Higher Intake of Dairy Is Associated with Lower Cardiometabolic Risks and Metabolic Syndrome in Asian Indians

There is conflicting evidence about the association between dairy products and cardiometabolic risk (CMR). We aimed to assess the association of total dairy intake with CMR factors and to investigate the association of unfermented and fermented dairy intake with CMR in Asian Indians who are known to have greater susceptibility to type 2 diabetes and cardiovascular diseases compared to white Europeans. The study comprised 1033 Asian Indian adults with normal glucose tolerance chosen from the Chennai Urban Rural Epidemiological Study (CURES). Dietary intake was assessed using a validated open-ended semi-quantitative food frequency questionnaire. Metabolic syndrome (MS) was diagnosed based on the new harmonising criteria using central obesity, dyslipidaemia [low high-density lipoprotein cholesterol (HDL) and increased serum triglycerides (TG)], hypertension and glucose intolerance. Increased consumption of dairy (≥5 cups per day of total, ≥4 cups per day of unfermented or ≥2 cups per day of fermented dairy) was associated with a lower risk of high fasting plasma glucose (FPG) [hazards ratio (HR), 95% confidence interval (CI): 0.68, 0.48−0.96 for total dairy; 0.57, 0.34−0.94 for unfermented dairy; and 0.64, 0.46−0.90 for fermented dairy; p < 0.05 for all] compared to a low dairy intake (≤1.4 cups per day of total dairy; ≤1 cup per day of unfermented dairy; and ≤0.1 cup per day of fermented dairy). A total dairy intake of ≥5 cups per day was also protective against high blood pressure (BP) (HR: 0.65, 95% CI: 0.43−0.99, p < 0.05), low HDL (HR: 0.63, 95% CI: 0.43−0.92, p < 0.05) and MS (HR: 0.71, 95% CI: 0.51−0.98, p < 0.05) compared to an intake of ≤1.4 cups per day. A high unfermented dairy intake (≥4 cups per day) was also associated with a lower risk of high body mass index (BMI) (HR: 0.52, 95% CI: 0.31−0.88, p < 0.05) compared to a low intake (≤1 cup per day), while a reduced risk of MS was observed with a fermented dairy intake of ≥2 cups per day (HR: 0.71, 95% CI: 0.51−0.98, p < 0.05) compared to an intake of ≤0.1 cup per day. In summary, increased consumption of dairy was associated with a lower risk of MS and components of CMR.

Development and validation of predictive risk models for sight threatening diabetic retinopathy in patients with type 2 diabetes to be applied as triage tools in resource limited settings

Background

Delayed diagnosis and treatment of sight threatening diabetic retinopathy (STDR) is a common cause of visual impairment in people with Type 2 diabetes. Therefore, systematic regular retinal screening is recommended, but global coverage of such services is challenging. We aimed to develop and validate predictive models for STDR to identify 'at-risk' population for retinal screening.

Methods

Models were developed using datasets obtained from general practices in inner London, United Kingdom (UK) on adults with type 2 Diabetes during the period 2007-2017. Three models were developed using Cox regression and model performance was assessed using C statistic, calibration slope and observed to expected ratio measures. Models were externally validated in cohorts from Wales, UK and India.

Findings

A total of 40,334 people were included in the model development phase of which 1427 (3·54%) people developed STDR. Age, gender, diabetes duration, antidiabetic medication history, glycated haemoglobin (HbA1c), and history of retinopathy were included as predictors in the Model 1, Model 2 excluded retinopathy status, and Model 3 further excluded HbA1c. All three models attained strong discrimination performance in the model development dataset with C statistics ranging from 0·778 to 0·832, and in the external validation datasets (C statistic 0·685 - 0·823) with calibration slopes closer to 1 following re-calibration of the baseline survival.

Interpretation

We have developed new risk prediction equations to identify those at risk of STDR in people with type 2 diabetes in any resource-setting so that they can be screened and treated early. Future testing, and piloting is required before implementation.

Funding

This study was funded by the GCRF UKRI (MR/P207881/1) and supported by the NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology.

Macronutrient Recommendations for Remission and Prevention of Diabetes in Asian Indians Based on a Data-Driven Optimization Model: The ICMR-INDIAB National Study

OBJECTIVE

To derive macronutrient recommendations for remission and prevention of type 2 diabetes (T2D) in Asian Indians using a data-driven optimization approach.

RESEARCH DESIGN AND METHODS

Dietary, behavioral, and demographic assessments were performed on 18,090 adults participating in the nationally representative, population-based Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study. Fasting and 2-h postglucose challenge capillary blood glucose and glycosylated hemoglobin (HbA1c) were estimated. With HbA1c as the outcome, a linear regression model was first obtained for various glycemic categories: newly diagnosed diabetes (NDD), prediabetes (PD), and normal glucose tolerance (NGT). Macronutrient recommendations were formulated as a constrained quadratic programming problem (QPP) to compute optimal macronutrient compositions that would reduce the sum of the difference between the estimated HbA1c from the linear regression model and the targets for remission (6.4% for NDD and 5.6% for PD) and prevention of progression in T2D in PD and NGT groups.

RESULTS

Four macronutrient recommendations (%E- Energy) emerged for 1) diabetes remission in NDD: carbohydrate, 49-54%; protein, 19-20%; and fat, 21-26%; 2) PD remission to NGT: carbohydrate, 50-56%; protein,18-20%; fat, 21-27%; 3 and 4) prevention of progression to T2D in PD and NGT: carbohydrate, 54-57% and 56-60%; protein, 16-20% and 14-17%, respectively; and fat 20-24% for PD and NGT.

CONCLUSIONS

We recommend reduction in carbohydrates (%E) and an increase in protein (%E) for both T2D remission and for prevention of progression to T2D in PD and NGT groups. Our results underline the need for new dietary guidelines that recommend appropriate changes in macronutrient composition for reducing the burden due to diabetes in South Asia.

Remission of Type 2 Diabetes: How, When, and for Whom?

Type 2 diabetes (T2DM) is conventionally considered a progressive disorder, with most patients requiring increasingly intensive therapy to control hyperglycemia over time. Recently, there has been a major paradigm shift towards trying to reverse T2DM. Emerging evidence suggests that remission of T2DM is feasible in a subset of patients. Identification and careful selection of candidates for remission are crucial for the success of these programs. Among various dietary strategies, low-calorie diets (LCDs) and low-carbohydrate diets (LCBDs) have been demonstrated as being effective in facilitating remission of T2DM in a targeted population within a clinical setting. Remission with LCBDs may be maintained in the absence of weight loss, however, long-term evidence is limited and remission may not be maintained without long-term carbohydrate restriction, which poses major challenges. In very low-calorie diets (VLCDs), weight loss of 15 kg or greater and maintenance of weight loss is the main driver and predictor of remission. However, most individuals with T2DM were unable to maintain remission beyond 2 years, despite being on VLCDs. More data are required on the long-term sustainability of remission in an ethnically diverse population like Asian Indians with T2DM who have less obesity and hence less weight to lose. Moreover, "re-reversal" or "relapse" of diabetes can occur in a large percentage of individuals who discontinue the dietary restrictions. Hence, regular follow-up by a multi-disciplinary team to ensure sustainability of the lifestyle modification is crucial to the maintenance of remission of T2DM.

Tele-Ophthalmology Versus Face-to-Face Retinal Consultation for Assessment of Diabetic Retinopathy in Diabetes Care Centers in India: A Multicenter Cross-Sectional Study

Aim: To evaluate the effectiveness of tele-ophthalmology (TO) versus face-to-face screening for diabetic retinopathy (DR) in diabetes care centers (DCC) across India. Methods: This is an observational, multicenter, retrospective, cross-sectional study of DR screening in individuals with diabetes performed across 35 branches of a chain of DCC in 20 cities in India over 1 year. In 30 DCC, DR screening was performed by TO, where retinal images obtained using Fundus on Phone camera were uploaded through the telemedicine network for centralized DR grading by eight retina specialists. In five DCC, DR screening was performed by fundus examination (FE) by the same retina specialists. The rate of detection of sight-threatening DR (STDR) (defined as the presence of proliferative DR and/or diabetic macular edema) through the two modes was compared. Results: A total of 58,612 individuals were screened for DR from January 1, 2018 to December 31, 2018: 25,316 by TO and 33,296 by FE. The mean age and mean duration of diabetes of the individuals with diabetes screened by TO was 55.8 ± 11.2 years and 9.5 ± 7.3 years; and in individuals screened by FE, it was 57.5 ± 11.6 years and 11.5 ± 8.0 years respectively. The mean glycated hemoglobin was 8.8% ± 2.1% and 8.5% ± 1.9% in the two groups, respectively. Any DR was detected in 31.7% (95% confidence interval [CI]: 31.0-32.3) by tele-screening and in 38.5% (95% CI: 37.9-39.0) by FE, whereas STDR was detected in 7.3% (95% CI: 7.0-7.7) by TO and in 10.5% (95% CI: 10.2-10.9) by FE. Overall, 11.4% individuals with diabetes in the TO group, including 4.1% with ungradable images, were advised referral to retina specialists for further management. Conclusion: Screening for DR at DCC using TO is feasible and effective for STDR detection in India and may be adopted throughout India.

Early retinal functional alteration in relation to diabetes duration in patients with type 2 diabetes without diabetic retinopathy

To examine the retinal structure and function in relation to diabetes duration and glycemia in patients without diabetic retinopathy (DR). 85 adults with type 2 diabetes without DR or macular edema underwent dilated indirect ophthalmoscopy, optical coherence tomography (OCT), ultra-wide field fundus photography, multifocal electroretinography (mfERG) and HbA_1C assessment. Patients were stratified as those with diabetes duration < 10 years and ≥ 10 years. Right eyes of all participants were analyzed. mfERG was analysed as ring 12, 34, 56. No significant differences were noted in OCT-derived retinal thickness measures between groups. mfERG P1 latencies were delayed, and amplitudes (nV/deg²) were reduced in all three rings in those with diabetes duration ≥ 10 years vs. < 10 years, with significant correlations to diabetes duration in all rings. Logistic regression showed that duration of diabetes ≥ 10 years was associated with greater age (odds ratio (OR) 1.081, 95% CI 1.022, 1.143) and lower P1 amplitudes in the middle ring (OR 0.924, 95% CI 0.854, 0.999). No significant correlations were observed between HbA_1c and retinal measures. In the absence of DR, early retinal functional alterations are detectable on mfERG in patients with longer diabetes duration, but with no difference in OCT-derived retinal thickness.

Impact of Lipid Genetic Risk Score and Saturated Fatty Acid Intake on Central Obesity in an Asian Indian Population

Abnormalities in lipid metabolism have been linked to the development of obesity. We used a nutrigenetic approach to establish a link between lipids and obesity in Asian Indians, who are known to have a high prevalence of central obesity and dyslipidaemia. A sample of 497 Asian Indian individuals (260 with type 2 diabetes and 237 with normal glucose tolerance) (mean age: 44 ± 10 years) were randomly chosen from the Chennai Urban Rural Epidemiological Study (CURES). Dietary intake was assessed using a previously validated questionnaire. A genetic risk score (GRS) was constructed based on cholesteryl ester transfer protein (CETP) and lipoprotein lipase (LPL) genetic variants. There was a significant interaction between GRS and saturated fatty acid (SFA) intake on waist circumference (WC) (Pinteraction = 0.006). Individuals with a low SFA intake (≤23.2 g/day), despite carrying ≥2 risk alleles, had a smaller WC compared to individuals carrying <2 risk alleles (Beta = −0.01 cm; p = 0.03). For those individuals carrying ≥2 risk alleles, a high SFA intake (>23.2 g/day) was significantly associated with a larger WC than a low SFA intake (≤23.2 g/day) (Beta = 0.02 cm, p = 0.02). There were no significant interactions between GRS and other dietary factors on any of the measured outcomes. We conclude that a diet low in SFA might help reduce the genetic risk of central obesity confirmed by CETP and LPL genetic variants. Conversely, a high SFA diet increases the genetic risk of central obesity in Asian Indians.

Cardiovascular disease, mortality, and their associations with modifiable risk factors in a multi-national South Asia cohort: a PURE substudy

AIM

To examine the incidence of cardiovascular disease (CVD), of death, and the comparative effects of 12 common modifiable risk factors for both outcomes in South Asia.

METHODS AND RESULTS

Prospective study of 33 583 individuals 35-70 years of age from India, Bangladesh, or Pakistan. Mean follow-up period was 11 years. Age and sex adjusted incidence of a CVD event and mortality rates were calculated for the overall cohort, by urban or rural location, by sex, and by country. For each outcome, mutually adjusted population attributable fractions (PAFs) were calculated in 32 611 individuals without prior CVD to compare risks associated with four metabolic risk factors (hypertension, diabetes, abdominal obesity, high non-HDL cholesterol), four behavioural risk factors (tobacco use, alcohol use, diet quality, physical activity), education, household air pollution, strength, and depression. Hazard ratios were calculated using Cox regression models, and average PAFs were calculated for each risk factor or groups of risk factors. Cardiovascular disease was the most common cause of death (35.5%) in South Asia. Rural areas had a higher incidence of CVD (5.41 vs. 4.73 per 1000 person-years) and a higher mortality rate (10.27 vs. 6.56 per 1000 person-years) compared with urban areas. Males had a higher incidence of CVD (6.42 vs. 3.91 per 1000 person-years) and a higher mortality rate (10.66 vs. 6.85 per 1000 person-years) compared with females. Between countries, CVD incidence was highest in Bangladesh, while the mortality rate was highest in Pakistan. The modifiable risk factors studied contributed to approximately 64% of the PAF for CVD and 69% of the PAF for death. Largest PAFs for CVD were attributable to hypertension (13.1%), high non-HDL cholesterol (11.1%), diabetes (8.9%), low education (7.7%), abdominal obesity (6.9%), and household air pollution (6.1%). Largest PAFs for death were attributable to low education (18.9%), low strength (14.6%), poor diet (6.4%), diabetes (5.8%), tobacco use (5.8%), and hypertension (5.5%).

CONCLUSION

In South Asia, both CVD and deaths are highest in rural areas and among men. Reducing CVD and premature mortality in the region will require investment in policies that target a broad range of health determinants.

Daily Almond Consumption Reduces Insulin Resistance and Serum Cholesterol Levels in Overweight Asian Indian Adults with Cardiometabolic Risk – A Randomized Controlled Trial

Objectives

The present study aimed to evaluate the efficacy of almonds consumption on insulin resistance, glycemia and lipid profile in overweight Asian Indian adults with cardiometabolic risks.

Methods

A parallel-arm open-labelled, randomized controlled trial was conducted on 184 adults with cardiometabolic risks (CMR) (92 in each group). Adults with CMR were identified using the harmonizing criteria which includes presence of minimum of 3 of the following conditions: raised blood pressure, dyslipidemia (raised triglycerides and lowered high-density lipoprotein cholesterol), impaired fasting glucose, and central obesity. The intervention group received 43g (1.5 oz) almonds/day for 12 weeks. The control group was instructed to follow their habitual diet except to exclude nuts in any form. The anthropometric, clinical, biochemical and dietary data of the participants were assessed periodically and their change from baseline were analysed using generalized linear model in SAS 9.4 version.

Results

The study was completed by 165 adults (response rate 82.5%). Their mean age was 40 years and waist circumference 97 ± 9.6 cm at baseline. Significant reductions [mean (95%CI)] in IR (−0.5(−1.0–0.0); P = 0.04), serum total cholesterol (−10.6 mg/dl (−17.8- −3.4); P = 0.004) and low-density lipoprotein cholesterol (−7.5 mg/dl (−14.2- −0.8); P = 0.03) were observed in the intervention group compared to the control group. Within the intervention group, significant reduction of 1% each for body weight, body mass index, waist circumference, 3% fasting glucose and 2% serum triglyceride were noted compared to baseline. Multiple 24hr dietary recall as a compliance marker revealed significant increase in total fat, MUFA, PUFA calories and dietary fibre with a propionate reduction in carbohydrate calories in the intervention group compared to control group.

Conclusions

Daily intake of 43g almonds reduced IR, total and LDL serum cholesterol in obese Asian Indians with CMR. Almond consumption also improved the overall quality of the diet.

Funding Sources

The present study was funded by Almond Board of California, Modesto, CA, USA.

Altered levels of neurobiological biomarkers at the interface of depression and gestational diabetes mellitus in Asian Indian women

AIM

Gestational diabetes mellitus (GDM) might predispose the mothers to depression. Studies have reported the role of biomarkers either in GDM or depression, but very few have examined them in GDM with depression. The present study profiled the circulating levels of brain-derived neurotrophic factor (BDNF), Beta Endorphin (BE) and nesfatin-1 in women with GDM (with and without depression).

METHODS

160 pregnant women at 24-28 weeks of pregnancy (NGT/GDM with & without depression, n = 40 each) were randomly selected from the ongoing STRiDE (STratification of Risk of Diabetes in Early pregnancy) study. Depression score was derived using PHQ-9 questionnaire and ELISA was used to quantify the biomarkers.

RESULTS

Circulatory levels of BDNF, BE and nesfatin-1 were lower in GDM women with or without depression compared to NGT without depression, however, nesfatin-1 levels were higher in NGT with depression. Notably, GDM with depression had the lowest levels of BDNF and BE. Both BDNF and BE levels were negatively correlated with depression, 1 h and 2 h plasma glucose. Regression analysis confirmed that each standard deviation decreases in BDNF and BE were independently associated with higher odds of GDM with or without depression even after adjusting for potential confounders.

CONCLUSION

Our study has identified altered levels of a panel of neurobiological biomarkers (BDNF/BE/nesfatin-1) in those with combined GDM and depression. BDNF/BE could be potential biomarkers to assess the higher risk of coexisting depression and GDM.

Achievement of guideline recommended diabetes treatment targets and health habits in people with self-reported diabetes in India (ICMR-INDIAB-13): a national cross-sectional study

BACKGROUND

There is little information on comprehensive diabetes care comprising glycaemic, lipid, and blood pressure control in India; therefore, we aimed to assess the achievement of treatment targets among adults with self-reported diabetes.

METHODS

The Indian Council of Medical Research (ICMR)-India Diabetes (INDIAB) study is a cross-sectional, population-based survey of adults aged 20 years or older in all 30 states and union territories of India. We used a stratified multistage sampling design, sampling states in a phased manner, and selected villages in rural areas and census enumeration blocks in urban areas. We used a three-level stratification method on the basis of geography, population size, and socioeconomic status for each state. For the outcome assessment, good glycaemic control was defined as HbA_1c of less than 7·0% (A), blood pressure control was defined as less than 140/90 mm Hg (B), and the LDL cholesterol target was defined as less than 100 mg/dL (C). ABC control was defined as the proportion of individuals meeting glycaemic, blood pressure, and LDL cholesterol targets together. We also performed multiple logistic regression to assess the factors influencing achievement of diabetes treatment targets.

FINDINGS

Between Oct 18, 2008, and Dec 17, 2020, 113 043 individuals (33 537 from urban areas and 79 506 from rural areas) participated in the ICMR-INDIAB study. For this analysis, 5789 adults (2633 in urban areas and 3156 in rural areas) with self-reported diabetes were included in the study population. The median age was 56·1 years (IQR 55·7-56·5). Overall, 1748 (weighted proportion 36·3%, 95% CI 34·7-37·9) of 4834 people with diabetes achieved good glycaemic control, 2819 (weighted proportion 48·8%, 47·2-50·3) of 5698 achieved blood pressure control, and 2043 (weighted proportion 41·5%, 39·9-43·1) of 4886 achieved good LDL cholesterol control. Only 419 (weighted proportion 7·7%) of 5297 individuals with self-reported diabetes achieved all three ABC targets, with significant heterogeneity between regions and states. Higher education, male sex, rural residence, and shorter duration of diabetes (<10 years) were associated with better achievement of combined ABC targets. Only 951 (weighted proportion 16·7%) of the study population and 227 (weighted proportion 36·9%) of those on insulin reported using self-monitoring of blood glucose.

INTERPRETATION

Achievement of treatment targets and adoption of healthy behaviours remains suboptimal in India. Our results can help governments to adopt policies that prioritise improvement of diabetes care delivery and surveillance in India.

FUNDING

Indian Council of Medical Research and Department of Health Research, Ministry of Health and Family Welfare.

Young-onset diabetes in Asian Indians is associated with lower measured and genetically determined beta cell function

AIMS/HYPOTHESIS

South Asians in general, and Asian Indians in particular, have higher risk of type 2 diabetes compared with white Europeans, and a younger age of onset. The reasons for the younger age of onset in relation to obesity, beta cell function and insulin sensitivity are under-explored.

METHODS

Two cohorts of Asian Indians, the ICMR-INDIAB cohort (Indian Council of Medical Research-India Diabetes Study) and the DMDSC cohort (Dr Mohan's Diabetes Specialties Centre), and one of white Europeans, the ESDC (East Scotland Diabetes Cohort), were used. Using a cross-sectional design, we examined the comparative prevalence of healthy, overweight and obese participants with young-onset diabetes, classified according to their BMI. We explored the role of clinically measured beta cell function in diabetes onset in Asian Indians. Finally, the comparative distribution of a partitioned polygenic score (pPS) for risk of diabetes due to poor beta cell function was examined. Replication of the genetic findings was sought using data from the UK Biobank.

RESULTS

The prevalence of young-onset diabetes with normal BMI was 9.3% amongst white Europeans and 24-39% amongst Asian Indians. In Asian Indians with young-onset diabetes, after adjustment for family history of type 2 diabetes, sex, insulin sensitivity and HDL-cholesterol, stimulated C-peptide was 492 pmol/ml (IQR 353-616, p<0.0001) lower in lean compared with obese individuals. Asian Indians in our study, and South Asians from the UK Biobank, had a higher number of risk alleles than white Europeans. After weighting the pPS for beta cell function, Asian Indians have lower genetically determined beta cell function than white Europeans (p<0.0001). The pPS was associated with age of diagnosis in Asian Indians but not in white Europeans. The pPS explained 2% of the variation in clinically measured beta cell function, and 1.2%, 0.97%, and 0.36% of variance in age of diabetes amongst Asian Indians with normal BMI, or classified as overweight and obese BMI, respectively.

CONCLUSIONS/INTERPRETATION

The prevalence of lean BMI in young-onset diabetes is over two times higher in Asian Indians compared with white Europeans. This phenotype of lean, young-onset diabetes appears driven in part by lower beta cell function. We demonstrate that Asian Indians with diabetes also have lower genetically determined beta cell function.

Food environment and diabetes mellitus in South Asia: A geospatial analysis of health outcome data

BACKGROUND

The global epidemic of type 2 diabetes mellitus (T2DM) renders its prevention a major public health priority. A key risk factor of diabetes is obesity and poor diets. Food environments have been found to influence people's diets and obesity, positing they may play a role in the prevalence of diabetes. Yet, there is scant evidence on the role they may play in the context of low- and middle-income countries (LMICs). We examined the associations of food environments on T2DM among adults and its heterogeneity by income and sex.

METHODS AND FINDINGS

We linked individual health outcome data of 12,167 individuals from a network of health surveillance sites (the South Asia Biobank) to the density and proximity of food outlets geolocated around their homes from environment mapping survey data collected between 2018 and 2020 in Bangladesh and Sri Lanka. Density was defined as share of food outlets within 300 m from study participant's home, and proximity was defined as having at least 1 outlet within 100 m from home. The outcome variables include fasting blood glucose level, high blood glucose, and self-reported diagnosed diabetes. Control variables included demographics, socioeconomic status (SES), health status, healthcare utilization, and physical activities. Data were analyzed in ArcMap 10.3 and STATA 15.1. A higher share of fast-food restaurants (FFR) was associated with a 9.21 mg/dl blood glucose increase (95% CI: 0.17, 18.24; p < 0.05). Having at least 1 FFR in the proximity was associated with 2.14 mg/dl blood glucose increase (CI: 0.55, 3.72; p < 0.01). A 1% increase in the share of FFR near an individual's home was associated with 8% increase in the probability of being clinically diagnosed as a diabetic (average marginal effects (AMEs): 0.08; CI: 0.02, 0.14; p < 0.05). Having at least 1 FFR near home was associated with 16% (odds ratio [OR]: 1.16; CI: 1.01, 1.33; p < 0.05) and 19% (OR: 1.19; CI: 1.03, 1.38; p < 0.05) increases in the odds of higher blood glucose levels and diagnosed diabetes, respectively. The positive association between FFR density and blood glucose level was stronger among women than men, but the association between FFR proximity and blood glucose level was stronger among men as well as among those with higher incomes. One of the study's key limitations is that we measured exposure to food environments around residency geolocation; however, participants may source their meals elsewhere.

CONCLUSIONS

Our results suggest that the exposure to fast-food outlets may have a detrimental impact on the risk of T2DM, especially among females and higher-income earners. Policies should target changes in the food environments to promote better diets and prevent T2DM.

Prediction of Major Adverse Cardiovascular Events From Retinal, Clinical, and Genomic Data in Individuals With Type 2 Diabetes: A Population Cohort Study

OBJECTIVE

Improved identification of individuals with type 2 diabetes at high cardiovascular (CV) risk could help in selection of newer CV risk-reducing therapies. The aim of this study was to determine whether retinal vascular parameters, derived from retinal screening photographs, alone and in combination with a genome-wide polygenic risk score for coronary heart disease (CHD PRS) would have independent prognostic value over traditional CV risk assessment in patients without prior CV disease.

RESEARCH DESIGN AND METHODS

Patients in the Genetics of Diabetes Audit and Research Tayside Scotland (GoDARTS) study were linked to retinal photographs, prescriptions, and outcomes. Retinal photographs were analyzed using VAMPIRE (Vascular Assessment and Measurement Platform for Images of the Retina) software, a semiautomated artificial intelligence platform, to compute arterial and venous fractal dimension, tortuosity, and diameter. CHD PRS was derived from previously published data. Multivariable Cox regression was used to evaluate the association between retinal vascular parameters and major adverse CV events (MACE) at 10 years compared with the pooled cohort equations (PCE) risk score.

RESULTS

Among 5,152 individuals included in the study, a MACE occurred in 1,017 individuals. Reduced arterial fractal dimension and diameter and increased venous tortuosity each independently predicted MACE. A risk score combining these parameters significantly predicted MACE after adjustment for age, sex, PCE, and the CHD PRS (hazard ratio 1.11 per SD increase, 95% CI 1.04-1.18, P = 0.002) with similar accuracy to PCE (area under the curve [AUC] 0.663 vs. 0.658, P = 0.33). A model incorporating retinal parameters and PRS improved MACE prediction compared with PCE (AUC 0.686 vs. 0.658, P < 0.001).

CONCLUSIONS

Retinal parameters alone and in combination with genome-wide CHD PRS have independent and incremental prognostic value compared with traditional CV risk assessment in type 2 diabetes.

Prescribing Patterns and Response to Antihyperglycemic Agents Among Novel Clusters of Type 2 Diabetes in Asian Indians

Aim: To assess the prescribing patterns and response to different classes of antihyperglycemic agents in novel clusters of type 2 diabetes (T2D) described in India. Materials and Methods: We attempted to replicate the earlier described clusters of T2D, in 32,867 individuals with new-onset T2D (within 2 years of diagnosis) registered between October 2013 and December 2020 at 15 diabetes clinics located across India, by means of k-means clustering utilizing 6 clinically relevant variables. Individuals who had follow-up glycated hemoglobin (HbA1c) up to 2 years were included for the drug response analysis (n = 13,247). Results: Among the 32,867 participants included in the study, 20,779 (63.2%) were males. The average age at diagnosis was 45 years and mean HbA1c at baseline was 8.9%. The same four clusters described in India earlier were replicated. Forty percent of the study participants belonged to the mild age-related diabetes cluster, followed by insulin-resistant obese diabetes (27%), severe insulin-deficient diabetes (21%), and combined insulin-resistant and insulin-deficient diabetes (12%) clusters. The most frequently used antihyperglycemic agents were sulfonylureas, metformin, and dipeptidyl peptidase-4 inhibitors apart from insulin. While there were significant differences in HbA1c reduction between drugs across clusters, these were largely driven by differences in the baseline (pretreatment) HbA1c. Conclusions: In this new cohort, we were able to reliably replicate the four subtypes of T2D earlier described in Asian Indians. Prescribing patterns show limited usage of newer antihyperglycemic agents across all clusters. Randomized clinical trials are required to establish differential drug responses between clusters.

Diabetes mortality and trends before 25 years of age: an analysis of the Global Burden of Disease Study 2019

BACKGROUND

Diabetes, particularly type 1 diabetes, at younger ages can be a largely preventable cause of death with the correct health care and services. We aimed to evaluate diabetes mortality and trends at ages younger than 25 years globally using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

We used estimates of GBD 2019 to calculate international diabetes mortality at ages younger than 25 years in 1990 and 2019. Data sources for causes of death were obtained from vital registration systems, verbal autopsies, and other surveillance systems for 1990-2019. We estimated death rates for each location using the GBD Cause of Death Ensemble model. We analysed the association of age-standardised death rates per 100 000 population with the Socio-demographic Index (SDI) and a measure of universal health coverage (UHC) and described the variability within SDI quintiles. We present estimates with their 95% uncertainty intervals.

FINDINGS

In 2019, 16 300 (95% uncertainty interval 14 200 to 18 900) global deaths due to diabetes (type 1 and 2 combined) occurred in people younger than 25 years and 73·7% (68·3 to 77·4) were classified as due to type 1 diabetes. The age-standardised death rate was 0·50 (0·44 to 0·58) per 100 000 population, and 15 900 (97·5%) of these deaths occurred in low to high-middle SDI countries. The rate was 0·13 (0·12 to 0·14) per 100 000 population in the high SDI quintile, 0·60 (0·51 to 0·70) per 100 000 population in the low-middle SDI quintile, and 0·71 (0·60 to 0·86) per 100 000 population in the low SDI quintile. Within SDI quintiles, we observed large variability in rates across countries, in part explained by the extent of UHC (r2=0·62). From 1990 to 2019, age-standardised death rates decreased globally by 17·0% (-28·4 to -2·9) for all diabetes, and by 21·0% (-33·0 to -5·9) when considering only type 1 diabetes. However, the low SDI quintile had the lowest decline for both all diabetes (-13·6% [-28·4 to 3·4]) and for type 1 diabetes (-13·6% [-29·3 to 8·9]).

INTERPRETATION

Decreasing diabetes mortality at ages younger than 25 years remains an important challenge, especially in low and low-middle SDI countries. Inadequate diagnosis and treatment of diabetes is likely to be major contributor to these early deaths, highlighting the urgent need to provide better access to insulin and basic diabetes education and care. This mortality metric, derived from readily available and frequently updated GBD data, can help to monitor preventable diabetes-related deaths over time globally, aligned with the UN's Sustainable Development Targets, and serve as an indicator of the adequacy of basic diabetes care for type 1 and type 2 diabetes across nations.

FUNDING

Bill & Melinda Gates Foundation.

Global burden of early pregnancy gestational diabetes mellitus (eGDM): A systematic review

AIMS

Gestational diabetes mellitus (GDM) diagnosed during the first trimester of pregnancy is called 'early pregnancy Gestational Diabetes Mellitus' (eGDM). The burden of eGDM has only been studied sporadically. This review aims to understand the global burden of eGDM in terms of prevalence, risk factors, pregnancy outcomes, treatment and postpartum dysglycemia.  METHODS: A review of epidemiologic studies reporting on early GDM screening as per Joanna Briggs Institute (JBI) methodology for prevalence reviews was conducted. A customized search strategy was used to search electronic databases namely, PubMed, CINAHL, EMBASE, Cochrane Library, Scopus, MEDLINE, Ovid, ScienceDirect, and Google Scholar. Three independent reviewers reviewed studies using Covidence software. Observational studies irrespective of study design and regardless of diagnostic criteria were included. Quality of evidence was appraised, and findings were synthesized.

RESULTS

Of 58 included studies, 41 reported a prevalence of eGDM, ranging from 0.7 to 36.8%. Body mass index (BMI), previous history of GDM, family history of diabetes and multiparity were reported as eGDM risk factors. Adverse pregnancy outcomes associated with eGDM were macrosomia, caesarean delivery, induction of labour, hypertension, preterm delivery, and shoulder dystocia. The incidence of postpartum dysglycemia and the need for insulin was higher in women with eGDM. The risk of bias was moderate. Heterogeneity of studies is a limitation. Meta-analysis was not performed.

CONCLUSIONS

There is heterogeneity in the prevalence of eGDM and intrapartum and postpartum ill effects for the mother and the offspring. There is a need to develop a universal screening protocol for eGDM.

Zone-wise examination of optical coherence tomography features and their correspondence to multifocal electroretinography in eyes with nonproliferative diabetic retinopathy

PURPOSE

To examine (1) the retinal structure by optical coherence tomography (OCT) and function by means of multifocal electroretinography (mfERG) in eyes with and without nonproliferative diabetic retinopathy (NPDR) (2) for correspondence between local retinal function and OCT zones with retinal lesions.

METHODS

One hundred and thirty-two eligible participants (30 with nonproliferative DR (NPDR) and 102 with diabetes with no DR) underwent comprehensive ophthalmic examination, optical coherence tomography for retinal thickness measures, mfERG, and ultra-wide field fundus photography. OCT Early Treatment Diabetic Retinopathy Study (ETDRS) grid was overlaid on to mfERG plots.

RESULTS

Those with NPDR had significantly thicker full retinal measures in the nine (ETDRS) zones compared to no DR. mfERG P1 latencies in rings 1-6 were significantly delayed, while the response densities in rings 4-6 were lower in the NPDR group. Significant negative correlation was noted between OCT thickness and mfERG P1 response densities in many ETDRS zones. Significant positive correlation was noted between P1 latencies and OCT thickness in a few zones. The combination of cystic spaces, microaneurysms, and hard exudates were present in all zones and were associated with a decrease in P1 response densities compared to no lesions. Reduced P1 response densities were associated with a sporadic delay in the mfERG latencies and vice versa. The number of lesions did not show correspondence to the mfERG measures.

CONCLUSIONS

In eyes with NPDR, retinal function is differentially correlated with the DR lesions on OCT and can be assessed using multimodal imaging modalities.

Association between number of abnormal glucose values and severity of fasting plasma glucose in IADPSG criteria and maternal outcomes in women with gestational diabetes mellitus

AIMS

The International Association for Diabetes in Pregnancy Study Group (IADPSG) criteria recommend a single-step diagnostic oral glucose tolerance test (OGTT) for diagnosis of gestational diabetes mellitus (GDM). The aim of this study was to examine the association between the number of abnormal glucose values and levels of FPG with pregnancy outcomes.

METHODS

Pregnant women (n=1,044) were screened for GDM at maternity centers in South India using IADPSG criteria. OGTTs were classified based on the number of abnormal glucose values (any one value or more than one value high) and fasting plasma glucose (FPG) values (<92mg/dl,92-100mg/dl,>100mg/dl) and correlated with pregnancy outcomes. Odds ratio were adjusted for age, BMI, gestational week at diagnosis, family history of diabetes, previous history of GDM, gestational week at delivery and birth weight. For macrosomia and large for gestation age, birth weight was excluded from the model.

RESULTS

Risk of caesarean section was significantly higher in women with any one abnormal glucose value (OR: 1.49; 95%CI: 1.07-2.09). This further increased in those with >1 value (OR: 1.35; 95%CI: 0.87-2.10), when compared to women with all values normal. Risk of large for gestation age (LGA) was higher in women with FPG 92-100mg/dl (OR: 1.37; 95%CI: 0.80-2.35) and in those with FPG >100mg/dl (OR: 1.87; 95%CI: 1.04-3.35), compared to those with FPG <92mg/dl.

CONCLUSIONS

The risk for poor pregnancy outcomes starts in those with one abnormal value in the OGTT or with FPG >92mg/dl but becomes significantly higher in those with higher abnormal values.

Frequency and association of self-reported oral cancer among individuals with type 2 diabetes at a tertiary care diabetes centre in South India - A retrospective study

AIM

To assess the frequency of self-reported oral cancer and associated factors among individuals with type 2 diabetes (T2D) at a tertiary care diabetes centre in South India.

METHODS

Individuals with T2D who reported that they had oral cancer were included from the Diabetes Electronic Medical Records (DEMR) database. To assess the association of oral cancer with T2D, a retrospective nested case-control study design was adopted. Individuals with T2D and oral cancer diagnosed after the diagnosis of T2D (n = 78) were considered 'cases', while T2D without oral cancer were considered 'controls' (312) [in a ratio of 1:4 for cases and controls]. The cases and controls were matched for age, gender and duration of diabetes. Logistic regression was used to model predictors of oral cancer in T2D patients.

RESULTS

Oral cancer was reported in 78 out of 379,138 (0.02%) individuals with T2D registered at the centre. Logistic regression analysis showed that a HbA1c value ≥ 9% had a significant association with oral cancer with an odds ratio of 2.3 (95% CI: 1.2-4.6) after adjusting for confounding factors. Among individuals with T2D, higher frequency of oral cancer prevalence and risk was observed among those who used any form of tobacco (32.6%, OR = 2.52, 95% CI: 1.5-4.3), consumed alcohol (29.2%, OR = 2.01, 95% CI: 1.2-3.3), and those with hypertension (23.9%, OR = 2.05, 95% CI: 1.2-3.6) and hypertriglyceridemia (24.7%, OR = 1.66, 95% CI: 1.01-2.7). Significant independent predictors of oral cancer among T2D were tobacco use (OR = 2.06, 95% CI: 1.1-4.00), high HbA1c (OR = 1.3, 95% CI: 1.03-1.5), hypertension (OR = 2.3, 95% CI: 1.3-4.2) and insulin use (OR = 1.8, 95% CI: 1.03-3.2).

CONCLUSIONS

Regular dental check-ups as part of the follow-up for individuals with T2D will identify and diagnose oral cancer earlier. Further research is required to assess the physiological and biological mechanisms leading to oral cancer in individuals with T2D.

Clinical Profile of Long-Term Survivors and Nonsurvivors with Type 1 Diabetes in India

Objective: To compare the clinical profile of long-term survivors and nonsurvivors with type 1 diabetes (T1D) in India. Research Design and Methods: This is a retrospective study of 76 individuals with T1D who had survived for at least 40 years ("survivors") and 51 individuals with T1D who had died with shorter duration of diabetes ("non-survivors"), from diabetes clinics in different cities of India. Prevalence of complications in both groups and causes of death of the nonsurvivors were analyzed. Retinopathy was diagnosed by retinal photography; chronic kidney disease (CKD) by urinary albumin excretion (micro-or macroalbuminuria) and estimated glomerular filtration rate; peripheral vascular disease (PVD) by doppler measurement of ankle-brachial pressure index; coronary artery disease (CAD) based on history of myocardial infarction or coronary revascularization, and neuropathy by biothesiometry. Results: Mean glycated hemoglobin (8.4% ± 1.5% vs. 10.7% ± 2.2%, P < 0.001), serum low-density lipoprotein cholesterol (91 ± 29 mg/dL vs. 107 ± 22 mg/dL, P = 0.004), and systolic blood pressure (135 ± 16 mmHg vs. 153 ± 37 mmHg, P = 0.003) were lower, and high-density lipoprotein cholesterol (51 ± 11 mg/dL vs. 43 ± 15 mg/dL, P = 0.002) higher, among survivors compared to nonsurvivors. Diabetic retinopathy, CKD, neuropathy, PVD, and CAD were more frequent among nonsurvivors. CAD [25.5%] and renal failure [23.5%] were the most frequent causes of death. Conclusions: In this first report of long-term survivors with T1D from India, we report that survivors had better glycemic and blood pressure control, more favorable lipid profiles and lower prevalence of complications compared to nonsurvivors. However, there could be other protective factors as well, which merit further studies.

Variations in glycated haemoglobin with age among individuals with normal glucose tolerance: Implications for diagnosis and treatment-Results from the ICMR-INDIAB population-based study (INDIAB-12)

AIM

To report on glycated haemoglobin (HbA1c) values among individuals with normal glucose tolerance (NGT) at different age groups, using data acquired from a large national survey in India.

MATERIALS AND METHODS

Data on glycaemic parameters at different age groups were obtained from the Indian Council of Medical Research-INdia DIABetes (ICMR-INDIAB) study, in adults aged ≥ 20 years representing all parts of India. Age-wise distribution of HbA1c was assessed among individuals with NGT (n = 14,222) confirmed by an oral glucose tolerance test using the World Health Organization (WHO) criteria. Results were validated in another large epidemiological study (n = 1077) conducted in Chennai, India.

RESULTS

Among NGT individuals, HbA1c increased gradually with age from 5.16 ± 0.71% (33 mmol/mol) in the age group of 20-29 years to 5.49 ± 0.69% (37 mmol/mol) in those aged 70 + years. In the validation study, conducted in another study population, HbA1c was 5.35 ± 0.43% (35 mmol/mol) in age group of 20-29 years and 5.74 ± 0.50% (39 mmol/mol) in those aged 70 and above. In the INDIAB study, for every decadal increase in age, there is a 0.08% increase in HbA1c and this increase was more significant in females (females: 0.10% vs. males: 0.06%) and in urban (urban: 0.10% vs. rural: 0.08%) population.

CONCLUSIONS

HbA1c levels increase steadily with age. This suggests that age-specific cutoffs be used while utilizing HbA1c to diagnose diabetes and prediabetes, so as to minimize the risk of overdiagnosis and unnecessary initiation of treatment in elderly people who could have physiological increase in HbA1c levels.