A prospective, multicentre, randomized, open-label comparison of a long-acting basal insulin analog glargine plus glulisine with premixed insulin in insulin naïve patients with Type 2 diabetes - A study from India

AIMS

We aimed to compare the effectiveness of Glargine plus Glulisine to premixed insulin analogue, as measured by HbA1c ≤ 7.0% in insulin naive Type 2 Diabetes (T2D) patients with elevated fasting and/or postprandial plasma glucose.

METHODS

Insulin-naive T2D patients (116 men, 84 women) on ≥ 2 oral hypoglycemic agents with inadequate glycemic control were randomized either to group 1 (insulin Glargine plus Glulisine, n = 101) or group 2 (Premixed Insulin analogue, n = 99).

RESULTS

In the intention to treat analysis, at week 24, percentage of patients with good glycaemic control (HbA1c ≤ 7.0%) was similar between the two groups (16.8% in Group 1 vs. 13.1% in Group 2, χ2 - 0.535, p = 0.47). Significant reductions in fasting and postprandial levels were observed in groups 1 and 2 at both post-baseline time points (Week 12 and 24). In group 1, reduction in HbA1c from baseline to week 12 was 0.6 ± 0.1 and 0.7 ± 0.2 at week 24, p < 0.0001 for all. In group 2, no significant change in HbA1c was observed. In group 1, 83.2% required an additional dose of glulisine and in group 2, 88.9% required an additional dose of premixed insulin. Hypoglycemic events were similar in both groups (0.12 events per person-year in group 1 and 0.13 events per person-year in group 2). Weight gain was non-significant in both groups.

CONCLUSIONS

Glargine plus Glulisine, though in higher dose was effective as premixed insulin in lowering HbA1c. Hypoglycemic events per person-year were similar in both groups.

Improvement in glycaemic control in patients with type 2 diabetes with treatment using an interactive mobile application - A pilot study from India

AIMS

We studied the outcome of glycaemic management using Diahome, a smart-phone application compared to conventional treatment. Overall acceptability of the application among users was also assessed.

METHODS

This is a retrospective, case-control study of patients on virtual diabetes care using the Diahome app (n = 441) and those visited the hospital out-patient services (n = 446) between April and June 2021. Men and women aged 45-60 years with type 2 diabetes (T2DM) were selected.

RESULTS

A total of 173 records with initial and follow-up visits were analyzed (app users n = 91, non-app users n = 82). Participants were aged 59 ± 12 years and were obese. The two groups were similar by age, gender distribution and duration of T2DM. Fasting blood glucose significantly reduced only among the app-users from a baseline level of 156 ± 70 mg/dl to 129 ± 40 mg/dl at follow-up (p < 0.02). Reduction in HbA1c levels was observed in both groups (p < 0.0001); percentage improvement was better among app (15.8%) than in non-app users (10.4%), p = 0.004. Triglycerides level were higher at both time points among app-users (p < 0.05) as compared to the other group. More than 56% of the users rated the performance of Diahome app as excellent; virtual consultation was rated the highest (71.5%) among the Diahome services.

DISCUSSION

Glycaemic management of diabetes using a dedicated mobile application was superior to in-person hospital visits. Its long-term effectiveness and cost savings need to be ascertained.

Serum and salivary adipokines in type 2 diabetes - Results of a pilot study in India

BACKGROUND AND AIMS

Association of serum and salivary adiponectin, apelin, visfatin and vaspin were studied in type 2 diabetes (T2DM) among Asian Indians. Their concentrations in periodontitis were also studied.

METHODS

In this cross-sectional analysis, men and women aged ≥35 years, with no history of diabetes, were screened for ≥3 risk factors for T2DM (n = 615). Eligible persons underwent a 75 gm oral glucose tolerance test and were categorized as Group A (Normal and Impaired Glucose Tolerant, n = 65) and Group B (Incident T2DM, n = 25). Screening for periodontitis was done. Saliva samples were collected in the morning. Participants refrained from food intake for about 2 hours prior to collection . Serum and saliva were stored for analysis.

RESULTS

Serum adiponectin was low (p = 0.006) in T2DM and correlated with its salivary levels (r = 0.46, p < 0.001). Serum apelin levels were similar, but salivary concentrations were higher (p = 0.014) in T2DM. Higher serum (p = 0.016) and salivary (p = 0.03) visfatin levels were seen in T2DM. Vaspin levels showed no significant difference in the two groups, either in blood or saliva. Serum adipokines did not differ in the presence of periodontitis. In saliva, higher vaspin (p = 0.034) and lower visfatin (p = 0.018) concentrations were observed.

CONCLUSIONS

The selected adipokines were measurable in saliva, in lower concentrations. Salivary adiponectin and visfatin measurements may be useful in studies on T2DM.

Concordance in incidence of diabetes among persons with prediabetes detected using either oral glucose tolerance test or glycated haemoglobin

AIMS

To study the concordance in the incidence of type 2 diabetes (T2DM) between cohorts with prediabetes, selected either by oral glucose tolerance test (OGTT) or glycosylated haemoglobin (HbA1c) at two years in a real world situation.

METHODS

Two cohorts with impaired glucose tolerance (IGT) were selected from the non-interventional arm of the Indian diabetes prevention programmes; a group selected by using OGTT (Cohort 1, n = 498), another selected based on the HbA1c criterion (Cohort 2, n = 504). Clinical and biochemical data collected for 24 months at 6 monthly intervals were used in assessing the cumulative incidence of T2DM using the respective diagnostic criteria. Intra and inter group comparisons were analysed using appropriate statistical tests. A multiple logistic regression analysis was used to identify the variables significantly associated with the incidence of diabetes.

RESULTS

Incidence of diabetes in both cohorts were similar at 12 and 24 months with either of the two criteria (25.3% with glucose and 27.5% with HbA1c, p = 0.41 at 24 months). The multivariate analysis confirmed the results. Only baseline waist circumference was positively associated with the incidence.

CONCLUSION

Both OGTT and HbA1c have similar utility and validity in identifying persons with IGT. Persons identified with either of the criterion had similar incidence of T2DM among Asian Indians.

Analysis of an Indian diabetes prevention programme on association of adipokines and a hepatokine with incident diabetes

To study the association and possible predictive role of visfatin, resistin, fetuin-A and chemerin with incident type 2 diabetes (T2DM) among Asian Indians with prediabetes. Their association with insulin resistance, β-cell function, glycaemia and anthropometry were also studied. This is a nested case-control study of a large 2-year prospective prevention trial in persons at high risk of developing T2DM. Baseline HbA1c values between 6.0% (42 mmol/mol) and 6.2% (44 mmol/mol) were chosen for this analysis (n = 144). At follow-up, persons with incident T2DM (HbA1c ≥ 6.5%, 48 mmol/mol) were grouped as cases (n = 72) and those reverted to normoglycaemia, (HbA1c < 5.7% (39 mmol/mol) as controls (n = 72). Insulin resistance showed the strongest association with incident T2DM ((Odds Ratio (OR): 23.22 [95%CI 6.36-84.77]; p < 0.0001). Baseline visfatin (OR: 6.56 [95%CI 2.21-19.5]; p < 0.001) and fetuin-A (OR: 1.01 [95%CI (1.01-1.04)]; p < 0.0001) independently contributed to the conversion of prediabetes to T2DM. The contribution was significantly higher when their elevated levels coexisted (OR: 12.63 [95%CI 3.57-44.63]; p < 0.0001). The area under the curve was 0.77 ± SE 0.4 (95%CI 0.69-0.85) and 0.80 ± SE 0.04 (95%CI 0.73-0.88) for visfatin (median 17.7 ng/ml, sensitivity and specificity: 75%, p < 0.0001) and fetuin-A (mean 236.2 µg/ml, sensitivity: 71%, specificity: 75%, p < 0.0001) respectively. Higher baseline visfatin and fetuin-A concentrations are strongly associated with incident T2DM and are predictive of future diabetes.

Management of Hyperglycemia in COVID-19 and Post-COVID-19 Syndrome - Proposed Guidelines for India

SARS-CoV-2 virus spread rapidly all over the globe in 2020 and the second wave has taken our nation, India by storm. The pandemic has posed unique challenges in people with metabolic disorders, including diabetes, hypertension, obesity, pulmonary, cardiovascular, kidney and non-alcoholic fatty liver disease. Uncontrolled diabetes, in conjunction with endocrine, inflammatory and metabolic effects of the infection itself has made management of hyperglycemia in COVID-19 infection particularly challenging. Furthermore, the post-COVID-19 syndrome has also emerged as a sequela in COVID-19 survivors, increasing the risk of death, complications and adding further burden on the health care system. With more than a year of experience, we have gained substantial insight; and now provide practical recommendations on the management of hyperglycemia in COVID-19 as well as post COVID-19 syndrome.

Secular trends in cardiovascular risk factors among urban and rural populations in Tamil Nadu, India - An ancillary analysis of the STRiDE-I study

AIMS

To study changes in cardiovascular (CV) risk factors; hypertension (HTN), dysglycaemia (DG) and dyslipidaemia (DL) and their interrelationship, in urban and rural Southern India, in a decade.

METHODS

Epidemiological data of a city (Chennai, n = 2192(2006), n = 3850(2016)) and peri-urban villages (Panruti, n = 2584 (2006), n = 2468 (2016)) among persons aged ≥ 20 years in 2006 and in 2016 were analysed. Age-standardized prevalence, prevalence ratios and interrelationships of HTN, DG and DL and effect of time in years, age, gender and obesity were calculated using Poisson regression analyses.

RESULTS

Response rates in urban and rural areas were 86.5% and 87.6% respectively. Mean age, general obesity (GO), abdominal obesity (AO), total calories and carbohydrate intake increased in both populations (p < 0.0001). Rural population had lower BMI than the urban but had higher AO, particularly among women. Physical activity decreased only in the urban population. HTN increased in urban population; in both, proportion of known HTN decreased, DG and DL increased.

CONCLUSIONS

In both populations, GO, AO, DG and DL increased; AO and DL were more common among rural women. HTN did not increase in the rural population. The risk factors increased rapidly even in rural areas projecting the impact of urbanisation on the CV burden.

Profile and prognosis of patients hospitalized for COVID-19 virus infection with and without diabetes - An observational study from South India

BACKGROUND AND AIMS

We studied the profile and outcome of patients hospitalized for coronavirus disease-19 (COVID-19) infection with and without type 2 diabetes (T2DM).

METHODS

In this observational study, clinical details of patients with COVID-19, identified by Reverse Transcription - Polymerase Chain Reaction admitted to 4 hospitals in Chennai, Tamil Nadu, India were collected from May to November 2020. A total of 845 (n = 423 with diabetes, n = 422 without diabetes) were selected for the analysis. Clinical details, biochemical and radiological investigations, diabetes treatment, intensive care, mortality and other adverse outcomes were recorded. Patients with clinical history of T2DM, glycosylated haemoglobin (HbA1c) of ≥6.5% (48 mmol/mol) and/or random blood glucose ≥200 mg/dl (11.1 mmol/l) were included. Statistical analyses were done using chi-square or 't' test and multiple logistic regression analysis.

RESULTS

At admission, patients with T2DM were older (p < 0.0001), had higher co-morbidities such as coronary artery disease (p = 0.02), hypertension (p < 0.0001), hypothyroidism (p = 0.03) and renal disorders (p = 0.01) than non-diabetes persons. Requirement for intensive care was higher among them. Acute renal injury or failure, pneumonia and myocardial infarction developed in higher percentage of T2DM. Mortality was significantly higher in T2DM (10.2% vs 5.9%, p = 0.02). However, in the multiple logistic regression analysis, only age (p < 0.0001) and renal disorders (p = 0.002) were significantly associated with mortality.

CONCLUSION

Our study showed that mortality was associated with higher age and renal disorders but did not show an association with diabetes, among patients hospitalized for COVID-19 infection.

Trend in the clinical profile of type 2 diabetes in India - Study from a diabetes care centre in South India

BACKGROUND AND AIM

Study the changing clinical and therapeutic profiles of type 2 diabetes (T2D) patients during a 10-year period in a diabetes care centre in Southern India.

METHODS

Retrospective, cross-sectional data of newly registered and review patients at four periods between 2009 and 2018 were analysed (n = 50,322). Clinical findings, anthropometry, blood pressure (BP), glycaemia, lipids, treatment, and co-morbid conditions were analysed. We studied the trends in age and gender distributions, body mass index (BMI), glycaemia, (Glycosylated haemoglobin A1c (HbA1c) levels), BP, cholesterol, triglycerides and therapeutic regimen during this period. Trend analyses were done.

RESULTS

Approximately 60% of patients were men. Percentages in 30-40 years increased, ∼60% were aged 50-69 years and proportion of older patients decreased (p < 0.0001). In 10 years, 85.9% was overweight, obesity increased from 22.1% to 25.0% (p < 0.0001) and <13% maintained normal BMI. HbA1c <7.0% remained approximately at 22%, percentage with moderate glycaemic control (HbA1c 7.0-7.9%) increased significantly, HbA1c of ≥9.0% decreased from 35.1% to 29.1% (p < 0.0001). Use of monotherapy decreased. Prevalence of hypertension increased from 16.2% to 21.6% (p < 0.0001); use of Angiotensin Receptor Blockers (ARB) and calcium channel blockers increased, Angiotensin Converting Enzyme Inhibitors and thiazides decreased (p < 0.0001). Increased use of statins paralleled with reduction in total cholesterol and LDLc.

CONCLUSION

Increasing percentages of younger patients and obesity, use of multiple drugs and reduction in HbA1c were the important observations. Rising prevalence of hypertension, increased use of ARB and statins with better control of dyslipidaemia was observed. Achievement of ideal HbA1c and BP were suboptimal.

A pragmatic and scalable strategy using mobile technology to promote sustained lifestyle changes to prevent type 2 diabetes in India and the UK: a randomised controlled trial

AIMS/HYPOTHESIS

This randomised controlled trial was performed in India and the UK in people with prediabetes to study whether mobile phone short message service (SMS) text messages can be used to motivate and educate people to follow lifestyle modifications, to prevent type 2 diabetes.

METHODS

The study was performed in people with prediabetes (n = 2062; control: n = 1031; intervention: n = 1031) defined by HbA1c ≥42 and ≤47 mmol/mol (≥6.0% and ≤6.4%). Participants were recruited from public and private sector organisations in India (men and women aged 35-55 years) and by the National Health Service (NHS) Health Checks programme in the UK (aged 40-74 years without pre-existing diabetes, cardiovascular disease or kidney disease). Allocation to the study groups was performed using a computer-generated sequence (1:1) in India and by stratified randomisation in permuted blocks in the UK. Investigators in both countries remained blinded throughout the study period. All participants received advice on a healthy lifestyle at baseline. The intervention group in addition received supportive text messages using mobile phone SMS messages 2-3 times per week. Participants were assessed at baseline and at 6, 12 and 24 months. The primary outcome was conversion to type 2 diabetes and secondary outcomes included anthropometry, biochemistry, dietary and physical activity changes, blood pressure and quality of life.

RESULTS

At the 2 year follow-up (n = 2062; control: n = 1031; intervention: n = 1031), in the intention-to-treat population the HR for development of type 2 diabetes calculated using a discrete-time proportional hazards model was 0.89 (95% CI 0.74, 1.07; p = 0.22). There were no significant differences in the secondary outcomes.

CONCLUSIONS/INTERPRETATION

This trial in two countries with varied ethnic and cultural backgrounds showed no significant reduction in the progression to diabetes in 2 years by lifestyle modification using SMS messaging.

TRIAL REGISTRATION

The primary study was registered on www.ClinicalTrials.gov (India, NCT01570946; UK, NCT01795833).

FUNDING

The study was funded jointly by the Indian Council for Medical Research and the UK Medical Research Council.

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.

Effectiveness of mobile phone text messaging in improving glycaemic control among persons with newly detected type 2 diabetes

AIMS

The aim of the study was to evaluate the effect of text messaging as a tool to improve glycaemic control among newly diagnosed T2D patients in a 2 year period.

METHODS

This is a multicentric, randomised controlled trial conducted in 2 states of India. The primary outcome was improvement in glycaemia measured by an HbA1c value of ≤7% (53 mmol/mol) with intervention. The secondary outcomes were changes in biochemical, dietary parameters and physical activity. Acceptability of text messages was assessed. Persons having HbA1c value of ≥6.5% (48 mmol/mol) at diagnosis were enrolled. A total of 248 participants with a mean age of 43.3 ± 8.7 years were recruited. Participants in the control group (n = 122) received standard care, the intervention group (n = 126) received customized text messages thrice a week. Both groups received personal advice at the beginning of the study.

RESULTS

Baseline characteristics were similar in both groups. At 24 months, both groups showed significant reduction in blood pressure and glycaemic variables in comparison to the baseline values. The intervention group showed significant lowering of LDLc also. Multivariate analysis showed that reduction in HbA1c was associated with intervention.

CONCLUSION

Text messaging can lead to improvement in glycaemic control through personal empowerment and sustained behavioural changes.

Secular TRends in DiabEtes in India (STRiDE-I): Change in Prevalence in 10 Years Among Urban and Rural Populations in Tamil Nadu

OBJECTIVE

The objective of the current study was to assess the secular trends in the prevalence of diabetes, prediabetes, and risk factors from two epidemiological surveys done 10 years apart in three adult populations of different geographic and socioeconomic backgrounds in Tamil Nadu, India.

RESEARCH DESIGN AND METHODS

This survey was conducted in 2016 using methodology similar to that used in 2006. Persons aged ≥20 years (n = 9,848) were screened for diabetes, prediabetes, and the risk variables. Fasting and 2-h plasma glucose, lipid profile, blood pressure, anthropometry, and socioeconomic and behavioral details were recorded. Comparative analyses of age-standardized prevalence were done. Prevalence ratios (PRs) between 2016 and 2006 of diabetes and also prediabetes were assessed using Poisson regression analyses.

RESULTS

Prevalence of diabetes increased from 18.6% (95% CI 16.6-20.5) to 21.9 (20.5-23.3) in the city, 16.4 (14.1-18.6) to 20.3 (18.9-21.6) in the town, and 9.2 (8.0-10.5) to 13.4 (11.9-14.8) in the periurban villages (PUVs) (P < 0.0001 in all). The PR showed a nonsignificant 8% rise in diabetes in the city, while significant increases had occurred in the town (39%) and PUVs (34%). Prevalence of prediabetes also increased. Age, family history of diabetes, and waist circumference were common risk determinants among the populations. Though general obesity and abdominal obesity increased, the latter was associated with the increased prevalence.

CONCLUSIONS

Prevalence of diabetes and prediabetes increased in all locations; the rise was significant only in the town and PUVs. Abdominal obesity is significantly associated with increased trend even among the villagers. Rural populations may be targeted for future public health measures to combat diabetes.

Incidence of Type 2 Diabetes is Higher among Men with Persistent Impaired Glucose Tolerance than in Transient Impaired Glucose Tolerance - A 5 year Follow up Study

OBJECTIVE

This was a 5 year comparative analysis of the incidence of type 2 diabetes in men who had persistent impaired glucose tolerance (P-IGT) versus transient impaired glucose tolerance (T-IGT). P-IGT (positive IGT on two oral glucose tolerance tests (OGTT), T-IGT (IGT in first OGTT and normal glucose tolerance (NGT) in the 2nd OGTT).

METHODS

The samples were collected from a randomized controlled diabetes prevention study. The prevention study was done using lifestyle modification (LSM) promoted by use of mobile short message services (SMS) for 2 years. The control group of the randomized study who received advice on LSM at only the baseline formed the P-IGT group for the 3 years follow up study (n=236). T-IGT (n=569) were available from those who had NGT on the 2nd OGTT while screening for the prevention study. The total diabetes incidence at 5 years in the study groups were compared using standard OGTT (WHO criteria).

RESULTS

The conversion rate to diabetes in 5 years was significantly lower among T-IGT than among P-IGT, OR=0.202 (95% CI, 0.145-0.296,p< 0.0001). P-IGT had higher rate of risk factors for diabetes than T-IGT.

CONCLUSION

The risk of conversion to diabetes was 80 percent lower in T-IGT than in P-IGT. Identification of P-IGT will help in selecting persons who require early intervention for diabetes.

Protocol for a clinical trial of text messaging in addition to standard care versus standard care alone in prevention of type 2 diabetes through lifestyle modification in India and the UK

BACKGROUND

Type 2 diabetes is a serious clinical problem in both India and the UK. Adoption of a healthy lifestyle through dietary and physical activity modification can help prevent type 2 diabetes. However, implementing lifestyle modification programmes to high risk groups is expensive and alternative cheaper methods are needed. We are using a short messaging service (SMS) programme in our study as a tool to provide healthy lifestyle advice and an aid to motivation. The aim of the study is to assess the efficacy and user acceptability of text messaging employed in this way for people with pre-diabetes (HbA1c 6.0% to ≤6.4%; 42-47 mmol/mol) in the UK and India.

METHODS/DESIGN

This is a randomised, controlled trial with participants followed up for 2 years. After being screened and receiving a structured education programme for prediabetes, participants are randomised to a control or intervention group. In the intervention group, text messages are delivered 2-3 times weekly and contain educational, motivational and supportive content on diet, physical activity, lifestyle and smoking. The control group undergoes monitoring only. In India, the trial involves 5 visits after screening (0, 6, 12, 18 and 24 months). In the UK there are 4 visits after screening (0, 6, 12 and 24 months). Questionnaires (EQ-5D, RPAQ, Transtheoretical Model of Behavioural Change, and food frequency (UK)/24 h dietary recall (India)) and physical activity monitors (Actigraph GT3X+ accelerometers) are assessed at baseline and all follow-up visits. The SMS acceptability questionnaires are evaluated in all follow-up visits. The primary outcome is progression to type 2 diabetes as defined by an HbA1c of 6.5% or over(India) and by any WHO criterion(UK). Secondary outcomes are the changes in body weight, body mass index, waist circumference, blood pressure, fasting plasma glucose; lipids; proportion of participants achieving HbA1c ≤6.0%; HOMA-IR; HOMA-β; acceptability of SMS; dietary parameters; physical activity and quality of life.

DISCUSSION

The study is designed to assess the efficacy of tailored text messaging in addition to standard lifestyle advice to reduce the progression from prediabetes to type 2 diabetes in the two different countries.

TRIAL REGISTRATION

ClinicalTrials.gov ; NCT01570946 , 4th April 2012 (India); NCT01795833 , 21st February 2013 (UK).

The post-trial analysis of the Indian SMS diabetes prevention study shows persistent beneficial effects of lifestyle intervention

AIMS

We had shown that mobile phone based text messaging was an effective tool to deliver lifestyle changes among Asian Indian men with a 36% relative risk reduction in incident diabetes over two years. The present analysis investigated whether beneficial effects of intervention on diabetes prevention persisted for an additional three years after withdrawal of active intervention.

METHODS

The primary two year randomized controlled trial (2010-2012) compared lifestyle changes with use of automated text messaging reminders in the intervention (n = 271) versus standard care advice (n = 266) at baseline. At the end of the study, both groups received additional advice on lifestyle changes by a trained dietician. Participants free of diabetes (n = 394) were invited three years later to ascertain the sustained effect of intervention. The primary outcome was incidence of type 2 diabetes. This trial is registered with ClinicalTrials.gov,number NCT02848547.

RESULTS

During the mean follow-up of 5 years, 346 out of 394 (87.8%) men were reviewed. Incidence of diabetes was reduced by 30% in the intervention group, with declining gap between-group differences over time (Kaplan-Meier analysis). Significant improvement in dietary adherence occurred in the intervention group at 2nd and 5th year follow up (trend χ2 = 21.35, p < 0.0001). Cox regression analysis showed that the 5th year incidence of diabetes was significantly reduced in the intervention group. Higher body mass index and 2 h plasma glucose at 24 months increased the incidence of diabetes.

CONCLUSIONS

Sustained reduction in incident diabetes was apparent after cessation of active lifestyle intervention. This was possibly associated with continuing practice of improved lifestyle.

mDiabetes initiative using text messages to improve lifestyle and health-seeking behaviour in India

Background

Data on the use of mobile technology in public health are sparse. Text messaging is cost-effective in disseminating information to large communities. The Ministry of Health and Family Welfare, Government of India, initiated and executed this mDiabetes programme.

Objectives

The main objective of this commissioned study was to test the feasibility of using mobile technology to reach a large number of people to improve their lifestyle and health-seeking behaviour. Participants’ interest, acceptability and scope for improvement were assessed.

Methods

This mDiabetes observational study was done in India between 2016 and 2017. Text messages inviting registrations were sent to 130 million people in the country, mostly to the working class. Respondents (n=107 548) were registered by dialling a given phone number (missed phone call) or through a website. Based on the response, participants were grouped into six categories: persons with diabetes, pregnant/lactating women, high-risk individuals, healthcare professionals, elderly and normal population. They received 90 messages on healthy living during the 6 months. The impact of intervention was assessed at the third and sixth months by feedback messages. Telephonic interviews were conducted at 1 year in a subpopulation (n=855).

Results

The registered respondents, 31 725, were grouped into six categories. 21.4% had diabetes and 5.3% had multiple risk factors. 15.6% responded to feedback messages. Among them, 57.2% followed a healthy diet, 72.3% practised advice on physical activity, 51.9% screened for diabetes and 67.3% checked their glycaemic status. The telephonic interviews showed that the programme was feasible and acceptable. The participants suggested use of interactive voice response system for registration and motivation.

Discussion and conclusion

The study demonstrated the feasibility and acceptability of mHealth in a large population to disseminate knowledge regarding diabetes and healthy lifestyle, and to improve health-seeking behaviour. It helped to identify the limitations and scope for future improvements.

Metformin in Prevention of Type 2 Diabetes

Identification and treatment of individuals with prediabetes is crucial. Effective interventional strategies are key to reducing the diabetes risk at the population level. Lifestyle intervention is found to be more effective but more expensive. Evidence of potential benefits from pharmacotherapy is accumulating. The choice of a pharmacologic intervention to reduce the progression of type 2 diabetes (T2DM) in high risk individuals must consider the balance between the benefit to risk ratio. A meta-analysis of the results of the three important studies has shown that metformin used for up to three years decrease the likelihood of progression to diabetes. Metformin showed greater beneficial effect in people with higher baseline Body Mass Index (BMI) and higher Fasting Plasma Glucose (FPG) than in leaner prediabetic counterparts with low FPG concentrations. Besides diabetes risk reduction, the drug has also proved to be cancer and cardio-protective. The National Institute for Clinical Excellence, UK has recommended the use of metformin in prevention of T2DM in adults at high risk on failure to adhere to lifestyle changes. In view of the long standing safety and tolerability, metformin could be prescribed to people who are unable to comply with lifestyle advice.

Health education on diabetes and other non-communicable diseases imparted to teachers shows a cascading effect. A study from Southern India

AIMS

The aims were to assess effect of a short training programme on non-communicable diseases (NCDs), particularly diabetes on school teachers and also on students who were in turn educated by them. Lifestyle changes made by both groups were assessed 6months later.

METHODS

Graduate teachers (n=1017) from 2 districts in Tamilnadu, India were trained using audio visual aids in batches of 100, on healthy lifestyle practices, prevention and management of diabetes. Pre and post training knowledge scores were assessed using questionnaires. Each teacher was requested to impart similar education to 100 high school students within 3months. Impact of the training on teachers and students was assessed using questionnaires 6months later. Feedback from the students' parents was also collected.

RESULTS

A total of 1017 teachers (men: 33.8%, women: 66.2%, urban: 68.8%, rural: 31.1%) were trained. Among them, 651 (men: 31.3%, women: 68.7%) responded for impact evaluation. Changes in knowledge and attitude were reported by 93.7% of teachers. Improvement in lifestyle of the students was assessed by 587 teachers, 60.4% of the students avoided junk foods, 57.5% advised their family members on diabetes. Outdoor games were played by 50.8% of the students. Improvement in knowledge, changes in lifestyle and a positive attitude towards health care delivery were achieved among teachers and students through this training programme.

CONCLUSIONS

Significant improvement in health perception among the teachers and students occurred even with a short training. It has demonstrated that non-medical personnel like teachers are efficient in disseminating health information on lifestyle diseases especially diabetes.

Impact of lifestyle intervention in primary prevention of Type 2 diabetes did not differ by baseline age and BMI among Asian-Indian people with impaired glucose tolerance

AIM

To investigate whether the effectiveness of lifestyle interventions on the incidence of diabetes was influenced by the baseline age and BMI of the Asian-Indian participants with prediabetes.

METHODS

Pooled data, obtained from two of our Indian Diabetes Prevention Programmes (2006, n=236 and 2013, n=473; total N=709) which had similar baseline characteristics and intervention principles, were analysed. For the present secondary analysis we dichotomously categorized the participants' baseline age (<45 and ≥45 years) and BMI (<25.0 and ≥ 25.0 kg/m² ). Glycaemic status was ascertained at 6-monthly intervals by oral glucose tolerance tests. The incidence rates of diabetes and relative risk reduction in both the intervention and the control group were calculated for categories of baseline age and BMI. Interactions between the intervention and baseline age and BMI on diabetes risk were also analysed.

RESULTS

Incident diabetes was diagnosed in 227 of the total 709 participants (32.0%) [control group 139 participants (38.8%) vs intervention group 88 participants (24.2%)] during the median follow-up period of 2 years. The overall relative risk reduction was 35.4% (95% CI 19.3-48.3). Lifestyle intervention was equally effective in both age groups [relative risk reduction in those aged <45 years: 43.7% (95% CI 19.8-60.5) and in those aged ≥ 45 years: 28.9% (95% CI 5.3-46.6) P for interaction = 0.52] and in categories of BMI [BMI <25 kg/m² : 36.1% (95% CI 9.5-54.9); and BMI ≥ 25 kg/m² : 34.8% (95% CI 12.9-51.2); P for interaction = 0.95].

CONCLUSIONS

In Asian-Indian individuals with prediabetes, the effectiveness of lifestyle intervention was not modified by baseline age and BMI.

Baseline level of 30-min plasma glucose is an independent predictor of incident diabetes among Asian Indians: analysis of two diabetes prevention programmes

BACKGROUND

The objective was to study the ability of the 30-min plasma glucose (30-min PG) during an oral glucose tolerance test to predict the future risk of type 2 diabetes among Asian Indians with impaired glucose tolerance.

METHODS

For the present analyses, we utilized data from 753 participants from two diabetes primary prevention studies, having complete data at the end of the study periods, including 236 from Indian Diabetes Prevention Programme-1 and 517 from the 2013 study. Baseline 30-min PG values were divided into tertiles: T1 < 9.1 mmol/L (<163.0 mg/dL); T2 9.2-10.4 mmol/L (164.0-187.0 mg/dL) and T3 ≥ 10.4 mmol/L (≥188 mg/dL). The predictive values of tertiles of 30-min PG for incident diabetes were assessed using Cox regression analyses RESULTS: At the end of the studies, 230 (30.5%) participants developed diabetes. Participants with higher levels of 30-min PG were more likely to have increased fasting, 2-h PG and HbA_1c levels, increased prevalence of impaired fasting glucose and decreased beta cell function. The progression rate of diabetes increased with increasing tertiles of 30-min PG. Cox's regression analysis showed that 30-min PG was an independent predictor of incident diabetes after adjustment for an array of covariates [Hazard Ratio (HR):1.44 (1.01-2.06)] CONCLUSIONS: This prospective analysis demonstrates, for the first time, an independent association between an elevated 30-min PG level and incident diabetes among Asian Indians with impaired glucose tolerance. Predictive utility of glycemic thresholds at various time points other than the traditional fasting and 2-h PG values should therefore merit further consideration. Copyright © 2016 John Wiley & Sons, Ltd.

Diabetes in Asia and the Pacific: Implications for the Global Epidemic

The last three decades have witnessed an epidemic rise in the number of people with diabetes, especially type 2 diabetes, and particularly in developing countries, where more than 80% of the people with diabetes live. The rise of type 2 diabetes in South Asia is estimated to be more than 150% between 2000 and 2035. Although aging, urbanization, and associated lifestyle changes are the major determinants for the rapid increase, an adverse intrauterine environment and the resulting epigenetic changes could also contribute in many developing countries. The International Diabetes Federation estimated that there were 382 million people with diabetes in 2013, a number surpassing its earlier predictions. More than 60% of the people with diabetes live in Asia, with almost one-half in China and India combined. The Western Pacific, the world's most populous region, has more than 138.2 million people with diabetes, and the number may rise to 201.8 million by 2035. The scenario poses huge social and economic problems to most nations in the region and could impede national and, indeed, global development. More action is required to understand the drivers of the epidemic to provide a rationale for prevention strategies to address the rising global public health "tsunami." Unless drastic steps are taken through national prevention programs to curb the escalating trends in all of the countries, the social, economic, and health care challenges are likely to be insurmountable.

A pragmatic and scalable strategy using mobile technology to promote sustained lifestyle changes to prevent type 2 diabetes in India-Outcome of screening

AIMS

We describe a two-step screening approach using non-invasive risk assessment and glycated hemoglobin (HbA1c) to identify participants for a diabetes prevention trial.

METHODS

A total of 6030 non-diabetic persons of 35-55 years were screened using risk assessment for diabetes. Those with three or more risk factors were screened using point of care HbA1c test. For this study, participants in HbA1c categories of 6.0% (42.1 mmol/mol)-6.4% (46.4 mmol/mol) were selected and their characteristics were analyzed.

RESULTS

Among 6030 persons, 2835 (47%) had three or more risk factors for diabetes. Among those screened with HbA1c, 43.2% (1225) had HbA1c values of <6.0% (42.1 mmol/mol), 46.8% (1327) had HbA1c values between 6.0% (42.1 mmol/mol) and ≤ 6.4% (46.4 mmol/mol) and 10% (283) had undiagnosed diabetes with ≥6.5% (47.5 mmol/mol). Positive family history was present in 53.2%, 81.7% were obese and 14.8% were overweight.

CONCLUSIONS

Opportunistic screening using a two-step approach: diabetes risk profile and HbA1c measurement detected a large percentage of individuals with prediabetes. Prediabetic persons recruited to the trial had higher percentage of obesity and presence of positive family history than those who had lower HbA1c values. Outcomes from this trial will enable comparisons with the previous prevention studies that used blood glucose levels as the screening criteria.

The oral disposition index is a strong predictor of incident diabetes in Asian Indian prediabetic men

AIMS

In this analysis, we sought to examine the prospective association of the disposition index (DIo) derived from oral glucose tolerance test with incident diabetes in Asian Indian men with impaired glucose tolerance (IGT).

METHODS

These post hoc analyses used data from a 2-year prospective study in primary prevention of diabetes using lifestyle intervention among 517 men with IGT. All the participants received standard lifestyle advice at baseline. The surrogate insulin sensitivity and insulin secretion measures were tested for their hyperbolic relationship. Predictive associations of various surrogate measures with incident diabetes were determined using receiver operating characteristic curves.

RESULTS

The combination of total area under the curve of insulin-to-glucose ratio (AUCinsulin/glucose) and Matsuda's insulin sensitivity index was the best equation to depict DIo [β: -0.954 (95 % CI -1.015 to -0.893)] compared to other measures tested in this cohort. There was an inverse association between change in DIo at the final follow-up and development of incident diabetes. Among the surrogate insulin measures studied, DIo [AUC (0.717 (95 % CI 0.675-0.756))] as a composite measure was superior than other surrogate indices.

CONCLUSIONS

Among the surrogate indices studied, DIo was the best measure associated with incident diabetes.

Adiponectin, leptin, interleukin-6 and HbA1c in the prediction of incident type 2 diabetes: A nested case-control study in Asian Indian men with impaired glucose tolerance

AIMS

The aims of this study were: (1) to assess the association of adiponectin, leptin and interleukin-6 (IL-6) with incidence of type 2 diabetes (T2DM) in Asian Indian men with impaired glucose tolerance (IGT) and (2) to evaluate the additional contribution of these with the well-established glycaemic marker HbA1c.

METHODS

This is an ancillary analyses of a nested case-control study derived from a prospective, prevention trial in India. All the participants had IGT at baseline. For this subanalysis a total of 147 (T2DM: 71; nondiabetic: 76) participants were selected based on the final glycemic outcomes. Association of these selected adipokines with T2DM were assessed using logistic regression analyses. Clinical usefulness of adding adipokine markers with HbA1c on prediction of T2DM was assessed using the area under the curve (AUC) of the receiver operating characteristics.

RESULTS

Baseline levels of adiponectin were lower and the levels of IL-6 were higher in T2DM cases when compared with non-diabetic cases (P<0.05). Levels of leptin were similar in both groups. In fully adjusted models, adiponectin (odds ratio (OR): 0.55 [95%CI: 0.33-0.91]; P=0.019) and IL-6 (OR: 2.27 [95%CI: 1.40-3.691]; P=0.001) were associated with diabetes. Addition of adiponectin to HbA1c improved the AUC (ΔAUC: 0.0619; P=0.0251), whereas addition of IL-6 did not improve the predictive power of HbA1c alone.

CONCLUSIONS

Adiponectin and IL-6 are independently associated with incident diabetes. However, they are unlikely to serve as simple tools to predict future risk of diabetes but may have a role in understanding the pathogenesis.

Retinol binding protein-4 predicts incident diabetes in Asian Indian men with prediabetes

The association of retinol binding protein-4 (RBP4) with incident type 2 diabetes (T2DM) in Asian Indian middle-aged men with impaired glucose tolerance (IGT) was studied. This was an ancillary analysis of a subsample from a cohort of participants with IGT in a 2 year prospective diabetes prevention program in India. For this analysis, 71 incident T2DM and 76 non-diabetic cases (non-progressors) based on the final glycemic outcome were selected. Baseline serum RBP4 was measured using competitive enzyme immunoassay. Correlations of RBP4 with relevant anthropometric and biochemical variables and also its association with diabetes were assessed using appropriate statistical analyses. Participants who developed T2DM had higher levels of serum RBP4 (21.3 [IQR: 17.7-24.9] µg/mL) compared with non-progressors (17.3 [IQR: 13.1-21.0] µg/mL; P = 0.001). Levels of RBP4 were lower than in Caucasians. Stepwise linear regression analysis showed that body mass index (BMI), systolic blood pressure, triglycerides, and HbA1c had independent associations with RBP4 levels. Multiple logistic regression analyses showed that RBP4 was independently associated with incident diabetes (odds ratio [OR] [95%confidence interval (CI)]: 1.69 [1.18-2.41]; P = 0.004). Adjustment for study group, age, BMI, waist circumference, 2 H plasma glucose, triglycerides, gamma glutamyl transferase, and insulin resistance weakened the significance of its association (OR [95%CI]: 1.65 [1.03-2.66]; P = 0.038).The results of this preliminary analyses showed that baseline serum RBP4 levels were independently associated with incident diabetes in Asian Indian men with IGT. It may be used as an additional predictor of future diabetes.

Improvement in diet habits, independent of physical activity helps to reduce incident diabetes among prediabetic Asian Indian men

AIMS

To assess the beneficial effects of the components of lifestyle intervention in reducing incidence of diabetes in Asian Indian men with impaired glucose tolerance (IGT) in India.

METHODS

This analysis was based on a 2 year prospective, randomized controlled primary prevention trial in a cohort of Asian Indian men with IGT (n=537) (Clinical Trial No: NCT00819455). Intervention and control groups were given standard care advice at baseline. Additionally, the intervention group received frequent, mobile phone based text message reminders on healthy lifestyle principles. Dietary intake and physical activity habits were recorded by validated questionnaires. The lifestyle goals were: reductions in consumption of carbohydrates, oil, portion size and body mass index of at least 1 unit (1 kg/m(2)) from baseline and maintenance of good physical activity. The association between diabetes and lifestyle goals achieved was assessed using multiple logistic regression analyses. Changes in insulin sensitivity (Matsuda's insulin sensitivity index) and oral disposition index during the follow-up were assessed.

RESULTS

At the end of the study, 123 (23.8%) participants developed diabetes. The mean lifestyle score was higher in the intervention group compared with control (2.59 ± 1.13 vs. 2.28 ± 1.17; P=0.002). Among the 5 lifestyle variables, significant improvements in the 3 dietary goal were seen with intervention. Concomitant improvement in insulin sensitivity and oral disposition index was noted. Higher lifestyle score was associated with lower risk of developing diabetes (odds ratio: 0.54 [95% CI: 0.44-0.70]; P<0.0001).

CONCLUSIONS

Beneficial effects of intervention were associated with increased compliance to lifestyle goals. The plausible mechanism is through improvement in insulin sensitivity and beta cell preservation.

Hypertriglyceridaemic waist phenotype as a simple predictive marker of incident diabetes in Asian-Indian men with prediabetes

AIM

To determine prospectively the association of baseline hypertriglyceridaemic waist phenotype with incident diabetes in Asian-Indian men with impaired glucose tolerance.

METHODS

In a randomized 2-year diabetes prevention trial in 517 men with impaired glucose tolerance, 123 (23.8%) developed diabetes. Baseline anthropometric, metabolic and clinical variables were estimated. Associations of hypertriglyceridaemic waist phenotype (waist circumference ≥ 90cm and a serum triglyceride level of ≥ 1.7 mmol/l) with insulin resistance and incident diabetes were assessed using multiple linear regression and Cox's proportional hazard models, respectively.

RESULTS

Men with an isolated enlarged waistline and hypertriglyceridaemic waist phenotype had significantly higher BMI and percentage of total body fat compared with the group with normal waistline and triglyceride levels and the group with isolated hypertriglyceridaemia. The men with hypertriglyceridaemic waist phenotype had higher insulin resistance (mean ± sd homeostasis model assessment of insulin resistance value: 3.6 ± 1.5) compared with those in the isolated enlarged waistline, the isolated hypertriglyceridaemia or the normal waistline and triglyceride level groups (3.1 ± 1.4, 2.7 ± 1.0 and 2.5 ± 1.1, respectively, all P < 0.05 compared with hypertriglyceridaemic waist phenotype). Multiple linear regression analyses showed that hypertriglyceridaemic waist phenotype was significantly associated with insulin resistance after adjusting for age, BMI, family history, percentage of total body fat, smoking, alcohol intake, 2-h plasma glucose and HDL cholesterol level. Hypertriglyceridaemic waist phenotype was independently associated with incident diabetes after adjusting for the above confounders and gamma-glutamyl transferase (hazard ratio 1.49, 95% CI 1.01-2.21; P = 0.047). The association of hypertriglyceridaemic waist phenotype with incident diabetes was abolished when insulin resistance was introduced into the model (hazard ratio 1.39, 95% CI 0.092-2.10; P=0.12).

CONCLUSIONS

Hypertriglyceridaemic waist phenotype is a simple clinical proxy measurement for insulin resistance and is strongly associated with incident diabetes in Asian-Indian men with impaired glucose tolerance.

Early improvement predicts reduced risk of incident diabetes and improved cardiovascular risk in prediabetic Asian Indian men participating in a 2-year lifestyle intervention program

OBJECTIVE

Objectives of this ancillary analysis of a prospective, prevention study among Asian Indians with impaired glucose tolerance (IGT) were a) to quantify the reduction in incident diabetes at 24 months in participants who achieved normal glucose tolerance (NGT) at 6 months (NGT-6 m) compared with the other participants, b) the factors influencing the reversal to NGT at the end of the study at 24 months (NGT-24 m), and c) to assess changes in cardiometabolic risk factors in different categories of dysglycemia at 24 months.

RESEARCH DESIGN AND METHODS

Data from a 2-year primary prevention trial were used. Effect of reversion to NGT-6 m on incidence of type 2 diabetes mellitus (T2DM) was analyzed using the Cox proportional hazards model. Predictive variables for reversal to NGT were identified using multiple logistic regression analysis. Changes in cardiometabolic risk factors were estimated according to the final glycemic status using fixed-effect, mixed-linear regression modeling.

RESULTS

The risk of T2DM in 2 years was lower by 75% in NGT-6 m group (hazard ratio 0.25 [95% CI 0.12-0.52]). Predictive variables for reversal to NGT-24 m were good baseline β-cell function (odds ratio [OR] 2.79 [95% CI 2.30-3.40]) and its further improvement (OR 5.70 [95% CI 4.58-7.08]), and NGT-6 m (OR 2.10 [95% CI 1.14-3.83]). BMI decreased in those who reverted to NGT. Deterioration to T2DM was associated with an increase in the levels of cardiometabolic risk factors.

CONCLUSIONS

Early reversion to NGT by lifestyle intervention in prediabetic men was associated with a significant reduction in subsequent incidence of diabetes. Good baseline β-cell function and its further improvement and NGT-6 m were associated with reversion to NGT-24 months. Reversion to NGT was associated with modest improvements, whereas conversion to T2DM was associated with significant worsening of the cardiometabolic risk profile.

Combining Fasting Plasma Glucose with Gamma-glutamyl Transferase Improves the Sensitivity to Predict Incident Diabetes in Asian Indian Men with Impaired Glucose Tolerance

OBJECTIVE

To study the associations of baseline gamma-glutamyltransferase (GGT) and alanine transaminase (ALT) with incident diabetes among Asian Indian men with impaired glucose tolerance (IGT).

METHODS

In a 2 year prospective, randomised, controlled primary prevention study of diabetes, among 537 IGT men aged 35-55 years, 123 incident diabetes (DM) cases occurred. Anthropometric {body mass index (BMI), waist circumference (WC)}, and laboratory measurements (fasting, 30 min and 2 hr plasma glucose (2 hr PG), HbA1c and plasma insulin, lipid profile, ALT, GGT) were estimated at baseline (Clinical Trial Identification No: NCT00819455). Predictive associations of baseline GGT and ALT values during the study were assessed using appropriate statistical methods.

RESULTS

Baseline GGT but not ALT was significantly higher in incident diabetes cases. Mean (95% CI) GGT decreased in subjects who reverted to normal glucose tolerance (NGT), whereas it increased in subjects who deteriorated to diabetes (NGT:-3.5 (-6.4 to -0.6); IGT:0.3 (-3.0 to 2.4); DM:8.3 (3.6 to 13.0) UL(-1); P < 0.0001). The risk of DM significantly increased with increasing baseline GGT after adjusting for confounders such as BMI, alcohol drinking, 2 hr PG and insulin resistance (2.02[1.35-3.02]; P = 0.001). Receiver operating characteristic curve showed that the model comprising of baseline fasting plasma glucose (FPG) and GGT (area-under-curve(AUC)[95% CI]: 0.668 [0.613-0.722]; P < 0.0001) was equally sensitive in identifying subjects with risk of diabetes as compared to 2 hr PG (AUC [95% CI]: 0.670 [0.614-0.725]; P < 0.0001) and HbA1c (AUC [95% CI]: 0.677 [0.619-0.734]; P < 0.0001) alone.

CONCLUSIONS

GGT was an independent predictor of incident diabetes. Combination of GGT and FPG offers a simple and sensitive tool to identify subjects at high risk of developing diabetes.

Screening among male industrial workers in India shows high prevalence of impaired glucose tolerance, undetected diabetes and cardiovascular risk clustering

OBJECTIVE

To study the magnitude of undetected diabetes, impaired glucose tolerance (IGT) and clustering of cardiometabolic risk factors among male industrial workers.

METHODS

Measurements of 2h post glucose blood glucose (2h PG), blood pressure, body mass index (BMI) and waist circumference (WC) were done in 8741 non-diabetic men of 35-55 years. Presence of family history of diabetes (FH) was noted. Risk associations with diabetes and IGT were studied using multiple logistic regression analysis. Clustering of overweight/obesity, abdominal obesity, hypertension was noted.

RESULTS

Prevalence of undetected diabetes (14.9%) and IGT (31.4%) were high. FH, age, hypertension and BMI showed strong associations with diabetes and IGT. More than 40% had clustering of risk factors.

CONCLUSION

High prevalence of undetected diabetes, IGT and clustering of cardiometabolic risk factors among young industrial workers mandates that regular screening for metabolic disorders should be undertaken to prevent development of severe morbidity in the productive years of life.

Liraglutide-induced acute pancreatitis

An obese lady of 51 year with Type 2 Diabetes Mellitus for 13 years was prescribed Liraglutide, a glucagon like peptide (GLP-1) analogue (Victoza) for glycaemic control and reduction of weight. She was on gliclazide and Insulin prior to initiation of Liraglutide. Eight weeks after initiation of GLP -1 analogue, she developed severe abdominal pain, nausea and vomiting. She was admitted to a private hospital and evaluated. Biochemical tests and CT scan revealed presence of pancreatitis and she was treated for acute pancreatitis. Liraglutide was withdrawn and symptoms subsided. Subsequent follow-up showed that pancreatic enzyme levels were normal.

Effectiveness of mobile phone messaging in prevention of type 2 diabetes by lifestyle modification in men in India: a prospective, parallel-group, randomised controlled trial

BACKGROUND

Type 2 diabetes can often be prevented by lifestyle modification; however, successful lifestyle intervention programmes are labour intensive. Mobile phone messaging is an inexpensive alternative way to deliver educational and motivational advice about lifestyle modification. We aimed to assess whether mobile phone messaging that encouraged lifestyle change could reduce incident type 2 diabetes in Indian Asian men with impaired glucose tolerance.

METHODS

We did a prospective, parallel-group, randomised controlled trial between Aug 10, 2009, and Nov 30, 2012, at ten sites in southeast India. Working Indian men (aged 35-55 years) with impaired glucose tolerance were randomly assigned (1:1) with a computer-generated randomisation sequence to a mobile phone messaging intervention or standard care (control group). Participants in the intervention group received frequent mobile phone messages compared with controls who received standard lifestyle modification advice at baseline only. Field staff and participants were, by necessity, not masked to study group assignment, but allocation was concealed from laboratory personnel as well as principal and co-investigators. The primary outcome was incidence of type 2 diabetes, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00819455.

RESULTS

We assessed 8741 participants for eligibility. 537 patients were randomly assigned to either the mobile phone messaging intervention (n=271) or standard care (n=266). The cumulative incidence of type 2 diabetes was lower in those who received mobile phone messages than in controls: 50 (18%) participants in the intervention group developed type 2 diabetes compared with 73 (27%) in the control group (hazard ratio 0·64, 95% CI 0·45-0·92; p=0·015). The number needed to treat to prevent one case of type 2 diabetes was 11 (95% CI 6-55). One patient in the control group died suddenly at the end of the first year. We recorded no other serious adverse events.

INTERPRETATION

Mobile phone messaging is an effective and acceptable method to deliver advice and support towards lifestyle modification to prevent type 2 diabetes in men at high risk.

FUNDING

The UK India Education and Research Initiative, the World Diabetes Foundation.

Primary prevention of Type 2 diabetes in South Asians--challenges and the way forward

Preventing diabetes is of enormous value, particularly for the South Asian countries, which have a huge healthcare burden from the onslaught of the disease. Type 2 diabetes has been proved to be preventable using lifestyle changes, even in South Asians despite their heightened risk profile. Strategies to improve awareness about diabetes and translation of preventive measures by innovative, culturally specific programmes have to be implemented at national levels. Integrated involvement of the government, community, media, healthcare and education services, and financial support from national and international organizations, are required. South Asian countries have initiated national programmes for diabetes prevention and management. It is also encouraging to note that joint ventures between developed countries such as the USA, UK and other European countries and centres of excellence in South Asia have been initiated to develop large-scale, community-oriented, pragmatic intervention strategies.

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.

Predictive value of HbA1c for incident diabetes among subjects with impaired glucose tolerance--analysis of the Indian Diabetes Prevention Programmes

AIMS

The objectives of the study were to assess the predictive value of baseline HbA(1c) for incident diabetes among the participants with impaired glucose tolerance in the Indian Diabetes Prevention Programmes 1 and 2.

METHODS

Data at baseline and at 3-year follow-up were analysed in combined cohorts of the Indian Diabetes Prevention Programmes 1 and 2. Within the 3 years, 324 of the 845 participants developed diabetes (World Health Organization criteria). The predictive value of baseline HbA(1c) for incident diabetes was determined by logistic regression analysis.

RESULTS

Baseline HbA(1c) values had heterogenous distribution. The distribution was similar in isolated impaired glucose tolerance or in impaired glucose tolerance in combination with impaired fasting glucose. A progressive increase in diabetes occurred with increasing HbA(1c). HbA(1c) showed the strongest association with incident diabetes in the multiple logistic regression analysis (odds ratio 3.548, P < 0.0001). The cut-off HbA(1c) of 43 mmol/mol (6.05%) had 67% sensitivity and 60% specificity to predict future diabetes. The diagnostic sensitivity of HbA(1c) of ≥ 48 mmol/mol (≥ 6.5%) was only 51%, with a specificity of 87%, when compared with the oral glucose tolerance glucose values.

CONCLUSIONS

Baseline HbA(1c) was highly predictive of future diabetes in Asian Indian subjects with impaired glucose tolerance and nearly 60% of the incidence occurred with values ≥ 42 mmol/mol (≥ 6.0). Diagnostic sensitivity of HbA(1c) ≥ 48 mmol/mol (≥ 6.5%) for new diabetes was only 51% using the oral glucose tolerance test as the standard for comparison.

Reinforcement of adherence to prescription recommendations in Asian Indian diabetes patients using short message service (SMS)--a pilot study

OBJECTIVES

To investigate the acceptability and feasibility of using short message services (SMS) via cell phones to ensure adherence to management prescriptions by diabetic patients.

METHODS

Type 2 diabetic patients with 5 or more years of diabetes and having HbA1c between 7.0% to 10% were randomized to the control arm (n = 105) to receive standard care and to the intervention arm (SMS, n = 110). Messages in English on principles of diabetes management were sent once in 3 days, the contents and frequencies varied as per the patients' preferences. The study duration was 1 year. All participants were advised to report for quarterly clinic visits. A comparative assessment of the clinical, biochemical and anthropometric outcomes was made among the groups at the annual visit.

RESULTS

Annual review was possible in 71% of intervention group and 63% of control group. SMS was acceptable to the patients and the median number requested was 2 per week. HbA1c and plasma lipids improved significantly in the SMS group.

CONCLUSIONS

The pilot study showed that frequent communication via SMS was acceptable to diabetic patients and it helped to improve the health outcomes.

Hypertriglyceridaemia either in isolation or in combination with abdominal obesity is strongly associated with atherogenic dyslipidaemia in Asian Indians

AIM

To assess the prevalence of isolated hypertriglyceridaemia (iHTG) and hypertriglyceridaemic waist phenotype (HTWP) in urban adult Asian Indian population and to study their associations with atherogenic dyslipidaemia.

METHODS

Data of an epidemiological survey (n=2117, M:F 1007:1110) was used. Prevalences of iHTG (fasting triglycerides (TG) ≥ 1.7 mmol/l) and HTWP (waist circumference male ≥ 90 cm and female ≥ 80 cm and TG ≥ 1.7 mmol/l), were assessed. Their prevalences in relation to glucose intolerance were also studied. Associations of iHTG and HTWP with the occurrence of atherogenic dyslipidaemia indicated by elevated LDL-C/HDL-C ratio of ≥2.5 were assessed using multiple logistic regression analyses.

RESULTS

iHTG, and HTWP were present in 13.4% and 17.8% respectively. Prevalence of HTWP was significantly higher among women. Prevalence of HTWP progressively increased with glucose intolerance. Nearly 60% of the subjects with iHTG or HTWP had atherogenic dyslipidaemia and prevalence was similar in both groups.

CONCLUSIONS

Hypertriglyceridaemia, present either as iHTG or HTWP was strongly associated with atherogenic dyslipidaemia. Dyslipidaemia occurred more frequently in glucose intolerance since the prevalence of both forms of hypertriglyceridaemia increased with glucose intolerance.

Changes in insulin secretion and insulin sensitivity in relation to the glycemic outcomes in subjects with impaired glucose tolerance in the Indian Diabetes Prevention Programme-1 (IDPP-1)

OBJECTIVE

The Indian Diabetes Prevention Programme-1 (IDPP-1) showed that lifestyle modification (LSM) and metformin were effective for primary prevention of diabetes in subjects with impaired glucose tolerance (IGT). Among subjects followed up for 3 years (n = 502), risk reductions versus those for the control group were 28.5, 26.4, and 28.2% in LSM, metformin (MET), and LSM plus MET groups, respectively. In this analysis, the roles of changes in secretion and action of insulin in improving the outcome were studied.

RESEARCH DESIGN AND METHODS

For this analysis, 437 subjects (93 subjects with normoglycemia [NGT], 150 subjects with IGT, and 194 subjects with diabetes) were included. Measurements of anthropometry, plasma glucose, and plasma insulin at baseline and at follow-up were available for all of them. Indexes of insulin resistance (homeostasis model assessment of insulin resistance) and beta-cell function (insulinogenic index [DeltaI/G]: 30-min fasting insulin divided by 30-min glucose) were also analyzed in relation to the outcome.

RESULTS

Subjects with IGT showed a deterioration in beta-cell function with time. Individuals with higher insulin resistance and/or low beta-cell function at baseline had poor outcome on follow-up. In relation to no abnormalities, the highest incidence of diabetes occurred when both abnormalities coexisted (54.9 vs. 33.7%, chi(2) = 7.53, P = 0.006). Individuals having abnormal insulin resistance (41.1%) or abnormal DeltaI/G (51.2%, chi(2) = 4.87, P = 0.027 vs. no abnormalities) had lower incidence. Normal beta-cell function with improved insulin sensitivity facilitated reversal to NGT, whereas deterioration in both resulted in diabetes. The beneficial changes were better with intervention than in the control group. Intervention groups had higher rates of NGT and lower rates of diabetes.

CONCLUSIONS

In the IDPP-1 subjects, beneficial outcomes occurred because of improved insulin action and sensitivity caused by the intervention strategies.