Diabetes in South-East Asia: an update

Rural and urban differences in the prevalence and determinants of Type-2 diabetes in Bangladesh

OBJECTIVE

To estimate the prevalence of Type 2 Diabetes (T2D) in urban and rural settings and identify the specific risk factors for each location.

METHOD

We conducted this study using data from the 2017-18 Bangladesh Demographic and Health Survey (BDHS), sourced from the DHS website. The survey employed a stratified two-stage sampling method, which included 7,658 women and 7,048 men aged 18 and older who had their blood glucose levels measured. We utilized chi-square tests and ordinal logistic regression to analyze the association between various selected variables in both urban and rural settings and their relationship with diabetes and prediabetes.

RESULTS

The prevalence of T2D was 10.8% in urban areas and 7.4% in rural areas, while pre-diabetes affected 31.4% and 27% of the populations in these respective settings. The study found significant factors influencing diabetes in both urban and rural regions, particularly in the 55-64 age group (Urban: AOR = 1.88, 95% CI [1.46, 2.42]; Rural: AOR = 1.87, 95% CI [1.54, 2.27]). Highly educated individuals had lower odds of T2D, while wealthier and overweight participants had higher odds in both areas. In rural regions, T2D risk was higher among caffeinated drink consumers and those not engaged in occupation-related physical activity, while these factors did not show significant influence in urban areas. Furthermore, urban participants displayed a significant association between T2D and hypertension.

CONCLUSION

Our study outlines a comprehensive strategy to combat the increasing prevalence of T2D in both urban and rural areas. It includes promoting healthier diets to control BMI level, encouraging regular physical activity, early detection through health check-ups, tailored awareness campaigns, improving healthcare access in rural regions, stress management in urban areas, community involvement, healthcare professional training, policy advocacy like sugary drink taxation, research, and monitoring interventions. These measures collectively address the T2D challenge while accommodating the distinct features of urban and rural settings.

Family Involvement to Stop the Conversion of Prediabetes to Diabetes

Prediabetes is a condition associated with an increased risk of developing diabetes, in which blood glucose levels are high but not high enough to be diagnosed as diabetes. The rapid increase in the prevalence of prediabetes is a major global health challenge. The incidence of prediabetes has increased to pandemic levels and can lead to serious consequences. Unfortunately, nearly 90% of prediabetic individuals are unaware of their ailment. A quarter of prediabetic individuals develop type 2 diabetes mellitus (T2DM) within 3-5 years. Although prediabetes is a reversible condition, the prevention of diabetes has received little attention. It is essential for prediabetic individuals to implement new health-improvement techniques. Focusing on family systems is one strategy to promote health, which is determined by health patterns that are often taught, established, and adjusted within family contexts. For disease prevention, a family-based approach may be beneficial. Family support is essential for the metabolic control of the disease. This study aimed to show several strategies for involving the patient's family members in preventing the conversion of prediabetes to T2DM and to emphasize that the patient's family members are a valuable resource to reduce the incidence of diabetes.

Glycaemic control and avenues for improvement among people with type 2 diabetes mellitus from rural Sri Lanka - a retrospective cohort study

Background

The majority of Sri Lankans and South Asians are rural dwellers but follow-up data on glycaemic control and its associations in rural communities are sparse. We followed up a cohort of hospital-based rural Sri Lankans with diabetes from diagnosis up to 24-months.

Methods

We conducted a retrospective cohort study of people with type-2 diabetes (T2DM) diagnosed 24 months before enrolment who were being followed up at Medical/Endocrine clinics of five hospitals selected by stratified random sampling in Anuradhapura, a rural district of Sri Lanka from June 2018 to May 2019 and retrospectively followed them up to the diagnosis of the disease. Prescription practices, cardiovascular risk factor control and their correlates were studied using self-administered and interviewer-administered questionnaires and perusing medical records. Data were analysed using SPSS version-22.

Findings

A total of 421 participants [mean age 58.3 ± 10.4 years, female 340 (80.8%)] were included in the study. Most participants were started on anti-diabetic medications in addition to lifestyle measures. Of them, 270 (64.1%) admitted poor dietary-control, 254 (60.3%) inadequate medication-compliance and 227 (53.9%) physical inactivity. Glycaemic control was assessed mainly on fasting plasma glucose (FPG) and glycated haemoglobin (HbA1c) data were available in only 44 (10.4%). Target achievements in FPG, blood pressure, body mass index and non-smoking at 24-months following initiation of treatment were 231/421 (54.9%), 262/365 (71.7%), 74/421 (17.6%) and 396/421 (94.1%) respectively.

Interpretation

In this cohort of rural Sri Lankans with type-2 diabetes mellitus, all were started on anti-diabetic medications at the diagnosis, but glycaemic target achievement was inadequate at 24 months. We identified the major patient-related reasons for poor blood glucose control were poor compliance with diet/lifestyle and/or medications and misconceptions about antidiabetic medications.

Funding

None.

Epidemiological profile and diabetes control of Type 1 Diabetes Mellitus patients in Karbala Governorate, Iraq

Background: Type1 Diabetes Mellitus is a common chronic diseases among children, and associated with morbidity, mortality, and enormous healthcare expenditures. Objectives; to estimate the prevalence, incidence, and describe the epidemiological characteristics of Type 1 Diabetes Mellitus among children in Karbala governorate. Methods: A cross-sectional study was conducted among all children who attended the main DM center in Karbala Teaching Hospital for Children, Public Clinics, and Primary Health Care centers. Data was collected by structured questionnaire and biochemical and anthropometric measurements. The statistical analysis data entry was conducted using Statistical Package for Social Sciences. Results: Total number of Type 1 Diabetes Mellitus patients aged 0-15 years in Karbala in 2015 was 199; making 44.66/100 5. Fifty-four patients were newly diagnosed patients making an incidence of 12.11/100 5. There was nearly equal distribution among both sexes. Most of the cases were from urban areas and most of the patients had a Family history of Type 2 Diabetes Mellitus. Diabetic ketoacidosis was reported in 16.8% of the patients. Only 31.6% of patients had HbA1c < 7%. Half of the patients had a history of admission to the hospital for diabetes. Logistic regression analysis revealed that the only independent variables significantly correlated with poor glycemic control were lack of Self-Monitoring Blood Glucose, irregular visits to the Diabetic Center, and positive family history of diabetes. Conclusion: Only one-third of T1DM children in Karbala city had controlled blood sugar. Lack of regular blood glucose monitoring and irregular contact with health care providers were the main determinants of uncontrolled blood sugar.

Effects of meditation on physiological and metabolic parameters in patients with type 2 diabetes mellitus "MindDM": study protocol for a randomized controlled trial

BACKGROUND

Sri Lanka is faced with the challenge of managing a large population with diabetes mellitus by 2030. Psychological stress plays a major role in disease outcome by exerting physiological, psychological and social effects on individuals with chronic disorders. Meditation-based interventions have positive effects on the management of stress and diabetes, which are mediated via modulation of neuro-humoral mechanisms and autonomic functions, among others. Mechanisms of bio-physiological effects of meditation are considered to be through reduction of stress hormones, improvement of insulin resistance and improvement of autonomic dysfunction.

METHODS

This study will be conducted as an open-label, randomized controlled clinical trial in the Faculty of Medicine, University of Colombo. The aim is to investigate the effects of meditation on glycaemic control and possible mechanisms of how meditation affects glycaemic control in patients with type 2 diabetes. The study was approved by the Ethics Review Committee of the Faculty of Medicine, University of Colombo (ERC/2019/094). Patients who are attending the professorial unit medical clinic with type 2 diabetes (172 in total) will be recruited based on inclusion-exclusion criteria. Patients who have never meditated or rarely meditated (less than once every three months) will be randomized using block randomization to meditation and waitlisted arms (1:1 allocation ratio). The meditation arm will undergo a mindfulness meditation program (selected after studying several meditation methods) conducted by a qualified instructor weekly for a period of 12 weeks in addition to usual care, while the waitlisted arm will only receive usual care. Daily meditation practices will be recorded in a diary. The primary outcome measure is HbA1c. Secondary outcome measures are fasting blood sugar, fructosamine, insulin resistance (calculated using fasting serum insulin), 24-h urinary cortisol, body mass index, cardiac autonomic reflex testing (Ewing's battery of tests) and orocecal transit time using hydrogen breath analysis. All these will be done prior to commencement of the intervention and after 3 months in both arms. Data will be analysed using SPSS V-23.

DISCUSSION

This study aims to identify the effect of mindfulness meditation on glycaemic control and the possible mechanisms (neuro humoral and autonomic functions) by which beneficial effects are mediated.

TRIAL REGISTRATION

Registered under Sri Lanka Clinical Trial Registry: SLCTR/2021/015 The Universal Trial Number (UTN) U1111-1266-8640.

Health-related quality of life and associated factors among type 2 diabetic adult patients in Debre Markos Referral Hospital, Northwest Ethiopia

Health-related quality of life (HRQOL) is a multifaceted concept that is strongly impacted by Type II diabetes in developing countries. The majority of studies indicate diabetes mellitus prevalence without looking at people's quality of life.

This study was conducted using an Institution-based cross-sectional design in Debre Markos Referral Hospital from March 03 to March 31, 2020. We evaluated HRQOL using the WHO quality of life BREF and data were obtained through face-to-face interviews. We used a systematic random sampling technique to select study participants. Data were entered into Epi data version 3.1 and exported to STATA version 14.0. Candidates for multivariable analysis were variables with a P-value less than 0.25 in the bivariable analysis and P-value less than 0.05 were considered to declare a statistically significant association. The final model was tested for its goodness of fit using Hosmer and Lemeshow's statistics.

The analysis included a total of 368 adult individuals with type II diabetes and 206 (56%) had a good HRQOL. Being male (AOR = 4.28, 95%CI:2.36, 7.78), having duration of disease of more than 59 months (AOR = 2.93, 95%CI:1.61, 5.34), doing a physical exercise (AOR = 2.33,95%CI:1.34, 4.05) and got counseling (AOR = 3.33; 95%CI:1.82, 5.94) were directly associated with good HRQOL whereas the presence of diabetic complications (AOR = 0.46, 95%CI:0.26, 0.80), comorbidity (AOR = 0.45; 95%CI:0.25, 0.84) and drinking alcohol (AOR = 0.27, 95%CI:0.16, 0.48) had an inverse relationship with good HRQOL.

More than half of type 2 diabetic adult patients had a good HRQOL. Being male, drinking alcohol, getting counseling, doing physical exercise, absence of diabetic complications, and comorbidity and long duration of disease were predictors of good HRQOL. Therefore, avoiding drinking alcohol and promoting physical exercise and counseling should be encouraged.

Reviewing physical exercise in non-obese diabetic Goto-Kakizaki rats

There is a high incidence of non-obese type 2 diabetes mellitus (non-obese-T2DM) cases, particularly in Asian countries, for which the pathogenesis remains mainly unclear. Interestingly, Goto-Kakizaki (GK) rats spontaneously develop insulin resistance (IR) and non-obese-T2DM, making them a lean diabetes model. Physical exercise is a non-pharmacological therapeutic approach to reduce adipose tissue mass, improving peripheral IR, glycemic control, and quality of life in obese animals or humans with T2DM. In this narrative review, we selected and analyzed the published literature on the effects of physical exercise on the metabolic features associated with non-obese-T2DM. Only randomized controlled trials with regular physical exercise training, freely executed physical activity, or skeletal muscle stimulation protocols in GK rats published after 2008 were included. The results indicated that exercise reduces plasma insulin levels, increases skeletal muscle glycogen content, improves exercise tolerance, protects renal and myocardial function, and enhances blood oxygen flow in GK rats.

Awareness, Treatment, and Control of Diabetes in Bangladesh: Evidence from the Bangladesh Demographic and Health Survey 2017/18

BACKGROUND

The prevalence of diabetes is increasing in Bangladesh from ∼5% in 2001 to ∼13% in 2017/18 (∼8.4 million cases). The prevalence of undiagnosed diabetes was also found to be higher at 6% in 2017/18. However, very little is known about the management of diabetes assessed by diabetes awareness, treatment, and control. We aimed to estimate the age-standardised prevalence of awareness, treatment, and control of diabetes and its associated factors.

METHODS

Cross-sectional data from 1,174 Bangladeshi adults aged 18 years and older available from the most recent nationally representative Bangladesh Demographic and Health Survey (BDHS) 2017-18 were analysed. Outcomes were age-standardised prevalence of awareness, treatment, and control of diabetes, estimated using the direct standardisation. Multilevel mixed-effects Poisson regression models were used to identify factors associated with awareness, treatment, and control of diabetes.

RESULTS

Of the respondents we analysed, 30.9% (95% CI, 28.2-33.6) were aware that they had the condition, and 28.2% (95% CI, 25.6-30.7) were receiving treatment. Among those treated for diabetes, 26.5% (95% CI, 19.5-33.5) had controlled diabetes. The prevalence of diabetes awareness, treatment, and control was lower in men than women. Factors positively associated with awareness and treatment were increasing age and hypertension, while factors negatively associated with awareness and treatment were being men and lower education. Factors associated with poor control were secondary education and residing in Rajshahi and Rangpur divisions.

CONCLUSIONS

This study provides evidence of poor management of diabetes in Bangladesh, especially in men. Less than one-third of the people with diabetes were aware of their condition. Just over one-fourth of the people with diabetes were on treatment, and among those who were treated only one-fourth had controlled diabetes. Interventions targeting younger people, in particular men and those with lower education, are urgently needed. Government policies that address structural factors including the cost of diabetes care and that strengthen diabetes management programmes within primary healthcare in Bangladesh are urgently needed.

Diabetes and Renin-Angiotensin-Aldosterone System: Pathophysiology and Genetics

Diabetes mellitus (DM) is a metabolic disorder and characterized by hyperglycemia. Being a concern of both the developed and developing world, diabetes is a global health burden and is a major cause of mortality world-wide. The most common is the type 2 diabetes mellitus (T2DM), which is mainly caused by resistance to insulin. Long-term complications of diabetes cause microvascular related problems (eg. nephropathy, neuropathy and retinopathy) along with macrovascular complications (eg. cardiovascular diseases, ischemic heart disease, peripheral vascular disease). Renin-angiotensin-aldosterone system (RAAS) regulates homeostasis of body fluid that in turn, maintains blood pressure. Thus, RAAS plays pivotal role in the pathogenesis of long-term DM complications like cardiovascular diseases and chronic kidney diseases. T2DM is a polygenic disease, and the roles of RAAS components in insulin signaling pathway and insulin resistance have been well documented. Hyperglycemia has been found to be associated with the increased plasma renin activity, arterial pressure and renal vascular resistance. Several studies have reported involvement of single variants within particular genes in initiation and development of T2D using different approaches. This chapter aims to investigate and discuss potential genetic polymorphisms underlying T2D identified through candidate gene studies, genetic linkage studies, genome wide association studies.

Relationship of Homocysteine With Gender, Blood Pressure, Body Mass Index, Hemoglobin A1c, and the Duration of Diabetes Mellitus Type 2

Introduction Increased levels of homocysteine (Hcy) may lead to endothelial damage and increase the risk of cardiovascular and renal malfunction. The current study aimed to evaluate the association of serum Hcy levels with gender, body mass index (BMI), duration of diabetes mellitus type 2 (DMT2), hemoglobin A1c (HbA1c), and blood pressure (BP).  Methodology  A prospective observational study was conducted at Hayatabad Medical Complex in Peshawar, Pakistan in the department of endocrinology from June 2020 to June 2021. All patients with diagnosed DMT2 above the age of 18 years were included in the study. Individuals with unconfirmed diagnoses with ages over 75 years were excluded from the study. All data including the patient's age, gender, and medical history were recorded. Height and weight were used to calculate the BMI. BP was examined thrice and a mean value was recorded for each patient. For laboratory investigation, a vial of 3 ml blood was extracted keeping sterile and aseptic conditions by a trained nurse. The sample was sent for the determination of HbA1c and serum Hcy levels. Measurement of serum Hcy was done by chemiluminescent microparticle immunoassay. All data were documented by the researchers on a predefined pro forma.  Results A total of 188 patients with DMT2 were included in the study with a mean age ± SD of 54.65 ± 8.42 years. Normal (<15 micromoles per liter [mcmol/l]) serum Hcy levels were reported in 75 (39.89%) individuals, while in 47 (41.59%) individuals, there was severe (>100 mcmol/l) hyperhomocysteinemia. More than half of the patients, i.e. 157 (83.52%), had HbA1c of greater than 7%, which indicated poor glycemic control. The study revealed that the majority of the female patients, i.e. 37 (78.72%), had severe hyperhomocysteinemia (p<0.0001). Similarly, there was a direct correlation between HbA1c levels and serum Hcy. Severe hyperhomocysteinemia was found in over 80% of the patients with poor glycemic control, i.e. HbA1c >7% (p<0.0001). Furthermore, the duration of DMT2 and hypertension were both significantly associated with increased levels of Hcy with p-values of <0.0001 and <0.0001, respectively. However, no association was found between hyperhomocysteinemia and BMI.  Conclusion The study revealed that increased levels of serum Hcy were associated with female gender, poor glycemic control (HbA1c >7%), BP, and duration of DMT2. However, the study failed to find an association between serum Hcy and BMI. It is recommended that patients with poor glycemic control or those with the duration of DMT2 of more than five years must be regularly checked for hyperhomocysteinemia and renal function tests.  Large-scale and multi-center studies are required in order to determine the validity of these findings. The current study suggests that patients with diabetes mellitus and hypertension are likely to have increased levels of Hcy and, therefore, must be regularly screened for hyperhomocysteinemia.

Core health-components, contextual factors and program elements of community-based interventions in Southeast Asia - a realist synthesis regarding hypertension and diabetes

Background

In Southeast Asia, diabetes and hypertension are on the rise and have become major causes of death. Community-based interventions can achieve the required behavioural change for better prevention. The aims of this review are 1) to assess the core health-components of community-based interventions and 2) to assess which contextual factors and program elements affect their impact in Southeast Asia.

Methods

A realist review was conducted, combining empirical evidence with theoretical understanding. Documents published between 2009 and 2019 were systematically searched in PubMed/Medline, Web of Science, Cochrane Library, Google Scholar and PsycINFO and local databases. Documents were included if they reported on community-based interventions aimed at hypertension and/or diabetes in Southeast Asian context; and had a health-related outcome; and/or described contextual factors and/or program elements.

Results

We retrieved 67 scientific documents and 12 grey literature documents. We identified twelve core health-components: community health workers, family support, educational activities, comprehensive programs, physical exercise, telehealth, peer support, empowerment, activities to achieve self-efficacy, lifestyle advice, activities aimed at establishing trust, and storytelling. In addition, we found ten contextual factors and program elements that may affect the impact: implementation problems, organized in groups, cultural sensitivity, synergy, access, family health/worker support, gender, involvement of stakeholders, and referral and education services when giving lifestyle advice.

Conclusions

We identified a considerable number of core health-components, contextual influences and program elements of community-based interventions to improve diabetes and hypertension prevention. The main innovative outcomes were, that telehealth can substitute primary healthcare in rural areas, storytelling is a useful context-adaptable component, and comprehensive interventions can improve health-related outcomes. This extends the understanding of promising core health-components, including which elements and in what Southeast Asian context.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11244-3.

Treatment regimens and glycosylated hemoglobin levels in youth with Type 1 and Type 2 diabetes: Data from SEARCH (United States) and YDR (India) registries

OBJECTIVE

To compare treatment regimens and glycosylated hemoglobin (A1c) levels in Type 1 (T1D) and Type 2 diabetes (T2D) using diabetes registries from two countries-U.S. SEARCH for Diabetes in Youth (SEARCH) and Indian Registry of youth onset diabetes in India (YDR).

METHODS

The SEARCH and YDR data were harmonized to the structure and terminology in the Observational Medical Outcomes Partnership Common Data Model. Data used were from T1D and T2D youth diagnosed <20 years between 2006-2012 for YDR, and 2006, 2008, and 2012 for SEARCH. We compared treatment regimens and A1c levels across the two registries.

RESULTS

There were 4003 T1D (SEARCH = 1899; YDR = 2104) and 611 T2D (SEARCH = 384; YDR = 227) youth. The mean A1c was higher in YDR compared to SEARCH (T1D:11.0% ± 2.9% vs 7.8% ± 1.7%, P < .001; T2D:9.9% ± 2.8% vs 7.2% ± 2.1%, P < .001). Among T1D youth in SEARCH, 65.1% were on a basal/bolus regimen, whereas in YDR, 52.8% were on once/twice daily insulin regimen. Pumps were used by 16.2% of SEARCH and 1.5% of YDR youth with T1D. Among T2D youth, in SEARCH and YDR, a majority were on metformin only (43.0% vs 30.0%), followed by insulin + any oral hypoglycemic agents (26.3% vs 13.7%) and insulin only (12.8% vs 18.9%), respectively.

CONCLUSION

We found significant differences between SEARCH and YDR in treatment patterns in T1D and T2D. A1c levels were higher in YDR than SEARCH youth, for both T1D and T2D, irrespective of the regimens used. Efforts to achieve better glycemic control for youth are urgently needed to reduce the risk of long-term complications.

Diabetes Mellitus and Renal Function: Current Medical Research and Opinion

Diabetes mellitus (DM), which is defined as high blood glucose level, is a major public health issue worldwide. An enormous amount of data has been gathered regarding DM as populations have been living with it for more than a decade; however, continually updating our knowledge of DM remains important. Comorbidities are among the major challenges associated with DM. Poorly controlled DM, especially type 2 DM (T2DM), is considered a risk factor for many diseases, including but not limited to chronic kidney disease (CKD). Complications might appear over time as the aging process changes body functions; moreover, a significant number of antidiabetic medications are eventually cleared by the kidneys, thereby increasing the burden on kidney function and placing diabetic patients at risk. The significantly high number of patients with uncontrolled diabetes resulting from kidney disease shows the impact of this condition on the quality of life of patients. This review presents an overview of the pathophysiology, etiology, and prevalence of CKD and abnormal renal parameters correlated with poorly controlled T2DM, with an emphasis on clinical studies involving the association between vitamin D insufficiency/deficiency and CKD among patients with T2DM.

The Effect of Surrounding Greenness on Type 2 Diabetes Mellitus: A Nationwide Population-Based Cohort in Taiwan

This study determines whether surrounding greenness is associated with the incidence of type 2 diabetes Mellitus (T2DM) in Taiwan. A retrospective cohort study determines the relationship between surrounding greenness and the incidence of T2DM during the study period of 2001–2012 using data from the National Health Insurance Research Database. The satellite-derived normalized difference vegetation index (NDVI) from the global MODIS database in the NASA Earth Observing System is used to assess greenness. Cox proportional hazard models are used to determine the relationship between exposure to surrounding greenness and the incidence of T2DM, with adjustment for potential confounders. A total of 429,504 subjects, including 40,479 subjects who developed T2DM, were identified during the study period. There is an inverse relationship between exposure to surrounding greenness and the incidence of T2DM after adjustment for individual-level covariates, comorbidities, and the region-level covariates (adjusted HR = 0.81, 95% CI: 0.79–0.82). For the general population of Taiwan, greater exposure to surrounding greenness is associated with a lower incidence of T2DM.

A High Prevalence of Vitamin D Deficiency Observed in an Irish South East Asian Population: A Cross-Sectional Observation Study

At northern latitudes, non-ethnic population groups can be at an increased risk of vitamin D deficiency (defined as a 25-hydroxyvitamin D [25(OH)D] status ≤30 nmol/L). The vitamin D status of ethnic minority groups has been examined both in UK and European populations, but not in the Irish context. The aim of this study is to assess the vitamin D status from a selection of the Dublin population of South East Asian descent. A search was conducted, using the laboratory information system of St James's Hospital, Dublin, for vitamin D requests by General practitioners. From 2013 to 2016, 186 participants were identified and 25(OH)D analysis was quantified using liquid chromatography-tandem mass spectrometry (LC-MS-MS). Overall, the median age was 32 years, 51% were male, and the 25(OH)D concentration ranged from 10 to 154 nmol/L. In total, 66.7% of the total sample were vitamin D deficient and 6.7% had a 25(OH)D status greater than 50 nmol/L (the 25(OH)D concentration defined by the EU as 'sufficient'). Females had a significantly higher 25(OH)D concentration than males (25.0 vs. 18.0 nmol/L; p = 0.001) but both groups had a significant proportion with deficient status (56% and 76.8%, respectively). Seasonal variation of 25(OH)D was not evident while high rates of deficiency were also observed in those aged <18 years and >50 years. Given the importance of vitamin D for health, this sub-population could be at a significantly increased risk of rickets, impaired bone metabolism, and osteoporosis. In addition, vitamin D deficiency has been associated with several non-bone related conditions, including cardiovascular disease and diabetes. Currently, there is no unique vitamin D intake or vitamin D status maintenance guidelines recommended for adults of non-Irish descent; this needs to be considered by the relevant public health bodies in Ireland.

Remote Peer Learning Between US and Cambodian Lay Health Workers to Improve Outcomes for Cambodians with Type 2 Diabetes: a Pilot Study

BACKGROUND

This paper reports a single-group, pre-post pilot of a peer-learning intervention between community health workers (CHWs) in the USA and Village Health Support Guides (Guides) in Cambodia to improve outcomes for Cambodians with type 2 diabetes (T2D).

METHOD

Two US-based CHWs were trained in a culturally derived cardiometabolic education curriculum called Eat, Walk, Sleep (EWS) and they were also trained in principles of peer learning. They in turn trained five Cambodia-based Guides remotely through videoconference with a phablet in EWS. Finally, Cambodia-based Guides met with 58 patients with diabetes, face-to-face in their villages, monthly for 6 months to deliver EWS. US-based CHWs and Cambodia-based Guides responded to surveys at baseline and post-treatment. Patients responded to surveys and provided blood pressure and blood samples at baseline and post-treatment.

RESULTS

For US-based CHWs, scores on all surveys of diabetes knowledge, self-evaluation, job satisfaction, and information technology improved, though no statistical tests were run due to sample size. For Cambodia-based Guides, all scores on these same measures improved except for job satisfaction. For patients, n = 60 consented, 2 withdrew, and 7 were lost to follow-up leaving n = 51 for analysis. In paired t tests, patients showed significantly decreased A1c, decreased systolic and diastolic blood pressures, improved attitudes toward medicines, and a trend for switching from all-white to part-brown rice. No changes were detected in self-reported physical activity, medication adherence, sleep quality, or frequency or amount of rice consumed.

CONCLUSION

If proven effective in a controlled trial, cross-country peer learning could eventually help other diaspora communities.

Trend in the clinical profile of type 2 diabetes in India - Study from a diabetes care centre in South India

BACKGROUND AND AIM

Study the changing clinical and therapeutic profiles of type 2 diabetes (T2D) patients during a 10-year period in a diabetes care centre in Southern India.

METHODS

Retrospective, cross-sectional data of newly registered and review patients at four periods between 2009 and 2018 were analysed (n = 50,322). Clinical findings, anthropometry, blood pressure (BP), glycaemia, lipids, treatment, and co-morbid conditions were analysed. We studied the trends in age and gender distributions, body mass index (BMI), glycaemia, (Glycosylated haemoglobin A1c (HbA1c) levels), BP, cholesterol, triglycerides and therapeutic regimen during this period. Trend analyses were done.

RESULTS

Approximately 60% of patients were men. Percentages in 30-40 years increased, ∼60% were aged 50-69 years and proportion of older patients decreased (p < 0.0001). In 10 years, 85.9% was overweight, obesity increased from 22.1% to 25.0% (p < 0.0001) and <13% maintained normal BMI. HbA1c <7.0% remained approximately at 22%, percentage with moderate glycaemic control (HbA1c 7.0-7.9%) increased significantly, HbA1c of ≥9.0% decreased from 35.1% to 29.1% (p < 0.0001). Use of monotherapy decreased. Prevalence of hypertension increased from 16.2% to 21.6% (p < 0.0001); use of Angiotensin Receptor Blockers (ARB) and calcium channel blockers increased, Angiotensin Converting Enzyme Inhibitors and thiazides decreased (p < 0.0001). Increased use of statins paralleled with reduction in total cholesterol and LDLc.

CONCLUSION

Increasing percentages of younger patients and obesity, use of multiple drugs and reduction in HbA1c were the important observations. Rising prevalence of hypertension, increased use of ARB and statins with better control of dyslipidaemia was observed. Achievement of ideal HbA1c and BP were suboptimal.

Effectiveness of Buerger-Allen Exercise on Lower Extremity Perfusion and Peripheral Neuropathy Symptoms among Patients with Diabetes Mellitus

Background:

Buerger-Allen Exercise (BAE) promote Lower Extremity Perfusion (LEP) via the wound healing process and reduce Peripheral Neuropathy Symptoms (PNS) among Diabetes Mellitus (DM) patients. We study the efficacy of BAE on LEP and PNS among patients with DM.

Materials and Methods:

This quasi-experimental study was conducted prospectively from July to October 2017. Fifty DM patients between the ages of 30 and 75 from both genders were selected using a purposive sampling technique and were assessed for LEP with a manual Ankle-Brachial Index (ABI) scale and assessed for PNS with Michigan Neuropathy Screening Instrument (MNSI). The BAE was demonstrated for 4 consecutive days. The intervention was repeated five times per day for each patient and the posttest was conducted 5^th day using the same tools.

Results:

The majority (n = 75, 75%) were 60–69 age group and 98% had education till primary school. 62% had diabetes and 20% of them had a history of peripheral arterial disease. 50% of participants had mildly impaired perfusion during pretest whereas abnormal neuropathy was seen in more than 70% cases which decreased posttest. A significant difference in PNS was seen after the implementation of BAE in both right LEP (t₄₈ = 6.81, p < 0.001) and left LEP t₄₈= 5.21, p < 0.001).

Conclusions:

BAE has to be taught to the patients with DM in improving the level of LEP and can be encouraged to practice in the hospital and home care setup.

Prevalence of diabetes and pre-diabetes in Bangladesh: a systematic review and meta-analysis

OBJECTIVE

The purpose of this paper is to perform a systematic review and meta-analysis in order to summarise the prevalence of diabetes and pre-diabetes and their associated risk factors in Bangladesh.

DESIGN

Systematic review and meta-analysis.

PARTICIPANTS

General population of Bangladesh.

DATA SOURCES

PubMed, Medline, Embase, Bangladesh Journals Online, Science Direct, Scopus, Cochrane Library and Web of Science were used to search for studies, published between 1st of January 1995 and 31st of August 2019, on the prevalence of diabetes and pre-diabetes and their associated risk factors in Bangladesh. Only articles published in the English language articles were considered. Two authors independently selected studies. The quality of the articles was also assessed.

RESULTS

Out of 996 potentially relevant studies, 26 population-based studies, which together involved a total of 80 775 individuals, were included in the meta-analysis. The pooled prevalence of diabetes in the general population was 7.8% (95% CI: 6.4-9.3). In a sample of 56 452 individuals, the pooled prevalence of pre-diabetes was 10.1% (95% CI: 6.7-14.0; 17 studies). The univariable meta-regression analyses showed that the prevalence of diabetes is associated with the factors: the year of study, age of patients and presence of hypertension. The prevalence of diabetes was significantly higher in urban areas compared with rural areas, while there was no significant gender difference.

CONCLUSIONS

This meta-analysis suggests a relatively high prevalence of pre-diabetes and diabetes in Bangladesh, with a significant difference between rural and urban areas. The main factors of diabetes include urbanisation, increasing age, hypertension and time period. Further research is needed to identify strategies for early detecting, prevention and treatment of people with diabetes in the population.

PROSPERO REGISTRATION NUMBER

CRD42019148205.

Effect of linagliptin, a dipeptidyl peptidase-4 inhibitor, compared with the sulfonylurea glimepiride on cardiovascular outcomes in Asians with type 2 diabetes: subgroup analysis of the randomized CAROLINA® trial

Objective

Linagliptin, a dipeptidyl peptidase-4 inhibitor, recently demonstrated cardiovascular (CV) safety versus placebo in Asians with advanced type 2 diabetes mellitus (T2DM) in the CARMELINA^® trial. We assessed its CV safety compared with the sulfonylurea glimepiride in Asians with relatively early T2DM in the CAROLINA^® trial.

Methods

Based on prespecified and post hoc subgroup analyses of the multinational CAROLINA^® trial in which adults with relatively early T2DM and elevated CV risk were randomized to linagliptin or glimepiride added to usual care, we analyzed data for participants from Asian countries. This included the primary outcome defined as time to first CV death, non-fatal myocardial infarction, or non-fatal stroke [three-point major adverse cardiovascular events (3P-MACE)].

Results

Of the 6033 participants, 933 (15.5%) were from Asia. During a median follow-up of 6.2 years, 3P-MACE occurred in 9.5% and 11.1% of the linagliptin and glimepiride groups, respectively (hazard ratio [HR] 0.85; 95% confidence interval [CI] 0.57-1.26]), consistent with the overall population (HR 0.98; 95% CI 0.84-1.13; P = 0.17 for treatment by region interaction). Similarly, there were no significant differences between groups for other outcomes, including CV death (HR 0.73; 95% CI 0.38-1.38), non-CV mortality (HR 0.76; 95% CI 0.37-1.57) and hospitalization for heart failure (HR 0.89; 95% CI 0.36-2.19). Hypoglycemia adverse events occurred in 13.1% of linagliptin patients versus 42.1% of glimepiride patients (HR 0.25; 95% CI 0.19-0.33; P < 0.0001) despite similar glycemic control. Body weight was slightly lower with linagliptin relative to glimepiride: weighted average mean difference over 256 weeks of - 1.82 kg (95% CI - 2.28 to - 1.35).

Conclusions

In Asian patients, linagliptin demonstrated similar CV safety to glimepiride with a markedly lower rate of hypoglycemia and modestly lower weight.

Linagliptin and cardiorenal outcomes in Asians with type 2 diabetes mellitus and established cardiovascular and/or kidney disease: subgroup analysis of the randomized CARMELINA® trial

Objective

Linagliptin, a dipeptidyl peptidase-4 inhibitor, demonstrated cardiovascular and renal safety in type 2 diabetes mellitus (T2DM) patients with established cardiovascular disease (CVD) with albuminuria and/or kidney disease in the multinational CARMELINA^® trial. We investigated the effects of linagliptin in Asian patients in CARMELINA^®.

Methods

T2DM patients with HbA1c 6.5-10.0% and established CVD with urinary albumin-to-creatinine ratio (UACR) > 30 mg/g, and/or prevalent kidney disease (estimated glomerular filtration rate [eGFR] 15-< 45 ml/min/1.73 m² or ≥ 45-75 with UACR > 200 mg/g), were randomized to linagliptin or placebo added to usual care. The primary endpoint was time to first occurrence of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke (3-point MACE).

Results

Of the 6979 patients, 555 (8.0%) were Asians living in Asia. During a median follow-up of 2.2 years, 3-point MACE occurred in 29/272 (10.7%) and 33/283 (11.7%) of linagliptin and placebo patients, respectively (hazard ratio [HR] 0.90; 95% confidence interval [CI] 0.55-1.48), consistent with the overall population (HR 1.02; 95% CI 0.89-1.17; P value for treatment-by-region interaction: 0.3349). Similar neutrality in Asian patients was seen for other cardiorenal events including the secondary kidney endpoint of death from renal failure, progression to end-stage kidney disease, or ≥ 40% eGFR decrease (HR 0.96; 95% CI 0.58-1.59). Linagliptin was associated with a nominal decrease in the risk of hospitalization for heart failure (HR 0.47; 95% CI 0.24-0.95). Overall in Asian patients, linagliptin had an adverse event rate similar to placebo, consistent with the overall population.

Conclusions

Linagliptin showed cardiovascular and renal safety in Asian patients with T2DM and established CVD with albuminuria and/or kidney disease.

From Pre-Diabetes to Diabetes: Diagnosis, Treatments and Translational Research

Diabetes, a silent killer, is one of the most widely prevalent conditions of the present time. According to the 2017 International Diabetes Federation (IDF) statistics, the global prevalence of diabetes among the age group of 20-79 years is 8.8%. In addition, 1 in every 2 persons is unaware of the condition. This unawareness and ignorance lead to further complications. Pre-diabetes is the preceding condition of diabetes, and in most of the cases, this ultimately leads to the development of diabetes. Diabetes can be classified into three types, namely type 1 diabetes, type 2 diabetes mellitus (T2DM) and gestational diabetes. The diagnosis of both pre-diabetes and diabetes is based on glucose criteria; the common modalities used are fasting plasma glucose (FPG) test and oral glucose tolerance test (OGTT). A glucometer is commonly used by diabetic patients to measure blood glucose levels with fast and rather accurate measurements. A few of the more advanced and minimally invasive modalities include the glucose-sensing patch, SwEatch, eyeglass biosensor, breath analysis, etc. Despite a considerable amount of data being collected and analyzed regarding diabetes, the actual molecular mechanism of developing type 2 diabetes mellitus (T2DM) is still unknown. Both genetic and epigenetic factors are associated with T2DM. The complications of diabetes can predominantly be classified into two categories: microvascular and macrovascular. Retinopathy, nephropathy, and neuropathy are grouped under microvascular complications, whereas stroke, cardiovascular disease, and peripheral artery disease (PAD) belong to macrovascular complications. Unfortunately, until now, no complete cure for diabetes has been found. However, the treatment of pre-diabetes has shown significant success in preventing the further progression of diabetes. To prevent pre-diabetes from developing into T2DM, lifestyle intervention has been found to be very promising. Various aspects of diabetes, including the aforementioned topics, have been reviewed in this paper.

Prevalence and Associations of Subclinical Peripheral Artery Disease among Patients with Type 2 Diabetes without Clinical Macrovascular Disease

Background:

Peripheral arterial disease (PAD) is an important marker of cardiovascular (CV) risk and the risk of PAD is markedly increased in patients with type 2 diabetes mellitus (T2DM). Consequently, early diagnosis and treatment of PAD in patients with T2DM are critically important to reduce the risk of CV events. The aim of this study was to determine the prevalence of asymptomatic PAD in patients with T2DM and to investigate the demographic and clinical associations of PAD among them.

Methods:

This cross-sectional study included 2423 diabetic patients >20 years old, who were regularly followed up at the regional diabetes clinic, Galle, Sri Lanka. Data were obtained using structured questionnaires for information on demographic characteristics and risk factors. Assessment of ankle-brachial pressure index (ABPI) was performed in all. PAD was diagnosed when ABPI was < 0.9 on either leg.

Results:

The overall prevalence of PAD was 15.3% with no significant age or gender difference. Patients with PAD had significantly higher systolic blood pressure (SBP) (127 vs 125 mmHg, P = 0.002) and diastolic blood pressure (DPB) (80 vs 78 mmHg, P = <0.001) and significantly lower estimated glomerular filtration rate (eGFR) (80 vs 84 ml/min, P = 0.007) than those without PAD. No significant relationships were found between the duration of diabetes mellitus, hypertension, dyslipidemia, and PAD.

Conclusions:

Prevalence of PAD was relatively high in the diabetic population of this study when compared with findings from other countries. There is a significant association of subclinical PAD with reduced eGFR among patients with T2DM.

Factors associated with geriatric morbidity and impairment in a megacity of Pakistan

BACKGROUND

The elderly population is increasing globally. In Pakistan, the elderly comprise 6% of the population that is predicted to triple by 2050. Non-communicable diseases are common health problems of the elderly in Pakistan, however, resulting geriatric impairments and disability are unknown. This study was conducted to determine geriatric impairments and identify associated socio-demographic factors and comorbidities among community dwelling elderly in Karachi, Pakistan.

METHODS

A cross-sectional study was conducted during 2013-2014. Community clusters were selected from all sub-districts of Karachi, the largest city of Pakistan. Data was collected from systematically selected households within these clusters from individuals, aged ≥60 years, using standardized questionnaires. Geriatric impairment was assessed through validated questions and tools. We screened for depression, dementia, mobility and functional status. Descriptive statistics were computed for socio-demographic factors. We estimated the prevalence and 95% CI for geriatric impairments and comorbidities.

RESULTS

A total of 1200 community-dwelling elderly participated in this study. More than half (n = 663, 55.3%) were females. The average age of the participants was 68.7 (SD = 7.8) years. Two-thirds suffered from chronic illness and the most common impairments were psychological and cognitive. Females were 2.45 times more at risk of developing three or more geriatric impairments. Participants with no formal education had the highest proportion (43.8%) of geriatric impairments. Participants living with more children were more likely to have three or more impairments.

CONCLUSION

A high burden of non-communicable diseases and associated impairments were identified among elderly in Karachi, Pakistan. High rates of psychological and cognitive impairments require urgent attention for resources and strategic planning in anticipation of a growing geriatric population.

Clinical correlates and pharmacological management of Asian patients with concomitant diabetes mellitus and heart failure

Asia is the center of convergence of the twin epidemics of diabetes mellitus (DM) and heart failure (HF). The regional and ethnic diversity across Asia, along with a high prevalence of a young, lean diabetic phenotype, emphasizes the importance of targeted public health strategies that address the unique needs of Asian patients with DM and HF. This review discusses the epidemiology, clinical correlates, pharmacological management, and outcomes of Asian patients with concomitant DM and HF.

Glycemic Control in Children and Youth With Type 1 Diabetes Mellitus in Saudi Arabia

Objective:

To determine the glycemic control and cardio-metabolic complications of children and adolescents with type 1 diabetes mellitus (T1DM) attending a tertiary care diabetes clinic in Saudi Arabia.

Methods:

We conducted a retrospective cross-sectional study of children and adolescents with T1DM attending King Abdulaziz Medical City-Jeddah from 2010 to 2013. We assessed their glycemic control and diabetes management. Vitamin D status was compared with glycemic control and gender differences.

Results:

We identified 301 subjects (53.5% females); mean age was 13.9 ± 3.8 years. The mean duration of diabetes was 7.7 ± 3.7 years, body mass index (BMI) was 21.1 ± 4.5 kg/m², and hemoglobin A_1c (HbA_1c) was 9.6% ± 1.9% in both genders. There were modest gender-specific differences in Saudi patients with T1DM, with males having more symptoms than females. Mean age at diagnosis of T1DM was slightly younger in males (6.01 ± 3.65 years) than in females (6.33 ± 3.45 years). Education was the most common reason for admission in males (32.9%), whereas diabetic ketoacidosis (DKA) was the most common reason in females (38.8%). Frequency of symptomatic hypoglycemic attacks was relatively higher in males (47.1%) than in females (42.9%). The majority of our patients (83%) were on intensive insulin regimen, having 4 injections or more per day. The remaining (17%) were on conventional insulin therapy. Only 26.2% had satisfactory HbA_1c (⩽8%). The mean level of 25-hydroxyvitamin D was 35.15 ± 15.9 nmol/L and cholesterol was 4.75 ± 1.1 nmol/L. Vitamin D deficiency (25-hydroxyvitamin D ⩽ 37.5 nmol/L) was detected in 63.6% males and 67.7% females. No significant correlation between HbA_1c and vitamin D deficiency was observed.

Conclusions:

Metabolic control among Saudi children with T1DM is less satisfactory compared with other countries. The high prevalence of vitamin D deficiency in this population supports the recommendation of vitamin D supplementation in T1DM subjects. Further studies in a larger cohort are needed to confirm our findings.

Socioeconomic Inequalities of Undiagnosed Diabetes in a Resource-Poor Setting: Insights from the Cross-Sectional Bangladesh Demographic and Health Survey 2011

Diabetes mellitus is rising disproportionately but is not frequently diagnosed until complications appear, which results in adverse health consequences. We estimated the prevalence of undiagnosed diabetes among adult diabetic patients and associated socioeconomic inequalities in Bangladesh. We used nationally representative cross-sectional Bangladesh Demographic and Health Survey (BDHS) 2011 data. Among patients with diabetes, we identified undiagnosed cases as having fasting plasma glucose ≥ 7.0 mmol/L, never having taken prescribed medicine and being told by health professionals. Among 938 patients with diabetes, 53.4% remained undiagnosed. The poorest (75.9%) and rural (59.0%) patients had significantly higher undiagnosed cases than the richest (36.0%) and urban (42.5%), respectively. Multiple logistic regression analysis revealed that the likelihood of being undiagnosed was lower among patients with age ≥ 70 years vs. 35–39 years (adjusted odds ratio (AOR) = 0.35; 95% confidence interval (CI) 0.19, 0.64) and patients with higher education vs. no education (AOR = 0.36; 95% CI 0.21, 0.62). Conversely, a high level of physical activity and being in a poor socioeconomic quintile were associated with a higher risk of remaining undiagnosed for diabetes. The Concentration Index (C) also showed that undiagnosed diabetes was largely distributed among the socioeconomically worse-off group in Bangladesh (C = −0.35). Nationwide diabetes screening programs may reduce this problem in Bangladesh and other similar low-income settings.

Qidong: a crucible for studies on liver cancer etiology and prevention

Qidong (Jiangsu, China) has been of interest to cancer epidemiologists and biologists because, until recently, it was an endemic area for liver cancer, having amongst the highest incidence rates in the world. The establishment of the Qidong Cancer Registry together with the Qidong Liver Cancer Institute in 1972 has charted the patterns of liver cancer incidence and mortality in a stable population throughout a period of enormous economic, social, and environmental changes as well as of improvements in health care delivery. Updated incidence trends in Qidong are described. Notably, the China age-standardized incidence rate for liver cancer has dropped by over 50% in the past several decades. Molecular epidemiologic and genomic deep sequencing studies have affirmed that infection with hepatitis B virus as well as dietary exposure to aflatoxins through contamination of dietary staples such as corn, and to microcystins – blue-green algal toxins found in ditch and pond water – were likely important etiologic factors that account for the high incidence of liver cancer in this region. Public health initiatives to facilitate universal vaccination of newborns against HBV and to improve drinking water sources in this rural area, as well as economic and social mandates serendipitously facilitating dietary diversity, have led to precipitous declines in exposures to these etiologic factors, concomitantly driving substantive declines in the liver cancer incidence seen now in Qidong. In this regard, Qidong serves as a template for the global impact that a package of intervention strategies may exert on cancer burden.

Association of homocysteine with body mass index, blood pressure, HbA1c and duration of diabetes in type 2 diabetics

Objective

To determine the Homocysteine levels in type 2 diabetics and correlate homocysteine with HbA1c levels, BMI, blood pressure and duration of diabetes.

Methods

This cross-sectional study was conducted in Endocrinology Unit of Hayatabad Medical Complex (HMC) Peshawar and Rehman Medical Institute (RMI) Peshawar over a period of six months from July 2015 to December 2015. Data was recorded and analyzed in SPSS v 20. P value of less than 0.05 was taken as significant. Bivariate Pearson's correlation test was used to see the relationship between homocysteine and BMI, systolic BP and duration of diabetes.

Results

One hundred twenty five patients were included in our study in which female were 68% and 32% were male with mean age of 51.45 ±8.37 years. Mean BMI expressed in kg/m² was 28.71±4.76, mean systolic blood pressure was 130±20.98 mmHg, mean diastolic blood pressure was 83.36±11.28 mmHg and mean duration of diabetes was 7.018± 6.18 years. Significant correlation was found between systolic blood pressure (r: 0.239, p: 0.007) and duration of diabetes with homocysteine (r: 0.302, p: 0.001). The correlation of homocysteine with HbA1c and BMI was not significant.

Conclusion

Systolic blood pressure and duration of diabetes showed a significant positive correlation with homocysteine. The correlation of homocysteine with HbA1c was not certain from researcher's point of view and further studies of larger sample size and longer duration must be conducted to ascertain the association between the two variables.

Association of Self-Reported Dietary and Drug Compliance with Optimal Metabolic Control in Patients with Type 2 Diabetes: Clinic-Based Single-Center Study in a Developing Country

Introduction

Influence of dietary and drug compliance of patients with diabetes on attainment of optimal metabolic (glucose and lipid) control remains underexplored in developing countries.

Materials and methods

Self-reported dietary and drug compliance score of 0–10, glycosylated hemoglobin (HbA1c), and low-density lipoprotein (LDL) levels were obtained from patients with diabetes. HbA1c <7% and LDL <100 mg/dL were used to define optimal glucose and lipid control, respectively. Proportions achieving each and both optimal parameters were estimated. Regression analysis was used to study the association of age, gender, age of onset and the duration of diabetes, self-reported dietary, and drug compliance scores with achievement of both parameters.

Results

Mean (SD) age and duration of diabetes of 207 patients were 55 (10) and 10 (03) years. Optimal glucose and LDL control were achieved by 30% and 62%, and 23% had achieved both. Regression analysis revealed significant association of self-reported high dietary compliance with achievement of both targets.

Conclusions

Findings highlight the suboptimal glucose and lipid control among patients with diabetes. Significant association of better dietary compliance with control of both parameters emphasizes the value of proper dietary adherence in achieving the optimal metabolic control among patients with diabetes.

Type 1 Diabetes Mellitus in Saudi Arabia: A Soaring Epidemic

Type 1 diabetes mellitus (T1DM) is quite prevalent in the world, with a proportion of 1 in every 300 persons and steadily rising frequency of incidence of about 3% every year. More alarmingly, the incidence of T1DM among infants is also increasing, with children as young as 6 months succumbing to it, instead of that at a rather established vulnerable age of around seven and near puberty, when the hormones antagonize the action of insulin. These reports pose a unique challenge of developing efficient T1DM management system for the young children. The Kingdom of Saudi Arabia (KSA) is the largest country in the Middle East that occupies approximately four-fifths of the Arabian Peninsula supporting a population of more than 33.3 million people, of whom 26% are under the age of 14 years. As per the Diabetes Atlas (8th edition), 35,000 children and adolescents in Saudi Arabia suffer from T1DM, which makes Saudi Arabia rank the 8th in terms of numbers of TIDM patients and 4th country in the world in terms of the incidence rate (33.5 per 100,000 individuals) of TIDM. However, in comparison with that in the developed countries, the number of research interventions on the prevalence, incidence, and the sociodemographic aspects of T1DM is woefully inadequate. In this review we discuss different aspects of T1DM in Saudi Arabia drawing on the published literature currently available.

Sleep Duration and Diabetic Kidney Disease

Aims: Abnormally short or long durations of sleep have been proposed as a risk factors for diabetes and its micro- and macro-vascular complications. However, the relationship between sleep duration and diabetic kidney disease (DKD) has not been well-characterized. Thus, we aimed to examine the association of sleep duration with DKD in two Asian populations. Methods: We included 1,258 persons (Malay, n = 403; Indian, n = 855) aged 40-80 years with diabetes from a population-based cross-sectional sample from Singapore. DKD was defined by low estimated glomerular filtration rate (eGFR <60 mL/min/1.73 m²) and albuminuria (urinary albumin-to-creatinine ratio ≥30 mg/g, only measured in Indian participants). Self-reported habitual sleep duration was categorized into 4 categories: very short (<5 h), short (5-6.9 h), normal (7-8 h) and long (>8 h). The associations of sleep duration with low eGFR and albuminuria were analyzed using multivariable logistic regression models adjusted for multiple potential confounders (including classic risk factors such as HbA1c and hypertension). Results: In total, 268 (21.3%) participants had low eGFR, and 271 (34.7% in Indians) had albuminuria. The number (%) of individuals with very short, short, normal, and long durations of sleep were 117 (9.3%), 629 (50.0%), 429 (34.1%), and 83 (6.6%), respectively. Long sleep duration was associated with a higher odds of renal insufficiency compared to normal sleep duration (OR [95% CI]: 2.31 [1.27-4.19]) on multivariable analysis. Similarly, both long and very short durations of sleep were associated with higher odds of albuminuria (OR [95%]: 2.44 [1.36, 4.38] and 2.37 [1.25, 4.50], respectively) in Indian participants (where data on albuminuria were available). Conclusions: Our study suggests that abnormally short or long durations of sleep were associated with DKD, manifesting as either a reduced eGFR or increased albuminuria. However, further longitudinal data would be required for confirmation.

Hypoglycaemia among Insulin-Treated Patients with Diabetes: Southeast Asia Cohort of IO HAT Study

Objective

To provide real-world data on hypoglycaemia incidence in patients with type 1 (T1D) or type 2 diabetes (T2D) from the Southeast Asian cohort of the International Operations Hypoglycaemia Assessment Tool (IO HAT) study.

Methodology

IO HAT was a non-interventional, multicentre, 6-month retrospective and 4-week prospective study of hypoglycaemic events among insulin-treated adults with T1D or T2D, including four countries in Southeast Asia (Singapore, Philippines, Indonesia, and Bangladesh). Data were collected using a two-part self-assessment questionnaire (SAQ1 for retrospective and SAQ2 for prospective). The primary endpoint was the percentage of patients experiencing at least one hypoglycaemic event during the 4-week prospective observational period (ClinicalTrials.gov Identifier: NCT02306681).

Results

A total of 2594 patients completed SAQ1. Nearly all patients reported experiencing any hypoglycaemic event in the 4-week prospective period (T1D, 100%; T2D, 97.3%), with all patients reporting higher rates in the prospective versus retrospective period. Severe hypoglycaemia was also reported higher prospectively (57.2% and 76.9%) than retrospectively (33.9% and 12.2%) in both T1D and T2D, respectively. Nocturnal hypoglycaemia was reported higher retrospectively than prospectively.

Conclusion

Incidence of any and severe hypoglycaemia in the Southeast Asian cohort of IO HAT was higher prospectively versus retrospectively, suggesting hypoglycaemia has previously been under-reported in this region.

Prevalence of low HDL cholesterol and its associations among Sri Lankan patients with diabetes mellitus on statin therapy

AIMS

We aimed to study the prevalence and associations of suboptimal high density lipoproteins level, a characteristic feature in diabetic dyslipidemia among patients under statin therapy.

MATERIALS AND METHODS

From a database of 2416 patients, data on age, gender, duration of diabetes, body mass index (BMI) and waist circumference (WC), low density lipoproteins (LDL), triglyceride, high density lipoproteins (HDL) were obtained. Prevalence of suboptimal HDL (<40mg/dL in males and <50mg/dL in females) and its association with gender, age, duration of diabetes, BMI and WC were studied.

RESULTS

The mean (SD) age of the sample (n=2416) was 53 (10) years and 64.2% of them (n=1550) were males. Prevalence of suboptimal HDL was 17.6%. Regression analysis revealed female gender, (OR 7.73, 95% CI 5.99-9.97) younger age (OR 0.98, 95% CI 0.97-0.99), higher BMI (OR1.05. 95% CI 1.00-1.2) and LDL level over 100mg/dL (OR 1.004, 95% CI 1.00-1.007) had significant associations with suboptimal HDL.

CONCLUSIONS

Every sixth diabetic patient on statins has suboptimal HDL level. Females, younger and obese diabetic individuals should be more focused on achieving optimal HDL cholesterol levels.

Oral glucose lowering with linagliptin and metformin compared with linagliptin alone as initial treatment in Asian patients with newly diagnosed type 2 diabetes and marked hyperglycemia: Subgroup analysis of a randomized clinical trial

AIMS/INTRODUCTION

Type 2 diabetes mellitus is an epidemic in Asia, yet clinical trials of glucose-lowering therapies often enroll predominantly Western populations. We explored the initial combination of metformin and linagliptin, a dipeptidyl peptidase-4 inhibitor, in newly diagnosed type 2 diabetes mellitus patients in Asia with marked hyperglycemia.

MATERIALS AND METHODS

This was a post-hoc subgroup analysis of a multinational, parallel-group clinical trial in which 316 newly diagnosed type 2 diabetes mellitus patients with glycated hemoglobin A1c (HbA1c) 8.5-12.0% were randomized to double-blind oral treatment with linagliptin/metformin or linagliptin monotherapy. The primary end-point was the change from baseline in HbA1c at week 24. We evaluated data for the 125 participants from Asian countries.

RESULTS

After 24 weeks, the mean ± standard error reduction from baseline in HbA1c (mean 10.0%) was -2.99 ± 0.18% with linagliptin/metformin and -1.84 ± 0.18% with linagliptin; a treatment difference of -1.15% (95% confidence interval -1.65 to -0.66, P < 0.0001). HbA1c <7.0% was achieved by 60% of participants receiving linagliptin/metformin. The mean bodyweight change after 24 weeks was -0.45 ± 0.41 kg and 1.33 ± 0.45 kg in the linagliptin/metformin and linagliptin groups, respectively (treatment difference -1.78 kg [95% confidence interval -2.99 to -0.57, P = 0.0043]). Drug-related adverse events occurred in 9.7% of participants receiving linagliptin/metformin and 4.8% of those receiving linagliptin. Hypoglycemia occurred in 6.5% and 4.8% of the linagliptin/metformin and linagliptin groups, respectively, with no severe episodes. Gastrointestinal disorders occurred in 12.9% and 12.7% of the linagliptin/metformin and linagliptin groups, respectively, with no associated treatment discontinuations.

CONCLUSIONS

In people from Asia with newly diagnosed type 2 diabetes mellitus and marked hyperglycemia, the initial combination of linagliptin and metformin substantially improved glycemic control without weight gain and with infrequent hypoglycemia. Initial oral combination therapy might be a viable treatment for such individuals.

A Consensus of Key Opinion Leaders on the Management of Pre-diabetes in the Asia-Pacific Region

The Asia-Pacific region carries a high disease burden, with over half of the global diabetic population residing in this region. Increasing evidence shows that without targeted intervention, the progression from impaired glucose tolerance (IGT) to type 2 diabetes occurs more frequently in Asians compared with Caucasians. Furthermore, IGT is independently associated with an increased risk of cardiovascular disease, and should be managed as early as possible. Because diabetes is now a major public health issue, strategies aimed at prevention and treatment are urgently required. Lifestyle modification, including weight loss, dietary changes and increased physical activity, play a major role in controlling the disease. Significant evidence also supports the effectiveness of a combination of lifestyle modification and pharmacologic therapy, such as metformin, in delaying the onset of diabetes. Although the importance of lifestyle interventions is well recognized throughout Asia, many countries do not have formal recommendations to guide the diagnosis and management of individuals at risk of progression to diabetes. At a recent regional meeting, experts from the Asian region convened to develop consensus recommendations to guide clinicians in the management of Asian patients with pre-diabetes. These consensus recommendations provide a clear and concise approach to the management of individuals with IGT based on the available evidence and current best clinical practice.

Using genetics to inform new therapeutics for diabetes

The genetic architecture of diabetes has been extensively studied. Numerous genetic markers for diabetes have been reported. However, the translation of such knowledge into clinical interventions has been inadequate. Areas covered: We performed a literature search on various frontiers in diabetes treatment that could be improved using genetic information: (1) understanding the mechanisms of existing antidiabetic drugs, (2) repurposing existing drugs for the treatment of diabetes, (3) complementing clinical trial findings; (4) finding novel treatment approaches; (5) better estimation of the efficacy of metabolic surgery. Expert commentary: The translation of genetic information to clinical intervention requires further study, including the development of an appropriate genetic risk score algorithm for type 2 diabetes. Genomic studies provide empirical explanations for clinical trial findings. Moreover, the mechanisms of antidiabetic drugs should be thoroughly investigated to enable clinical trials and pharmacogenomics studies of these drugs. As metabolic surgery becomes more prevalent for the treatment of diabetes, genetic approaches may improve patient prioritization.

pH-sensitive peptide hydrogel for glucose-responsive insulin delivery

Glucose-responsive system is one of important options for self-regulated insulin delivery to treat diabetes, which has become an issue of great public health concern in the world. In this study, we developed a novel and biocompatible glucose-responsive insulin delivery system using a pH-sensitive peptide hydrogel as a carrier loaded with glucose oxidase, catalase and insulin. The peptide could self-assemble into hydrogel under physiological conditions. When hypoglycemia is encountered, neighboring alkaline amino acid side chains are significantly repulsed due to reduced local pH by the enzymatic conversion of glucose into gluconic acid. This is followed by unfolding of individual hairpins, disassembly and release of insulin. The glucose-responsive hydrogel system was characterized on the basis of structure, conformation, rheology, morphology, acid-sensitivity and the amount of consistent release of insulin in vitro and vivo. The results illustrated that our system can not only regulate the blood glucose levels in vitro but also in mice models having STZ-induced diabetes.

STATEMENT OF SIGNIFICANCE

In this report, we have shown the following significance supported by the experimental results. 1. We successfully developed, characterized and screened a novel pH-responsive peptide. 2. We successfully developed a novel and biocompatible pH-sensitive peptide hydrogel as glucose-responsive insulin delivery system loaded with glucose oxidase, catalase and insulin. 3. We successfully confirmed that the hydrogel platform could regulate the blood glucose level in vitro and in vivo. Overall, we have shown enough significance and novelty with this smart hydrogel platform in terms of biomaterials, peptide chemistry, self-assembly, hydrogel and drug delivery. So we believe this manuscript is suitable for Acta Biomaterialia.

Conversion of gestational diabetes mellitus to future Type 2 diabetes mellitus and the predictive value of HbA1c in an Indian cohort

AIM

To investigate the distribution of and risk factors for dysglycaemia (Type 2 diabetes and prediabetes) in women with previous gestational diabetes mellitus in India.

METHODS

All women (n = 989) from two obstetric units in New Delhi and Hyderabad with a history of gestational diabetes were invited to participate, of whom 366 (37%) agreed. Sociodemographic, medical and anthropometric data were collected and 75-g oral glucose tolerance test were carried out.

RESULTS

Within 5 years (median 14 months) of the pregnancy in which they were diagnosed with gestational diabetes, 263 (72%) women were dysglycaemic, including 119 (32%) and 144 (40%) with Type 2 diabetes and prediabetes, respectively. A higher BMI [odds ratio 1.16 per 1-kg/m² greater BMI (95% CI 1.10, 1.28)], presence of acanthosis nigricans [odds ratio 3.10, 95% CI (1.64, 5.87)], postpartum screening interval [odds ratio 1.02 per 1 month greater screening interval 95% CI (1.01, 1.04)] and age [odds ratio 1.10 per 1-year older age 95% CI (1.04, 1.16)] had a higher likelihood of having dysglycaemia. The American Diabetes Association-recommended threshold HbA_1c value of ≥ 48 mmol/mol (6.5%) had a sensitivity and specificity of 81.4 and 90.7%, respectively, for determining the presence of Type 2 diabetes postpartum.

CONCLUSION

The high post-pregnancy conversion rates of gestational diabetes to diabetes reported in the present study reinforce the need for mandatory postpartum screening and identification of strategies for preventing progression to Type 2 diabetes. Use of the American Diabetes Association-recommended HbA_1c threshold for diabetes may lead to significant under-diagnosis.

Diabetic care initiatives to prevent blindness from diabetic retinopathy in India

It is estimated that 65 million (17%) of 382 million persons with diabetes mellitus (DM) globally reside in India. While globally 35% persons with DM have diabetic retinopathy (DR), this proportion is reportedly lower in India, other countries in South Asia and China. We reviewed published data from 2008 onwards from PubMed, which ascertained DR in population-based representative samples. We also reviewed the risk factors for DR, on awareness regarding eye complications and on accessing an eye examination. Thirteen research studies have reported on the prevalence of DR among persons with DM; this prevalence was lower than the global level in China, India, and Nepal. Eleven studies reported DR risk factors association. The duration of diabetes and level of glycemic control were universally acknowledged DR risk factors. We identified 7 studies in the Asia region that researched the level of awareness about diabetes eye complications and the practice of accessing an eye examination. Excepting 1 study in China, others reported a significant proportion being aware that diabetes leads to eye complications. But the awareness was not translated into a positive practice-most studies reported only 20-50% of the persons with diabetes actually having had their eyes examined. The present review highlights the observation that the risk factors for DR need an integrated diabetic care pathway where the eye care team has to work in close collaboration and partnership with a diabetic care team has to reduce the risk of blindness from DR.

Training Cambodian Village Health Support Guides in Diabetes Prevention: Effects on Guides' Knowledge and Teaching Activities Over 6 Months

BACKGROUND

Type 2 diabetes is a pressing public health concern in Cambodia, a country with limited human resource capacity due to genocide. Cambodian village health support guides (Guides) promote health at the local level.

PURPOSE

This paper reports preliminary results of training Guides in diabetes prevention.

METHOD

The curriculum, called Eat, Walk, Sleep was delivered to Guides in Siem Reap province once over 3 h. Participants completed a pretest and posttest on diabetes knowledge. Guides were offered continuing education through Eat, Walk, Sleep resources and were encouraged to teach Eat, Walk, Sleep in their villages. For each of 6 months following their training, Guides completed a checklist regarding their activities.

RESULTS

One hundred eighty-five Guides attended one of ten trainings. Knowledge scores increased significantly from pretest to posttest. During 6 months of follow-up, n = 159 Guides (85 %) completed at least one monthly checklist. Guides reported high rates of uptake and delivery of the Eat, Walk, Sleep curriculum and moderate rates of continuing education about diabetes.

CONCLUSION

Diabetes prevention in Cambodia is nascent. Guides show excellent uptake and dissemination of the curriculum. Future research should examine effect of support for Guide activities and the effect of the curriculum on villager health behaviors, and ultimately, on rates of type 2 diabetes.

Biochemical and Clinical Profile in Type 2 Diabetics with Depression

INTRODUCTION

There were 72 million adults with Diabetes Mellitus (DM) in 2013 in the South East Asian region of which India is a part. This figure is expected to rise to more than 123 million by 2035. Some studies have also shown that there is an increased risk of depression in subjects with Type 2 Diabetes Mellitus (T2DM). The present study is an attempt to decipher whether there is any difference in the metabolic and clinical profile between patients having T2DM with depression and without depression.

AIM

To study the clinical and biochemical profile of subjects with T2DM and depression and compare a non-depressed diabetic cohort on the same parameters.

MATERIALS AND METHODS

The cross-sectional study was conducted at a tertiary care teaching hospital in rural Andhra Pradesh. Patients with T2DM who fulfilled the inclusion and exclusion criteria and attending the outpatient clinic of the General Medicine department were the subjects of this study. The subjects with T2DM were categorized as depressed or non-depressed after administering the Patient Health Questionnare-9. Out of them 30 subjects with depression and 30 without depression were selected. Samples for blood were collected and analysed for glucose, urea, creatinine, lipid profile and glycated haemoglobin. Urine micro protein was estimated. Anthropometric measurements, blood pressure and chronic complications were recorded.

RESULTS

The two groups were similar on most of the socio-demographic parameters, biochemical and many of the clinical parameters like age, waist circumference, glycated haemoglobin, lipid profile and insulin use. The Chi-square test for association between the categorical variables like use of insulin, gender predilection, exercise and complications with depression were not significant.

CONCLUSION

The study did not show any significant difference between the two groups in terms of the biochemical and clinical profile.

Diabetic Care through Public–Private Partnership in Rural Set-up

Introduction

Prevalence of diabetes is increasing rapidly in across the world and India is no exception. In the year 2000, the World Health Organization (WHO) estimated that India had 32 million diabetic. One of the proven strategies to improve access to healthcare, especially in the areas that are underserved or un-served through public healthcare services, is Public–Private Partnerships (PPPs).

Methodology

The case study is based on the observation of the facilities and service delivery, desk review of service delivery statistics of the PHC, in-depth interviews with stakeholders.

Findings

It was observed that the Valam Primary health Centre (PHC) is an excellent example of locally-initiated, village-level PPP model to cater to rural population. It was quite evident from the available records that PHC is having adequate supply of strips and glucometer to perform the investigation to monitor the blood sugar level of diabetic or suspected cases, which was not available even in other PHCs of the same block. Round the clock availability of the diagnostic equipment reflects the commitment of the NGO for providing the optimal diabetes investigation care to the residents in and around Valam PHC level.

Recommendation

The Valam Diabetic Care Model is an excellent example of locally-initiated PPP model and this kind of model should be encouraged in resource constrain areas.