Long-term effect of rosiglitazone and/or ramipril on the incidence of diabetes

AIMS/HYPOTHESIS

The Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication (DREAM) trial reported that 3 years of therapy with rosiglitazone reduced the primary outcome of diabetes or death by 60%. Here we investigated whether an effect on diabetes prevention persists more than 1.5 years after therapy has been discontinued.

METHODS

The DREAM On passive follow-up study was conducted at 49 of the 191 DREAM sites. Consenting participants were invited to have a repeat OGTT 1-2 years after active therapy ended. A diagnosis of diabetes at that time was based on either a fasting or 2 h plasma glucose level of ≥7.0 mmol/l or ≥11.1 mmol/l, respectively, or a confirmed diagnosis by a non-study physician. Regression to normoglycaemia was defined as a fasting and 2 h plasma glucose level of <6.1 mmol/l and <7.8 mmol/l, respectively.

RESULTS

After a median of 1.6 years after the end of the trial and 4.3 years after randomisation, rosiglitazone participants had a 39% lower incidence of the primary outcome (hazard ratio [HR] 0.61, 95% CI 0.53-0.70; p < 0.0001) and 17% more regression to normoglycaemia (95% CI 1.01-1.34; p = 0.034). When the analysis was restricted to the passive follow-up period, a similar incidence of both the primary outcome and regression was observed in people from both treatment groups (HR 1.00, 95% CI 0.81-1.24 and HR 1.14, 95% CI 0.97-1.32, respectively). Similar effects were noted when new diabetes was analysed separately from death. Ramipril did not have any significant long-term effect.

CONCLUSIONS/INTERPRETATION

Time-limited exposure to rosiglitazone reduces the longer term incidence of diabetes by delaying but not reversing the underlying disease process.

Screening with OGTT alone or in combination with the Indian diabetes risk score or genotyping of TCF7L2 to detect undiagnosed type 2 diabetes in Asian Indians

BACKGROUND & OBJECTIVES

With increasing number of people with diabetes worldwide, particularly in India, it is necessary to search for low cost screening methods. We compared the effectiveness and costs of screening for undiagnosed type 2 diabetes mellitus (T2DM), using oral glucose tolerance testing (OGTT) alone, or following a positive result from the Indian Diabetes Risk Score (IDRS) or following a positive result from genotyping of the TCF7L2 polymorphisms in Asian Indians.

METHODS

In subjects without known diabetes (n=961) recruited from the Chennai Urban Rural Epidemiology Study (CURES), OGTT, IDRS, and genotyping of rs12255372 (G/T) and rs7903146(C/T) of TCF7L2 polymorphisms were done. IDRS includes four parameters: age, abdominal obesity, family history of T2DM and physical activity.

RESULTS

OGTT identified 72 subjects with newly diagnosed diabetes (NDD), according to the World Health Organization criteria of fasting plasma glucose ≥ 126 mg/dl or a plasma glucose ≥ 200 mg/dl, 2 h after 75 g oral glucose load. IDRS screening (cut-off ≥ 60) yielded 413 positive subjects, which included 54 (75%) of the 72 NDD subjects identified by OGTT. Genotyping yielded 493 positive subjects which only included 36 (50%) of the 72 NDD subjects showing less discriminatory power. Screening with both SNPs missed 27 (37.5%) NDD subjects identified by IDRS. In contrast, IDRS missed only 9 (12.5%) of the NDD subjects identified by genotyping. Total screening cost for OGTT alone, or with IDRS were rs 384,400 and 182,810 respectively. Comparing OGTT alone to IDRS followed by OGTT, the incremental cost per additional NDD subject detected by doing OGTT on everyone was rs 11,199 (rs 201,590 for detecting additional 18 NDD subjects).

INTERPRETATION & CONCLUSIONS

For screening a population of subjects without diagnosed diabetes in India, a simple diabetes risk score is more effective and less expensive than genotyping or doing OGTT on the whole population.

Tubular surface segmentation for extracting anatomical structures from medical imagery

This work provides a model for tubular structures, and devises an algorithm to automatically extract tubular anatomical structures from medical imagery. Our model fits many anatomical structures in medical imagery, in particular, various fiber bundles in the brain (imaged through diffusion-weighted magnetic resonance (DW-MRI)) such as the cingulum bundle, and blood vessel trees in computed tomography angiograms (CTAs). Extraction of the cingulum bundle is of interest because of possible ties to schizophrenia, and extracting blood vessels is helpful in the diagnosis of cardiovascular diseases. The tubular model we propose has advantages over many existing approaches in literature: fewer degrees-of-freedom over a general deformable surface hence energies defined on such tubes are less sensitive to undesirable local minima, and the tube (in 3-D) can be naturally represented by a 4-D curve (a radius function and centerline), which leads to computationally less costly algorithms and has the advantage that the centerline of the tube is obtained without additional effort. Our model also generalizes to tubular trees, and the extraction algorithm that we design automatically detects and evolves branches of the tree. We demonstrate the performance of our algorithm on 20 datasets of DW-MRI data and 32 datasets of CTA, and quantify the results of our algorithm when expert segmentations are available.

Effects of ethnicity on diabetes incidence and prevention: results of the Diabetes REduction Assessment with ramipril and rosiglitazone Medication (DREAM) trial

AIMS

Risk of Type 2 diabetes varies by ethnicity, but whether ethnicity remains important among those who have impaired glucose tolerance or impaired fasting glucose is uncertain. Whether the effect of thiazolidinedione treatment on diabetes prevention in persons with non-diabetic dysglycaemia varies by ethnicity is also not known. We addressed these questions using data collected in the DREAM trial.

METHODS

A 2-by-2 factorial double-blind randomized controlled trial to compare the effects of rosiglitazone and ramipril on the primary outcome of diabetes or death in persons meeting criteria for impaired glucose tolerance or impaired fasting glucose. The effect of these interventions by ethnicity was estimated using Cox regression analysis.

RESULTS

Of 5269 adults, 2365 were randomly assigned to rosiglitzone and 2634 to placebo. South Asians showed a higher hazard for the primary outcome compared with Europeans (hazard ratio, 95% confidence interval 2.21, 1.41-3.47) adjusted for age, gender, BMI, waist-hip ratio and geographic region. A lesser increase in risk was seen in Black people (1.37, 1.04-1.81). A significant reduction in risk of the primary outcome with rosiglitazone treatment assignment was seen in all ethnic groups, but the treatment effect significantly differed by ethnicity (P=0.0242), with South Asians experiencing a smaller, and Latinos a larger preventive effect.

CONCLUSIONS

Ethnicity is an important risk factor for Type 2 diabetes in dysglycaemic persons. All ethnic groups experienced a large significant reduction in diabetes risk because of rosiglitazone. The magnitude of this reduction differed by ethnicity. Given the post hoc nature of this analysis, further confirmation of these findings is needed.

Association of hypoadiponectinemia with non-alcoholic fatty liver disease in urban south Indians--(CURES - 81)

BACKGROUND & OBJECTIVES

Association between adiponectin and non-alcoholic fatty liver disease (NAFLD) has been reported in west. Studies in Indian population are lacking. This study was undertaken to assess the association of hypoadiponectinemia with NAFLD in Asian Indians.

METHOD

In this cross-sectional study, subjects were randomly selected from Phase 5 of the Chennai Urban Rural Epidemiology Study (CURES), an epidemiological study based on a representative population of Chennai in south India. One hundred twenty one subjects without NAFLD and 72 subjects with NAFLD were selected. NAFLD was diagnosed by ultrasonography. Serum adiponectin levels were measured using radioimmunoassay. Insulin resistance was calculated using Homeostasis Assessment model (HOMA-IR).

RESULTS

Serum adiponectin values were significantly lower in subjects with NAFLD compared to those without [5.6 μg/ml (95% Confidence Interval (CI) 5.0 - 6.3 μg/ml] vs 7.4 μg/ml (95% CI: 6.7 - 8.1 μg/ml, P<0.01). Adiponectin levels decreased with increasing severity of NAFLD. Subjects with moderate to severe steatosis had significantly lower adiponectin levels (5.1μg/ml, 95% CI: 4.1- 6.4 μg/ml) compared to subjects with mild steatosis (5.9 μg/ml, 95% CI: 5.0 - 6.9 μg/ml; P<0.001) and subjects without NAFLD (7.3 μg/ml, 95% CI: 6.6 - 8.0 μg/ml; P<0.01). Multiple logistic regression analysis revealed adiponectin to be negatively associated with NAFLD [Odds Ratio (OR): 0.865, 95% Confidence Interval (CI): 0.792- 0.944, P=0.001]. This remained statistically significant even after adjusting for confounding factors age, gender, body mass index, insulin resistance, waist circumference, total cholesterol, triglycerides and glucose intolerance (OR: 0.873, 95% CI: 0.793 - 0.961; P=0.005).

INTERPRETATION & CONCLUSION

NAFLD is associated with lower serum adiponectin levels independent of conventional cardiovascular risk factors in Asian Indians known to have high prevalence of diabetes and coronary artery disease.

Anthropometric measures and glucose levels in a large multi-ethnic cohort of individuals at risk of developing type 2 diabetes

AIMS/HYPOTHESES

We determined: (1) which of BMI, waist circumference, hip circumference and WHR has the strongest association and explanatory power for newly diagnosed type 2 diabetes and glucose status; and (2) the impact of considering two measures simultaneously. We also explored variation in anthropometric associations by sex and ethnicity.

METHODS

We performed cross-sectional analysis of 22,293 men and women who were from five ethnic groups and 21 countries, and at risk of developing type 2 diabetes. Standardised anthropometric associations with type 2 diabetes and AUC of glucose status from OGTT (AUC(OGTT)) were determined using multiple regression. Explanatory power was assessed using the c-statistic and adjusted r (2).

RESULTS

An increase in BMI, waist circumference or WHR had similar positive associations with type 2 diabetes, AUC(OGTT) and explanatory power after adjustment for age, sex, smoking and ethnicity (p < 0.01). However, using BMI and WHR together resulted in greater explanatory power than with other models (p < 0.01). Associations were strongest when waist circumference and hip circumference were used together, a combination that had greater explanatory power than other models except for BMI and WHR together (p < 0.01). Results were directionally similar according to sex and ethnicity; however, significant variations in associations were observed among these subgroups.

CONCLUSIONS/INTERPRETATION

The combination of BMI and WHR, or of waist circumference and hip circumference has the best explanatory power for type 2 diabetes and glucose status compared with a single anthropometric measure. Measurement of waist circumference and hip circumference is required to optimally identify people at risk of type 2 diabetes and people with elevated glucose levels.

The Indian type 2 diabetes risk score also helps identify those at risk of macrovasvular disease and neuropathy (CURES-77)

AIMS

To see whether the diabetic individuals identified by the Indian Diabetes Risk Score (IDRS) also have a higher prevalence of diabetes related complications.

METHODS

Type 2 diabetic subjects were selected from the Chennai Urban Rural Epidemiology Study in south India. Four field stereo retinal colour photography was done and diabetic retinopathy [DR] was classified according to Early Treatment Diabetic Retinopathy Study grading system. Coronary artery disease was diagnosed using Minnesota coding of 12-lead electrocardiograms. Diabetic peripheral neuropathy (DPN) was diagnosed if vibratory perception threshold [VPT] of the right great toe measured by biothesiometry was > or =20. The criterion for diagnosis of peripheral vascular disease (PVD) was an ankle-brachial index < 0.9. Macroalbuminuria was diagnosed if urinary albumin excretion was > or =300 microg/mg creatinine. A total of 1476 individuals who had information on all test parameters were included for analysis.

RESULTS

Subjects with IDRS score > or =60 had significantly higher prevalence of coronary artery disease (CAD) [9.2% vs. 5.4%, p = 0.043], DPN [29.2% vs. 8.8%, p < 0.001] and PVD [4.8% vs. 1.9%, p = 0.038] compared to subjects with IDRS score <60. However, the prevalence of DR and macroalbuminuria did not differ between the two IDRS subgroups. Age explained much of the observed differences in prevalence of CAD, PVD and DPN between the two IDRS subgroups.

CONCLUSIONS

This study further extends the clinical usefulness of IDRS to predicting diabetic complications like CAD, PVD and DPN as well.

Imaging of meningioma progression by matrix-assisted laser desorption ionization time-of-flight mass spectrometry

Often considered benign, meningiomas represent 32% of intracranial tumors with three grades of malignancy defined by the World Health Organization (WHO) histology based classification. Malignant meningiomas are associated with less than 2 years median survival. The inability to predict recurrence and progression of meningiomas induces significant anxiety for patients and limits physicians in implementing prophylactic treatment approaches. This report presents an analytical approach to tissue characterization based on matrix-assisted laser desorption ionization time-of-flight (MALDI TOF) mass spectrometry imaging (MSI) which is introduced in an attempt to develop a reference database for predictive classification of brain tumors. This pilot study was designed to evaluate the potential of such an approach and to begin to address limitations of the current methodology. Five recurrent and progressive meningiomas for which surgical specimens were available from the original and progressed grades were selected and tested against nonprogressive high-grade meningiomas, high-grade gliomas, and nontumor brain specimens. The common profiling approach of data acquisition was compared to imaging and revealed significant benefits in spatially resolved acquisition for improved spectral definition. A preliminary classifier based on the support vector machine showed the ability to distinguish meningioma image spectra from the nontumor brain and from gliomas, a different type of brain tumor, and to enable class imaging of surgical tissue. Although the development of classifiers was shown to be sensitive to data preparation parameters such as recalibration and peak picking criteria, it also suggested the potential for maturing into a predictive algorithm if provided with a larger series of well-defined cases.

Visceral & subcutaneous abdominal fat in relation to insulin resistance & metabolic syndrome in non-diabetic south Indians

BACKGROUND & OBJECTIVES

The objective of the study was to determine whether visceral or subcutaneous component of abdominal fat was associated with insulin resistance and metabolic syndrome in non- diabetic Asian Indians.

METHODS

This cross-sectional study had on 120 individuals with normal glucose tolerance (49 males and 71 females). A single slice CT scan at L4- L5 was done for measurement of visceral and subcutaneous abdominal fat. Metabolic syndrome was defined according to the South Asian Modified National Cholesterol Education Program Adult Treatment Panel III criteria (SAM-NCEP) criteria. Insulin Sensitivity Index (ISI-Matsuda) was used to assess insulin sensitivity/resistance.

RESULTS

Linear regression analysis revealed that visceral, but not subcutaneous fat was associated with serum triglycerides (R(2);=0.457,beta= 0.34; P=0.006), HDL cholesterol (R(2);=0.430, beta= -0.051; P=0.018) and ISI-Matsuda (R(2);=0.437, beta= -0.05; P=0.039) after adjusting for age, gender and BMI. Visceral fat showed significant association with metabolic syndrome (OR: 1.013, 95% CI: 1.001- 1.025; P=0.041) even after adjusting for age, gender, body mass index and glycated haemoglobin whereas subcutaneous fat did not show such an association.

INTERPRETATION & CONCLUSION

These results indicate that in non-diabetic Asian Indians, visceral, but not subcutaneous component of abdominal fat is associated with insulin resistance, cardiovascular risk factors and metabolic syndrome.

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.

Distributed Trust Based Authentication Scheme in a Clustered Environment Using Threshold Cryptography for Vehicular Ad Hoc Network

A Vehicular Ad-Hoc Network, or VANET, is a form of Mobile Ad-Hoc Network to provide communications among nearby vehicles and between vehicles and nearby fixed equipments. Security has become a prime concern in providing communication between these vehicles. Unlike wired networks, the characteristics of Vehicular Ad Hoc Networks (VANETs) pose a number of non-trivial challenges to security design. In this paper, the authors present a threshold security mechanism with a mobility based Clustering for Open Inter Vehicle Communication Networks (COIN). Nodes that have a similar moving pattern are grouped into a cluster, and unlike other clustering algorithms, it takes the moving pattern of the vehicles into consideration with the driver’s intention. The stability of clusters is estimated based on relative mobility of cluster members. A threshold cryptographic scheme is employed on top of the clusters to protect routing information and data traffic. To ensure distributed trust in the clustered environment, the private key (k) is divided into n pieces in such a way that k is easily reconstructable from any p number of pieces.

Impact of alcohol on coronary heart disease in Indian men

BACKGROUND

Moderate alcohol consumption is known to be protective against coronary heart disease (CHD). However, the INTERHEART study, a case-control study of acute myocardial infarction (MI) patients, revealed that alcohol consumption in South Asians was not protective against CHD. We therefore planned to study cardiovascular risk factor and CHD prevalence among male alcohol users as compared to age matched lifetime abstainers.

METHODS

The subjects for this study were recruited from a cross-sectional survey carried out among employees and their family members aged 20-69 years in 10 medium-to-large industries from diverse sites in India, using a stratified random sampling technique. Information on education, behavioral, clinical and biochemical risk factors of CHD and alcohol use was obtained through standardized instruments. CHD diagnosis was based on Rose Questionnaire or a prior physician diagnosed CHD.

RESULTS

A total of 4465 subjects were present or past alcohol users. The mean age of alcohol users and lifetime abstainers was 42.8+/-11.0 years and 42.8+/-11.1 years, respectively (p=0.90). Systolic blood pressure and diastolic blood pressure were significantly higher in alcohol users (128.7+/-17.6 mmHg/80.1+/-11.3 mmHg) as compared to lifetime abstainers (126.9+/-15.9 mmHg/79.5+/-10.3 mmHg, p<0.01). Fasting blood sugar in alcohol users (98.7+/-30.5 mg%) was also significantly higher than lifetime abstainers (96.6+/-26.0 mg%, p<0.01). Total cholesterol was lower in alcohol users (179.1+/-41.1 mg%) as compared to lifetime abstainers (182.7+/-38.2 mg%, p<0.01). HDL cholesterol was higher in alcohol users (42.9+/-10.8 mg%) as compared to lifetime abstainers (41.3+/-10.0 mg%, p<0.01). Body mass index (BMI) was lower in alcohol users as compared to lifetime abstainers (22.7+/-4.1 kg/m2 vs. 24.0+/-3.3 kg/m2, p<0.001). Tobacco use was significantly higher in alcohol users (63.1% vs. 20.7%). The odds ratio (OR) of having CHD after adjusting for tobacco use, BMI and education was 1.4 (95%CI 1.0-1.9) in alcohol users as compared to controls. The OR was 1.2 (95%CI 0.8-1.6) in occasional alcohol users, 1.6 (95%CI 1.0-2.2) in regular alcohol users and 2.1 (95% CI 1.1-3.0) in past alcohol users as compared to controls.

CONCLUSION

We did not observe an inverse (protective) association between alcohol intake and the prevalence of CHD. In contrast, our study indicated an association in the reverse direction, suggesting possible harm of alcohol for coronary risk in Indian men. This relationship needs to be further examined in large, prospective study.

Adiponectin and carotid intimal medial thickness in subjects with and without glucose intolerance (CURES-82)

OBJECTIVE

This study assessed the association of serum adiponectin with carotid intimal medial thickness (IMT) in Asian Indians with different grades of glucose intolerance.

METHODS

Subjects with normal glucose tolerance (NGT) (n = 520), impaired glucose tolerance (IGT) (n = 115), and type 2 diabetes mellitus (T2DM) (n = 540) were recruited from the Chennai Urban Rural Epidemiology Study, in south India. Adiponectin levels were measured using radioimmunoassay. Carotid IMT was assessed by high resolution B-mode ultrasonography. Insulin resistance was calculated using the homeostasis assessment model.

RESULTS

Subjects with glucose intolerance (i.e., IGT and T2DM) were older compared to subjects with NGT. Waist circumference, systolic blood pressure, and serum triglycerides were higher among subjects with IGT and T2DM compared to subjects with NGT (P < 0.001). Subjects with glucose intolerance had significantly higher mean carotid IMT values and lower adiponectin compared to subjects with NGT (P < 0.001). Serum adiponectin levels were significantly correlated with IMT among NGT (P = 0.005) and IGT (P = 0.005) subjects but not in subjects with diabetes. Linear regression analysis revealed adiponectin to be negatively associated with IMT (P < 0.001) even after adjusting for age, gender, body mass index, insulin resistance, and glucose intolerance (P < 0.001).

CONCLUSIONS

Carotid IMT is associated with lower serum adiponectin levels independent of conventional cardiovascular risk factors in urban South Indians.

WITHDRAWN: Association of uncoupling protein 2 and 3 gene polymorphisms with type 2 diabetes in Asian Indians

Ahead of Print article withdrawn by publisher.

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.

Double burden of underweight and overweight among children (10-19 years of age) of employees working in Indian industrial units

BACKGROUND

Along with the existing problem of underweight, overweight in children is increasing in the developing world. However, there is little information on its magnitude and pattern in the Indian context. We aimed to study the pattern and correlates of overweight in Indian children and adolescents.

METHODS

A total of 3750 children in the age group of 10-19 years, who were family members of randomly selected employees from 10 different industrial sites in India, were surveyed using an interviewer-administered questionnaire.

RESULTS

The prevalence of underweight was highest in peri-urban areas (30.2% and 53.2% according to Indian and international criteria, respectively). In urban and highly urban areas, the prevalence of underweight was 14.1% and 9.8%, respectively, according to the Indian criteria, and 27.1% and 19.2%, respectively, according to international criteria. The proportion of overweight children was highest in the highly urban category (19.1% and 13.4% according to Indian and international criteria, respectively). The level of urbanization (OR 3.1 and 4.7 for overweight in urban and highly urban areas, respectively, compared with peri-urban areas, p < 0.001), physical activity (OR 0.4, p < 0.001, in children with physical activity score > or = 75th percentile compared with a score < or = 75th percentile) and frequency of meals outside the home (OR 12, p < 0.001, if > 25% weekly meals taken outside the home compared with < 25% of weekly meals outside home) were significant predictors of overweight.

CONCLUSION

There is a double burden of underweight and overweight among Indian children and adolescents.

Identification of novel variants in the hepatocyte nuclear factor-1alpha gene in South Indian patients with maturity onset diabetes of young

CONTEXT

Mutations in the HNF 1A gene are the most common cause of maturity-onset diabetes of the young (MODY) in most populations. India currently has the largest number of people with diabetes in the world, and onset of type 2 diabetes occurs at a younger age with possible overlap with MODY. There are very few data on MODY mutations from India.

OBJECTIVE

The objective was to screen coding and promoter regions of HNF1A gene for mutations in unrelated South Indian subjects in whom a clinical diagnosis of MODY was made.

DESIGN

This was an observational cross-sectional study.

SETTING

The study was conducted at a diabetes specialties centre in Chennai in southern India.

PATIENTS

Ninety-six unrelated south Indian subjects in whom clinical diagnosis of MODY was made were included in the study. The control population comprised of 57 unrelated nondiabetic subjects selected from the Chennai Urban Rural Epidemiology Study, a study conducted on a representative population (aged > or =20 yr) of Chennai.

RESULTS

We identified nine novel variants comprising seven mutations (one novel mutation -538G>C at promoter region and six novel coding region mutations) and two polymorphisms in the HNF1A gene. Functional studies revealed reduced transcriptional activity of the HNF1A promoter for two promoter variants. We also observed cosegregation with diabetes of the Arg263His coding region mutation in eight members of one MODY family, whereas it was absent in nondiabetic subjects of this family.

CONCLUSION

This study suggests that mutations in the HNF1A gene comprise about 9% of clinically diagnosed MODY subjects in southern India and a novel Arg263His mutation cosegregates with MODY in one family.

Effects of a polypill (Polycap) on risk factors in middle-aged individuals without cardiovascular disease (TIPS): a phase II, double-blind, randomised trial

BACKGROUND

The combination of three blood-pressure-lowering drugs at low doses, with a statin, aspirin, and folic acid (the polypill), could reduce cardiovascular events by more than 80% in healthy individuals. We examined the effect of the Polycap on blood pressure, lipids, heart rate, and urinary thromboxane B2, and assessed its tolerability.

METHODS

In a double-blind trial in 50 centres in India, 2053 individuals without cardiovascular disease, aged 45-80 years, and with one risk factor were randomly assigned, by a central secure website, to the Polycap (n=412) consisting of low doses of thiazide (12.5 mg), atenolol (50 mg), ramipril (5 mg), simvastatin (20 mg), and aspirin (100 mg) per day, or to eight other groups, each with about 200 individuals, of aspirin alone, simvastatin alone, hydrochlorthiazide alone, three combinations of the two blood-pressure-lowering drugs, three blood-pressure-lowering drugs alone, or three blood-pressure-lowering drugs plus aspirin. The primary outcomes were LDL for the effect of lipids, blood pressure for antihypertensive drugs, heart rate for the effects of atenolol, urinary 11-dehydrothromboxane B2 for the antiplatelet effects of aspirin, and rates of discontinuation of drugs for safety. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00443794.

FINDINGS

Compared with groups not receiving blood-pressure-lowering drugs, the Polycap reduced systolic blood pressure by 7.4 mm Hg (95% CI 6.1-8.1) and diastolic blood pressure by 5.6 mm Hg (4.7-6.4), which was similar when three blood-pressure-lowering drugs were used, with or without aspirin. Reductions in blood pressure increased with the number of drugs used (2.2/1.3 mm Hg with one drug, 4.7/3.6 mm Hg with two drugs, and 6.3/4.5 mm Hg with three drugs). Polycap reduced LDL cholesterol by 0.70 mmol/L (95% CI 0.62-0.78), which was less than that with simvastatin alone (0.83 mmol/L, 0.72-0.93; p=0.04); both reductions were greater than for groups without simvastatin (p<0.0001). The reductions in heart rate with Polycap and other groups using atenolol were similar (7.0 beats per min), and both were significantly greater than that in groups without atenolol (p<0.0001). The reductions in 11-dehydrothromboxane B2 were similar with the Polycap (283.1 ng/mmol creatinine, 95% CI 229.1-337.0) compared with the three blood-pressure-lowering drugs plus aspirin (350.0 ng/mmol creatinine, 294.6-404.0), and aspirin alone (348.8 ng/mmol creatinine, 277.6-419.9) compared with groups without aspirin. Tolerability of the Polycap was similar to that of other treatments, with no evidence of increasing intolerability with increasing number of active components in one pill.

INTERPRETATION

This Polycap formulation could be conveniently used to reduce multiple risk factors and cardiovascular risk.

Prevalence of non-alcoholic fatty liver disease in urban south Indians in relation to different grades of glucose intolerance and metabolic syndrome

AIM

To estimate prevalence of non-alcoholic fatty liver disease (NAFLD) and its association with glucose intolerance (type 2 diabetes (DM), prediabetes) and metabolic syndrome (MS) in urban south Indians.

METHODS

This study was carried out in 541 subjects (response rate 92%) of the original sample of 26,001 subjects in the Chennai Urban Rural Epidemiology Study maintaining the representativeness. Anthropometry and lipid estimations were done in all and oral glucose tolerance test in all, except self-reported diabetic subjects. NAFLD was diagnosed by ultrasonography and MS by modified Adult Treatment Panel III (ATP III) criteria. DM, impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) were defined using WHO consulting group criteria.

RESULTS

Overall prevalence of NAFLD was 32% (173/541 subjects) (men: 35.1%, women: 29.1%, p=0.140). Prevalence of most cardio-metabolic risk factors was significantly higher in NAFLD subjects. Prevalence of NAFLD (54.5%) was higher in subjects with DM compared to those with prediabetes (IGT or IFG) (33%), isolated IGT (32.4%), isolated IFG (27.3%) and normal glucose tolerance (NGT) (22.5%) (DM vs. prediabetes: p<0.05, DM vs. NGT: p<0.001, prediabetes vs. NGT: p<0.05). Even after adjusting for age, gender and waist circumference, NAFLD was associated with diabetes (OR: 2.9, 95% C.I.: 1.9-4.6, p<0.001) and MS (OR: 2.0, 95% C.I.: 1.3-3.1, p<0.001).

CONCLUSION

NAFLD is present in a third of urban Asian Indians and its prevalence increases with increasing severity of glucose intolerance and in MS. This is the first population-based prevalence of NAFLD from south Asia which faces the brunt of the diabetes epidemic.

Unexpected and abnormally low HDL cholesterol levels on combination hypolipidemic therapy

In general, Indians have low HDL cholesterol levels. Fenofibrate, a drug widely used in the treatment of hypertriglyceridemia, usually also increases HDL cholesterol. There have been a few reports in the literature of a paradoxical decrease in serum HDL-cholesterol in patients treated with fenofibrate, either alone or in combination with a statin. We report three cases of paradoxical decrease in serum HDL-cholesterol in type 2 diabetic patients treated with a statin-fenofibrate combination.

Reliability and validity of a modified PHQ-9 item inventory (PHQ-12) as a screening instrument for assessing depression in Asian Indians (CURES-65)

OBJECTIVES

To evaluate the validity and reliability of the modified Patient Health Questionnaire(PHQ) 12 item instrument as a screening tool for assessing depression compared to the PHQ-9 in a representative south Indian urban population.

METHODS

The Chennai Urban Rural Epidemiology Study [CURES] is a large cross-sectional study conducted in Chennai, South India. In Phase 1 of CURES(urban component), 26,001 individuals aged > or =20 years individuals were selected by a systematic sampling technique of whom one hundred subjects were randomly selected, using computer-generated numbers, for this validation study. Two self-reported questionnaires (modified PHQ-12 item and PHQ-9 item) were administered to the subjects to compare their effectiveness in detecting depression. Reliability and validity were assessed and Receiver Operating Characteristic (ROC) curves were plotted. Pearson's correlation was used to compare the two questionnaires.

RESULTS

The mean age of the study was 38.6 +/- 11.6 years and 48% were males. Pearson's correlation coefficient between the modified PHQ-12 and the PHQ-9 item was 0.913 [p < 0.0001]. Factor Analysis revealed that the modified PHQ-12 item scale can be used as a unidimensional scale and had excellent internal consistency (Cronbach's alpha: 0.88). A cut point of >4 calculated using the ROC curves for the modified PHQ-12 item had the highest sensitivity (92.0%) and specificity (90.7%) using PHQ-9 as the gold standard. The positive predictive value was 76.7%, and the negative predictive value, 97.1% and the area under the ROC curve, 0.979 (95% Confidence Interval: 0.929 - 0.997, p < 0.0001).

CONCLUSION

The modified PHQ-12 item is a valid and reliable instrument for large scale population based screening of depression in Asian Indians and a cut point score of greater than 4 gave the highest sensitivity and specificity.

Association of leukocyte count and hsCRP with metabolic abnormalities in subjects with normal glucose tolerance (CURES - 64)

OBJECTIVE

The aim of the present study was to assess the association of leukocyte count and high sensitivity C-Reactive protein (hsCRP) with metabolic abnormalities in subjects with normal glucose tolerance.

METHODS

Subjects with Normal Glucose Tolerance (NGT) (n = 865) were recruited from the Chennai Urban Rural Epidemiology Study [CURES]. Standard methods were used for assessing hsCRP [Nephelometry, in a subset] and leukocytes [Flowcytometry, Sysmex SF-3000]. Insulin resistance was calculated using the Homeostasis Assessment model (HOMA-IR).

RESULTS

Body mass index, waist circumference, systolic and diastolic blood pressure, fasting plasma glucose, HbA1c, serum cholesterol, LDL cholesterol, HOMA IR and hsCRP increased significantly with increasing tertiles of leukocyte count [p for trend < 0.001]. Both leukocyte count and hsCRP showed a positive correlation with cardiovascular risk factors. Leukocyte count showed a positive correlation with hsCRP [p = 0.008]. Both mean leukocyte count [p < 0.001] and hsCRP [p = 0.04] were higher in subjects with Metabolic Syndrome (MS), which increased with increase in number of metabolic abnormalities [p for trend < 0.001]. Regression models showed leukocyte count [p < 0.001] and hsCRP [p = 0.03] to be associated with MS, even after adjusting for age and gender.

CONCLUSION

A significant association exists between systemic inflammation [leukocyte count and hsCRP] and MS/cardiovascular risk factors in Asian Indians even among non-diabetic subjects.

Prevalence and determinants of diabetes mellitus in the Indian industrial population

AIM

To highlight the regional difference in the prevalence of diabetes mellitus (DM) and to explore determinants in variability in the Indian industrial population.

METHODS

A cross-sectional survey was carried out among the employees and their family members (10 930 individuals, mean age 39.6 years, 6764 male) of eleven medium-to-large industries from diverse sites in India, using a stratified random sampling technique. Information on behavioural, clinical and biochemical risk factors of DM was obtained, through standardized instruments. DM was diagnosed when fasting blood glucose was > or = 7.0 mmol/l and/or individuals took drug treatment for DM. Multiple logistic regression analysis was carried out to identify the potential predictors of DM.

RESULT

In the 20 to 69-year-old age group, the crude prevalence of DM and impaired fasting glucose was 10.1 and 5.3%, respectively. Urban sites had a higher prevalence and awareness of DM status. Individuals in the lower education group had a high prevalence of DM (11.6%). In diabetic subjects, 38.4% were unaware that they had diabetes. Waist-circumference-to-height ratio had a higher DM predictive power than waist circumference and body mass index. The risk factors associated with overall prevalence of DM were: age, sex, low-education level, family history of DM, hypertension and overweight/obesity. Interaction of risk factors was observed only in urban high-prevalence sites.

CONCLUSION

There are wide regional variations in the prevalence of DM in India. The high burden of undetected diabetes, even in settings with universal access to on-site health care, highlights the need for innovative prevention and control strategies.

Relation between age and coronary heart disease (CHD) risk in Asian Indian patients with diabetes: A cross-sectional and prospective cohort study

OBJECTIVE

Non-migrant Asian Indians have a high prevalence of diabetes and coronary heart disease (CHD). Since the relation between age and CHD risk in this population is not known, the appropriateness of existing age threshold for patients with diabetes to be suitable for primary CHD prevention with statins is not known. We aimed to determine an age threshold above which patients develop a higher risk of CHD and would merit routine statin prescription.

DESIGN

Cross-sectional analysis of 1087 patients with diabetes from the Chennai Urban Rural Epidemiological Studies (CURES). CHD risk assessment was calculated using the United Kingdom Prospective Study (UKPDS) risk engine, externally validated by using data obtained from the 7-year follow-up cohort of the Chennai Urban Population Study (CUPS). Relation between age and CHD risk was determined and the age threshold for increased CHD risks was calculated using line of best fit.

RESULTS

UKPDS risk engine overestimates CHD event rates by 50% in this population. Age is a strong independent predictor of CHD risk. Transition from low to moderate-risk category for men and women with diabetes occurred at ages 37 and 50 years, respectively. Sensitivity for fulfilling this CHD risk criteria are 98.7% for men and 87.1% for women.

CONCLUSIONS

Statins should be routinely prescribed to all Asian Indian men and women with diabetes above the ages of 37 and 50 years, respectively. For patients below these age thresholds, decision to initiate statins should be based on patient's individual cardiovascular risk factors. This strategy may facilitate public health efforts to reduce CHD events in India.

Increased awareness about diabetes and its complications in a whole city: effectiveness of the "prevention, awareness, counselling and evaluation" [PACE] Diabetes Project [PACE-6]

AIMS AND OBJECTIVES

To determine the effectiveness of a large scale multipronged diabetes awareness program provided through community involvement in Chennai.

MATERIAL AND METHODS

Mass awareness and free screening camps were conducted between 2004-2007 at various locations of Chennai as part of the Prevention, Awareness, Counselling and Evaluation [PACE] Diabetes Project. During a 3-year period, 774 diabetes awareness camps were conducted to reach the public directly. After the PACE project was completed, 3000 individuals, representative of Chennai, were surveyed in 2007 using a systematic stratified random sampling technique. The results were compared to a similar survey carried out, as part of the Chennai Urban Rural Epidemiology Study [CURES] in 2001-2002, which served as a measure of baseline diabetes awareness.

RESULTS

Awareness of a condition called "diabetes" increased significantly from 75.5% in 2001-2002 (CURES) to 81% (p < 0.001) in 2007 (PACE). 74.1% of the citizens of Chennai are now aware that the prevalence of diabetes is increasing as compared to 60.2% earlier [p < 0.001]. Significantly more people felt that diabetes could be prevented (p < 0.001), and that a combination of diet and exercise were needed to do so (p < 0.001). Respondents reporting obesity, family history of diabetes, hypertension and mental stress as risk factors increased significantly after PACE (p < 0.001). More people were able to correctly identify the eyes (PACE 38.1% compared to CURES--16.1%, p < 0.001), kidney (PACE 42.3% compared to CURES 16.10%, p < 0.001), heart (PACE 4.6% compared to CURES 5.8%, p < 0.001) and feet (PACE 35.0% vs. CURES 21.9%, p < 0.001) as the main organs affected by diabetes.

CONCLUSION

Through direct public education and mass media campaigns, awareness about diabetes and its complications can be improved even in a whole city. If similar efforts are implemented state-wise and nationally, prevention and control of non-communicable diseases, specifically diabetes and cardiovascular disease, is an achievable goal in India.

BMI compared with central obesity indicators in relation to diabetes and hypertension in Asians

OBJECTIVE

To compare BMI with waist circumference (WC), waist-to-hip ratio (WHR), and waist-to-stature ratio (WSR) in association with diabetes or hypertension.

METHODS AND PROCEDURES

Cross-sectional data from 16 cohorts from the DECODA (Diabetes Epidemiology: Collaborative Analysis of Diagnostic criteria in Asia) study, comprising 9,095 men and 11,732 women, aged 35-74 years, of different ethnicities were included in this meta-analysis.

RESULTS

Age-adjusted odds ratios (ORs) for diabetes in men (women) for 1 s.d. increase in BMI, WC, WHR, and WSR were 1.52 (1.59), 1.54 (1.70), 1.53 (1.50), and 1.62 (1.70), respectively; and the corresponding ORs for hypertension were 1.68 (1.55), 1.66 (1.51), 1.45 (1.28), and 1.63 (1.50). Paired homogeneity tests (BMI with each of the three) adjusted for age and cohort showed that diabetes had stronger association with WSR than BMI (P=0.001) in men but with WC and WSR than BMI (both P<0.05) in women. Hypertension had stronger association with BMI than WHR in men (P<0.001) and had the strongest with BMI than the others (WHR P<0.001; WSR P<0.01; and WC P<0.05) in women. Areas under the receiver operating characteristic (ROC) curves adjusted for age and cohort were slightly larger for diabetes for WSR 0.735 (0.748) in men (women) and WC 0.749 (women only) than BMI 0.725 (0.742) while for hypertension larger for BMI 0.760 (0.766) than WHR 0.748 (0.751), but their 95% CIs were all overlapped.

DISCUSSION

WSR was stronger than BMI in association with diabetes, but these indicators were equally strongly associated with hypertension in Asians.

Prevention awareness counselling and evaluation (PACE) diabetes project: a mega multi-pronged program for diabetes awareness and prevention in South India (PACE- 5)

OBJECTIVE

The Prevention Awareness Counselling Evaluation (PACE) Diabetes Project is a large scale community based project carried out to increase awareness of diabetes and its complications in Chennai city (population: 4.7 million) through 1) public education 2) media campaigns 3) general practitioner training 4) blood sugar screening and 5) community based "real life" prevention program

METHODS

Education took place in multiple forms and venues over the three-year period of the PACE project between 2004-2007. With the help of the community, awareness programs were conducted at residential sites, worksites, places of worship, public places and educational institutions through lectures, skits and street plays. Messages were also conveyed through popular local television and radio channels and print media. The General Practitioners (GPs) program included training in diabetes prevention, treatment and the advantages of early detection of complications. Free random capillary blood glucose testing was done for individuals who attended the awareness programs using glucose meter.

RESULTS

Over a three-year period, we conducted 774 education sessions, 675 of which were coupled with opportunistic blood glucose screening. A total of 76,645 individuals underwent blood glucose screening. We also set up 176 "PACE Diabetes Education Counters" across Chennai, which were regularly replenished with educational materials. In addition, we trained 232 general practitioners in diabetology prevention, treatment and screening for complications. Multiple television and radio shows were given and messages about diabetes sent as Short Message Service (SMS) through mobile phones. Overall, we estimate that we reached diabetes prevention messages to nearly two million people in Chennai through the PACE Diabetes Project, making it one of the largest diabetes awareness and prevention programs ever conducted in India.

CONCLUSION

Mass awareness and screening programs are feasible and, through community empowerment, can help in prevention and control of non-commuincable diseases such as diabetes and its complications on a large scale.

Challenges in diabetes care in India: sheer numbers, lack of awareness and inadequate control

With an estimated 40 million people suffering from the condition, the largest in any country in the world, diabetes has become a major health care problem in India. Recent epidemiological studies from India point to the great burden due to diabetes and its micro and macrovascular complications. This is primarily because the status of diabetes control in India is far from ideal. Based on the available data, the mean glycated hemoglobin levels are around 9% which is at least 2% higher than the goal currently suggested by international bodies. The IMPROVE study has helped identify the barriers to good control of diabetes both among patients as well as physicians in today's practice. However the recent ACCORD study points to the dangers of overaggressive treatment, especially in high risk in elderly patients. A balanced approach to improve awareness about diabetes and its control both among patients and the medical fraternity is urgent need of the hour in India. The associated risks of tight control in high risk groups should also be kept in mind.

Risk factors for diabetic retinopathy in a South Indian Type 2 diabetic population--the Chennai Urban Rural Epidemiology Study (CURES) Eye Study 4

AIMS

To determine risk factors for diabetic retinopathy (DR) in an urban South Indian Type 2 diabetic population.

METHODS

The Chennai Urban Rural Epidemiology Study is a large cross-sectional study conducted in Chennai, South India. A total of 1736 Type 2 diabetic subjects were recruited for this study, which included 1382 known diabetic subjects (90.4% response rate) and 354 randomly selected, newly detected diabetic subjects diagnosed by oral glucose tolerance test. All subjects underwent four-field stereo retinal colour photography, graded by the Early Treatment Diabetic Retinopathy Study protocol.

RESULTS

Of the 1736 Type 2 diabetic subjects photographed, photographs could be graded in 1715 subjects. Stepwise ordinal logistic regression analysis revealed that male gender (P = 0.041), duration of diabetes (P < 0.0001), glycated haemoglobin (HbA(1c); P < 0.0001), macroalbuminuria (P = 0.0002) and insulin therapy (P = 0.0001) were significantly associated with severity of DR. The risk for developing DR was 7.7 times (95% confidence interval 4.71-12.48, P < 0.0001) for elevated postprandial plasma glucose levels compared with 4.2 times (95% confidence interval 2.78-6.34, P < 0.0001) for elevated fasting plasma glucose when the fourth quartile values were compared with the first quartile glucose values.

CONCLUSIONS

In South Indian Type 2 diabetic subjects, duration of diabetes, HbA1c, male gender, macroalbuminuria and insulin therapy were independent risk factors for severity of DR. Postprandial hyperglycaemia indicated a higher risk for DR compared with elevated fasting plasma glucose levels.

Islet autoimmunity status in Asians with young-onset diabetes (12-40 years): association with clinical characteristics, beta cell function and cardio-metabolic risk factors

In this paper, the islet autoimmunity status and relation to clinical characteristics, beta cell function and cardio-metabolic risk factors in young-onset Asian diabetic patients are evaluated at baseline. The study population consisted of 912 patients (from China, India, Malaysia and Singapore) with age 12-40 years and diabetes duration <12 months. Autoantibodies to glutamic acid decarboxylase (GADA) and tyrosine phosphatase (IA-2A), beta cell function and cardio-metabolic risk parameters were assessed. Among our young patient cohort, 105 (11.5%) patients were GADA and/or IA-2A positives (Ab +ve). Ab +ve patients were younger, leaner, had more severe hyperglycaemia and lower beta cell function. The frequency of metabolic syndrome was significantly lower in Ab +ve patients (27%) compared to Ab -ve patients (54%). However, a substantial proportion of patients in both groups of patients had atherogenic dyslipidaemia, hypertension and albuminuria (micro or macro). In our study cohort, only one in 10 Asian youth with new-onset diabetes had evidence of islet autoimmunity. At least 60% of Ab +ve and 50% of Ab -ve patients demonstrated classical features of type 1 and type 2 diabetes respectively. Regardless of autoimmunity status, the cardio-metabolic risk factors, in particular atherogenic dyslipidaemia, hypertension and albuminuria were common in our patients with young-onset diabetes.

Prevalence and risk factors for diabetic neuropathy in an urban south Indian population: the Chennai Urban Rural Epidemiology Study (CURES-55)

AIMS

This study was conducted to determine the prevalence of, and risk factors for, diabetic neuropathy (DN) in south Indian Type 2 diabetic subjects.

METHODS

Subjects were recruited from the Chennai Urban Rural Epidemiology Study, conducted on a representative cohort from Chennai city. A total of 1629 diabetic subjects were included, of whom 1291 were known to have diabetes (KD) subjects and 338 were randomly selected newly detected diabetic (NDD) subjects. Neuropathy was diagnosed if vibratory perception threshold at the great toe, measured by biothesiometry, exceeded mean + 2 sd of a healthy non-diabetic study population aged 20-45 years (cut point > or = 20 V).

RESULTS

The overall prevalence of DN was 26.1% (age-adjusted 13.1%) with no significant difference in gender. The prevalence of neuropathy was significantly higher in KD subjects compared with NDD subjects (27.8 vs. 19.5%, P = 0.002). The prevalence of diabetic retinopathy (24.1 vs. 15.3%, P < 0.0001) and hypertension (51.1 vs. 40.0%, P < 0.0001) were higher in those with neuropathy compared with those without. The odds ratio for neuropathy in subjects with duration of diabetes > 15 years compared with < or = 5 years was 5.7 (95% confidence interval: 3.52-9.08, P < 0.0001). Regression analysis showed age (P < 0.0001), glycated haemoglobin (P = 0.001) and duration of diabetes (P = 0.045) to be significantly associated with neuropathy.

CONCLUSIONS

This cross-sectional population-based study shows that, among urban south Indian Type 2 diabetic subjects, the prevalence of DN is 26.1% and that DN is significantly associated with age, glycated haemoglobin and duration of diabetes.

Incidence of diabetes and pre-diabetes in a selected urban south Indian population (CUPS-19)

OBJECTIVES

Several cross-sectional studies have reported on the prevalence of diabetes in India. However, there are virtually no longitudinal population-based studies on the incidence of diabetes from India. The aim of the study was to determine the incidence of diabetes and prediabetes in an urban south Indian population.

METHODS

The Chennai Urban Population Study [CUPS], an ongoing epidemiological study in two residential colonies in Chennai [the largest city in southern India, formerly called Madras] was launched in 1996; the baseline study was completed in 1997. Follow-up examination was performed after a mean period of 8 years. At follow-up, 501 [47.0%] subjects had moved out of this colonies and were lost to follow-up. Of the remaining 564 individuals, 513 [90.9%] provided blood samples for biochemical analysis. Regression analysis was done using incident diabetes as dependant variable to identify factors associated with development of diabetes or pre-diabetes.

RESULTS

Among subjects with normal glucose tolerance (NGT) at baseline [n=476], 64 (13.4%) developed diabetes and 48 (10.1%) developed pre-diabetes (IGT or IFG). The incidence rate of diabetes was 20.2 per 1000 person years and that of pre-diabetes was 13.1 per 1000 person years among subjects with NGT. Of the 37 individuals who were pre-diabetic at baseline, 15 (40.5%) developed diabetes [incidence rate: 64.8 per 1000 person years], 16 (43.2%) remained as pre-diabetic and 6 (16.2%) reverted to normal during the follow-up period. Regression analysis revealed obesity [Odds Ratio (OR): 2.1, p=0.001], abdominal obesity [OR: 2.23, p<0.001] and hypertension [OR: 2.57, p<0.001] to be significantly associated with incident diabetes. The Indian Diabetes Risk Score (IDRS) showed the strongest association with incident diabetes [OR: 5.14, p<0.001].

CONCLUSION

The study shows that the incidence of diabetes is very high among urban south Indians. While obesity, abdominal obesity and hypertension were associated with incident diabetes, IDRS was the strongest predictor of incident of diabetes in this population.

Epidemiology and causation of coronary heart disease and stroke in India

Cardiovascular diseases are major causes of mortality and disease in the Indian subcontinent, causing more than 25% of deaths. It has been predicted that these diseases will increase rapidly in India and this country will be host to more than half the cases of heart disease in the world within the next 15 years. Coronary heart disease and stroke have increased in both urban and rural areas. Case-control studies indicate that tobacco use, obesity with high waist:hip ratio, high blood pressure, high LDL cholesterol, low HDL cholesterol, abnormal apolipoprotein A-1:B ratio, diabetes, low consumption of fruits and vegetables, sedentary lifestyles and psychosocial stress are important determinants of cardiovascular diseases in India. These risk factors have increased substantially over the past 50 years and to control further escalation it is important to prevent them. National interventions such as increasing tobacco taxes, labelling unhealthy foods and trans fats, reduction of salt in processed foods and better urban design to promote physical activity may have a wide short-term impact.

Coenzyme Q10 (CoQ10) in isolated diastolic heart failure in hypertrophic cardiomyopathy (HCM)

It is well known that by improving mitochondrial bioenergetics, Coenzyme Q10 improves the systolic function in heart failure. The aim of this study was to see whether it benefits the diastolic dysfunction in hypertrophic cardiomyopathy (HCM) cases since diastolic relaxation also requires energy like the systole. 200 mg/day of CoQ10 was added to the conventional treatment in 46 patients with HCM diagnosed clinically and by echocardiography and by excluding cases of long standing hypertension. A comparable group of 41 age/sex matched cases received only conventional therapy. There was a significant improvement in the parameters like NYHA class > or = 1, in quality of life (QOL) on 6 minutes walk test, in diastolic dysfunction by > or = 1 parameter and in MR > or = 1 grade. Post treatment echocardiogram showed significant reduction in left ventricular outflow tract (LVOT) gradient > or = 15 mm Hg in obstructive cases (12 out of 46) in the treatment group. The mean interventricular septal thickness (IVS) showed a 22.4% reduction (p < 0.005). The mean posterior wall thickness showed a 23.1% reduction (p < 0.005). No patient in the treatment Group had ventricular tachycardia (VT) whereas 4 cases in the control group had VT. In both groups 1 patient was lost due to sudden cardiac death (SCD).

Surveillance for risk factors of cardiovascular disease among an industrial population in southern India

BACKGROUND

We assessed (i) the risk of cardiovascular disease in an industrial population in Chennai, southern India and (ii) whether the status of treatment and control of diabetes and hypertension would be different in an industrial population, which is provided free healthcare, compared with the general population of Chennai.

METHODS

Subjects residing in the residential areas of 2 industries (Indian Airlines and Integral Coach Factory) in Chennai in southern India were recruited. The subjects were employees (n = 440) selected by an age- and sex-stratified random sampling method, and their family members (n = 727) in the age group of 20-69 years; a total of 1167 subjects. Fasting plasma glucose, lipid estimations and anthropometric measurements were done in all the subjects. Information on demographic and lifestyle determinants was obtained using a questionnaire. Diabetes was diagnosed using the American Diabetes Association criteria and metabolic syndrome was defined by the Adult Treatment Panel III criteria with modified waist definition for Asian Indians.

RESULTS

Age-adjusted prevalence of major risk factors for cardiovascular disease using the 2001 Census of India were as follows: diabetes 11.9%; hypertension 25.4%; dyslipidaemia 40.2%; hypertriglyceridaemia 28.3%; overweight (body mass index > or = 23 kg/m2) 60.2%; and metabolic syndrome 34.1%. Use of tobacco in any form was present in 22.9% of men and 0.5% of women; 79% of the subjects followed a sedentary lifestyle. Among subjects receiving medication, 42.1% of subjects with diabetes and 55.3% of subjects with hypertension had their disease under adequate control. A comparison of these results with the general population of Chennai showed that the industrial population had a higher prevalence of cardiovascular risk factors in spite of having better access to healthcare facilities.

CONCLUSIONS

The prevalence of cardiovascular disease was high in this industrial population of Chennai. Although the overall treatment and control of diabetes and hypertension was better than that in the general population, it was still inadequate and this emphasizes the need for greater awareness about non-communicable diseases.