Comparison of capillary whole blood versus venous plasma glucose estimations in screening for diabetes mellitus in epidemiological studies in developing countries

Effect of Arterialization on Venous Blood Glucose Concentrations and Implications for Observed Continuous Glucose Monitoring Accuracy

Background: Heating of the arm and/or hand ("arterialization") is sometimes used in continuous glucose monitoring (CGM) performance studies with the reported aim of reducing differences between venous and capillary glucose concentrations. In this study, the effect of heating on venous glucose concentrations and CGM accuracy was investigated. Methods: A heating pad set to 50°C (122°F) was used with 20 participants to heat either the dominant or nondominant arm and hand. Venous and capillary samples were obtained every 15 min on both arms throughout each of three 6-h glucose challenges. CGM sensors were worn on each upper arm for each of the three visits. Results: Heating of the arm led to a median increase in venous glucose concentrations of +1.4%. No similar effect on capillary concentrations was observed. As a result, the median capillary to venous difference decreased from +5.9% in the nonheated arm to +4.2% in the heated arm. CGM accuracy observed in this study was affected by the selection of heated venous, nonheated venous, or capillary glucose concentrations as comparator data. The heating effect was more pronounced with rapidly decreasing glucose concentrations. Temperatures on the skin did not exceed 40°C (104°F). No adverse events or protocol deviations were associated with the use of the heating pad. Conclusions: Heating of the arm led to a small increase in venous glucose concentrations, but venous concentrations did not reach the level of capillary glucose concentrations. CGM accuracy observed in this study varied depending on the selected comparator data. This study was registered at the German Clinical Trials Register (DRKS00031197).

Feasibility of a Type 2 Diabetes Prevention Program at Nationwide Level in General Practice: A Pilot Study in Italy

BACKGROUND

Lifestyle interventions halt the progression of prediabetes to frank type 2 diabetes (T2D). However, the feasibility of a diabetes prevention program promoting tailored interventions on a national scale and conducted by primary care physicians is unclear.

METHODS

General practitioners located in ten different regions throughout Italy enrolled random subjects without known metabolic diseases to identify individuals with prediabetes and prescribe them an intervention based on physical activity. Using a simple stepwise approach, people referring to their primary care physician for any reason were screened for their diabetes risk with a web-based app of the Findrisc questionnaire. Those at risk for T2D, i.e., with a Findrisc score >9, were invited to come back after overnight fasting to measure fasting glycaemia (FG). Those with 100 ≤ FG < 126 mg/dL were considered as people with prediabetes and compiled the Physical Activity Readiness Questionnaire (PAR-Q) to then receive a personalised prescription of physical activity.

RESULTS

Overall, 5928 people were enrolled and compiled the questionnaire. Of these, 2895 (48.8%) were at risk for T2D. Among these, FG was measured in 2168 subjects (participation rate 75%). The numbers of individuals with undetected prediabetes and T2D according to FG were 755 and 79 (34.8% and 3.6% of those assessing FG), respectively. Of the 755 subjects in the prediabetes range, 739 compiled the PAR-Q and started a personalised program of physical activity (participation rate 97%). Physicians involved in the study reported a mean of 6 min to perform the screening.

CONCLUSIONS

Overall, these data suggest the feasibility of a national diabetes prevention program developed by general practitioners using a simple stepwise approach starting from a web app to intercept individuals with prediabetes.

Metabolic non-communicable disease health report of India: the ICMR-INDIAB national cross-sectional study (ICMR-INDIAB-17)

BACKGROUND

Non-communicable disease (NCD) rates are rapidly increasing in India with wide regional variations. We aimed to quantify the prevalence of metabolic NCDs in India and analyse interstate and inter-regional variations.

METHODS

The Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study, a cross-sectional population-based survey, assessed a representative sample of individuals aged 20 years and older drawn from urban and rural areas of 31 states, union territories, and the National Capital Territory of India. We conducted the survey in multiple phases with a stratified multistage sampling design, using three-level stratification based on geography, population size, and socioeconomic status of each state. Diabetes and prediabetes were diagnosed using the WHO criteria, hypertension using the Eighth Joint National Committee guidelines, obesity (generalised and abdominal) using the WHO Asia Pacific guidelines, and dyslipidaemia using the National Cholesterol Education Program-Adult Treatment Panel III guidelines.

FINDINGS

A total of 113 043 individuals (79 506 from rural areas and 33 537 from urban areas) participated in the ICMR-INDIAB study between Oct 18, 2008 and Dec 17, 2020. The overall weighted prevalence of diabetes was 11·4% (95% CI 10·2-12·5; 10 151 of 107 119 individuals), prediabetes 15·3% (13·9-16·6; 15 496 of 107 119 individuals), hypertension 35·5% (33·8-37·3; 35 172 of 111 439 individuals), generalised obesity 28·6% (26·9-30·3; 29 861 of 110 368 individuals), abdominal obesity 39·5% (37·7-41·4; 40 121 of 108 665 individuals), and dyslipidaemia 81·2% (77·9-84·5; 14 895 of 18 492 of 25 647). All metabolic NCDs except prediabetes were more frequent in urban than rural areas. In many states with a lower human development index, the ratio of diabetes to prediabetes was less than 1.

INTERPRETATION

The prevalence of diabetes and other metabolic NCDs in India is considerably higher than previously estimated. While the diabetes epidemic is stabilising in the more developed states of the country, it is still increasing in most other states. Thus, there are serious implications for the nation, warranting urgent state-specific policies and interventions to arrest the rapidly rising epidemic of metabolic NCDs in India.

FUNDING

Indian Council of Medical Research and Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Instrument-free single-step direct estimation of the plasma glucose level from one drop of blood using smartphone-interfaced analytics on a paper strip

We demonstrated an instrument-free miniaturized adaptation of the laboratory gold standard methodology for the direct estimation of plasma glucose from a drop of whole blood using a low-cost single-user-step paper-strip sensor interfaced with a smartphone. Unlike a majority of the existing glucose meters that use whole blood-based indirect sensing technologies, our direct adaptation of the gold-standard laboratory benchmark could eliminate the possibilities of cross interference with other analytes present in the whole blood by facilitating an in situ plasma separation, capillary flow and colorimetric reaction occurring concomitantly, without incurring additional device complexity or embodiment. The test reagents were dispensed in lyophilized form, and the resulting paper strips were found to be stable over three months stored in a normal freezer, rendering easy adaptability commensurate with the constrained supply chains in extreme resource-poor settings. Quantitative results could be arrived at via a completely-automated mobile-app-based image analytics interface developed using dynamic machine learning, obviating manual interpretation. The tests were demonstrated to be of high efficacy, even when executed by minimally trained frontline personnel having no special skill of drawing precise volume of blood, on deployment at under-resourced community centres having no in-built or accessible healthcare infrastructure. Clinical validation using 220 numbers of human blood samples in a double-blinded manner evidenced sensitivity and specificity of 98.11% and 96.7%, respectively, as compared to the results obtained from a laboratory-benchmarked biochemistry analyser, establishing its efficacy for public health and community disease management in resource-limited settings without any quality compromise of the test outcome.

Prevalence and correlates of undiagnosed, diagnosed, and total type 2 diabetes among adults in Morocco, 2017

The study aimed to estimate the prevalence and associated factors of undiagnosed type 2 diabetes (T2D) among adults in Morocco. Cross-sectional data were analyzed from 4779 people (≥ 18 years, mean age 41.7 years) who participated in the Morocco STEPS nationally representative survey in 2017 and had completed fasting blood glucose measurement. The results indicate that the prevalence of undiagnosed T2D was 5.9% (44.7% of total T2D), diagnosed T2D 7.3% and total T2D 13.2%. In the adjusted multinomial logistic regression analysis, older age (≥ 50 years), receipt of health care advice, and obesity were positively associated with undiagnosed T2D. Older age (≥ 50 years), urban residence, receipt of health care advice, ever cholesterol screening, moderate sedentary behaviour, obesity, hypertension, and elevated total cholesterol were positively associated with diagnosed T2D. In adjusted logistic regression analysis, older age (≥ 50 years), receipt of health care advice and cholesterol screening were negatively associated with undiagnosed T2D versus diagnosed T2D. A significant proportion of adults in Morocco had undiagnosed T2D and several associated factors were identified that can help guide interventions.

Burden of Type 2 Diabetes and Associated Cardiometabolic Traits and Their Heritability Estimates in Endogamous Ethnic Groups of India: Findings From the INDIGENIUS Consortium

To assess the burden of type 2 diabetes (T2D) and its genetic profile in endogamous populations of India given the paucity of data, we aimed to determine the prevalence of T2D and estimate its heritability using family-based cohorts from three distinct Endogamous Ethnic Groups (EEGs) representing Northern (Rajasthan [Agarwals: AG]) and Southern (Tamil Nadu [Chettiars: CH] and Andhra Pradesh [Reddys: RE]) states of India. For comparison, family-based data collected previously from another North Indian Punjabi Sikh (SI) EEG was used. In addition, we examined various T2D-related cardiometabolic traits and determined their heritabilities. These studies were conducted as part of the Indian Diabetes Genetic Studies in collaboration with US (INDIGENIUS) Consortium. The pedigree, demographic, phenotypic, covariate data and samples were collected from the CH, AG, and RE EEGs. The status of T2D was defined by ADA guidelines (fasting glucose ≥ 126 mg/dl or HbA1c ≥ 6.5% and/or use of diabetes medication/history). The prevalence of T2D in CH (N = 517, families = 21, mean age = 47y, mean BMI = 27), AG (N = 530, Families = 25, mean age = 43y, mean BMI = 27), and RE (N = 500, Families = 22, mean age = 46y, mean BMI = 27) was found to be 33%, 37%, and 36%, respectively, Also, the study participants from these EEGs were found to be at increased cardiometabolic risk (e.g., obesity and prediabetes). Similar characteristics for the SI EEG (N = 1,260, Families = 324, Age = 51y, BMI = 27, T2D = 75%) were obtained previously. We used the variance components approach to carry out genetic analyses after adjusting for covariate effects. The heritability (h²) estimates of T2D in the CH, RE, SI, and AG were found to be 30%, 46%, 54%, and 82% respectively, and statistically significant (P ≤ 0.05). Other T2D related traits (e.g., BMI, lipids, blood pressure) in AG, CH, and RE EEGs exhibited strong additive genetic influences (h² range: 17% [triglycerides/AG and hs-CRP/RE] - 86% [glucose/non-T2D/AG]). Our findings highlight the high burden of T2D in Indian EEGs with significant and differential additive genetic influences on T2D and related traits.

Lifetime risk of diabetes in metropolitan cities in India

AIMS/HYPOTHESIS

We aimed to estimate the lifetime risk of diabetes and diabetes-free life expectancy in metropolitan cities in India among the population aged 20 years or more, and their variation by sex, age and BMI.

METHODS

A Markov simulation model was adopted to estimate age-, sex- and BMI-specific lifetime risk of developing diabetes and diabetes-free life expectancy. The main data inputs used were as follows: age-, sex- and BMI-specific incidence rates of diabetes in urban India taken from the Centre for Cardiometabolic Risk Reduction in South Asia (2010-2018); age-, sex- and urban-specific rates of mortality from period lifetables reported by the Government of India (2014); and prevalence of diabetes from the Indian Council for Medical Research INdia DIABetes study (2008-2015).

RESULTS

Lifetime risk (95% CI) of diabetes in 20-year-old men and women was 55.5 (51.6, 59.7)% and 64.6 (60.0, 69.5)%, respectively. Women generally had a higher lifetime risk across the lifespan. Remaining lifetime risk (95% CI) declined with age to 37.7 (30.1, 46.7)% at age 60 years among women and 27.5 (23.1, 32.4)% in men. Lifetime risk (95% CI) was highest among obese Indians: 86.0 (76.6, 91.5)% among 20-year-old women and 86.9 (75.4, 93.8)% among men. We identified considerably higher diabetes-free life expectancy at lower levels of BMI.

CONCLUSIONS/INTERPRETATION

Lifetime risk of diabetes in metropolitan cities in India is alarming across the spectrum of weight and rises dramatically with higher BMI. Prevention of diabetes among metropolitan Indians of all ages is an urgent national priority, particularly given the rapid increase in urban obesogenic environments across the country. Graphical abstract.

Effectiveness of a Female Community Health Volunteer-Delivered Intervention in Reducing Blood Glucose Among Adults With Type 2 Diabetes: An Open-Label, Cluster Randomized Clinical Trial

IMPORTANCE

Female community health volunteers (FCHVs) are frontline community health workers who have been a valuable resource in improving public health outcomes in Nepal, but their value is understudied in diabetes care.

OBJECTIVE

To assess whether an FCHV-delivered intervention is associated with reduced blood glucose levels among adults with type 2 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

This community-based, open-label, 2-group, cluster randomized clinical trial with a 12-month delayed control group design was conducted in 14 clusters of a semiurban setting in Western Nepal. A total of 244 adults with type 2 diabetes were recruited between November 2016 and April 2017. The follow-up assessment was conducted at 12 months after enrollment. Data analysis was performed from January to February 2019.

INTERVENTIONS

Seven clusters were randomized to the FCHV-delivered intervention in which 20 FCHVs provided home visits 3 times a year (once every 4 months) for health promotion counseling and blood glucose monitoring. If participants had blood glucose levels of 126 mg/dL or higher, the FCHVs referred them to the nearest health facility, and if participants were taking antihyperglycemic medication, they were followed up by the FCHVs for adherence to their medication. Seven clusters were randomized to usual care (control group).

MAIN OUTCOMES AND MEASURES

The primary outcome was the change in mean fasting blood glucose from baseline to 12-month follow-up. Secondary outcomes included changes in mean systolic blood pressure, mean diastolic blood pressure, mean body mass index, percentage change in the proportion of low physical activity, harmful alcohol consumption, current smoking, low fruit and vegetable intake, and antihyperglycemic medication status.

RESULTS

Of 244 participants, 120 women (56.6%) and 92 men (43.4%) completed the trial. At baseline, the mean (SD) age was 51.71 (8.77) years; 127 participants were in the intervention group, and 117 participants were in the control group (usual care). At baseline, the mean (SD) fasting blood glucose level was 156.06 (44.48) mg/dL (158.48 [45.50] mg/dL in the intervention group and 153.43 [43.39] mg/dL in the control group). At 12-month follow-up, the mean fasting blood glucose decreased by 22.86 mg/dL in the intervention group, whereas it increased by 7.38 mg/dL in the control group. The mean reduction was 27.90 mg/dL greater with the intervention (95% CI, -37.62 to -18.18 mg/dL; P < .001). In secondary outcome analyses, there was a greater decline in mean systolic blood pressure in the intervention group than in the control group (-5.40 mm Hg; 95% CI, -8.88 to -1.92 mm Hg; P = .002). There was detectable difference in the intake of antihyperglycemic medication between the groups (relative risk, 1.35; 95% CI, 1.1 to 1.74; P = .02).

CONCLUSIONS AND RELEVANCE

These findings suggest that an FCHV-delivered intervention is associated with reduced blood glucose levels among adults with type 2 diabetes in a low-resource setting in Nepal.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03304158.

Periodontitis and identification of undiagnosed hyperglycemia

Abstract Introduction Individuals with pre-diabetes have altered glycemic levels, are generally asymptomatic, and are at increased risk for developing type 2 diabetes mellitus. Objective Identify the prevalence of periodontal individuals with undiagnosed hyperglycemia and associated impact factors. Material and method Fifty-six patients with periodontitis and without diabetes self-report, users of dental clinic services at Federal University of Juiz de Fora were included in this research, during one year and a half of experimental evaluation. Socioeconomic and demographic data, anthropometric patterns, fasting capillary blood glucose, and complete periodontal examination (six sites per tooth) were evaluated. Result The sample consisted of 58.9% female, mean age 53 years old, 58.9% obese/overweight and 45.3% had a low level of education. A total of 28.6% (n=16) participants had undiagnosed hyperglycemia (between 100 to 160 mm / dL), of which 81.3% were obese/overweight, 25% were smokers, 56.3% reported having a history of diabetes in the family, 93.8% had a family income up to 2 brazilian´s minimum wages. BMI values were higher in the group of patients with hyperglycemia (29.8 ± 5.7, p = 0.03) compared to the group without hyperglycemia (26.6 ± 5.6). Patients with hyperglycemia had a greater number of sites with clinical attachment loss (CAL) between 4 and 6 mm (p = 0.04) when compared with the normoglycemic group. Conclusion Undiagnosed CAL attachment loss between 4 and 6 mm due to periodontitis than normoglycemic individuals.

Capillary glucose concentration during oral glucose tolerance test for the diagnosis of gestational diabetes

OBJECTIVE

To assess concordance between two point-of-care testing (POCT) devices and the standard laboratory method in screening for gestational diabetes mellitus (GDM) in Huesca.

METHODS

Pregnant women who met criteria for an oral glucose tolerance test (OGTT) and attended the laboratory between October 2017 and November 2018 were recruited in this prospective observational study. Glucose was measured in venous (laboratory) and capillary blood (Accu-Chek or Contour Next glucometers). GDM was diagnosed attending to NDDG criteria for venous samples or capillary-specific cut-off. Linear regression, Passing-Bablok, Bland-Altman, and the kappa coefficient were used to study concordance between POCT and laboratory method.

RESULTS

Data from 109 women were analyzed (57 for Accu-Chek, 52 for Contour Next). Statistical analyses showed good agreement between both POCT and laboratory method. There were no statistical differences in fasting glucose measurements between capillary and venous samples and both POCT devices meet the ISO 15197 standard. Accu-Chek showed good agreement (k=0.629) regarding the laboratory method in classifying GDM, with an acceptable inter-evaluator bias of 3.5% (P<0.001).

CONCLUSION

POCT can be used to obtain fasting values and reduce overall waiting times for patients. Additionally, Accu-Chek can be used to diagnose GDM in remote areas applying specific cut-off values.

Diabetes mellitus and laboratory medicine in sub-Saharan Africa: challenges and perspectives

Diabetes mellitus is an increasing public health problem in sub-Saharan Africa with a substantial socioeconomic burden. Although laboratory medicine has been recognized as one of the six key public health functions, there are still gaps in strengthening of laboratory services in developing countries. In the last decades, a lot of progress has been made in the diagnostic field of infectious diseases, whereas the diagnosis of noncommunicable diseases is still insufficient and uneven. This article analyses the challenges encountered in diagnosing and monitoring of diabetes mellitus in sub-Saharan Africa and explores new alternative diagnostic tools.

Risk of developing Diabetes Mellitus among urban poor South Indian population using Indian Diabetes Risk Score

Background:

Diabetes mellitus is increasing its share of burden to the health-related problems in developing countries such as India. Urban slum residents constitute the “vulnerable population” who lack the basic health amenities. Lack of effective screening for primary prevention has been one of the reasons for the rising burden.

Materials and Methods:

The cross-sectional study was conducted among 400 adults aged between 30 and 60 years residing in a settled slum of Rukmini Nagar area of Belagavi city, Karnataka. Data were collected after taking written informed consent from each participant using a pretested questionnaire that included demographic information and details of the risk factors. Risk of developing diabetes was assessed by using Indian Diabetes Risk Score. Results are expressed as proportions, and analysis was done using Chi-square test and multiple logistic regression analysis.

Results:

The mean age of participants was 44.3 ± 8.7 years. The proportion of low, moderate, and high risk of developing diabetes mellitus was 7%, 63%, and 30%, respectively. The prevalence of newly diagnosed cases was 10.25%. Moreover, 57.1% of them with positive family history were in the high risk category; 76.9% of the sedentary workers were at higher risk; overweight and obese individuals had higher proportion of the high and moderate risk (P < 0.0001). Correlation coefficient (R) was 0.782, and coefficient of determination (R²) was 0.61.

Conclusions:

Our study demonstrated that advancing age, low physical activity, family history, overweight, and obesity were the prominent factors that predicted the risk of diabetes in the near future. Hence, focused interventions for urban slum dwellers are imperative and draw special attention.

Distribution of diabetes, hypertension and non-communicable disease risk factors among adults in rural Bangladesh: a cross-sectional survey

Background

Non-communicable diseases (NCDs) are increasing in low-income settings. We conducted a survey of risk factors, blood pressure and blood glucose in rural Bangladesh and assessed variations by age, sex and wealth.

Methods

We surveyed a random sample of 12 280 adults aged >30 years in 96 villages in rural Bangladesh. Fieldworkers measured blood glucose and conducted an glucose tolerance test with a repeat blood test 120 min post glucose ingestion. Blood pressure, anthropometric, socioeconomic, lifestyle and behavioural risk factors data were also collected. Data were analysed to describe the prevalence of diabetes, intermediate hyperglycaemia, hypertension and NCD risk factors by age, sex and wealth.

Results

Women had higher levels of overweight or obesity and lower levels of physical activity and fruit and vegetable consumption than men; 63% of men used tobacco compared with 41.3% of women. Overweight or obesity and abdominal obesity (waist to hip ratio) increased with socioeconomic status (least poor vs most poor: OR (95% CI) 3.21 (2.51 to 4.11) for men and 2.83 (2.28 to 3.52) for women). Tobacco use, passive smoke exposure and salt consumption fell with increasing socioeconomic status in both sexes. Clustering of risk factors showed more than 70% of men and women reported at least three risk factors. Women in the least poor group were 33% more likely to have three or more risk factors compared with women in the most poor group (1.33 (95% CI 1.17 to 1.58)). The combined prevalence of impaired fasting glucose, impaired glucose tolerance and diabetes was 26.1% among men and 34.9% among women, and increased with age. The prevalence of prehypertension and hypertension was 30.7% and 15.9% among men and 27.2% and 22.5% among women, with similar rising prevalence with age.

Conclusion

NCD risk factors, hyperglycaemia and raised blood pressure are an immediate health threat in rural Bangladesh. Initiatives to improve detection, treatment and prevention strategies are needed.

Structural equation modeling to identify the risk factors of diabetes in the adult population of North India

Background

A non-communicable disease risk factor survey (based on World Health Organization STEP approach to Surveillance, i.e., WHO-STEPS) was done in the state of Punjab, India in a multistage stratified sample of 5127 individuals. The study subjects were administered the WHO STEPS questionnaire and also underwent anthropometric and biochemical measurements. This study aimed at exploring the risk factors of diabetes using a Structural Equation Modeling (SEM) approach in the North Indian state of Punjab.

Results

Overall prevalence of diabetes mellitus among the study participants was found out to be 8.3% (95% CI 7.3-9.4%). The final SEM had excellent fit considering the model parameters. The following risk factors deemed to have a direct statistically significant effect on blood sugar status: family history of diabetes (4.5), urban residence (3.1), triglycerides (0.46), increasing waist circumference (0.18), systolic blood pressure (0.11), and increasing age (0.05). There are specific indirect effects of alcohol use (1.43, p = 0.001), family h/o diabetes (0.844, p = 0.001), age (0.156, p < 0.001), waist circumference (0.028, p = < 0.001) and weekly fruit intake (- 0.009, p = 0.034) on fasting blood glucose. Indirect effects of waist circumference, alcohol intake and age on blood sugar levels are mediated by raised blood pressure. Waist circumference mediates the indirect effects of age, family h/o of diabetes, alcohol intake and weekly fruit intake on blood sugar levels. Triglycerides also mediated the indirect effects between age and diabetes.

Conclusions

Family history of diabetes, urban residence, alcohol use, increasing age, and waist circumference are the key variables affecting diabetes status in the Indian population. The results of this study further strengthens the evidence that lifestyle changes in the form of physical activity and healthy diet are required to prevent and control diabetes. Those with family h/o diabetes constitute a high risk group and should be targeted with regular screening and lifestyle intervention package.

Geographic and sociodemographic variation of cardiovascular disease risk in India: A cross-sectional study of 797,540 adults

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of mortality in India. Yet, evidence on the CVD risk of India's population is limited. To inform health system planning and effective targeting of interventions, this study aimed to determine how CVD risk-and the factors that determine risk-varies among states in India, by rural-urban location, and by individual-level sociodemographic characteristics.

METHODS AND FINDINGS

We used 2 large household surveys carried out between 2012 and 2014, which included a sample of 797,540 adults aged 30 to 74 years across India. The main outcome variable was the predicted 10-year risk of a CVD event as calculated with the Framingham risk score. The Harvard-NHANES, Globorisk, and WHO-ISH scores were used in secondary analyses. CVD risk and the prevalence of CVD risk factors were examined by state, rural-urban residence, age, sex, household wealth, and education. Mean CVD risk varied from 13.2% (95% CI: 12.7%-13.6%) in Jharkhand to 19.5% (95% CI: 19.1%-19.9%) in Kerala. CVD risk tended to be highest in North, Northeast, and South India. District-level wealth quintile (based on median household wealth in a district) and urbanization were both positively associated with CVD risk. Similarly, household wealth quintile and living in an urban area were positively associated with CVD risk among both sexes, but the associations were stronger among women than men. Smoking was more prevalent in poorer household wealth quintiles and in rural areas, whereas body mass index, high blood glucose, and systolic blood pressure were positively associated with household wealth and urban location. Men had a substantially higher (age-standardized) smoking prevalence (26.2% [95% CI: 25.7%-26.7%] versus 1.8% [95% CI: 1.7%-1.9%]) and mean systolic blood pressure (126.9 mm Hg [95% CI: 126.7-127.1] versus 124.3 mm Hg [95% CI: 124.1-124.5]) than women. Important limitations of this analysis are the high proportion of missing values (27.1%) in the main outcome variable, assessment of diabetes through a 1-time capillary blood glucose measurement, and the inability to exclude participants with a current or previous CVD event.

CONCLUSIONS

This study identified substantial variation in CVD risk among states and sociodemographic groups in India-findings that can facilitate effective targeting of CVD programs to those most at risk and most in need. While the CVD risk scores used have not been validated in South Asian populations, the patterns of variation in CVD risk among the Indian population were similar across all 4 risk scoring systems.

The prevalence of gestational diabetes mellitus amongst black South African women is a public health concern

AIMS

This study aimed to determine the prevalence of gestational diabetes mellitus (GDM) amongst black South African women, describe GDM-associated risk factors and clinical management, and evaluate the efficacy of the fasting plasma glucose reading in diagnosing GDM.

METHODS

A cross-sectional screening study was performed. Pregnant women were recruited from the Chris Hani Baragwanath Academic Hospital in Johannesburg. A total of 1906 women underwent a two-hour 75 g oral glucose tolerance test at 24-28 weeks gestation. The World Health Organization's 2013 criteria were used to diagnose GDM.

RESULTS

A total of 174/1906 (9.1% (95% confidence interval (CI) 7.9, 10.5)) women were diagnosed with GDM. These women had significantly higher weights and body mass indexes (BMIs), were significantly older, of higher household socioeconomic status, more likely to report a family history of diabetes, and more likely to be diagnosed with anaemia than women without GDM. An age of ≥35 years, BMI ≥ 30 kg/m², and a family history of diabetes were significant risk factors. The fasting plasma glucose reading had a high sensitivity (83.3% (95% CI 77.0, 88.5)) in diagnosing GDM and 56.9% of the women with GDM were managed by diet therapy alone.

CONCLUSION

This is the largest GDM prevalence study in South Africa to date. A diagnosis of GDM increases the risk of both mother and child developing Type 2 diabetes which causes further health complications, decreases longevity, and burdens a country's healthcare system. Therefore, a GDM prevalence of 9.1% is concerning and warrants further discussion around current GDM screening policies.

Diabetes and Hypertension in India: A Nationally Representative Study of 1.3 Million Adults

IMPORTANCE

Understanding how diabetes and hypertension prevalence varies within a country as large as India is essential for targeting of prevention, screening, and treatment services. However, to our knowledge there has been no prior nationally representative study of these conditions to guide the design of effective policies.

OBJECTIVE

To determine the prevalence of diabetes and hypertension in India, and its variation by state, rural vs urban location, and individual-level sociodemographic characteristics.

DESIGN, SETTING, AND PARTICIPANTS

This was a cross-sectional, nationally representative, population-based study carried out between 2012 and 2014. A total of 1 320 555 adults 18 years or older with plasma glucose (PG) and blood pressure (BP) measurements were included in the analysis.

EXPOSURES

State, rural vs urban location, age, sex, household wealth quintile, education, and marital status.

MAIN OUTCOMES AND MEASURES

Diabetes (PG level ≥126 mg/dL if the participant had fasted or ≥200 mg/dL if the participant had not fasted) and hypertension (systolic BP≥140 mm Hg or diastolic BP≥90 mm Hg).

RESULTS

Of the 1 320 555 adults, 701 408 (53.1%) were women. The crude prevalence of diabetes and hypertension was 7.5% (95% CI, 7.3%-7.7%) and 25.3% (95% CI, 25.0%-25.6%), respectively. Notably, hypertension was common even among younger age groups (eg, 18-25 years: 12.1%; 95% CI, 11.8%-12.5%). Being in the richest household wealth quintile compared with being in the poorest quintile was associated with only a modestly higher probability of diabetes (rural: 2.81 percentage points; 95% CI, 2.53-3.08 and urban: 3.47 percentage points; 95% CI, 3.03-3.91) and hypertension (rural: 4.15 percentage points; 95% CI, 3.68-4.61 and urban: 3.01 percentage points; 95% CI, 2.38-3.65). The differences in the probability of both conditions by educational category were generally small (≤2 percentage points). Among states, the crude prevalence of diabetes and hypertension varied from 3.2% (95% CI, 2.7%-3.7%) to 19.9% (95% CI, 17.6%-22.3%), and 18.0% (95% CI, 16.6%-19.5%) to 41.6% (95% CI, 37.8%-45.5%), respectively.

CONCLUSIONS AND RELEVANCE

Diabetes and hypertension prevalence is high in middle and old age across all geographical areas and sociodemographic groups in India, and hypertension prevalence among young adults is higher than previously thought. Evidence on the variations in prevalence by state, age group, and rural vs urban location is critical to effectively target diabetes and hypertension prevention, screening, and treatment programs to those most in need.

Cardiovascular Health Status and Metabolic Syndrome in Adults Living in a Transition European Country: Findings from a Population-Based Study

BACKGROUND AND PURPOSE

There are only a few published studies on the relationship between cardiovascular health (CVH) status as proposed by the American Heart Association and the metabolic syndrome (MetS) in persons with cardiovascular disease (CVD). The aim of this study was to assess the prevalence of CVH and MetS and their correlation in the adult population of the Republic of Srpska, Bosnia and Herzegovina, in order to evaluate which set of cardiovascular risk factors (low or medium CVH status and MetS), or the combination of both, is a better predictor for the occurrence of CVD.

METHODS

We included 3601 adults (aged ≥25 years) from the Republic of Srpska National Health Survey 2010. CVH status was evaluated according to the American Heart Association criteria, whereas MetS was defined using the criteria of the National Cholesterol Education Program's Adult Treatment Panel III.

RESULTS

The prevalence of low or medium CVH status and MetS is significantly higher in participants who had experienced CVD than in those free of CVD. Our study showed that predictors for CVD occurrence were presence of MetS (odds ratio 3.61, 95% confidence intervals 2.14-6.07) and presence of both sets of cardiovascular risk factors in the same person (odds ratio 4.23, 95% confidence intervals 1.50-11.93).

CONCLUSION

Our results suggest that presence of both sets of cardiovascular risk factors (low or medium CVH status and MetS) is the strongest predictor of CVD. Identification of individuals with cardiovascular risk factors may provide opportunities to intervene earlier and can help reduce the risk of developing CVD.

Prevalence of diabetes and prediabetes in 15 states of India: results from the ICMR-INDIAB population-based cross-sectional study

BACKGROUND

Previous studies have not adequately captured the heterogeneous nature of the diabetes epidemic in India. The aim of the ongoing national Indian Council of Medical Research-INdia DIABetes study is to estimate the national prevalence of diabetes and prediabetes in India by estimating the prevalence by state.

METHODS

We used a stratified multistage design to obtain a community-based sample of 57 117 individuals aged 20 years or older. The sample population represented 14 of India's 28 states (eight from the mainland and six from the northeast of the country) and one union territory. States were sampled in a phased manner: phase I included Tamil Nadu, Chandigarh, Jharkhand, and Maharashtra, sampled between Nov 17, 2008, and April 16, 2010; phase II included Andhra Pradesh, Bihar, Gujarat, Karnataka, and Punjab, sampled between Sept 24, 2012, and July 26, 2013; and the northeastern phase included Assam, Mizoram, Arunachal Pradesh, Tripura, Manipur, and Meghalaya, with sampling done between Jan 5, 2012, and July 3, 2015. Capillary oral glucose tolerance tests were used to diagnose diabetes and prediabetes in accordance with WHO criteria. Our methods did not allow us to differentiate between type 1 and type 2 diabetes. The prevalence of diabetes in different states was assessed in relation to socioeconomic status (SES) of individuals and the per-capita gross domestic product (GDP) of each state. We used multiple logistic regression analysis to examine the association of various factors with the prevalence of diabetes and prediabetes.

FINDINGS

The overall prevalence of diabetes in all 15 states of India was 7·3% (95% CI 7·0-7·5). The prevalence of diabetes varied from 4·3% in Bihar (95% CI 3·7-5·0) to 10·0% (8·7-11·2) in Punjab and was higher in urban areas (11·2%, 10·6-11·8) than in rural areas (5·2%, 4·9-5·4; p<0·0001) and higher in mainland states (8·3%, 7·9-8·7) than in the northeast (5·9%, 5·5-6·2; p<0·0001). Overall, 1862 (47·3%) of 3938 individuals identified as having diabetes had not been diagnosed previously. States with higher per-capita GDP seemed to have a higher prevalence of diabetes (eg, Chandigarh, which had the highest GDP of US$ 3433, had the highest prevalence of 13·6%, 12.8-15·2). In rural areas of all states, diabetes was more prevalent in individuals of higher SES. However, in urban areas of some of the more affluent states (Chandigarh, Maharashtra, and Tamil Nadu), diabetes prevalence was higher in people with lower SES. The overall prevalence of prediabetes in all 15 states was 10·3% (10·0-10·6). The prevalence of prediabetes varied from 6·0% (5·1-6·8) in Mizoram to 14·7% (13·6-15·9) in Tripura, and the prevalence of impaired fasting glucose was generally higher than the prevalence of impaired glucose tolerance. Age, male sex, obesity, hypertension, and family history of diabetes were independent risk factors for diabetes in both urban and rural areas.

INTERPRETATION

There are large differences in diabetes prevalence between states in India. Our results show evidence of an epidemiological transition, with a higher prevalence of diabetes in low SES groups in the urban areas of the more economically developed states. The spread of diabetes to economically disadvantaged sections of society is a matter of great concern, warranting urgent preventive measures.

FUNDING

Indian Council of Medical Research and Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Method Comparison (Agreement) Studies: Myths and Rationale

Unprecedented technological growth in the last quarter of twentieth century has resulted in improved health care and opened new domains of health care research. This technological leap also facilitated the paradigm shift from hospital care to home care through development of 'point of care' devices. As early diagnoses and timely referral is a key to health management, these devices play an important role in improving health. Validation of the new technology in different settings is necessary before adopting it to practice. For a binary result like pregnancy test, it is trivial to use statistical tools like sensitivity, specificity etc. For a continuous variable like blood glucose level the analysis is not straightforward. Many of us misinterpret 'association' as 'agreement'. This misinterpretation is reflected in studies which have compared two different technologies. The findings of well conducted studies do not contribute to the evidence base just because of wrong analysis strategy. We delineate on finer nuances of analysis and interpretation of method comparison studies.

Noncommunicable disease in rural India: Are we seriously underestimating the risk? The Nallampatti noncommunicable disease study

AIM

To assess the prevalence of noncommunicable diseases in a true rural farming population in South India and compare the data with the landmark contemporary Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study.

METHODS

Local Ethics Committee approval and informed consent was obtained from all participants. Inclusion criteria were participants, aged ≥20 and ≤85 years, from Nallampatti, a classical farming village from Tamil Nadu state, India. All participants were administered a detailed questionnaire, had anthropometric measurements including height, weight, and waist circumference. Bloods were drawn for random blood glucose, glycated hemoglobin (HbA1c), nonfasting lipid profile, Cystatin C, uric acid, and hemoglobin. All participants had carotid intima-media thickness (CIMT) done by high-resolution B-mode carotid ultrasound.

RESULTS

More than 50% of the population had either diabetes or prediabetes based on HbA1c. Nearly, 40% of the population had hypertension with suboptimal control in those with known hypertension. Nearly, a third of the population had dyslipidemia, elevated cystatin C levels, and abnormal CIMT. The burden was higher than the comparable ICMR-INDIAB study in rural Tamil Nadu.

CONCLUSION

One-third to one-half of this rural farming population is at risk of cardiovascular disease, with poor control of preexisting cardiovascular risk factors. Current Indian data may underestimate the risk in different ethnic populations and regions of India. Long-term follow-up of this cohort for the incident cardiovascular disease will shed light on the true cardiovascular risk in a typical South Indian rural farming population.

Analytical Performance Evaluation of Infopia Element™ Auto-coding Blood Glucose Monitoring System for Self-Monitoring of Blood Glucose

BACKGROUND

Element™ Auto-coding Blood Glucose Monitoring System (BGMS; Infopia Co., Ltd., Anyang-si, Korea) was developed for self-monitoring of blood glucose (SMBG).

METHODS

Precision, linearity, and interference were tested. Eighty-four capillary blood samples measured by Element™ BGMS were compared with central laboratory method (CLM) results in venous serum. Accuracy was evaluated using ISO 15197:2013 criteria.

RESULTS

Coefficients of variation (CVs; mean) were 2.4% (44.2 mg/dl), 3.7% (100.6 mg/dl), and 2.1% (259.8 mg/dl). Linearity was shown at concentrations 39.25-456.25 mg/l (y = 0.989 + 0.984x, SE = 17.63). Up to 15 mg/dl of galactose, ascorbic acid, and acetaminophen, interference > 10.4% was not observed. Element™ BGMS glucose was higher than CLM levels by 3.2 mg/dl (at 200 mg/dl) to 8.2 mg/dl (at 100 mg/dl). The minimum specification for bias (3.3%) was met at 140 and 200 mg/l glucose. In the Clarke and consensus error grids, 100% of specimens were within zone A and B. For Element™ BGMS values, 92.9% (78/84) to 94.0% (79/84) were within a 15 mg/dl (< 100 mg/dl) or 15% (> 100 mg/dl) of the average CLM value.

CONCLUSION

Element™ BGMS was considered an appropriate SMBG for home use; however, the positive bias at low-to-mid glucose levels requires further improvement.

Short-term and long-term cardiovascular risk, metabolic syndrome and HIV in Tanzania

OBJECTIVE

To compare short-term and long-term cardiovascular disease (CVD) risk scores and prevalence of metabolic syndrome in HIV-infected adults receiving and not receiving antiretroviral therapy (ART) to HIV-negative controls.

METHODS

A cross-sectional study including 151 HIV-infected, ART-naive, 150 HIV-infected on ART and 153 HIV-negative adults. Traditional cardiovascular risk factors were determined by standard investigations. The primary outcome was American College of Cardiology/American Heart Association Atherosclerotic CVD (ASCVD) Risk Estimator lifetime CVD risk score. Secondary outcomes were ASCVD 10-year risk, Framingham risk scores, statin indication and metabolic syndrome.

RESULTS

Compared with HIV-negative controls, more HIV-infected adults on ART were classified as high lifetime CVD risk (34.7% vs 17.0%, p<0.001) although 10-year risk scores were similar, a trend which was similar across multiple CVD risk models. In addition, HIV-infected adults on ART had a higher prevalence of metabolic syndrome versus HIV-negative controls (21.3% vs 7.8%, p=0.008), with two common clusters of risk factors. More than one-quarter (28.7%) of HIV-infected Tanzanian adults on ART meet criteria for statin initiation.

CONCLUSIONS

HIV-infected ART-treated individuals have high lifetime cardiovascular risk, and this risk seems to develop rapidly in the first 3-4 years of ART as does the development of clusters of metabolic syndrome criteria. These data identify a new subgroup of low short-term/high-lifetime risk HIV-infected individuals on ART who do not currently meet criteria for CVD risk factor modification but require further study.

Factors associated with glucose tolerance, pre-diabetes, and type 2 diabetes in a rural community of south India: a cross-sectional study

BACKGROUND

India's national rural prevalence of type 2 diabetes has quadrupled in the past 25 years. Despite the growing rural burden, few studies have examined putative risk factors and their relationship with glucose intolerance and diabetes in rural areas. We undertook a cross-sectional study to determine the prevalence of impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and type 2 diabetes in a rural area of south India. In addition, we determined which factors were associated with type 2 diabetes.

METHODS

We sampled 2 % of the adult population from 17 villages using a randomized household-level sampling technique. Each participant undertook a questionnaire that included basic descriptive information and an assessment of socioeconomic status, physical activity, and dietary intake. Height, weight, waist and hip circumference, and blood pressure measurements were taken. An oral glucose tolerance test was used to determine diabetes status. We used stepwise logistic model building techniques to determine associations between several putative factors and type 2 diabetes.

RESULTS

753 participants were included in the study. The age- and sex-standardized prevalence of IFG was 3.9 %, IGT was 5.6 %, and type 2 diabetes was 10.8 %. Factors associated with type 2 diabetes after adjusting for confounders included physical activity [OR 0.81], rurality [OR 0.76], polyunsaturated fat intake [OR 0.94], body mass index [OR 1.85], waist to hip ratio [OR 1.62], and tobacco consumption [OR 2.82].

CONCLUSION

Our study contributes to the growing body of research suggesting that diabetes is a significant concern in rural south India. Associated risk factors should be considered as potential targets for reducing health burdens in India.

Use of capillary blood glucose for screening for gestational diabetes mellitus in resource-constrained settings

AIMS

The aim of the study was to evaluate usefulness of capillary blood glucose (CBG) for diagnosis of gestational diabetes mellitus (GDM) in resource-constrained settings where venous plasma glucose (VPG) estimations may be impossible.

METHODS

Consecutive pregnant women (n = 1031) attending antenatal clinics in southern India underwent 75-g oral glucose tolerance test (OGTT). Fasting, 1- and 2-h VPG (AU2700 Beckman, Fullerton, CA) and CBG (One Touch Ultra-II, LifeScan) were simultaneously measured. Sensitivity and specificity were estimated for different CBG cut points using the International Association of Diabetes in Pregnancy Study Groups (IADPSG) criteria for the diagnosis of GDM as gold standard. Bland-Altman plots were drawn to look at the agreement between CBG and VPG. Correlation and regression equation analysis were also derived for CBG values.

RESULTS

Pearson's correlation between VPG and CBG for fasting was r = 0.433 [intraclass correlation coefficient (ICC) = 0.596, p < 0.001], for 1H, it was r = 0.653 (ICC = 0.776, p < 0.001), and for 2H, r = 0.784 (ICC = 0.834, p < 0.001). Comparing a single CBG 2-h cut point of 140 mg/dl (7.8 mmol/l) with the IADPSG criteria, the sensitivity and specificity were 62.3 and 80.7 %, respectively. If CBG cut points of 120 mg/dl (6.6 mmol/l) or 110 mg/dl (6.1 mmol/l) were used, the sensitivity improves to 78.3 and 92.5 %, respectively.

CONCLUSIONS

In settings where VPG estimations are not possible, CBG can be used as an initial screening test for GDM, using lower 2H CBG cut points to maximize the sensitivity. Those who screen positive can be referred to higher centers for definitive testing, using VPG.

Prevalence and correlates of diabetes mellitus in Uganda: a population-based national survey

OBJECTIVE

We analysed fasting blood glucose (FBG) and other data collected as part of a population-based nationwide non-communicable disease risk factor survey, to estimate the prevalence of impaired fasting glycaemia (IFG) and diabetes mellitus and to identify associated factors in Uganda.

METHODS

The nationwide cross-sectional survey was conducted between April and July 2014. Participants were adults aged 18-69 years. A multistage stratified sample design was used to produce a national representative sample. Fasting capillary glucose was measured to estimate glycaemia. Data were managed with WHO e-STEPs software and Epi Info. Stata(®) survey procedures were used to account for the sampling design, and sampling weights were used to account for differential probability of selection between strata.

RESULTS

Of the 3689 participants, 1467 (39.8%) were males, and 2713 (73.5%) resided in the rural areas. The mean age was 35.1 years (standard deviation = 12.6) for males and 35.8 years (13.2) for females. The overall prevalence of IFG was 2.0% (95% confidence interval (CI) = 1.5-2.5%), whereas that of diabetes mellitus was 1.4% (95% CI 0.9-1.9%). The prevalence of IFG was 2.1% (95% CI 1.3-2.9%) among males and 1.9% (95% CI 1.3-2.6%) among females, whereas that of diabetes mellitus was 1.6% (95% CI 0.8-2.6%) and 1.1% (95% CI 0.6-1.7%), respectively. The prevalence of IFG was 2.6% (95% CI 1.4-3.8%) among urban and 1.9% (95% CI 1.3-2.4%) among rural residents, whereas that of diabetes mellitus was 2.7% (95% CI 1.4-4.1) and 1.0% (95% 0.5-1.6%), respectively. The majority of participants identified with hyperglycaemia (90.5% IFG and 48.9% diabetes) were not aware of their hyperglycaemic status. Factors associated with IFG were region of residence, body mass index and total cholesterol; factors associated with diabetes mellitus were age, sex, household floor finish and abdominal obesity.

CONCLUSION

The prevalence of IFG and of diabetes mellitus is low in the Ugandan population, providing an opportunity for the prevention of diabetes. The majority of persons with hyperglycaemia were not aware of their hyperglycaemic status, which implies a likelihood of presenting late with complications.

Glucose Metabolism Disorders, HIV and Antiretroviral Therapy among Tanzanian Adults

INTRODUCTION

Millions of HIV-infected Africans are living longer due to long-term antiretroviral therapy (ART), yet little is known about glucose metabolism disorders in this group. We aimed to compare the prevalence of glucose metabolism disorders among HIV-infected adults on long-term ART to ART-naïve adults and HIV-negative controls, hypothesizing that the odds of glucose metabolism disorders would be 2-fold greater even after adjusting for possible confounders.

METHODS

In this cross-sectional study conducted between October 2012 and April 2013, consecutive adults (>18 years) attending an HIV clinic in Tanzania were enrolled in 3 groups: 153 HIV-negative controls, 151 HIV-infected, ART-naïve, and 150 HIV-infected on ART for ≥ 2 years. The primary outcome was the prevalence of glucose metabolism disorders as determined by oral glucose tolerance testing. We compared glucose metabolism disorder prevalence between each HIV group vs. the control group by Fisher's exact test and used multivariable logistic regression to determine factors associated with glucose metabolism disorders.

RESULTS

HIV-infected adults on ART had a higher prevalence of glucose metabolism disorders (49/150 (32.7%) vs.11/153 (7.2%), p<0.001) and frank diabetes mellitus (27/150 (18.0%) vs. 8/153 (5.2%), p = 0.001) than HIV-negative adults, which remained highly significant even after adjusting for age, gender, adiposity and socioeconomic status (OR = 5.72 (2.78-11.77), p<0.001). Glucose metabolism disorders were significantly associated with higher CD4+ T-cell counts. Awareness of diabetes mellitus was <25%.

CONCLUSIONS

HIV-infected adults on long-term ART had 5-fold greater odds of glucose metabolism disorders than HIV-negative controls but were rarely aware of their diagnosis. Intensive glucose metabolism disorder screening and education are needed in HIV clinics in sub-Saharan Africa. Further research should determine how glucose metabolism disorders might be related to immune reconstitution.

Association of socioeconomic status measured by education, and cardiovascular health: a population-based cross-sectional study

OBJECTIVE

Cardiovascular health (CVH) is a relatively new concept defined by the American Heart Association (AHA). The aim of the present study was to assess whether the indices of CVH were discriminators of socioeconomic status (SES) in the adult population of the Republic of Srpska (RS).

DESIGN

Population-based cross-sectional study.

SETTING

RS, Bosnia and Herzegovina.

PARTICIPANTS

The study involved 4165 adults aged ≥18 years (mean age 50.2; 54% women) who participated in the National Health Survey performed from September to November 2010 in the RS.

STUDY VARIABLES

Participant's education was a proxy for SES. Potential discriminators of SES were indices of CVH presented according to AHA as: ideal health behaviours index (non-smoking, body mass index <25 kg/m(2), physical activity at goal level and healthy diet); ideal health factors index (untreated total cholesterol <200 mg/dL, untreated blood pressure <120/<80 mm Hg, untreated fasting glucose <100 mg/dL and non-smoking); and ideal CVH status (defined as all seven ideal health metrics present) versus intermediate and poor CVH status.

RESULTS

Participants with high educational levels had a significantly greater number of ideal CVH metrics, and ideal health factor metrics compared with those with low or medium educational level (OR 0.88 95% CI 0.77 to 0.99 and OR 0.88 95% CI 0.80 to 0.96; OR 0.81 95% CI 0.69 to 0.96 and OR 0.77 95% CI 0.68 to 0.87; respectively). The number of ideal behaviour metrics was not a discriminator of educational groups. Concerning the categories of CVH status the poor CVH was a discriminator for low and medium education compared with those with high education (OR 1.93 95% CI 1.24 to 3.01 and OR 1.54 95% CI 1.08 to 2.19, respectively).

CONCLUSIONS

Our findings emphasise the large potential for preventing cardiovascular disease, showing a low proportion with a favourable CVH profile, especially among low-educated people. It is necessary to consider prevention strategies aimed at improving CVH in RS, targeting primarily low educational groups.

Opinion and knowledge among hospital medical staff regarding diagnosis of diabetes and proper usage of a specific test tube for glucose analysis

BACKGROUND

Accuracy of blood sugar values, as examined by glucose analysis, has significant importance on the diagnosis of diabetes and follow up of diabetes treatment. Usage of a designated test tube significantly improves the accuracy of measurement. Knowledge of the medical staff is a major determinant in the current usage of such a technology. The aim of the study was to assess the level of knowledge exhibited by medical staff in the diabetes field and specifically for the usage of a designated tube to test blood glucose level.

METHODS

A prospective study. The staff of the internal and surgical departments and outpatient clinics at the Wolfson Medical Center completed a questionnaire that assessed the level of knowledge about the designated glucose test tube, other randomly used test tubes, the parameters that influence the blood glucose values in a non-designated tube and the diagnosis of diabetes.

RESULTS

A number of 160 questionnaires (50% from internal departments, 36% from surgical departments and 14% from outpatient clinics) were analysed. The majority of the staff members (65%) knew that diabetes is diagnosed by glucose levels in blood. Of the 35% that did not know, 91% were nurses. The majority (75%) knew that diabetes is diagnosed during fasting conditions; however, most of the staff indicated that 12 h is needed. Only 25% knew of the designated test tube, and most of the staff indicated that a regular chemistry tube was the tube of choice for them. The staff exhibited poor level of knowledge regarding the parameters that influence the quality of the test.

CONCLUSIONS

Staff members are not aware of the various aspects of diabetes diagnosis and the designated test tube for glucose measurements, and most of them use a tube that gives inaccurate measurements, therefore there is an urgent need to improve diabetes knowledge among staff members.

Fasting capillary blood glucose: an appropriate measurement in screening for diabetes and pre-diabetes in low-resource rural settings

OBJECTIVE

To evaluate the efficiency of fasting capillary blood glucose (FCG) measurement as compared with fasting venous plasma glucose (FPG) measurement in screening diabetes and pre-diabetes in low-resource rural settings.

SUBJECTS AND METHODS

In 2010, 993 participants were randomly selected from 9 villages in Yunnan province using cluster sampling method. Samples for FCG and FPG test were obtained after demographics and physical examination. The oral glucose tolerance test was performed in parallel as gold standard for diagnosis. Diagnostic capacities of the FCG measurement in predicting undiagnosed diabetes and pre-diabetes were assessed. The performance of FCG and FPG tests was compared.

RESULTS

Fifty-seven individuals with undiagnosed diabetes and 145 subjects with pre-diabetes were detected. The concordance between FCG and FPG levels was high (r = 0.75, p < 0.001). The area under the curve (AUC) for FCG test in predicting diabetes was 0.88 [95% confidence interval (CI) 0.82-0.93] with the optimal cutoff value of 5.65 mmol/l, sensitivity of 84.2%, and specificity of 79.3%. The corresponding values in FPG tests were 0.92 (95% CI 0.88-0.97) (AUC), 6.51 mmol/l (optimal cutoff point), 82.5% (sensitivity) and 98.3% (specificity), respectively. No significant difference was found in the AUC for the two screening strategies.

CONCLUSION

FCG measurement is considered to be a convenient, practicable screening method in low-resource rural communities with acceptable test properties.

Silica-dispersed glucose oxidase for glucose sensing: in vitro testing in serum and blood and the effect of condensation pH

The objectives of this study were to examine the feasibility of using glucose oxidase (GOx) dispersed in a silica matrix for glucose monitoring in whole blood, and then to assess whether the flexibility of silica sol-gel chemistry could be exploited to enhance glucose sensor performance and stability. Silica-dispersed GOx was deployed on platinized platinum (Pt) wire to form a Clark-type amperometric glucose sensor. Sensors were calibrated using buffered glucose standard solutions, and then tested against glucose spiked human serum and whole blood. All serum and whole blood measurements met the minimum FDA requirement of falling within the "A+B region" of a Clark Error Grid. To our knowledge this is the first report of using silica-dispersed GOx to measure glucose in whole blood. The effect of condensation pH on sensor performance was assessed by dispersing GOx in silica condensed at pH 3, 7 and 12, and then testing the sensor response against glucose calibration standards. The pH 12 silica sensors had statistically faster response time, and higher sensor sensitivity compared to pH 7, pH 3 silica and glutaraldehyde crosslinked sensors. Membranes of the pH 12 silica had statistically higher glucose diffusion coefficient than did the pH 7 and 3 sensors. GOx dispersed in pH 12 silica also had the longest half life. We hypothesize that the gel-like pH 12 silica gels provided reduced barriers to glucose diffusion, and the more aqueous microenvironment provided greater stability for the enzyme.

Screening for hyperglycemia in the developing world: rationale, challenges and opportunities

BACKGROUND

The prevalence of diabetes and prediabetes are increasingly high in developing countries, where detection rates remain very low. This manuscript discusses the rationale, challenges and opportunities for early detection of diabetes and prediabetes in developing countries.

METHODS

PubMed was searched up to March 2012 for studies addressing screening for hyperglycemia in developing countries. Relevant studies were summarized through key questions derived from the Wilson and Junger criteria.

RESULTS

In developing countries, diabetes predominantly affects working-age persons, has high rates of complications and devastating economic impacts. These countries are ill-equipped to handle advanced stages of the disease. There are acceptable and relatively simple tools that can aid screening in these countries. Interventions shown to be cost-effective in preventing diabetes and its complications in developed countries can be used in screen-detected people of developing countries. However, effective implementation of these interventions remains a challenge, and the costs and benefits of diabetes screening in these settings are less well-known. Implementing screening policies in developing countries will require health systems strengthening, through creative funding and staff training.

CONCLUSIONS

For many compelling reasons, screening for hyperglycemia preferably targeted, should be a policy priority in developing countries. This will help reorient health systems toward cost-saving prevention.

Cross-sectional study of conjugated linoleic acid in adipose tissue and risk of diabetes

BACKGROUND

Some experimental studies on conjugated linoleic acid (CLA) and insulin regulation suggested that CLA could be associated with risk of diabetes, but epidemiologic studies are lacking.

OBJECTIVE

The aim of the study was to test whether the amount of CLA in adipose tissue is associated with risk of diabetes.

DESIGN

A cross-sectional design was used to test the study hypothesis in 232 adults with diabetes and 1512 adults without diabetes who lived in Costa Rica. The cis-9, trans-11 and trans-10, cis-12 CLA isomers in adipose tissue and 48 other fatty acids were assessed by using gas chromatography. Prevalence ratios (PRs) and 95% CIs were estimated by using Poisson regression adjusted for potential confounders.

RESULTS

The mean (±SD) percentage of total fatty acids of CLA for the cis-9, trans-11 isomer in adipose tissue was 0.57 ± 0.18% in adults without diabetes and 0.53 ± 0.17% in adults with diabetes (P = 0.0078). The trans-10, cis-12 CLA isomer was not detected in adipose tissue. The cis-9, trans-11 CLA isomer was associated with a lower risk of diabetes. In comparison with the first quintile, the PR (95% CI) for the fifth quintile was 0.48 (0.31, 0.76) (P-trend = 0.0005) in the basic and 0.46 (0.29, 0.72) (P-trend = 0.0002) in the multivariable model. Additional adjustment for other fatty acids in adipose tissue including trans-9 16:1, which is a fatty acid that was previously associated with diabetes, did not modify the results.

CONCLUSION

The observed inverse association between the cis-9, trans-11 CLA in adipose tissue and diabetes risk is consistent with the hypothesis that CLA may be involved in insulin regulation.

Comparison of venous plasma glucose and capillary whole blood glucose in the diagnosis of gestational diabetes mellitus: a community-based study

BACKGROUND

Universal screening for gestational diabetes mellitus (GDM) is advocated in Indian women as they have the highest frequency of GDM among the South Asian population. For this the diagnostic procedure has to be simple, economical, and evidence based. Hence, this study was undertaken to compare point-of-care measured capillary whole blood glucose (CBG) with a glucometer and laboratory-estimated venous plasma glucose (VPG) and to suggest which is feasible as a diagnostic tool.

METHODS

Consecutive pregnant women in the third trimester were included in this study with the approval of the institutional ethical committee. They were given 75 g of oral glucose in the fasting state. After 2 h, CBG was measured by finger prick using an Accu-Chek(®) glucometer (Roche Diagnostics India Pvt. Ltd., Mumbai, India), and venous blood was drawn to estimate VPG in the laboratory by the glucose oxidase-peroxidase method. The diagnosis of GDM was based on a 2-h plasma glucose level of ≥7.8 mmol/L (World Health Organization criteria).

RESULTS

Among 819 pregnant women, 86 (10.5%) were diagnosed as having GDM. The CBG value at a 2-h plasma glucose level of ≥7.8 mmol/L had a sensitivity of 80.2% and specificity of 98.5% with false-positive and false-negative rates of 1.5% and 19.8%, respectively. The area under the receiver operator characteristic curve of CBG was 0.991.

CONCLUSION

The CBG value at a 2-h plasma glucose level of ≥7.8 mmol/L may be recommended for the diagnosis of GDM in healthcare centers where laboratory technology is not available.

Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: phase I results of the Indian Council of Medical Research-INdia DIABetes (ICMR-INDIAB) study

AIMS/HYPOTHESIS

This study reports the results of the first phase of a national study to determine the prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in India.

METHODS

A total of 363 primary sampling units (188 urban, 175 rural), in three states (Tamilnadu, Maharashtra and Jharkhand) and one union territory (Chandigarh) of India were sampled using a stratified multistage sampling design to survey individuals aged ≥ 20 years. The prevalence rates of diabetes and prediabetes were assessed by measurement of fasting and 2 h post glucose load capillary blood glucose.

RESULTS

Of the 16,607 individuals selected for the study, 14,277 (86%) participated, of whom 13,055 gave blood samples. The weighted prevalence of diabetes (both known and newly diagnosed) was 10.4% in Tamilnadu, 8.4% in Maharashtra, 5.3% in Jharkhand, and 13.6% in Chandigarh. The prevalences of prediabetes (impaired fasting glucose and/or impaired glucose tolerance) were 8.3%, 12.8%, 8.1% and 14.6% respectively. Multiple logistic regression analysis showed that age, male sex, family history of diabetes, urban residence, abdominal obesity, generalised obesity, hypertension and income status were significantly associated with diabetes. Significant risk factors for prediabetes were age, family history of diabetes, abdominal obesity, hypertension and income status.

CONCLUSIONS/INTERPRETATIONS

We estimate that, in 2011, Maharashtra will have 6 million individuals with diabetes and 9.2 million with prediabetes, Tamilnadu will have 4.8 million with diabetes and 3.9 million with prediabetes, Jharkhand will have 0.96 million with diabetes and 1.5 million with prediabetes, and Chandigarh will have 0.12 million with diabetes and 0.13 million with prediabetes. Projections for the whole of India would be 62.4 million people with diabetes and 77.2 million people with prediabetes.

The Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study: methodological details

BACKGROUND

Currently available estimates of diabetes prevalence in India are based on published data derived from very few studies. The Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study is a community-based survey conceived with the aim of obtaining the prevalence rates of diabetes in India as a whole, covering all 28 states, the National Capital Territory of Delhi, and two of the union territories in the mainland of India, with a total sample size of 124,000 individuals.

METHODS

A stratified multistage sampling design has been used. In all study subjects, a structured questionnaire was administered and anthropometric parameters and blood pressure were measured. Fasting capillary blood glucose was first determined using a glucose meter. An oral glucose load was then administered to all subjects except those with self-reported diabetes, and the 2 h post-load capillary blood glucose was estimated. In every fifth subject, a fasting venous sample was collected for measurement of lipids and creatinine, a resting 12-lead electrocardiogram was performed, and dietary assessment questionnaire was administered. In all diabetic subjects, an additional diabetes questionnaire was used and a fasting venous sample drawn for glycated hemoglobin.

RESULTS

All biological samples collected were analyzed in a central laboratory. All data collected were stored electronically. Quality control was achieved through multiple tiers of checks.

CONCLUSIONS

The ICMR-INDIAB study is the first of its kind attempting to provide accurate and comprehensive state- and national-level data on diabetes prevalence in India.

Analysis of the Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study

The Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study is the first nationally representative survey of diabetes in India. It aims to provide national and regional counts of diabetes and prediabetes and also of cardiovascular risk factors. This ambitious and complex survey uses robust sampling techniques, standardized methods, appropriate quality assurance, and a three-phase data collection. However, the survey should be completed within a reasonable time span to avoid a differential effect of secular trends on regional estimates. A high response rate and low missing values must also be ensured. Reliance on capillary whole blood glucose (CBG) for the diagnosis of hyperglycemic states is a limitation of the survey. However, this is a reasonable compromise given the practical challenges of such a large study. Despite a good correlation between CBG and venous plasma glucose (VPG), the use of CBG may misclassify glycemic status. A better characterization of the CBG-VPG relationship, and the performance of CBG for detecting hyperglycemia, using a much larger sample, seems therefore advisable. This should be possible given that venous blood has been collected on a sizeable subset of participants. The Indian Council of Medical Research and the Madras Diabetes Research Foundation deserve praise for this massive undertaking, which will highlight areas for policy action and establish a national framework for noncommunicable disease (NCD) surveillance. The ICMR-INDIAB survey lays the foundation for effective NCD prevention and control and for applied public health research.