Random capillary blood glucose cut points for diabetes and pre-diabetes derived from community-based opportunistic screening in India

District-Wise Heterogeneity in Blood Pressure Measurements, Prehypertension, Raised Blood Pressure, and Their Determinants Among Indians: National Family Health Survey-5

Objective: The objective of the study was to determine the prevalence and determinants of ever-measured blood pressure, prehypertension, and raised blood pressure at national, state and district levels in India. Methods: We analysed data from the National Family Health Survey (NFHS-5), on 743,067 adults aged 18-54 years. The sample consisted of 87.6% females and 12.4% males. We estimated prevalence rates and determined adjusted odds ratios for various dependent variables related to blood pressure. Geographical variations were visualized on the map of India, and multivariate logistic regression was employed at state and district levels, with significance set at p < 0.05. Results: The prevalence of ever-measured blood pressure varied widely, from 30.3% to 98.5% across districts, with southern and northern regions showing higher rates. Prehypertension affected 33.7% of the population, with varying prevalence across districts. Raised blood pressure was there in 15.9%, with notably higher rates in southern region (16.8%). Determinants included age, gender, education, wealth, lifestyle, obesity, and blood glucose levels. Conclusion: These findings demonstrate the subnational variations in blood pressure, can guide evidence-based interventions at the state and district level, towards reducing the burden of raised blood pressure and enhancing overall population health.

Effect of short- versus long-term serum glucose levels on early ischemic water homeostasis and functional outcome in patients with large vessel occlusion stroke

BACKGROUND AND PURPOSE

In ischemic stroke, the impact of short- versus long-term blood glucose level (BGL) on early lesion pathophysiology and functional outcome has not been assessed. The purpose of this study was to directly compare the effect of long-term blood glucose (glycated hemoglobin [HbA1c]) versus serum BGL on early edema formation and functional outcome.

METHODS

Anterior circulation ischemic stroke patients who underwent mechanical thrombectomy after multimodal computed tomography (CT) on admission were analyzed. Endpoints were early ischemic cerebral edema, measured by quantitative net water uptake (NWU) on initial CT and functional independence at Day 90.

RESULTS

A total of 345 patients were included. Patients with functional independence had significantly lower baseline NWU (3.1% vs. 8.3%; p < 0.001) and lower BGL (113 vs. 123 mg/dL; p < 0.001) than those without functional independence, while HbA1c levels did not differ significantly (5.7% vs. 5.8%; p = 0.15). A significant association was found for NWU and BGL (ß = 0.02, 95% confidence interval [CI] 0.006-0.03; p = 0.002), but not for HbA1c and NWU (ß = -0.16, 95% CI -0.53-0.21; p = 0.39). Mediation analysis showed that 67% of the effect of BGL on functional outcome was mediated by early edema formation.

CONCLUSION

Aggravated early edema and worse functional outcome was associated with elevated short-term serum BGL, but not with HbA1c levels. Hence, the link between short-term BGL and early edema development might be used as a target for adjuvant therapy in patients with ischemic stroke.

Small Area Geographic Estimates of Cardiovascular Disease Risk Factors in India

Importance

With an aging population, India is facing a growing burden of cardiovascular diseases (CVDs). Existing programs on CVD risk factors are mostly based on state and district data, which overlook health disparities within macro units.

Objective

To quantify and geovisualize the extent of small area variability within districts in CVD risk factors (hypertension, diabetes, and obesity) in India.

Design, Setting, and Participants

This cross-sectional study analyzed nationally representative data from the National Family Health Survey 2019-2021, encompassing individuals aged 15 years or older, for hypertension (n = 1 715 895), diabetes (n = 1 807 566), and obesity (n = 776 023). Data analyses were conducted from July 1, 2022, through August 1, 2023.

Exposures

Geographic units consisting of more than 30 000 small areas, 707 districts, and 36 states or Union Territories across India.

Main Outcomes and Measures

For primary outcomes, CVD risk factors, including hypertension, diabetes, and obesity, were considered. Four-level logistic regression models were used to partition the geographic variability in each outcome by state or Union Territory (level 4), district (level 3), and small area (level 2) and compute precision-weighted small area estimates. Spatial distribution of district-wide means, within-district small area variability, and their correlation were estimated.

Results

The final analytic sample consisted of 1 715 895 individuals analyzed for hypertension (mean [SD] age, 39.8 [17.3] years; 921 779 [53.7%] female), 1 807 566 for diabetes (mean [SD] age, 39.5 [17.2] years; 961 977 [53.2%] female), and 776 023 for obesity (mean [SD] age, 30.9 [10.2] years; 678 782 [87.5%] women). Overall, 21.2% of female and 24.1% of male participants had hypertension, 5.0% of female and 5.4% of men had diabetes, and 6.3% of female and 4.0% of male participants had obesity. For female participants, small areas (32.0% for diabetes, 34.5% for obesity, and 56.2% for hypertension) and states (30.0% for hypertension, 46.6% for obesity, and 52.8% for diabetes) accounted for the majority of the total geographic variability, while districts accounted for the least (13.8% for hypertension, 15.2% for diabetes, and 18.9% for obesity). There were moderate to strong positive correlations between district-wide mean and within-district variability (r = 0.66 for hypertension, 0.94 for obesity, and 0.96 for diabetes). For hypertension, a significant discordance between district-wide mean and within-district small area variability was found. Results were largely similar for male participants across all categories.

Conclusions and Relevance

This cross-sectional study found a substantial small area variability, suggesting the necessity of precise policy attention specifically to small areas in program formulation and intervention to prevent and manage CVD risk factors. Targeted action on policy-priority districts with high prevalence and substantial inequality is required for accelerating India's efforts to reduce the burden of noncommunicable diseases.

Burden of undiagnosed and suboptimally controlled diabetes in selected regions of India: Results from the SMART India population-level diabetes screening study

AIMS

To estimate the prevalence of undiagnosed diabetes and suboptimally controlled diabetes and the associated risk factors by community screening in India.

METHODS

In this multi-centre, cross-sectional study, house-to-house screening was conducted in people aged ≥40 years in urban and rural areas across 10 states and one union territory in India between November 2018 and March 2020. Participants underwent anthropometry, clinical and biochemical assessments. Capillary random blood glucose and point-of-care glycated haemoglobin (HbA1c ) were used to diagnose diabetes. The prevalence of undiagnosed diabetes and suboptimal control (HbA1c ≥53 mmol/mol [≥7%]) among those with known diabetes was assessed.

RESULTS

Among the 42,146 participants screened (22,150 urban, 19,996 rural), 5689 had known diabetes. The age-standardised prevalence of known diabetes was 13.1% (95% CI 12.8-13.4); 17.2% in urban areas and 9.4% in rural areas. The age-standardised prevalence of undiagnosed diabetes was 6.0% (95% CI 5.7-6.2); similar in both urban and rural areas with the highest proportions seen in the East (8.0%) and South (7.8%) regions. When we consider all people with diabetes in the population, 22.8% of individuals in urban areas and 36.7% in rural areas had undiagnosed diabetes. Almost 75% of the individuals with known diabetes had suboptimal glycaemic control.

CONCLUSIONS

High prevalence of undiagnosed diabetes and suboptimally controlled diabetes emphasises the urgent need to identify and optimally treat people with diabetes to reduce the burden of diabetes.

Antidiabetic effects of protein hydrolysates from Trachinotus ovatus and identification and screening of peptides with α-amylase and DPP-IV inhibitory activities

In the present study, the antidiabetic properties of Trachinotus ovatus protein hydrolysates (TOH) in streptozotocin-induced diabetic mice were investigated, and peptides with α-amylase (AAM) and dipeptidyl peptidase IV (DPP-IV) inhibitory activities were identified and screened. The results showed that TOH alleviated body weight loss, polyphagia, blood glucose elevation and insulin secretion decline in diabetic mice. After 4 weeks of TOH administration, random blood glucose (RBG) decreased significantly. The TOH groups showed a dose-dependent reduction in fasting blood glucose (FBG), especially in the high-dose TOH group, which reduced FBG by 58% versus the effect of metformin. Moreover, TOH exerted a remarkable protective effect on hepatorenal function, as evidenced by increased superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GPX) and decreased serum urea levels. Histopathological studies confirmed that TOH can significantly protect the kidney and pancreas from histological changes, which was of great benefit for ensuring the normal secretion of insulin and preventing the occurrence of complications such as diabetic nephropathy. Two fractions with higher inhibitory activity against AAM and DPP-IV, F4 and F6, were obtained from the ultrafiltration of TOH-2 (≤3 kDa). A total of 19 potentially active peptides from F4 and 3 potentially active peptides from F6 were screened by LC‒MS/MS combined with bioinformatic analysis. These peptides are small molecular peptides composed of 2-6 amino acids, rich in characteristic amino acids such as proline, arginine, phenylalanine and asparagine, and contain high proportions of peptides (68% for F4, 67% for F6) with hydrophobicity ≥50%. They offer potent antidiabetic potential and could potentially bind to the active sites in the internal cavities of the target enzymes AAM and DPP-IV. In summary, this study revealed for the first time the antidiabetic effects of protein hydrolysates of Trachinotus ovatus and their derived peptides, which are promising natural ingredients with the potential to be used for the treatment or prevention of diabetes.

Assessment of Overweight, Obesity, Central Obesity, and Type 2 Diabetes among Adolescents in Qatar: A Cross-Sectional Study

Qatar has a high obesity and type 2 diabetes mellitus (T2DM) burden. This study aimed to (1) determine the prevalence of overweight, obesity, and T2DM in 13-17-year-old adolescents and (2) evaluate associations with adolescents' lifestyle and breastfeeding history, parental weight, and familial T2DM history. A cross-sectional study (double-stage cluster sampling) was conducted in 2018-2020 using a self-administered parental and adolescent questionnaire. In the results, 23.4% of the adolescents (107/459) were overweight; 19.9% (91/459) were obese; and 37.6% (171/459) had evidence of central obesity. Random blood sugar (RBS) was suggestive of prediabetes (≥140 mg/dL) for 23 (5.0%) adolescents and T2DM (≥200 mg/dL) for none. In multivariable analysis, obesity was significantly associated with no breastfeeding (OR = 3.17, 95% CI: 1.09-9.26) compared to breastfed adolescents for ≥6 months, with first-degree family history of T2DM (OR = 2.27; 95% CI: 1.22-4.27), with maternal obesity (OR = 2.40; 95% CI: 1.01-5.70), and with acanthosis nigricans in adolescents (OR = 19.8; 95% CI: 8.38-46.9). Central obesity was significantly associated with maternal obesity (OR = 2.21; 95% CI: 1.14-4.27) and with acanthosis nigricans (OR = 3.67; 95% CI: 1.88-7.18). Acanthosis nigricans (OR = 4.06; 95% CI: 1.41-11.7) was the only factor associated with elevated RBS. Addressing future disease burden among adults in Qatar will require extensive health and well-being programs, focused on healthy lifestyles and behaviors such as nutritious diets, physical activity, stress management, and self-care.

Prevalence of multimorbidity and associated treatment burden in primary care settings in Kerala: a cross-sectional study in Malappuram District, Kerala, India

Background: Multimorbidity or co-existence of two or more chronic conditions is common and associated with reduced quality of life and increased risk of death. We aimed to estimate the prevalence and pattern of multimorbidity in primary care settings in Kerala and the associated treatment burden, and quality of life. Methods: A cross-sectional survey was conducted among 540 adult participants in Malappuram District, Kerala. A multi-stage cluster sampling method was employed. Hypertension, diabetes, chronic obstructive pulmonary disease, depression and anxiety screening were done by trained medical professionals. The remaining medical conditions were self-reported by the respondent and verified with patient held health records. The health-related quality of life [HRQoL] was measured using the EQ-5D-5L tool. The MTBQ tool was used for measuring the multimorbidity treatment burden. Logistic regression was used to identify variables associated with multi-morbidity. Results: Overall, the prevalence of multimorbidity was 39.8% (35.7 – 44.1). The prevalence of multimorbidity among men (42.6%) was relatively higher than that in women (38.1%). Lower educational attainment, higher age group, and overweight or obesity status were independently associated with higher prevalence of multimorbidity. The most common pairs of coexisting chronic conditions reported in the study were hypertension and diabetes in males (66.7%) and females (70.8%). All domains of quality of life were impaired in individuals with multimorbidity. Conclusion: Multimorbidity is a norm and affects two of five participants seeking care in primary care settings in Kerala. The social gradient in the prevalence of multimorbidity was evident with higher prevalence in individuals with low educational attainment. Multimorbidity seriously impairs quality of life and increases treatment burden. The focus of management should move beyond individual diseases, and pivot towards interventions targeting multi-morbidity management, with a specific focus for people living in lower socio-economic strata.

Clinical algorithms for the management of intrapartum maternal urine abnormalities

AIM

To develop evidence-based clinical algorithms for management of common intrapartum urinary abnormalities.

POPULATION

Women with singleton, term pregnancies in active labour and immediate postnatal period, at low risk of complications.

SETTING

Healthcare facilities in low- and middle-income countries.

SEARCH STRATEGY

A systematic search and review were conducted on the current guidelines from WHO, NICE, ACOG and RCOG. Additional search was done on PubMed and The Cochrane Database of Systematic Reviews up to May 2020.

CASE SCENARIOS

Four common intrapartum urinary abnormalities were selected: proteinuria, ketonuria, glycosuria and oliguria. Using reagent strip testing, glycosuria was defined as ≥2+ on one occasion or of ≥1+ on two or more occasions. Proteinuria was defined as ≥2+ and presence of ketone indicated ketonuria. Oliguria was defined as hourly urine output ≤30 ml. Thorough initial assessment using history, physical examination and basic investigations helped differentiate most of the underlying causes, which include diabetes mellitus, dehydration, sepsis, pre-eclampsia, shock, anaemia, obstructed labour, underlying cardiac or renal problems. A clinical algorithm was developed for each urinary abnormality to facilitate intrapartum management and referral of complicated cases for specialised care.

CONCLUSIONS

Four simple, user-friendly and evidence-based clinical algorithms were developed to enhance intrapartum care of commonly encountered maternal urine abnormalities. These algorithms may be used to support healthcare professionals in clinical decision-making when handling normal and potentially complicated labour, especially in low resource countries.

TWEETABLE ABSTRACT

Evidence-based clinical algorithms developed to guide intrapartum management of commonly encountered urinary abnormalities.

Effectiveness and implementation of a lifestyle modification intervention for women with isolated impaired fasting glucose: Study protocol for a hybrid type 2 study in Kerala, India

Background: Isolated impaired fasting glucose (i-IFG) constitutes a major group in the prediabetic spectrum among Indians, and thus it is imperative to identify effective diabetes prevention strategies. This study aims to evaluate the effects of an intensive community-based lifestyle modification program on regression to normoglycemia among women with i-IFG, compared to a control group at 24 months. The study also aims to evaluate the implementation of the intervention, via both process and implementation outcomes. Methods: We will use a hybrid design (Effectiveness-implementation hybrid type 2 trial) to test the effectiveness and implementation of the lifestyle modification intervention. Effectiveness is evaluated using a randomized controlled trial among 950 overweight or obese women, aged 30 to 60 years, with i-IFG on an oral glucose tolerance test in the Indian state of Kerala. The intervention involves an intensive lifestyle modification program through group and individually mentored sessions using behavioural determinants and behavioural change techniques.  The intervention group will receive the intervention for a period of 12 months and the control group will receive general health advice through a health education booklet. Data on behavioural, clinical, and biochemical measures will be collected using standard methods at 12 and 24 months. The primary outcome will be regression to normoglycemia at 24 months, as defined by the American Diabetes Association criteria. Discussion: This study will provide the first evidence on the effects of lifestyle interventions on regression to normoglycemia in people with i-IFG among Indians. CTRI registration: CTRI/2021/07/035289 (30/07/2021).

Clozapine induces metformin-resistant prediabetes/diabetes that is associated with poor clinical efficacy in patients with early treatment-resistant schizophrenia

BACKGROUND

Two distinct subtypes of treatment-resistant schizophrenia (TRS) have been recently reported, including early-treatment resistance (E-TR) and late-treatment resistance (L-TR). This study was to assess clozapine-induced metformin-resistant prediabetes/diabetes and its correlation with clinical efficacy in schizophrenia E-TR subtype.

METHODS

This prospective cohort study enrolled 230 patients with schizophrenia E-TR subtype and they were treated with adequate doses of clozapine for 16 weeks, during which patients with prediabetes/diabetes were assigned to receive add-on metformin. The main outcomes and measures included incidence of clozapine-induced prediabetes/diabetes and metformin-resistant prediabetes/diabetes, and the efficacy of clozapine as assessed by the Positive and Negative Syndrome Scale (PANSS) score.

RESULTS

Clozapine-induced prediabetes/diabetes occurred in 76.52% of patients (170 prediabetes and 6 diabetes), of which the blood sugar of 43 (24.43%) patients was controlled with metformin. Despite add-on metformin, 47.06% (74/170) of prediabetes patients progressed to diabetes. In total, the incidence of clozapine-induced metformin-resistant prediabetes/diabetes was 75.57% (133/176). On completion of 16-week clozapine treatment, 16.52% (38/230) patients showed clinical improvement with PANSS scores of ≥50% declining. Furthermore, clozapine-induced prediabetes/diabetes was significantly correlated with the poor clinical efficacy of clozapine for schizophrenia E-TR subtype.

CONCLUSIONS

The incidence of clozapine-induced metformin-resistant prediabetes/diabetes was considerably high in the schizophrenia E-TR subtype. Clozapine-induced metformin-resistant prediabetes/diabetes represents an independent risk factor that adversely affects the clinical efficacy of clozapine for the schizophrenia E-TR subtype. This study provided new evidence for re-evaluating the use of clozapine for TRS, especially E-TR subtype, and the use of metformin for the glycemic control of clozapine-induced prediabetes/diabetes.

Cost-effectiveness of population-based screening for diabetes and hypertension in India: an economic modelling study

BACKGROUND

India faces a high burden of diabetes and hypertension. Currently, there is a dearth of economic evidence about screening programmes, affected age groups, and frequency of screening for these diseases in Indian settings. We assessed the cost effectiveness of population-based screening for diabetes and hypertension compared with current practice in India for different scenarios, according to type of screening test, population age group, and pattern of health-care use.

METHODS

We used a hybrid decision model (decision tree and Markov model) to estimate the lifetime costs and consequences from a societal perspective. A meta-analysis was done to assess the effectiveness of population-based screening. Primary data were collected from two Indian states (Haryana and Tamil Nadu) to assess the cost of screening. The data from the National Health System Cost Database and the Costing of Health Services in India study were used to determine the health system cost of diagnostic tests and cost of treating diabetes or hypertension and their complications. A total of 962 patients were recruited to assess out-of-pocket expenditure and quality of life. Parameter uncertainty was evaluated using univariate and multivariable probabilistic sensitivity analyses. Finally, we estimated the incremental cost per quality-adjusted life-year (QALY) gained with alternative scenarios of scaling up primary health care through a health and wellness centre programme for the treatment of diabetes and hypertension.

FINDINGS

The incremental cost per QALY gained across various strategies for population-based screening for diabetes and hypertension ranged from US$0·02 million to $0·03 million. At the current pattern of health services use, none of the screening strategies of annual screening, screening every 3 years, and screening every 5 years was cost-effective at a threshold of 1-time per capita gross domestic product in India. In the scenario in which health and wellness centres provided primary care to 20% of patients who were newly diagnosed with uncomplicated diabetes or hypertension, screening the group aged between 30 and 65 years every 5 years or 3 years for either diabetes, hypertension, or a comorbid state (both diabetes and hypertension) became cost-effective. If the share of treatment for patients with newly diagnosed uncomplicated diabetes or hypertension at health and wellness centres increases to 70%, from the existing 4% at subcentres and primary health centres, annual population-based screening becomes a cost saving strategy.

INTERPRETATION

Population-based screening for diabetes and hypertension in India could potentially reduce time to diagnosis and treatment and be cost-effective if it is linked to comprehensive primary health care through health and wellness centres for provision of treatment to patients who screen positive.

FUNDING

None.

ADA Diabetes Risk Test Adaptation in Indonesian Adult Populations: Can It Replace Random Blood Glucose Screening Test?

Aims

The use of non-invasive and easily available assessment tools such as the ADA diabetes risk test is recommended for diabetes screening among general population. This study aims to assess the validity of the ADA diabetes risk test in screening for screening hyperglycemia in Indonesian population.

Methods

This cross-sectional study conducted at primary health care in Cibeber sub district at Cilegon city, Banten province, Indonesia. Subjects were aged ≥45 years old without a prior diagnosis of diabetes were recruited consecutively. The risk of hyperglycemia was measured using the ADA Diabetes Risk Test. Random capillary blood glucose (RcBG) with a cut-off value >140 mg/dL used as a comparison.

Results

From a total of 134 subjects, 23.13% of subjects (n = 31) had hyperglycemia. The ADA Diabetes Risk Test gave an area under the ROC curve (AUC) of 0.71 (95% CI: 0.60-0.81) with an optimal cut-off of value ≥5. The sensitivity of the ADA diabetes risk test in diagnosing hyperglycemia was 68% with a false-negative rate (FNR) of 32.26%. Meanwhile, at a cut-off value ≥4, the sensitivity of the ADA Diabetes Risk Test was 93% with an FNR of 9.7%.

Conclusion

ADA diabetes risk test provides a valuable result as a diabetes screening tool in the Indonesian population, thus promotes intervention strategies for population known to be at risk

Burden of increased blood glucose due to modifiable risk factors among men in India

BACKGROUND AND AIMS

Worldwide, many diabetes cases are occurring mainly due to lifestyle risk factors. Hence, to quantify and compare the attributable burden of key modifiable risk factors associated with increased Blood Glucose (BG) among Indian states and districts.

METHODS

The study used the National Family Health Survey (2015-16) data to estimate Population Attributable Risk (PAR) for increased BG (>140 mg/dl) among men aged 15-54 years in 640 districts of 36 States/Union Territories (UTs), India. We have considered three key modifiable factors such as high Body Mass Index (BMI), use of tobacco and alcohol. Population Attributable Risk techniques were employed to address the attributable burden of increased blood glucose due to modifiable risk factors.

RESULTS

Substantial variations were found in the burden of increased BG due to high BMI, alcohol and tobacco use in India. The overall burden of increased BG due to high BMI, tobacco and alcohol in India was 28.5%, 2.1% and 6.4%, respectively. Regional variations in BG were found in high BMI, tobacco and alcohol consumption groups. The high burden of increased BG related to the above key modifiable risk factors mostly seen in North-Eastern' districts due to alcohol, Southern and Northern' districts was due to high BMI. However, the higher burden due to tobacco was reported in Central, Eastern and North-Eastern' districts.

CONCLUSION

Three modifiable risk factors are contributing significantly to increased BG among men. Since there are regional differences in their contributions, state/district, specific targeted interventions may be necessary to control increased BG among men in India.

Protocol on a multicentre statistical and economic modelling study of risk-based stratified and personalised screening for diabetes and its complications in India (SMART India)

INTRODUCTION

The aim of this study is to develop practical and affordable models to (a) diagnose people with diabetes and prediabetes and (b) identify those at risk of diabetes complications so that these models can be applied to the population in low-income and middle-income countries (LMIC) where laboratory tests are unaffordable.

METHODS AND ANALYSIS

This statistical and economic modelling study will be done on at least 48 000 prospectively recruited participants aged 40 years or above through community screening across 20 predefined regions in India. Each participant will be tested for capillary random blood glucose (RBG) and complete a detailed health-related questionnaire. People with known diabetes and all participants with predefined levels of RBG will undergo further tests, including point-of-care (POC) glycated haemoglobin (HbA1c), POC lipid profile and POC urine test for microalbuminuria, retinal photography using non-mydriatic hand-held retinal camera, visual acuity assessment in both eyes and complete quality of life questionnaires. The primary aim of the study is to develop a model and assess its diagnostic performance to predict HbA1c diagnosed diabetes from simple tests that can be applied in resource-limited settings; secondary outcomes include RBG cut-off for definition of prediabetes, diagnostic accuracy of cost-effective risk stratification models for diabetic retinopathy and models for identifying those at risk of complications of diabetes. Diagnostic accuracy inter-tests agreement, statistical and economic modelling will be performed, accounting for clustering effects.

ETHICS AND DISSEMINATION

The Indian Council of Medical Research/Health Ministry Screening Committee (HMSC/2018-0494 dated 17 December 2018 and institutional ethics committees of all the participating institutions approved the study. Results will be published in peer-reviewed journals and will be presented at national and international conferences.

TRIAL REGISTRATION NUMBER

ISRCTN57962668 V1.0 24/09/2018.

Diagnostic accuracy of tests for type 2 diabetes and prediabetes: A systematic review and meta-analysis

AIM

This systematic review aimed to ascertain the diagnostic accuracy (sensitivity and specificity) of screening tests for early detection of type 2 diabetes and prediabetes in previously undiagnosed adults.

METHODS

This systematic review included published studies that included one or more index tests (random and fasting tests, HbA1c) for glucose detection, with 75-gram Oral Glucose Tolerance Test (or 2-hour post load glucose) as a reference standard (PROSPERO ID CRD42018102477). Seven databases were searched electronically (from their inception up to March 9, 2020) accompanied with bibliographic and website searches. Records were manually screened and full text were selected based on inclusion and exclusion criteria. Subsequently, data extraction was done using standardized form and quality assessment of studies using QUADAS-2 tool. Meta-analysis was done using bivariate model using Stata 14.0. Optimal cut offs in terms of sensitivity and specificity for the tests were analysed using R software.

RESULTS

Of 7,151 records assessed by title and abstract, a total of 37 peer reviewed articles were included in this systematic review. The pooled sensitivity, specificity, positive (LR+) and negative likelihood ratio (LR-) for diagnosing diabetes with HbA1c (6.5%; venous sample; n = 17 studies) were 50% (95% CI: 42-59%), 97.3% (95% CI: 95.3-98.4), 18.32 (95% CI: 11.06-30.53) and 0.51 (95% CI: 0.43-0.60), respectively. However, the optimal cut-off for diagnosing diabetes in previously undiagnosed adults with HbA1c was estimated as 6.03% with pooled sensitivity of 73.9% (95% CI: 68-79.1%) and specificity of 87.2% (95% CI: 82-91%). The optimal cut-off for Fasting Plasma Glucose (FPG) was estimated as 104 milligram/dL (mg/dL) with a sensitivity of 82.3% (95% CI: 74.6-88.1%) and specificity of 89.4% (95% CI: 85.2-92.5%).

CONCLUSION

Our findings suggest that at present recommended threshold of 6.5%, HbA1c is more specific and less sensitive in diagnosing the newly detected diabetes in undiagnosed population from community settings. Lowering of thresholds for HbA1c and FPG to 6.03% and 104 mg/dL for early detection in previously undiagnosed persons for screening purposes may be considered.

Topical chlorhexidine 0.2% versus topical natamycin 5% for fungal keratitis in Nepal: rationale and design of a randomised controlled non-inferiority trial

INTRODUCTION

Fungal infections of the cornea, fungal keratitis (FK), are challenging to treat. Current topical antifungals are not always effective and are often unavailable, particularly in low-income and middle-income countries where most cases occur. Topical natamycin 5% is usually first-line treatment, however, even when treated intensively, infections may progress to perforation of the eye in around a quarter of cases. Alternative antifungal medications are needed to treat this blinding disease.Chlorhexidine is an antiseptic agent with antibacterial and antifungal properties. Previous pilot studies suggest that topical chlorhexidine 0.2% compares favourably with topical natamycin. Full-scale randomised controlled trials (RCTs) of topical chlorhexidine 0.2% are warranted to answer this question definitively.

METHODS AND ANALYSIS

We will test the hypothesis that topical chlorhexidine 0.2% is non-inferior to topical natamycin 5% in a two-arm, single-masked RCT. Participants are adults with FK presenting to a tertiary ophthalmic hospital in Nepal. Baseline assessment includes history, examination, photography, in vivo confocal microscopy and cornea scrapes for microbiology. Participants will be randomised to alternative topical antifungal treatments (topical chlorhexidine 0.2% and topical natamycin 5%; 1:1 ratio, 2-6 random block size). Patients are reviewed at day 2, day 7 (with reculture), day 14, day 21, month 2 and month 3. The primary outcome is the best spectacle corrected visual acuity (BSCVA) at 3 months. Primary analysis (intention to treat) will be by linear regression, with treatment arm and baseline BSCVA prespecified covariates. Secondary outcomes include epithelial healing time, scar/infiltrate size, ulcer depth, hypopyon size, perforation and/or therapeutic penetrating keratoplasty (corneal transplant), positive reculture rate (day 7) and quality of life (EuroQol-5 dimensions, WHO/PBD-VF20, WHOQOL-BREF).

ETHICS AND DISSEMINATION

The Nepal Health Research Council, the Nepal Department of Drug Administration and the London School of Hygiene and Tropical Medicine ethics committee have approved the trial. The results will be presented at local and international meetings and submitted to peer-reviewed journals for publication.

TRIAL REGISTRATION NUMBER

ISRCTN14332621; pre-results.

Increased blood glucose level following hysterectomy among reproductive women in India

BACKGROUND

In recent years, the hysterectomy, a surgical removal of the uterus, has received increased attention in health policy debates in India. The trigger for this was a series of media reports that highlighted an unusual surge in the number of women undergoing hysterectomies with a significant number of cases involving young and early menopausal women from low-income families. When menopause occurs as a result of hysterectomy, then the hormones such as estrogen and progesterone affect how the body cells respond to insulin. To date, we have not come across a national study following blood glucose levels among women who undergo a hysterectomy.

METHODS

The study used the Indian fourth round of National Family Health Survey data, which is a cross-sectional nationally representative sample of 699,686 women in the age group 15-49 years and conducted during 2015-16. Bivariate and multivariate logistic regressions were used to examine the effect of hysterectomy on blood glucose level of > 140 mg/dl among women of reproductive age groups.

RESULTS

The blood glucose level of > 140 mg/dl was much higher among women who had undergone a hysterectomy (12.2%) compared to non-hysterectomy women (5.7%). The pattern holds true among relevant background characteristics such as age, place of residence, education, caste, religion, wealth, marital status, body mass index (BMI), anaemia and consumption of tobacco. The adjusted odds after controlling for significant background factors, women who underwent hysterectomy experienced 15% higher odds of blood glucose level of > 140 mg/dl compared those who did not.

CONCLUSIONS

The results indicated increased blood glucose level among women post hysterectomy. Hence, the government of India should consider developing evidence-based policies and programming to provide effective targeted interventions for the better reproductive health of women.

Co-existence of diabetes and TB among adults in India: a study based on National Family Health Survey data

Multiple studies suggest that diabetes mellitus (DM) is a potential risk factor for tuberculosis (TB) development and treatment, especially in low- and middle-income countries. The study aimed to test concomitancy between DM and TB among adults in India. Data were from the 2015-16 National Family Health Survey (NFHS-4). The study sample comprised 107,575 men aged 15-54 and 677,292 women aged 15-49 for which data on DM status were available in the survey. The association between state-level prevalence of TB and DM was examined and robust Poisson regression analysis applied to examine the effect of DM on TB. A high prevalence of TB was observed among individuals with diabetes in India in 2015-16. A total of 866 per 100,000 men and 405 per 100,000 women who self-reported having diabetes also had TB; among those who self-reported not having diabetes the ratios were 407 per 100,000 men and 241 per 100,000 women. The risk of having TB among those who self-reported having DM was higher for both men (2.03, 95% CI: 1.26, 3.28) and women (1.79, 95% CI: 1.48, 2.49) than for those who did not self-report having DM. Adults who were diagnosed with diabetes (including pre-diabetes) also had a higher rate of TB (477 per 100,000 men and 331 per 100,000 women) than those who were not diagnosed (410 per 100,000 men and 239 per 100,000 women). Adults from poor families, with lower BMIs, lower levels of literacy and who were not working had a higher risk of TB-DM co-morbidity. The state-level pattern of co-morbidity, the under-reporting of DM (undiagnosed) and TB stigmatization are discussed. The study confirms that diabetes is an important co-morbid feature with TB in India, and reinforces the need to raise awareness on screening for the co-existence of DM and TB with integrated health programmes for the two conditions.

Obesity and its Link to Undiagnosed Diabetes Mellitus and Hypertension in Rural Parts of Western India

BACKGROUND

Obesity and overweight are becoming major health concerns worldwide. Hence, we studied the association between overweight and obesity with new-onset diabetes and hypertension in a selected rural population.

METHODOLOGY

Community health workers made house-to-house visits, inviting adults >20 years of age who were at a higher risk of diabetes, from a predefined rural area of Maharashtra, to visit a mobile diabetes clinic operating in a hub and spoke manner. Sociodemographic data and anthropometric measurements were recorded. BMI and waist circumference was classified according to the WHO recommended cutoffs for Asians. Subjects with capillary blood fasting glucose of ≥126 mg/dL or random glucose of ≥200 mg/dL by glucometer were diagnosed as diabetes and blood pressure of ≥140/90 mmHg by sphygmomanometer were diagnosed as hypertension. Subjects with a known history of diabetes mellitus and hypertension were excluded.

RESULTS

Out of 29,324 total population, 16.5% of subjects were overweight and 26.4% were obese. Mean ± SD of BMI of the participants was 22.9 ± 4.1 kg/m² in males and 22.4 ± 4.2 kg/m² in females. Around 35% of males and 30.5% of females had a high waist circumference of ≥90 cm and ≥80 cm, respectively, 20.5% of subjects had newly diagnosed hypertension, and 11.4% of subjects had newly diagnosed diabetes mellitus. The occurrence of newly diagnosed hypertension and diabetes showed an increasing trend with increasing BMI.

CONCLUSION

Our community-based screening suggested a high prevalence of overweight and obesity in rural India. There was a high prevalence of newly diagnosed hypertension and diabetes in this population.

Cut-off Value of Random Blood Glucose among Asian Indians for Preliminary Screening of Persons with Prediabetes and Undetected Type 2 Diabetes Defined by the Glycosylated Haemoglobin Criteria

Aim

The increased morbidity and mortality due to type 2 diabetes can be partly due to its delayed diagnosis. In developing countries, the cost and unavailability of conventional screening methods can be a setback. Use of random blood glucose (RBG) may be beneficial in testing large numbers at a low cost and in a short time in identifying persons at risk of developing diabetes. In this analysis, we aim to derive the values of RBG corresponding to the cut-off values of glycosylated hemoglobin (HbA1c) used to define prediabetes and diabetes.

Methods

Based on their risk profile of developing diabetes, a total of 2835 individuals were screened for a large diabetes prevention study. They were subjected to HbA1c testing to diagnose prediabetes and diabetes. Random capillary blood glucose was also performed. Correlation of RBG with HbA1c was computed using multiple linear regression equation. The optimal cut-off value for RBG corresponding to HbA1c value of 5.7% (39 mmol/mol), and ≥ 6.5% (48 mmol/mol) were computed using the receiver operating curve (ROC). Diagnostic accuracy was assessed from the area under the curve (AUC) and by using the Youden’s index.

Results

RBG showed significant correlation with HbA1c (r=0.40, p<0.0001). Using the ROC analysis, a RBG cut-off value of 140.5 mg/dl (7.8 mmol/L) corresponding to an HbA1c value of 6.5% (48mmol/mol) was derived. A cut-off value could not be derived for HbA1c of 5.7% (39 mmol/mol) since the specificity and sensitivity for identifying prediabetes were low.

Conclusion

Use of a capillary RBG value was found to be a simple procedure. The derived RBG cut-off value will aid in identifying people with undiagnosed diabetes. This preliminary screening will reduce the number to undergo more cumbersome and invasive diagnostic testing.

Elevated blood glucose is associated with aggravated brain edema in acute stroke

BACKGROUND AND PURPOSE

Clinical outcome after endovascular thrombectomy in patients with acute ischemic stroke still varies significantly. Higher blood glucose levels (BGL) have been associated with worse clinical outcome, but the pathophysiological causes are not yet understood. We hypothesized that higher levels of BGL are associated with more pronounced ischemic brain edema and worse clinical outcome mediated by cerebral collateral circulation.

METHODS

178 acute ischemic stroke patients who underwent mechanical thrombectomy were included. Early ischemic brain edema was determined using quantitative lesion water uptake on initial computed tomography (CT) and collateral status was assessed with an established 5-point scoring system in CT-angiography. Good clinical outcome was defined as functional independence (modified Rankin Scale [mRS] score 0-2). Multivariable logistic regression analysis was performed to predict functional independence and linear regression analyses to investigate the impact of BGL and collateral status on water uptake.

RESULTS

The mean BGL at admission was significantly lower in patients with good outcome at 90 days (116.5 versus 138.5 mg/dl; p < 0.001) and early water uptake was lower (6.3% versus 9.6%; p < 0.001). The likelihood for good outcome declined with increasing BGL (odds ratio [OR] per 100 mg/dl BGL increase: 0.15; 95% CI 0.02-0.86; p = 0.039). Worse collaterals (1% water uptake per point, 95% CI 0.4-1.7%) and higher BGL (0.6% per 10 mg/dl BGL, 95% CI 0.3-0.8%) were significantly associated with increased water uptake.

CONCLUSION

Elevated admission BGL were associated with increased early brain edema and poor clinical outcome mediated by collateral status. Patients with higher BGL might be targeted by adjuvant anti-edematous treatment.

Standardizing hypertension management in a primary care setting in India through a protocol based model

Hypertension is a leading cause of death in India. Control rates of hypertension are abysmal, even for people on treatment. There are a number of barriers to adequate control of hypertension in India, including therapeutic inertia and the lack of a systematic, simplified approach. Standardizing hypertension management through an evidence based model that sets thresholds for diagnosis, treatment goals, follow up intervals and choice of drugs can lead to improved management of hypertension in an individual hospital or health system. In this paper, we summarize the evidence for such a model, and adapt it to the Indian context, focusing on maximizing effectiveness, safety and ease of use by a non-expert. This model can be utilized by individual practitioners, hospitals, primary health centers (PHCs) and the Health and Wellness Centers (HWCs) under the Ayushman Bharat initiative.

Prevalence of Diabetes Mellitus and Exposure to Suspended Particulate Matter

BACKGROUND

Evidence from various epidemiological studies has shown an association between particulate matter 2.5 (PM2.5) and diabetes mellitus. A prospective study from the United States reported that exposure to PM2.5 alters endothelial function, and leads to insulin resistance and reduction in peripheral glucose uptake. There is a paucity of data on the relation between air pollution and diabetes in low- and middle-income countries.

OBJECTIVES

To estimate the prevalence of type 2 diabetes among people living in areas with higher exposures of suspended PM2.5 compared to people living in areas with lower exposures in Chennai, Tamil Nadu, India.

METHODS

A cross-sectional study was carried out in two areas of Chennai city. The PM2.5 affecting vulnerable areas were stratified from a list of air quality monitoring stations in Tamil Nadu Pollution Control Board and Central Pollution Control Board. The highest and lowest areas of exposure were selected from the list. Households were randomly selected for the study. A total of 201 (67 male, 134 female) individuals from a high exposure area (HEA) and 209 (76 male 133 female) individuals from a low exposure area (LEA) were recruited for the study. Adults over 18 years of age were screened for random capillary blood glucose (RCBG) by glucometer (OneTouch Ultra).

RESULTS

The prevalence of diabetes (34.8% vs 19.6% p =0.001) was 77.5% higher among people living in areas of high particulate matter exposure compared to people living in less exposed areas. Multivariable logistic regression analysis showed that age, gender, residential area, and family history of diabetes were significantly associated with the prevalence of diabetes (p<0.05).

CONCLUSIONS

The present study indicates a link between high levels of exposure to PM2.5 and diabetes mellitus. Further prospective studies on populations exposed to elevated pollution are needed to establish whether this association has a causative link.

PARTICIPANT CONSENT

Obtained.

ETHICS APPROVAL

The study was approved by the Ethics Committee of the Prof. M Viswanathan Diabetes Research Centre, Chennai, India.

COMPETING INTERESTS

The authors declare no competing financial interests.

Changes in Screening Practices for Prediabetes and Diabetes Since the Recommendation for Hemoglobin A1c Testing

OBJECTIVE

Screening involves the presumptive identification of asymptomatic individuals at increased risk for unrecognized disease. We examined changes in screening practices for prediabetes and diabetes since January 2010, when HbA_1c was first recommended as an option for screening and diagnosis.

RESEARCH DESIGN AND METHODS

We studied members without diabetes of an HMO ≥45 years of age continuously enrolled for ≥3 years and assigned to primary care clinicians affiliated with a large academic health system. We defined screening as the first oral glucose tolerance test, HbA_1c, or glucose test performed between 2010 and 2014.

RESULTS

Of 12,772 eligible patients, 9,941 (78%) were screened at least once over 3 years. HbA_1c was the initial screening test 14% of the time and glucose 86% of the time. Of those screened with HbA_1c, 63% had abnormal results defined as HbA_1c ≥5.7% (≥39 mmol/mol). Of those tested with glucose, 30% had abnormal results defined as glucose ≥100 mg/dL, and 5% had abnormal results defined as glucose ≥126 mg/dL. Patients with abnormal HbA_1c levels and those with glucose levels ≥126 mg/dL were equally likely to be scheduled for follow-up appointments (41% vs. 39%), but those with abnormal HbA_1c levels were more likely to be diagnosed with prediabetes or diabetes (36% vs. 26%).

CONCLUSIONS

As we observed in 2004, rates of screening are high. HbA_1c is still used less frequently than glucose for screening but is more likely to result in a clinical diagnosis. Evidence to support guidelines to define the role of random glucose screening, including definition of appropriate cut points and follow-up, is needed.

Evaluation of continuous glucose monitoring system for detection of alterations in glucose homeostasis in pediatric patients with β-thalassemia major

BACKGROUND

Disturbances of glucose metabolism are common in β-thalassemia major (β-TM).

AIM

This study was conducted to assess the pattern of glucose homeostasis in pediatric β-TM patients comparing oral glucose tolerance test (OGTT) and continuous glucose monitoring system (CGMS).

METHODS

Two-hundred β-TM patients were studied and those with random blood glucose (RBG) ≥7.8 mmol/L (140 mg/dL) were subjected to OGTT, insertion of CGMS and measurement of fasting C peptide, fasting insulin, and hemoglobin A1c (HbA1c).

RESULTS

Twenty patients (10%) had RBG ≥ 7.8 mmol/L. Using OGTT, 6 out of 20 patients (30%) had impaired glucose tolerance (IGT) while 7 (35%) patients were in the diabetic range. CGMS showed that 7/20 (35%) patients had IGT and 13 (65%) patients had diabetes mellitus (DM); 10 of the latter group had HbA1c readings within diabetic range. The percentage of diabetic patients diagnosed by CGMS was significantly higher than that with OGTT (P = 0.012). Serum ferritin was the only independent variable related to elevated RBG. All β-TM patients with DM were non-compliant to chelation therapy.

CONCLUSIONS

The use of CGMS in the diagnosis of early glycemic abnormalities among pediatric patients with β-TM appears to be superior to other known diagnostic modalities.

Changing Perspectives in Tribal Health: Rising Prevalence of Lifestyle Diseases among Tribal Population in India

Background:

The major focus of studies related to health among tribes in India has been on malnutrition. The world is in the stage of epidemiological transition, and noncommunicable diseases are overtaking the communicable diseases not only in general but also among the tribal population.

Objectives:

A cross-sectional study was conducted to find out the prevalence of diabetes and hypertension among the tribal population.

Methodology:

A house-to-house survey using a semi-structured questionnaire was conducted in three randomly selected tribal villages. Participants aged 18 and above from both genders were included. Blood pressure was recorded and random blood sugar was estimated for all the participants. Chi-square test was used to study association for categorical variables and one-way ANOVA and Student's t-test were used to study association for continuous variables. A P < 0.05 was considered significant.

Results:

A total of 952 tribal people were interviewed. About 40.2% were males and 59.8% were females. About 82.2% were Illiterate. 18.9% were underweight compared to 8.8% who were overweight or obese. The prevalence of diabetes was 3.8% (36 participants) of which 77.8% was newly detected. Increasing age was associated with diabetes. Overall, prevalence of hypertension was 16.7% (159 participants) of which 62.9% were newly detected. Age, gender, body mass index, and literacy status were associated with the presence of hypertension. Only eight participants had both diabetes and hypertension.

Conclusion:

Noncommunicable diseases burden in tribal population is as high as in the general population. Effective strategies to prevent this have to be devised.

Effectiveness of Color Coded Diabetic Control Monitoring Charts among Elderly Diabetics Attending Outreach Primary Care Geriatric Clinics in Rural Karnataka: An Open Label Randomized Control Trial

INTRODUCTION

Type 2 diabetes mellitus problem is progressively rising every day. The adherence to the treatment approaches and health-seeking make major difference in case of diabetics particularly elderly. Visual tools improve the involvement of patients in their care, especially among populations with low health literacy.

OBJECTIVE

To evaluate the effectiveness of color-coded diabetic control monitoring charts on glycemic control among elderly diabetics.

METHODOLOGY

144 elderly diabetic patients attending rural primary care geriatric clinics were randomized into two groups. Those randomized to the intervention group received the color-coded diabetic monitoring chart and a health education package in addition to the usual consultation services. Baseline and 1-year follow-up glycated hemoglobin (HbA1C) values were used to assess the effectiveness of the intervention.

RESULTS

The results of multivariate linear regression analysis showed that there was an average reduction of 0.265% in HbA1C value in the intervention group when compared to the nonintervention group when adjusted for baseline HbA1C and number of visits during the intervention period (β coefficient = 0.265, P < 0.05).

CONCLUSION

Color-coded diabetes charts are effective in achieving glycemic control among elderly diabetics, and steps should be made to inculcate visually appealing management approaches in case of elderly diabetic patients.

The Practical Approach to Care Kit (PACK) guide: developing a clinical decision support tool to simplify, standardise and strengthen primary healthcare delivery

For the primary health worker in a low/middle-income country (LMIC) setting, delivering quality primary care is challenging. This is often complicated by clinical guidance that is out of date, inconsistent and informed by evidence from high-income countries that ignores LMIC resource constraints and burden of disease. The Knowledge Translation Unit (KTU) of the University of Cape Town Lung Institute has developed, implemented and evaluated a health systems intervention in South Africa, and localised it to Botswana, Nigeria, Ethiopia and Brazil, that simplifies and standardises the care delivered by primary health workers while strengthening the system in which they work. At the core of this intervention, called Practical Approach to Care Kit (PACK), is a clinical decision support tool, the PACK guide. This paper describes the development of the guide over an 18-year period and explains the design features that have addressed what the patient, the clinician and the health system need from clinical guidance, and have made it, in the words of a South African primary care nurse, 'A tool for every day for every patient'. It describes the lessons learnt during the development process that the KTU now applies to further development, maintenance and in-country localisation of the guide: develop clinical decision support in context first, involve local stakeholders in all stages, leverage others' evidence databases to remain up to date and ensure content development, updating and localisation articulate with implementation.

Prevalence, Awareness, Treatment, and Control of Hypertension and Its Risk Factors in (Central) Vietnam

Introduction

The objective of this study is to describe the prevalence, awareness, treatment, and control of hypertension and its associated risk factors in (Central) Vietnam.

Methods

In this cross-sectional study, a multistage sampling was used to select 969 participants from the general population aged from 40 to 69 years. The cardiovascular risk factors were collected throughout the interviews with a standardized questionnaire. Multivariate logistic regression analysis was conducted to test the relationship between the prevalence, awareness, treatment, and control of hypertension and the prevalence of risk factors.

Results

The prevalence of hypertension was 44.8%. It was higher in men than in women (51.3% versus 39.7%, p < 0.001). In total 67.3% (74.5% in women, 60.1% in men; p = 0.001) of the participants were aware of their hypertension, 33.2% (37.5% in women, 28.9% in men; p = 0.01) of the participants were treated, and 12.2% (16.7% in women, 7.8% in men; p < 0.001) of the hypertensive participants' hypertension was controlled. Age, gender, place of residence, body mass index, and diabetes were found to be independent risk factors for hypertension.

Conclusion

The prevalence of hypertension in Vietnam is high, and the proportion of treated and controlled patients is rather low.

Idiopathic macular telangiectasis type 2 and co-existent diabetic retinopathy

Background

To study the interaction between idiopathic macular telangiectasis type 2 (MacTel2) and coexistent diabetic retinopathy (DR) during long term follow up.

Methods

A retrospective chart review was done for all eyes with MacTel2 and DR with a minimum 2 years follow up. Eyes with other retinal disorders and poor quality imaging were excluded. Data collected included demographics, presenting visual acuity, systemic evaluation, treatments done, duration of follow up, and final visual outcomes.

Results

Out of 951 patients with MacTel2, 277 patients had diabetes. Out of 277 patients, 44 eyes of 22 patients had MacTel2 coexisting with DR. Twenty-eight eyes of 14 patients were included in this study. All cases of MacTel2 were bilateral with a preponderance of women (71.42%). Mean follow up was 93.07 ± 84.03 months with a mean random blood sugar level of 135.41 ± 45.47 mg% at presentation. Twenty-five (89.28%) eyes presented with mild non-proliferative diabetic retinopathy. Two (7.14%) eyes progressed in their DR staging from baseline. Stage III MacTel2 were noted in 11 (39.28)% eyes at baseline. None of these eyes progressed to stage V during follow up. Mean presenting logMAR BCVA was 0.214 ± 0.227 which dropped to 0.399 ± 0.301 at last visit (p = 0.0005). Diabetic macula edema (DME) was not noted in any eye till last follow up.

Conclusions

12.5% of eyes with MacTel2 in diabetic patients had coexistent DR. MacTel2 led to slowly progressive visual loss irrespective of the presence of DR.

Prevalence of diabetes and its relation with age and sex in Turaif city, northern Saudi Arabia in 2016-2017

Background

The prevalence of diabetes in Saudi Arabia has increased dramatically during the last decades. This increase has been attributed to significant changes in cultural and socio-economic factors.

Objective

The aim of this study was to determine prevalence of diabetes and its relation with age and sex in Turaif city, northern Saudi Arabia.

Methods

This was a cross-sectional study carried out during the academic year 2016–2017 over a period of 6 months (October 01, 2016 to March 30, 2017). A total of 1,287 Saudi national individuals of both sexes, aged from 1 year to more than 65 years were included in the study. Data were collected by a predesigned questionnaire covering medical history of diabetes, age and sex.

Results

Mean age (± SD) was 24.29 (±13.96) years with the minimum age at 1 year and the maximum age at 93 years, male to female ratio was 42.5% to 57.5%. The total prevalence of DM among the studied population was 5.8% and pre-diabetic cases were 6.8%. There were significant relationships between age/sex, and the occurrence of diabetes among the studied population (p<0.05).

Conclusions

The total prevalence rate of DM among the studied population of Turaif city, northern Saudi Arabia was 5.8% and pre-diabetic cases were 6.8%. Awareness campaigns and prevention programs about diabetes should be instituted and the existing ones must be strengthened. Adequate commitment from the Ministry of Health is also advocated.

Risk factor of type 2 diabetes mellitus among adolescents from rural area of India

Context:

Health system is likely to encounter more adolescents with Type 2 diabetes mellitus (T2DM) as a consequence of obesity and sedentary lifestyle. Intervention at various stages of the life cycle is needed as cumulative effect of risk factors accumulated from fetal life to adult increases risk of noncommunicable disease.

Aims:

The aim of this study was to find out awareness regarding T2DM and distribution of risk factor for T2DM in adolescents from the rural areas of Wardha district, India.

Methodology:

A cross-sectional study conducted in the rural area of India involves 412 adolescent boys and girls selected by systematic random sampling technique. Data collected by a face-to-face interview and waist-hip ratio (WHR), body mass index, random capillary blood glucose (RCBG) were estimated.

Results:

65.1% were aware of T2DM. Girls, older adolescents, higher education were associated with awareness (P < 0.001). Totally, 204 (49.51%) had some risk factors for T2DM, of these 191 (46.6%) had sedentary lifestyle, 153 (31.7%) adolescents had nutritional risk factors, 69 (43.4%) boys had WHR >0.90 and 113 (71.1%) girls had WHR >0.85, 103 (25%) adolescents had RCBG ≥110 mg/dl, and 77 (18.7%) participants reported family history of DM.

Conclusions:

Considering the risk factors of T2DM among adolescents from the rural area, there is a need for prevention programs for creating awareness related to T2DM, early identification of risk factor for T2DM, and targeted interventions. The study may serve as a formative research for developing and testing interventions aimed at primary prevention of T2DM among adolescents from rural India.

Use of Cooking Fuels and Cataract in a Population-Based Study: The India Eye Disease Study

BACKGROUND

Biomass cooking fuels are commonly used in Indian households, especially by the poorest socioeconomic groups. Cataract is highly prevalent in India and the major cause of vision loss. The evidence on biomass fuels and cataract is limited.

OBJECTIVES

To examine the association of biomass cooking fuels with cataract and type of cataract.

METHODS

We conducted a population-based study in north and south India using randomly sampled clusters to identify people ≥ 60 years old. Participants were interviewed and asked about cooking fuel use, socioeconomic and lifestyle factors and attended hospital for digital lens imaging (graded using the Lens Opacity Classification System III), anthropometry, and blood collection. Years of use of biomass fuels were estimated and transformed to a standardized normal distribution.

RESULTS

Of the 7,518 people sampled, 94% were interviewed and 83% of these attended the hospital. Sex modified the association between years of biomass fuel use and cataract; the adjusted odds ratio (OR) for a 1-SD increase in years of biomass fuel use and nuclear cataract was 1.04 (95% CI: 0.88, 1.23) for men and 1.28 (95% CI: 1.10, 1.48) for women, p interaction = 0.07. Kerosene use was low (10%). Among women, kerosene use was associated with nuclear (OR = 1.76, 95% CI: 1.04, 2.97) and posterior subcapsular cataract (OR = 1.71, 95% CI: 1.10, 2.64). There was no association among men.

CONCLUSIONS

Our results provide robust evidence for the association of biomass fuels with cataract for women but not for men. Our finding for kerosene and cataract among women is novel and requires confirmation in other studies. Citation: Ravilla TD, Gupta S, Ravindran RD, Vashist P, Krishnan T, Maraini G, Chakravarthy U, Fletcher AE. 2016. Use of cooking fuels and cataract in a population-based study: the India Eye Disease Study. Environ Health Perspect 124:1857-1862; http://dx.doi.org/10.1289/EHP193.

Estimating the proportion of persons with diabetes developing diabetic retinopathy in India: A systematic review and meta-analysis

BACKGROUND

Available evidence from India shows that the control of diabetes is poor in majority of the population. This escalates the risk of complications. There is no systematic review to estimate the magnitude of diabetic retinopathy (DR) in India.

MATERIALS AND METHODS

A systematic literature search was carried out in Ovid Medline and EMBASE databases using Mesh and key search terms. Studies which reported the proportion of people with diabetes with DR in a representative community population were included. Two independent reviewers reviewed all the retrieved publications. Data were extracted using a predefined form. Review Manager software was used to perform meta-analysis to provide a pooled estimate. Studies included were assessed for methodological quality using selected items from the STROBE checklist.

RESULTS

Seven studies (1999-2014; n = 8315 persons with diabetes) were included in the review. In the meta-analysis, 14.9% (95% confidence interval [CI] 10.7-19.0%) of known diabetics aged ≥30 years and 18.1% (95% CI 14.8-21.4) among those aged ≥50 years had DR. Heterogeneity around this estimate ranged from I(2)= 79-87%. No linear trend was observed between age and the proportion with DR. The overall methodological quality of included studies was moderate.

CONCLUSIONS

Early detection of DR is currently not prioritized in public health policies for noncommunicable diseases and blindness programs. Methodological issues in studies suggest that the proportion of diabetics with DR is underestimated in the Indian population. Future research should emphasize more robust methodology for assessing diabetes and DR status.

Developing a Screening Algorithm for Type II Diabetes Mellitus in the Resource-Limited Setting of Rural Tanzania

BACKGROUND

Noncommunicable diseases are on pace to outnumber infectious disease as the leading cause of death in sub-Saharan Africa, yet many questions remain unanswered with concern toward effective methods of screening for type II diabetes mellitus (DM) in this resource-limited setting. We aim to design a screening algorithm for type II DM that optimizes sensitivity and specificity of identifying individuals with undiagnosed DM, as well as affordability to health systems and individuals.

METHODS

Baseline demographic and clinical data, including hemoglobin A1c (HbA1c), were collected from 713 participants using probability sampling of the general population. We used these data, along with model parameters obtained from the literature, to mathematically model 8 purposed DM screening algorithms, while optimizing the sensitivity and specificity using Monte Carlo and Latin Hypercube simulation.

RESULTS

An algorithm that combines risk assessment and measurement of fasting blood glucose was found to be superior for the most resource-limited settings (sensitivity 68%, sensitivity 99% and cost per patient having DM identified as $2.94). Incorporating HbA1c testing improves the sensitivity to 75.62%, but raises the cost per DM case identified to $6.04. The preferred algorithms are heavily biased to diagnose those with more severe cases of DM.

CONCLUSIONS

Using basic risk assessment tools and fasting blood sugar testing in lieu of HbA1c testing in resource-limited settings could allow for significantly more feasible DM screening programs with reasonable sensitivity and specificity.

Why screening for type 2 diabetes is necessary even in poor resource settings

Screening for type 2 diabetes (T2DM) remains controversial, in spite of the explosive increase in the prevalence of the disorder and the morbidity and mortality associated with its complications. In this review, we attempt to show that T2DM is an ideal candidate disease for screening, and why screening is needed to improve clinical outcomes and prevent complications. We also suggest that screening can be made more cost-effective by adopting a targeted approach and utilizing low-cost tools. We conclude that screening for T2DM is warranted even in resource-constrained settings, and provide examples from rural India showing that such an approach is feasible with meticulous planning and judicious allocation of resources.

Effect of mobile reminders on screening yield during opportunistic screening for type 2 diabetes mellitus in a primary health care setting: A randomized trial

Objective. We wanted to study whether mobile reminders increased follow-up for definitive tests resulting in higher screening yield during opportunistic screening for diabetes. Methods. This was a facility-based parallel randomized controlled trial during routine outpatient department hours in a primary health care setting in Puducherry, India (2014). We offered random blood glucose testing to non-pregnant non-diabetes adults with age >30 years (667 total, 390 consented); eligible outpatients (random blood glucose ≥ 6.1 mmol/l, n = 268) were requested to follow-up for definitive tests (fasting and postprandial blood glucose). Eligible outpatients either received (intervention arm, n = 133) or did not receive mobile reminder (control arm, n = 135) to follow-up for definitive tests. We measured capillary blood glucose using a glucometer to make epidemiological diagnosis of diabetes. The trial was registered with Clinical Trial Registry of India (CTRI/2014/10/005138). Results. 85.7% of outpatients in intervention arm returned for definitive test when compared to 53.3% in control arm [Relative Risk = 1.61, (0.95 Confidence Interval — 1.35, 1.91)]. Screening yield in intervention and control arm was 18.6% and 10.2% respectively. Etiologic fraction was 45.2% and number needed to screen was 11.9. Conclusion. In countries like India, which is emerging as the diabetes capital of the world, considering the wide prevalent use of mobile phones, and real life resource limited settings in which this study was carried out, mobile reminders during opportunistic screening in primary health care setting improve screening yield of diabetes.

•

First RCT to determine the effect of mobile reminders on screening yield for diabetes mellitus.

•

Operational research conducted in real world primary health care setting.

•

Outpatients with random blood glucose ≥ 6.1 mmol/l among adults >30y were eligible for definitive tests.

•

Mobile reminders for eligible outpatients was introduced as a reminder system.

Primary care screening for individuals with impaired glucose metabolism with focus on impaired glucose tolerance

AIM

To evaluate the utility of three short questions (the Skövde Form) combined with a random plasma glucose, and HbA1c as alternative tools for detection of individuals with impaired glucose metabolism (IGM), and particularly impaired glucose tolerance (IGT).

METHODS

Three questions concerning BMI ≥ 25 kg/m(2), heredity for type 2 diabetes, and known hypertension were asked in a random population of 573 individuals. All with two positive answers or one positive answer and a random plasma glucose > 7.2 mmol/l were invited for an oral glucose tolerance test and an HbA1c examination. FINDRISC was completed for comparison.

RESULTS

The positive predictive value (PPV) for IGM, using the Skövde Form, was 31% while sensitivity and specificity were 59% and 73%, respectively. Corresponding values for IGT were 11%, 50% and 69%. Using HbA1c ≥ 42 mmol/mol, the PPV for IGM was 64% while sensitivity and specificity were 28% and 97%, respectively. The corresponding values for IGT were 15%, 16% and 94%.

CONCLUSION

The Skövde Form combined with a random plasma glucose may be used as an alternative tool for detection of individuals with IGM and IGT in particular. HbA1c may be used to identify individuals with type 2 diabetes but fails to detect most individuals with prediabetes.

Exercise patterns and behaviour in Asian Indians: data from the baseline survey of the Diabetes Community Lifestyle Improvement Program (D-CLIP)

AIMS

This paper attempts to describe the patterns of exercise and the perceived benefits and barriers to exercise in an urban south Indian population.

METHODS

Study participants were recruited from the baseline survey of the D-CLIP (Diabetes Community Lifestyle Improvement Program). Frequency, duration, type and location of exercise were assessed using a questionnaire, while a Likert type scale was used to assess perceived benefits of and barriers to exercise. Quality of life was measured using the EQ-5D.

RESULTS

Out of 1281 participants (63.7% males), 24.1% reported doing ≥150min of exercise/week ("exercisers") compared to 75.9% "non-exercisers". Exercisers were significantly older (47 vs. 43 years), better educated (68.8% vs. 60%), had a higher monthly income (41% vs. 29.2%), consumed more fruits (38.2% vs. 25.6%) and vegetables (84.1% vs. 77.7%) and had better perceived state of health (81.1% vs. 76.8%), compared to non-exercisers. Exercisers had significantly lower HOMA-IR, higher Matsuda index and lower prevalence of low HDL cholesterol compared to non-exercisers. However, there were no significant differences in cardio-metabolic risk factors like diabetes, hypertension and obesity between the two groups. Walking was the most common type of exercise. Both exercisers and non-exercisers perceived the benefits of exercising, but barriers weighed more heavily on exercise behaviour.

CONCLUSIONS

Urgent steps are needed to improve overall exercise levels in India by addressing barriers and improving the quality of exercise performed so as to enhance overall metabolic health.

Opportunistic Screening for Hypertension and Selected Cardiovascular Risk Factors among Adults Attending a Primary Health Center in Puducherry, India

BACKGROUND

India is currently suffering from an epidemic of noncommunicable diseases; it is thus imperative to screen for cardiovascular risk factors in people visiting Primary Health Centers (PHCs). The objective of the study was to measure the amount of undiagnosed hypertension and selected cardiovascular risk factors present among the adult population through opportunistic screening at the PHC.

METHODS

A facility-based opportunistic screening program was carried out in a PHC in rural Puducherry. Patients and accompanying persons aged 30 years and above, who attended the daily outpatient department (OPD) were included. The OPD provides outpatient services and medical procedures or tests without requirement of an overnight stay, and functions for 4 h a day. Known hypertensive patients and pregnant women were excluded. Information on age, gender, diabetes status, and personal history of tobacco and alcohol use were collected using an interview schedule. Height, weight and waist circumference were measured, along with blood pressure and blood sugar using standard protocols. Systolic blood pressure (SBP) ≥140 and/or diastolic blood pressure (DBP) ≥90 mm Hg was taken as hypertension. SBP of 120-139 mm Hg and/or DBP of 80-89 mm Hg were taken as prehypertension.

RESULTS

A total of 324 participants were screened; 56.8% were females. The mean standard deviation (SD) age of the participants was 47.7 (SD 12.6) years. Hypertension and prehypertension were present in 17.9% and 37.7% of the participants respectively. 17.3% participants had diabetes. 22.2% and 21.3% of all participants were current users of tobacco and alcohol respectively. Generalized obesity was present in 31.8% of the participants; 19.1% were overweight. 45.1% participants had central obesity.

CONCLUSIONS

A relatively large proportion of adults were found to have prehypertension and obesity, thus showing the need for early intervention.