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 Byetta was withdrawn, the patient was treated for acute pancreatitis and the symptoms subsided.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.