Novel subgroups of type 2 diabetes and their association with microvascular outcomes in an Asian Indian population: a data-driven cluster analysis: the INSPIRED study

INTRODUCTION

Type 2 diabetes is characterized by considerable heterogeneity in its etiopathogenesis and clinical presentation. We aimed to identify clusters of type 2 diabetes in Asian Indians and to look at the clinical implications and outcomes of this clustering.

RESEARCH DESIGN AND METHODS

From a network of 50 diabetes centers across nine states of India, we selected 19 084 individuals with type 2 diabetes (aged 10-97 years) with diabetes duration of less than 5 years at the time of first clinic visit and performed k-means clustering using the following variables: age at diagnosis, body mass index, waist circumference, glycated hemoglobin, serum triglycerides, serum high-density lipoprotein cholesterol and C peptide (fasting and stimulated). This was then validated in a national epidemiological data set of representative individuals from 15 states across India.

RESULTS

We identified four clusters of patients, differing in phenotypic characteristics as well as disease outcomes: cluster 1 (Severe Insulin Deficient Diabetes, SIDD), cluster 2 (Insulin Resistant Obese Diabetes, IROD), cluster 3 (Combined Insulin Resistant and Deficient Diabetes, CIRDD) and cluster 4 (Mild Age-Related Diabetes, MARD). While SIDD and MARD are similar to clusters reported in other populations, IROD and CIRDD are novel clusters. Cox proportional hazards showed that SIDD had the highest hazards for developing retinopathy, followed by CIRDD, while CIRDD had the highest hazards for kidney disease.

CONCLUSIONS

Compared with previously reported clustering, we show two novel subgroups of type 2 diabetes in the Asian Indian population with important implications for prognosis and management. The coexistence of insulin deficiency and insulin resistance seems to be peculiar to the Asian Indian population and is associated with an increased risk of microvascular complications.

Acceptability and Utilization of Newer Technologies and Effects on Glycemic Control in Type 2 Diabetes: Lessons Learned from Lockdown

Aim: To evaluate the effects of a prolonged lockdown due to Coronavirus (COVID-19) on the adoption of newer technologies and changes in glycemic control on patients with type 2 diabetes (T2D) in India. Methods: The study population included a random list of 3000 individuals with T2D derived from 30,748 individuals who had visited a large tertiary diabetes center during the past year. The survey was carried out through a telephonic interview. A structured questionnaire was used to collect information on changes in lifestyle, access and challenges to diabetes care and use of technologies such as telemedicine facilities and use of self-monitoring of blood glucose (SMBG), etc. Results: Of the 2510 individuals successfully interviewed (83.7% response rate), 382 (15.2%) reported having attempted to consult their health care providers during the lockdown, of whom only 30.6% utilized the telemedicine facility. However, 96 (82%) of those who utilized the telemedicine facility (n = 117) were happy with their experience and 68 (58.1%) were willing to continue to use the facility in the future. Only 11.4% of participants utilized online support for management of diabetes. Use of SMBG increased significantly from 15.5% to 51.3% during the lockdown. There was an improvement in glycemic control during the lockdown (HbA1c:before vs. during lockdown: 8.2% ± 1.9% vs. 7.7% ± 1.7%, P < 0.001) in a nonrandomly selected subset of subjects (n = 205). Conclusions: Acceptance of telemedicine facilities remains suboptimal in this Asian Indian population, in spite of high levels of satisfaction among those who utilized it. The COVID-19 pandemic and the subsequent lockdown have not adversely affected metabolic control in our patients, and indeed there appears to be an improvement in HbA1c levels. Greater accessibility and acceptance of technology could help individuals with diabetes to maintain better contact with their physicians and ensure better metabolic control in the future.

Altered circulatory levels of miR-128, BDNF, cortisol and shortened telomeres in patients with type 2 diabetes and depression

AIMS

Several studies have reported the role of biomarkers either in diabetes or depression. The present study is aimed at profiling the circulating levels of miR-128, brain-derived neurotrophic factor (BDNF), cortisol and telomere length in patients with type 2 diabetes with and without depression compared to individuals with normal glucose tolerance.

METHODS

Study subjects (n = 160) were recruited from an ongoing epidemiological study in southern India. Non-diabetic and diabetic individuals were diagnosed as per the World Health Organization criteria. Depression score was derived using PHQ-12 questionnaire. Real-time quantitative PCR and ELISA methodologies were used to quantify the biomarkers.

RESULTS

Circulatory levels of miR-128 and cortisol were significantly (p < 0.05) increased with decreased BDNF levels and shortened telomeres in T2DM patients with or without depression compared to NGT individuals. T2DM patients with depression had the highest levels of miR-128 and cortisol and lowest levels of BDNF and telomere length compared to other groups. Pearson correlation analysis showed miR-128 levels were negatively associated with BDNF, telomere length and HDL cholesterol and positively correlated with cortisol, depression score, poor glycemic control and insulin resistance. Regression analysis confirmed that miR-128 was significantly associated with depression score even after adjusted for several confounding factors. However, this association was lost when adjusted for cortisol or telomere length.

CONCLUSIONS

Patients with type 2 diabetes and depression exhibited increased circulatory levels of miR-128 and serum cortisol and decreased levels of BDNF and shortened telomeres. These neuroendocrine signatures were more markedly altered in those with combined diabetes and depression.

Increased prevalence of self-reported fractures in Asian Indians with diabetes: Results from the ICMR-INDIAB population based cross-sectional study

BACKGROUND

Diabetes mellitus (DM), has been associated with increased fracture risk. However, there are no data pertaining to the prevalence of fractures for patients with DM in India. The aim of this study was to determine the prevalence of fractures in Asian Indians with and without diabetes.

METHODS

The study used the data of Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study, a community- based cross sectional survey conceived with the aim of obtaining the prevalence rates of diabetes in India as a whole. A community-based sample of 57,117 individuals aged ≥20 years was obtained. Diabetes was diagnosed by oral glucose tolerance test using capillary blood (except in self-reported diabetes). Fractures were self-reported.

RESULTS

Fracture data were available in 54,093 subjects. Out of these, 1416 (2.6%) had fractures. Overall prevalence of diabetes and prediabetes was 7.1% and 10.5% respectively. Prevalence of fractures was significantly higher in diabetes group (4%) compared with non-diabetes group (2.5%). In multivariate logistic regression analysis, diabetes was associated with an increased risk (1) of any fracture (OR=1.28, 95% CI: 1.07-1.5) and (2) of low trauma fracture (hip and spine combined) (OR = 1.8, 95% CI:1.1-2.8). After gender stratification, diabetes was a risk factor for fracture only in women. Age (>40 years) in women, high waist circumference (>90 cm) in men, alcohol consumption and urban residence in both men and women were other significant contributors to fracture risk.

CONCLUSION

Increased prevalence of self-reported fractures was seen in individuals with diabetes in this population-based study from India.

Repositioning of the global epicentre of non-optimal cholesterol

High blood cholesterol is typically considered a feature of wealthy western countries1,2. However, dietary and behavioural determinants of blood cholesterol are changing rapidly throughout the world3 and countries are using lipid-lowering medications at varying rates. These changes can have distinct effects on the levels of high-density lipoprotein (HDL) cholesterol and non-HDL cholesterol, which have different effects on human health4,5. However, the trends of HDL and non-HDL cholesterol levels over time have not been previously reported in a global analysis. Here we pooled 1,127 population-based studies that measured blood lipids in 102.6 million individuals aged 18 years and older to estimate trends from 1980 to 2018 in mean total, non-HDL and HDL cholesterol levels for 200 countries. Globally, there was little change in total or non-HDL cholesterol from 1980 to 2018. This was a net effect of increases in low- and middle-income countries, especially in east and southeast Asia, and decreases in high-income western countries, especially those in northwestern Europe, and in central and eastern Europe. As a result, countries with the highest level of non-HDL cholesterol-which is a marker of cardiovascular risk-changed from those in western Europe such as Belgium, Finland, Greenland, Iceland, Norway, Sweden, Switzerland and Malta in 1980 to those in Asia and the Pacific, such as Tokelau, Malaysia, The Philippines and Thailand. In 2017, high non-HDL cholesterol was responsible for an estimated 3.9 million (95% credible interval 3.7 million-4.2 million) worldwide deaths, half of which occurred in east, southeast and south Asia. The global repositioning of lipid-related risk, with non-optimal cholesterol shifting from a distinct feature of high-income countries in northwestern Europe, north America and Australasia to one that affects countries in east and southeast Asia and Oceania should motivate the use of population-based policies and personal interventions to improve nutrition and enhance access to treatment throughout the world.

A Nutrigenetic Approach to Investigate the Relationship between Metabolic Traits and Vitamin D Status in an Asian Indian Population

Studies in Asian Indians have examined the association of metabolic traits with vitamin D status. However, findings have been quite inconsistent. Hence, we aimed to explore the relationship between metabolic traits and 25-hydroxyvitamin D [25(OH)D] concentrations. We investigate whether this relationship was modified by lifestyle factors using a nutrigenetic approach in 545 Asian Indians randomly selected from the Chennai Urban Rural Epidemiology Study (219 normal glucose tolerant individuals, 151 with pre-diabetes and 175 individuals with type 2 diabetes). A metabolic genetic risk score (GRS) was developed using five common metabolic disease-related genetic variants. There was a significant interaction between metabolic GRS and carbohydrate intake (energy%) on 25(OH)D (Pinteraction = 0.047). Individuals consuming a low carbohydrate diet (≤62%) and those having lesser number of metabolic risk alleles (GRS ≤ 1) had significantly higher levels of 25(OH)D (p = 0.033). Conversely, individuals consuming a high carbohydrate diet despite having lesser number of risk alleles did not show a significant increase in 25(OH)D (p = 0.662). In summary, our findings show that individuals carrying a smaller number of metabolic risk alleles are likely to have higher 25(OH)D levels if they consume a low carbohydrate diet. These data support the current dietary carbohydrate recommendations of 50%-60% energy suggesting that reduced metabolic genetic risk increases 25(OH)D.

Correlation between markers of renal function and sight-threatening diabetic retinopathy in type 2 diabetes: a longitudinal study in an Indian clinic population

INTRODUCTION

Previous epidemiological studies have reported on the prevalence of diabetic kidney disease (DKD) and diabetic retinopathy (DR) from India. The aim of this study is to evaluate the effect of DKD on the development of new-onset DR and sight-threatening diabetic retinopathy (STDR) in Asian Indians with type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

The study was done on anonymized electronic medical record data of people with T2D who had undergone screening for DR and renal work-up as part of routine follow-up at a tertiary care diabetes center in Chennai, South India. The baseline data retrieved included clinical and biochemical parameters including renal profiles (serum creatinine, estimated glomerular filtration rate (eGFR) and albuminuria). Grading of DR was performed using the modified Early Treatment Diabetic Retinopathy Study grading system. STDR was defined as the presence of proliferative diabetic retinopathy (PDR) and/or diabetic macular edema. DKD was defined by the presence of albuminuria (≥30 µg/mg) and/or reduction in eGFR (<60 mL/min/1.73 m²). Cox regression analysis was used to evaluate the hazard ratio (HR) for DR and STDR.

RESULTS

Data of 19 909 individuals with T2D (mean age 59.6±10.2 years, mean duration of diabetes 11.1±12.1 years, 66.1% male) were analyzed. At baseline, DR was present in 7818 individuals (39.3%), of whom 2249 (11.3%) had STDR. During the mean follow-up period of 3.9±1.9 years, 2140 (17.7%) developed new-onset DR and 980 individuals with non-proliferative DR (NPDR) at baseline progressed to STDR. Higher serum creatinine (HR 1.5, 95% CI 1.3 to 1.7; p<0.0001), eGFR <30 mL/min/1.73 m² (HR 4.9, 95% CI 2.9 to 8.2; p<0.0001) and presence of macroalbuminuria >300 µg/mg (HR 3.0, 95% CI 2.4 to 3.8; p<0.0001) at baseline were associated with increased risk of progression to STDR.

CONCLUSIONS

DKD at baseline is a risk factor for progression to STDR. Physicians should promptly refer their patients with DKD to ophthalmologists for timely detection and management of STDR.

Reproducibility and construct validity of a food frequency questionnaire for assessing dietary intake in rural and urban Asian Indian adults

BACKGROUND AND OBJECTIVES

To evaluate the reproducibility and construct validity of the Madras Diabetes Research Foundation FFQ (MDRF-FFQ) with biomarkers for its use in epidemiological settings in India.

METHODS AND STUDY DESIGN

The MDRF-FFQ was administered to 500 participants representing rural and urban areas of 10 Indian states, twice at an interval of 12 months. Reproducibility was assessed using intra cluster correlation coefficients (ICC). Construct validity of carbohydrate and fat intake was assessed using baseline serum lipids by regression analysis.

RESULTS

Reproducibility as measured by ICC was 0.50-0.77 for saturated fatty acids (SFA) and energy in urban and 0.61-0.72 for protein and SFA in rural areas. The ICC for food groups was 0.53-0.77 for whole grains, fruits and vegetables in urban and 0.50-0.89 for animal foods and whole grains in rural areas. After adjusting for potential confounders, carbohydrate intake was positively associated with serum triglycerides (TG) (β [SE]: +2.3 [0.72] mg/dL; p=0.002) and inversely with high density lipoprotein cholesterol (HDL) (β [SE]:-0.48 [0.12], p<0.001), while dietary fat and SFA (% Energy) were positively associated with HDL, low density lipoprotein (LDL) and total cholesterol and inversely with TG.

CONCLUSIONS

The MDRF-FFQ can be considered as a reliable and valid tool to measure the long-term dietary exposure in respect of macronutrient intakes in Indian populations despite diverse dietary practices.

Prevalence of vitamin D deficiency in urban south Indians with different grades of glucose tolerance

The present study assessed the prevalence of vitamin D deficiency in an urban south Indian population in individuals with different grades of glucose tolerance. A total of 1500 individuals (900 normal glucose tolerance (NGT), 300 prediabetes and 300 with type 2 diabetes mellitus (T2DM)) who were not on vitamin D supplementation were randomly selected from the Chennai Urban Rural Epidemiological Study follow-up study. Anthropometric, clinical examination and biochemical investigations (25-hydroxyvitamin D (25(OH)D), insulin, glycated Hb (HbA1c) and serum lipids) were measured. Vitamin D deficiency was defined as serum 25(OH)D < 20·0 ng/ml, insufficiency as 20-29·9 ng/ml and sufficiency as ≥30 ng/ml. Of the 1500 individuals studied, 45 % were males and the mean age was 46 (sd 12) years. Vitamin D levels lowered with increasing degrees of glucose tolerance (NGT: 21 (sd 11); prediabetes: 19 (sd 10); T2DM: 18 (sd 11) ng/ml, P < 0·001). The overall prevalence of vitamin D deficiency was 55 % and was significantly higher among individuals with T2DM (63 %) followed by prediabetes (58 %) and NGT (51 %) (Pfor trend < 0·001). Women had 1·6 times the risk of vitamin D deficiency compared with men (unadjusted OR 1·6 (95 % CI 1·3, 2·0) and adjusted OR 1·6 (95 % CI 1·2, 1·9)). However, there was no increasing trend observed with increasing age. The prevalence of abdominal obesity (66 v. 49 %), generalised obesity (80 v. 64 %), the metabolic syndrome (45 v. 37 %) and insulin resistance (38 v. 27 %) was significantly higher in those with vitamin D deficiency compared with those without. This study shows that vitamin D deficiency is highly prevalent in this urban south Indian population and was higher among individuals with T2DM and prediabetes compared with those with NGT.

Adaptations and patient responses to behavioral intervention components in a depression-focused chronic disease care model implemented in India

Integrated care models offer one approach to treat patients with chronic multimorbidity. However, because these models consist of multiple components designed to provide individualized care, they should be adapted to best meet the needs of patients in diverse settings. This paper presents qualitative and quantitative data from a realist process evaluation embedded in the INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) study to uncover what worked, for whom, how, and in what circumstances. We aimed to examine adaptations made to a care coordinator-led behavioral intervention, and how patients responded to adaptations, through a secondary analysis of these data. A purposive sample of 62 patients and 3 care coordinators were recruited based on their involvement with the INDEPENDENT care model across two clinics. Patients were interviewed and surveyed about their experiences in the care model and care coordinators were interviewed about their experiences implementing intervention components. Interview data were coded for reported modifications in intervention content, tools, and delivery; then, these adaptations were categorized by how they served to enhance implementation in the Indian context. Adaptations made in the delivery of this care model served two functions: (a) to improve health promotion communication between care coordinators and patients and (b) to improve patient engagement. Patients' expressed needs were consistent with what care coordinators perceived. Patients were satisfied with adaptations designed to improve intervention fit for local contexts. Study findings demonstrate that adapting components of an integrated care model can enhance patient satisfaction and engagement with behavioral interventions.

Assessment of diabetic retinopathy in type 1 diabetes in a diabetes care center in South India-Feasibility and awareness improvement study

The prevalence of youth-onset diabetes, both type 1 diabetes (T1D) and young-onset type 2 diabetes (YT2D) are gradually increasing in India. Early and repetitive screening for diabetic retinopathy (DR) is essential to provide timely management, and thereby prevent visual impairment due to the silent sight-threatening microvascular complication of diabetes. A study was undertaken at a diabetes care center in Chennai, south India, to assess the feasibility of screening for DR in T1D in a diabetes clinic and determine the burden of sight-threatening DR (STDR) in individuals with T1D. 315 people with T1D were screened for DR (mean age at onset of diabetes 12.3 ± 6.4 years) by digital retinal color photography, at the urban diabetes center, in a semi-urban and rural diabetes clinic. Counseling about diabetes and the importance of annual screening for retinopathy was provided by diabetes educators. Participants were reviewed after 6 months/1 year based on ophthalmologist's advice. DR was detected in 37.1% (n = 117), 42 (13%) of whom had STDR.Three-quarter participants were compliant with the annual follow-up retinal examination. The peer support group was established for participants with T1D and their families to foster interactions with service providers. The peer group meetings helped to increase the awareness of retinopathy among the parents and individuals with T1D. This narrative provides details of the study that shows that screening for DR among individuals with T1D in a diabetes clinic is a feasible model, irrespective of its location.

Development and validation of the neighborhood environment walkability scale for youth across six continents

BACKGROUND

The IPEN International Physical Activity and Environment Network Adolescent project was conducted using common study protocols to document the strength, shape, and generalizability of associations of perceived neighborhood environment attributes with adolescents' physical activity and overweight/obesity using data from 15 countries. Countries did not use identical versions of the Neighborhood Environment Walkability Scale for Youth (NEWS-Y) to measure perceived neighborhood environment attributes. Therefore, this study derived a measurement model for NEWS-Y items common to all IPEN Adolescent countries and developed a scoring protocol for the IPEN Adolescent version of the NEWS-Y (NEWS-Y-IPEN) that maximizes between-country comparability of responses. Additionally, this study examined between- and within-country variability, and construct validity of the NEWS-Y-IPEN subscales in relation to neighborhood-level socio-economic status and walkability.

METHODS

Adolescents and one of their parents (N = 5714 dyads) were recruited from neighborhoods varying in walkability and socio-economic status. To measure perceived neighborhood environment, 14 countries administered the NEWS-Y to parents and one country to adolescents. Confirmatory factor analysis was used to derive comparable country-specific measurement models of the NEWS-Y-IPEN. Country-specific standard deviations quantified within-country variability in the NEWS-Y-IPEN subscales, while linear mixed models determined the percentage of subscale variance due to between-country differences. To examine the construct validity of NEWS-Y-IPEN subscales, we estimated their associations with the categorical measures of area-level walkability and socio-economic status.

RESULTS

Final country-specific measurement models of the factor-analyzable NEWS-Y-IPEN items provided acceptable levels of fit to the data and shared the same factorial structure with five latent factors (Accessibility and walking facilities; Traffic safety; Pedestrian infrastructure and safety; Safety from crime; and Aesthetics). All subscales showed sufficient levels of within-country variability. Residential density had the highest level of between-country variability. Associations between NEWS-Y-IPEN subscales and area-level walkability and socio-economic status provided strong evidence of construct validity.

CONCLUSIONS

A robust measurement model and common scoring protocol of NEWS-Y for the IPEN Adolescent project (NEWS-Y-IPEN) were derived. The NEWS-Y-IPEN possesses good factorial and construct validity, and is able to capture between-country variability in perceived neighborhood environments. Future studies employing NEWS-Y-IPEN should use the proposed scoring protocol to facilitate cross-study comparisons and interpretation of findings.

A Pilot Study Evaluating the Effects of Diabetes Specific Nutrition Supplement and Lifestyle Intervention on Glycemic Control in Overweight and Obese Asian Indian Adults with Type 2 Diabetes Mellitus

BACKGROUND AND OBJECTIVES

Medical nutrition therapy plays a crucial role achievement of optimal glycemic control in individuals with diabetes. This study aims to evaluate the effects of diabetes specific nutrition supplement (DSNS) along with lifestyle intervention in overweight and obese adults with Type 2 Diabetes Mellitus (T2DM).

METHODS

A total of 120 overweight or obese individuals aged 30 - 65 years with T2DM, were randomly allocated to intervention (IG, n=60) and control (CG, n=60) groups in this 12-week study. All participants received dietary counselling with diet chart of 1400 kcal/day and recommendations for physical activity. DSNS was included in the dietary regimen adjusted within the daily calorie recommendations for intervention group. All participants were followed up monthly for anthropometric, biochemical and clinical assessments. Continuous glucose monitoring was performed during the initial 2 weeks and last 2 weeks of the study in a sub- sample using Flash Glucose Monitoring device to study glycemic excursions. Data was analyzed for the differences between intervention vs. control group using linear models.

RESULTS

Compared to the control group, the intervention group showed significant reduction in glycosylated haemoglobin (IG: -0.95% vs. CG: -0.48%; p=0.020) and fasting blood glucose (IG: -18.47 mg/dL vs. CG: 1.34mg/dL; p=0.03) as well as a greater reduction in postprandial plasma glucose (IG: -29.77mg/dL vs. CG: -2.64mg/dL; p=0.053). There was also a significant reduction from baseline in incremental Area under the Curve (iAUC) (p=0.01) in the intervention group (Δ -22 mg) compared to the control group (Δ -7.9 mg) with a corresponding reduction in the Mean Amplitude of Glycemic Excursion (MAGE) (P=0.04). There was no difference between groups in body weight, waist circumference, blood pressure, and lipid profile. None of the subjects in the study reported serious adverse events.

CONCLUSION

This pilot study showed that a diabetes specific nutritional supplement was useful in improving glycemic control and reducing glycemic response in overweight and obese Asian Indian adults with T2DM.

Glycemic Index and Microstructure Evaluation of Four Cereal Grain Foods

To determine the glycemic index (GI) of selected cereals and association with their microstructure. The GI of whole grain pilaf (WGP), instant brown rice (IBR), whole maize ugali (MWU), and refined maize ugali (RMU) was assessed in a randomized trial. Fourteen healthy participants with mean age of 25 years were administered 50 g portions of available carbohydrates from glucose and various test foods after an overnight fast on separate occasions. Capillary blood samples of participants were used to measure blood glucose over 2 hr. The GI was calculated as per standard protocol. The microstructure of test foods, determined by scanning electron microscopy was evaluated to understand the measured GI values. The GI (mean ± standard error) of IBR was the highest (87.8 ± 6.8) followed by RMU (74.7 ± 6.5) and WMU (71.4 ± 5.1). WGP had medium GI (58.9 ± 5.1; P < 0.01 vs. IBR). Microstructure examination of IBR revealed disruption of bran layer and presence of fissures indicating loss of intactness of bran. Stereozoom images for WGP revealed intact bran and germ. For RMU and WMU, the grain was milled leading to loss of integrity. IBR, RMU, and WMU have high GI values, which is likely due to disruption of bran layer, endosperm modification (IBR), and loss of grain matrix (WMU, RMU). WGP has medium GI probably due to fairly intact bran and germ. PRACTICAL APPLICATION: Wholegrain or whole meal flour may not necessarily be low in glycemic index (GI; low GI < 55; medium 55 to 69 and high GI ≥70). "Ugali" a commonly consumed cereal staple food in Tanzania made from either refined or whole meal maize flour was found to be a high GI food. Intact whole grain foods, such as whole grain pilaf (mixed intact whole grains) is a healthier alternative to milled whole grains such as whole meal maize flour. Instant quick cooking brown rice exhibited a high GI, due to the processing method, suggesting that regular brown rice may be a healthier option.

Association of dietary patterns and dietary diversity with cardiometabolic disease risk factors among adults in South Asia: The CARRS study

BACKGROUND AND OBJECTIVES

To investigate the association of dietary patterns and dietary diversity with cardiometabolic disease risk factors among South Asians.

METHODS AND STUDY DESIGN

In a population based study conducted in 2010-11, we recruited 16,287 adults aged >20 years residing in Delhi, Chennai, and Karachi. Diet was assessed using an interviewer-administered 26-item food frequency questionnaire. Principal component analysis identified three dietary patterns: Prudent, Indian, and Non-Vegetarian. We also computed a dietary diversity score. Multinomial and binary logistic regressions were used to calculate adjusted prevalence (95% confidence intervals) of cardio-metabolic disease risk factors across quartiles of dietary pattern and dietary diversity scores.

RESULTS

The adjusted prevalence of diagnosed diabetes was lower among participants in the highest versus lowest quartile of the Prudent Pattern (4.7% [3.8-5.6] versus 10.3% [8.5-12.0]), and the Indian Pattern (4.8% [3.7-5.9] versus 8.7% [6.7-10.6] in highest versus lowest quartile, respectively). Participants following the Indian Pattern also had lower adjusted prevalence of diagnosed hypertension (7.0% [5.4-8.5] versus 10.6% [8.6-12.5] in highest versus lowest quartile, respectively). Participants in the highest versus lowest quartile of the dietary diversity score had a lower adjusted prevalence of diagnosed diabetes (4.1% [3.0-5.2] versus 8.2% [7.1-9.3]), diagnosed hypertension (6.7% [5.3-8.1] versus 10.3% [9.1-11.5]), and undiagnosed hypertension (14.2% [12.0-16.4] versus 18.5% [16.9-20.1]).

CONCLUSIONS

High dietary diversity appears to be protective against cardio-metabolic disease risk factors in this urban cohort of South Asian adults. Further investigation to understand the underlying mechanism of this observation is warranted.

Development and evaluation of nutritional, sensory and glycemic properties of finger millet (Eleusine coracana L.) based food products

BACKGROUND AND OBJECTIVES

Finger millet (Eleusine coracana L.) (FM) is rich in dietary fibre and is therefore expected to elicit a lower glycemic response compared to other grains. However, there is little data on the glycemic properties of FM-based products. We evaluated the nutritional, sensory and glycemic properties of decorticated millet with lower polish (DFM-LDP), flakes (FMF), vermicelli (FMV) and extruded snack (FMES) (both FMV and FMES with 7-8% added soluble fibre).

METHODS AND STUDY DESIGN

The nutrient contents of the FM products were evaluated by standard AOAC (Association of Official Analytical Chemists) and AACC (American Association of Cereal Chemists) methods. Sensory evaluation was conducted monadically using a 9-point hedonic scale using untrained panel members. GI testing was conducted using a standardized validated protocol. The study was conducted according to the guidelines laid down by the Declaration of Helsinki, and was approved by the Ethics Committee of the Madras Diabetes Research Foundation.

RESULTS

The products had dietary fibre (DF) content between 5.8-15.6 g%. FMES was unique in having a very low fat content (0.17%). Evaluation of sensory perception revealed moderate acceptance of millet based products. The glycemic indices (GI) (mean±SEM) of the products were 84.7±7.7%, 82.3±6.4%, 65.5±5.1% and 65.0±6.6% for DFM-LDP, FMF, FMV and FMES respectively.

CONCLUSIONS

DFM-LDP and FMF (purely finger millet based products) elicited higher glycemic responses. Comparatively, FMV and FMES (with added functional ingredients) exhibited medium GI values and, are healthier dietary options. It is possible to prepare FM products with lower GI by utilizing functional ingredients.

Engagement and Weight Loss: Results from the Mobile Health and Diabetes Trial

Background: Prevalence of type 2 diabetes (T2D) is increasing worldwide. Identifying and targeting individuals at high risk, is essential for preventing T2D. Several studies point to mobile health initiatives delivered through personal smart devices being a promising approach to diabetes prevention, through weight loss. The aim of the mobile health and diabetes (mDiab) trial was twofold: to achieve 5% weight loss and to look at the association of weight loss with degree of engagement with the mDiab app. Methods: The mDiab randomized control trial was carried out among smartphone users who are at high risk for T2D mellitus in three cities-Chennai, Bengaluru, and New Delhi in India. The intervention was delivered through a mobile phone application along with weekly coach calls for 12 weeks. While individuals in the intervention group individuals received the app, which enabled tracking their weight, physical activity, and diet along with 12 weekly video lessons on T2D prevention and coach calls, the control group received usual care. Results: The intervention group experienced a significant 1 kg weight loss while the control group lost 0.3 kg (P < 0.05). More individuals in the intervention group (n = 139, 15%) met the 5% weight loss target than in the control group (n = 131, 9%). In the intervention group those who viewed the videos experienced greater weight loss (2.4 kg) than those who only attended coach calls (0.9 kg) (P < 0.01). Conclusions: An mHealth intervention helped to achieve moderate weight loss. Future studies should explore the sustainability of this weight loss.

Even minimal polishing of an Indian parboiled brown rice variety leads to increased glycemic responses

BACKGROUND AND OBJECTIVES

To evaluate the effect of polishing on the glycemic properties of Indian parboiled brown rice.

METHODS AND STUDY DESIGN

We evaluated the effect of different degrees of polishing on the glycemic and insulinemic responses of Bapatla (BPT-5204), Indian parboiled Indica rice variety. Brown rice (BR), under milled rice (UMR) and white rice (WR) with 2.3% and 9.7% degree of polishing (DOP), respectively, were prepared and evaluated for the glycemic properties. Incremental Area Under the Curves (IAUC) were estimated for both glycemic index (GI) in 12 healthy participants (6 men, 6 women) and 24 hr glycemic response studies in 13 overweight participants (5 men, 8 women) using continuous glucose monitoring (CGM) system with ≈2000 kcal/day rice diets. Differences in pre and post meal insulin (Δ) were assessed.

RESULTS

The GI of WR (GI=79.6) and UMR (GI=73) were significantly higher than BR (GI=57.6) (p<0.01). Similar results were obtained for 24 hr glycemic responses [IAUC: WR=58.4, UMR=55.5, BR=34.7 mg*5 min/dL, respectively]. The Δ Insulin responses were lower with BR meals compared with UMR and WR (p=0.025; p=0.003).

CONCLUSIONS

Both UMR and WR had a high GI while BR had a medium GI. This could have influenced the 24 h glycaemic and insulinemic responses of BR which had the lowest responses as compared with UMR and WR, and the latter two had similar higher responses. Thus any degree of polishing leads to higher glycaemic responses.

Isolated HbA1c identifies a different subgroup of individuals with type 2 diabetes compared to fasting or post-challenge glucose in Asian Indians: The CARRS and MASALA studies

AIMS

Guidelines recommend hemoglobin A1c (HbA1c) as a diagnostic test for type 2 diabetes, but its accuracy may differ in certain ethnic groups.

METHODS

The prevalence of type 2 diabetes by HbA1c, fasting glucose, and 2 h glucose was compared in 3016 participants from Chennai and Delhi, India from the CARRS-2 Study to 757 Indians in the U.S. from the MASALA Study. Type 2 diabetes was defined as fasting glucose ≥ 7.0 mmol/L, 2-h glucose ≥ 11.1 mmol/L, or HbA1c ≥ 6.5%. Isolated HbA1c diabetes was defined as HbA1c ≥ 6.5% with fasting glucose < 7.0 mmol/L and 2 h glucose < 11.1 mmol/L.

RESULTS

The age, sex, and BMI adjusted prevalence of diabetes by isolated HbA1c was 2.9% (95% CI: 2.2-4.0), 3.1% (95% CI: 2.3-4.1), and 0.8% (95% CI: 0.4-1.8) in CARRS-Chennai, CARRS-Delhi, and MASALA, respectively. The proportion of diabetes diagnosed by isolated HbA1c was 19.4%, 26.8%, and 10.8% in CARRS-Chennai, CARRS-Delhi, and MASALA respectively. In CARRS-2, individuals with type 2 diabetes by isolated HbA1c milder cardio-metabolic risk than those diagnosed by fasting or 2-h measures.

CONCLUSIONS

In Asian Indians, the use of HbA1c for type 2 diabetes diagnosis could result in a higher prevalence. HbA1c may identify a subset of individuals with milder glucose intolerance.

Are excess carbohydrates the main link to diabetes & its complications in Asians?

Dietary carbohydrates form the major source of energy in Asian diets. The carbohydrate quantity and quality play a vital function in the prevention and management of diabetes. High glycaemic index foods elicit higher glycaemic and insulinaemic responses and promote insulin resistance and type 2 diabetes (T2D) through beta-cell exhaustion. This article reviews the evidence associating dietary carbohydrates to the prevalence and incidence of T2D and metabolic syndrome (MS) in control of diabetes and their role in the complications of diabetes. Cross-sectional and longitudinal studies show that higher carbohydrate diets are linked to higher prevalence and incidence of T2D. However, the association seems to be stronger in Asian-Indians consuming diets high in carbohydrates and more marked on a background of obesity. There is also evidence for high carbohydrate diets and risk for MS and cardiovascular disease (CVD). However, the quality of carbohydrates is also equally important. Complex carbohydrates such as brown rice, whole wheat bread, legumes, pulses and green leafy vegetables are good carbs. Conversely, highly polished rice or refined wheat, sugar, glucose, highly processed foods such as cookies and pastries, fruit juice and sweetened beverages and fried potatoes or French fries are obviously ‘bad’ carbs. Ultimately, it is all a matter of balance and moderation in diet. For Indians who currently consume about 65-75 per cent of calories from carbohydrates, reducing this to 50-55 per cent and adding enough protein (20-25%) especially from vegetable sources and the rest from fat (20-30%) by including monounsaturated fats (e.g. groundnut or mustard oil, nuts and seeds) along with a plenty of green leafy vegetables, would be the best diet prescription for the prevention and management of non-communicable diseases such as T2D and CVD.

Clinical profile of nonalcoholic Fatty liver disease among young patients with type 1 diabetes mellitus seen at a diabetes speciality center in India

OBJECTIVE

To estimate the prevalence and clinical profile of nonalcoholic fatty liver disease (NAFLD) among young type 1 diabetes mellitus (T1DM) patients at a tertiary care diabetes center in India.

METHODS

Electronic medical records of T1DM patients (age at first diagnosis of T1DM ≤25 years) registered between January 1992 and May 2013 who had undergone ultrasonography and denied history of any alcohol intake (n = 736) were reviewed. NAFLD was diagnosed if there was any degree of fatty liver. Retinopathy was initially assessed by direct and indirect ophthalmoscopy and later by retinal photography. Nephropathy was diagnosed if urine protein excretion was >500 mg/day, and neuropathy was diagnosed if a patient's vibration perception threshold on biothesiometry was ≥20 V.

RESULTS

A total of 204/736 (27.7%) T1DM patients had NAFLD. Compared to T1DM subjects without NAFLD those with NAFLD had higher body mass index (BMI) (18.9 ± 4.2 vs. 20.2 ± 4.7 kg/m2, P<.001), waist circumference (67.9 ± 13.2 vs. 71.9 ± 13.3 cm, P<.05), systolic blood pressure (110 ± 15 vs. 116 ± 18 mm Hg, P<.001) and diastolic blood pressure (72 ± 9 vs. 74 ± 10 mm Hg, P<.05), while fasting blood glucose (201 ± 101 vs. 183 ± 101 mg/dL, P<.05) and alkaline phosphatase (419 [12.5] vs. 315 [15.8], P<.001) levels were lower in patients with T1DM with NAFLD. Multiple logistic regression analysis showed a significant association between NAFLD and retinopathy (odds ratio [OR]: 2.01, 95% confidence interval [CI]: 1.13-3.43; P = .017, after adjusting for sex, duration of diabetes, overweight/obesity, hypertension, fasting plasma glucose, nephropathy, and nephropathy (OR: 1.89, 95% CI: 1.02-3.50; P = .042), after adjusting for sex and fasting plasma glucose.

CONCLUSIONS

This study suggests that NAFLD is also seen among T1DM patients and that it has an independent and significant association with retinopathy and nephropathy.

Effect of a Novel High Fiber Rice Diet on 24-Hour Glycemic Responses in Asian Indians Using Continuous Glucose Monitoring: A Randomized Clinical Trial

BACKGROUND

We have recently demonstrated a medium glycemic index for novel high fiber white rice (HFWR) variety compared to regular white rice (RWR). However, substituting HFWR for RWR during the whole day's diet may provide extended benefits. The current study aims to assess the 24 h glycemic responses of a HFWR diet compared to a RWR diet.

METHODS

Continuous glucose monitoring (CGM) was used to assess the glycemic profile in 18 overweight, non-diabetic Asian Indians aged 25 to 50 in a randomized cross-over design. The volunteers were provided with iso-caloric (≈2100 kcal/day) HFWR or RWR based diets for four continuous days and switched diets after appropriate washout. Fasting blood samples for insulin assessments were collected at baseline and at the end of 4 day feeding. The glucose response in terms of incremental area under the curve (IAUC) was recorded. General linear model was used to assess the adjusted mean change of fasting insulin level of HFWR compared to RWR. Age and sex were adjusted as confounders in the model.

RESULTS

The average 24 h glucose response for HFWR was significantly lower (IAUC 66.3 ± 3.1 mg-5 min/dL) than RWR (IAUC 79.8 ± 5.7 mg-5 min/dL). The adjusted mean change in fasting insulin levels from baseline was also lower for HFWR compared to RWR. HFWR elicited a 34% and 30% lower 24 h glycemic and insulin response respectively, compared to RWR.

CONCLUSION

Replacing RWR with HFWR may be a healthier alternative for Asian Indians who are at a higher risk of developing type 2 diabetes.

Multimorbidity in South Asian adults: prevalence, risk factors and mortality

BACKGROUND

We report the prevalence, risk factors and mortality associated with multimorbidity in urban South Asian adults.

METHODS

Hypertension, diabetes, heart disease, stroke and chronic kidney disease were measured at baseline in a sample of 16 287 adults ages ≥20 years in Delhi, Chennai and Karachi in 2010-11 followed for an average of 38 months. Multimorbidity was defined as having ≥2 chronic conditions at baseline. We identified correlates of multimorbidity at baseline using multinomial logistic models, and we assessed the prospective association between multimorbidity and mortality using Cox proportional hazards models.

RESULTS

The adjusted prevalence of multimorbidity was 9.4%; multimorbidity was highest in adults who were aged ≥60 years (37%), consumed alcohol (12.3%), body mass index ≥25 m/kg2 (14.1%), high waist circumference (17.1%) and had family history of a chronic condition (12.4%). Compared with adults with no chronic conditions, the fully adjusted relative hazard of death was twice as high in adults with two morbidities (hazard ratio [HR] = 2.3; 95% confidence interval [CI]: 1.6, 3.3) and thrice as high in adults with ≥3 morbidities (HR = 3.1; 95% CI: 1.9, 5.1).

CONCLUSION

Multimorbidity affects nearly 1 in 10 urban South Asians, and each additional morbidity carries a progressively higher risk of death. Identifying locally appropriate strategies for prevention and coordinated management of multimorbidity will benefit population health in the region.

1,5 Anhydroglucitol in gestational diabetes mellitus

OBJECTIVE

1,5 Anhydroglucitol (1,5 AG) is reported to be a more sensitive marker of glucose variability and short-term glycemic control (1-2 weeks) in patients with type1 and type 2 diabetes. However, the role of 1,5 AG in gestational diabetes mellitus (GDM) is not clear. We estimated the serum levels of 1,5 AG in pregnant women with and without GDM.

METHODS

We recruited 220 pregnant women, 145 without and 75 with GDM visiting antenatal clinics in Tamil Nadu in South India. Oral glucose tolerance tests (OGTTs) were carried out using 82.5 g oral glucose (equivalent to 75 g of anhydrous glucose) and GDM was diagnosed based on the International Association of Diabetes and Pregnancy Study Group criteria. Serum 1,5 AG levels were measured using an enzymatic, colorimetric assay kit (Glycomark®, New York, NY). Receiver operating characteristic (ROC) curves were used to identify 1,5 AG cut-off points to identify GDM.

RESULTS

The mean levels of the 1,5 AG were significantly lower in women with GDM (11.8 ± 5.7 μg/mL, p < 0.001) compared to women without GDM (16.2 ± 6.2 μg/mL). In multiple logistic regression analysis, 1.5 AG showed a significant association with GDM (odds ratio [OR]: 0.876, 95% confidence interval [CI]: 0.812-0.944, p < 0.001) after adjusting for potential confounders. 1,5 AG had a C statistic of 0.693 compared to Fructosamine (0.671) and HbA1c (0.581) for identifying GDM. A 1,5 AG cut-off of 13.21 μg/mL had a C statistic of 0.6936 (95% CI: 0.6107-0.7583, p < 0.001), sensitivity of 67.6%, and specificity of 65.3% to identify GDM.

CONCLUSION

1,5AG levels are lower in pregnant women with GDM compared to individuals without GDM.

The impact of air pollution on deaths, disease burden, and life expectancy across the states of India: the Global Burden of Disease Study 2017

BACKGROUND

Air pollution is a major planetary health risk, with India estimated to have some of the worst levels globally. To inform action at subnational levels in India, we estimated the exposure to air pollution and its impact on deaths, disease burden, and life expectancy in every state of India in 2017.

METHODS

We estimated exposure to air pollution, including ambient particulate matter pollution, defined as the annual average gridded concentration of PM2.5, and household air pollution, defined as percentage of households using solid cooking fuels and the corresponding exposure to PM2.5, across the states of India using accessible data from multiple sources as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017. The states were categorised into three Socio-demographic Index (SDI) levels as calculated by GBD 2017 on the basis of lag-distributed per-capita income, mean education in people aged 15 years or older, and total fertility rate in people younger than 25 years. We estimated deaths and disability-adjusted life-years (DALYs) attributable to air pollution exposure, on the basis of exposure-response relationships from the published literature, as assessed in GBD 2017; the proportion of total global air pollution DALYs in India; and what the life expectancy would have been in each state of India if air pollution levels had been less than the minimum level causing health loss.

FINDINGS

The annual population-weighted mean exposure to ambient particulate matter PM2·5 in India was 89·9 μg/m3 (95% uncertainty interval [UI] 67·0-112·0) in 2017. Most states, and 76·8% of the population of India, were exposed to annual population-weighted mean PM2·5 greater than 40 μg/m3, which is the limit recommended by the National Ambient Air Quality Standards in India. Delhi had the highest annual population-weighted mean PM2·5 in 2017, followed by Uttar Pradesh, Bihar, and Haryana in north India, all with mean values greater than 125 μg/m3. The proportion of population using solid fuels in India was 55·5% (54·8-56·2) in 2017, which exceeded 75% in the low SDI states of Bihar, Jharkhand, and Odisha. 1·24 million (1·09-1·39) deaths in India in 2017, which were 12·5% of the total deaths, were attributable to air pollution, including 0·67 million (0·55-0·79) from ambient particulate matter pollution and 0·48 million (0·39-0·58) from household air pollution. Of these deaths attributable to air pollution, 51·4% were in people younger than 70 years. India contributed 18·1% of the global population but had 26·2% of the global air pollution DALYs in 2017. The ambient particulate matter pollution DALY rate was highest in the north Indian states of Uttar Pradesh, Haryana, Delhi, Punjab, and Rajasthan, spread across the three SDI state groups, and the household air pollution DALY rate was highest in the low SDI states of Chhattisgarh, Rajasthan, Madhya Pradesh, and Assam in north and northeast India. We estimated that if the air pollution level in India were less than the minimum causing health loss, the average life expectancy in 2017 would have been higher by 1·7 years (1·6-1·9), with this increase exceeding 2 years in the north Indian states of Rajasthan, Uttar Pradesh, and Haryana.

INTERPRETATION

India has disproportionately high mortality and disease burden due to air pollution. This burden is generally highest in the low SDI states of north India. Reducing the substantial avoidable deaths and disease burden from this major environmental risk is dependent on rapid deployment of effective multisectoral policies throughout India that are commensurate with the magnitude of air pollution in each state.

FUNDING

Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.