. Field floristic survey and secondary data (such as published literature, floras, books, and forest working plans) were used to assess the forest dynamics in terms of forest type and species composition among the preindependence period, the postindependence period, and the present (i.e., before and after 1980). The satellite data analysis revealed a considerable amount of changes in all forest types during the 13 years. The comparison of species composition and forest types between the past and present revealed that need-based forest management along with anthropogenic activity have altered the primary deciduous forest in to secondary and postextraction secondary forests such as southern thorn and southern thorn scrub forests in the middle [400-900 m above mean sea level (MSL)] and lower slopes (<400 m MSL). However, the evergreen forests present at the upper slope (>900 m MSL) and plateau seemed not to be much affected by the forest management. The changes estimated by the satellite data processing in the major forest types such as evergreen, deciduous, southern thorn, and southern thorn scrub are really alarming because these changes have occurred after the implementation of a forest conservation act. The dependence of local people on forests for various purposes in this region is also considerably high, which might be a key factor for the changes in the forests. The results of this study not only provide an outlook on the present status of the forests and the change trends but also provide the basis for further studies on forests in the EG of TN.

Immediate impact of a diabetes training programme for primary care physicians--an endeavour for national capacity building for diabetes management in India

AIMS

India faces a huge burden from diabetes. National capacity for management of diabetes has to be strengthened by improving knowledge of physicians treating diabetes, especially in semi urban and rural areas. A training programme was formulated and conducted at national level, as a step towards this goal.

METHODS

Physicians from 6 states of India (n=3023, M:F 2311:712), aged 30-55 years, with service of >or=3 years, (government n=1720, private n=1303, semi urban and rural areas (n=1581:1442)) were trained in diabetes care in 5-day workshops between March 2004 to December 2006. Impact of training was assessed by pre- and post-training knowledge scores, feedback on usefulness of training modules, prioritizing activities to be introduced in their practice and methods to be used for raising public awareness on diabetes.

RESULTS

The training significantly improved knowledge on treatment, complications, pathophysiology and diagnosis of diabetes (p<0.001). The participants considered information on preventive aspects of diabetes and foot care as highly educative. Patient education and team-training were considered important in diabetes management. Interest was evinced in raising public awareness about the disease.

CONCLUSIONS

Well-planned short training programmes are useful in improving knowledge and in creating enthusiasm to improve diabetes care and awareness.

Exenatide and acute pancreatitis

For a female, type 2 diabetic patient, with 4 years duration of diabetes, Exenatide (Byetta) was prescribed as glycaemic control was not satisfactory along with Glimepiride and Metformin. She had gastrointestinal disturbances, since the first day of the injection. From the eighth day she developed signs of acute pancreatitis which was confirmed with CT-Scan and biochemical investigations. Byetta was withdrawn, the patient was treated for acute pancreatitis and the symptoms subsided.

REVIEW paper: pathophysiology of myocardial reperfusion injury: the role of genetically engineered mouse models

Coronary heart disease is the leading cause of death worldwide, affecting millions of men and women each year. Following an acute myocardial infarction, early and successful reperfusion therapy with thrombolytic therapy or primary percutaneous coronary intervention plays an important role in minimizing tissue injury associated with cessation of blood flow. The process of restoring blood flow to the ischemic myocardium, however, can induce additional injury. This phenomenon, termed myocardial ischemia-reperfusion (MI-R) injury, can paradoxically reduce the beneficial effects of myocardial reperfusion. MI-R injury is characterized by the formation of oxygen radicals upon reintroduction of molecular oxygen to the ischemic tissue, resulting in widespread lipid and protein oxidative modifications, mitochondrial injury, and cell death. In addition, studies have shown that MI-R is characterized by an inappropriate immune response in the microcirculation, resulting in leukocyte-endothelial cell interactions mediated by the upregulation of both leukocyte and endothelial cell adhesion molecules. Furthermore, MI-R ameliorates the production of certain cardioprotective factors such as nitric oxide. Advances in the generation of genetically modified mouse models enable researchers to identify the functional importance of genes involved in these processes.

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.

Awareness about diabetes and its complications in the general and diabetic population in a city in southern India

OBJECTIVE

The study was done to find out the levels of awareness on diabetes in urban adult Indian population and to identify factors that influenced the awareness, including presence of diabetes.

RESEARCH DESIGN AND METHODS

In population aged > or =20 years (n=3681, M=1769, F=1912), details regarding awareness about diabetes in relation with physical activity, healthy and unhealthy diet, causes, symptoms, prevention, complications and measures to improve health were collected using a questionnaire. A high total score indicated good knowledge. Influence of age, gender, educational status, occupation and presence of diabetic history was analysed.

RESULTS

Fifty percent of subjects scored less than 15. Maximum scored was 51/65. The median total score was 16. Total score was significantly lower in women than in men (15.0 versus 17.0, p<0.0001). Educational status was low in women. Higher education (16.0 versus 12.0, p<0.0001) and professional or executive jobs (17.0 versus 15.0, p<0.0001) were significantly associated with better awareness. Age had no influence. Knowledge regarding causes of diabetes, its prevention and the methods to improve health was significantly low among the general population. Diabetic subjects had better knowledge about symptoms of diabetes and the preventive aspects.

CONCLUSIONS

The low median score indicated that the awareness was generally poor. The score was low especially in women and subjects with low education. The study highlights the urgent need for strategies to spread awareness about diabetes in the general population. Diabetic subjects also required better education on many aspects.

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.

Biochemical characterization of Sf9 Sp-family-like protein factors reveals interesting features

We earlier documented the involvement of novel Sp-family-like protein factors in transcription from the Autographa californica nucleopolyhedrovirus (AcNPV) polyhedrin (polh) gene promoter [Ramachandran et al. (2001) J. Biol. Chem. 276: 23440-23449]. These zinc-dependent Sp-like factors bind to two putative Sp-factor-binding motifs, present within the AcSp sequence upstream of the polh promoter, with very high affinity (K(d) = 2.1 x 10(-12) M). Like other polh-promoter-associated host transcription factors, these Sp-like factors display tolerance to high ion concentrations up to even 3 M NaCl. An electrophoretic mobility shift assay demonstrated a probable cross-talk between the Spodoptera frugiperda (Sf9) Sp-family-like proteins and the TFIID complex. In complementary experiments, specific replacements of the Sp-factor-binding motifs with TATA-like elements resulted in expression of a luciferase reporter gene to almost the same level as that obtained with a wild-type native construct. Our results point to the possibility of the involvement of TFIID and Sf9 Sp protein interaction in transcription from the baculovirus polyhedrin promoter.

Prevention of type 2 diabetes: a review

One of the major public health challenges of the 21st century is type 2 diabetes. WHO estimates that by 2025 as many as 200-300 million people worldwide will have developed the disease. A distressing increase in children is perhaps the most alarming sign of something going wrong. Roughly half of the risk of type 2 diabetes can be attributed to environmental exposure and the other half to genetics. Central themes for prevention are the risk factors overweight, sedentary lifestyle, certain dietary components and perinatal factors. Overweight is the most critical risk factor, and should be targeted for prevention of type 2 diabetes especially among children and youths. Ethnicity and perinatal factors are also worth considering. Today we know that prevention helps. In the US Diabetes Prevention Programme for high risk individuals, there was a 58% relative reduction in the progression to diabetes in the lifestyle group compared with the controls. Within the lifestyle group, 50% achieved the goal of more than 7% weight reduction, and 74% maintained at least 150 min of moderately intense activity each week. This review discusses different forms of prevention, and proposes first of all to target people with Impaired Glucose Tolerance with increasing activity and altering dietary factors. And secondly, population-based measures to encourage increased physical activity and decreased consumption of energy-dense foods are important, and may target school children and young people, certain ethnic groups and women with gestational diabetes.

Metabolic syndrome does not increase the risk of conversion of impaired glucose tolerance to diabetes in Asian Indians--Result of Indian diabetes prevention programme

AIMS

In this study, we assessed for the prevalence of metabolic syndrome (MetS) in the cohort of subjects with impaired glucose tolerance (IGT) in the Indian Diabetes Prevention Programme and studied whether the syndrome enhanced the conversion to diabetes.

METHODS

Effectiveness of lifestyle modification (LSM), metformin (Met) and LSM plus Met was tested in a randomised, controlled primary prevention study in subjects with IGT n=502 (M:W 397:105) at a median follow up of 30 months. Baseline prevalence of MetS was calculated using the WHO criteria. Insulin resistance (IR) was calculated using homeostasis model assessment (HOMA) method.

RESULTS

MetS was present in 233 subjects (46.4%; 95% CI 41.9-50.9) in the total group, in men (n=168; 42.3%; 95% CI 37.4-47.3) and in women (n=65; 61.9%; 95% CI 51.9-71.2) (men versus women chi(2)=12.8, p=0.0005). Insulin resistance (HOMA-IR>or=4.1) was present in 69.1% with no gender difference. IR increased proportionately with increasing number of abnormalities, in IGT (39.8%), IGT plus one abnormality (56.5%) and IGT plus any two or more abnormalities (69.1%) (Mantel Haenszel chi(2)=22.8, p<0.0001). Incidence of diabetes was similar in subjects with (40.3%) (n=94/233) or without (40.1%) (n=108/269) MetS (p=0.97). Cox's regression analysis confirmed that MetS did not enhance the conversion rate of IGT to diabetes both in the control (HR=0.88, 95% CI 0.53-1.47, p=0.63) and in the total group (HR=1.02, 95% CI 0.78-1.35, p=0.88), after correcting for effects of intervention.

CONCLUSION

Prevalence of MetS is high in Asian Indian IGT subjects, especially in women. However, it did not influence the rate of conversion of IGT to diabetes.

Persistent impaired glucose tolerance has similar rate of risk factors as for diabetes--results of Indian diabetes prevention programme (IDPP)

OBJECTIVE

To determine the occurrence of persistent impaired glucose tolerance (IGT) (two times OGTT positive) and to compare the physical and clinical characteristics with subjects having transient IGT or diabetes.

RESEARCH DESIGN AND METHODS

Nondiabetic subjects aged 35-55 years were screened (n=10,839, M:W 8667:2172) using 2h capillary blood glucose. IGT was diagnosed in 1332 (12.3%). Among them, 1025 (77%) responded for a second OGTT and 531 subjects (51.8%) had persistent IGT. Biochemical, demographic and anthropometric characteristics were compared among the normal (NGT, 30.1%), IGT and diabetic subjects (DM, 18%) at second GTT.

RESULTS

All had similar age. BMI, waist circumference and body fat percentage were lower in NGT than in IGT and diabetes. IGT and diabetes had similar characteristics. Family history of diabetes was the highest in persistent IGT.

CONCLUSION

Among the screened subjects, 1 in 20 had persistent IGT. Subject with persistent IGT had higher rates of risk factors for diabetes, such as high BMI, waist circumference and body fat percentage.

Expression of TGF-β1, TGF-β2, TGF-β3 and the Receptors TGF-βRI and TGF-βRII in Placentomes of Artificially Inseminated and Nuclear Transfer Derived Bovine Pregnancies

Bovine nuclear transfer pregnancies are characterized by a high incidence of placental abnormalities, notably, increased placentome size and deficiencies in trophoblast cell function and establishment of placental vasculature. Alterations in gene expression during placental growth and development may contribute to the appearance of large placentomes in pregnancies derived from nuclear transfer. The placenta synthesizes a number of cytokines and growth factors, including the transforming growth factor-betas (TGF-betas) that are involved in the establishment, maintenance and/or regulation of pregnancy. All forms of TGF-beta and their receptors are present at the fetal-maternal interface of the bovine placentome, where they are thought to play an important role in regulating growth, differentiation, and function of the placenta. Using real-time RT-PCR, we have examined the expression of TGF-beta1, TGF-beta2, TGF-beta3 and the receptors TGF-betaRI and TGF-betaRII in placentomes of artificially inseminated (AI) and nuclear transfer (NT)-derived bovine pregnancies at days 50, 100 and 150 of gestation. TGF-beta1, TGF-beta2 and TGF-beta3 mRNA expression increased by 2.0-2.8-fold, while TGF-betaRI and TGF-betaRII mRNA expression decreased by 1.7-2.0-fold in NT placentomes compared to AI controls at all gestational ages examined. These findings indicate that NT placentomes may be resistant to the growth suppressive effects of TGF-betas and could contribute to the placental proliferative abnormalities observed in NT-derived placentas. Alternatively, deficiencies in placentation may provide a mechanism whereby TGF-betas are dysregulated in NT pregnancies.

The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1)

AIMS/HYPOTHESIS

Lifestyle modification helps in the primary prevention of diabetes in multiethnic American, Finnish and Chinese populations. In a prospective community-based study, we tested whether the progression to diabetes could be influenced by interventions in native Asian Indians with IGT who were younger, leaner and more insulin resistant than the above populations.

METHODS

We randomised 531 (421 men 110 women) subjects with IGT (mean age 45.9+/-5.7 years, BMI 25.8+/-3.5 kg/m(2)) into four groups. Group 1 was the control, Group 2 was given advice on lifestyle modification (LSM), Group 3 was treated with metformin (MET) and Group 4 was given LSM plus MET. The primary outcome measure was type 2 diabetes as diagnosed using World Health Organization criteria.

RESULTS

The median follow-up period was 30 months, and the 3-year cumulative incidences of diabetes were 55.0%, 39.3%, 40.5% and 39.5% in Groups 1-4, respectively. The relative risk reduction was 28.5% with LSM (95% CI 20.5-37.3, p=0.018), 26.4% with MET (95% CI 19.1-35.1, p=0.029) and 28.2% with LSM + MET (95% CI 20.3-37.0, p=0.022), as compared with the control group. The number needed to treat to prevent one incident case of diabetes was 6.4 for LSM, 6.9 for MET and 6.5 for LSM + MET.

CONCLUSIONS/INTERPRETATION

Progression of IGT to diabetes is high in native Asian Indians. Both LSM and MET significantly reduced the incidence of diabetes in Asian Indians with IGT; there was no added benefit from combining them.

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.

Bacterial cell microarrays for the detection and characterization of antibodies against surface antigens

Bacterial cell surface antigens interact with the host immune system resulting in the production of antibodies. Detection of antibodies against surface antigens has applications in diagnosis of many bacterial infections, assessment of immune status and epidemiological studies. We developed a microarray platform, for antibody detection, by printing Gram-negative and Gram-positive whole bacterial cells on nitrocellulose coated glass substrates. Antibody binding was detected using fluorophore labeled secondary antibodies. The sensitivity of antibody detection was found to be 0.1 microg/ml. Using bacterial cell microarrays it was also possible to successfully detect antibodies against Francisella tularensis in canine serum samples declared positive for tularemia based on microagglutination antibody titer. Use of bacterial cells as the antigen source in immunoassays has the advantages of simulating in vivo presentation of surface antigens and also eliminating the need for antigen purification. The microarray format gives the added advantage of simultaneous detection of antibodies against multiple bacteria employing only small amounts of samples and reagents.

Profile of diabetic foot complications and its associated complications--a multicentric study from India

AIM

The aims of this study were to determine. The prevalence of foot complications such as neuropathy, peripheral vascular disease (PVD), amputations and infections and the associated diabetic complications and practice of foot care among these subjects.

METHODS

A total of 1319 type 2 diabetic patients, were selected from four different centres across India. The centres were Diabetes Research Centre (DRC), Chennai, Government Rajaji Hospital (GRH), Madurai, Christian Medical College (CMC), Vellore and All India Institute of Medical Science (AIIMS), Delhi. Details were collected regarding foot problems and associated complications.

RESULTS

The prevalence of neuropathy was 15% (n=193) and PVD was 5% (n=64). Infections were present in 7.6% (n=100) of patients. The infection rate varied from 6-11% in the different centres. Nearly 3% of subjects had undergone a minor or major amputation.

DISCUSSION

This study found that the prevalence of infection was 6-11% and prevalence of amputation was 3% in type 2 diabetic patients. Neuropathy (15%) was found to be an important risk factor for diabetic foot infections. Effective foot care advice should be propagated to reduce the burden imposed by diabetic foot complication particularly in developing countries like India.

Derivation and validation of diabetes risk score for urban Asian Indians

OBJECTIVE

Simple risk scores for identifying people with undiagnosed diabetes have been developed, mostly in Caucasian groups. This may not be suitable for Asian Indians, therefore this study was undertaken to develop and validate a simple diabetes risk score in an urban Asian Indian population with a high prevalence of diabetes. We also tested whether this score was applicable to South Asian migrants living in a different cultural context.

RESEARCH DESIGN AND METHODS

A population based Cohort of 10,003 participants aged >or=20 years was divided into two equal halves (Cohorts 1 and 2), after excluding people with known diabetes. Cohort 1 (n=4993) was used to derive the risk score. Validation of the score was performed in the other half of the survey population (Cohort 2) (n=5010). The validation was also done in a separate survey population in Chennai, India (Cohort 3) (n=2002) (diagnosis of diabetes was based on OGTT) and in the South Asian Cohort of the 1999 Health Survey for England (n=676) (fasting glucose value>or=7 mmol/l and HbA1c>or=6.5% were used for diagnosis). A logistic regression model was used to compute the beta coefficients for risk factors. The risk score value was derived from a receiver operating characteristic curve.

RESULTS

The significant risk factors included in the risk score were age, BMI, waist circumference, family history of diabetes and sedentary physical activity. A risk score value of >21 gave a sensitivity, specificity, positive predictive value and negative predictive value of 76.6%, 59.9%, 9.4% and 97.9% in Cohort 1, 72.4%, 59%, 8.3% and 97.6% in Cohort 2 and 73.7%, 61.0%, 12.2% and 96.9% in Cohort 3, respectively. The higher distribution of risk factors in the UK Cohort means that at the same cut point the score was much more sensitive but also less specific. (sensitivity 92.2%, specificity 25.7%, positive predictive value of 21.6% and negative predictive value of 93.7%).

CONCLUSIONS

A diabetes risk score involving simple non-biochemical measurements was developed and validated in a native Asian Indian population. This easily applicable simple score could play an important role as the first step in the process of identifying individuals with an increased likelihood of having prevalent but undiagnosed diabetes. The different distribution of risk factors with the migrant Asian Indians living in England and the different relationship between sensitivity and specificity for the same score demonstrate that risk scores and cut-points developed and tested even within one ethnic group cannot be generalized to individuals of the same ethnic group living in a different cultural setting where the distribution of risk factors for diabetes is different.

Development of a reliable and valid psychosocial measure of self-perception of health in type 2 diabetes

OBJECTIVES

The aim was to develop a reliable and valid psychosocial measure of self-perception of health in type 2 diabetes.

METHODS

Item analysis and factor analyses were done in order to stabilize and establish principal components of the questionnaire. Reliability (internal consistency aspect) was established using Chronbach's alpha method. Concurrent and discriminant validities were established using conventional methods.

RESULTS

Factor analysis yielded 12 significant factors (eigen value > or =1), but first six components were retained based on Scree test. These six principal varimax factors explain 49.7% of variance of psychosocial measure of self-perception of health.

CONCLUSIONS

The final version after all these psychometric procedures had 27 items with six principal components. They were appropriately named as follow: (I) Positive self-feeling; (II) Sociality; (III) Attention seeking; (IV) Feel healthy; (V) Worry about health; (VI) Dependence. Total variance explained is 49.7%.

Lipopolysaccharide microarrays for the detection of antibodies

Lipopolysaccharide (LPS) is the major component of Gram-negative bacterial outer membrane. LPS are immunogenic and show species/strain specificity. The demonstration of anti-LPS antibodies in clinical samples is of diagnostic value in certain Gram-negative bacterial infections. In the present study we explored the possibility of immobilizing LPS isolated from different bacteria in a microarray format for the detection of anti-LPS antibodies. LPS was successfully immobilized on nitrocellulose-coated glass slides, preserving the accessibility of epitopes for antibody binding. Specificity of the LPS arrays was established using four different monoclonal antibodies specific for Escherichia coli O111, E. coli O157, Francisella tularensis and Salmonella typhimurium O-antigens and a panel of LPS preparations. The detection limit of antibodies was found to be 10 ng/ml, which is about a 100-fold greater sensitivity compared to conventional immunofluorescence assays. Furthermore, using LPS arrays, tularemia positive canine serum samples could be differentiated from negative samples based on the presence of significantly higher levels of anti-F. tularensis LPS antibodies in positive samples. LPS arrays will facilitate simultaneous screening of samples against multiple antigens and are expected to find applications in diagnostics and seroepidemiology.

Levels of transforming growth factor beta 1 in south Indian type 2 diabetic subjects

BACKGROUND AND AIMS

The prosclerotic cytokine TGFbeta has been implicated as an important downstream mediator in the progression of the renal pathological changes occurring in diabetic patients. This study was undertaken to determine (1) whether serum levels of zTGFbeta1 was elevated in South Indian type 2 diabetic subjects and (2) whether treatment with oral hypoglycaemic agents/insulin and angiotensin-converting enzyme inhibitors (ACEI) and/or angiotensin receptor blockers (ARB) influenced TGFbeta1 levels in diabetic subjects.

METHODS

Among the 131 study subjects, 101 were consecutive type 2 diabetic patients and the other 30 subjects were non-diabetic, normoglycaemic (NGT, M : F 15 : 15) healthy subjects who had undergone an Oral Glucose Tolerance Test (OGTT) during medical checkup. TGFbeta1 was determined using solid-phase sandwich enzyme-linked immunosorbent assay.

RESULTS

Mean serum TGFbeta1 levels were significantly elevated (p < 0.0001) in the type 2 diabetic subjects (30 +/- 13.1 ng/mL) when compared with the non-diabetic subjects (19 +/- 8.3 ng/mL). Diabetic subjects who were being treated with a combination of OHA and insulin (n = 53;25.6 +/- 11.5 ng/mL) had significantly (p = 0.0009) lower levels of TGFbeta1 when compared with those who were being treated with OHA alone (n = 48;34.1 +/- 13.4 ng/mL). Nearly 36% of the diabetic subjects were being treated with ACEI/ARB, and they had significantly (p = 0.01) lower levels of TGFbeta1 (n = 36;25.4 +/- 12.6 ng/mL) when compared with those who were not being treated with ACEI/ARB (n = 65;32 +/- 12.9 ng/mL).

CONCLUSION

The present study demonstrated significantly elevated TGFbeta1 levels in South Indian type 2 diabetic patients when compared with the non-diabetic subjects. Insulin and ACEI/ARB treatment appears to have a protective effect by lowering TGFbeta1 concentrations in these subjects.

The EIF2AK3 gene region and type I diabetes in subjects from South India

Mutations in the EIF2AK3 gene underlie susceptibility to the Wolcott-Rallison syndrome, which is a monogenic disease associated with insulin-deficient neonatal diabetes. Furthermore, suggestive evidence of linkage between type 1 diabetes (T1DM) and the EIF2KA3 chromosomal region has been reported in Scandinavian families. We have investigated the hypothesis that polymorphic variants in and around the EIF2AK3 gene might partially account for susceptibility to T1DM in South Indian subjects. Excess transmission of the common alleles of two polymorphic markers (D2S1786 and 15INDEL, located within the gene) downstream of EIF2AK3, either singly (D2S1786, P = 0.01) and 15INDEL (P = 0.02) or as a combination (P < 0.001), were found in 234 families with a T1DM proband. There was also a clear paternal effect for the 15INDEL marker (P = 0.005) on disease susceptibility. The presence of the common allele of both markers was found in decreased frequency in the subjects with normal glucose tolerance compared to probands with T1DM (both P <or= 0.0001). Major common mutations of the EIF2AK3 gene in T1DM were excluded. In conclusion, this pilot study demonstrates an association between the region around the EIF2AK3 locus and T1DM susceptibility.

Epidemiology of diabetes in India--three decades of research

India has nearly 33 million diabetic subjects today, which is briefly contributed by the urban population. The scenario is changing rapidly due to socio-economic transition occurring in the rural areas also. Availability of improved modes of transport, and less strenuously as in the vicinity have resulted in decreased physical activities. Better economic conditions have produced changes in diet habits. The conditions are more favourable for expression of diabetes in the population, which already has a racial and genetic susceptibility of the disease. Recent epidemiological data show that the situations are similar throughout the country. Prediabetic conditions like impaired glucose tolerance and impaired fasting glucose are also on the rise, indicating the possibility of further rise in the prevalence of diabetes. Metabolic syndrome, which is a constellation of cardiovascular risk factors, of which hyperglycaemia and insulin resistance are components, is also widely prevalent. The conversion to diabetes is enhanced by the low thresholds for the risk factors, such as age, body mass index and upper body adiposity. Indians have a genetic phenotype characterized by low body mass index, but with high upper body adiposity, high body fat percentage and high level of insulin resistance. With a high genetic predisposition and the high susceptibility to the environmental insults, the Indian population faces a high risk for diabetes and its associated complications. Early diagnosis of high risk groups and appropriate intervention by lifestyle modification may solution for the disease burden.