A study on the glycemic, lipid and blood pressure control among the type 2 diabetes patients of north Kerala, India

Poor glycemic control and its predictors among people living with diabetes in low- and middle-income countries: a systematic review and meta-analysis

INTRODUCTION

Variability in blood glucose remains a challenge in diabetic management. Therefore, this review aimed to estimate the overall poor glycemic control and identify its predictors among people living with diabetes in low- and middle-income countries (LMICs).

METHODS

The authors searched articles in PubMed, Embase, OVID, CINAHL Plus, Cochrane Library, PsychInfo, Google, and Google Scholar. The search results were exported to the Rayyan software to check their eligibility. The Newcastle-Ottawa scale was used to assess the study quality. Stata version 17 was used for analysis. A random effect model was computed. Heterogeneity was assessed by the Cochrane Q test and I-squared (I2). The funnel plot asymmetry test and/or Egger's regression test (p < 0.05) were used to detect the publication bias. Then it was treated by the trim and fill analysis. The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the reference number CRD42023430175.

RESULTS

In total, forty-nine articles were used. Of which forty-five articles with 15,981 participants were used for pooled prevalence estimation. The pooled prevalence of poor glycemic control among people living with diabetes in LMICs was found to be 69.06% (95% CI: 65.66-72.46), I2 = 96.1%, p < 0.001). Alcohol intake (AOR = 2.07: 95% CI: 1.27-3.36), poor adherence to dietary recommendations (AOR = 3.16, 95% CI: 1.13-8.85), poor adherence to anti-diabetic medication (AOR = 2.85, 95% CI: 1.04 -7.85), diabetic complications (AOR = 1.37, 95% CI: 1.00-1.88), and co-morbid conditions (AOR = 1.98, 95% CI: 1.28-30.07) were found to be predictors of poor glycemic control.

CONCLUSIONS

The pooled prevalence of poor glycemic control was significantly high in LMICs. Drinking alcohol, poor adherence to dietary recommendations, poor adherence to anti-diabetic medication, diabetes complications, and co-morbid conditions were found to be the determinants of poor glycemic control among people living with diabetes. Tight glycemic control strategies have been implemented to achieve optimal blood glucose. Further research on the regional and contextual factors influencing glycemic control would be recommended.

Adiponectin and HbA1c levels among Indian patients with diabetes mellitus

Adiponectin is closely related to glucose metabolism and newly diagnosed type 2 diabetes mellitus (T2DM), and other kinds of diabetes linked to the risk of T2DM. Therefore, it is of interest to report the correlation between adiponectin levels and glycosylated hemoglobin (HbA1c) as a diagnostic marker of T2DM and healthy control. Total 210 participants were included of IPD & OPD healthy controls with glycosylated hemoglobin levels under 6% were included. Blood samples, collected using sterile clot activator or plain vials, were stored at -20°C. The biomarker score that comprised significant differences in age, gender distribution, and metabolic indicators are seen between the diabetes (n=105) and control (n=105) groups. Increase in both Adiponectin and HbA1c% Mean±SD (6.86±0.23, p<0.0001; 22.71±2.01; p<0.0001) is indicative of deteriorating glycaemic control and an accompanying rise in inflammatory response. Positively correlate adiponectin levels with HbA1c levels (r2=0.398; p<0.0001), suggesting a link between inflammatory response and glucose control. Lower adiponectin levels are statistically associated with diabetes. Diabetes and adiponectin were negatively correlated and positive linear relationship between HbA1c and adiponectin levels. Adiponectin may be a significant factor useful in understanding the pathophysiology; they are likely to be straight forward instruments for predicting future risk of diabetes.

The LongitudinAl Nationwide stuDy on Management And Real-world outComes of diabetes in India over 3 years (LANDMARC trial)

INTRODUCTION

LANDMARC (CTRI/2017/05/008452), a prospective, observational real-world study, evaluated the occurrence of diabetes complications, glycemic control and treatment patterns in people with type 2 diabetes mellitus (T2DM) from pan-India regions over a period of 3 years.

METHODS

Participants with T2DM (≥25 to ≤60 years old at diagnosis, diabetes duration ≥2 years at the time of enrollment, with/without glycemic control and on ≥2 antidiabetic therapies) were included. The proportion of participants with macrovascular and microvascular complications, glycemic control and time to treatment adaptation over 36 months were assessed.

RESULTS

Of the 6234 participants enrolled, 5273 completed 3 years follow-up. At the end of 3-years, 205 (3.3%) and 1121 (18.0%) participants reported macrovascular and microvascular complications, respectively. Nonfatal myocardial infarction (40.0%) and neuropathy (82.0%) were the most common complications. At baseline and 3-years, 25.1% (1119/4466) and 36.6% (1356/3700) of participants had HbA1c <7%, respectively. At 3-years, population with macrovascular and microvascular complications had higher proportion of participants with uncontrolled glycemia (78.2% [79/101] and 70.3% [463/659], respectively) than those without complications (61.6% [1839/2985]). Over 3-years, majority (67.7%-73.9%) of the participants were taking only OADs (biguanides [92.2%], sulfonylureas [77.2%] and DPP-IV inhibitors [62.4%]). Addition of insulin was preferred in participants who were only on OADs at baseline, and insulin use gradually increased from 25.5% to 36.7% at the end of 3 years.

CONCLUSION

These 3-year trends highlight the burden of uncontrolled glycemia and cumulative diabetes-related complications, emphasizing the importance of optimizing diabetes management in India.

Assessment of lipid profile with HbA1c in type 2 diabetic Iraqi patients

Insulin-induced hyperglycemia is the hallmark of diabetes mellitus (DM), including various metabolic disorders. Diabetic people are more likely to develop dyslipidemia, hypertension, and obesity. Type 2 diabetes ‎(T2DM), the most common illness, is generally asymptomatic in its early stages and can go misdiagnosed for years. Diabetes screening may be beneficial in some cases since early identification and treatment can lessen the burden of diabetes and its consequences.‎ This study aimed to find the relationship between Glycated hemoglobin (HbA1c) ‎and lipid profile components in T2DM‎ patients. Methods: This descriptive-analytical and cross-sectional study was performed on the control group and T2DM patients in ‎Medical City in Baghdad between March and June 2021‎. A total of 90 patients with T2DM and ‎‎45 healthy control were included in this study. In the control group, healthy volunteer individuals participated. For all subjects, HbA1c, fasting blood sugar/FBS, and lipid profile (Total Cholesterol/TC, Triglyceride/TG, High-density Lipoprotein/HDL, Low-density Lipoprotein/LDL, and Very Low-density Lipoprotein/VLDL) were assessed. Among T2DM patients, 62.22% (n= 56) were male, and 37.78% (n= ‎‎34) were female. Mean ± SD levels of HbA1c, TC, TG, LDL, VLDL, HDL, and FBS were 7.33±0.56 ‎‎% (168.21±9.23, 146.10±9.64, 137.23±8.32, 41.05±5.86, 43.85±6.17, and ‎‎208.81±52.1) mg/dl respectively in the T2DM group. In the control group, ‎the Mean ± SD results of the same parameters were 4.91±0.27%, ‎‎(171.20±3.57, 116.60±8.25, 105.05±2.11, 41.83±4.92, 44.04±5.54, ‎‎96.20±7.8) mg/dl respectively. Results demonstrated statistically significant ‎‎differences between T2DM patients and control groups in HbA1c ‎‎(p equal to 0.0025), TG ‎(p equal to 0.015), LDL ‎ ‎(p=0.0029),‎ and FBS ‎(p=0.02‎). Pearson correlation analysis of HbA1c with other variables showed a significant ‎positive correlation with serum TC, TG, LDL, and ‎FBS ‎(r=0.573, P<0.01; ‎r=0.655, P <0.001; r=0.498, P<0.05‎; r=0.691, ‎P<‎0.001‎; ‎‏respectively). At the same time, the data showed a negative connection between HbA1c and HDL (r= - 0.562, P<0.01). The findings of this study reveal that diabetic people do not have a satisfactory HbA1c level. Furthermore, HbA1c shows a significant correlation with TC, TG, LDL, and VLDL, whereas it has a significant negative correlation with HDL. The study's findings showed that HbA1c might be a useful marker for predicting dyslipidemia in T2DM patients. Keywords: T2DM, Lipid profile, HbA1c.

Assessment of lipid profile with HbA1c in type 2 diabetic Iraqi patients

Insulin-induced hyperglycemia is the hallmark of diabetes mellitus (DM), including various metabolic disorders. Diabetic people are more likely to develop dyslipidemia, hypertension, and obesity. Type 2 diabetes ‎(T2DM), the most common illness, is generally asymptomatic in its early stages and can go misdiagnosed for years. Diabetes screening may be beneficial in some cases since early identification and treatment can lessen the burden of diabetes and its consequences.‎ This study aimed to find the relationship between Glycated hemoglobin (HbA1c) ‎and lipid profile components in T2DM‎ patients. This descriptive-analytical and cross-sectional study was performed on the control group and T2DM patients in ‎Medical City in Baghdad between March and June 2021‎. A total of 90 patients with T2DM and ‎‎45 healthy control were included in this study. In the control group, healthy volunteer individuals participated. For all subjects, HbA1c, fasting blood sugar/FBS, and lipid profile (Total Cholesterol/TC, Triglyceride/TG, High-density Lipoprotein/HDL, Low-density Lipoprotein/LDL, and Very Low-density Lipoprotein/VLDL) were assessed. Among T2DM patients 62.22% (n= 56) were male and 37.78% (n= ‎‎34) were female. Mean ± SD levels of HbA1c, TC, TG, LDL, VLDL, HDL, and FBS were 7.33±0.56 ‎‎% (168.21±9.23, 146.10±9.64, 137.23±8.32, 41.05±5.86, 43.85±6.17, and ‎‎208.81±52.1) mg/dl respectively in the T2DM group. In the control group, ‎the Mean ± SD results of the same parameters were 4.91±0.27%, ‎‎(171.20±3.57, 116.60±8.25, 105.05±2.11, 41.83±4.92, 44.04±5.54, ‎‎96.20±7.8) mg/dl respectively. Results demonstrated statistically significant ‎‎differences between T2DM patients and control groups in HbA1c ‎‎(p equal to 0.0025), TG ‎(p equal to 0.015), LDL ‎ ‎(p=0.0029),‎ and FBS ‎(p=0.02‎). Pearson correlation analysis of HbA1c with other variables showed a significant ‎positive correlation with serum TC, TG, LDL, and ‎FBS ‎(r=0.573, P<0.01; ‎r=0.655, P <0.001; r=0.498, P<0.05‎; r=0.691, ‎P<‎0.001‎; ‎‏respectively). While the data showed a negative connection between HbA1c and HDL (r= - 0.562, P<0.01) The findings of this study reveal that diabetic people do not have a satisfactory HbA1c level. Furthermore, HbA1c shows a significant correlation with TC, TG, LDL, and VLDL, whereas it has a significant negative correlation with HDL. The study showed that HbA1c might be useful for predicting dyslipidemia in T2DM patients. Keywords: T2DM, Lipid profile, HbA1c.

Uncontrolled Blood Pressure and Associated Factors Among Persons With Diabetes: A Community Based Study From Kerala, India

The coexistence of raised blood pressure (BP) in people with type 2 diabetes mellitus (T2DM) is a major contributor to the development and progression of both macrovascular and microvascular complications. The aim of our study was to determine the prevalence of uncontrolled BP and its associated factors in persons with T2DM in a district in Kerala.

One-year trends from the LANDMARC trial: A 3-year, pan-India, prospective, longitudinal study on the management and real-world outcomes of type 2 diabetes mellitus

Introduction

Longitudinal data on management and progression of type 2 diabetes mellitus (T2DM) in India are scarce. LANDMARC (CTRI/2017/05/008452), first‐of‐its‐kind, pan‐India, prospective, observational study aimed to evaluate real‐world patterns and management of T2DM over 3 years.

Methods

Adults (≥25 to ≤60 years old at T2DM diagnosis; diabetes duration ≥2 years at enrolment; controlled/uncontrolled on ≥2 anti‐diabetic agents) were enrolled. The first‐year trends for glycaemic control, therapy and diabetic complications, including those from metropolitan and non‐metropolitan cities are reported here.

Results

Of 6236 enrolled participants, 5654 completed 1 year in the study. Although the overall mean glycated haemoglobin (HbA1c) improved by 0.5% (baseline: 8.1%) at 1 year, only 20% of the participants achieved HbA1c <7%. Participants from metropolitan and non‐ metropolitan cities showed similar decrease in glycaemic levels (mean change in HbA1c: −0.5% vs. −0.5%; p = .8613). Among diabetic complications, neuropathy was the predominant complication (815/6236, 13.1% participants). Microvascular complications (neuropathy, nephropathy and retinopathy) were significantly (p < .0001) higher in non‐metropolitan than metropolitan cities. Hypertension (2623/6236, 78.2%) and dyslipidaemia (1696/6236, 50.6%) continued to be the most commonly reported cardiovascular risks at 1 year. After 1 year, majority of the participants were taking only oral anti‐diabetic drugs (OADs) (baseline: 4642/6236 [74.4%]; 1 year: 4045/6013 [67.3%]), while the proportion of those taking insulin along with OADs increased (baseline: 1498/6236 [24.0%] vs. 1 year: 1844/6013 [30.7%]). Biguanides and sulfonylureas were the most used OADs. The highest increase in use was seen for dipeptidyl peptidase‐IV inhibitors (baseline: 3047/6236 [48.9%]; 1 year: 3529/6013 [58.7%]). Improvement in all glycaemic parameters was significantly (p < .0001) higher in the insulin vs. the insulin‐naïve subgroups; in the insulin‐naïve subgroup, no statistical difference was noted in those who received >3 vs. ≤3 OADs.

Conclusions

First‐year trends of the LANDMARC study offer insights into real‐world disease progression, suggesting the need for controlling risk factors and timely treatment intensification in people with T2DM.

The Cardiology Society of India-Kerala Acute Heart Failure Registry: poor adherence to guideline-directed medical therapy

AIMS

Data on the burden of acute heart failure (AHF) admissions, practice patterns, and outcomes are rare from India and other low- and middle-income countries. We aimed to describe the baseline characteristics, guideline-directed medical therapy (GDMT) prescribing patterns and 90-day mortality rates in patients admitted with AHF in Kerala, India.

METHODS AND RESULTS

The Cardiology Society of India-Kerala Acute Heart Failure Registry (CSI-KHFR) is an observational registry from 50 hospitals in Kerala, India, with prospective follow-up. Consecutive patients with AHF, who consented to participate, were enrolled. The 2016 European Society of Cardiology criteria were used for the diagnosis of AHF. Kaplan-Meier survival analysis and Cox-proportional hazard models were used for data analysis. The variables in the MAGGIC risk score were used in the multivariable model. A total of 7507 patients with AHF (37% female) participated in the CSI-KHFR. The mean age was 64.3 (12.9) years. More than two-third had reduced ejection fraction (EF) (67.5%). Nearly one-fourth (28%) of patients with heart failure (HF) with reduced EF received GDMT. Overall, in-hospital and 90-day mortality rates were 7% and 11.6%, respectively. Prescriptions of different components of GDMT were independently associated with 90-day mortality.

CONCLUSION

The CSI-KHFR recorded an in-hospital and 90-day mortality of 7% and 11.6%, respectively. Only one of four patients received GDMT. AHF mortality was independently associated with GDMT initiation. Quality improvement initiatives that focus on increasing GDMT prescription may improve the survival of HF patients in India.

Effectiveness of a Non-pharmacological Intervention to Control Diabetes Mellitus in a Primary Care Setting in Kerala: A Cluster-Randomized Controlled Trial

Background: Despite being the first Indian state with a dedicated Non-Communicable Disease (NCD) program, glycemic control among a large proportion of patients is low in Kerala. This study tries to find evidence for a standardized non-pharmacological strategy delivered through Junior Public Health Nurses (JPHNs) in achieving and maintaining glycemic control among diabetic patients registered with NCD clinics of primary health care settings. Design: A cluster randomized controlled trial was conducted among adult patients with Diabetes Mellitus attending NCD clinics of primary care settings of South Kerala, India. JPHNs of the intervention group received additional module-based training while standard management continued in the control group. Sequence generation was done by random permuted blocks method and a cluster of 12 patients was selected from each of the 11 settings by computer-generated random numbers. Patients were followed up for 6 months with monthly monitoring of Fasting Blood Sugar (FBS), Post-Prandial Blood Sugar (PPBS), blood pressure, Body Mass Index (BMI), and health-related behaviors. Knowledge and skills/practice of JPHNs were also evaluated. Analysis of Covariance was done to study the final outcome adjusting for the baseline values and a model for glycemic control was predicted using multilevel modeling. Results: We analyzed 72 participants in the intervention group and 60 participants in the control group according to the intention-to-treat principle. The intervention was associated with a significant reduction in FBS (p < 0.001) and PPBS (p < 0.001) adjusting for the baseline values. The achievement of glycemic control was 1.5 (95% CI: 1.05-2.3) times better with intervention and they showed a better trend of maintenance of glycemic control (FBS, p = 0.003 and PPBS, p = 0.039). Adjusting for clustering and the baseline values, the intervention showed a significant effect on FBS (B = -3.1, SE = 0.57; p < 0.001) and PPBS (B = -0.81, SE = 0.3; p < 0.001) with time. Drug adherence score (p < 0.001), hours of physical activity (p < 0.001), BMI (p = 0.002), fruit intake (p = 0.004), and green leafy vegetable intake (p = 0.01) were the major predictors of FBS control. The practice/skills score of the JPHNs significantly improved with intervention (p < 0.001) adjusting for baseline values. Conclusion: A well-designed health worker intervention package incorporated into the existing health system can translate into attitude change and skill development in the health workers which can reflect in the improvement of glycemic control among the patients. Trial registration: [URL: http://www.ctri.nic.in], identifier [CTRI/2017/11/010622].

Consumption of fruits, vegetables and salt in the context of control of type 2 diabetes and hypertension in Kerala, India

Background

Proper diet is necessary to control hypertension and diabetes. This paper describes the combined fruit and vegetable, and salt intake of adults (>=18 years) who were detected to have hypertension or diabetes.

Methods

We analysed the data from a state-wide survey of 12012 adults using the World Health Organization STEPs for NCD risk factor surveillance. We evaluated the recommended intake of fruit and vegetable (>=5 servings/day) and salt (<5 gm/day) across participants divided into four strata, and the probabilities were also estimated using the fitted multiple binary logistic regression models.

Results

Overall, 13.9% (95%CI: 12.2%-15.9%) and 29.4% (95%CI: 28%-30.8%) of participants consumed the recommended level of fruit and vegetable, and salt, respectively. Adjusted odds ratios were not significantly different across the four strata based on the status of treatment and control of diabetes or hypertension. The likelihood of following the recommended fruit and vegetable intake was highest for 50-69-year-old females with above high school education, obese, under treatment for diabetes or hypertension, and had normal values of FBS and BP (0.28). The likelihood for recommended salt intake was highest for 50-69-year-old males with above high school education and had normal BMI, under treatment for diabetes or hypertension, and had normal values of FBS and BP (0.69).

Conclusion

The status of diabetes or hypertension did not show considerable influence in the fruit, vegetable, and salt intake of adults in general. A detailed exploration of the accessibility and acceptability of such recommended intakes in the Kerala context is warranted.

Baseline characteristics of participants in the LANDMARC trial: A 3-year, pan-india, prospective, longitudinal study to assess management and real-world outcomes of diabetes mellitus

Introduction

Longitudinal data on progression, complications, and management of type 2 diabetes mellitus (T2DM) across India are scarce. LANDMARC (CTRI/2017/05/008452), the first pan‐India, longitudinal, prospective, observational study, aims to understand the management and real‐world outcomes of T2DM over 3 years.

Methods

Adults (≥25 to ≤60 years old at T2DM diagnosis; diabetes duration ≥2 years at enrollment; controlled/uncontrolled on ≥2 anti‐diabetic agents) were enrolled. Baseline characteristics were analyzed using descriptive statistics.

Results

Of the 6279 recruited participants, 6236 were eligible for baseline assessment (56.6% [n/N = 3528/6236] men; mean ± SD age: 52.1 ± 9.2 years, diabetes duration: 8.6 ± 5.6 years). mean ± SD HbA1c, fasting plasma glucose, and postprandial glucose values were 64 ± 17 mmol/mol (8.1 ± 1.6%), 142.8 ± 50.4 mg/dl, and 205.7 ± 72.3 mg/dl, respectively. Only 25.1% (n/N = 1122/6236) participants had controlled glycemia (HbA1c < 53 mmol/mol, <7%). Macrovascular and microvascular complications were prevalent in 2.3% (n/N = 145/6236) and 14.5% (n/N = 902/6236) participants, respectively. Among those with complications, non‐fatal myocardial infarction (n/N = 74/145, 51.0%) and neuropathy (n/N = 737/902, 81.7%) were the most reported macrovascular and microvascular complication, respectively. Hypertension (n/N = 2566/3281, 78.2%) and dyslipidemia (n/N = 1635/3281, 49.8%) were the most reported cardiovascular risks. Majority (74.5%; n/N = 4643/6236) were taking oral anti‐diabetic drugs (OADs) only, while 24.4% (n/N = 1522/6236) participants were taking OADs+insulin. Biguanides (n/N = 5796/6236, 92.9%) and sulfonylureas (n/N = 4757/6236, 76.3%) were the most reported OADs. Basal (n/N = 837/6236, 13.4%) and premix (n/N = 684/6236, 11.0%) insulins were the most reported insulins.

Conclusions

Baseline data from LANDMARC help understand the clinical/medical profile of study participants and underscore the extent of suboptimal glycemic control and prevalence of associated complications in a vast majority of Indians with T2DM.

Cardiovascular Risk Prediction using JBS3 Tool: A Kerala based Study

Background:

Accuracy of Joint British Society calculator3 (JBS3) cardiovascular (CV) risk assessment tool may vary across the Indian states, which is not verified in south Indian, Kerala based population.

Objectives:

To evaluate the traditional risk factors (TRFs) based CV risk estimation done in Kerala based population.

Methods:

This cross-sectional study uses details of 977 subjects aged between 30 and 80 years, recorded from the medical archives of clinical locations at Ernakulum district, in Kerala. The risk categories used are Low (<7.5%), Intermediate (≥7.5% and <20%), and High (≥20%) 10-year risk classifications. The lifetime classifications are Low lifetime (≤39%) and High lifetime (≥40%) are used. The study evaluated using statistical analysis; the Chi-square test was used for dependent and categorical CV risk variable comparisons. A multivariate ordinal logistic regression analysis for the 10-year risk and odds logistic regression analysis for the lifetime risk model identified the significant risk variables.

Results:

The mean age of the study population is 52.56±11.43 years. With 39.1% in low, 25.0% in intermediate, and 35.9% has high 10-year risk. Low lifetime risk with 41.1%, the high lifetime risk has 58.9% subjects. The intermediate 10-year risk category shows the highest reclassifications to High lifetime risk. The Hosmer-Lemeshow goodness-of-fit statistics indicates a good model fit.

Conclusion:

Timely interventions using risk predictions can aid in appropriate therapeutic and lifestyle modifications useful for primary prevention. Precaution to avoid short-term incidences and reclassifications to a high lifetime risk can reduce the CVD related mortality rates.

Achievement of guideline targets of glycemic and non-glycemic parameters in North Indian type 2 diabetes mellitus patients: A retrospective analysis

BACKGROUND AND AIMS

Though, the prevalence of diabetes is increasing in the worldwide, achievement of glycemic and non-glycemic targets remain suboptimal. We conducted this retrospective cross-sectional study at two endocrine clinics of Aligarh (Uttar Pradesh) in north India.

MATERIALS AND METHODS

After screening the records of 13800 patients, 12140 patients of type 2 diabetes mellitus who were attending the clinic regularly every three to four months, were included in the final analysis. The data regarding patient's height, weight, body mass index, blood pressure, blood glucose, HbA1c, lipid profile and complications were obtained.

RESULTS

Mean age was 49.7 ± 11.3 years; males and females were almost equal in number. 2891 (23.8%) subjects were of age less than 40 years. 9614 (80%) patients had diabetes duration of less than 5 years. 3311 (27.3%) subjects were having an HbA1c of <7%, HbA1c 7-8% in 3711 (30.5%), HbA1c 8-9% in 2653 (21.9%) whereas HbA1c of >9% in 2465 (20.3%) subjects. The microvascular complications; diabetic nephropathy, diabetic neuropathy and diabetic retinopathy were present in 7.5%, 14.9% and 16.2% respectively. Hypertension was present in 25.8% and coronary artery disease was present in 15.5% of patients. Overall 27.3%, 41.7%, 44.1%, 45.3% and 67.7% of patients achieved their HbA1c, triglyceride, HDL, LDL and hypertension targets respectively, as per American Diabetes Association 2020 guidelines.

CONCLUSION

Despite availability of multiple drugs and guidelines, the attainment rates of glycemic and non-glycemic targets remain suboptimal. A more aggressive approach in the treatment of type 2 diabetes is required.

Current Practices and Gaps in Management of Dyslipidemia in Type 2 Diabetes Mellitus (T2DM) in Accordance with American Diabetes Association (ADA) Guidelines: A Subset Analysis from a Real-World, Cross-Sectional Observational Study (LEADD Study)

BACKGROUND

Diabetic dyslipidemia is a risk factor for coronary artery disease (CAD) in patients with type 2 diabetes mellitus (T2DM). American Diabetes Association (ADA) provides internationally accepted guidelines to manage dyslipidemia in T2DM.

OBJECTIVE

To assess if ADA guidelines are followed for managing dyslipidemia in patients with T2DM in India.

METHODS

This was a subset analysis of a prospective, cross sectional, observational study (LEADD Study) conducted at 199 sites across India to evaluate dyslipidemia management practices in T2DM patients (N=4002), in a real-world setting. The data was stratified based on age and atherosclerotic cardiovascular disease (ASCVD) and ASCVD risk factors to record the percentages of T2DM patients achieving LDL-C target and treated optimally with the Guideline directed intensity of statin. Analysis was conducted using descriptive statistics.

RESULTS

As per ADA 2018 targets: LDL-C levels (<100mg/dL) were seen in 30.6% of participants. High intensity statins were prescribed to 13.4% of the participants with LDL levels ≥100 mg/dL. ASCVD risk assessment details were available for 89.2% of participants. Data was not available for smoking and albuminuria. In participants <40 years of age, 80% and 64.2% with ASCVD and ASCVD risk factors, respectively, did not achieve target LDL-C levels. In this age group, 15.6% and 83.3% of participants with ASCVD risk factors and ASCVD group, respectively, were not receiving statins in the recommended dose. In participants ≥40 years of age, 88.0% and 91.5% with ASCVD and ASCVD risk factors, respectively, did not have LDL-C levels as per ADA 2018 targets. In this age group, 87.2% and 77.9% of participants with ASCVD risk factors and ASCVD, respectively, were not receiving statins in the recommended dose.

CONCLUSION

The sub-analysis of LEADD study shows sub-optimal adherence to ADA 2018 guidelines for management of diabetic dyslipidemia.

Availability, price and affordability of essential medicines for managing cardiovascular diseases and diabetes: a statewide survey in Kerala, India

OBJECTIVE

Limited access to essential medicines (EMs) for cardiovascular disease (CVD) and diabetes is a major concern in low- and middle-income countries. We aimed to generate data on availability, price and affordability of EMs for CVD and diabetes in India.

METHODS

Using WHO/HAI survey methodology, we evaluated availability and prices of 23 EMs in 30 public sector facilities (government hospitals and semi-public/government-subsidised-discount-pharmacies (GSDPs)) and 60 private retail pharmacies across six districts in Kerala state, India (November 2018 - May 2019). Median Price Ratios (MPRs) were calculated by comparing consumer prices with international reference prices. We also analysed data (collected in July 2020) on six anti-hypertensive fixed-dose-combinations (FDCs) that were designated as 'essential' by the WHO in 2019.

RESULTS

Mean availability of surveyed generic EMs was 45.7% in government hospitals, 64.7% in GSDPs and 72.0% in private retail pharmacies. On average, the most-sold and highest-priced generics, respectively, were 6.6% and 8.9% costlier than the lowest-priced generics (LPG). Median MPR for LPG was 2.71 in private retail and 2.25 in GSDPs. Monthly supply of LPG would cost the lowest-paid worker 1.11 and 0.79 days' wages in private retail and GSDPs, respectively. Mean availability of the surveyed FDCs was poor (private retail: 15-85%; GSDPs: 8.3-66.7%), and the private retail prices of FDCs were comparable to the sum of corresponding constituent monotherapies.

CONCLUSION

Availability of CVD and diabetes EMs fall short of WHO's 80% target in both sectors. Although availability in the private retail pharmacies was near-optimal, prices appear unaffordable compared to GSDPs. Initiatives such as mandating generic prescribing, adding the WHO-approved FDCs in local EM lists, improving price transparency, and streamlining medicine supply to ensure equitable access to EMs, especially in the public sector, are crucial in tackling Kerala's ever-increasing CVD burden.

Real-world evidence of glycemic control among patients with type 2 diabetes mellitus in India: the TIGHT study

Objective

To determine glycemic control in adult patients with type 2 diabetes receiving antidiabetic therapy as part of routine healthcare in India.

Research design and methods

This was a retrospective analysis of cross-sectional data of patients with type 2 diabetes receiving oral hypoglycemic agents (OHAs) with or without insulin between 2015 and 2017. We assessed proportion of patients with uncontrolled glycemia and performed logistic regression to evaluate its association with various risk factors and microvascular complications.

Results

A total of 55 639 eligible records were identified; mean age of patients was 54.31 (±11.11) years. One-third of the study population had microvascular complications, predominantly neuropathy. Nearly 76.6% of patients had uncontrolled glycated hemoglobin (HbA1c) ≥7% (53 mmol/mol); 62% of these patients had HbA1c between 7% and 8% (53-64 mmol/mol). Glycemic control from combination of OHAs with or without insulin varied between 14.2% and 24.8%. In multivariate analysis, factors statistically associated with uncontrolled glycemia were obesity (OR: 1.15), hypertension (stage I OR: 1.65 and stage II OR: 2.73) and diabetes duration >5 years (OR: 1.19) (p<0.001). Similarly, the odds of having any microvascular complication increased with duration of diabetes (past 1-2 years, OR: 1.67; 2-5 years, OR: 2.53; >5 years, OR: 4.01; p<0.0001), hypertension (stage I, OR: 1.18 and stage II, OR: 1.34; p<0.05) and uncontrolled HbA1c (OR: 1.28; p<0.0001).

Conclusions

Indian population with type 2 diabetes has a high burden (76.6%) of poor glycemic control. This study highlights the need for early implementation of optimum diabetes pharmacotherapy to maintain recommended glycemic control, thereby reducing burden of microvascular complications.

High level of individual lipid profile and lipid ratio as a predictive marker of poor glycemic control in type-2 diabetes mellitus

Introduction: Diabetes is often accompanied by undiagnosed dyslipidemia. The aim of the study is to investigate the clinical relevance of lipid profiles and lipid ratios as predictive biochemical models for glycemic control in patients with type 2 diabetes mellitus (T2DM). Methods: This is a retrospective study recruiting 140 patients with T2DM during a one-year period, 2018-2019, at the Diabetic Center Sanglah General Hospital and Internal Medicine Polyclinic Puri Raharja General Hospital. Demographic characteristics, glycosylated hemoglobin (HBA1c) , and lipid profile were recorded and analyzed using SPSS version 25.0 for Windows. The sample is then classified into good (HBA1c≤7) and poor (HBA1c>7) glycemic control. Risk analysis model, receiver operator characteristics (ROC) analysis, and correlation test were used to evaluate the association of HBA1c level with lipid profile and lipid ratio parameters. Result: Lipid profile findings such as total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) , triglycerides (TG), and lipid ratio parameter (LDL-C to high-density lipoprotein cholesterol (HDL-C) ratio) were higher in patients in the poor glycemic control group (p<0.05) and HDL-C was significantly lower in patients with poor glycemic control (p=0.001). There is a significant positive correlation between LDL, total cholesterol, LDL-C, TG, and TC to HDL-C ratio, triglycerides, and TC/HDL-C ratio with HBA1c level. Meanwhile, a negative correlation was observed on HDL-C with the HBA1c level. Only TC/HDL-C ratio and LDL-C/HDL-C ratio parameters may be used as predictive models (AUC>0.7), with cutoff point, sensitivity, and specificity of 4.68 (77%; 52%) and 3.06 (98%; 56%) respectively. A risk analysis model shows that the LDL-C/HDL-C ratio parameter is the most influential risk factor in the occurrence of poor glycemic control (adjusted OR =38.76; 95% CI: 27.32-56.64; p<0.001). Conclusion: Lipid profiles (LDL-C) and lipid ratios (LDL-C/HDL-C and TC/HDL-C ratio) show potential markers that can be used in predicting glycemic control in patients with T2DM.

Diabetes in the Kokan region of India

BACKGROUND

BKL Walawalkar Hospital is situated near the village of Dervan in the Kokan region of the state of Maharashtra in India. A survey of 2200 surrounding villages showed 51.8% adults had body mass index (BMI) below <18.5 kg/m² and only 4.5% were overweight. A survey of 11521 adolescent girls from rural schools showed 64% prevalence of thinness. In the same region, government survey reported the prevalence of diabetes around 7%, and 70% prevalence of leanness. This reinforced the fact that the overall population of Kokan is lean. Hence, we decided to investigate body composition of diabetic people from our hospital clinic by carrying out a clinic-based case control study.

AIM

To study body composition of diabetics in a rural clinic of Kokan.

METHODS

In a case-control study, 168 type 2 diabetic patients (102 men) attending the outpatient department at a rural hospital and 144 non-diabetic controls (68 men) in the Chiplun area of the Kokan region were recruited. History of diabetes (age of onset, duration), anthropometric measurements (height, weight, waist and hip circumference) were recorded. Body composition was measured by bioimpedance using the TANITA analyzer.

RESULTS

More than 45% of diabetic subjects had a 1^st degree family history of diabetes, and more than 50% had macrovascular complications. The average BMI in diabetic subjects was 24.3 kg/m². According to World Health Organization standards, prevalence of underweight was 8% and that of normal BMI was around 50%. Underweight and normal diabetic subjects (men as well as women) had significantly lower body fat percentage, higher muscle mass percentage, lower visceral fat and lower basal metabolic rate when compared to their overweight counterparts.

CONCLUSION

The diabetic population in Kokan has near normal body composition, and BMI has considerable limitations in assessing body composition and it also lacks sensitivity for assessing risk for diabetes in this population. High prevalence of family history of diabetes may point towards genetic predisposition. Leanness is an inherent characteristic of this population and its metabolic significance needs further investigations with a larger sample size.