Type 2 diabetes in South Asians: a pathophysiologic focus on the Asian-Indian epidemic

Assessment of Serum Omentin-1 and Interleukin-6 in the Diagnosis of Early Stages of Diabetic Nephropathy: A Cross-Sectional Observational Study

Introduction The pathogenesis of diabetic nephropathy highlights the progression of inflammation and fibrosis from tubular to glomerular damage during the early stages of kidney involvement in diabetic individuals. As urine albumin serves as a marker for glomerular function, its detection indicates a stage of diabetic nephropathy where the glomerulus is already compromised. Consequently, relying solely on urine albumin for diagnosis becomes questionable. In our pursuit of identifying innovative biomarkers for the early detection of diabetic nephropathy, this study was crafted to explore the relationship between chemokines, omentin-1, interleukin-6, and microalbuminuria. Materials and methods Our study cohort comprised 116 patients diagnosed with diabetes mellitus. In our study, participants were stratified into two groups based on their urine albumin levels: Group 1, characterized by urine albumin creatinine ratio <30 mg/gm and estimated glomerular filtration rate >90 ml/min, and Group 2, with urine albumin creatinine ratio ≥30 mg/gm and <300 mg/gm, and estimated glomerular filtration rate >60 ml/min and <90 ml/min. Serum creatinine, glycated hemoglobin (HbA1c), fasting blood sugar and post-prandial blood sugar, lipid profile, total protein, albumin, fasting insulin, omentin-1, and interleukin-6 were estimated. Result There was a significant difference in the medians of serum urea, creatinine, omentin-1, interleukin-6, urine albumin creatinine ratio, and estimated glomerular filtration rate levels in the two groups. There was no difference in fasting blood sugar, post-prandial blood sugar, HbA1c, serum lipids, fasting insulin, and homeostatic model assessment for insulin resistance. The receiver operating characteristic curve plotted for the newer biomarkers of diabetic nephropathy showed that there was a significant diagnostic utility in diabetic nephropathy detection of serum omentin (p=0.000), interleukin-6 (p=0.002), and interleukin-6: omentin-1 ratio (p=0.000), which correlated well with the routine test that is urine microalbumin estimation. Risk assessment demonstrated that type 2 diabetes mellitus patients with an interleukin-6: omentin-1 ratio ≥0.26 had significantly higher odds, with an odds ratio of 3.97, for developing diabetic nephropathy, which was statistically significant. Conversely, a ratio of ≤0.26 was associated with kidney protection among patients with type 2 diabetes mellitus. Conclusion Our findings revealed decreased levels of omentin-1 and increased levels of interleukin-6 in the group with diabetic nephropathy compared to those without diabetic nephropathy among patients with type 2 diabetes mellitus. Interleukin-6: omentin-1 ratio of ≤0.26 was associated with kidney protection among patients with type 2 diabetes mellitus. Based on the results obtained from this study, we propose that measuring the serum interleukin-6: omentin-1 ratio in patients with type 2 diabetes mellitus may assist in identifying the early stages of diabetic nephropathy before the onset of microalbuminuria. Timely intervention in these patients predisposed to diabetic nephropathy can aid in better treatment outcomes in type 2 diabetes mellitus.

Abdominal fat depots and their association with insulin resistance in patients with type 2 diabetes

BACKGROUND

Asian-Indians show thin fat phenotype, characterized by predominantly central deposition of excess fat. The roles of abdominal subcutaneous fat (SAT), intra-peritoneal adipose tissue, and fat depots surrounding the vital organs (IPAT-SV) and liver fat in insulin resistance (IR), type-2 diabetes (T2D) and metabolic syndrome (MetS) in this population are sparsely investigated.

AIMS AND OBJECTIVES

Assessment of liver fat, SAT and IPAT-SV by MRI in subjects with T2D and MetS; and to investigate its correlation with IR, specifically according to different quartiles of HOMA-IR.

METHODS

Eighty T2D and the equal number of age sex-matched normal glucose tolerant controls participated in this study. Abdominal SAT, IPAT-SV and liver fat were measured using MRI. IR was estimated by the Homeostatic Model Assessment for Insulin Resistance (HOMA-IR).

RESULTS

T2D and MetS subjects have higher quantity liver fat and IPAT-SV fat than controls (P = 9 x 10-4 and 4 x 10-4 for T2D and 10-4 and 9 x 10-3 for MetS subjects respectively). MetS subjects also have higher SAT fat mass (P = 0.012), but not the BMI adjusted SAT fat mass (P = 0.48). Higher quartiles of HOMA-IR were associated with higher BMI, W:H ratio, waist circumference, and higher liver fat mass (ANOVA Test P = 0.020, 0.030, 2 x 10-6 and 3 x 10-3 respectively with F-values 3.35, 3.04, 8.82, 4.47 respectively). In T2D and MetS subjects, HOMA-IR showed a moderately strong correlation with liver fat (r = 0.467, P < 3 x 10-5 and r = 0.493, P < 10-7), but not with SAT fat and IPAT-SV. However, in MetS subjects IPAT-SV fat mass showed borderline correlation with IR (r = 0.241, P < 0.05), but not with the BMI adjusted IPAT-SV fat mass (r = 0.13, P = 0.26). In non-T2D and non-MetS subjects, no such correlation was seen. On analyzing the correlation between the three abdominal adipose compartment fat masses and IR according to its severity, the correlation with liver fat mass becomes stronger with increasing quartiles of HOMA-IR, and the strongest correlation is seen in the highest quartile (r = 0.59, P < 10-3). On the other hand, SAT fat mass tended to show an inverse relation with IR with borderline negative correlation in the highest quartile (r = -0.284, P < 0.05). IPAT-SV fat mass did not show any statistically significant correlation with HOMA-IR, but in the highest quartile it showed borderline, but statistically insignificant positive correlation (P = 0.07).

CONCLUSION

In individuals suffering from T2D and MetS, IR shows a trend towards positive and borderline negative correlation with liver fat and SAT fat masses respectively. The positive trend with liver fat tends to become stronger with increasing quartile of IR. Therefore, these findings support the theory that possibly exhaustion of protective compartment's capacity to store excess fat results in its pathological deposition in liver as ectopic fat.

Metabolic Syndrome and Chronic Disease Risk in South Asian Immigrants: A Review of Prevalence, Factors, and Interventions

South Asians (SAs) are among the fastest-growing ethnic groups in the U.S. Metabolic syndrome (MetS) is a condition that is characterized by multiple health factors that increase the risk for chronic diseases, such as cardiovascular disease (CVD) and diabetes. MetS prevalence among SA immigrants ranges from 27-47% in multiple cross-sectional studies using different diagnostic criteria, which is generally higher compared to other populations in the receiving country. Both genetic and environmental factors are attributed to this increased prevalence. Limited intervention studies have shown effective management of MetS conditions within the SA population. This review reports MetS prevalence in SAs residing in non-native countries, identifies contributing factors, and discusses ways to develop effective community-based strategies for health promotion targeting MetS among SA immigrants. There is a need for more consistently evaluated longitudinal studies to facilitate the development of directed public health policy and education to address chronic diseases in the SA immigrant community.

An Atypical Form of Diabetes Among Individuals With Low BMI

OBJECTIVE

Diabetes among individuals with low BMI (<19 kg/m2) has been recognized for >60 years as a prevalent entity in low- and middle-income countries (LMICs) and was formally classified as "malnutrition-related diabetes mellitus" by the World Health Organization (WHO) in 1985. Since the WHO withdrew this category in 1999, our objective was to define the metabolic characteristics of these individuals to establish that this is a distinct form of diabetes.

RESEARCH DESIGN AND METHODS

State-of-the-art metabolic studies were used to characterize Indian individuals with "low BMI diabetes" (LD) in whom all known forms of diabetes were excluded by immunogenetic analysis. They were compared with demographically matched groups: a group with type 1 diabetes (T1D), a group with type 2 diabetes (T2D), and a group without diabetes. Insulin secretion was assessed by C-peptide deconvolution. Hepatic and peripheral insulin sensitivity were analyzed with stepped hyperinsulinemic-euglycemic pancreatic clamp studies. Hepatic and myocellular lipid contents were assessed with 1H-nuclear magnetic resonance spectroscopy.

RESULTS

The total insulin secretory response was lower in the LD group in comparison with the lean group without diabetes and the T2D group. Endogenous glucose production was significantly lower in the LD group than the T2D group (mean ± SEM 0.50 ± 0.1 vs. 0.84 ± 0.1 mg/kg · min, respectively; P < 0.05). Glucose uptake was significantly higher in the LD group in comparison with the T2D group (10.1 ± 0.7 vs. 4.2 ± 0.5 mg/kg · min; P < 0.001). Visceral adipose tissue and hepatocellular lipids were significantly lower in LD than in T2D.

CONCLUSIONS

These studies are the first to demonstrate that LD individuals in LMICs have a unique metabolic profile, suggesting that this is a distinct entity that warrants further investigation.

The Prevalence of Clinical Characteristics of Polycystic Ovary Syndrome among Indigenous Women: A Systematic Search and Review of the Literature

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among reproductive-aged women; however, to date there has been no synthesis of the burden of PCOS specifically among indigenous women. We aimed to systematically identify and collate studies reporting prevalence and clinical features of PCOS among indigenous women worldwide. We performed a comprehensive search of six databases (Ovid MEDLINE, MEDLINE In Process & Other Non-Indexed Citations, EMBASE, EBM reviews, CINAHL, and SCOPUS) supplemented by gray literature searches and the screening of reference lists. A narrative synthesis was conducted. Fourteen studies met inclusion criteria; however, one was excluded as it assessed only children and adolescents younger than 15 years, with limited clinical relevance. Studies examined indigenous women from Australia, Sri Lanka, New Zealand, and the United States. Prevalence of PCOS was reported in only four studies and ranged from 3.05% for women in Sri Lanka to 26% for women in Australia. All included studies reported on at least one clinical feature of PCOS. Of the studies that reported on a comparison group from the same country, there was evidence of more severe features in indigenous women from New Zealand and the United States. The limited evidence available warrants further investigation of the burden of PCOS in indigenous women to build the knowledge base for effective and culturally relevant management of this condition.

An evaluation of dietary intakes of a selected group of South Asian migrant women with gestational diabetes mellitus

Background: Women of South Asian descent have an increased risk of developing gestational diabetes mellitus (GDM), and type 2 diabetes mellitus compared to Caucasian women. Dietary advice provided by health practitioners to this group has been found to be culturally inappropriate. The aim of this study was to describe the dietary intakes of South Asian women with gestational diabetes and use this information to develop culturally appropriate dietary models for education and support of dietary management.Method: An in-depth diet and lifestyle survey was administered with 13 eligible women. Dietary histories were collected for pre-pregnancy, during pregnancy and post-GDM diagnosis to evaluate changes in dietary intake, diet and health beliefs and traditional foods consumed during pregnancy.Results: The diets of participants did not meet nutrient requirements for pregnancy; specific areas on concern were dietary fibre, calcium, iron, folate and iodine. Vegetarians were particularly at risk with regards to energy and protein intake. Generally dietary intakes of these women with GDM were not consistent with guidelines for management of GDM. Confusion about what they should eat for GDM, health practitioner advice and conflict with cultural expectations about foods to consume during pregnancy was evident.Conclusion: The dietary information collected from these women was used to model sample menus for GDM that were culturally appropriate and consistent with vegetarian and non-vegetarian eating patterns.

Introducing physiology of diabetes to American Asian middle school and high school students

Diabetes, a chronic condition that impacts millions, is a complex disease. Understanding the disease can contribute to increasing awareness about this debilitating condition and preventing occurrences. Furthermore, inculcation of physiology knowledge may lead to an increased likelihood of career goals that align with this area of study. In pursuit of these goals, we set out to educate middle and high school students about diabetes. Thirty (16 high school; 14 middle school) students from a Sunday school program at an urban religious center completed a 10-question pretest as a way to measure initial knowledge about diabetes. Following completion of the survey, a 1-h education session was presented by a local physician who also brought a glucometer and insulin syringes for students to have a hands-on experience with some disease-specific tools. A posttest was administered following the presentation. The posttest consisted of 11 questions, where all but 2 questions were the same as for the pretest, measuring improvement of prior knowledge and engagement in the presentation. The overall posttest average score increased by approximately two correct responses, which was a significant improvement (P < 0.0001), suggesting that the students were motivated to and did learn diabetes concepts. This study also suggests that exposing students to educational activities related to physiology is beneficial and may lead to an increase in interest in physiology, an awareness of diabetes, and perhaps the development of healthy habits.

Cardiovascular Disease & Cancer Risk Among South Asians: Impact of Sociocultural Influences on Lifestyle and Behavior

A comprehensive literature review revealed cultural beliefs, societal obligations, and gender roles within the South Asian community to be indirect contributors to the health of South Asian immigrants (SAIs). Health professionals need to increase their work with SAI communities to change less beneficial cultural elements such as misconceptions about health and exercise, and lack of communication when using alternative medicines. Community engaged efforts and continuing medical education are both needed to improve the health of the South Asian immigrant population in a culturally appropriate manner.

Economic Impact of Diabetes in South Asia: the Magnitude of the Problem

PURPOSE OF REVIEW

To critically assess and identify gaps in the current literature on the economic impact of diabetes in South Asia.

RECENT FINDINGS

The total annual (direct medical and non-medical and indirect) costs for diabetes care in South Asia range from $483-$2637 per patient, and on an average 5.8% of patients with diabetes suffer catastrophic spending i.e. when households reduce basic expenditure by 40% to cope with healthcare costs. The mean direct costs per patient are positively associated with a country's gross domestic product (GDP) per capita, although there is wide heterogeneity across South Asian countries. With an estimated 84 million people suffering from diabetes in South Asia, diabetes imposes a substantial economic burden on individuals, families, and society. Since the disease burden increasingly occurs in the most productive midlife period, it adversely affects workforce productivity and macroeconomic development. Diabetes-related complications lead to markedly higher treatment costs, causing catastrophic medical spending for many households, thus underscoring the importance of preventing diabetes-related complications.

A cross-sectional and spatial analysis of the prevalence of multimorbidity and its association with socioeconomic disadvantage in South Africa: A comparison between 2008 and 2012

This study utilised data from the National Income Dynamics Study, a longitudinal study with a sample of approximately 28 000 people, to investigate the cross-sectional and spatial distribution of multimorbidity and the association with socioeconomic disadvantage in South Africa for 2008 and 2012. Multimorbidity increased in prevalence from 2.73% to 2.84% in adults between 2008 and 2012 and was associated with age, socioeconomic deprivation, obesity and urban areas. Hypertension was found frequently coexisting with diabetes. Spatial analysis showed clusters (hot spots) of higher multimorbidity prevalence in parts of KwaZulu-Natal and the Eastern Cape, which compared with the socioeconomic disadvantage spatial pattern. Although these results were limited to a district level analysis, this study has provided a platform for future local level research and has provided insight into the socioeconomic determinants of disease multimorbidity within a developing country.

Racial/ethnic differences in clinical and biochemical type 2 diabetes mellitus risk factors in children

OBJECTIVE

To examine whether periadolescent children demonstrate the significant racial/ethnic differences in body fatness relative to BMI and in the prevalence and relationship of body composition to risk factors for type 2 diabetes (T2DM) as in adults.

DESIGN AND METHODS

Family history of obesity and T2DM, anthropometry, insulin sensitivity and secretory capacity, lipids, and cytokines (IL-6, CRP, TNF-α, and adiponectin) were examined in a cohort of 994 middle school students (47% male, 53%, female; 12% African American, 14% East Asian, 13% South Asian, 9% Caucasian, 44% Hispanic, and 8% other).

RESULTS

Fractional body fat content was significantly greater at any BMI among South Asians. There were racial/ethnic specific differences in lipid profiles, insulin secretory capacity, insulin sensitivity, and inflammatory markers corrected for body fatness that are similar to those seen in adults. Family history of T2DM was associated with lower insulin secretory capacity while family history of obesity was more associated with insulin resistance.

CONCLUSIONS

Children show some of the same racial/ethnic differences in risk factors for adiposity-related comorbidities as adults. BMI and waist circumference cutoffs to identify children at-risk for adiposity-related comorbidities should be adjusted by racial/ethnic group as well as other variables such as birthweight and family history.

Type 2 Diabetes Risk among Asian Indians in the US: A Pilot Study

The purpose of this pilot study was to investigate type 2 diabetes risk among Asian Indians of Kerala ethnicity living in a West Texas County of the USA. The study used a descriptive correlational design with thirty-seven adult nondiabetic Asian Indian subjects between 20 and 70 years of age. The measurement included nonbiochemical indices of obesity, family history of type 2 diabetes, length of immigration in the US, history of hypertension, physical activity pattern, and fruit and vegetable intake. The majority of the subjects showed an increased nonbiochemical indices corresponding with overweight and obesity, placing them at risk for type 2 diabetes and associated cardiovascular complications. The physical activity pattern indicated a sedentary lifestyle. The decreased physical activity was associated with a higher Body Mass Index (BMI) and body fat percentage; length of residence in the US greater than 10 years was associated with increased body fat percentage and BMI; family history of type 2 diabetes was associated with an increase in body fat percentage. Fruit and vegetable intake pattern was not associated with a risk for type 2 diabetes. Further studies are recommended for risk surveillance among Asian Indian population living in the US.

The association of 25 hydroxyvitamin D and parathyroid hormone with metabolic syndrome in two ethnic groups in South Africa

INTRODUCTION

Though inconsistent, a number of studies have shown an association between vitamin D (25(OH)D) status, parathyroid hormone (PTH) and the metabolic syndrome (Met S). These have largely been carried out in Caucasians or black subjects living in high income countries. There no data on the relationship of 25(OH)D and PTH status with Met S in populations resident in Africa. The aims of this study were to evaluate if there was an association of 25(OH)D or PTH with Met S in non-Caucasian populations in South Africa, and whether these molecules explained ethnic differences in the prevalence of Met S and its individual components.

METHODS

We measured anthropometry, serum 25(OH)D and PTH levels and the components of Met S, plus related metabolic variables, in 374 African and 350 Asian Indian healthy adults from the greater Johannesburg metropolitan area.

RESULTS

Met S was diagnosed in 29% of the African and 46% of the Asian Indian subjects (p<0.0001). Subjects with Met S had higher PTH than those without Met S, (p<0.0001), whilst 25(OH)D levels were not significantly different (p = 0.50). In multivariate analysis, 25(OH)D was not associated with any components of the Met S however PTH was shown to be positively associated with systolic (p = 0.018) and diastolic (p = 0.005) blood pressures and waist circumference (p<0.0001) and negatively associated with HOMA (p = 0.0008) levels. Logistic regression analysis showed that Asian Indian ethnicity (OR 2.24; 95% CIs 1.57, 3.18; p<0.0001) and raised PTH (OR 2.48; 95% CIs 1.01, 6.08; p = 0.04; adjusted for 25(OH)D) produced an increased risk of Met S but 25(OH)D did not (OR 1.25; 95% CI 0.67, 2.24; p = 0.48).

CONCLUSIONS

Plasma PTH but not 25(OH)D is an independent predictor of the Met S in African and Asian Indians in South Africa.

Pharmacogenomic Research in South Africa: Lessons Learned and Future Opportunities in the Rainbow Nation

South Africa, like many other developing countries, stands to benefit from novel diagnostics and drugs developed by pharmacogenomics guidance due to high prevalence of disease burden in the region. This includes both communicable (e.g., HIV/AIDS and tuberculosis) and non-communicable (e.g., diabetes and cardiovascular) diseases. For example, although only 0.7% of the world's population lives in South Africa, the country carries 17% of the global HIV/AIDS burden and 5% of the global tuberculosis burden. Nobel Peace Prize Laureate Archbishop Emeritus Desmond Tutu has coined the term Rainbow Nation, referring to a land of wealth in its many diverse peoples and cultures. It is now timely and necessary to reflect on how best to approach new genomics biotechnologies in a manner that carefully considers the public health needs and extant disease burden in the region. The aim of this paper is to document and review the advances in pharmacogenomics in South Africa and importantly, to evaluate the direction that future research should take. Previous research has shown that the populations in South Africa exhibit unique allele frequencies and novel genetic variation in pharmacogenetically relevant genes, often differing from other African and global populations. The high level of genetic diversity, low linkage disequilibrium and the presence of rare variants in these populations question the feasibility of the use of current commercially available genotyping platforms, and may partially account for genotype-phenotype discordance observed in past studies. However, the employment of high throughput technologies for genomic research, within the context of large clinical trials, combined with interdisciplinary studies and appropriate regulatory guidelines, should aid in acceleration of pharmacogenomic discoveries in high priority therapeutic areas in South Africa. Finally, we suggest that projects such as the H3Africa Initiative, the SAHGP and PGENI should play an integral role in the coordination of genomic research in South Africa, but also other African countries, by providing infrastructure and capital to local researchers, as well as providing aid in addressing the computational and statistical bottlenecks encountered at present.

Obesity-associated genetic variants in young Asian Indians with the metabolic syndrome and myocardial infarction

OBJECTIVE

Associations between obesity-related polymorphisms and the metabolic syndrome in 485 young ( ≤ 45 Years) Asian Indian patients with acute myocardial infarction (AMI), and 300 matched controls were assessed.

METHODS

Genetic variants included the adiponectin 45T→G and 276G→T, LEPR K109R and Q223R, MC4R-associated C→T and FTO A→T polymorphisms.

RESULTS

The metabolic syndrome, as defined by NCEP ATP III and IDF criteria, was diagnosed in 61 and 60% of patients, respectively. No relationship was found between the obesity-associated polymorphisms and the metabolic syndrome, or between AMI patients and controls. The MC4R-associated TT genotype occurred more frequently in patients with lower triglyceride levels (p = 0.024), while the adiponectin 45 TT genotype occurred more commonly in patients with normal fasting glucose levels (p = 0.004). The LEPR Q223R TT genotype was associated with low high-density lipoprotein (HDL) cholesterol levels (p = 0.003).

CONCLUSION

The metabolic syndrome occurs commonly in young Asian Indian patients with AMI. No relationship was found between any obesity-associated polymorphism and the metabolic syndrome. Particular genotypes may exert protective or disadvantageous effects on individual components of the metabolic syndrome.

Critical limb ischaemia in a diabetic population from an Asian Centre: angiographic pattern of disease and 3-year limb salvage rate with percutaneous angioplasty as first line of treatment

Purpose:

Lower extremity amputation prevention (LEAP) is an ongoing program in our institution aimed at salvaging limbs in patients with critical limb ischemia (CLI). Patients in the LEAP program with reconstructible anatomy on initial Doppler imaging received either bypass surgery or percutaneous transluminal balloon angioplasty (PTA). We present the 3 year limb salvage rate and angiographic disease patterns in 42 consecutive diabetic patients with CLI who received PTA in 2005.

Methods and Material:

26 women and 16 men with diabetes between the ages of 45 and 91 years old (mean age, 70.8 years) received PTA in 2005. Presenting symptoms were rest pain (n = 22), pre-existing gangrene (n = 17), non-healing ulcer (n = 16) and cellulitis (n = 2). The aim of the PTA was to achieve straight-line flow from the abdominal aorta down to the patent dorsalis pedis or plantar arch, with limb salvage as the ultimate outcome. Failure of treatment was defined as any amputation above the level of a Syme’s amputation or the need for further surgical bypass. Technical success was achieved in 90% (38 out of 42 patients).

Results:

Limb salvage rates were 93% at 1 month, 87% at 3 months, 82% at 6 months, 78% at 1 year, 69% at 2 years and 66% at 3 years. Mortality was 17% (n = 7) at 3 years. Of the 13 patients with failed therapy, 3 underwent bypass, 9 had amputations and 1 had bypass followed by amputation. Four of the cases required further intervention due to worsening gangrene and infection, while the remaining was due to persistent rest pain. The rest of the 32 patients had no lower limb related issues at the end of 3 years, with improvement of the presenting symptoms. Patterns of treated segments were aortoiliac occlusions (n = 3), pure infrapopliteal disease (n = 3), femoropopliteal with at least 1 good infrapopliteal run-off vessel (n = 14) and combined femoropopliteal and infrapopliteal disease (n = 25).

Conclusion:

Involvement of infrapopliteal vessels that needs to be treated is common in Asian diabetics. While early limb salvage rates up to 1 year are similar, the 3 year limb salvage rates in Asian diabetics are lower than the western population.

The burden of non-communicable diseases in South Africa

15 years after its first democratic election, South Africa is in the midst of a profound health transition that is characterised by a quadruple burden of communicable, non-communicable, perinatal and maternal, and injury-related disorders. Non-communicable diseases are emerging in both rural and urban areas, most prominently in poor people living in urban settings, and are resulting in increasing pressure on acute and chronic health-care services. Major factors include demographic change leading to a rise in the proportion of people older than 60 years, despite the negative effect of HIV/AIDS on life expectancy. The burden of these diseases will probably increase as the roll-out of antiretroviral therapy takes effect and reduces mortality from HIV/AIDS. The scale of the challenge posed by the combined and growing burden of HIV/AIDS and non-communicable diseases demands an extraordinary response that South Africa is well able to provide. Concerted action is needed to strengthen the district-based primary health-care system, to integrate the care of chronic diseases and management of risk factors, to develop a national surveillance system, and to apply interventions of proven cost-effectiveness in the primary and secondary prevention of such diseases within populations and health services. We urge the launching of a national initiative to establish sites of service excellence in urban and rural settings throughout South Africa to trial, assess, and implement integrated care interventions for chronic infectious and non-communicable diseases.

Higher liver fat content among Japanese in Japan compared with non-Hispanic whites in the United States

Among Asians, including Japanese, obesity is related to dyslipidemia and insulin resistance at a lower level of body mass index (BMI) compared with non-Hispanic whites (NHW). We hypothesize that this ethnic difference in the relationship between BMI and metabolic risks is partly associated with the ethnic difference in fat distribution, namely, liver fat as well as visceral adipose tissue. To compare liver fat content among Japanese vs NHW men, regional computed tomographic images were taken to measure liver computed tomographic density in population-based samples of 313 Japanese and 288 NHW men aged 40 to 49 years, along with the assessment of metabolic parameters. Liver fat content was higher in Japanese than NHW men (liver to spleen attenuation ratio [lower value means higher liver fat content]: 1.01 +/- 0.16 vs 1.07 +/- 0.15, respectively; P < .01), despite a lower mean BMI in Japanese men (BMI: 23.6 +/- 2.9 vs 27.8 +/- 4.2 kg/m(2), P < .01). Moreover, Japanese men had a greater disposition for fatty liver with a small increase in BMI than NHW (P < .01), whereas both groups had a similar relationship between visceral adipose tissue and BMI. In both groups, liver fat content correlated with triglycerides, homeostasis model assessment of insulin resistance, and C-reactive protein. Liver fat content is higher among Japanese than NHW; and this ethnic difference becomes more robust with a small increase in BMI, suggesting that fatty liver is a sensitive marker for the failure of the adipose tissue to expand to accommodate an increased energy influx, and is associated with similar metabolic risk in Japanese despite lower BMI compared with NHW men.

Health status and health services utilization among older Asian Indian immigrants

This study examines the health status and utilization of physicians, hospitals, emergency departments, and traditional medicine among older Asian Indian immigrants (n = 100). The data for this study derives from the Asian American Elders in New York City (AAENYC) Study, which used a regional probability sampling. Multivariate analyses were guided by the Andersen behavioral model. The number of medical conditions is significant in predicting the likelihood of physician visits while age and having medical insurance predicted the likelihood of hospital stays. Having medical insurance was also a significant predictor for the use of emergency department services while poor English proficiency was associated with the use of traditional medicine.

Prevalence of metabolic syndrome and associated risk factors in Asian Indians

OBJECTIVE

This study examined the association between metabolic syndrome, lifestyle behaviors, and perception and knowledge of current health and cardiovascular disease (CVD) among Asian Indians in the US.

METHOD

The sample comprised of 143 adult Asian Indians recruited through health fairs for survey and bioclinical measures.

RESULTS

The prevalence of metabolic syndrome was 32%, much higher than other ethnic groups, did not vary by gender but increased with age. Respondents had high physical inactivity and poor knowledge of CVD risk factors. Dietary behavior, age, number of years lived in the US, self-rated physical and mental health and BMI were significant predictors and explained 40.1% of variance in metabolic syndrome score. Poorer physical health status had the greatest predictive influence on metabolic syndrome.

CONCLUSION

Asian Indians are a high risk group for CVD.

Metabolic risk factors, insulin-resistance and lifestyle in children of type 2 diabetes patients in Karachi, Pakistan

AIMS

To assess metabolic risk factors, insulin-resistance and lifestyle in children aged 8-20 years of patients with type 2 diabetes and to compare these with children aged 8-20 years of non-diabetic subjects.

METHODS

Case-control study. Data were collected from 37children/adolescents of type 2 diabetes patients and 37 controls from parents without diabetes. Variables included physical activity, diet, socioeconomic class, family history, ethnic background, anthropometric measures, blood pressure and fasting glucose and insulin.

RESULTS

Groups were comparable for age and gender. Differences between cases and controls were found for BMI (22.6 vs. 19.1kg/m(2), p=0.004), waist circumference (70.1 vs. 62.1cm, p=0.014), systolic blood pressure (104.5+/-15.1 vs. 97.9+/-13.4mmHg, p=0.05), diastolic blood pressure (66.2+/-10.9 vs. 60.7+/-10.1mmHg, p=0.025). Vegetable intake (3% of cases having two and 19% one full serving a day vs., respectively, 14% and 32% amongst controls, p=0.01) was less favourable in cases, and physical activity tended to be (5h vs. 9h/week, p=0.065).

CONCLUSIONS

Children of type 2 diabetes patients have higher BMI and blood pressure than controls but also lead a less healthy lifestyle. This suggests that both genetic and lifestyle factors contribute to the increased risk of metabolic syndrome in children and early preventive measures towards changing lifestyle could help in prevention.

Diet-induced central obesity and insulin resistance in rabbits

The present study was designed to examine whether rabbits fed a diet containing high fat and sucrose could develop obesity and insulin resistance (IR), the major pathophysiological features of metabolic syndrome. Male Japanese white rabbits were fed either a normal chow diet (control) or high fat and sucrose diet (HFSD) for 36 weeks. Plasma levels of triglycerides (TG), total cholesterol (TC), glucose and insulin were measured. To evaluate glucose metabolism, we performed an intravenous glucose tolerance test. In addition, we compared adipose tissue accumulation in HFSD-fed rabbits with that in normal rabbits. HFSD constantly and significantly led to an increase in body weight of HFSD-fed rabbits, caused by significantly higher visceral adipose tissue accumulation. Although there were no differences in plasma TG, TC, glucose, insulin levels and blood pressure between the two groups, HFSD-fed rabbits showed impaired glucose clearance associated with higher levels of insulin secretion compared to control rabbits. Our results showed that HFSD induced IR and increased adipose accumulation in rabbits, suggesting that HFSD-fed rabbits may become a model for research on human IR and obesity.

Prevalence and clinical characteristics of maternally inherited diabetes and deafness caused by the mt3243A > G mutation in young adult diabetic subjects in Sri Lanka

AIMS

The maternally inherited mt3243A > G mutation is associated with a variable clinical phenotype including diabetes and deafness (MIDD). We aimed to determine the prevalence and clinical characteristics of MIDD in a large South Asian cohort of young adult-onset diabetic patients from Sri Lanka.

METHODS

DNA was available from 994 subjects (age of diagnosis 16-40 years, age at recruitment < or = 45 years). Mutation screening was performed using a QRT-PCR method on an ABI 7900HT system using sequence-specific probes. Samples with heteroplasm > or = 5.0% were considered positive.

RESULTS

Nine (four males) mutation-positive subjects were identified (prevalence 0.9%). They were diagnosed at a younger age (25.9 +/- 4.8 years vs. 31.9 +/- 5.6 years, P = 0.002) and were lean (body mass index [BMI] 18.7 +/- 2.7 kg/m(2) vs. 24.7 +/- 4.0 kg/m(2), P < 0.001) compared to NMCs. One mutation-positive subject (11.1%) had metabolic syndrome, compared to 633 (64.3%) of NMCs. Insulin therapy within 6 months of diagnosis was used in four (44.0%) carriers compared to 6.9% of NMCs (P = 0.002). Combined screening criteria of any two of maternal history of diabetes, personal history of hearing impairment and family history of hearing impairment only identified five (55%) of the carriers, with a positive predictive value of 7.4%.

CONCLUSIONS

The prevalence of mt3243A > G mutation among young adult-onset diabetic subjects from Sri Lanka was 0.9%. Our study demonstrates that a maternal family history of diabetes and either a personal and/or family history of deafness only distinguish half of patients with MIDD from Sri Lankan subjects with young-onset diabetes.

Insulin resistance and body fat distribution in South Asian men compared to Caucasian men

OBJECTIVE

South Asians are susceptible to insulin resistance even without obesity. We examined the characteristics of body fat content, distribution and function in South Asian men and their relationships to insulin resistance compared to Caucasians.

RESEARCH DESIGN AND METHODS

Twenty-nine South Asian and 18 Caucasian non-diabetic men (age 27+/-3 and 27+/-3 years, respectively) underwent euglycemic-hyperinsulinemic clamp for insulin sensitivity, underwater weighing for total body fat, MRI of entire abdomen for intraperitoneal (IP) and subcutaneous abdominal (SA) fat and biopsy of SA fat for adipocyte size.

RESULTS

Compared to Caucasians, in spite of similar BMI, South Asians had higher total body fat (22+/-6 and 15+/-4% of body weight; p-value<0.0001), higher SA fat (3.5+/-1.9 and 2.2+/-1.3 kg, respectively; p-value = 0.004), but no differences in IP fat (1.0+/-0.5 and 1.0+/-0.7 kg, respectively; p-value = 0.4). SA adipocyte cell size was significantly higher in South Asians (3491+/-1393 and 1648+/-864 microm2; p-value = 0.0001) and was inversely correlated with both glucose disposal rate (r-value = -0.57; p-value = 0.0008) and plasma adiponectin concentrations (r-value = -0.71; p-value<0.0001). Adipocyte size differences persisted even when SA was matched between South Asians and Caucasians.

CONCLUSIONS

Insulin resistance in young South Asian men can be observed even without increase in IP fat mass and is related to large SA adipocytes size. Hence ethnic excess in insulin resistance in South Asians appears to be related more to excess truncal fat and dysfunctional adipose tissue than to excess visceral fat.

Mechanisms of the components of the metabolic syndrome that predispose to diabetes and atherosclerotic CVD

The metabolic syndrome represents a summation of obesity-driven risk factors for atherosclerotic CVD and type 2 diabetes. Definitions of the syndrome vary but in general agree closely in identifying subjects. The relationships between the metabolic syndrome and atherosclerotic CVD and diabetes also vary, with relative risks of approximately 1.5-3.0 and approximately 3.0-5.0 respectively. Insulin resistance appears to explain much of the pathophysiology of the syndrome. Both increased fatty acid flux and an excess of circulating pro-inflammatory cytokines are likely mediators. With increased waist circumference, increases in fatty acid delivery to the liver result in higher rates of hepatic glucose production and increases in the secretion of apoB-containing lipoproteins. Concomitant changes in HDL ensue, including a replacement of the cholesterol content with TAG, an accelerated clearance from the plasma and thus a reduced number of HDL particles. Typically also present are increases in small dense LDL. Hypertension in part relates to the insulin resistance, but may involve other mechanisms. Impaired fasting glucose often relates to defects in insulin secretion in addition to insulin resistance, and probably more than any other component of the syndrome predicts the increased incidence of type 2 diabetes. Although not included in the diagnostic criteria, increases in pro-inflammatory cytokines and pro-thrombotic factors, in addition to decreases in plasma adiponectin, may also contribute to the increased incidence of atherosclerotic CVD and diabetes. In general, the greater the number of metabolic syndrome components, the greater the risk for these outcomes. The cytokines and pro-thrombotic factors also appear to contribute.

Abdominal obesity, waist circumference and cardio-metabolic risk: awareness among primary care physicians, the general population and patients at risk--the Shape of the Nations survey

OBJECTIVE

Abdominal obesity, measured by waist circumference (WC), is a more accurate predictor of cardiometabolic risk than general obesity measured by body mass index (BMI). The 'Shape of the Nations' survey was performed to assess knowledge and understanding of the increased risk associated with abdominal obesity.

RESEARCH DESIGN AND METHODS

Approximately 100 primary care physicians (PCPs), 400 members of the general population and 100 patients at risk for cardiovascular disease (CVD) were interviewed in each of 27 countries using a structured questionnaire. Demographic characteristics were obtained and subjects were asked about their understanding of risk factors, assessment of body weight and shape, and use of WC to assess cardiometabolic risk.

RESULTS

On average, 39% of all people visiting a PCP worldwide were overweight or obese, according to PCP reports; in North America, this proportion was 49%. Abdominal obesity was recognised by 58% of PCPs worldwide as a significant risk factor for heart disease; an equal proportion considered high BMI to be a risk factor. Worldwide, 45% of all physicians reported never measuring WC and 52% overestimated the WC that puts their patients at risk. In the general population, 42% were aware of the association between abdominal obesity and risk, but a higher proportion (60%) considered high BMI an important risk factor. Very few of the general population measured their waist or knew the WC that is considered to confer significantly increased risk. More than half (59%) of at-risk patients had not been informed by their doctors about the link between abdominal obesity and heart disease.

CONCLUSIONS

The Shape of the Nations survey findings demonstrate the need for education and action to improve preventive health efforts worldwide by educating PCPs, the general population and patients at risk about the dangers of abdominal obesity and of WC as an easy, reliable way to assess cardiometabolic risk.

Metabolic syndrome components in Indian migrants with type 2 diabetes. A matched comparative study

OBJECTIVE

To study the metabolic syndrome (MS) in Indian subjects with type 2 diabetes (T2D) in comparing them with controls from the Indian community and from the general population.

METHOD

An adapted definition of MS by the Third report of the National Cholesterol Education Program's Adult Treatment Panel III was used. We defined three groups matched for sex and age (+/-5 years). Non parametric tests for comparison of matched samples and conditional logistic regression were used.

RESULTS

We selected 71 Indians with T2D (group 1) and two control groups with fasting blood glucose<6.1 mmol/L: 71 Indians (group 2) and 213 subjects from the general population (group 3). Patients were 24 to 76 years-old and each group contained 56% men. Globally, MS was identified in 77% of the group 1 when diabetes was taken into account. When diabetes was excluded there were 47% of MS in group 1, 18% in group 2 and 16% in group 3. The clusters of four factors (hypertension, large waist circumference, hypertriglyceridemia and Low HDL-C) were more common in Indians. The most frequent factors were hypertriglyceridemia and large waist circumference in Indians. Indians with T2D had a 5-fold higher risk of MS than the general population group, OR (95% CI): 4.93 (2.71 - 8.97); P<0.001.

CONCLUSION

The high frequency of MS and of hypertriglyceridemia in Indians with T2D highlights the need for screening and management of MS in this population facing a high cardiovascular risk.

Ethnic differences in control of cardiovascular risk factors in patients with type 2 diabetes attending an Inner London diabetes clinic

BACKGROUND

South Asians have higher risk of diabetic complications compared with white Europeans. The aim of this study was to compare management of cardiovascular risk factors between Bangladeshis and white Europeans.

METHODS

A retrospective survey of all diabetic patients attending an Inner London hospital diabetic clinic over one year was undertaken. Data were obtained from the hospital diabetes database: presence of macrovascular (myocardial infarction, angina, stroke, transient ischaemic attack, cardiac intervention) and microvascular disease (neuropathy, retinopathy, and nephropathy), glycated haemoglobin, blood pressure, lipids, smoking, and body mass index (BMI) were all determined.

RESULTS

A total of 1162 white European and 912 Bangladeshi patients with full data available were included in the analyses. The groups were equivalent in age, sex, duration of diabetes. Compared with white Europeans, Bangladeshis had more macrovascular disease (19.5% v 11.9% p<0.01), sight threatening retinopathy (7.2% v 3.8%, p<0.01), and nephropathy (15.3% v 9.1%, p<0.01). In addition, Bangladeshis had significantly more male smokers (28.1% v 22.1%, p<0.01), poorer glycaemic control (mean HbA1c 8.6% v 8.1%, p = 0.039), greater proportion with uncontrolled hypercholesterolaemia (total cholesterol >5.0 mmol/l, 31.6% v 26% p = 0.05), and poorer control of blood pressure (proportion with BP >140/80 mm Hg, 43.2% v 32.1%, p<0.01).

CONCLUSIONS

South Asians with type 2 diabetes have poorer glycaemic, blood pressure, and lipid control than white Europeans. The reasons for this are probably multifactorial.

Ethnicity and diabetic heart disease

Ethnicity is a complex yet important construct and an independent risk factor for diabetic heart disease (DHD) with paramount clinical significance. Clinicians should try to better understand the role of ethnicity through more questions. The risk of DHD is modified by ethnicity through more questions. The risk of DHD is modified by ethnicity, and its management may require a culturally sensitive individualized approach. Findings from Caucasian populations cannot be fully extrapolated to other ethnic groups, thereby emphasizing the importance of future research with ethnicity-based threshold for obesity. Available limited data support the interaction between genetic predisposition, environmental risk, and lifestyle choices and disparities based on ethnicity as the likely cause for ethnic variations in DHD.

[Prevalence of diabetes mellitus in young Asian Indian immigrants in Santa Coloma de Gramenet (Spain)]

BACKGROUND AND OBJECTIVE

There is a general agreement to consider Asian Indian subjects, specially those who immigrated to Western countries, as a high-risk population to develop type 2 diabetes mellitus (DM2). This could be mainly explained by reasons based on the immigration changes, particularly the metabolic impact of a westernized diet (environmental hypothesis) or reasons based in the presence of tissue resistance to insulin (genetic hypothesis). The aim of the study was to estimate the prevalence of DM2 in 3 populations of Asian Indian immigrants, non-Asian Indian immigrants and autochthonous subjects.

POPULATION AND METHOD

An observational multicenter study was performed in 3 primary care centers from Santa Coloma de Gramenet (Barcelona, Spain). Subjects from Asian Indian, non-Asian Indian and autochthonous origin born between 1948-73 were compared. Their DM2 prevalence as well as sociodemographic and clinical data among diabetic patients were analyzed.

RESULTS

The overall prevalence of DM2 was 4.6 %. The prevalence of DM2 was higher among Asian Indian immigrants (20.9%, 95% CI, 12.1-29.1) compared with autochthonous (3.6%; 95% CI, 2.9-9.3; p < 0.001) and non-Asian Indian immigrants (9.7%; 95% CI, 5.3-14.1; p = 0.013). Nevertheless, differences between autochthonous and non-Asian Indian immigrants were found (p < 0.001). Asian Indians subjects had an earlier diagnosis age, especially those younger than 44 years, than those of non-Asian Indian immigrants and autochthonous groups (p < 0.002 and p < 0.006, respectively).

CONCLUSIONS

Taken together, these results suggest that young immigrant populations have a higher prevalence of DM2 compared with autochthonous ones. Indeed, the prevalence of DM2 among immigrant Asian Indians represents the highest reported in the European Union so far and shows differences with non-Asian Indian immigrants. In spite of this, these differences are not totally conclusive in statistical terms; further studies are needed to compare both populations.

Diabetic neuropathy

Diabetic neuropathy (DN) refers to symptoms and signs of neuropathy in a patient with diabetes in whom other causes of neuropathy have been excluded. Distal symmetrical neuropathy is the commonest accounting for 75% DN. Asymmetrical neuropathies may involve cranial nerves, thoracic or limb nerves; are of acute onset resulting from ischaemic infarction of vasa nervosa. Asymmetric neuropathies in diabetic patients should be investigated for entrapment neuropathy. Diabetic amyotrophy, initially considered to result from metabolic changes, and later ischaemia, is now attributed to immunological changes. For diagnosis of DN, symptoms, signs, quantitative sensory testing, nerve conduction study, and autonomic testing are used; and two of these five are recommended for clinical diagnosis. Management of DN includes control of hyperglycaemia, other cardiovascular risk factors; alpha lipoic acid and L carnitine. For neuropathic pain, analgesics, non-steroidal anti-inflammatory drugs, antidepressants, and anticonvulsants are recommended. The treatment of autonomic neuropathy is symptomatic.

A Community-based Picture of Type 2 Diabetes Mellitus in Vietnam

There has been a significant increase in the prevalence of type 2 diabetes mellitus (T2DM) in Vietnam. We found that Vietnamese with T2DM had a normal body mass index (BMI), but high levels of total body fat and abdominal fat. Based on published reports together with our own findings, we believe that a sedentary lifestyle and an abundance of starchy foods and also Western style energy-rich foods are factors associated with disease. The staple food of the Vietnamese is still polished-rice which has high glycemic index values. In addition, a Westernized diet, and the chronic consumption of high-glycemic index foods together with a sedentary lifestyle result in insulin resistance and diabetes. The average BMI of T2DM patients is <or= 23 kg/m(2), greater than that 20 years ago. In addition,these patients have high levels of body fat, especially abdominal fat, measured as the waist to hip ratio (WHR >or= 0.90). We therefore, tentatively suggest a BMI of 23 kg/m(2) together with a WHR of 0.90 for males and 0.85 for females as new cutoff values for the risk of T2DM in Vietnamese. These findings have important implications for primary prevention because they indicate that screening and intervention should focus on high-risk populations.

Serum resistin is associated with C-reactive protein & LDL cholesterol in type 2 diabetes and coronary artery disease in a Saudi population

AIMS

Resistin is an adipocyte-derived factor implicated in obesity-associated type 2 diabetes (T2DM). This study examines the association between human serum resistin, T2DM and coronary heart disease.

METHODS

One hundred and fourteen Saudi Arabian patients (male: female ratio 46:68; age 51.4 (mean +/- SD)11.7 years; median and range: 45.59 (11.7) years and BMI: 27.1 (mean +/- SD) 8.1 Kgm2 median and range: 30.3 (6.3) were studied. Serum resistin and C-reactive protein (CRP), a marker of inflammation CRP levels, were measured in all subjects. (35 patients had type 2 diabetes mellitus (T2DM); 22 patients had coronary heart disease (CHD).

RESULTS

Serum resistin levels were 1.2-fold higher in type 2 diabetes and 1.3-fold higher in CHD than in controls (p = 0.01). In addition, CRP was significantly increased in both T2DM and CHD patients (p = 0.007 and p = 0.002 respectively). The use of regression analysis also determined that serum resistin correlated with CRP levels (p = 0.04, R2 0.045).

CONCLUSION

The findings from this study further implicate resistin as a circulating protein associated with T2DM and CHD. In addition this study also demonstrates an association between resistin and CRP, a marker of inflammation in type 2 diabetic patients.

Insulin resistance plays a significant role in liver fibrosis in chronic hepatitis C and in the response to antiviral therapy

OBJECTIVES

To assess whether insulin resistance is associated with liver fibrosis in a group of patients with chronic hepatitis C virus (HCV) infection and whether there were any differences in insulin resistance between Asians and the indigenous Caucasian population. Secondly, to assess whether insulin resistance is associated with sustained virological response to antiviral therapy.

METHODS

We determined insulin resistance in 59 (30 Caucasians; 29 Asians) consecutive patients with HCV prior to starting antiviral therapy. Insulin resistance was measured using the homeostasis model assessment of insulin resistance (HOMA-IR). The relationship between insulin resistance and biochemical, virological, and histological data together with response to antiviral therapy was assessed.

RESULTS

In multivariable analyses, insulin resistance as measured using the HOMA-IR model correlated positively with the stage of fibrosis, with higher degrees of insulin resistance in those with greater degrees of fibrosis (p < 0.001). This significant relationship remained even after excluding cirrhotic patients, or after adjusting for other factors associated with fibrosis in univariable analyses. Insulin resistance was significantly higher in Asians than Caucasians (p= 0.004). Around half (55.6%) of patients completing a course of antiviral treatment had a sustained virological response. Multivariable logistic regression identified HCV genotype 3, lower fasting glucose levels, and lower aspartate transaminase (AST) levels as being associated with a higher odds of a sustained virological response. After adjusting for these variables, Asian ethnicity, higher fasting insulin levels, and higher HOMA-IR levels were all associated with a poorer virological response to therapy.

CONCLUSIONS

Insulin resistance contributes to liver fibrosis in chronic HCV infection; this relationship is not genotypic specific. Asian patients had higher insulin resistance than Caucasians. Insulin resistance is also an important predictor of sustained response to antiviral therapy.

The metabolic syndrome

The metabolic syndrome is a common metabolic disorder that results from the increasing prevalence of obesity. The disorder is defined in various ways, but in the near future a new definition(s) will be applicable worldwide. The pathophysiology seems to be largely attributable to insulin resistance with excessive flux of fatty acids implicated. A proinflammatory state probably contributes to the syndrome. The increased risk for type 2 diabetes and cardiovascular disease demands therapeutic attention for those at high risk. The fundamental approach is weight reduction and increased physical activity; however, drug treatment could be appropriate for diabetes and cardiovascular disease risk reduction.