Prevalence and risk factor of diabetes among the elderly people in West Bengal: evidence-based LASI 1st wave

BACKGROUND

The complication of Diabetes is one of the important health issues among the older adult population in any region. The higher risks of diabetes prevalence among older adult people in the countries was due to social-cultural changes such as increasing urbanization, dietary changes, without physical activity, and unhealthy lifestyle behavior. The present study examines the prevalence and associated risk factors of diabetes among older adults in the state of West Bengal.

METHODS

The first wave of the Longitudinal Ageing Study in India 2017-18 was used to achieve the study objectives. Descriptive statistics with multinomial logistic regression models were used to carry out crude and adjusted odds ratios with 95% confidence intervals and examine the associated risk factors of diabetes prevalence among older adults.

RESULTS

The findings of the study indicate that the overall prevalence of diabetes among the study participants was found to be 12.4% which was significantly higher in urban areas (19%) compare to rural areas (6%). The socio-economic and bio-demographic factors like educational status, richest background family, marital status, obesity, and family history of diabetes were significantly associated with higher risks of diabetes prevalence among the older adult population in West Bengal. The risks of diabetes in the richest adult people were significantly higher than in the poorest adult people (OR = 2.78; 95% CI: 1.974-3.917). The higher risks of diabetes mellitus among the richest wealthy people are because of lifestyle behavior, smoking, and tobacco consumption respectively.

CONCLUSION

The study needs to policy and awareness program to reduce economic inequality and prevention of diabetes care and treatment-seeking behavior, especially for the older adult population in West Bengal.

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.

Unequal burden of equal risk factors of diabetes between different gender in India: a cross-sectional analysis

Many studies have supported that the burden of diabetes is shared differently by different genders due to various factors associated with it. This study aims at capturing whether women and men with a similar background, dietary and smoking habits, and biological conditions (blood pressure and body mass index (BMI)) are being affected equally or differently by diabetes. We have used cross-sectional data of NFHS-4 by covering the age group 15-49 years. Association between socio-economic background, dietary habits, biological conditions, and diabetes has been estimated using two separate multivariate logistic regression models. Results show that the overall prevalence of diabetes is higher among men (2.63%) than women (2.35%). Whereas, women belonging to urban areas (3.53%), Christian category (3.92%), richer section (3.22%), women with no schooling (2.51%), those reported never to consume pulses (2.66%) and green vegetables (2.40%) and daily consuming eggs (3.66%) and chicken or meat (3.54%) are more affected by diabetes than their men counterparts. Whereas men residing in rural areas (2.30%), belonging to the general category (3.12%), SCs (2.37%) and STs (1.72%) are more affected than their women counterparts. Results have also shown a higher prevalence of diabetes among obese men (11.46%), non-vegetarian (2.71%) and those who watch television almost every day (3.03%) as compared to their women counterparts. Regression analyses show that the richest, hypertensive, and obese women and men are significantly more likely to suffer from diabetes. This study concludes that women and men with similar socio-economic status, biological conditions, dietary and smoking habits are being affected differently by diabetes. Thus, there is a need for gender dimension in research to understand and validate the differences in the needed interventions for diabetes control in India.

NANO-BIOTECHNOLOGY AND ITS INNOVATIVE PERSPECTIVE IN DIABETES MANAGEMENT

Diabetes occurs due to the imbalance of glucose in the body known as glucose homeostasis, thus leading to metabolic changes in the body. The two stages hypoglycemia or hyperglycemia classify diabetes into various categories. Various bio-nanotechnological approaches are coupled up with nano particulates, polymers, liposome, various gold plated and solid lipid particulates, regulating transcellular transport, non specific cellular uptake, and paracellular transport, leading to oral, trans-dermal , pulmonary, buccal , nasal , specific gene oriented administration to avoid the patient's non compliance with the parental routes of administration. Phytochemicals are emerging strategies for the future prospects of diabetes management.

Glycemic improvement with a novel interim intervention technique using retrospective professional continuous glucose monitoring (GLITTER study): A study from Mumbai, India

BACKGROUND/AIMS

To assess the efficacy of a novel interim intervention technique using retrospective, blinded, professional continuous glucose monitoring system (pro CGM) with the Freestyle Libre Pro system over a 14-day single sensor wear-period.

METHODS

A retrospective analysis comprised of 105 consecutive adults at single centre in India with Type 2 diabetes, HbA1c > 53 mmol/mol (>7%), on non-insulin divabetes agents and/or insulin. The interim intervention technique included three visits over 14 days: Visit 1, sensor placed and patients asked to keep a food log while on pro-CGM; Visit 2 (within 1 week), interim assessment of pro CGM and diet or pharmacotherapy modifications made accordingly; Visit 3 at day 14, pro CGM re-evaluated to assess glycemic control. Glucose target range was set at 70-180 mg/dL. Analyses included pre & post daily average glucose, time in range, time above range, and time below range.

RESULTS

Average time for interim analysis was 5 days after pro CGM initiation. At Visit 3, daily average glucose decreased from 191.3 mg/dL at baseline to 137.4 mg/dL (p < 0.001). Time in range improved from 42.2% to 80.2% (p < 0.001). Time above range decreased from 52.1% to 18.3% (p < 0.001), with a concurrent decrease in time below range from 5.7% to 1.5% (p < 0.001). Recurrent hypoglycemia was detected in 27 (25.7%) individuals, whose average baseline time below range reduced from 21.1% to 1.9% (p < 0.001).

CONCLUSION

The interim intervention technique is a cost effective and efficient method for improving glucose outcomes through lifestyle and pharmacotherapy modifications and while utilizing a single pro-CGM sensor.

LOCATION OF STUDY

Wockhardt Hospital, Mumbai, India. CLINICAL REGISTRATION: not applicable due to retrospective chart review study design.

The utility of Problem Areas in Diabetes (PAID) scale amongst patients with Type 2 diabetes (T2DM): An experience from a teaching hospital in Southern India

Objectives:

The purpose of this study was to establish the prevalence of diabetes-specific psychological distress (DSPD) among patients with type 2 diabetes mellitus (T2DM) using the “Problem areas in diabetes” (PAID) scale at a teaching hospital in southern India. Other objectives included observing the relationship between socio-demographic factors and DSPD and, finally exploring the level of acceptance of the PAID scale by Asian–Indian patients.

Methods:

The patients with T2DM aged >18 years attending the diabetes outpatient clinic were recruited. They completed two sets of questionnaires; PAID and a satisfactory questionnaire, which included socio-demographic characteristics and questions relating to the acceptance of PAID. Statistical analysis was performed using Stata 13.1 and Excel.

Results:

A total of 253 questionnaires were completed, including 157 (62.1%) male and 96 (37.9%) female patients. The prevalence of DSPD was 32.8% (83/253). Younger age (OR 3.65, 95% CI 1.36–9.80) and presence of retinopathy (OR 2.60, 95% CI 1.12–6.04) were significantly associated with DSPD. However, it was observed that one-third of the patients had an elevated level of distress regardless of socio-demographic or clinical factors. PAID was well accepted by the participants and 84.6% (214/253) were pleased to complete it again.

Conclusion:

About one-third of the patients with T2DM had DSPD. Psychological distress was higher in the younger age group and those with retinopathy. PAID is an easy, well-accepted questionnaire and would serve as a useful tool to screen for DSPD.

Differential risk factors and morbidity/mortality pattern in type 2 diabetes: A study among two Mendelian populations with different ancestry (India)

BACKGROUND AND AIMS

Association studies of type 2 diabetes mellitus (T2DM) with risk factors have shown variable results. Moreover, population-specific comparative investigations are negligible. Therefore, the present study aimed to evaluate the association of dyslipidemia and obesity with impaired fasting glucose (IFG) and T2DM among two ethnically, geographically and culturally different populations in India.

METHODS

This was a cross-sectional study among Jats and Meiteis, each inhabiting a separate geographical region. A total of 2371 individuals, age ≥30 years were recruited through household survey. Obesity variables were captured using anthropometric measurements while fasting blood (2.5 mL) was drawn to measure lipid and glucose levels using enzymatic assay by spectrophotometer. Participants were categorized under normal, IFG and T2DM groups, indicative of diabetes progression stages. Statistical analysis was performed using SPSS 16.0 version.

RESULTS

Significant differential distribution of lipid and obesity variables among IFG and T2DM in both populations were observed. Odds ratio revealed high TC and all obesity variables except BMI posed significant increased risk for T2DM among Jats. Abnormal TG, VLDL, WC, and WHtR posed significant increased risk for T2DM among Meiteis. Age-cohort wise prevalence of T2DM showed increasing trend at ≥60 years among Jats and decreasing trend at ≥60 years among Meiteis, suggesting a potential higher morbidity in the former and mortality in latter because of T2DM.

CONCLUSIONS

The present study observed a differential association of risk factors for T2DM among Jats and Meiteis. This study emphasize the need to implement community-specific intervention programs for prevention, treatment and management of T2DM.

Assessment of dental caries and gingival status among a group of type 1 diabetes mellitus and healthy children of South India - a comparative study

Background Diabetes mellitus is a metabolic disorder. However, dental caries and periodontal health have not attracted much interest in diabetic patients. This study was carried out to assess the dental caries status and gingival health status in children with type 1 diabetes mellitus (T1DM). Methods The study group consisted of 80 children, aged 6-18 years, with T1DM. The dental caries status was recorded using the World Health Organisation (WHO) criteria. Gingival health was assessed using the Loe and Silness gingival index (GI). Data obtained were subjected to statistical analysis. Results The mean dental caries status for primary (decayed, extracted, filled teeth [deft]) and permanent dentition (decayed, missing, filled teeth [DMFT]) scores in diabetic children were 0.44±1.28 and 1.26±2.49, respectively. The GI scores of diabetic children were 0.33±0.48. GI in the study group significantly correlated with DMFT (p<0.001) and deft (p≤0.05). Conclusions Dental caries in primary dentition was lower in diabetic children but was not statistically significant, whereas dental caries in permanent dentition was significantly higher. The gingival condition of diabetic children was healthy.

The increasing burden of diabetes and variations among the states of India: the Global Burden of Disease Study 1990-2016

BACKGROUND

The burden of diabetes is increasing rapidly in India but a systematic understanding of its distribution and time trends is not available for every state of India. We present a comprehensive analysis of the time trends and heterogeneity in the distribution of diabetes burden across all states of India between 1990 and 2016.

METHODS

We analysed the prevalence and disability-adjusted life-years (DALYs) of diabetes in the states of India from 1990 to 2016 using all available data sources that could be accessed as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, and assessed heterogeneity across the states. The states were placed in four groups based on epidemiological transition level (ETL), defined on the basis of the ratio of DALYs from communicable diseases to those from non-communicable diseases and injuries combined, with a low ratio denoting high ETL and vice versa. We assessed the contribution of risk factors to diabetes DALYs and the relation of overweight (body-mass index 25 kg/m2 or more) with diabetes prevalence. We calculated 95% uncertainty intervals (UIs) for the point estimates.

FINDINGS

The number of people with diabetes in India increased from 26·0 million (95% UI 23·4-28·6) in 1990 to 65·0 million (58·7-71·1) in 2016. The prevalence of diabetes in adults aged 20 years or older in India increased from 5·5% (4·9-6·1) in 1990 to 7·7% (6·9-8·4) in 2016. The prevalence in 2016 was highest in Tamil Nadu and Kerala (high ETL) and Delhi (higher-middle ETL), followed by Punjab and Goa (high ETL) and Karnataka (higher-middle ETL). The age-standardised DALY rate for diabetes increased in India by 39·6% (32·1-46·7) from 1990 to 2016, which was the highest increase among major non-communicable diseases. The age-standardised diabetes prevalence and DALYs increased in every state, with the percentage increase among the highest in several states in the low and lower-middle ETL state groups. The most important risk factor for diabetes in India was overweight to which 36·0% (22·6-49·2) of the diabetes DALYs in 2016 could be attributed. The prevalence of overweight in adults in India increased from 9·0% (8·7-9·3) in 1990 to 20·4% (19·9-20·8) in 2016; this prevalence increased in every state of the country. For every 100 overweight adults aged 20 years or older in India, there were 38 adults (34-42) with diabetes, compared with the global average of 19 adults (17-21) in 2016.

INTERPRETATION

The increase in health loss from diabetes since 1990 in India is the highest among major non-communicable diseases. With this increase observed in every state of the country, and the relative rate of increase highest in several less developed low ETL states, policy action that takes these state-level differences into account is needed urgently to control this potentially explosive public health situation.

FUNDING

Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Prevalence of dysglycaemia in rural Andhra Pradesh: 2005, 2010, and 2014

BACKGROUND

Communities in rural Andhra Pradesh may be at increasing risk of diabetes. In the present study we analyzed three cross-sectional studies over 9 years to estimate the changing prevalence of dysglycemia (diabetes and prediabetes).

METHODS

The 2005 study sampled 4535 individuals from 20 villages, the 2010 study sampled 4024 individuals from 14 villages, and the 2014 project of 62 254 individuals sought to include all adults aged 40-85 years from 54 villages. Blood glucose levels were estimated using a hand-held device in 2005 and 2014 and using HbA1c dried blood spots in 2010.

RESULTS

In primary analyses restricted to assays based on fasting samples (2005, n = 3243; 2014, n = 749), the prevalence estimates for dysglycemia were 53.7% (95% confidence interval [CI] 51.8%-55.7%) in 2005 and 62.0% (95% CI 58.5%-65.4%) in 2014 (P < 0.001). Over the same period, mean body mass index (BMI) increased from 22.2 to 24.3 kg/m² (mean difference 2.1 kg/m² ; 95% CI 2.0-2.2 kg/m² ; P < 0.001). In secondary analyses using data from all participants (2005, n = 4535; 2010, n = 4024; 2014, n = 62 254), regardless of measurement technique, the estimated prevalence of dysglycemia was 53.9% (95% CI 52.0%-55.9%) in 2005, 50.5% (95% CI 46.1%-54.9%) in 2010, and 41.3% (95% CI 40.9%-41.7%) in 2014 (P < 0.001).

CONCLUSIONS

The prevalence of dysglycemia was high at every assessment using every measurement method. Dysglycemia in this population is most likely to have risen with the rise in BMI. The decline in prevalence suggested by the secondary analyses was likely due to confounding from the different assessment methods.

Prevalence of depression in patients of type 2 diabetes mellitus: A cross sectional study in a tertiary care centre

AIMS

The present study aims to study the prevalence of depression in patients with uncomplicated type II diabetes mellitus and to find its association with various socio-demographic factors in the same.

MATERIALS AND METHODS

A cross-sectional, single interview study was performed in an outpatient department of an endocrinology institute. Total 80 type II DM patients without any associated complications of diabetes were included in this study. To diagnose Depressive Episode, structured clinical interview for DSM V was applied. Severity of depression was assessed by Hamilton Rating Scale for Depression (HAM-D). To assess socio-demographic characteristics of the patients, all of them were evaluated with a semi-structured socio-demographic performa.

RESULTS

38.75% patients (N=31) were found to be suffering from depression. Among them 48.38% were moderately depressed and none were suffering from very severe depression. Significant association was not found between depression and socio-demographic factors of age (p=0.920), gender (p=0.251), economic profile (p=0.583), local background of the patient (p=0.646), educational qualification (p=0.935) and marital status (p=0.644). Similarly no association was found with duration of diabetes, HbA1c and BMI.

CONCLUSION

Exclusion of complicated cases didn't seem to influence overall prevalence of depression, although reduction in severity was apparent. Thus even in those diabetic patients who are leading a complication free life, a detailed psychiatric analysis to rule out depression is mandatory.

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.

Nonalcoholic fatty liver disease (NAFLD) without insulin resistance: Is it different?

BACKGROUND AND AIMS

Nonalcoholic fatty liver disease (NAFLD) is considered the hepatic manifestation of insulin resistance [IR]. However, a significant proportion of NAFLD patients are devoid of IR. Is NAFLD sans IR a different entity? The aim of the study was to compare the anthropometric, metabolic, biochemical, ultrasonography, and histological profile of NAFLD patients with and without IR.

METHODS

Retrospective analyses of 336 NAFLD patients diagnosed during the last two years was done. Patients without IR were compared with those with IR.

RESULTS

Out of 336 patients, 153 [45.53%] were without IR. Although age, gender, BMI and transaminase levels were comparable, significantly higher proportion of patients in non-IR group were non-obese [43.14% vs. 25/14%; P=0.0005], and had mild fatty change on ultrasonography; [78.43% vs. 67.21%; P=0.022]. Higher proportion of them had elevated transaminases; [67.97% vs. 56.83%; P=0.036]. Serum triglyceride [178.52±78.78 vs. 204.86±94.72 mg/dl; P=0.02], FBG [85.39±13.80 vs. 98.93±31.56 mg/dl; P=0.00], PGBG [123.76±36.77 vs. 148.07±64.67m g/dl; P=0.00], and serum insulin [6.33±2.18 vs. 15.39±12.56 μIU/ml; P=0.00] were significantly lower in patients without IR. Although there was no difference in histology, interestingly fibrosis was seen in one third of patients despite absence of IR.

CONCLUSION

Nearly half of our NAFLD population was without IR; one third of them had significant fibrosis. NAFLD is probably a heterogeneous disease and IR is not the sole factor responsible for NAFLD; further studies are needed to find out other possible etiological factors.

Polymorphisms in oxidative stress pathway genes and risk of diabetic nephropathy in South Indian type 2 diabetic patients

AIM

Diabetic nephropathy (DN), a common microvascular complication of type 2 diabetes mellitus (T2DM) is polygenic, with a vast array of genes contributing to disease susceptibility. Accordingly, we explored the association between DN and six polymorphisms in oxidative stress related genes, namely eNOS, p22phox subunit of NAD(P)H oxidase, PARP-1 and XRCC1 in South Indian T2DM subjects.

METHODS

The study included 155 T2DM subjects with DN and 162 T2DM patients with no evidence of DN. The selected polymorphisms were genotyped by polymerase chain reaction and Taqman allele discrimination assay.

RESULTS

No significant difference was observed in the genotype and allele distribution of eNOS -786T > C, intron 4a4b, p22phox 242C > T and XRCC1 Arg399Gln polymorphisms between T2DM groups with and without DN. Contrastingly, there appeared to be a significant association of eNOS 894G > T and PARP-1 Val762Ala polymorphisms with DN wherein, the presence of 894T allele was associated with an enhanced risk for DN [P = 0.005; OR = 1.78 (1.17-2.7)], while the 762Ala allele seemed to confer significant protection against DN [P = 0.02; OR = 0.59 (0.37-0.92)]. Multiple logistic regression analysis revealed a significant and independent association of eNOS 894G > T, PARP-1 Val762Ala polymorphisms and hypertension with DN in T2DM individuals.

CONCLUSIONS

eNOS 894G > T and PARP-1 Val762Ala polymorphisms appeared to associate significantly with DN, with the former contributing to an enhanced risk and the latter to a reduced susceptibility to DN in South Indian T2DM individuals.

Molecular docking studies of (4Z, 12Z)-cyclopentadeca-4, 12-dienone from Grewia hirsuta with some targets related to type 2 diabetes

Background

Management of diabetes without any side effects is still a challenge to the medical system. This leads to increasing demand for natural products with antidiabetic activity with fewer side effects. Grewia hirsuta (Tiliaceae) is a traditional herbal medicinal plant and is reported to possess a variety of pharmacological actions. In the present research, a compound (4Z, 12Z)-cyclopentadeca-4, 12-dienone isolated from Grewia hirsuta was taken as ligand for molecular docking studies. Evaluation of hypoglycemic activity through an extensive in silico docking approach with molecular targets such as aldose reductase, glucokinase, pyruvate dehydrogenase kinase isoform 2, peroxisome proliferator-activated receptor-gamma, glycogen synthase kinase-3, 11β-Hydroxysteroid dehydrogenase, and glutamine: fructose-6-phosphate amidotransferase were performed.

Methods

Isolation of the (4Z, 12Z)-cyclopentadeca-4,12-dienone from the methanol extract of the leaves of Grewia hirsuta was performed by the column chromatography to yield different fractions. These fractions were then subjected to purification and the structure was elucidated and confirmed by spectroscopic methods including UV, FTIR, ¹H, ¹³C NMR and the accurate mass determination was carried out using the Q-TOF mass spectrometer. In-vivo experimentation was performed with evaluation of α-glucosidase, α-amylase and MTT assay that had been reported by the author in the earlier paper. Molecular docking study was performed with GLIDE docking software.

Results

The docking studies of the ligand (4Z, 12Z)-cyclopentadeca-4, 12-dienone with seven different target proteins showed that this is a good inhibitor, which docks well with various targets related to diabetes mellitus. Hence (4Z, 12Z)-cyclopentadeca-4,12-dienone can be considered for developing into a potent anti-diabetic drug.

Conclusion

The results of the current study have revealed that the leaves of the selected plant Grewia hirsuta contains a potential inhibitor for diabetes (4Z, 12Z)-cyclopentadeca-4,12-dienone. Thus enabling a possibility of this plant extract as a new alternative to existing diabetic approaches.

The economic burden of diabetes in India: a review of the literature

BACKGROUND

Diabetes and its complications are a major cause of morbidity and mortality in India, and the prevalence of type 2 diabetes is on the rise. This calls for an assessment of the economic burden of the disease.

OBJECTIVE

To conduct a critical review of the literature on cost of illness studies of diabetes and its complications in India.

METHODS

A comprehensive literature review addressing the study objective was conducted. An extraction table and a scoring system to assess the quality of the studies reviewed were developed.

RESULTS

A total of nineteen articles from different regions of India met the study inclusion criteria. The third party payer perspective was the most common study design (17 articles) while fewer articles (n =2) reported on costs from a health system or societal perspective. All the articles included direct costs and only a few (n =4) provided estimates for indirect costs based on income loss for patients and carers. Drug costs proved to be a significant cost component in several studies (n =12). While middle and high-income groups had higher expenditure in absolute terms, costs constituted a higher proportion of income for the poor. The economic burden was highest among urban groups. The overall quality of the studies is low due to a number of methodological weaknesses. The most frequent epidemiological approach employed was the prevalence-based one (n =18) while costs were mainly estimated using a bottom up approach (n =15).

CONCLUSION

The body of literature on the costs of diabetes and its complications in India provides a fragmented picture that has mostly concentrated on the direct costs borne by individuals rather than the healthcare system. There is a need to develop a robust methodology to perform methodologically rigorous and transparent cost of illness studies to inform policy decisions.

Diabetes care may be improved with Steno Quality Assurance Tool--a self-assessment tool in diabetes management

To evaluate if improvements in the quality of diabetes care in Indian clinics can be obtained by simple self-surveillance PC-based software.

METHOD

Nineteen Indian diabetes clinics were introduced to the principles of quality assurance (QA), and to a software program, the Steno Quality Assurance Tool (SQAT). Data was entered for an initial 3 months period. Subsequently data were analyzed by the users, who designed plans to improve indicator status and set goals for the upcoming period. A second data entry period followed after 7-9 months.

RESULTS

QA data was analyzed from 4487 T2DM patients (baseline) and 4440 (follow-up). The average examination frequency per clinic of the following indicators increased significantly: lipid examination (72-87%) (p=0.007), foot examination (80-94%) (p=0.02), HbA1c investigation (59-77%) (p=0.006), and urine albumin excretion investigation (72-87%) (p=0.006). Outcome parameters also improved significantly: mean (SD) fasting and post prandial BG reduced from 144(16) to 132(16)mg/dl (p=0.02) and 212(24)-195(29)mg/dl (p=0.03), respectively. Systolic BP reduced from 139(6) to 133(4) (p=0.0008)mmHg and diastolic BP from 83(3) to 81(3)mmHg (p=0.002).

CONCLUSION

Quality of diabetes care can be improved by applying SQAT, a QA self-surveillance software that enables documentation of changes in process and outcome indicators.

High prevalence of metabolic syndrome among urban subjects in India: a multisite study

OBJECTIVE

Metabolic syndrome is an important cardiovascular risk factor. To determine its prevalence among urban subjects in India we performed a multisite study.

METHODS

The study was performed at eleven cities using cluster sampling. 6198 subjects (men 3426, women 2772, response 62%, age 48±10 years) were evaluated for socio-demographic, lifestyle, anthropometric and biochemical factors. Prevalence of metabolic syndrome was determined using harmonized Asian-specific criteria. Significant socioeconomic and lifestyle associations were determined.

RESULTS

Age adjusted prevalence (%, 95% confidence intervals) of metabolic syndrome in men and women was 33.3 (31.7-34.9) and 40.4 (38.6-42.2) (harmonized criteria), 23.9 (22.4-26.4) and 34.5 (32.0-36.1) (modified Adult Treatment Panel-3, ATP-3) and 17.2 (15.3-19.1) and 22.8 (20.1-24.2) (ATP-3). Individual components of metabolic syndrome in men and women, respectively, were: high waist circumference 35.7 (34.1-37.3) and 57.5 (55.6-59.3), high blood pressure 50.6 (48.9-52.3) and 46.3 (44.4-48.1), impaired fasting glucose/diabetes 29.0 (27.5-30.5) and 28.0 (26.3-29.7), low HDL cholesterol 34.1 (32.5-35.7) and 52.8 (50.9-54.7) and high triglycerides 41.2 (39.5-42.8) and 31.5 (29.7-33.2) percent. Prevalence of metabolic syndrome was significantly greater in subjects with highest vs. lowest categories of education (45 vs. 26%), occupation (46 vs. 40%), fat intake (52 vs. 45%), sedentary lifestyle (47 vs. 38%) and body mass index (66 vs. 29%) (p<0.05).

CONCLUSION

There is high prevalence of metabolic syndrome in urban Indian subjects. Socioeconomic (high educational and occupational status) and lifestyle (high fat diet, low physical activity, overweight and obesity) factors are important.

Diabetes in South-East Asia: an update

According to the recent estimates by the International Diabetes Federation (IDF), South East-Asia (SEA) Region consisting of India, Sri Lanka, Bangladesh, Bhutan, Mauritius and Maldives, is home to more than 72 million adults with diabetes in 2013 and is expected to exceed 123 million in 2035. Nearly 95% of people with diabetes have type 2 diabetes (T2DM). Although type 1 diabetes (T1DM) is relatively rare in these countries, its prevalence is also rising. Furthermore, a large number (24.3 million) of people also have impaired glucose tolerance (IGT). Several characteristic differences are seen in the clinical and immunological presentation of these people when compared with their European counterparts. A sharp increase in the prevalence of T2DM has been observed in the SEA Region, both in urban and rural areas, which is mostly associated with the lifestyle transitions towards urbanisation and industrialisation. Evidence suggests that a large portion of T2DM may be preventable by lifestyle modification. However, morbidity and early mortality occur as a result of inadequate healthcare facilities for early detection and initiation of therapy, as well as suboptimal management of diabetes and associated morbidities. This is largely preventable by primary prevention of diabetes and enhancing awareness about the disease among the public and the healthcare providers. There is an urgent need for concerted efforts by government and non-governmental sectors to implement national programmes aimed at prevention, management and surveillance of the disease.

Prevalence of diabetes and cardiovascular risk factors in middle-class urban participants in India

OBJECTIVES

To determine the prevalence of diabetes and awareness, treatment and control of cardiovascular risk factors in population-based participants in India.

METHODS

A study was conducted in 11 cities in different regions of India using cluster sampling. Participants were evaluated for demographic, biophysical, and biochemical risk factors. 6198 participants were recruited, and in 5359 participants (86.4%, men 55%), details of diabetes (known or fasting glucose >126 mg/dL), hypertension (known or blood pressure >140/>90 mm Hg), hypercholesterolemia (cholesterol >200 mg/dL), low high-density lipoprotein (HDL) cholesterol (men <40, women <50 mg/dL), hypertriglyceridemia (>150 mg/dL), and smoking/tobacco use were available. Details of awareness, treatment, and control of hypertension and hypercholesterolemia were also obtained.

RESULTS

The age-adjusted prevalence (%) of diabetes was 15.7 (95% CI 14.8 to 16.6; men 16.7, women 14.4) and that of impaired fasting glucose was 17.8 (16.8 to 18.7; men 17.7, women 18.0). In participants with diabetes, 27.6% were undiagnosed, drug treatment was in 54.1% and control (fasting glucose ≤130 mg/dL) in 39.6%. Among participants with diabetes versus those without, prevalence of hypertension was 73.1 (67.2 to 75.0) vs 26.5 (25.2 to 27.8), hypercholesterolemia 41.4 (38.3 to 44.5) vs 14.7 (13.7 to 15.7), hypertriglyceridemia 71.0 (68.1 to 73.8) vs 30.2 (28.8 to 31.5), low HDL cholesterol 78.5 (75.9 to 80.1) vs 37.1 (35.7 to 38.5), and smoking/smokeless tobacco use in 26.6 (23.8 to 29.4) vs 14.4 (13.4 to 15.4; p<0.001). Awareness, treatment, and control, respectively, of hypertension were 79.9%, 48.7%, and 40.7% and those of hypercholesterolemia were 61.0%, 19.1%, and 45.9%, respectively.

CONCLUSIONS

In the urban Indian middle class, more than a quarter of patients with diabetes are undiagnosed and the status of control is low. Cardiovascular risk factors-hypertension, hypercholesterolemia, low HDL cholesterol, hypertriglyceridemia, and smoking/smokeless tobacco use-are highly prevalent. There is low awareness, treatment, and control of hypertension and hypercholesterolemia in patients with diabetes.

Pathogenesis of type 2 diabetes in South Asians

The risk of developing type 2 diabetes mellitus (T2DM) is exceptionally high among both native and migrant South Asians. T2DM occurs more often and at a younger age and lower BMI, and the risk of coronary artery and cerebrovascular disease, and renal complications is higher for South Asians compared with people of White Caucasian descent. The high prevalence of T2DM and its related complications in South Asians, which comprise one-fifth of the total world's population, poses a major health and socioeconomic burden. The underlying cause of this excess risk, however, is still not completely understood. Therefore, gaining insight into the pathogenesis of T2DM in South Asians is of great importance. The predominant mechanism, in this ethnicity seems to be insulin resistance (IR) rather than an impaired β-cell function. In this systematic review, we describe several possible mechanisms that may underlie or contribute to the increased IR observed in South Asians.

Burden of diabetes mellitus and prediabetes in tribal population of India: a systematic review

OBJECTIVE

To estimate the burden of diabetes mellitus and pre-diabetes in tribal populations of India.

METHODS

The authors reviewed studies from 2000 to 2011 that documented the prevalence of diabetes mellitus in various tribal populations of India. The search was performed using electronic and manual methods. Meta-analysis of data on point prevalence was performed.

RESULTS

A total of seven studies were retrieved. The prevalence of diabetes mellitus ranged from 0.7% to 10.1%. The final estimate of diabetes prevalence obtained after pooling of data from individual studies, was 5.9% (95% CI; 3.1-9.5%). The prevalence for impaired fasting glucose (IFG) varied from 5.1% to 13.5% and impaired glucose tolerance (IGT), from 6.6% to 12.9%.

CONCLUSION

Chronic disease research in tribal populations is limited. The reported prevalence of IFG/IGT was higher than the prevalence of diabetes and this observation could be suggestive of a potential increase in diabetes in the coming years. Given that lifestyle changes have occurred in the tribal populations, there is a need to synthesize evidence(s) relating to diabetes and other chronic diseases in these marginalized populations and inform policy makers.

Comparison of DEXA-derived body fat measurement to two race-specific bioelectrical impedance equations in healthy Indians

AIM

Prevalence of obesity is increasing in Asian Indians. Reliable, precise and convenient methods to estimate body composition are required. This study aimed to test the accuracy of bioelectrical impedance analysis (BIA) estimates of body composition among Asian Indians according to two BIA equations--one developed for Asians, the other for Caucasians.

METHODS

Two hundred apparently healthy Asian Indians (100 males, 100 females; mean age 36.6 ± 7.6 years; mean BMI 16.6-46.7 kg/m(2)) underwent BIA assessment of fat mass (FM), fat free mass (FFM) and percentage body fat (%BF) using Tanita Multi-Frequency Body Composition Analyzer MC-180MA (Tanita Corporation, Tokyo, Japan). One set of BIA values was automatically calculated by the analyzer (Caucasian figures), the other set by Tanita (Japanese Asian figures). Results were compared to dual X-ray absorptiometry (DEXA) as the standard measure.

RESULTS

A moderate level of relative agreement was found between the DEXA-derived measurement of %BF and the estimate from both the Caucasian (r(2)=0.75; p<0.001) and Asian equation (r(2)=0.7; p<0.001). Despite this, the level of absolute agreement was poor, with large bias and wide limits of agreement. According to the Caucasian equation the mean difference between methods was -8.3 ± 3.9 (95% limits of agreement -20.10 to 9.40), for the Asian equations mean difference was -5.4 ± 4.3 (95% limits of agreement -20.63 to 11.41).

INTERPRETATION AND CONCLUSIONS

When compared to DEXA, the current Asian and Caucasian Tanita formulae significantly under-estimate the %BF of Asian Indians.

Stress and diabetes in socioeconomic context: a qualitative study of urban Indians

Type 2 diabetes has escalated in urban India in the past two decades. Historically a disease of the affluent, recent epidemiological evidence indicates rising diabetes incidence and prevalence in urban India's middle class and working poor. Although there is substantial qualitative data about people with diabetes from high-income countries, scant resources provide insight into diabetes experiences among those in India, and lower-income groups specifically. In this article, we use individual-level analysis of illness narratives to understand how people experience and understand diabetes across income groups in Delhi, India. We conducted in-depth qualitative interviews and administered the Hopkins Symptoms Check-List (HSCL-25) to evaluate depression among 59 people with diabetes in northeast Delhi between December 2011 and February 2012. We analyzed their responses to: 1) what caused your diabetes?; 2) what do you find most stressful in your daily life?; and 3) where do you seek diabetes care? We found few people held diabetes beliefs that were congruent with socio-spiritual or biomedical explanatory models, and higher income participants commonly cited "tension" as a contributor to diabetes. Stress associated with children's futures, financial security, and family dynamics were most commonly reported, but how these subjective stresses were realized in people's lives varied across income groups. Depression was most common among the poorest income group (55%) but was also reported among middle- (38%) and high-income (29%) participants. One-quarter of respondents reported diabetes distress, but only those from the low-income community reported co-occurring depression and these respondents often revealed poor access to diabetes care. These data suggest that lower-income populations not only have higher rates of depression but also may be more likely to delay health care and therefore develop diabetes complications. This research has many implications for public health care in India as diabetes prevalence shifts to affect lower income groups who concurrently experience higher rates of depression and poorer access to medical care.

Trends in prevalence of diabetes in Asian countries

Diabetes is a major lifestyle disorder, the prevalence of which is increasing globally. Asian countries contribute to more than 60% of the world’s diabetic population as the prevalence of diabetes is increasing in these countries. Socio-economic growth and industrialization are rapidly occurring in many of these countries. The urban-rural divide in prevalence is narrowing as urbanization is spreading widely, adversely affecting the lifestyle of populations. Asians have a strong ethnic and genetic predisposition for diabetes and have lower thresholds for the environmental risk factors. As a result, they develop diabetes at a younger age and at a lower body mass index and waist circumference when compared with the Western population. The adverse effect of physical inactivity and fatty food are manifested as the increasing rate of overweightness and obesity, even among children. The health care budgets for the disease management are meager and the health care outcome is far from the optimum. As a result, complications of diabetes are common and the economic burden is very high, especially among the poor strata of the society. National endeavors are urgently needed for early diagnosis, effective management and for primary prevention of diabetes. This editorial aims to highlight the rising trend in prevalence of diabetes in Asia, its causative factors and the urgent need to implement national strategies for primary prevention of type 2 diabetes.

Prevalence and risk factors for self-reported diabetes among adult men and women in India: findings from a national cross-sectional survey

OBJECTIVE

We examined the distribution of diabetes and modifiable risk factors to provide data to aid diabetes prevention programmes in India.

DESIGN

Population-based cross-sectional survey of men and women included in India's third National Family Health Survey (NFHS-3, 2005-2006).

SETTING

The sample is a multistage cluster sample with an overall response rate of 98 %. All states of India are represented in the sample (except the small Union Territories), covering more than 99 % of the country's population.

SUBJECTS

Women (n 99 574) and men (n 56 742) aged 20-49 years residing in the sample households.

RESULTS

Prevalence of diabetes was 1598/100 000 (95 % CI 1462, 1735) among men and 1054/100 000 (95 % CI 974, 1134) among women in India. Rural-urban and marked geographic variation were found with higher rates in south and north-eastern India. Weekly and daily fish intake contributed to a significantly higher risk of diabetes among both women and men. Risks of diabetes increased with increased BMI, age and wealth status of both women and men, but no effects of the consumption of milk/curd, vegetables, eggs, television watching, alcohol consumption or smoking were found. Daily consumption of pulse/beans or fruits was associated with a significantly reduced risk of diabetes among women, whereas non-significant inverse associations were observed in the case of men.

CONCLUSIONS

Prevalence was underestimated using self-reports. The wide variation in self-reported diabetes is unlikely to be due entirely to reporting biases or access to health care, and indicates that modifiable risk factors exist. Prevention of diabetes should focus on obesity and target specific socio-economic groups in India.

Consensus physical activity guidelines for Asian Indians

India is currently undergoing rapid economic, demographic, and lifestyle transformations. A key feature of the latter transformation has been inappropriate and inadequate diets and decreases in physical activity. Data from various parts of India have shown a steady increase in the prevalence of lifestyle-related diseases such as type 2 diabetes mellitus (T2DM), the metabolic syndrome, hypertension, coronary heart disease (CHD), etc., frequently in association with overweight or obesity. Comparative data show that Asian Indians are more sedentary than white Caucasians. In this review, the Consensus Group considered the available physical activity guidelines from international and Indian studies and formulated India-specific guidelines. A total of 60 min of physical activity is recommended every day for healthy Asian Indians in view of the high predisposition to develop T2DM and CHD. This should include at least 30 min of moderate-intensity aerobic activity, 15 min of work-related activity, and 15 min of muscle-strengthening exercises. For children, moderate-intensity physical activity for 60 min daily should be in the form of sport and physical activity. This consensus statement also includes physical activity guidelines for pregnant women, the elderly, and those suffering from obesity, T2DM, CHD, etc. Proper application of guidelines is likely to have a significant impact on the prevalence and management of obesity, the metabolic syndrome, T2DM, and CHD in Asian Indians.

Ethnicity and cardiovascular health research: pushing the boundaries by including comparison populations in the countries of origin

Chronic diseases such as cardiovascular diseases (CVD) are major health problems in most ethnic minority and migrant populations living in high income countries. By the same token, CVD is a looming threat that is creating a double burden in most of the countries where these populations originate from. The causes of the rising burden are unclear, but they are likely to be multifaceted. Traditionally, ethnicity and health research have mostly concentrated on comparing the health of ethnic minority groups with the majority populations of the countries in which they live. This is an important area of research which illuminates ethnic inequalities in health. However, a few studies on international comparisons show that a lot can be learned from comparing similar ethnic groups living in different industrialised countries. Equally, comparing ethnic minority and migrant populations to similar populations in their countries of origin will generate new knowledge about factors that predispose them to poor health outcomes. Thus, to make progress in the field of ethnicity and health research, we need a new conceptual framework that simultaneously studies migrant/ethnic groups in the country of settlement, in similar countries of settlement, and in the countries of ancestral origin. Such studies need to go beyond the commonest design of cross-sectional studies to include more cohort studies, interventions and linkage studies. This article discusses (1) the burden of CVD in ethnic minority and migrant populations; (2) approaches to understanding predisposing factors; and (3) application of the results to give insight into the potential threats that their countries of origin are likely to face.

Determinants of urban-rural differences in cardiovascular risk factors in middle-aged women in India: a cross-sectional study

OBJECTIVES

Cardiovascular diseases (CVD) are the most important cause of death amongst middle-aged Indian women. To determine prevalence of CVD risk factors and their determinants we performed a nationwide study.

METHODS

Population based studies amongst women 35-70 years were performed in four urban and five rural locations in India. Location based stratified sampling was performed and we enrolled 4624 (rural 2616, urban 2008) of eligible 8000 women (58%). Demographic details, medical history, diet, physical activity and anthropometry were recorded using standardised techniques. Blood haemoglobin, glucose and total cholesterol were determined. Risk factors were diagnosed using current guidelines. Descriptive statistics are reported. Stepwise multivariate logistic regression was performed to identify determinants of urban-rural differences.

RESULTS

In urban women mean body mass index (BMI), waist circumference, waist-hip ratio (WHR), systolic BP, haemoglobin, fasting glucose and cholesterol were significantly greater (p<0.01). Age-adjusted prevalence of risk factors (%) in urban vs rural was of obesity BMI ≥ 25 kg/m(2) (45.6 vs 22.5), truncal obesity WHR>0.9 (44.3 vs 13.0), hypertension (37.5 vs 29.3), hypercholesterolemia ≥ 200 mg/dl (27.7 vs 13.5), and diabetes (15.1 vs 4.3) greater whilst any tobacco use (19.6 vs 41.6) or smoking lower. Significant determinants of urban-rural differences were greater income and literacy, dietary fats, low physical activity, obesity and truncal obesity (p<0.01).

CONCLUSIONS

Greater prevalence of CVD risk factors in urban middle-aged women is explained by greater income and literacy, dietary fat, low physical activity and obesity.

A community-based study of metabolic syndrome and its components among women of rural community in Ballabgarh, Haryana

BACKGROUND

The metabolic syndrome is an important cluster of coronary heart disease risk factors with common insulin resistance. Although the prevalence of metabolic syndrome is high among Asians, including Indians, no sizeable literature is available about the magnitude of metabolic syndrome in rural areas, especially in women.

METHODS

Blood pressure and anthropometric measurements were noted in 307 women, aged ≥20 years, selected through a multistage sampling technique. Blood samples were collected after overnight fasting and subjected to biochemical quantification such as fasting blood glucose, triglycerides, and high-density lipoprotein cholesterol (HDL-C). Data were analyzed using updated National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) definition by modifying the waist circumference cutoffs as per Asia-Pacific guidelines.

RESULTS

Overall metabolic syndrome was observed in 12.0% [95% confidence interval (CI); 8.5-16.8] of the rural women population. Women in the age group ≥60 years had the highest prevalence (27.8%), whereas those in the age group 20-39 years had the lowest prevalence (4.2%). At least one component of metabolic syndrome was present in nearly 95% of the study respondents; 41.6% had at least two, 12.0% had at least three, and 2.6% had at least four components of metabolic syndrome. None of the participants had all the five components.

CONCLUSION

The current prevalence of metabolic syndrome in women in rural communities of the selected area, although less than that in their urban counterparts, could be a serious problem in the future. It is incumbent on government agencies and the medical community to address this issue to prevent the consequences of its increased burden.

Translating evidence into policy for cardiovascular disease control in India

Cardiovascular diseases (CVD) are leading causes of premature mortality in India. Evidence from developed countries shows that mortality from these can be substantially prevented using population-wide and individual-based strategies. Policy initiatives for control of CVD in India have been suggested but evidence of efficacy has emerged only recently. These initiatives can have immediate impact in reducing morbidity and mortality. Of the prevention strategies, primordial involve improvement in socioeconomic status and literacy, adequate healthcare financing and public health insurance, effective national CVD control programme, smoking control policies, legislative control of saturated fats, trans fats, salt and alcohol, and development of facilities for increasing physical activity through better urban planning and school-based and worksite interventions. Primary prevention entails change in medical educational curriculum and improved healthcare delivery for control of CVD risk factors-smoking, hypertension, dyslipidemia and diabetes. Secondary prevention involves creation of facilities and human resources for optimum acute CVD care and secondary prevention. There is need to integrate various policy makers, develop effective policies and modify healthcare systems for effective delivery of CVD preventive care.

Imbalanced dietary profile, anthropometry, and lipids in urban Asian Indian adolescents and young adults

OBJECTIVE

To analyze the macronutrient, micronutrient, food intake pattern, anthropometry, and lipid profile of urban Asian Indian adolescents and young adults and compare it with the nutrient profile of rural Asian Indian and American adolescents.

METHODS

This was a cross-sectional, epidemiologic descriptive study. Body mass index (BMI), percentage body fat, waist and hip circumferences, skinfold thickness, serum lipids, and dietary intake were assessed in 1236 subjects (607 males, 629 females) aged 13-25 years from schools and colleges of a metropolitan city of India.

RESULTS

The mean age and BMI of study subjects were 17.6 +/- 2.4 years (range 13-25 years) and 19.8 +/- 3.3 kg/m(2) (range 11.9-35.9 kg/m(2)), respectively. The mean daily percentages of total energy contributed by carbohydrates, total fats, proteins, saturated fatty acids (SFAs), monounsaturated fatty acids (MUFAs), polyunsaturated fatty acids (PUFAs), omega-3 PUFAs, omega-6 PUFAs, and trans-fatty acids for all subjects were 53%, 34%, 11%, 11%, 10%, 9%, 1%, 8%, and 0.3%, respectively. The absolute daily intake of total fat was 84 +/- 29 g/d in males and 72 +/- 21 g/d in females, which was approximately 4 times the recommended dietary allowance for Asian Indians (20-22 g/d). Among food groups, a high intake of milk, milk products, roots, and tubers was observed. In these young individuals, the prevalence of hypercholesterolemia (males > or =169 mg/dl; females > or =181 mg/dl) and overweight (BMI > or =23.1 kg/m(2)) was 14.4% and approximately 16%, respectively. On comparison with rural Asian Indian adolescents, an inappropriately high intake of total fat was observed in our subjects. On the other hand, the percentage of energy intake of SFAs in Asian Indian and American adolescents was at par.

CONCLUSIONS

High total fat and SFA intake and a low intake of MUFAs and omega-3 PUFAs showed imbalanced nutrition, which could be responsible for the increasing prevalence of obesity and insulin resistance in urban Asian Indian adolescents and young adults. Nutritional strategies for reducing SFA intake and balancing the omega-3/omega-6 PUFAs ratio should be urgently applied in Asian Indian adolescents and are also presented in this paper.

Obesity-related non-communicable diseases: South Asians vs White Caucasians

South Asians are at higher risk than White Caucasians for the development of obesity and obesity-related non-communicable diseases (OR-NCDs), including insulin resistance, the metabolic syndrome, type 2 diabetes mellitus (T2DM) and coronary heart disease (CHD). Rapid nutrition and lifestyle transitions have contributed to acceleration of OR-NCDs in South Asians. Differences in determinants and associated factors for OR-NCDs between South Asians and White Caucasians include body phenotype (high body fat, high truncal, subcutaneous and intra-abdominal fat, and low muscle mass), biochemical parameters (hyperinsulinemia, hyperglycemia, dyslipidemia, hyperleptinemia, low levels of adiponectin and high levels of C-reactive protein), procoagulant state and endothelial dysfunction. Higher prevalence, earlier onset and increased complications of T2DM and CHD are often seen at lower levels of body mass index (BMI) and waist circumference (WC) in South Asians than White Caucasians. In view of these data, lower cut-offs for obesity and abdominal obesity have been advocated for Asian Indians (BMI; overweight >23 to 24.9 kg m(-2) and obesity ≥ 25 kg m(-2); and WC; men ≥ 90 cm and women ≥ 80 cm, respectively). Imbalanced nutrition, physical inactivity, perinatal adverse events and genetic differences are also important contributory factors. Other differences between South Asians and White Caucasians include lower disease awareness and health-seeking behavior, delayed diagnosis due to atypical presentation and language barriers, and religious and sociocultural factors. All these factors result in poorer prevention, less aggressive therapy, poorer response to medical and surgical interventions, and higher morbidity and mortality in the former. Finally, differences in response to pharmacological agents may exist between South Asians and White Caucasians, although these have been inadequately studied. In view of these data, prevention and management strategies should be more aggressive for South Asians for more positive health outcomes. Finally, lower cut-offs of obesity and abdominal obesity for South Asians are expected to help physicians in better and more effective prevention of OR-NCDs.

Maternal capital and the metabolic ghetto: An evolutionary perspective on the transgenerational basis of health inequalities

There is particular interest in understanding socioeconomic and ethnic variability in health status. The developmental origins of disease hypothesis emphasize the importance of growth patterns across the life-course in relation to noncommunicable disease risk. The physiological components of cardiovascular risk, collectively termed the metabolic syndrome, derive in part from a disparity between the homeostatic "metabolic capacity" of vital organs and the "metabolic load" induced by large tissue masses, a rich diet and sedentary behavior. From an evolutionary perspective, the risk of such disparity is decreased by maternal physiology regulating offspring growth trajectory during gestation and lactation. Maternal capital, defined as phenotypic resources enabling investment in the offspring, allows effective buffering of the offspring from nutritional perturbations and represents the environmental niche initially occupied by the offspring. Offspring growth patterns are sensitive to the magnitude of maternal capital during early windows of plasticity. Offspring life-history strategy can then respond adaptively to further factors across the life-course, but only within the context of this initial maternal influence on growth. Maternal somatic capital is primarily gained or lost across generations, through variable rates of fetal and infant growth. I argue that the poor nutritional experience of populations subjected to colonialism resulted in a systematic loss of maternal capital, reflected in downward secular trends in stature. Accelerating the recovery of somatic capital within generations overloads metabolic capacity and exacerbates cardiovascular risk, reflected in increased disease rates in urbanizing and emigrant populations. Public health policies need to benefit metabolic capacity without exacerbating metabolic load.

Long-term effects of a carbohydrate-rich diet on fasting blood sugar, lipid profile, and serum insulin values in rural Bengalis

BACKGROUND

The prevalence of Type 2 diabetes is increasing in rural areas of India, where there is also often a lack of health infrastructure. Thus, a proper dietary study with the view of combating diabetes is essential. The aim of the present study was to determine the long-term effect of a carbohydrate-rich diet in rural Bengal.

METHODS

Volunteers (n = 320) were selected from three villages in Kharagpur and were randomly divided into a control and experimental group (n = 160 in each). The design of the study was such that non-significant differences in any of the dependent variables were maintainted prior to the application of control or treatment modes. In the control group, volunteers consumed <70% carbohydrate as part of their diet, whereas in the experimental group carbohydrate consumption was >70%. Blood samples from both groups were collected on yearly basis for 5 years and fasting blood sugar (FBS), lipid profile and serum insulin values were analyzed.

RESULTS

The blood biochemistry profiles were monitored before the start and at the end of the study. The results indicate that increased intake of carbohydrate causes significant increases in FBS (P < 0.05) and serum insulin (P < 0.05), as well as changes in the lipid profile, particularly triglycerides (P < 0.05) and very low-density lipoprotein-cholesterol (VLDL-C; P < 0.05).

CONCLUSIONS

The effects of increased carbohydrate on FBS, serum insulin, triglycerides and VLDL-C indicate that a proper nutritional policy needs to be implemented for this population of rural, low-income Bengalis.

Innovative research for equitable diabetes care in India

The emergence of non-communicable diseases (NCD) in South Asia and other low- and middle-income countries presents a growing and costly public health challenge. The surreptitious and rapid escalation of these chronic conditions will soon surpass attempts to quantify and appropriately respond to these overwhelming health threats. Given the elevated risk of cardio-metabolic diseases (diabetes, cardiovascular disease, and kidney disease) and projected morbidity and mortality burdens in the Asian Indian population group, the lack of representative data to support national response strategies will likely result in crippling health and socioeconomic losses. We describe how systematic research may help to reconcile India's data deficits and may be applied towards prioritizing resource allocation and addressing shortfalls in disease prevention and control efforts. Expanding the scope of and contextualizing NCD health research in India may also have tremendous benefits for resource allocation and planning in other developing countries.

Cardiovascular risk factors in the normoglycaemic Asian-Indian population--influence of urbanisation

AIMS/HYPOTHESIS

The aim of this study was to investigate the prevalence of cardiovascular risk factors in normoglycaemic Asian-Indians and its association with urbanisation and plasma glucose.

METHODS

Data on 5,517 normoglycaemic individuals aged >/=20 years (1,521, 1,851 and 2,145 inhabitants of a city, a town and villages, respectively), from a 2006 diabetes survey, were used. The presence of single and multiple abnormalities, including obesity, abdominal obesity, hypertension and dyslipidaemia, was analysed. Risk associations for hypertension and dyslipidaemia were analysed using multivariate analysis after adjusting for confounding variables.

RESULTS

Both the prevalence and clustering of cardiovascular risk variables were higher in urban areas than in villages, and were higher in the city than in the town. Nearly half (47%) of the normoglycaemic individuals from villages had at least one risk factor. Age, male sex, BMI, waist circumference, lack of physical activity and living in an urban environment were associated with hypertension and dyslipidaemia; postprandial glucose level showed no association with hypertension or dyslipidaemia after adjusting for these risk factors. Fasting plasma glucose level showed an independent association with dyslipidaemia.

CONCLUSIONS/INTERPRETATION

There is a high prevalence of cardiovascular risk factors even among normoglycaemic individuals, and this is highest in urban areas. Fasting plasma glucose level showed an association with dyslipidaemia but not hypertension.

Current scenario of diabetes in India

India, a country experiencing rapid socioeconomic progress and urbanization, carries a considerable share of the global diabetes burden. Studies in different parts of India have demonstrated an escalating prevalence of diabetes not only in urban populations, but also in rural populations as a result of the urbanization of lifestyle parameters. The prevalence of prediabetes is also high. Recent studies have shown a rapid conversion of impaired glucose tolerance to diabetes in the southern states of India, where the prevalence of diabetes among adults has reached approximately 20% in urban populations and approximately 10% in rural populations. Because of the considerable disparity in the availability and affordability of diabetes care, as well as low awareness of the disease, the glycemic outcome in treated patients is far from ideal. Lower age at onset and a lack of good glycemic control are likely to increase the occurrence of vascular complications. The economic burden of treating diabetes and its complications is considerable. It is appropriate that the Indian Government has initiated a national program for the management and prevention of diabetes and related metabolic disorders. Lifestyle modification is an effective tool for the primary prevention of diabetes in Asian Indians. The primary prevention of diabetes is urgently needed in India to curb the rising burden of diabetes.

Oxidative stress pathway genes and chronic renal insufficiency in Asian Indians with Type 2 diabetes

BACKGROUND

There are significant regional variations in prevalence of diabetes and diabetic chronic renal insufficiency (CRI) in India. Oxidative stress plays an important role in the development of diabetic complications. To determine the importance of the polymorphisms in the genes involved in maintenance of cellular redox balance, we performed a case control study in subjects from south and north India.

METHODS

Successive cases presenting to the study centers with Type 2 diabetes of >2 years duration and moderate CRI (n=194, south India 104, north India 90) diagnosed by serum creatinine >or=2 mg/dl after exclusion of nondiabetic causes of CRI were compared with diabetes subjects with no evidence of renal disease (n=224, south India 149, north India 75). Twenty-six polymorphisms from 13 genes from the oxidative stress pathway were analyzed using polymerase chain reaction-restriction fragment length polymorphism. Genes included were superoxide dismutases (SOD1, 2, 3), uncoupling proteins (UCP1, 2), endothelial nitric oxide synthase (NOS3), glutathione-S-transferases (GST) (M1, T1, P1), vascular endothelial growth factor (VEGF), paraoxonase (PON) 1 and 2, and nicotinamide adenine dinucleotide phosphate reduced, oxidase p22(phox). Genes were tested for their association with CRI using chi(2) test.

RESULTS

In south Indian (SI) subjects there was significant allelic and genotypic association of the wild-type allele in SOD2 (Ala9Val; P=.002 and P=.013, respectively), UCP1 (-112 T>G, P=.012 and P=.009; Ala64Thr, P=.015 and P=.004), NOS3 (Glu298Asp, P=.002 and P=.009) and GSTP1 (Ile105Val, P=.003 and P=.004) genes with development of CRI. None of these observations were replicated in the north Indian (NI) subjects. A genotypic but not allelic association was observed for two markers, VEGF (-460 T>C) and PON1 (Arg192Gly) among NI diabetic CRI subjects.

CONCLUSION

The nonreplication of association suggests differential genetic susceptibility of the two populations to diabetic chronic renal insufficiency. In the SI diabetic subjects, oxidative stress pathway genes might be an important predictor for the development of diabetic complications. Further, the association of wild-type alleles may suggest that they confer greater survival ability to comorbid complications and may be nephroprotective.