The Southall Diabetes Survey: prevalence of known diabetes in Asians and Europeans

Diabetes Susceptibility Assessment Using the Indian Diabetes Risk Score: A Cross-Sectional Analytical Study on Young Medical Students in Chennai, South India

Background Youth must identify their diabetes risk factors because the disease is currently affecting young people at an epidemic rate. The Indian Diabetes Risk Score (IDRS) is a reliable and affordable method for determining a person's risk of developing diabetes. This study aims to evaluate the ability of the IDRS to predict type 2 diabetes mellitus (T2DM) and investigate the relationship between diabetes risk and other variables in young medical students. Methodology In this cross-sectional analytical survey of a cohort of 670 undergraduate medical scholars over six months, a meticulously designed semi-structured questionnaire was administered. The questionnaire captured sociodemographic specifics, substance use habits (tobacco and alcohol), dietary patterns, and physical activity patterns in line with the WHO STEPwise approach to non-communicable disease risk factor surveillance and the IDRS tool. Results There was an equal proportion of males and females. The majority were in their second year of study. Overall, 5.2% of students reported tobacco use, while alcohol consumption was reported by 25.6% of the cohort. Furthermore, IDRS score insights revealed that 80.2% of the participants exhibited low diabetes risk, 18.9% were categorized as moderate risk, and 0.9% demonstrated high risk. Gender (adjusted prevalence ratio (PR) = 1.8, 95% confidence interval (CI) 1.3-2.7) and tobacco usage (adjusted PR = 1.6 (1.1 to 2.2)) were found to be significantly associated with higher IDRS scores on multivariable analysis. Conclusions Illuminating the landscape of risk determinants among medical students in Chennai, this study accentuates the pressing need for bespoke interventions, underpinned by behavioral change theories. Such strategies can potentially catalyze healthier lifestyle shifts, shaping favorable public health trajectories in the foreseeable future.

Diabetes risk during pregnancy among second-generation immigrants: A national cohort study in Sweden

BACKGROUND AND AIMS

Gestational diabetes is more common in many first-generation immigrant women in Europe and other Western countries. Less is known about second-generation immigrant women; such knowledge is needed to understand generational influences on diabetes risk. We aimed to study second-generation immigrant women regarding the presence of all types of diabetes during pregnancy.

METHODS AND RESULTS

A cohort study was conducted using the Swedish National Birth Register, the National Patient Register, and the Total Population Register. We used Cox regression analysis to compute hazard ratios (HRs) and 99% confidence intervals (99% CI) for any diabetes during pregnancy and specific subtypes (gestational diabetes, pre-existing diabetes type 1, pre-existing diabetes type 2) in second-generation immigrant women compared with Swedish-born women with two Swedish-born parents while adjusting for sociodemographic factors, family history of diabetes, body mass index, smoking habits, and comorbidities. The study population included a total of 989,986 deliveries and 17,938 diabetes cases. The fully adjusted HR (with 99% CI) for any type of diabetes during pregnancy among second-generation immigrant women was 1.11 (1.05-1.18). Higher risks were found in women with parents from Africa, Asia, or Eastern Europe, as well as Denmark. A lower risk for pre-existing type 1 diabetes was found overall and for women with parents from most geographic regions.

CONCLUSION

In this national cohort study, the risk of all types of diabetes during pregnancy was increased in second-generation immigrant women. Diabetes prevention and treatment is especially important in these women both before and during pregnancy.

Fetuin-A mediates the difference in adipose tissue insulin resistance between young adult pakistani and norwegian patients with type 2 diabetes

BACKGROUND

South-Asian immigrants to Western countries have a high prevalence of type 2 diabetes mellitus (T2DM) and increased adipose tissue insulin resistance (AT-IR), as compared to their Western counterparts. Fetuin-A is a hepatokine known to influence AT-IR.

AIM

Can plasma fetuin-A concentrations explain an ethnic difference in adipose tissue insulin resistance?

METHODS

We performed a two-step euglycemic-hyperinsulinaemic clamp and measured plasma concentrations of fetuin-A and non-esterified fatty acids (NEFA), in 18 Pakistani and 21 Norwegians with T2DM (age 29-45y) in Norway. AT-IR was calculated as NEFA-suppression during the clamp. The adipokines/cytokines leptin, adiponectin, visfatin, PTX3, IL-1β, INF-γ, and IL-4 were measured in fasting plasma. Liver fat was estimated by CT-scans.

RESULTS

Despite a lower BMI, Pakistani patients displayed higher AT-IR than Norwegians. NEFA-suppression during clamp was lower in Pakistani than Norwegians (mean=-20.6%, 95%CI=[-40.8, -0.01] and p = 0.046). Plasma fetuin-A concentration was higher in Pakistani than Norwegians (43.4 ng/mL[12.7,74.0], p = 0.007) and correlated negatively to %NEFA-suppression during clamp (rho=-0.39, p = 0.039). Plasma fetuin-A concentration explained 22% of the ethnic difference in NEFA-suppression during the clamp. Pakistani patients exhibited higher plasma leptin and lower PTX3 levels than Norwegian, and plasma visfatin correlated positively to plasma fetuin-A levels in the Pakistani patients. We observed no correlation between plasma fetuin-A and liver fat, but fetuin-A correlated negatively with plasma IL-1β, INF-γ, and IL-4 concentrations. Plasma IL-4 concentration was lower in Pakistani than in Norwegian patients.

CONCLUSION

Fetuin-A may contribute to explain the discrepancy in T2DM prevalence between Pakistani and Norwegians patients by influencing AT-IR.

'Diabetes doesn't matter as long as we're keeping traditions alive': a qualitative study exploring the knowledge and awareness of Type 2 diabetes and related risk factors amongst the young Punjabi Sikh population in the UK

Objectives: It is well known that Sikhs are at an increased risk of Type 2 Diabetes (T2DM) due to a genetic predisposition. High level of education is associated with lower incidence of T2DM. Young Sikhs are well educated compared to other South Asian sub-groups. Despite this, T2DM rates remain high in Sikhs. The uptake of preventative services is also low within Sikhs. At present, no research has been conducted with the young Punjabi Sikh population on diabetes awareness in the UK. To address this gap, this study explores the knowledge and awareness of T2DM and related modifiable risk factors in the UK Punjabi Sikh community. Views surrounding T2DM health-seeking behaviours are also explored.Design: A qualitative design comprising of 1-to-1 semi-structured interviews was adopted. Thirteen Punjabi Sikh participants between the ages of 18-30 took part. Participants were recruited through a Sikh temple and University of Manchester Sikh Society using purposive and snowball sampling in West Yorkshire and North West England. Data were analysed using inductive thematic analysis taking a critical realist stance.Results: Three themes were identified: (1) Perceptions of the causes of T2DM, (2) Perceptions of factors impacting physical activity and diet, and (3) Attitudes towards health-seeking behaviours.Conclusions: The findings show that although well educated, participants overlooked physical activity as contributing factor towards T2DM onset. Additionally, gender and cultural norms influenced physical activity and diet, as these are passed through generations to preserve the collectivist Sikh culture. Exploration of health seeking behaviours also found young Punjabi Sikhs perceived the internet to be the preferred tool to seek T2DM information. These findings hold implications for health professionals, as the information and preventative services provided to Sikhs can be tailored to be culturally appropriate and in line with cultural and gender norms, such as bhangra dancing for physical activity.

Diabetes and COVID-19: Diseases of racial, social and glucose intolerance

Diabetes and coronavirus disease 2019 (COVID-19) are worldwide pandemics that have had a major impact on public health throughout the globe. Risk factors for developing diabetes and having adverse outcomes of COVID-19 appear to be similar; metabolic factors (such as obesity), non-White ethnicity and poorer socioeconomic status appear to be risk factors for both. Diabetes and COVID-19 have a significant effect on populations adversely affected by health inequality. Whilst we hope that COVID-19 will be mitigated by widespread use of vaccines, no such prospect exists for mitigating the pandemic of diabetes. In this brief opinion review, I compare risk factors for diabetes and adverse outcomes of COVID-19 and argue that tackling health and social inequality is likely to play a major role in solving the global diabetes pandemic and improve outcomes of COVID-19.

Association of risk factors with type 2 diabetes: A systematic review

Diabetes is the leading cause of severe health complications and one of the top 10 causes of death worldwide. To date, diabetes has no cure, and therefore, it is necessary to take precautionary measures to avoid its occurrence. The main aim of this systematic review is to identify the majority of the risk factors for the incidence/prevalence of type 2 diabetes mellitus on one hand, and to give a critical analysis of the cohort/cross-sectional studies which examine the impact of the association of risk factors on diabetes. Consequently, we provide insights on risk factors whose interactions are major players in developing diabetes. We conclude with recommendations to allied health professionals, individuals and government institutions to support better diagnosis and prognosis of the disease.

A head-to-head comparison review of biological and toxicological studies of isomaltulose, d-tagatose, and trehalose on glycemic control

Diabetes mellitus is the most common metabolic disorder contributing to significant morbidity and mortality in humans. Different preventive and therapeutic agents, as well as various pharmacological strategies or non-pharmacological tools, improve the glycemic profile of diabetic patients. Isomaltulose, d-tagatose, and trehalose are naturally occurring, low glycemic sugars that are not synthesized by humans but widely used in food industries. Various studies have shown that these carbohydrates can regulate glucose metabolism and provide support in maintaining glucose homeostasis in patients with diabetes, but also can improve insulin response, subsequently leading to better control of hyperglycemia. In this review, we discussed the anti-hyperglycemic effects of isomaltulose, D-tagatose, and trehalose, comparing their properties with other known sweeteners, and highlighting their importance for the development of the pharmaceutical and food industries.

Incidence and pathophysiology of diabetes in South Asian adults living in India and Pakistan compared with US blacks and whites

INTRODUCTION

We compared diabetes incidence in South Asians aged ≥45 years in urban India (Chennai and Delhi) and Pakistan (Karachi), two low-income and middle-income countries undergoing rapid transition, with blacks and whites in the US, a high-income country.

RESEARCH DESIGN AND METHODS

We computed age-specific, sex-specific and body mass index (BMI)-specific diabetes incidence from the prospective Center for Cardiometabolic Risk Reduction in South Asia Study (n=3136) and the Atherosclerosis Risk in Communities Study (blacks, n=3059; whites, n=9924). We assessed factors associated with incident diabetes using Cox proportional hazards regression.

RESULTS

South Asians have lower BMI and waist circumference than blacks and whites (median BMI, kg/m²: 24.9 vs 28.2 vs 26.0; median waist circumference, cm 87.5 vs 96.0 vs 95.0). South Asians were less insulin resistant than blacks and whites (age-BMI-adjusted homeostatic model assessment of insulin resistance, µIU/mL/mmol/L: 2.30 vs 3.45 vs 2.59), and more insulin deficient than blacks but not whites (age-BMI-adjusted homeostasis model assessment of β-cell dysfunction, µIU/mL/mmol/L: 103.7 vs 140.6 vs 103.9). Age-standardized diabetes incidence (cases/1000 person-years (95% CI)) in South Asian men was similar to black men and 1.6 times higher (1.37 to 1.92) than white men (26.0 (22.2 to 29.8) vs 26.2 (22.7 to 29.7) vs 16.1 (14.8 to 17.4)). In South Asian women, incidence was slightly higher than black women and 3 times (2.61 to 3.66) the rate in white women (31.9 (27.5 to 36.2) vs 28.6 (25.7 to 31.6) vs 11.3 (10.2 to 12.3)). In normal weight (BMI <25 kg/m²), diabetes incidence adjusted for age was 2.9 times higher (2.09 to 4.28) in South Asian men, and 5.3 times (3.64 to 7.54) in South Asian women than in white women.

CONCLUSIONS

South Asian adults have lower BMI and are less insulin resistant than US blacks and whites, but have higher diabetes incidence than US whites, especially in subgroups without obesity. Factors other than insulin resistance (ie, insulin secretion) may play an important role in the natural history of diabetes in South Asians.

Non-pharmacological interventions for the prevention of type 2 diabetes mellitus in low and middle-income countries: protocol for a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

The disease burden caused by type 2 diabetes mellitus is a prime public health concern. The prevalence and rate of deaths from diabetes mellitus in low- and middle-income countries (LMICs) are higher than the high-income countries. Increased physical activity and a balanced diet are essential and successful measures to prevent the onset of diabetes mellitus. This systematic review aims to explore the available non-pharmacological approaches for the prevention of type 2 diabetes mellitus in LMICs.

METHODS AND ANALYSIS

Six online databases will be explored to get related randomized controlled trials (RCTs) published in English from inception to September 2020, and two coders will independently screen, identify studies, extract data, and assess the risk of bias in each article. The searched articles will be included by applying specific inclusion and exclusion criteria. Joanna Briggs Institute's tool for RCTs will be used for appraising the trials critically. Narrative synthesis and pooled effect of the interventions will be demonstrated. A meta-analysis will be conducted using the random-effects model if assumptions are fulfilled.

DISCUSSION

This review is an attempt to explore the available non-pharmacological approaches for the prevention of type 2 diabetes mellitus in LMICs. Findings from the review will highlight effective non-pharmacological measures for the prevention of type 2 diabetes mellitus to guide policy for future strategies.

SYSTEMATIC REVIEW REGISTRATION

The review protocol has been registered ( CRD42020191507 ).

Adult Diabetes and Prediabetes Prevalence in Kuwait: Data from the Cross-Sectional Kuwait Diabetes Epidemiology Program

BACKGROUND

This study aimed to estimate the prevalence of diabetes and prediabetes in adults in Kuwait.

METHODS

The Kuwait Diabetes Epidemiology Program was a nationally representative, cross-sectional study of diabetes and obesity in Kuwait conducted between 2011 and 2014. The survey sampled 4937 adults in Kuwait aged 20 years or more and recorded participants' demographics, behaviours, medical history, physical measurements and blood biochemical measurements. Prediabetes was defined as fasting plasma glucose between 6.1 and 6.9 mmol/L or HbA1c between 6 and 6.4% (42-47 mmol/mol). Diabetes was defined as self-reported history with prescribed glucose-lowering medication or FPG ≥7mmol/L or HbA1c level ≥6.5% (≥48 mmol/mol).

RESULTS

The overall adjusted prevalence of diabetes was 19.1%. The overall adjusted prevalence of prediabetes was 13.5%. Diabetes prevalence was 5.4%, 14.2%, 38.7% and 64.8% in adults aged 20-29, 30-44, 45-59 and 60 years or more, respectively. Diabetes prevalence was 22.4% in men and 14.4% in women. Prediabetes prevalence was 14.8% in men and 11.5% in women. In Kuwaitis, diabetes and prediabetes prevalence was 21.8% and 11.1%, respectively, while prevalence in non-Kuwaitis was 18.2% for diabetes and 14.3% for prediabetes.

CONCLUSION

These findings illustrate the severe public health challenge posed by diabetes in Kuwait.

Effects of the Lysulin™ supplementation on pre-diabetes: A randomized double-blind, placebo-controlled clinical trial

BACKGROUND AND AIMS

Diabetes is a leading cause of morbidity and mortality worldwide. Recent studies have demonstrated that nutraceutical products have beneficial effects in diabetes. Present study aims to investigate whether a product (Lysulin™) containing amino acid lysine, micronutrient zinc and vitamin C will have beneficial effects in pre-diabetes.

METHODS

A randomized, double-blind, placebo-controlled trial was conducted for a period of 6 months. The two parallel groups (1:1) were Lysulin™ (Interventional group-IG) and placebo (control group-CG). Evaluations were done at baseline, 1, 3 and 6 months. Primary outcome was defined as change in glycaemic control measured by HbA1c from baseline. Other outcomes included change in; fasting plasma glucose (FPG), 2-h OGTT plasma glucose and lipid profile from baseline. Three multiple regression analyses were performed, where change in FPG, 2-h OGTT, and HbA1c post intervention from baseline respectively were the continuous dependent variable with other independent variables.

RESULTS

One hundred and ten participants were recruited, 50% (n = 55) were males and mean age (±SD) was 46.7 ± 9.9 years. A significantly higher percentage of participants in CG (25.4%, n = 14) developed diabetes in comparison to IG (7.3%, n = 4) (p = 0.018). FPG, 2-h OGTT and HbA1c significantly reduced in the IG only. Both total cholesterol and LDL cholesterol decreased significantly from baseline only in the IG. In all three regression models the best predictor of respective dependent variable was Lysulin™ treatment.

CONCLUSIONS

Lysulin™ improved glycaemic control, with reduced progression to diabetes, in those with pre-diabetes. Treatment also showed a beneficial reduction in total and LDL cholesterol levels.

TRIAL REGISTRATION

Sri Lanka Clinical Trials Registry, identifier: SLCTR/2018/022 (http://slctr.lk/trials/1290). Registered on 13th July 2018; Study protocol version 2.0 (23rd March 2018).

Barriers to diabetes awareness and self-help are influenced by people's demographics: perspectives of South Asians with type 2 diabetes

Aim: To determine whether barriers to diabetes awareness and self-help differ in South Asian participants of different demographic characteristics (age, gender, and literacy) with type 2 diabetes living in the United Kingdom. Methods: Six focus group discussions (FGDs) were carried out in patients who were categorized according to age (30-60 years, ≥60 years), gender (male, female) and literacy status (literate, illiterate). Data were analysed following the iterative process of thematic analysis techniques. Results: Barriers were demographic-specific. The illiterate groups reported language as the major barrier to improved diabetes awareness and self-help. The literate groups reported that information provided by healthcare providers was general, and not specific to their diet/culture. Major barriers to adherence to the recommended diet for diabetes included: insufficient knowledge/awareness about nutritional content of food (all groups); lack of self-will to resist eating sweets, especially during weddings/festivals (literate older groups/literate younger females/illiterate older males); difficulty cooking separate meals for diabetic and non-diabetic family members (illiterate/literate older females). Other barriers to seeking advice/help ranged from not wanting to disclose their diabetes as it may affect employment/work (literate groups) to fear of being singled out at social gatherings (illiterate groups). General lack of motivation to exercise was reported by all groups. Time constraints and not knowing what/how to exercise was reported by literate younger groups whilst the illiterate older groups reported to not having suitable exercising facilities at local communities. Different barriers were also reported when accessing healthcare; language barriers (illiterate groups), restricted access to doctors' appointments/difficulty attending specific appointment slots offered by General Practitioners (literate females). Conclusion: Different barriers exist to improved awareness about diabetes and self-help in different patient demographics. Lack of culturally appropriate diabetes educational/awareness programs in the community appeared to be a major barrier in most older and illiterate participants while younger participants reported time constraint.

Empowering local communities to make lifestyle changes: is the Health Mela a potential solution?

Background

Health Melas are community-led public health events held in the North West of England that provide health information and free health checks. This descriptive observational study evaluates whether Health Melas are able to identify undiagnosed cardiovascular disease (CVD) risk factors in hard-to-reach communities and encourage individuals to make lifestyle changes.

Methods

Attendees ≥18 years at three separate Health Melas in 2016–2017 were invited to participate in screening and counselling for CVD risk factors as part of a Health MOT. Information was collected about demographics, CVD risk factors, blood pressure, total cholesterol, blood sugar and attendees’ feedback. QRISK2 scoring system was used to estimate CVD risk.

Results

375 attendees completed a questionnaire. The highest proportion (36.9%) of attendees were from areas of the lowest Index of Health Deprivation and Disability quintile; 38.8% were of South Asian ethnicity. Of the attendees who were eligible for a free National Health Service Health Check, 9.1% had received one. Overall, 57.5% of all attendees had a QRISK2 score ≥10% (of whom 56.9% were not on statins), 92.2% of attendees believed the Health Mela will help them to make lifestyle changes, 98.2% said they had improved their understanding of their health, and 99.6% thought the Health Mela was useful. 73.6% of those who had received a previous Health MOT reported making lifestyle changes. There was a positive correlation between South Asian ethnicity and QRISK2 score.

Conclusion

This study suggests the Health Melas successfully involve South Asian populations and people from a lower Index of Health Deprivation and Disability. Attendees felt the events were useful, improved understanding of their health needs and encouraged them to make lifestyle changes. High rates of modifiable CVD risk factors were newly identified and a high proportion of attendees were found to be at intermediate to high risk of CVD.

The relationships between macronutrient and micronutrient intakes and type 2 diabetes mellitus in South Asians: A review

BACKGROUND

South Asians (SA) have increased prevalence of type 2 diabetes mellitus (T2DM). The role of nutrient intakes in T2DM in SA is not well understood, however.

OBJECTIVE

The paper reviewed the relationship between macronutrient and micronutrients intakes and T2DM in SA.

METHODS

The MEDLINE database was searched for relevant papers on this topic in SA.

RESULTS

There was some evidence that dietary fiber and linoleic acid intake may reduce but carbohydrates may increase the risk of T2DM. Some studies found higher energy from protein and fat in subjects with T2DM versus controls. Other studies, however, found lower carbohydrate intake among those with T2DM or no relationship between diet composition and T2DM. Several vitamins and minerals were also inversely related to T2DM.

CONCLUSIONS

The data were limited to a few epidemiological studies. Most studies did not distinguish between undiagnosed and known T2DM. Subjects with known T2DM are more likely to have changed their diet. Prospective cohort or randomized controlled studies examining the role of diet composition, using precise image-assisted dietary assessment method and blood biomarkers, in the development of T2DM among migrant and native SA are needed. Lastly, a more complete nutrient database for foods consumed by SA is needed.

Contribution of lower physical activity levels to higher risk of insulin resistance and associated metabolic disturbances in South Asians compared to Europeans

BACKGROUND

Insulin resistance and related metabolic disturbances are major risk factors for the higher T2D risk and associated morbidity and mortality amongst South Asians. The contribution of physical activity to the increased prevalence of insulin resistance and related disturbances amongst South Asians is unknown.

METHODS

We recruited 902 South Asian and European men and women, aged 35-85 years from the ongoing LOLIPOP study. Clinical characterisation comprised standardised questionnaire and measurement of height, weight, waist and hip circumference and blood pressure. Fasting bloods were taken for assessment of glucose, insulin, lipids and HbA1c. Physical activity was quantified using a validated accelerometer, Actigraph GT3X+, worn for 7 days. Univariate and multivariate approaches were used to investigate the relationship between ethnicity, physical activity, insulin resistance and related metabolic disturbances.

RESULTS

Total physical activity was ~31% (P = 0.01) lower amongst South Asians compared to Europeans (Mean MET.minutes [SD]: 1505.2 [52] vs. 2050.9 [86.6], P<0.001). After adjusting for age and sex, total physical activity had a negative association with HOMA-IR (B [SE]: -0.18 [0.08], P = 0.04) and fasting glucose levels (B[SE]: -0.11 [0.04], P = 0.02). There was no association between physical activity and other glycemic and lipid parameters. Total physical activity per week contributed towards the differences in insulin resistance and associated metabolic disturbances between South Asians and Europeans.

CONCLUSION

Lower levels of physical activity may contribute to the increased insulin resistance in South Asians compared to Europeans. Our results suggest that lifestyle modification through increased physical activity may help to improve glucose metabolism and reduce the burden of excess T2D and related complications amongst South Asians.

Impact of health literacy on diabetes outcomes: a cross-sectional study from Lahore, Pakistan

OBJECTIVES

To evaluate the functional health literacy of patients with type 2 diabetes in Lahore and its impact on glycaemic control.

STUDY DESIGN

A six-month cross-sectional study.

METHODS

Health literacy in 204 patients with diabetes was evaluated using a validated questionnaire (Short Test of Functional Health Literacy [s-TOFHLA]).

RESULTS

The frequency distribution among various age groups (P = 0.003), education levels (P = 0.0005), socio-economic status levels (P = 0.0005) and glycated haemoglobin (HbA_1C) levels (P = 0.0005) differed significantly with health literacy level. The majority of patients with diabetes (86.1%) with poor glycaemic control (HbA_1C >9%) had inadequate health literacy and were more likely to have retinopathy (odds ratio = 13.1, P = 0.003). Health literacy levels were not significantly different when compared for antidiabetic therapies (P = 0.234). Significant associations were observed between predictors of glycaemic control (s-TOFHLA score [P = 0.0005], education status [P = 0.0005] and disease risks [P = 0.005]) and HbA_1C, level. However, after adjusting for basic characteristics, only s-TOFHLA score had a significant association with HbA_1C level (P = 0.001).

CONCLUSIONS

These data suggest that inadequate health literacy is potentially associated with poor glycaemic control, and microvascular and macrovascular complications, particularly retinopathy. As such, educational and training programmes should be introduced to improve functional health literacy of patients with diabetes for better glycaemic control.

Need to improve awareness and treatment compliance in high-risk patients for diabetic complications in Nepal

OBJECTIVE/INTRODUCTION

It is known that knowledge, awareness, and practice influence diabetic control. We compared factors pertaining to healthy lifestyle (exercising, avoiding smoking), self-help (attending appointments, following treatment regimens), and diabetic awareness in high-risk patients for diabetic complications, specifically, those on insulin versus non-insulin treatment, and also those with a longer diabetic duration (≥5 years) versus a shorter duration.

METHODS

200 consecutive patients with type 2 diabetes (52.0±11.6 years) attending diabetic clinic at a referral hospital in Nepal were recruited. A structured questionnaire explored non-clinical parameters including age, gender, diabetic duration, awareness about diabetes control, self-help, and lifestyle. Clinical data were also measured: HbA1c, fasting blood sugar (FBS), blood pressure, and treatment type (insulin, diet/tablet).

RESULTS

A significantly higher proportion of patients on insulin (vs non-insulin) or with diabetic duration ≥5 years (vs <5 years) self-reported not doing regular exercise, forgetting to take medicine, and not knowing whether their diabetes was controlled (p≤0.005). HbA1c/FBS levels were significantly higher for patients on insulin or with a longer diabetic duration (p≤0.001). 92% of those on insulin (vs 31% on non-insulin) and 91% with diabetic duration ≥5 years (vs 28% of <5 years) self-reported to seeking medical help due to episodes of uncontrolled blood sugar in the last year (p<0.001).

CONCLUSION

Poor self-help/lifestyle and reduced knowledge/awareness about diabetic control was found in patients on insulin or with longer diabetic duration. This is a worrying finding as these patients are already at high risk for developing diabetic complications. The findings highlight need for targeting this more vulnerable group and provide more support/diabetic educational tools.

Diabetes mellitus and high blood pressure in relation to BMI among adult non-pregnant women in Bangladesh

PURPOSE

To investigate the association between overweight and obesity (in terms of BMI) and diabetes, HBP and diabetes-HBP comorbidity among adult women non-pregnant in Bangladesh.

METHODS

Information about demographics, socioeconomic, blood pressure and blood glucose levels were collected for 2022 women ageing above 35 years were collected from Bangladesh Demographic and Health Survey (BDHS 2011). The primary outcome variables were diabetes and high blood pressure. Diabetes was defined as fasting plasma glucose value ≥7.0mmol/L and HBP as systolic blood pressure ≥140mmHg or diastolic blood pressure ≥90mmHg. Blood pressure and plasma glucose measurement were performed by standard clinical procedures. Data were analysed using cross-tabulation, chi-square tests and logistic regression methods.

RESULTS

Mean age of the participants was 41.42 (SD=4.37). 38.7% of the women had BMI values ≥25. The prevalence of HBP, diabetes, and diabetes-HBP comorbidity was respectively 18% and 5.1%, and 2%. The adjusted odds of having diabetes, HBP and Diabetes-HBP comorbidity were respectively 2.14 (p=0.002; 95%CI=1.31-3.48), 2.3 (p=<0.0001; 95%CI=1.70-2.98), and 3.4 (p=0.004; 95%CI=1.47-7.81) times higher among overweight/obese women compared to those with normal weight.

CONCLUSIONS

Overweight and obesity account for a major proportion of diabetes, HBP and the comorbidity of these two among non-pregnant women. There remains a considerable risk for future expansion of diabetes and HBP as the prevalence of overweight/obesity is rising constantly. Maintaining a healthy BMI needs to be regarded as among the most important diabetes and HBP preventive strategies among Bangladeshi women.

Cinnamomum zeylanicum (Ceylon cinnamon) as a potential pharmaceutical agent for type-2 diabetes mellitus: study protocol for a randomized controlled trial

BACKGROUND

Previous studies have explored the anti-diabetic effects of Cinnamomum cassia extract in vivo and in vitro. However, there are no studies at present exploring the effects of the indigenous species of Sri Lankan cinnamon (Cinnamomum zeylanicum) in patients with diabetes mellitus. The present study aims to evaluate the potential effects of Cinnamomum zeylanicum extract as a pharmaceutical agent in patients with type-2 diabetes mellitus.

METHODS/DESIGN

The study will be conducted as a randomized, double-blind, placebo-controlled clinical trial for a period of 4 months at the Medical Clinic, University Medical Unit, National Hospital of Sri Lanka. A total of 210 subjects with diabetes, in three equal groups, will be recruited for the study. The patients will be randomized in a 1:1:1 ratio according to the method of block randomization and the subjects will be randomly and equally assigned into two test groups (n = 70 each) and one placebo group (n = 70). The population will be stratified at randomization based on age, gender and disease severity. The treatment drug is a capsule containing Cinnamomum zeylanicum extract as the active ingredient and the placebo capsule will contain lactose monohydrate. Two doses of Cinnamomum zeylanicum extracts (250 mg and 500 mg of the cinnamon extract) will be used. The study drugs will be double blinded to both investigators and participants. The visits and the evaluations will be done as follows: screening (visit 0), 1 month (visit 1), 2 months (visit 2), 3 months (visit 3) and 4 months (visit 4). The following primary outcome measures will be evaluated: glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG) and serum insulin. Secondary outcome measures include: Body Mass Index (BMI) and other anthropometric parameters, blood pressure, total cholesterol, low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL) and triglycerides (TAG). Data will be analyzed using SPSS version 14.

DISCUSSION

We describe the protocol for a clinical trial design evaluating the effects of Cinnamomum zeylanicum (Ceylon cinnamon) in patients with type-2 diabetes mellitus. The result of the present study, positive or negative, should provide a step change in the evidence guiding current and future policies regarding the use of cinnamon dietary supplementation in patients with diabetes.

TRIAL REGISTRATION

Sri Lanka Clinical Trials Registry (SLCTR), identifier: SLCTR/2017/010 ( http://slctr.lk/trials/714 ). Registered on 5 April 2017; study protocol version 3.1 21 March 2017.

Cardiovascular and Mortality Risks in Migrant South Asians with Type 2 Diabetes: Are We Winning the Battle?

PURPOSE OF REVIEW

We seek to describe the relationship between diabetes mellitus and cardiovascular risk in migrant South Asians compared to native white Europeans, and to determine the temporal change in this relationship over recent years.

RECENT FINDINGS

Recent evidence suggests that the excess mortality risk associated with diabetes is lower in the migrant South Asian population compared with white Europeans. By contrast, South Asians continue to demonstrate elevated cardiovascular morbidity compared to white Europeans, although to a lesser extent than was observed in previous decades. The excess mortality previously observed in South Asian migrants has attenuated with a lower mortality risk compared to white Europeans observed in several recent studies. We speculate that these findings may relate in part to earlier diabetes diagnosis and more prolonged exposure to cardiovascular risk factor management in the South Asian population. Further study is required to confirm these hypotheses.

Ethnic Variability in Glycemic Response to Sucrose and Isomaltulose

The aim of this study was to compare the glycemic response of Caucasians and Asians to two disaccharides of different glycemic index (GI), and to examine if ethnic groups that showed the largest glycemic response to sucrose would benefit the most when it is replaced with isomaltulose. Forty healthy participants (10 Chinese; 10 Malays; 10 Caucasians; and 10 Indians) consumed beverages containing 50 g of sucrose or isomaltulose on two separate occasions using a randomized crossover design. Capillary blood glucose was measured in a fasted state and at 15, 30, 45, 60, 90, and 120 min after beverage ingestion. Glycemic response to sucrose was significantly higher in Malays compared to Caucasians (p = 0.041), but did not differ between Caucasians vs. Chinese (p = 0.145) or vs. Indians (p = 0.661). When sucrose was replaced with isomaltulose, glycemic responses were significantly reduced in all ethnic groups, with the largest reduction in glycemic response being observed in Malays. Malays, who had the greatest glycemic response to sucrose, also showed the greatest improvement in glycemic response when sucrose was replaced with isomaltulose. This implies that Malays who are more susceptible to type 2 diabetes mellitus may benefit from strategies that replace high GI carbohydrate with lower GI alternatives to assist in glycemic control.

Health-Related Quality of Life, Subjective Health Complaints, Psychological Distress and Coping in Pakistani Immigrant Women With and Without the Metabolic Syndrome : The InnvaDiab-DEPLAN Study on Pakistani Immigrant Women Living in Oslo, Norway

The increasingly high number of immigrants from South-East Asia with The Metabolic Syndrome (MetS) is an important challenge for the public health sector. Impaired glucose is essential in MetS. The blood glucose concentration is not only governed by diet and physical activity, but also by psychological distress which could contribute to the development of MetS. The aim of this study is to describe health-related quality of life, subjective health complaints (SHC), psychological distress, and coping in Pakistani immigrant women, with and without MetS. As a part of an randomized controlled intervention study in Oslo, Norway, female Pakistani immigrants (n = 198) answered questionnaires regarding health related quality of life, SHC, psychological distress, and coping. Blood variables were determined and a standardized oral glucose tolerance test was performed. The participants had a high score on SHC and psychological distress. About 40% of the participants had MetS, and this group showed significantly lower general health, lower physical function, and more bodily pain, than those without MetS. Those with MetS also had more SHC, depressive symptoms, higher levels of somatisation, and scored significantly lower on the coping strategy of active problem solving. Pakistani immigrant women seem to have a high prevalence of SHC and psychological distress, especially those with MetS.

Diabetes in Immigrant Tibetan Muslims in Kashmir, North India

Tibetan Muslims have migrated from Lhasa (3000 m altitude) to Srinagar, India (altitude 1500 m) about 55 years back. We set out to study the prevalence of diabetes and prediabetes among this immigrant population. All consenting adults aged ≥18 years were questioned about a previous history of diabetes or any other medical history. Anthropometric data were recorded. Fasting blood glucose was measured in duplicate by Accu-check glucometer and HbA1C levels were measured. Of the 281 participants, 26 (9.25%) had diabetes whereas 46 (16.4%) had pre-diabetes; 24 reporting doctor-diagnosed diabetes. Participants with diabetes/pre-diabetes were more likely to be obese, smokers and hypertensive. Multiple logistic regression analysis revealed age to be significantly associated with a higher prevalence of diabetes. One in four adults ≥18 years among Tibetan Muslims have diabetes or prediabetes. Migration to lower altitude could have contributed to this high prevalence.

Review: Diabetes mellitus in South African Indians

Diabetes mellitus is common in the South Asian population residing in the Indian diaspora. Cardiovascular disease is a major cause of death in the Indians of South Africa. This study reviews the epidemiology and clinical pattern of diabetes mellitus in the South African Indian population from the available published literature. The concept of insulin resistance in the Indian population group appears to be interesting and has a novel approach towards explaining the high risk of cardiovascular disease. Dietary factors and physical inactivity could contribute to diabete mellitus.

Type 2 diabetes in people of South Asian origin: potential strategies for prevention

South Asians have a one in three lifetime risk for the development of diabetes, developing the condition ten years earlier than Europids. The high social and economic burden of diabetes in South Asians is augmented by greater rates of attrition from renal and cardiovascular disease. This article reviews the epidemiology and pathogenesis of diabetes in South Asians, and potential strategies by which the condition could be prevented or delayed in this high risk group.

The rising tide of type 2 diabetes

The number of people with diabetes is now considered to have reached epidemic proportions. Globally more the 150 million people have diabetes, accounting for more than 2% of the world's population and 3—5% of adults in most westernised societies. The incidence rates of type 1 and particularly type 2 diabetes are increasing in all societies and on all continents. Type 2 diabetes accounts for more than 95% of all diabetes. Type 2 diabetes is highly prevalent in the elderly and is now emerging in childhood. In developed countries diabetes and its complications constitute the fourth or fifth leading cause of death, and type 2 diabetes reduces remaining lifespan by 5—10 years. Diabetes (all types) is estimated to affect about 2.4 million people (prevalence of 4%) in the UK, of whom 1.4 million (prevalence of 2.5%) are diagnosed and one million undiagnosed. With the global prevalence of diabetes predicted to exceed 220 million by 2010 and 300 million by 2025 there is a major international challenge for optimal intervention and prevention strategies.

Review: Diabetes and cardiac disease in South Asians

South Asians have a higher prevalence of diabetes, coronary heart disease and cardiovascular death. Their predisposition to insulin resistance partly explains this excess risk. After immigration, the adoption of a western diet allied to increased sedentary behaviour leads to weight gain, hypertension and hyperlipidaemia, factors which in turn combine to amplify the chances of getting heart disease. Further contributory factors are increased sub-clinical inflammation, increased thrombogenic tendency and higher serum homocysteine levels. South Asians with diabetes might do as well as White people with respect to intensive glycaemic and blood pressure control. However, there is little evidence for measures to reduce cardiovascular risk as South Asians have not been included as a subgroup in most large trials. Future prospective studies, including studies on the prevention of diabetes and cardiovascular disease in this high-risk population, are therefore urgently required.

Should Physical Activity Recommendations for South Asian Adults Be Ethnicity-Specific? Evidence from a Cross-Sectional Study of South Asian and White European Men and Women

International public health guidelines recommend that adults undertake at least 150 min.week⁻¹ of moderate-intensity physical activity. However, the underpinning evidence has largely been obtained from studies of populations of white European descent. It is unclear whether these recommendations are appropriate for other ethnic groups, particularly South Asians, who have greater cardio-metabolic risk than white Europeans. The objective of our study was to determine the level of moderate-intensity physical activity required in South Asians adults to confer a similar cardio-metabolic risk profile to that observed in Europeans of similar age and body mass index (BMI) undertaking the currently recommended levels of 150 min.week⁻¹. 148 South Asians and 163 white Europeans aged 18 to 70 years were recruited. Physical activity was measured objectively via vertical axis accelerations from hip-worn accelerometers. Factor analysis was used to summarize the measured risk biomarkers into a single underlying latent “factor” describing overall cardio-metabolic risk. Sex did not modify the association between physical activity and the cardio-metabolic risk factor, so data for both sexes were combined and models adjusted for age, sex, BMI and accelerometer wear time. We estimated that South Asian adults needed to undertake 232 (95% Confidence interval: 200 to 268) min.week⁻¹ in order to obtain the same cardio-metabolic risk factor score as a white European undertaking 150 minutes of moderate-equivalent physical activity per week. The present findings suggest that South Asian men and women need to undertake ~230 minutes of moderate intensity physical activity per week. This equates to South Asians undertaking an extra 10–15 minutes of moderate intensity physical activity per day on top of existing recommendations.

Harnessing the Power of Difference: Colonialism and British Chronic Disease Research, 1940-1975

Recent studies of post-war chronic disease epidemiology have generally focused on the histories of research in the USA and UK. Using the archival records of a major British funding body, the Colonial Medical Research Committee and its successor the Tropical Medical Research Board, this article demonstrates the advantages of bringing a post-colonial analytic to this historiography. It highlights how the administrative and medical interests in population difference at the centre of the new epidemiology came to map onto political apparatus initially created to know, reform and govern colonial subjects. Although detached from imperial aims, British medical scientists nonetheless attached value to colonial populations on the basis of British benefit and turned various sites into laboratories to extract it. This relationship did not die with the end of imperial rule. British scientists continued to pursue chronic disease epidemiology in former colonies well into the post-war period, informing debates about Britain's own public health concerns.

Type 2 Diabetes: Why We Are Winning the Battle but Losing the War? 2015 Kelly West Award Lecture

Diabetes is among the biggest of the 21st-century global health challenges. In the U.S. and other high-income countries, thanks to investments in science, dedication to implementing these findings, and measurement of quality of care, there have been improvements in diabetes management and declines in rate of diabetes complications and mortality. This good news, however, is overshadowed by the ever-increasing absolute numbers of people with diabetes and its complications and the unprecedented growth of diabetes in low- and middle-income countries of the world. To comprehensively win the war against diabetes requires 1) concerted attention to prevention and 2) expansion of global research to better inform population-level policies to curb diabetes but also to better understand individual- and population-level variations in pathophysiology and phenotypes globally so that prevention and treatment can be tailored. For example, preliminary data show that thin people in low- and middle-income countries such as India commonly experience type 2 diabetes. Global studies comparing these thin Asian Indians with other high-risk groups such as Pima Indians, a population with a high mean BMI, suggest that type 2 diabetes may not be a single pathophysiological entity. Pima Indians may represent the well-studied phenotype of poor insulin action (type 2A), whereas Asian Indians represent the grossly understudied phenotype of poor insulin secretion (type 2B). This has major implications for diagnosis, prevention, and treatment and highlights the mismatch between where diabetes burdens occur (i.e., low- and middle-income countries) and where research happens (i.e., high-income countries). Correcting this imbalance will advance our knowledge and arsenal to win the global war against diabetes.

Use of plasma triglyceride/high-density lipoprotein cholesterol ratio to identify increased cardio-metabolic risk in young, healthy South Asians

Background & objectives:

Prevalence of insulin resistance and associated dyslipidaemia [high triglyceride (TG) and low high-density lipoprotein cholesterol (HDL-C) concentrations] are increased in South Asian individuals; likely contributing to their increased risk of type-2 diabetes and cardiovascular disease. The plasma concentration ratio of TG/HDL-C has been proposed as a simple way to identify apparently healthy individuals at high cardio-metabolic risk. This study was carried out to compare the cardio-metabolic risk profiles of high-risk South Asian individuals identified by an elevated TG/HDL-C ratio versus those with a diagnosis of the metabolic syndrome.

Methods:

Body mass index, waist circumference, blood pressure, and fasting plasma glucose, insulin, TG, and HDL-C concentrations were determined in apparently healthy men (n=498) and women (n=526). The cardio-metabolic risk profile of “high risk” individuals identified by TG/HDL-C ratios in men (≥ 3.5) and women (≥2.5) was compared to those identified by a diagnosis of the metabolic syndrome.

Results:

More concentrations of all cardio-metabolic risk factors were significantly higher in “high risk” groups, identified by either the TG/HDL-C ratio or a diagnosis of the metabolic syndrome. TG, HDL-C, and insulin concentrations were not significantly different in “high risk” groups identified by either criterion, whereas plasma glucose and blood pressure were higher in those with the metabolic syndrome.

Interpretation & conclusions:

Apparently healthy South Asian individuals at high cardio-metabolic risk can be identified using either the TG/HDL-C ratio or the metabolic syndrome criteria. The TG/HDL-C ratio may be used as a simple marker to identify such individuals.

The association between physical activity and sexual dysfunction in patients with diabetes mellitus of European and South Asian origin: The Oxford Sexual Dysfunction Study

Background

The present study aims to evaluate the relationship between physical activity and sexual dysfunction amongst an ethnic South Asian population living in the United Kingdom and compare the association with that of the native Caucasian population.

Methods

Twenty-five general practitioner clinics from eight primary care trusts in the United Kingdom collaborated in the Oxford Sexual Dysfunction Study. In each practice, a sample of diabetic and non-diabetic patients of European/Europid and South Asian origin were invited for the study. Erectile dysfunction (ED) was assessed using a five-item version of the International Index of Erectile Function. Premature ejaculation (PE) was diagnosed using the premature ejaculation diagnostic tool. Libido was assessed by asking participants to grade their desire for sexual activity. Physical activity during the past week was assessed using the short version of the International Physical Activity Questionnaire (IPAQ). A binary logistic regression analysis was performed in all adults, Europids and South Asians with ‘presence of ED’ as the dichotomous dependent variable (0 = ED absent; 1 = ED present) and age, diabetes status, physical activity, ethnicity, current smoking and use of antihypertensive medications as the independent variables.

Results

Sample size was 510, and mean age was 56.9 ± 9.7 years. There were 63.9 % (n = 326) Europid males in the study population. The prevalence of ED was 64.5 % and it was significantly higher in men with diabetes than in those without diabetes (84.4 vs. 49.0 %, p < 0.001). The overall prevalence of PE was 28.8 %, (with diabetes 32.6 %, without diabetes 25.8 %; p = 0.109). Reduced libido was reported by 26.9 % of study participants (with diabetes 32.8 %, without diabetes 22.0 %; p < 0.01). The median (IQR) total physical activity of the study population was 2373 (3612) MET-min/week. In the IPAQ categorical score, 36.8 % (n = 184/434) males were ‘highly active’, and 17.8 % (n = 89/434) were ‘inactive’. In all adults, age (OR: 1.06), South Asian ethnicity (OR: 1.40), physical inactivity (OR: 1.62) and presence of diabetes (OR: 3.90) all were associated with significantly increased risk of developing ED. A similar result was observed in Europids but not in South Asians.

Conclusions

Erectile dysfunction was associated with physical inactivity, mainly in Europid males, irrespective of diabetes status. This association was not observed in South Asian males with or without diabetes.

Adipose tissue and metabolic syndrome: too much, too little or neither

Obesity is strongly associated with metabolic syndrome. Recent research suggests that excess adipose tissue plays an important role in development of the syndrome. On the other hand, persons with a deficiency of adipose tissue (e.g. lipodystrophy) also manifest the metabolic syndrome. In some animal models, expansion of adipose tissue pools mitigates adverse metabolic components (e.g. insulin resistance, hyperglycaemia and dyslipidemia). Hence, there are conflicting data as to whether adipose tissue worsens the metabolic syndrome or protects against it. This conflict may relate partly to locations of adipose tissue pools. For instance, lower body adipose tissue may be protective whereas upper body adipose tissue may promote the syndrome. One view holds that in either case, the accumulation of ectopic fat in muscle and liver is the driving factor underlying the syndrome. If so, there may be some link between adipose tissue fat and ectopic fat. But the mechanisms underlying this connection are not clear. A stronger association appears to exist between excessive caloric intake and ectopic fat accumulation. Adipose tissue may act as a buffer to reduce the impact of excess energy consumption by fat storage; but once a constant weight has been achieved, it is unclear whether adipose tissue influences levels of ectopic fat. Another mechanism whereby adipose tissue could worsen the metabolic syndrome is through release of adipokines. This is an intriguing mechanism, but the impact of adipokines on metabolic syndrome risk factors is uncertain. Thus, many potential connections between adipose tissue and metabolic syndrome remain to unravelled.

Diabetes in India: what is different?

PURPOSE OF REVIEW

The purpose of this study was to review the epidemiology and pathogenesis of diabetes in Asian Indians with a particular focus on 'Asian Indian type 2 diabetes phenotype'.

RECENT FINDINGS

The prevalence of diabetes is rapidly increasing among Asian Indians, particularly in the past two decades. The diabetes rates in urban India now exceed that seen in Indians migrated to developed nations. Urbanization, changes from traditional healthier diets to high-refined carbohydrate intake, and sedentary lifestyle have contributed to this steep increase in the prevalence of diabetes in India. Type 2 diabetes among Asian Indians is characterized by onset at a younger age, greater abdominal obesity despite relatively lower BMI, greater insulin resistance, and early decline in beta cell function. Asian Indians are also at a higher risk for premature coronary artery disease.

SUMMARY

The clinical profile of type 2 diabetes in Asian Indians differs from Caucasians with higher central obesity, increased inflammatory markers such as high sensitive C-reactive protein, greater insulin resistance, early loss of beta cell function, and a higher risk of coronary artery disease. Mechanistic studies are needed to characterize the pathophysiology of the Asian Indian phenotype.

The influence of family history of diabetes on disease prevalence and associated metabolic risk factors among Sri Lankan adults

AIMS

To describe the influence of family history on diabetes prevalence and associated metabolic risk factors in a nationally representative sample from Sri Lanka.

METHODS

A cross sectional national survey was conducted among 5000 adults in Sri Lanka. Family history was evaluated at three levels: (1) parents, (2) grandparents (paternal and maternal) and (3) siblings. A binary-logistic regression analysis controlling for confounders (age, gender, BMI and physical activity) was performed in all patients with 'presence of diabetes' as the dichotomous dependent variable and using family history in father, mother, maternal grandmother/grandfather, paternal grandmother/grandfather, siblings and children as binary independent variables.

RESULTS

The sample size was 4485, mean age was 46.1 ± 15.1 years and 39.5% were males. In all adults, the prevalence of diabetes was significantly higher in patients with a family history (23.0%) than those without (8.2%) (P < 0.001). When family history was present in both parents, the prevalence of diabetes was 32.9%. Presence of a family history significantly increased the risk of diabetes [odds ratio (OR): 3.35, 95% confidence interval (CI): 2.78-4.03], obesity (OR: 2.45, 95% CI: 1.99-2.99), hypertension (OR: 1.25, 95% CI: 1.08-1.45) and metabolic syndrome (OR: 2.28, 95% CI: 1.97-2.63). In all adults, the presence of a family history of diabetes in a father (OR: 1.29, 95% CI: 1.02-1.63), mother (OR: 1.23, 95% CI: 1.11-1.36), paternal grandfather (OR: 1.27, 95% CI: 1.14-1.41), siblings (OR: 4.18, 95% CI: 3.34-5.22) and children (OR: 5.47, 95% CI: 2.93-10.19) was associated with a significantly increased risk of developing diabetes.

CONCLUSIONS

Family history and diabetes had a graded association in the Sri Lankan population, because the prevalence increased with the increasing number of generations affected. Family history of diabetes was also associated with the prevalence of obesity, metabolic syndrome and hypertension. Individuals with a family history of diabetes form an easily identifiable group who may benefit from targeted interventions.

Type 2 diabetes in youth in South Asia

People of South Asian origin are at a high risk of developing diabetes compared to that of other ethnic groups. Recent evidence suggests an emerging epidemic of youth-onset type 2 diabetes (T2DM) in the region, in parallel with the childhood obesity epidemic. Many risk factors such as foetal and early-life influences, the South Asian phenotype, family history of diabetes and environment factors are responsible for the early occurrence of T2DM in South Asia. The high risk supports the need for the opportunistic screening of children and adolescents for diabetes in South Asian countries. Early detection, lifestyle modification, weight reduction and drugs are central to the care of children with T2DM. Both population-based preventive strategies and interventions targeting children and adolescents with obesity and impaired glucose tolerance are required to combat the epidemic of youth-onset T2DM in South Asia.

Circulating insulin-like growth factor-binding protein 3 levels, independent of insulin-like growth factor 1, associate with truncal fat and systolic blood pressure in South Asian and white European preschool children

AIMS

To study the effect of the insulin-like growth factor (IGF) system on growth, adiposity and systolic blood pressure (SBP) in early life in British-born South Asian (SA) and White European (WE) children.

METHODS

The effect of IGF-1 and insulin-like growth factor-binding protein 3 (IGFBP-3) over the first 4 years in 204 healthy SA and WE children was investigated by mixed linear regression modelling. This enabled inclusion of all follow-up observations and adjustment for repeated measures.

RESULTS

At birth, SA babies were shorter and lighter than WE babies. Over 4 years, SA ethnicity was associated with lower height, weight and body mass index (BMI) standard deviation score (SDS), higher subscapular/triceps skinfold thickness (Ss/Tr SFT) and lower SBP (all p < 0.01). IGF-1 was associated with greater height (p = 0.03), weight (p < 0.001) and BMI SDS (p < 0.001), and IGFBP-3 with greater weight SDS (p < 0.001), BMI SDS (p = 0.001), Ss/Tr SFT (p = 0.003) and SBP (p = 0.023).

CONCLUSIONS

Over this first 4-year period of life, SA ethnicity was associated with being shorter, lighter, having more superficial truncal adiposity and lower SBP. IGFBP-3 (and not IGF-1) was independently associated with both superficial truncal adiposity and SBP, suggesting that IGFBP-3 is a potential metabolic and cardiovascular marker in healthy children in the early years of life.

Cardiovascular disease mortality in Asian Americans

BACKGROUND

Asian Americans are a rapidly growing racial/ethnic group in the United States. Our current understanding of Asian-American cardiovascular disease mortality patterns is distorted by the aggregation of distinct subgroups.

OBJECTIVES

The purpose of the study was to examine heart disease and stroke mortality rates in Asian-American subgroups to determine racial/ethnic differences in cardiovascular disease mortality within the United States.

METHODS

We examined heart disease and stroke mortality rates for the 6 largest Asian-American subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) from 2003 to 2010. U.S. death records were used to identify race/ethnicity and cause of death by International Classification of Diseases-10th revision coding. Using both U.S. Census data and death record data, standardized mortality ratios (SMRs), relative SMRs (rSMRs), and proportional mortality ratios were calculated for each sex and ethnic group relative to non-Hispanic whites (NHWs).

RESULTS

In this study, 10,442,034 death records were examined. Whereas NHW men and women had the highest overall mortality rates, Asian Indian men and women and Filipino men had greater proportionate mortality burden from ischemic heart disease. The proportionate mortality burden of hypertensive heart disease and cerebrovascular disease, especially hemorrhagic stroke, was higher in every Asian-American subgroup compared with NHWs.

CONCLUSIONS

The heterogeneity in cardiovascular disease mortality patterns among diverse Asian-American subgroups calls attention to the need for more research to help direct more specific treatment and prevention efforts, in particular with hypertension and stroke, to reduce health disparities for this growing population.

Pregnancy glycaemia and cord-blood levels of insulin and leptin in Pakistani and white British mother-offspring pairs: findings from a prospective pregnancy cohort

AIMS/HYPOTHESIS

To determine the extent to which gestational fasting and postload levels of glucose explain differences in infant fat mass between UK-born Pakistani and white British infants.

METHODS

Analyses were undertaken in a prospective pregnancy cohort study of 1,415 women and their singleton live-born infants (629 white British and 786 Pakistani). Infant fat mass was assessed by cord-blood leptin levels and fetal insulin secretion by cord-blood insulin levels. Maternal OGTTs were completed at 26-28 weeks of gestation.

RESULTS

Pakistani women had higher fasting and postload glucose levels and greater incidence of gestational diabetes than white British women. Higher fasting and postload glucose levels were associated with higher cord-blood levels of insulin and leptin in all participants, irrespective of ethnicity. Cord-blood leptin levels were 16% (95% CI 6, 26) higher in Pakistani than in white British infants. After adjustment for fasting glucose levels, this difference attenuated to 7% (-3, 16), and with additional adjustment for cord-blood insulin levels it attenuated further to 5% (-4, 14). Path analyses supported the hypothesis that fasting glucose levels mediate the relationship of Pakistani ethnicity to greater fat mass at birth, as measured by cord-blood leptin levels; on average, 19% of this mediation involved fetal insulin secretion. Postload glucose levels did not act as an important mediator of ethnic differences in cord-blood leptin levels. Results were very similar when 130 women with gestational diabetes were removed.

CONCLUSIONS/INTERPRETATION

These novel findings suggest a role of maternal pregnancy glycaemia in mediating differences in fat mass between Pakistani and white British infants.

Adipose tissue distribution in relation to insulin sensitivity and inflammation in Pakistani and Norwegian subjects with type 2 diabetes

Immigrants from South Asia to Western countries have a high prevalence of type 2 diabetes mellitus (T2DM) associated with obesity. We investigated the relationship between diabetes and adipose tissue distribution in a group of younger T2DM subjects from Norway and Pakistan. Eighteen immigrant Pakistani and 21 Norwegian T2DM subjects (age 29-45, 49% men) were included. They underwent anthropometrical measurements including bioelectrical impedance analysis, CT scans measuring fatty infiltration in liver and adipose and muscle tissue compartments in mid-abdomen and thigh, a euglycemic clamp, and blood samples for serum insulin and plasma glucose, adipokines and inflammation markers. Adipose tissue distribution was similar in Norwegians and Pakistanis. Pakistanis, but not Norwegians, showed a negative correlation between insulin sensitivity and visceral adipose tissue (VAT, rs = - 0.704, p = 0.003). Subcutaneous adipose tissue (SAT) correlated to leptin in both Pakistanis and Norwegians (rs = 0.88, p < 0.001 and 0.67, p = 0.001). SAT also correlated to C-reactive protein (CRP) in the Pakistanis only (rs = 0.55, p = 0.03), and superficial SAT to Interleukin-1 receptor antagonist (IL-1RA) in Norwegians only (rs = 0.47, p = 0.04). In conclusion, despite similar adipose tissue distribution in the two groups Pakistanis were more insulin resistant, with a negative correlation of VAT to insulin sensitivity, not present in Norwegians. The correlation of adipose tissue to Leptin, CRP and IL-1RA showed ethnic differences.

Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus

BACKGROUND

Ethnic minority groups in upper-middle-income and high-income countries tend to be socioeconomically disadvantaged and to have a higher prevalence of type 2 diabetes than is seen in the majority population.

OBJECTIVES

To assess the effectiveness of culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus.

SEARCH METHODS

A systematic literature search was performed of the following databases: The Cochrane Library, MEDLINE, EMBASE, PsycINFO, the Education Resources Information Center (ERIC) and Google Scholar, as well as reference lists of identified articles. The date of the last search was July 2013 for The Cochrane Library and September 2013 for all other databases. We contacted authors in the field and handsearched commonly encountered journals as well.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of culturally appropriate health education for people over 16 years of age with type 2 diabetes mellitus from named ethnic minority groups residing in upper-middle-income or high-income countries.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. When disagreements arose regarding selection of papers for inclusion, two additional review authors were consulted for discussion. We contacted study authors to ask for additional information when data appeared to be missing or needed clarification.

MAIN RESULTS

A total of 33 trials (including 11 from the original 2008 review) involving 7453 participants were included in this review, with 28 trials providing suitable data for entry into meta-analysis. Although the interventions provided in these studies were very different from one study to another (participant numbers, duration of intervention, group versus individual intervention, setting), most of the studies were based on recognisable theoretical models, and we tried to be inclusive in considering the wide variety of available culturally appropriate health education.Glycaemic control (as measured by glycosylated haemoglobin A1c (HbA1c)) showed improvement following culturally appropriate health education at three months (mean difference (MD) -0.4% (95% confidence interval (CI) -0.5 to -0.2); 14 trials; 1442 participants; high-quality evidence) and at six months (MD -0.5% (95% CI -0.7 to -0.4); 14 trials; 1972 participants; high-quality evidence) post intervention compared with control groups who received 'usual care'. This control was sustained to a lesser extent at 12 months (MD -0.2% (95% CI -0.3 to -0.04); 9 trials; 1936 participants) and at 24 months (MD -0.3% (95% CI -0.6 to -0.1); 4 trials; 2268 participants; moderate-quality evidence) post intervention. Neutral effects on health-related quality of life measures were noted and there was a general lack of reporting of adverse events in most studies - the other two primary outcomes for this review. Knowledge scores showed improvement in the intervention group at three (standardised mean difference (SMD) 0.4 (95% CI 0.1 to 0.6), six (SMD 0.5 (95% CI 0.3 to 0.7)) and 12 months (SMD 0.4 (95% CI 0.1 to 0.6)) post intervention. A reduction in triglycerides of 24 mg/dL (95% CI -40 to -8) was observed at three months, but this was not sustained at six or 12 months. Neutral effects on total cholesterol, low-density lipoprotein (LDL) cholesterol or high-density lipoprotein (HDL) cholesterol were reported at any follow-up point. Other outcome measures (blood pressure, body mass index, self-efficacy and empowerment) also showed neutral effects compared with control groups. Data on the secondary outcomes of diabetic complications, mortality and health economics were lacking or were insufficient.Because of the nature of the intervention, participants and personnel delivering the intervention were rarely blinded, so the risk of performance bias was high. Also, subjective measures were assessed by participants who self-reported via questionnaires, leading to high bias in subjective outcome assessment.

AUTHORS' CONCLUSIONS

Culturally appropriate health education has short- to medium-term effects on glycaemic control and on knowledge of diabetes and healthy lifestyles. With this update (six years after the first publication of this review), a greater number of RCTs were reported to be of sufficient quality for inclusion in the review. None of these studies were long-term trials, and so clinically important long-term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of the studies made subgroup comparisons difficult to interpret with confidence. Long-term, standardised, multi-centre RCTs are needed to compare different types and intensities of culturally appropriate health education within defined ethnic minority groups, as the medium-term effects could lead to clinically important health outcomes, if sustained.

Cardiovascular risk among South Asians living in Canada: a systematic review and meta-analysis

BACKGROUND

South Asians represent about 3% of the Canadian population and have a higher burden of certain cardiovascular risk factors and cardiovascular disease (CVD) compared with white people. The objective of this study was to review the literature to compare cardiovascular risk factors and disease management practices among adult South Asian and white Canadians.

METHODS

We searched MEDLINE, Embase, Cochrane and Cumulative Index to Nursing and Allied Health Literature databases from their inception through Feb. 17, 2014 and the reference lists of the selected articles. English-language studies of interventions and observational studies of biological mechanisms underlying CVD risk in South Asians conducted in Canada were eligible for inclusion. Where appropriate, we used random-effects meta-analyses to integrate results comparing the CVD risk profiles of South Asian and white Canadians.

RESULTS

We included 50 articles (n = 5 805 313 individuals) in this review. Compared with white Canadians, South Asian Canadians had a higher prevalence and incidence of CVD, an increased prevalence of diabetes (odds ratio [OR] 2.25, 95% confidence interval [CI] 1.81 to 2.80, p < 0.001) and hypertension (OR 1.11, 95% CI 1.02 to 1.22, p = 0.02), lower high-density lipoprotein cholesterol levels (mean difference -0.19 mmol/L, 95% CI -0.25 to -0.13 mmol/L, p < 0.001) and a higher percentage of body fat (men: absolute mean difference 3.23%, 95% CI 0.83% to 5.62%, p = 0.008; women: absolute mean difference 4.09%, 95% CI 3.46% to 4.72%, p < 0.001). South Asian people are also more sedentary, consume higher levels of carbohydrates and are less likely to smoke tobacco (OR 0.38, 95% CI 0.24 to 0.60, p < 0.001]) than white Canadians. No differences in access to diagnostic tests, outcomes following cardiovascular surgery or use of cardiac rehabilitation programs were apparent.

INTERPRETATION

Compared with white people, South Asian people living in Canada have a higher prevalence and incidence of CVD and possess a unique cardiovascular risk profile.

Differences in socioeconomic position, lifestyle and health-related pregnancy characteristics between Pakistani and White British women in the Born in Bradford prospective cohort study: the influence of the woman's, her partner's and their parents' place of birth

OBJECTIVE

To examine differences between Pakistani and White British women in relation to socioeconomic position, lifestyle and health-related pregnancy characteristics, and to determine whether these differences vary depending on the woman's, her partner's and both of their parents' place of birth.

DESIGN

Prospective cohort study.

SETTING

Bradford, UK PARTICIPANTS: 3656 Pakistani and 3503 White British women recruited to the Born in Bradford study.

MAIN OUTCOME MEASURES

Socioeconomic position (employment status; level of education; receipt of benefits; housing tenure), lifestyle characteristics (body mass index (BMI) at the start of pregnancy; smoking during pregnancy) and health-related pregnancy characteristics (hypertensive disorders of pregnancy; gestational diabetes; fasting glucose, postload glucose and fasting insulin at ∼27 weeks gestation).

RESULTS

Fewer Pakistani women were employed (OR 0.17, 95% CI 0.15 to 0.19), the difference being markedly less for UK born women. UK born Pakistani women were more likely, and South Asian born less likely, to be educated post 16 than White British women. Smoking was uncommon among Pakistani women, though the difference comparing UK born Pakistani women to White British women was less than for other groups. BMI was lower among Pakistani compared to White British women (adjusted mean difference -1.12, 95% CI -1.43 to -0.81), the difference being greatest when partners were UK born irrespective of the woman's place of birth. Pakistani women had higher fasting and postload glucose (mean difference 0.20 mmol/L, 95% CI 0.17 to 0.24; 0.37, 95% CI 0.28 to 0.45), higher fasting insulin and were more likely to have gestational diabetes (GDM).

CONCLUSIONS

Our results suggest that some socioeconomic, lifestyle and pregnancy characteristics could be beginning to change in response to migration to the UK, with generally beneficial changes, that is, improving education and employment prospects, lower BMI and no evidence that being UK born has further increased the risk of GDM, but some negative, that is, slight increases in smoking.

Retinopathy among young adults with Diabetes Mellitus from a tertiary care setting in Sri Lanka

BACKGROUND

Diabetic retinopathy (DR) is one of the leading causes for complete loss of vision among working-aged adults around the world. The present study aims to evaluate the rate of DR and its risk factors among the adults with young-onset diabetes from a tertiary care setting in Sri Lanka.

METHODS

A consecutive sample of 1,007 individuals referred from multiple centers, were invited for the study. Ophthalmological evaluation was done, with dilated indirect ophthalmoscopy by an Ophthalmologist. Retinopathy was classified according to the International Clinical DR Disease Severity Scale. An interviewer-administered questionnaire was used to collect socio-demographic and anthropometric details. Seated blood pressure, Fasting Blood Glucose (FBG), HbA1c and urine microalbumin were also measured. Data were analysed using SPSSv14. A binary logistic regression analysis was performed in all patients, with 'presence of DR' as the dichotomous dependent variable and other independent covariates.

RESULTS

Sample size was 684 (response rate-67.9%), mean age was 37.1 ± 5.9 years and 36.0% were males. Mean duration of diabetes was 5.2 ± 4.0 years. Previous retinal screening had been done in 51.0% by a non-specialist doctor and in 41.5% by a consultant ophthalmologist. Rate of any degree of DR in the study population was 18.1% (Males 16.4%, Females 20.0%; P = NS). In patients with DR, majority had mild Non-Proliferative DR (NPDR) (57.2%), while 32.2% had moderate NPDR, 0.8% had severe NPDR and 9.7% had maculopathy. Mean age, duration of diabetes, systolic (SBP) and diastolic blood pressure (DBP), FBG, HbA1c and urine microalbumin levels were significantly higher amongst the patients with DR. The results of the binary logistic regression indicate that the duration of diabetes (OR:1.24), HbA1c (OR:1.19), age (OR:1.11), urine Microalbumin (OR:1.11) and DBP (OR:1.04) all were significantly associated with DR.

CONCLUSIONS

In this large multi center study, nearly one in five adults with young-onset diabetes was found to have retinopathy. Age, duration of diabetes, HbA1C and urine Microalbumin levels were significantly associated with the presence of retinopathy, while HbA1c was also a significant factor determining severity. Nearly 50% of the study population has never undergone retinal screening by an ophthalmologist, highlighting the need for well organized screening programs.

Effect of a lifestyle intervention on weight change in south Asian individuals in the UK at high risk of type 2 diabetes: a family-cluster randomised controlled trial

BACKGROUND

The susceptibility to type 2 diabetes of people of south Asian descent is established, but there is little trial-based evidence for interventions to tackle this problem. We assessed a weight control and physical activity intervention in south Asian individuals in the UK.

METHODS

We did this non-blinded trial in two National Health Service (NHS) regions in Scotland (UK). Between July 1, 2007, and Oct 31, 2009, we recruited men and women of Indian and Pakistani origin, aged 35 years or older, with waist circumference 90 cm or greater in men or 80 cm or greater in women, and with impaired glucose tolerance or impaired fasting glucose determined by oral glucose tolerance test. Families were randomised (using a random number generator program, with permuted blocks of random size, stratified by location [Edinburgh or Glasgow], ethnic group [Indian or Pakistani], and number of participants in the family [one vs more than one]) to intervention or control. Participants in the same family were not randomised separately. The intervention group received 15 visits from a dietitian over 3 years and the control group received four visits in the same period. The primary outcome was weight change at 3 years. Analysis was by modified intention to treat, excluding participants who died or were lost to follow-up. We used linear regression models to provide mean differences in baseline-adjusted weight at 3 years. This trial is registered, number ISRCTN25729565.

FINDINGS

Of 1319 people who were screened with an oral glucose tolerance test, 196 (15%) had impaired glucose tolerance or impaired fasting glucose and 171 entered the trial. Participants were in 156 family clusters that were randomised (78 families with 85 participants were allocated to intervention; 78 families with 86 participants were allocated to control). 167 (98%) participants in 152 families completed the trial. Mean weight loss in the intervention group was 1.13 kg (SD 4.12), compared with a mean weight gain of 0.51 kg (3.65) in the control group, an adjusted mean difference of -1.64 kg (95% CI -2.83 to -0.44).

INTERPRETATION

Modest, medium-term changes in weight are achievable as a component of lifestyle-change strategies, which might control or prevent adiposity-related diseases.

FUNDING

National Prevention Research Initiative, NHS Research and Development; NHS National Services Scotland; NHS Health Scotland.

Forecasting the burden of type 2 diabetes in Singapore using a demographic epidemiological model of Singapore

OBJECTIVE

Singapore is a microcosm of Asia as a whole, and its rapidly ageing, increasingly sedentary population heralds the chronic health problems other Asian countries are starting to face and will likely face in the decades ahead. Forecasting the changing burden of chronic diseases such as type 2 diabetes in Singapore is vital to plan the resources needed and motivate preventive efforts.

METHODS

This paper describes an individual-level simulation model that uses evidence synthesis from multiple data streams-national statistics, national health surveys, and four cohort studies, and known risk factors-aging, obesity, ethnicity, and genetics-to forecast the prevalence of type 2 diabetes in Singapore. This comprises submodels for mortality, fertility, migration, body mass index trajectories, genetics, and workforce participation, parameterized using Markov chain Monte Carlo methods, and permits forecasts by ethnicity and employment status.

RESULTS

We forecast that the obesity prevalence will quadruple from 4.3% in 1990 to 15.9% in 2050, while the prevalence of type 2 diabetes (diagnosed and undiagnosed) among Singapore adults aged 18-69 will double from 7.3% in 1990 to 15% in 2050, that ethnic Indians and Malays will bear a disproportionate burden compared with the Chinese majority, and that the number of patients with diabetes in the workforce will grow markedly.

CONCLUSIONS

If the recent rise in obesity prevalence continues, the lifetime risk of type 2 diabetes in Singapore will be one in two by 2050 with concomitant implications for greater healthcare expenditure, productivity losses, and the targeting of health promotion programmes.