Association between number of abnormal glucose values and severity of fasting plasma glucose in IADPSG criteria and maternal outcomes in women with gestational diabetes mellitus

AIMS

The International Association for Diabetes in Pregnancy Study Group (IADPSG) criteria recommend a single-step diagnostic oral glucose tolerance test (OGTT) for diagnosis of gestational diabetes mellitus (GDM). The aim of this study was to examine the association between the number of abnormal glucose values and levels of FPG with pregnancy outcomes.

METHODS

Pregnant women (n=1,044) were screened for GDM at maternity centers in South India using IADPSG criteria. OGTTs were classified based on the number of abnormal glucose values (any one value or more than one value high) and fasting plasma glucose (FPG) values (<92mg/dl,92-100mg/dl,>100mg/dl) and correlated with pregnancy outcomes. Odds ratio were adjusted for age, BMI, gestational week at diagnosis, family history of diabetes, previous history of GDM, gestational week at delivery and birth weight. For macrosomia and large for gestation age, birth weight was excluded from the model.

RESULTS

Risk of caesarean section was significantly higher in women with any one abnormal glucose value (OR: 1.49; 95%CI: 1.07-2.09). This further increased in those with >1 value (OR: 1.35; 95%CI: 0.87-2.10), when compared to women with all values normal. Risk of large for gestation age (LGA) was higher in women with FPG 92-100mg/dl (OR: 1.37; 95%CI: 0.80-2.35) and in those with FPG >100mg/dl (OR: 1.87; 95%CI: 1.04-3.35), compared to those with FPG <92mg/dl.

CONCLUSIONS

The risk for poor pregnancy outcomes starts in those with one abnormal value in the OGTT or with FPG >92mg/dl but becomes significantly higher in those with higher abnormal values.

Isolated HbA1c identifies a different subgroup of individuals with type 2 diabetes compared to fasting or post-challenge glucose in Asian Indians: The CARRS and MASALA studies

AIMS

Guidelines recommend hemoglobin A1c (HbA1c) as a diagnostic test for type 2 diabetes, but its accuracy may differ in certain ethnic groups.

METHODS

The prevalence of type 2 diabetes by HbA1c, fasting glucose, and 2 h glucose was compared in 3016 participants from Chennai and Delhi, India from the CARRS-2 Study to 757 Indians in the U.S. from the MASALA Study. Type 2 diabetes was defined as fasting glucose ≥ 7.0 mmol/L, 2-h glucose ≥ 11.1 mmol/L, or HbA1c ≥ 6.5%. Isolated HbA1c diabetes was defined as HbA1c ≥ 6.5% with fasting glucose < 7.0 mmol/L and 2 h glucose < 11.1 mmol/L.

RESULTS

The age, sex, and BMI adjusted prevalence of diabetes by isolated HbA1c was 2.9% (95% CI: 2.2-4.0), 3.1% (95% CI: 2.3-4.1), and 0.8% (95% CI: 0.4-1.8) in CARRS-Chennai, CARRS-Delhi, and MASALA, respectively. The proportion of diabetes diagnosed by isolated HbA1c was 19.4%, 26.8%, and 10.8% in CARRS-Chennai, CARRS-Delhi, and MASALA respectively. In CARRS-2, individuals with type 2 diabetes by isolated HbA1c milder cardio-metabolic risk than those diagnosed by fasting or 2-h measures.

CONCLUSIONS

In Asian Indians, the use of HbA1c for type 2 diabetes diagnosis could result in a higher prevalence. HbA1c may identify a subset of individuals with milder glucose intolerance.

Lipid Profile in Childhood-and Youth-Onset Type 2 Diabetes and their Association with Microvascular Complications

AIM

To assess the lipid profiles in childhood and youth onset type 2 diabetes (T2DM) and study their association with microvascular complications.

METHODS

Clinical details of individuals with childhood and youth onset T2DM, age at diagnosis between 10 and 25 yrs (n=1340) were retrieved from electronic medical records. Lipid abnormalities were classified based on the NCEP (ATP III) guidelines and management of dyslipidemia in children and adolescents with diabetes. Retinopathy was assessed by retinal photography; nephropathy, if albumin excretion was ≥300 mg/g of creatinine or if the 24 hour protein excretion was >500 mg and neuropathy by elevated vibration perception threshold (≥20 V) on biothesiometry.

RESULTS

Out of 1,340 individuals with childhood and youth with T2DM, 53.3% of them were male. The mean age and duration of diabetes were 28.4 ± 10.4 and 7.4 ± 9.5 years respectively. Overall, the prevalence of dyslipidemia was 82.1%. Prevalence of hypercholesterolemia, hypertriglyceridemia, low HDL-C and high LDL-C were 40.7%, 52.8%, 59.1 % and 64.5% respectively. In logistic regression, both in unadjusted and adjusted model, hypercholesterolemia, and hypertriglyceridemia were associated with diabetic retinopathy [OR:1.8, CI:1.4-2.4, p<0.001 and 1.7, 1.3-2.2, p<0.001] and nephropathy [OR:1.7, CI:1.1-2.5, p=0.015 and 1.8, 1.2-2.8, p=0.007]. Additionally, hypercholesterolemia was associated with neuropathy, even after adjusting for age at diagnosis of diabetes and glycated hemoglobin [OR1.6, 1.0-2.5, p=0.041].

CONCLUSIONS

Lipid abnormalities are common and associated with microvascular complications among these T2DM individuals. This underscores the need for effective control of lipids among childhood and youth onset T2DM.

Ethnic Variations in Diabetes and Prediabetes Prevalence and the roles of Insulin Resistance and β-cell Function: The CARRS and NHANES Studies

•

We compared the hyperglycemia prevalence in Asian Indians to other ethnic groups.

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The prevalence of diabetes was higher in Indians compared to other ethnic groups.

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The prevalence of prediabetes was lower in Indians compared to other ethnic groups.

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These differences may be driven by impaired β-cell function.

Aims

It is unclear how the prevalence of diabetes in Asian Indians in urban India compares to that of race/ethnic groups in the US that may have different underlying susceptibilities. Therefore, we examined ethnic variations in the prevalence of type 2 diabetes, iIFG, iIGT, IFG + IGT, and the associated risk factors in Asian Indians in Chennai, India, and Whites, Blacks, and Hispanics in the United States.

Methods

Cross-sectional analyses, using representative samples of 4867 Asian Indians aged 20–74 years from Chennai, India, in the Centre for Cardiometabolic Risk Reduction in South-Asia study (CARRS) (2010–2011) and 6512 US Whites, Blacks, and Hispanics aged 20–74 years from the National Health and Nutrition Examination Survey (NHANES) (2007–2012).

Results

The age-adjusted prevalence of type 2 diabetes was highest in Asian Indians (men: 28.4, 95% CI: 25.9, 31.0; women: 30.6, 95% CI, 27.5, 33.9) and lowest in Caucasians (men: 12.2, 95% CI, 10.3, 14.4, women: 9.5, 95% CI, 7.9, 11.5). Asian Indians had the lowest prediabetes prevalence (men: 19.0, 95% CI, 17.2, 20.8; women: 27.2, 95% CI, 22.8, 32.1) and Caucasians had the highest (men; 46.5, 95% CI, 43.5, 49.6, women: 34.4, 95% CI, 31.7, 37.3). However, there were differences in prediabetes prevalence by gender and prediabetes state. The inclusion of HOMA-β in standardized polytomous logistic regression models resulted in a greater odds of diabetes in Blacks and Hispanics compared to Asian Indians.

Conclusions

The high prevalence of diabetes in Asian Indians may be due to innate susceptibilities for β-cell dysfunction in this high risk population.

Association of adiposity, measured by skinfold thickness, with parental history of diabetes in a South Indian population: data from CURES-114

PURPOSE OF THE STUDY

To look at the association of central and peripheral skinfold thickness with parental history of diabetes in subjects without diabetes.

METHODS

Subjects with no parental history of diabetes (n=1132), subjects with one parent with diabetes (n=271) and subjects with both parents with diabetes (n=51) were recruited from the Chennai Urban Rural Epidemiological Study (CURES) conducted between 2001 and 2003. Biceps, triceps, medial calf, mid-thigh, chest, abdomen, mid-axillary, suprailiac and subscapsular sites were measured with Lange skinfold callipers.

RESULTS

Trunk fat measurements, such as chest (p=0.020), mid-axillary (p=0.005), suprailiac (p=0.014), subscapsular (p<0.001) and abdomen (p=0.010) skinfolds, were highest in subjects with both parents with diabetes followed by those with one parent with diabetes, and lowest in those with no parental history of diabetes. However, the peripheral fat measurements, ie, biceps, triceps, medial calf and mid-thigh, were not significantly different between the study groups. Total truncal and peripheral fat skinfold thicknesses showed a significant positive association with other indices of obesity such as body mass index (BMI) and waist circumference in relation to trunk fat (BMI: r=0.748, p<0.001; waist: r=0.776, p<0.001) and peripheral fat (BMI: r=0.681, p<0.001; waist: r=0.569, p<0.001).

CONCLUSIONS

A significant association was observed between truncal and peripheral fat, assessed by skinfold thickness, and parental history of diabetes among subjects without diabetes in this urban South Indian population.

Prevalence of chronic kidney disease in two major Indian cities and projections for associated cardiovascular disease

India is experiencing an alarming rise in the burden of non-communicable diseases, but data on the incidence of chronic kidney disease (CKD) are sparse. Using the Center for Cardiometabolic Risk Reduction in South Asia surveillance study (a population-based survey of Delhi and Chennai, India) we estimated overall, and age-, sex-, city-, and diabetes-specific prevalence of CKD, and defined the distribution of the study population by the Kidney Disease Improving Global Outcomes (KDIGO) classification scheme. The likelihood of cardiovascular events in participants with and without CKD was estimated by the Framingham and Interheart Modifiable Risk Scores. Of 12,271 participants, 80% had complete data on serum creatinine and albuminuria. The prevalence of CKD and albuminuria, age standardized to the World Bank 2010 world population, were 8.7% (95% confidence interval: 7.9 to 9.4%) and 7.1% (6.4 to 7.7%) respectively. Nearly 80% of patients with CKD had an abnormally high hemoglobin A1c (5.7 and above). Based on KDIGO guidelines, 6.0, 1.0, and 0.5% of study participants are at moderate, high, or very high risk for experiencing CKD-associated adverse outcomes. The cardiovascular risk scores placed a greater proportion of patients with CKD in the high-risk categories for experiencing cardiovascular events, when compared with participants without CKD. Thus one in 12 persons living in two of India’s largest cities have evidence of CKD, with features that put them at high risk for adverse outcomes.

Association of serum adiponectin with diabetic microvascular complications among south Indian type 2 diabetic subjects - (CURES-133)

OBJECTIVES

To assess the association of serum adiponectin and microvascular complications of diabetes in an urban south Indian type 2 diabetic population.

DESIGN AND METHODS

Diabetic subjects [n=487] were included from Chennai Urban Rural Epidemiology Study (CURES). Four-field stereo retinal color photography was done and diabetic retinopathy (DR) was classified as non-proliferative DR (NPDR) or proliferative DR (PDR) according to the Early Treatment Diabetic Retinopathy Study grading system. Sight threatening DR (STDR) was defined as the presence of NPDR with diabetic macular edema, and/or PDR. Neuropathy was diagnosed if vibratory perception threshold of the great toe using biothesiometry exceeded ≥20V. Nephropathy was diagnosed if urinary albumin excretion (UAE) was ≥30μg/mg creatinine. Serum total adiponectin levels were measured by radioimmunoassay.

RESULTS

Subjects with any microvascular complications had significantly higher levels of adiponectin levels compared to those without the complications (geometric mean: 6.1 vs. 5.3μg/mL, p=0.004). The adiponectin level was significantly higher in subjects with DR (6.8 vs. 5.5μg/mL, p=0.004) and neuropathy (5.6 vs. 6.5μg/mL, p=0.024) compared to those without. Adiponectin levels were not significantly different in subjects with and without nephropathy. Serum adiponectin levels increased with the severity of DR [No DR - 5.5μg/mL; NPDR without DME - 6.5μg/mL; STDR - 8.3μg/mL, p=0.001]. Regression analysis revealed adiponectin to be associated with microvascular disease (presence of neuropathy and/or retinopathy and/or nephropathy) (OR: 1.44, 95% CI: 1.01-2.06, p=0.049) even after adjusting for age, gender, BMI, HbA1c, diabetes of duration, serum cholesterol and triglycerides, hypertension and medication status.

CONCLUSION

In Asian Indians with type 2 diabetes, serum adiponectin levels are associated with microvascular complications and also with the severity of retinopathy.

Knowledge and awareness of diabetes in urban and rural India: The Indian Council of Medical Research India Diabetes Study (Phase I): Indian Council of Medical Research India Diabetes 4

BACKGROUND

Representative data on knowledge and awareness about diabetes is scarce in India and is extremely important to plan public health policies aimed at preventing and controlling diabetes.

AIM

The aim of the following study is to assess awareness and knowledge about diabetes in the general population, as well as in individuals with diabetes in four selected regions of India.

MATERIALS AND METHODS

The study subjects were drawn from a representative sample of four geographical regions of India, Chandigarh, Tamil Nadu, Jharkhand and Maharashtra representing North, South, East and West and covering a population of 213 million. A total of 16,607 individuals (5112 urban and 11,495 rural) aged ≥20 years were selected from 188 urban and 175 rural areas. Awareness of diabetes and knowledge of causative factors and complications of diabetes were assessed using an interviewer administered structured questionnaire in 14,274 individuals (response rate, 86.0%), which included 480 self-reported diabetic subjects.

RESULTS

Only 43.2% (6160/14,274) of the overall study population had heard about a condition called diabetes. Overall urban residents had higher awareness rates (58.4%) compared to rural residents (36.8%) (P < 0.001). About 46.7% of males and 39.6% of females reported that they knew about a condition called diabetes (P < 0.001). Of the general population, 41.5% (5726/13,794) knew about a condition called diabetes. Among them, 80.7% (4620/5726) knew that the prevalence of diabetes was increasing, whereas among diabetic subjects, it was 93.0% (448/480). Among the general and diabetic population, 56.3% and 63.4% respectively, were aware that diabetes could be prevented. Regarding complications, 51.5% of the general population and 72.7% diabetic population knew that diabetes could affect other organs. Based on a composite knowledge score to assess knowledge among the general population, Tamil Nadu had the highest (31.7) and Jharkhand the lowest score (16.3). However among self-reported diabetic subjects, Maharashtra had the highest (70.1) and Tamil Nadu, the lowest score (56.5).

CONCLUSION

Knowledge and awareness about diabetes in India, particularly in rural areas, is poor. This underscores the need for conducting large scale diabetes awareness and education programs.

Type 2 diabetes in South Asians: similarities and differences with white Caucasian and other populations

Type 2 diabetes mellitus (T2DM) is one of the leading causes of morbidity and mortality. While all ethnic groups are affected, the prevalence of T2DM in South Asians, both in their home countries and abroad, is extremely high and is continuing to rise rapidly. Innate biological susceptibilities coupled with rapid changes in physical activity, diet, and other lifestyle behaviors are contributing factors propelling the increased burden of disease in this population. The large scope of this problem calls for investigations into the cause of increased susceptibility and preventative efforts at both the individual and population level that are aggressive, culturally sensitive, and start early. In this review, we outline the biological and environmental factors that place South Asians at elevated risk for T2DM, compared with Caucasian and other ethnic groups.

Noncommunicable diseases risk factor surveillance: experience and challenge from India

Noncommunicable diseases (NCDs) are reaching epidemic proportions worldwide and in India. Surveillance of NCD risk factors are therefore needed as they could help in policy planning and implementation of preventive measures. This article will focus on the experiences gained, and challenges faced, in conducting NCD risk factor surveillance studies in India. Two major surveillance studies on NCDs were conducted in India - the World Health Organization (WHO) - Indian Council of Medical Research (ICMR) NCD risk factor surveillance study and the Integrated Disease Surveillance Project (IDSP). The WHO-ICMR study was a six-site pilot study representing six different geographical locations in India with a sample size of 44,537 including rural, peri-urban/slum and urban. Phase 1 of the IDSP was completed and included seven states in India with a sample size of 5000 per state. The NCD risk factor surveillance showed that high prevalence of diabetes, hypertension and obesity in urban areas with slightly lower prevalence rates in semi-urban and rural areas. There are several challenges in obtaining data on NCD risk factors, which include challenges in obtaining anthropometric and blood pressure measures and in assessing tobacco consumption, diet and physical activity. The challenges in field operations include contacting and convincing subjects, creating rapport, tracking subjects, climatic conditions, recall ability and interviewer skills. Success in surveillance studies depends on anticipating and managing these challenges

CONCLUSION

Improving country-level surveillance and monitoring is a valuable step in prevention and control of NCDs in India.

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

AIMS/HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS/INTERPRETATIONS

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

The need for obtaining accurate nationwide estimates of diabetes prevalence in India - rationale for a national study on diabetes

According to the World Diabetes Atlas, India is projected to have around 51 million people with diabetes. However, these data are based on small sporadic studies done in some parts of the country. Even a few multi-centre studies that have been done, have several limitations. Also, marked heterogeneity between States limits the generalizability of results. Other studies done at various time periods also lack uniform methodology, do not take into consideration ethnic differences and have inadequate coverage. Thus, till date there has been no national study on the prevalence of diabetes which are truly representative of India as a whole. Moreover, the data on diabetes complications is even more scarce. Therefore, there is an urgent need for a large well-planned national study, which could provide reliable nationwide data, not only on prevalence of diabetes, but also on pre-diabetes, and the complications of diabetes in India. A study of this nature will have enormous public health impact and help policy makers to take action against diabetes in India.

The Indian type 2 diabetes risk score also helps identify those at risk of macrovasvular disease and neuropathy (CURES-77)

AIMS

To see whether the diabetic individuals identified by the Indian Diabetes Risk Score (IDRS) also have a higher prevalence of diabetes related complications.

METHODS

Type 2 diabetic subjects were selected from the Chennai Urban Rural Epidemiology Study in south India. Four field stereo retinal colour photography was done and diabetic retinopathy [DR] was classified according to Early Treatment Diabetic Retinopathy Study grading system. Coronary artery disease was diagnosed using Minnesota coding of 12-lead electrocardiograms. Diabetic peripheral neuropathy (DPN) was diagnosed if vibratory perception threshold [VPT] of the right great toe measured by biothesiometry was > or =20. The criterion for diagnosis of peripheral vascular disease (PVD) was an ankle-brachial index < 0.9. Macroalbuminuria was diagnosed if urinary albumin excretion was > or =300 microg/mg creatinine. A total of 1476 individuals who had information on all test parameters were included for analysis.

RESULTS

Subjects with IDRS score > or =60 had significantly higher prevalence of coronary artery disease (CAD) [9.2% vs. 5.4%, p = 0.043], DPN [29.2% vs. 8.8%, p < 0.001] and PVD [4.8% vs. 1.9%, p = 0.038] compared to subjects with IDRS score <60. However, the prevalence of DR and macroalbuminuria did not differ between the two IDRS subgroups. Age explained much of the observed differences in prevalence of CAD, PVD and DPN between the two IDRS subgroups.

CONCLUSIONS

This study further extends the clinical usefulness of IDRS to predicting diabetic complications like CAD, PVD and DPN as well.

Reliability and validity of a modified PHQ-9 item inventory (PHQ-12) as a screening instrument for assessing depression in Asian Indians (CURES-65)

OBJECTIVES

To evaluate the validity and reliability of the modified Patient Health Questionnaire(PHQ) 12 item instrument as a screening tool for assessing depression compared to the PHQ-9 in a representative south Indian urban population.

METHODS

The Chennai Urban Rural Epidemiology Study [CURES] is a large cross-sectional study conducted in Chennai, South India. In Phase 1 of CURES(urban component), 26,001 individuals aged > or =20 years individuals were selected by a systematic sampling technique of whom one hundred subjects were randomly selected, using computer-generated numbers, for this validation study. Two self-reported questionnaires (modified PHQ-12 item and PHQ-9 item) were administered to the subjects to compare their effectiveness in detecting depression. Reliability and validity were assessed and Receiver Operating Characteristic (ROC) curves were plotted. Pearson's correlation was used to compare the two questionnaires.

RESULTS

The mean age of the study was 38.6 +/- 11.6 years and 48% were males. Pearson's correlation coefficient between the modified PHQ-12 and the PHQ-9 item was 0.913 [p < 0.0001]. Factor Analysis revealed that the modified PHQ-12 item scale can be used as a unidimensional scale and had excellent internal consistency (Cronbach's alpha: 0.88). A cut point of >4 calculated using the ROC curves for the modified PHQ-12 item had the highest sensitivity (92.0%) and specificity (90.7%) using PHQ-9 as the gold standard. The positive predictive value was 76.7%, and the negative predictive value, 97.1% and the area under the ROC curve, 0.979 (95% Confidence Interval: 0.929 - 0.997, p < 0.0001).

CONCLUSION

The modified PHQ-12 item is a valid and reliable instrument for large scale population based screening of depression in Asian Indians and a cut point score of greater than 4 gave the highest sensitivity and specificity.

Increased awareness about diabetes and its complications in a whole city: effectiveness of the "prevention, awareness, counselling and evaluation" [PACE] Diabetes Project [PACE-6]

AIMS AND OBJECTIVES

To determine the effectiveness of a large scale multipronged diabetes awareness program provided through community involvement in Chennai.

MATERIAL AND METHODS

Mass awareness and free screening camps were conducted between 2004-2007 at various locations of Chennai as part of the Prevention, Awareness, Counselling and Evaluation [PACE] Diabetes Project. During a 3-year period, 774 diabetes awareness camps were conducted to reach the public directly. After the PACE project was completed, 3000 individuals, representative of Chennai, were surveyed in 2007 using a systematic stratified random sampling technique. The results were compared to a similar survey carried out, as part of the Chennai Urban Rural Epidemiology Study [CURES] in 2001-2002, which served as a measure of baseline diabetes awareness.

RESULTS

Awareness of a condition called "diabetes" increased significantly from 75.5% in 2001-2002 (CURES) to 81% (p < 0.001) in 2007 (PACE). 74.1% of the citizens of Chennai are now aware that the prevalence of diabetes is increasing as compared to 60.2% earlier [p < 0.001]. Significantly more people felt that diabetes could be prevented (p < 0.001), and that a combination of diet and exercise were needed to do so (p < 0.001). Respondents reporting obesity, family history of diabetes, hypertension and mental stress as risk factors increased significantly after PACE (p < 0.001). More people were able to correctly identify the eyes (PACE 38.1% compared to CURES--16.1%, p < 0.001), kidney (PACE 42.3% compared to CURES 16.10%, p < 0.001), heart (PACE 4.6% compared to CURES 5.8%, p < 0.001) and feet (PACE 35.0% vs. CURES 21.9%, p < 0.001) as the main organs affected by diabetes.

CONCLUSION

Through direct public education and mass media campaigns, awareness about diabetes and its complications can be improved even in a whole city. If similar efforts are implemented state-wise and nationally, prevention and control of non-communicable diseases, specifically diabetes and cardiovascular disease, is an achievable goal in India.

Prevention awareness counselling and evaluation (PACE) diabetes project: a mega multi-pronged program for diabetes awareness and prevention in South India (PACE- 5)

OBJECTIVE

The Prevention Awareness Counselling Evaluation (PACE) Diabetes Project is a large scale community based project carried out to increase awareness of diabetes and its complications in Chennai city (population: 4.7 million) through 1) public education 2) media campaigns 3) general practitioner training 4) blood sugar screening and 5) community based "real life" prevention program

METHODS

Education took place in multiple forms and venues over the three-year period of the PACE project between 2004-2007. With the help of the community, awareness programs were conducted at residential sites, worksites, places of worship, public places and educational institutions through lectures, skits and street plays. Messages were also conveyed through popular local television and radio channels and print media. The General Practitioners (GPs) program included training in diabetes prevention, treatment and the advantages of early detection of complications. Free random capillary blood glucose testing was done for individuals who attended the awareness programs using glucose meter.

RESULTS

Over a three-year period, we conducted 774 education sessions, 675 of which were coupled with opportunistic blood glucose screening. A total of 76,645 individuals underwent blood glucose screening. We also set up 176 "PACE Diabetes Education Counters" across Chennai, which were regularly replenished with educational materials. In addition, we trained 232 general practitioners in diabetology prevention, treatment and screening for complications. Multiple television and radio shows were given and messages about diabetes sent as Short Message Service (SMS) through mobile phones. Overall, we estimate that we reached diabetes prevention messages to nearly two million people in Chennai through the PACE Diabetes Project, making it one of the largest diabetes awareness and prevention programs ever conducted in India.

CONCLUSION

Mass awareness and screening programs are feasible and, through community empowerment, can help in prevention and control of non-commuincable diseases such as diabetes and its complications on a large scale.

Risk factors for diabetic retinopathy in a South Indian Type 2 diabetic population--the Chennai Urban Rural Epidemiology Study (CURES) Eye Study 4

AIMS

To determine risk factors for diabetic retinopathy (DR) in an urban South Indian Type 2 diabetic population.

METHODS

The Chennai Urban Rural Epidemiology Study is a large cross-sectional study conducted in Chennai, South India. A total of 1736 Type 2 diabetic subjects were recruited for this study, which included 1382 known diabetic subjects (90.4% response rate) and 354 randomly selected, newly detected diabetic subjects diagnosed by oral glucose tolerance test. All subjects underwent four-field stereo retinal colour photography, graded by the Early Treatment Diabetic Retinopathy Study protocol.

RESULTS

Of the 1736 Type 2 diabetic subjects photographed, photographs could be graded in 1715 subjects. Stepwise ordinal logistic regression analysis revealed that male gender (P = 0.041), duration of diabetes (P < 0.0001), glycated haemoglobin (HbA(1c); P < 0.0001), macroalbuminuria (P = 0.0002) and insulin therapy (P = 0.0001) were significantly associated with severity of DR. The risk for developing DR was 7.7 times (95% confidence interval 4.71-12.48, P < 0.0001) for elevated postprandial plasma glucose levels compared with 4.2 times (95% confidence interval 2.78-6.34, P < 0.0001) for elevated fasting plasma glucose when the fourth quartile values were compared with the first quartile glucose values.

CONCLUSIONS

In South Indian Type 2 diabetic subjects, duration of diabetes, HbA1c, male gender, macroalbuminuria and insulin therapy were independent risk factors for severity of DR. Postprandial hyperglycaemia indicated a higher risk for DR compared with elevated fasting plasma glucose levels.

Prevalence and risk factors for diabetic neuropathy in an urban south Indian population: the Chennai Urban Rural Epidemiology Study (CURES-55)

AIMS

This study was conducted to determine the prevalence of, and risk factors for, diabetic neuropathy (DN) in south Indian Type 2 diabetic subjects.

METHODS

Subjects were recruited from the Chennai Urban Rural Epidemiology Study, conducted on a representative cohort from Chennai city. A total of 1629 diabetic subjects were included, of whom 1291 were known to have diabetes (KD) subjects and 338 were randomly selected newly detected diabetic (NDD) subjects. Neuropathy was diagnosed if vibratory perception threshold at the great toe, measured by biothesiometry, exceeded mean + 2 sd of a healthy non-diabetic study population aged 20-45 years (cut point > or = 20 V).

RESULTS

The overall prevalence of DN was 26.1% (age-adjusted 13.1%) with no significant difference in gender. The prevalence of neuropathy was significantly higher in KD subjects compared with NDD subjects (27.8 vs. 19.5%, P = 0.002). The prevalence of diabetic retinopathy (24.1 vs. 15.3%, P < 0.0001) and hypertension (51.1 vs. 40.0%, P < 0.0001) were higher in those with neuropathy compared with those without. The odds ratio for neuropathy in subjects with duration of diabetes > 15 years compared with < or = 5 years was 5.7 (95% confidence interval: 3.52-9.08, P < 0.0001). Regression analysis showed age (P < 0.0001), glycated haemoglobin (P = 0.001) and duration of diabetes (P = 0.045) to be significantly associated with neuropathy.

CONCLUSIONS

This cross-sectional population-based study shows that, among urban south Indian Type 2 diabetic subjects, the prevalence of DN is 26.1% and that DN is significantly associated with age, glycated haemoglobin and duration of diabetes.

Diabetic retinopathy: an Indian perspective

Diabetic retinopathy (DR) can be defined as damage to microvascular system in the retina due to prolonged hyperglycaemia. The prevalence of DR in the Chennai Urban Rural Epidemiology (CURES) Eye Study in south India was 17.6 per cent, significantly lower than age-matched western counterparts. However, due to the large number of diabetic subjects, DR is likely to pose a public health burden in India. CURES Eye study showed that the major systemic risk factors for onset and progression of DR are duration of diabetes, degree of glycaemic control and hyperlipidaemia. Hypertension did not play a major role in this cross-sectional analysis. The role of oxidative stress, atherosclerotic end points and genetic factors in susceptibility to DR has been studied. It was found that DR was associated with increased intima-media thickness and arterial stiffness in type 2 Indian diabetic subjects suggesting that common pathogenic mechanisms might predispose to diabetic microangiopathy. Curcumin, an active ingredient of turmeric, has been shown to inhibit proliferation of retinal endothelial cells in vivo. Visual disability from DR is largely preventable if managed with timely intervention by laser. It has been clearly demonstrated that in type 2 south Indian diabetic patients with proliferative DR who underwent Pan retinal photocoagulation, 73 per cent eyes with good visual acuity (6/9) at baseline maintained the same vision at 1 yr follow up. There is evidence that DR begins to develop years before the clinical diagnosis of type 2 diabetes. Our earlier study demonstrated that DR is present in 7 per cent of newly diagnosed subjects, hence routine retinal screening for DR even at the time of diagnosis of type 2 diabetes may help in optimized laser therapy. Annual retinal examination and early detection of DR can considerably reduce the risk of visual loss in diabetic individuals.

Association of hypertension with cluster of insulin resistance syndrome factors: the Chennai Urban Population Study (CUPS-12)

The objective of this study was to investigate the association of insulin resistance and the cluster of insulin resistance syndrome (IRS) factors with hypertension in a native urban population from southern India. The Chennai Urban Population Study (CUPS) is an epidemiological study involving two residential areas in Chennai in southern India. Of the total of 1399 eligible subjects (age >or=20 years), 1262 (90.2%) participated in the study. Subjects were classified as hypertensives if they had systolic blood pressure (SBP) >or=140 mmHg or diastolic blood pressure (DBP) >or=0 mmHg, if they were known hypertensives, or if they were receiving treatment with antihypertensive drugs. Insulin resistance was computed using the homeostasis model assessment (HOMA IR). The overall prevalence of hypertension in the population was 22.1%. Prevalence of hypertension increased with an increase in quartiles of fasting insulin levels ( p=0.035) and HOMA IR ( p=0.03). Logistic regression analysis revealed that HOMA IR was significantly associated with hypertension, which was not altered even after addition of risk factors like age, smoking habit and alcohol consumption into the model. However, inclusion of variables associated with IRS abolished the association of insulin resistance with hypertension. Factor analysis identified four factors: factor 1 had positive loading of body mass index, age, systolic and diastolic blood pressures; factor 2 had positive loading of HOMA IR, fasting plasma glucose, triglycerides and body mass index; factor 3 had positive loading of waist-hip ratio, triglycerides and smoking habit and negative loading of alcohol consumption; factor 4 was loaded with age and serum cholesterol. Factor 1, the hypertension factor loaded with systolic and diastolic blood pressures, shared a correlation with the insulin resistance cluster through body mass index. Our results suggest that the "insulin resistance cluster" is associated with hypertension in this urban population of southern India.

The Chennai Urban Rural Epidemiology Study (CURES)--study design and methodology (urban component) (CURES-I)

The report of World Health Organization (WHO) shows that India tops the world with the largest number of diabetic subjects. This increase is attributed to the rapid epidemiological transition accompanied by urbanization, which is occurring in India. There is very little data regarding the influence of affluence on the prevalence of diabetes and its complications particularly retinopathy in the Indian population. Furthermore, there are very few studies comparing the urban/rural prevalence of diabetes and its complications. The Chennai Urban Rural Epidemiology Study (CURES) is designed to answer the above questions. CURES is initially planned as a cross-sectional study to evolve later into a longitudinal study. Subjects for the urban component of the CURES have been recruited from within the corporation limits of Chennai City. Chennai (formerly Madras), the largest city in Southern India and the fourth largest in India has been divided into 10 zones and 155 wards. 46 wards were selected by a systematic random sampling method to represent the whole of Chennai. Twenty thousand and one individuals were recruited for the study, this number being derived based on a sample size calculation. The study has three phases. Phase one is a door to door survey which includes a questionnaire, anthropometric, fasting capillary blood glucose and blood pressure measurements. Phase two focussed on the prevalence of diabetic complications particularly retinopathy using standardized techniques like retinal photography etc. Diabetic subjects identified in phase one and age and sex matched non-diabetic subjects will participate in these studies. Phase three will include more detailed studies like clinical, biochemical and vascular studies on a sub-sample of the study subjects selected on a stratified basis from phase one. CURES is perhaps one of the largest systematic population based studies to be done in India in the field of diabetes and its complications like retinopathy, nephropathy and neuropathy.

Is the 'rule of halves' in hypertension still valid?--Evidence from the Chennai Urban Population Study

AIM OF THE STUDY

The aim of the present study was to assess the applicability of the rule of halves in an urban population in South India.

METHODS

The Chennai Urban Population Study (CUPS) is an ongoing population based study involving two residential colonies representing a middle and lower socio-economic status in Chennai city. The response rate for the study was 90.1%. Based on a glucose tolerance test (GTT), the study subjects were categorized as having normal glucose tolerance test (NGT), impaired glucose tolerance test (IGT) or diabetes. Blood pressure was measured for all the study subjects and the subjects were classified as hypertensive using the criteria, systolic blood pressure (SBP) > or = 140 mm Hg and/or diastolic blood pressure > or = 90 mmHg and/or known hypertensives and/or treatment with antihypertensive drugs. Controlled hypertension was defined as SBP < 140 mmHg and DBP < 90 mmHg.

RESULTS

The overall prevalence of hypertension in this population is 22.1% (279/1262). Of these 279 individuals with hypertension, only 37.3% (104/279) were known hypertensives. Of the 104 known hypertensives, only 52 subjects (50%) were under any kind of antihypertensive therapy. Of these 52 individuals, only 21 (40%) had blood pressure under control. Prevalence of hypertension was higher in subjects with glucose intolerance. Awareness and treatment of hypertension was slightly higher among the diabetic hypertensive subjects. Analysis on the different social classes revealed that the prevalence, awareness and treatment of hypertension to be significantly higher among the middle income group compared to lower income group.

CONCLUSION

The rule of halves is still valid in this urban South Indian population and thus the awareness, treatment and control measures for hypertension are still inadequate in this population.

Prevalence and risk factors of hypertension in a selected South Indian population--the Chennai Urban Population Study

OBJECTIVE

Hypertension is a major public health problem in developing countries. There is however very little population based data particularly in South India. The aim of this study is to determine the prevalence of hypertension and its associated risk factors in an urban South Indian population at Chennai.

METHODS

The Chennai Urban Population Study (CUPS) is an epidemiological study involving two residential areas in Chennai in South India. Of the total of 1399 eligible subjects (age > or = 20 years), 1262 (90.2%) participated in the study. All the study subjects underwent a glucose tolerance test (GTT) and were categorized as having normal glucose tolerance (NGT), impaired glucose tolerance (IGT) or diabetes mellitus (DM). Subjects were classified as hypertensive using the criteria, systolic blood pressure (SBP) > or = 140 mm Hg, and/or diastolic blood pressure (DBP) > or = 90 mm Hg and/or treatment with anti-hypertensive drugs. Twelve-lead resting electrocardiography (ECG) was performed in 1175 individuals and peripheral Doppler studies were done in 50% of the individuals (n=631).

RESULTS

The overall crude prevalence of hypertension (HTN) in this population is 21.1% (n=266) while the age standardized prevalence is 17.0%. Body mass index (BMI) and waist-hip ratio (WHR) were significantly higher (p < 0.001) in the HTN group compared to the non-hypertensive individuals. The prevalence of diabetes (p < 0.001), obesity (p < 0.001), CAD (p = 0.001) and PVD (p = 0.0055) was higher among the hypertensive compared to normotensive group. Multiple logistic regression analysis revealed HTN to be significantly associated with age (p < 0.001), body mass index (p < 0.001) and glucose intolerance (p = 0.005).

CONCLUSION

The prevalence of hypertension appears to be high in this urban South Indian population and this calls for urgent steps for its prevention and control.

Diabetes & coronary artery disease

Over 20 million people are affected by diabetes in India. These numbers are expected to increase to 57 million by 2025. Diabetic patients are at increased risk of atherosclerosis and its clinical sequelae, particularly coronary artery disease (CAD). CAD remains the most important cause of mortality among diabetic patients. The pathophysiological process of atherosclerosis in diabetic subjects is accelerated by several factors such as hyperglycaemia, insulin resistance, abnormal lipid profile, oxidative modification of lipoproteins, increased blood pressure, altered rate of fibrinolysis, etc. These changes in diabetics render the dormant atherosclerotic plaque vulnerable precipitating an early clinical event. Thus CAD in diabetic subjects carries a worse prognosis than in non-diabetic subjects. This review focuses on the potential role of various risk factors contributing to atherosclerosis in diabetic patients.

The changing scenario of the diabetes epidemic: implications for India

Diabetes mellitus is one of the main threats to human health in the 21st century. The prevalence of diabetes ranges from nearly 0 per cent in New Guinea to 50 per cent in the Pima Indians. The past two decades have seen an explosive increase in the number of people diagnosed with diabetes world-wide. The World Health Organization (WHO) estimated that there were 135 million diabetics in 1995 and this number would increase to 300 million by the year 2025. India leads the world today with the largest number of diabetics in any given country. In the 1970s, the prevalence of diabetes among urban Indians was reported to be 2.1 per cent and this has now risen to 12.1 per cent. Moreover, there is an equally large pool of individuals with impaired glucose tolerance (IGT), many of whom will develop type 2 diabetes mellitus in the future. Diabetes can affect nearly every organ system in the body. The Chennai Urban Population Study (CUPS) showed that prevalence of diabetic retinopathy, nephropathy and neuropathy is not very different in urban south Indians compared to that reported among Europeans. However, coronary artery disease (CAD) occurs with increased prevalence and at a younger age (premature CAD), while peripheral vascular disease showed the opposite trend, with lower prevalence compared to that reported in Europeans. There is an urgent need for lifestyle intervention, with the incorporation of a healthy diet, an increase in physical activity and weight reduction as a means of preventing diabetes in those who are in the prediabetic stage and thus prevent the diabetes epidemic, which is looming large in our country.