Association of the leptin receptor Q223R (rs1137101) polymorphism with obesity measures in Sri Lankans

Objective

The role of genetic factors in the development of obesity is largely unreported in Sri Lankans. The Q223R (rs1137101) single nucleotide polymorphism (SNP) of the leptin receptor (LEPR) gene has been associated with obesity measures in various ethnicities. We investigated the association of the Q223R polymorphism with obesity related anthropometric measures and biochemical parameters fasting blood glucose and lipid profile in a sample of 530 Sri Lankan adult subjects (age 18–70 years) representing both urban and rural areas of residence.

Results

The LEPR Q223R variant G allele frequency was 0.54. The polymorphism was associated with body mass index (p = 0.04) and waist circumference (p = 0.02) measures in overweight and obese (BMI ≥ 25 kgm⁻²) subjects with the variant allele conferring a greater risk of adiposity. Residency in urban areas eliminated the protective effect of the non-risk genotype (AA) in the development of obesity.

Responders to insulin therapy at 18 months in adults with newly diagnosed diabetes: which insulin regimen?

OBJECTIVES

To describe baseline characteristics of responders to insulin therapy (HbA(1c) targets < 58 mmol/mol, 7.5%) at 18 months among adults with newly diagnosed diabetes.

METHODS

A retrospective UK study derived from 479 general practices electronic dataset. We included all adults (age > 18 years) with newly diagnosed diabetes who required insulin therapy within 6 months of diagnosis. The data comprised insulin regimen (long-acting only; premixed insulin only; basal bolus insulin regimen), gender, Townsend quintile, baseline and an 18-month measurement of clinical and biochemical variables. Multiple imputations were undertaken and logistic regression used to assess the effect of covariates.

RESULTS

A total of 1492 patients (aged 19-93 years) were analysed. Means (SD) baseline HbA(1c) and BMI were 10.3% (2.6%) and 29.6 (7.0%), respectively. Following multiple imputation for missing data, logistic regression analysis indicated important covariates to achieve HbA(1c) targets were baseline HbA(1c), lipid lowering therapy, gender and age. Including all covariates, those treated with premixed insulin were 47% more likely to achieve target HbA(1c) at 18 months than those treated with a basal-bolus regimes (adjusted OR 1.47; 95% CI 1.12-1.92, P = 0.006)) and 32% more likely than those treated with long-acting insulin was (adjusted OR 1.32; 95% CI 1.01-1.74, P = 0.044). Those with a higher baseline HbA(1c) level, on lipid-lowering therapy, women and younger patients had a lower response rate. Mean weight gain (SD) was 2.4 kg (8.5 kg) and was not influenced by treatment regimen.

CONCLUSION

The use of premixed insulin regimen among newly diagnosed patients with diabetes appears to be most effective in reaching HbA(1c) target values, independent of other confounders. The appropriate choice of insulin regimen at initiation should therefore take into account various metabolic and psychosocial factors.

Cardiovascular and metabolic risk profiles in young and old patients with type 2 diabetes

BACKGROUND

Young patients (aged < 40 years) with type 2 diabetes (T2D) have a high lifetime risk of developing cardiovascular disease (CVD). However, little is known about the CVD risk profile of this cohort in the UK primary care setting.

AIM

To determine CVD risk profile of young patients with T2D without CVD compared to older (aged >40 years) subjects.

DESIGN

A cross-sectional study using The Health Improvement Network (THIN) database, which contains anonymized patient information from more than 300 general practices throughout England and Wales.

METHODS

T2D subjects above the age of 18 years without previous CVD and not on lipid or blood pressure lowering therapy were randomly selected. Data on glycaemic control and CVD risk factors [weight, body mass index (BMI), lipid profile] were collected.

RESULTS

A total of 49,919 patients with T2D were identified, of whom 2756 (0.5%) and 47,163 (99.5%) were aged below and above 40 years, respectively. Despite being at least 30 years younger (mean age: early vs. later onset; 33.8 vs. 66.9 years, P < 0.001), the proportions of adverse CVD risk profiles for young patients were similar to the older cohort with T2D. For young vs. old patients: the prevalence of BMI >25: 84.4% vs. 85.3%, P = 0.77; total cholesterol >4 mmol/l: 53.4% vs. 53.8%, P = 0.76; systolic hypertension: 58.2 vs. 58.4%, P = 0.36 and diastolic hypertension: 28.1 vs. 28.5%, P = 0.73). Glycaemic controls were similarly suboptimal between the two groups (mean HbA1c: young vs. old; 7.6% vs. 7.5%, P = 0.49). The prevalence of risk factor clustering were also similar between young vs. old patients with T2D.

DISCUSSION

Young T2D subjects possess risk factors that confer high lifetime risk for macrovascular complications, and therefore merits aggressive cardioprotective treatment.

Age threshold for vascular prophylaxis by aspirin in patients without diabetes

OBJECTIVE

To determine an appropriate age threshold at which to prescribe aspirin for primary cardiovascular disease (CVD) prevention among men and women without diabetes.

DESIGN

Cross-sectional study.

SETTING

304 general practices in England and Wales contributing to The Health Improvement Network (THIN) electronic patient files.

PARTICIPANTS

Subjects aged between 30 and 75 years without diabetes, not prescribed any lipid-lowering treatment and with no previous history of CVD. Subjects had to have been registered by their practices for the whole of the preceding 12 months to be included in the analysis.

OUTCOMES MEASURES

Relation between age and coronary heart disease (CHD) risk, and the age threshold at which subjects without diabetes develop an estimated 10-year CHD risk of >or=10%.

RESULTS

The age transition from <10% to >10%, 10-year CHD risk for men and women without diabetes occurred at ages 47.8 for men and 57.3 for women.

CONCLUSIONS

In the absence of significant bleeding risks, aspirin should routinely be considered for all men and women without diabetes above the ages of 48 and 57 years, respectively, for primary CVD prevention. For subjects below these age thresholds or for those above the age of 75 years, the decision to initiate aspirin should be based on a patient's individual cardiovascular risk profiles. These proposed age thresholds aim to take into account a patient's gender, bleeding risk and the cardioprotective benefits of low-dose aspirin treatment.

Relation between age and coronary heart disease (CHD) risk in Asian Indian patients with diabetes: A cross-sectional and prospective cohort study

OBJECTIVE

Non-migrant Asian Indians have a high prevalence of diabetes and coronary heart disease (CHD). Since the relation between age and CHD risk in this population is not known, the appropriateness of existing age threshold for patients with diabetes to be suitable for primary CHD prevention with statins is not known. We aimed to determine an age threshold above which patients develop a higher risk of CHD and would merit routine statin prescription.

DESIGN

Cross-sectional analysis of 1087 patients with diabetes from the Chennai Urban Rural Epidemiological Studies (CURES). CHD risk assessment was calculated using the United Kingdom Prospective Study (UKPDS) risk engine, externally validated by using data obtained from the 7-year follow-up cohort of the Chennai Urban Population Study (CUPS). Relation between age and CHD risk was determined and the age threshold for increased CHD risks was calculated using line of best fit.

RESULTS

UKPDS risk engine overestimates CHD event rates by 50% in this population. Age is a strong independent predictor of CHD risk. Transition from low to moderate-risk category for men and women with diabetes occurred at ages 37 and 50 years, respectively. Sensitivity for fulfilling this CHD risk criteria are 98.7% for men and 87.1% for women.

CONCLUSIONS

Statins should be routinely prescribed to all Asian Indian men and women with diabetes above the ages of 37 and 50 years, respectively. For patients below these age thresholds, decision to initiate statins should be based on patient's individual cardiovascular risk factors. This strategy may facilitate public health efforts to reduce CHD events in India.

Dengue viral infections

Dengue viral infections are one of the most important mosquito borne diseases in the world. They may be asymptomatic or may give rise to undifferentiated fever, dengue fever, dengue haemorrhagic fever (DHF), or dengue shock syndrome. Annually, 100 million cases of dengue fever and half a million cases of DHF occur worldwide. Ninety percent of DHF subjects are children less than 15 years of age. At present, dengue is endemic in 112 countries in the world. No vaccine is available for preventing this disease. Early recognition and prompt initiation of appropriate treatment are vital if disease related morbidity and mortality are to be limited. This review outlines aspects of the epidemiology of dengue infections, the dengue virus and its mosquito vector, clinical features and pathogenesis of dengue infections, and the management and control of these infections.

Feasibility of using different approaches for recruiting younger twins to establish a population based twin register in Sri Lanka

Identifying twins for a population-based register can be achieved through birth records or community surveys. We studied the feasibility and effectiveness of different methods of identifying and recruiting twins to establish a population based register. To trace twins a population survey was carried out using an interviewer administered questionnaire. We also inspected the birth registration certificates at a divisional secretariat reported from a specified hospital between the years of 1985-1997 and compared it to the birth register of this same hospital. To recruit twins a random sample of 75 twin pairs (150 twins) identified at the Divisional Secretariat were contacted through the post and 25 twin pairs (50 twins) were personally visited. The prevalence of twins was 6.5 twins per 1000 people in the area surveyed. The twinning rate at the hospital was 18.92 twins per 1000 births. A discrepancy of 38 multiples births between the hospital labour room records and those registered at the DS was noted. The response from the postal invitation for recruitment was 59% and the response from the personal invitation was 68%. (Difference 9.4% 95% CI; 7.06-11.73). Community survey and systematic inspection of birth records either at the hospital or the birth registration office was an effective method to trace twins. Once traced, personal contact was more effective than the postal invitation for recruitment of younger twins. A cost-effective approach would be to use a postal coverage followed by personal contact for non-responders. The alternative method, community coverage, would have financial implications.

Glycaemic indices of different varieties of rice grown in Sri Lanka

OBJECTIVE

Varieties of red raw rice are widely believed to have a better nutritional quality. The physiological effects of consuming different varieties of rice may not be so. The glycaemic index has been developed as an indicator of the physiological effect of foods. It is the glycaemic response of a 50 g carbohydrate portion of food expressed as a percentage of that of a standard. The objective of this study was to determine the glycaemic indices of different varieties of rice grown in Sri Lanka.

DESIGN

Digestible carbohydrate content of 11 varieties of rice flour and bread were determined. Fasting blood samples followed by half-hourly samples for two hours were drawn after giving portions of either cooked rice or bread containing 50 g carbohydrate each.

SETTING

Fibre mill in Gampaha district.

SUBJECTS

Twenty-two fibre mill workers aged between 25 and 50 years.

MEASUREMENTS

The area under the blood glucose curve (AUC) for varieties of rice for a subject was calculated. Average AUC of 3 values for bread were calculated. Glycaemic index of each variety of rice was determined from the above variables.

RESULTS

Glycaemic indices of varieties of rice differ. The glycaemic indices of varieties of red raw rice varied between 56 and 73 and the variety Bg 350 had the lowest glycaemic index. There was no significant difference between mean glycaemic index of varieties of white raw and some varieties of red raw rice (p = 0.2). Parboiled varieties of red raw rice had a significantly lower glycaemic index than white raw rice (p = 0.04) and some of the red raw rice (p = 0.005).

CONCLUSIONS

The glycaemic index cannot be predicted from the colour of the rice grain. Red parboiled varieties of rice and Bg 350 can be recommended for patients with diabetes.

Screening based on risk factors for gestational diabetes in an Asian population

The results of glucose tolerance testing (OGTT) in 1004 consecutive women were examined with respect to risk factors for gestational diabetes mellitus (GDM). GDM was diagnosed in 41 of 1004 (4.08%) women. GDM was present in 7.8% of women aged over 35 years (compared to 3.1% if less than 35 years), in 8.1% women with a body mass index (BMI) >/=30 (compared to 3.6% if BMI <30) and in 5.2% of women with a family history of diabetes (compared to 3.9% in the absence of family history of diabetes). Past history of macrosomic babies (over 4 kg) was present in 12.1% of GDMs compared to 8.4% of non-diabetic pregnancies (NDP). A history of unexplained perinatal loss was present in 4.8% of GDMs compared to 2.2% of non-diabetic pregnancies (NDP). Thirteen per cent of grandmultiprous women had GDM compared to 3.9% in women with low parity. The proportion of women who had more than one risk factor was 16.7%. A combination of one or all of these risk factors predicted GDM in only 24 of 41 (58.5%) cases. Selective testing on the basis of risk factors using WHO criteria for diagnosis of GDM would miss over 40% of all cases in our population. Hence, this study supports the policy of universal screening for GDM in populations similar to ours.

Cross-cultural adaptation and preliminary validation of a zygosity determination questionnaire for twins in Sri Lanka

We report the process of adaptation into Sinhala of a questionnaire given to mothers of twins to determine zygosity. Adaptation and validation was carried out in three stages. Firstly, we used a nominal group to translate the English version and to assess the extent of agreement (consensus measurement) on the appropriateness of the translation and resolve disagreement (consensus development). Secondly we used a qualitative interview with 25 mothers of twins. The three main stems of the translated questionnaire were used as a semi-structured interview, and the responses noted verbatim. These were categorised and analysed, and the translated full questionnaire was then presented as closed questions with fixed choice responses. The categorised responses generated during the qualitative interview were compared with the responses to the fixed choices in the full questionnaire. The third stage was the appraisal of the questionnaire by 17 bilingual parents of twins. The source and translated version of the questionnaire were given to them at least 3 days apart. The responses were rated and the total scores were computed to determine the zygosity. This step was carried out to measure the validity and reliability of the Sinhala version. A perfect correlation between the original and adapted version was obtained, with a kappa of 1. The results suggest that the Sinhala version of the questionnaire is conceptually equivalent to the original questionnaire. Comparison of the zygosity determination by using this adapted questionnaire with results from analysis of genetic markers on Sri Lankan twins is needed for final validation of the translated questionnaire.

Establishing a twin register in Sri Lanka

Nearly all twin registers are based in developed countries and there is no twin register in the developing world. Our objectives were to initiate the process of establishing a nationwide twin register in Sri Lanka by starting a volunteer register first and working towards a population-based register. Regular newspaper advertisements, feature articles, radio talks, and television programmes were used to publicise a competition for twins, their parents/relatives and friends requesting them to participate by sending in details of twins. The competition ran from 28 March 1997 for a period of 3 months. It offered prizes for three winners selected by drawing lots. Advertisements highlighted the objective of the competition as establishing a twin register for future research and emphasised that informed consent would be obtained for individual research projects. Those who registered comprise 4602 twin pairs (same sex: male--1564, female--1885; different sex--1153), 80 sets of triplets (same sex: male--17, female--31; different sex--42) and two sets of quadruplets (different sex). The oldest twins, triplets, quadruplets are 85, 46, and 5 years old, respectively; 88.0% of twins are less than 30 years old. Although others have previously used media publicity to enrol twins in twin registers, we believe this to be the first time that twins have been enrolled through competition. We have more young twins, and our gender and zygosity proportions after applying Weinburg's rule do not match the proportions expected from a volunteer twin sample. Establishing a twin register for research purposes has proved possible in a developing country.

The prevalence of gestational diabetes in a Sri Lankan antenatal clinic

INTRODUCTION

Early diagnosis of gestational diabetes mellitus (GDM) is a prerequisite to reducing fetal and neonatal complications of GDM.

OBJECTIVES

(a) To ascertain the prevalence of GDM in a Sri Lankan pregnant population. Using the 75 g oral glucose tolerance test (GTT) and WHO criteria. (b) To establish the predictive value of a 50 g glucose challenge test (GCT) compared to the GTT (c) To compare the outcome of pregnancy in GDM with 'non-diabetic pregnancy' (NDP) STUDY DESIGN: Prospective study on a cohort of pregnant women attending antenatal clinics.

SETTING

Sri Jayawardenepura General Hospital (SJGH) RESULTS: Of the 721 patients, 131 (18%) had a positive GCT. 40 (5.5%) patients had GDM. If a one-hour GCT of 7.8 mmol/l was considered suspicious of GDM the sensitivity of the glucose challenge test was 63% and the specificity 84%. Statistically significant differences in the prevalence was found when the women were > 35 years [Relative risk (RR) = 3.87 (95% CI-2.06 to 7.27)] or the body mass index > or = 25. (RR = 2.45 (95 CI-1.30 to 4.61) Presence or absence of high parity, family history of diabetes or recurrent abortions had no significant impact on the prevalence of GDM. Mean birth weight was higher (p < 0.05) in GDM (3615 SD 103) than in NDP (2898 SD 143.6). The likelihood of having a caesarean section was higher (p < 0.01, Relative risk (RR) 2.50, 95% CI 1.56-3.95) in GDM when compared to NDP. A higher incidence of hydramnios (p < 0.01 RR 3.41 95% CI 1.44-8.05) was recorded in GDM when compared to NDP.

CONCLUSION

The prevalence of GDM in the antenatal clinics at SJGH is 5.5%. Traditional risk factors did not predict GDM. GDM is associated with a higher risk of caesarean section, hydramnios and macrosomia. Hence screening for GDM should be performed in all pregnant women at 24 to 28 weeks of pregnancy using a GCT.

Long-term complications in newly diagnosed Sri Lankan patients with type 2 diabetes mellitus

We screened 597 newly-diagnosed diabetic patients (201 women) mean +/- SD age 42.3 +/- 6.2 years to determine the prevalence of diabetic complications; 22% presented because of symptoms of diabetes, 27% were diagnosed when hyperglycaemia was discovered at a health screening, and 36% were diagnosed while being treated for intercurrent illness. Neuropathy was present in 25.1%, nephropathy in 29%, retinopathy in 15%, coronary vascular disease in 21%, stroke in 5.6%, peripheral vascular disease in 4.8%, hypertension in 23%, obesity in 16%, central obesity in 21.3%, hypercholesterolaemia in 11%, hypertriglyceridaemia in 14%, and low high-density lipoprotein cholesterol in 12%. The prevalence of coronary vascular disease, hypertension, stroke, neuropathy and retinopathy at the time of diagnosis were higher in our patients than in Caucasian and Indo-Asian patients in the UK. Both a genetic predisposition to develop complications, and exposure to a longer duration of asymptomatic hyperglycaemia due to poor access to adequate health care, may contribute to the high frequency of complications at diagnosis. Since complications are already present at diagnosis, there is a case for implementing primary prevention programmes combined with screening for diabetes in high-risk groups.

The prevalence of peripheral neuropathy in newly diagnosed patients with non-insulin-dependent diabetes mellitus

INTRODUCTION

Neuropathy is considered to be a longterm complication of diabetes.

AIMS

To determine the prevalence of peripheral neuropathy in 112 Sri Lankan patients with recently diagnosed non-insulin-dependent diabetes and a control population of 100 people.

METHODS

A diagnosis of peripheral neuropathy was made using a clinical symptom score, clinical examination, quantitative sensory testing and electrophysiological studies.

RESULTS

9.8% of diabetic patients at diagnosis had peripheral neuropathy, 2.6% had foot ulcers, 7.1% had signs of neuropathy, abnormal vibration perception threshold and nerve conduction abnormalities and 15.1% had abnormal nerve conduction velocity without signs or symptoms of neuropathy. The peroneal nerve conduction velocity was higher in diabetic patients when compared to controls. There was an inverse correlation between nerve conduction velocity and fasting blood glucose in diabetic patients (p < 0/05). This association was stronger for peroneal nerve conduction velocity (r = -0.73) than for median nerve motor conduction velocity (r = -0.42).

CONCLUSIONS

Symptomatic peripheral neuropathy is common among Sri Lankans with newly diagnosed non-insulin-dependent diabetes. This may be due to a later presentation of diabetes or a genetic predisposition.

Patient mixed biphasic insulin in a diabetic clinic

INTRODUCTION

Improved glycaemic control is possible with the use of multiple injections of premixed insulin. These are expensive, and not available in state hospitals.

OBJECTIVES

To study the cost, patient acceptance and efficacy of a patient mixed and administered combination of soluble and lente (biphasic) insulin administered twice a day.

PATIENTS

A cohort of 25 patients with poor glycaemic control on a single dose of 100 units or more of lente insulin. 25 patients matched for age and glycaemic control were used as a control.

SETTING

The diabetic clinic of the National Hospital Sri Lanka.

METHOD

A prospective study of a cohort of patients.

RESULTS

Mean fasting blood glucose decreased from 8.3 mmol/l (SD 3.1) to 6.9 mmol/l (SD 2.3, p < 0.01) and mean blood glucose levels declined from 12.3 mmol/l (SD 4.1) to 10.1 mmol/l (SD 4.7, p < 0.01) in the biphasic group. Total mean insulin dose fell from 80 units (SD 12) to 61 units (SD 11) in the biphasic group, but increased in the control group from 82 units (SD 16) to 91 units (SD 13.1). The diabetes well-being score in the biphasic group was 91.5 (SD 35.3), while the control group had a score of 63.7 (SD 21.3 p < 0.01). Mean glycosylated haemoglobin (HbA1c %) was 8.1 (SD 2.7) in the biphasic group compared to 9.2 (SD 3.3) in the control group.

CONCLUSION

Patient mixed and administered biphasic insulin on a twice daily basis is feasible, acceptable to patients, results in better glycaemic control and affords better patient satisfaction.

An audit of structure, process and outcome of care of the diabetic clinic, National Hospital of Sri Lanka

AIMS

To audit the structure, process and outcome of care.

SETTING

The diabetic clinic, National of Hospital Sri Lanka (NHSL).

METHODS

A previously validated MCQ paper of 10 questions which assessed knowledge of diabetes on insulin therapy, dietary management, management during acute illness and management of emergencies was administered to all patients. The function of the clinic was assessed using previously validated audit case record forms.

MEASURES OF OUTCOME

Diabetes knowledge among patients, waiting times, bypassing of local institutions, availability of diagnostic equipment, screening activities and time spent for consultation.

RESULTS

The clinic had a daily average attendance of 186 patients seen between 0800 to 1200 hours. A single medical officer spent 2.1 minutes for each patient. No screening was performed. There were no facilities to examine patients or for them to sit during consultation. The diabetes knowledge score was 15.1 (SD 3) from a maximum score of 40.43% had bypassed a local institution. Reasons for bypass included non-availability of drugs and the expectation of quality care at NHSL. Patients spent a mean of 1.5 (SD 0.7) hours travelling to the clinic and waited a mean of 1.56 (SD 0.4) hours to see the doctor and 1.3, (SD 0.12) hours to obtain drugs.

CONCLUSIONS

The services of the diabetic clinic do not meet the standards expected of a clinic at a tertiary referral centre. Lack of planning and resources (space, manpower and management skills) can be identified as principal shortcomings.

Macrovascular disease in Sri Lankan kidney transplant recipients

INTRODUCTION

Macrovascular diseases such as angina, myocardial infarction, stroke and peripheral occlusive arterial disease are common causes of mortality and morbidity in transplant patients.

OBJECTIVES

To study the frequency and determinants if vascular disease in Sri Lankan patients with renal transplants.

PATIENTS

A cohort of 237 renal transplant recipients (163 males (76%), mean age 35.09, SD 11.05 years).

SETTING

Patients under follow up at the Faculty of Medicine Transplant program.

METHOD

Prospective study of a cohort of patients.

RESULTS

Macrovascular diseases developed in 42% of transplant recipients. 5.6% had transient ischaemic attacks, 2.8% strokes, 18.2% angina, 8.4% myocardial infarctions, 2.3% underwent lower extremity amputations because of vascular insufficiency, 7% peripheral vascular occlusive disease and 49.5% were hypertensive. Male sex (odds ratio of 2.87, 95% CI 1.33-6.85, p = 0.006), serum cholesterol greater than 6.2 mmol/l at transplant (odds ratio 8.60, 95% CI 2.53-38.9, p = 0.0001) at 5 years after transplant (odds ratio 10.25, 95% CI 1.22-22.9, p = 0.01) were associated with a higher risk of macrovascular disease. Pre-transplant diabetes was associated with a higher risk of macrovascular disease and lower extremity amputation (odds ratio 4.53, 95% CI 1.32-6.76, p = 0.007).

CONCLUSIONS

Strategies to screen for and treat potential risk factors should form an integral part of the follow up for Sri Lankan and Asian kidney transplant recipients.

Limited joint mobility in Sri Lankan patients with non-insulin-dependent diabetes

Two hundred and sixteen patients with non-insulin-dependent diabetes (NIDDM) and 216 age- and gender-matched controls were studied to assess the prevalence of limited joint mobility (LJM). Joint mobility was measured by goniometry at metacarpophalangeal and subtalar joints, and those in whom a prayer sign was elicited were said to have cheiroarthropathy. Forty diabetic patients and 10 controls had cheirorathropathy. The mean range of motion was reduced at metacarpophalangeal joints in diabetic patients with cheiroarthropathy (36.8 +/- 9.2) and without cheiroarthropathy (45.7 +/- 8.1) when compared to controls (51.4 +/- 9, P < 0.01). Mobility at subtalar joints was reduced in those with cheiroarthropathy (25 +/- 5.3, P < 0.01) when compared to controls (32.4 +/- 4.1) and diabetic patients without cheiroarthropathy (27.4 +/- 4.6). No differences in subtalar mobility existed between diabetic patients without cheiroarthropathy and controls. Significant differences were observed in the presence of foot ulceration (35 vs 16%) in those with and without cheiroarthropathy. We conclude that cheiroarthropathy is seen in Sri Lankan patients with NIDDM and that significant limitation of joint mobility is present in patients with NIDDM who do not have overt cheiroarthropathy and that overt cheiroarthropathy may be a marker for a high risk of foot ulceration.

The prevalence of neuropathic foot ulceration in Sri Lankan diabetic patients

OBJECTIVE

To determine the prevalence of diabetic neuropathy and neuropathic ulceration among patients with non-insulin dependent diabetes (NIDDM) attending a Sri Lankan diabetic clinic.

SETTING

The diabetic clinic of the General Hospital Colombo (Sri Lanka National Hospital).

RESEARCH DESIGN AND METHOD

Five hundred randomly selected diabetic patients (mean age 47.4 SD 17.59 years, 275 were males, mean duration of diabetes 5.29, SD 6.44 years) were screened for diabetic neuropathy using a neuropathy symptom score (NSS) neurological disability score (NDS) and pressure preception threshold using Semmes Weinstein monofilaments.

RESULTS

Patients with neuropathy were older (mean 55.69 years SD 14.16) than those who did not (mean 47.1 years, SD 15.05 p = 0.001) and had diabetes for a longer period (mean 7.5, SD 8 years vs 4.8 SD 5.66, p = 0.002). 123 (30.6%, 95% CI 28-32%) patients had neuropathy according to the criteria used. 51(10.2%, 95% CI 8.2-12.2%) had a foot ulcer, a history of foot ulceration or a lower extremity amputation due to neuropathic ulceration. 26(5.1%, 95% CI 3.2-7%) patients had neuropathic foot ulcers at presentation and a further 14 (2.8%, 95% CI 1.4-4.2%) had developed an ulcer within one year of diagnosis of diabetes. 24 (4.8%, 95% CI 3-6.8%) had a history of lower extremity amputation.

CONCLUSION

Neuropathic ulceration is a significant cause of morbidity in patients with NIDDM. One third of all NIDDM patients attending the clinic had a risk of foot ulceration. Preventive foot care programmes should be implemented at all diabetic clinics in Sri Lanka.

The prevalence of obesity and other coronary risk factors in a suburban Sri Lankan community

Increasing numbers of developing nations experience a rising incidence of non-communicable diseases in parallel with economic development. Thus, developing countries such as Sri Lanka face the double burden of both communicable and non-communicable diseases. We therefore conducted a study to assess the prevalence of obesity, diabetes mellitus, impaired glucose tolerance (IGT), dyslipidaemias, hypertension, central (android) obesity, hypertension and smoking habits in a random sample of 633 (312 male) subjects selected from an electoral list with a target population of 2974 persons. The prevalence (age standardized to the world population of Segi 95% CI) was IGT 5.27 (3.74-7.78), diabetes 5.02 (3.59-6.53), hypertension 15.25 (11.67-18.8), hypercholesterolaemia 14.86 (11.09-18.61), hypertriglyceridaemia 8.46 (6.27-10.64), low HDL cholesterol 11.18 (8.35-13.99), obesity 9.89 (7.24-12.52) and android obesity 16.35 (12.47-20.24). We conclude that the high prevalence of coronary risk factors is an indication for initiating programmes for primary prevention of obesity, diabetes and coronary heart disease in Sri Lanka.

The work of a diabetes clinic: an audit

OBJECTIVE

To audit outcome and process of care at the diabetic and medical clinics.

DESIGN

Prospective interventional study with each patient acting as a retrospective control.

SETTING

The Sri Jayawardenepura General Hospital (SJGH) diabetic clinic.

PATIENTS

250 consecutive patients with NIDDM transferred to the diabetic clinic from the general medical clinic.

INTERVENTION

Participation in a structured scheme of health care delivery which included patient education dietary advice and screening for complications.

MEASUREMENTS

Fasting blood glucose, patients' knowledge score, patient satisfaction, frequency of screening.

RESULTS

A Significant improvement was seen after attendance at the diabetic clinic in fasting blood glucose (8.7 SD 1.3 vs 12.5 SD 3.2 mmol/l, p < 0.05), body mass index (26.8 SD 0.6 vs 27.4 SD 0.4 kg/m2, p < 0.05), admission rates (10% vs 21%, p < 0.05), patients knowledge score (76 SD 12 vs 42 SD 16%, p < 0.05) rates of screening for retinopathy (88% vs 6%, p < 0.05) and patient satisfaction in clinical care (87% vs 13%, p < 0.05). There was no significant improvement in cholesterol levels (5.7 SD 0.1 vs 5.8 SD 0.9 mmol/l).

CONCLUSIONS

The diabetes clinic is a more efficient system and a more appropriate setting to care for patients with NIDDM.

The prevalence of foot ulceration and its correlates in type 2 diabetic patients: a population-based study

The prevalence of peripheral neuropathy, peripheral vascular disease, and foot ulceration in Type 2 diabetic patients in the community were determined in a community-based study. Eight hundred and eleven subjects (404 male, 407 female, mean age 65.4 (range 34-90) years, diabetes duration 7.4 (0-50) years) from 37 general practices in three UK cities were studied. Neuropathy was diagnosed clinically using modified neuropathy disability scores which were ascertained using structured interviews and clinical examinations by one observer in each city. Peripheral vascular disease was diagnosed if a history of revascularization was present or > or = 2 foot pulses were absent. History of current or previous foot ulceration was recorded. The prevalence of neuropathy was 41.6% (95% confidence limits 38.3-44.9%) and the prevalence of PVD, 11% (9.1-13.7%). Forty-eight percent of neuropathic patients reported significant neuropathic symptoms. Forty-three patients (5.3% (3.8-6.8%)) had current or past foot ulcers; 20 of these were pure neuropathic ulcers, 13 neuroischaemic, 5 pure vascular, and 5 were unclassified. Multiple logistic regression showed history of amputation, neuropathy disability score, and peripheral vascular disease to be significantly associated with foot ulceration after adjusting for age and diabetes duration. A substantial proportion of Type 2 diabetic patients, often elderly patients who do not attend hospitals, suffered from peripheral neuropathy and peripheral vascular disease. These patients are at risk of foot ulceration and may benefit from preventive footcare.

Impaired glucose tolerance and diabetes mellitus in a suburban Sri Lankan community

The prevalence of impaired glucose tolerance and diabetes mellitus was studied in a suburban Sri Lankan community using 1985 WHO criteria. Oral 75 g glucose tolerance tests were performed on 633 subjects aged 30-64 years. The age-standardized prevalence rates for diabetes mellitus were 5.02 (95% CI 3.59-6.43) and impaired glucose tolerance 5.27 (95% CI 3.74-6.78). A total of 21% of diabetic patients were not known to have diabetes and were diagnosed for the first time during the survey. Obesity was more common (P < 0.05) in diabetic patients (21%) when compared to non-diabetic subjects (10.5%). Diabetes mellitus is a common health problem in Sri Lanka, and there is a need for developing national policies for its prevention and control.

Prevalence of retinopathy in a Sri Lankan diabetes clinic

OBJECTIVE

To determine the prevalence of diabetic retinopathy among patients with non-insulin dependent diabetes (NIDDM) attending a Sri Lankan diabetes clinic and assess the skills of non-ophthalmologist in screening for retinal disease.

RESEARCH DESIGN AND METHOD

One thousand and three consecutive diabetic patients were screened for diabetic eye disease using a standardised technique based on the WHO Multinational Study.

RESULTS

31.3% (95% confidence intervals 28.0% to 31.6%) had retinopathy, 23% (95% confidence intervals 21% to 25%) had cataract and 20% (95% confidence intervals 17% to 23%) had previously undetected refraction errors. 4.1% (95% confidence intervals 2.1% to 6.0%) of patients were blind due to advanced retinal disease while 6.2% (95% confidence intervals 5.0% to 7.2%) were blind as a result of cataract. General physicians had a 90.6% sensitivity and 100% specificity in screening for retinal disease.

CONCLUSIONS

Retinopathy accounts for significant visual handicap. Untreated cataract is more commonly associated with blindness. Undiagnosed errors of refraction account for significant visual handicap in Sri Lankan diabetic patients. Physicians trained in techniques of retinal screening can correctly assess diabetic retinal changes in a high proportion of patients.

The prevalence of macrovascular disease and lipid abnormalities amongst diabetic patients in Sri Lanka

The prevalence of macrovascular disease and hyperlipidaemia was examined in 500 patients with non-insulin-dependent diabetes mellitus attending a diabetic clinic in a Sri Lankan teaching hospital and 250 controls matched for age and gender. Macrovascular disease was assessed using a modified World Health Organisation questionnaire and modified Minnesota coding of electrocardiogram recordings. Twenty-one per cent of diabetic patients and 14.3% of controls had hypercholesterolaemia (P < 0.05). Macrovascular disease was present in 13.4% of diabetic patients and 8.2% of controls. Significant differences were seen in the prevalence of hypertension (15.6% vs 4.8%, P < 0.05), obesity (16.2% vs 9.7%, P < 0.05), peripheral vascular disease (5.6% vs 2%, P < 0.05) and electrocardiographic abnormalities (12% vs 6%, P < 0.05) in diabetic patients when compared to controls. Hyperlipidaemia and macrovascular disease is common in non-insulin-dependent diabetic patients in Sri Lanka and accounts for significant morbidity.

Knowledge about diabetes and metabolic control in diabetic patients

It is widely accepted that patient education is an essential adjunct to the care of diabetic patients. A randomised controlled clinical trial in patient education was conducted at a diabetic and general medical clinic in Sri Jayawardenepura General Hospital. Two groups of diabetic patients matched for age, gender and duration of diabetes were allocated randomly to conventional care at general medical clinics or to a diabetes clinic where specific educational objectives were defined and patients trained to achieve these objectives. The doctors treating these patients were not 'blinded' to treatment groups. Diabetes knowledge was assessed using a diabetes knowledge scale and metabolic control assessed by mean fasting blood glucose. The patients attending the diabetic clinic showed significant improvement in both knowledge scores (67% vs 34%, p < 0.01) and mean fasting blood glucose 6.38 +/- 0.85 mmol/l vs 9.7 +/- 1.7 mmol/l, p < 0.01) at 6 months. We conclude that diabetes education improves patient knowledge and diabetes control.

Diabetes in the elderly in a developing country

In developing countries diabetes in the elderly is thought to be uncommon and is consequently ignored by health planners. We assessed the prevalence of complications of diabetes mellitus and frequency of hospital admissions in patients aged 60 and over in a hospital diabetic clinic in Sri Lanka. Elderly diabetic patients, though comprising only 23% of clinic patients, accounted for 46% of admissions. The prevalence of coronary artery disease, peripheral vascular disease, cerebrovascular disease, hypertension and visual handicap was increased in the diabetic patients when compared to age and gender matched controls. We conclude that diabetes in the elderly is a significant cause of morbidity in Sri Lanka.

Semmes-Weinstein monofilaments: a simple, effective and inexpensive screening device for identifying diabetic patients at risk of foot ulceration

Both vibration perception threshold (VPT) by biothesiometry and pressure perception using Semmes-Weinstein monofilaments (filaments) have been proposed to identify diabetic patients at risk of foot ulceration. The two methods were compared in 182 subjects attending a national patients conference. Both measures were made over the great toe. Filaments of three calibres were used: 4.17, 5.07 and 6.10 bending with 1, 10 and 75 g force, respectively. Pressure perception was normal (4.17) in 122 patients (group 1) whereas in 45 patients it was grade 5.07 (group 2) and 6.10 or greater in 15 (group 3). The corresponding mean VPT (+/- SD) for the three groups were 10.6 (+/- 6.7), 22.8 (+/- 12.7) and 32 (+/- 14.3), respectively. The mean VPT for the 3 groups were significantly different (P less than 0.001). The filaments were more sensitive (100%) but less specific (77.7%) in identifying patients who had foot ulcers compared to biothesiometry which was less sensitive (78.6%) but more specific (93.4%). The filaments are therefore reliable and may be superior to biothesiometry in screening for patients at risk of foot ulceration since sensitivity is the more important parameter. In addition, they are inexpensive (12 pounds) compared to the biothesiometer (400 pounds) and are simple and easy to use.

Risk factors for non-ischaemic foot ulceration in diabetic nephropathy

It is recognized that diabetic patients with nephropathy frequently have macrovascular disease leaving them at risk of ischaemic foot lesions. In order to assess non-vascular risk factors for foot ulceration 64 patients were stratified into four groups: microalbuminuria, albuminuria with creatinine clearance greater than 40 ml min-1, chronic renal failure (clearance less than 40 ml min-1), and a non-nephropathic diabetic control group. Vibration perception threshold was measured by biothesiometry, peroneal nerve conduction velocity by conventional methods, and dynamic foot pressure by pedobarography. Vibration perception threshold was elevated in all three groups when compared with age-matched normal and diabetic control groups. Mean vibration perception threshold was 20.8 +/- 8.6 (+/- SD) in the microalbuminuria group (p less than 0.001 compared with age-matched normal control group), 28.1 +/- 5.6 (p less than 0.001) in the albuminuria group, 38.9 +/- 9.4 (p less than 0.001) in the renal failure group, 14.8 +/- 5.2 in the diabetic control group and 12.3 +/- 2.9 in the normal control group. Peroneal motor conduction velocity was reduced in all three groups when compared with normal control subjects, microalbuminuria 38.6 +/- 4.2 m s-1 (p less than 0.001), albuminuria 38.0 +/- 6.1 m s-1 (p less than 0.01), renal failure 35.5 +/- 1.2 m s-1 (p less than 0.001), diabetic control 40.6 +/- 1.8 m s-1, and normal 43.1 +/- 2.3 m s-1.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationship of limited joint mobility to abnormal foot pressures and diabetic foot ulceration

OBJECTIVE

To investigate the role of limited joint mobility (LJM) in causing abnormal foot pressures and foot ulceration.

RESEARCH DESIGN AND METHODS

The subjects were recruited from a general diabetes clinic where patients were screened for neuropathy, retinopathy, and elevated plantar foot pressure. Sixty-four patients in five groups were matched by age and sex in the following groups: group 1, patients with LJM and neuropathy; group 2, nonneuropathic diabetic patients with LJM; group 3, patients with neuropathy and no LJM; group 4, diabetic control subjects; and group 5, nondiabetic control subjects. Joint mobility was assessed in the foot at subtalar and metatarsophalangeal joints; plantar foot pressures were assessed by optical pedobarography and neuropathic status by a Biothesiometer and electrophysiology.

RESULTS

Joint mobility was reduced at both sites in groups 1 and 2 compared with groups 3, 4, and 5 (P less than 0.001). Plantar foot pressures were significantly higher in groups 1 and 2 compared with groups 3, 4, and 5 (P less than 0.001). No differences in plantar foot pressures were observed between groups 1 and 2. There were strong correlations between plantar foot pressures and joint mobility in the foot (r = -0.7, P less than 0.001). Previous foot ulceration was present in 65% of patients in group 1, none in group 2, and 5% in group 3.

CONCLUSIONS

1) LJM may be a major factor in causing abnormally high plantar foot pressures, 2) abnormal plantar foot pressures alone do not lead to foot ulceration, and 3) LJM contributes to foot ulceration in the susceptible neuropathic foot.

Studies of experimental hosiery in diabetic neuropathic patients with high foot pressures

High plantar pressures and painless trauma are associated with the development of foot ulcers in diabetic patients. Padded hosiery has been reported to reduce plantar pressures in patients at risk of ulceration. Using the optical pedobarograph we have studied 10 patients who regularly wore experimental padded hosiery for 6 months. The hosiery continued to provide substantial and significant reduction in peak forefoot pressures at 3 months (mean reduction 15.5%, p less than 0.01) and 6 months (17.6%, p less than 0.01), although the level of reduction was less than that seen at baseline (31.3%, p less than 0.05). In addition, commercially available hosiery designed as sportswear has been tested, and compared with experimental hosiery. Although these socks (with high or medium density padding) provided significant pressure reduction versus barefoot (mean 17.4% and 10.4%, p less than 0.01), this was not as great as that seen with experimental hosiery (27%, p less than 0.05). Thus the use of socks designed to reduce pressure stress on diabetic neuropathic feet is effective, and continues to be so for a considerable period of time. Commercially available sports socks may also have a place in the management of the diabetic insensitive foot.

Use of experimental padded hosiery to reduce abnormal foot pressures in diabetic neuropathy

High pressures under the feet of diabetic patients with neuropathy are associated with the development of plantar ulceration. The aim of management is the reduction of such stresses with orthoses and insoles. An American hosiery manufacturer has developed socks designed to reduce stress on athletes' feet, and we report a preliminary evaluation of this technique in the reduction of elevated plantar pressure in 27 neuropathic diabetic patients. With a computerized optical pedobarograph, three footsteps on each side were recorded under three conditions: 1) barefoot, 2) wearing the patients' own hosiery, and 3) wearing experimental patented padded hosiery. The patients' own hosiery did not have a significant effect on plantar pressure, but the experimental hosiery reduced both peak forefoot pressure and the area under the time-pressure curve (P less than .001) by a mean of 26 and 29%, respectively. We conclude that the experimental hosiery is effective in reducing vertical pressures under the diabetic foot and, in conjunction with established orthotic techniques, may be a useful addition to the treatment of the diabetic patient at risk for foot ulceration.