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The Asian Journal of
Diabetology VOLUME13, 16,NUMBER NUMBER21 VOLUME
January-March 2013
xxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxx Socioeconomic Burden of Diabetes Mellitus in the Urban Population of North xxxxxxxxxxxxxxxxxxxxxxxxx Karnataka, India xxxxxxxxxxxxxxxxxxxxxxxx A Hospital-based Observational Study of xxxxxxxxxxxxxxxxxxxxxxxxx Type 2 Diabetic Subjects from India xxxxxxxxxxxxxxxxxxxxxxxx
Tuberous Xanthoma in Diabetes Mellitus xxxxxxxxxxxxxxxxxxxxxxxxx
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Diet for Indian Diabetics xxxxxxxxxxxxxxxxxxxxxxxxx
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Dr Vijay Viswanathan Editor
Dr Dr KK KK Aggarwal Aggarwal Group Editor-in-Chief Group Editor-in-Chief
The Asian Journal of
DIABETOLOGY
IJCP Group of Publications
Volume 16, Number 1, January-March 2013
Dr Sanjiv Chopra Prof. of Medicine & Faculty Dean Harvard Medical School Group Consultant Editor
FROM THE DESK OF GROUP EDITOR-IN-CHIEF
Dr Deepak Chopra Chief Editorial Advisor Padma Shri and Dr BC Roy National Awardee
Dr KK Aggarwal
Group Editor-in-Chief
5
Pioglitazone Ban is Controversial
KK Aggarwal
Dr Veena Aggarwal MD, Group Executive Editor Anand Gopal Bhatnagar Editorial Anchor
IJCP Editorial Board Obstetrics and Gynaecology Dr Alka Kriplani
ORIGINAL STUDY
Dr Thankam Verma, Dr Kamala Selvaraj Cardiology Dr Praveen Chandra, Dr SK Parashar Paediatrics Dr Swati Y Bhave
6
Socioeconomic Burden of Diabetes Mellitus in the Urban Population of North Karnataka, India
Sanjay Kambar, Praveen GS, Avinash Kavi, Nikhil P Hawal, Ravindra NR
Diabetology Dr CR Anand Moses, Dr Sidhartha Das Dr A Ramachandran, Dr Samith A Shetty ENT Dr Jasveer Singh Dentistry Dr KMK Masthan Dr Rajesh Chandna
CLINICAL STUDY
Gastroenterology Dr Ajay Kumar Dr Hasmukh J Shroff
13 A Hospital-based Observational Study of Type 2 Diabetic Subjects from India
Nephrology
Dermatology
Mayur Patel, Ina M Patel, Yash M Patel, Suresh K Rathi
Dr Georgi Abraham Neurology Dr V Nagarajan Orthopedics Dr J Maheshwari Journal of Applied Medicine & surgery Dr SM Rajendran Dr Jayakar Thomas
CASE REPORT
Advisory Bodies Heart Care Foundation of India Non-Resident Indians Chamber of Commerce & Industry World Fellowship of Religions
21 Tuberous Xanthoma in Diabetes Mellitus
Sonia Jain, AP Jain
SYMPOSIUM ON NUTRITION AND HEALTH
Published, Printed and Edited by Dr KK Aggarwal, on behalf of IJCP Publications Ltd. and Published at E - 219, Greater Kailash, Part - 1 New Delhi - 110 048 E-mail: editorial@ijcp.com
25 Diet for Indian Diabetics
Shilpa S Joshi
Printed at IG Printers Pvt. Ltd., New Delhi
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LIGHTER READING 32 Lighter Side of Medicine
Editorial Policies The purpose of IJCP Academy of CME is to serve the medical profession and provide print continuing medical education as a part of their social commitment. The information and opinions presented in IJCP group publications reflect the views of the authors, not those of the journal, unless so stated. Advertising is accepted only if judged to be in harmony with the purpose of the journal; however, IJCP group reserves the right to reject any advertising at its sole discretion. Neither acceptance nor rejection constitutes an endorsement by IJCP group of a particular policy, product or procedure. We believe that readers need to be aware of any affiliation or financial relationship (employment, consultancies, stock ownership, honoraria, etc.) between an author and any organization or entity that has a direct financial interest in the subject matter or materials the author is writing about. We inform the reader of any pertinent relationships disclosed. A disclosure statement, where appropriate, is published at the end of the relevant article. Note: Asian Journal of Diabetology does not guarantee, directly or indirectly, the quality or efficacy of any product or service described in the advertisements or other material which is commercial in nature in this issue.
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FROM THE DESK OF GROUP EDITOR-IN-CHIEF Dr KK Aggarwal
Padma Shri and Dr BC Roy National Awardee Sr. Physician and Cardiologist, Moolchand Medcity, New Delhi President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group and eMedinewS NAtional Vice President, Elect, IMA Director, IMA AKN Sinha Institute (08-09) Hony. Finance Secretary, IMA (07-08) Chairman, IMA AMS (06-07) President, Delhi Medical Association (05-06) emedinews@gmail.com http://twitter.com/DrKKAggarwal Krishan Kumar Aggarwal (Facebook)
Pioglitazone Ban is Controversial
D
octors in India have shown their concern following unexpected decision by the Government to suspend the sales of Pioglitazone (pio). The Government suspended the manufacture, sale and distribution of pio at the end of June citing the concerns for adverse effects, particularly, bladder cancer according to a report published in BMJ. The doctors in the country feel that it should not have been banned. In fact, unless a drug comes into the category of poison, no drug should be banned only because of some side effects. In US, the drug is still available with some warning. In France, it was banned three years ago and in Germany it has been suspended sales only for the new patients. In no other country it is banned. Banning is always based in any country only on the basis of the data of that country. In India, there are no reports that use of pio has caused bladder cancer. For most diabetologists, the news came as a shock as they were not taken into confidence. I personally feel that when the Government decides to ban a particular drug, IMA, Specialty Organizations to which the drug belongs, MCI, etc. should be taken into confidence. The drug has been in Indian market for 12 years and has never shown any safety concerns. Three million patients in India are on pio and in one stroke, the Government has asked them to stop the drug. Alternative is to shift to gliptins which are available at 10 times the cost. Is it the gliptin market which has pressurized the Government to ban the pio. Pio is more suited for Indians as it is the drug of choice for insulin resistance, which is like an epidemic in Indian population. Also in India, pio is used in lower doses i.e., 7.15-15 mg which is not the case in Western countries. The Indian market for pio as of today is worth 120 million $. The doctors are protesting and now the Government has agreed to a meeting of technical experts to discuss the situation. Hope the decision is reversed.
Asian Journal of Diabetology, Vol. 16, No.1, January-March 2013
5
ORIGINAL STUDY
Socioeconomic Burden of Diabetes Mellitus in the Urban Population of North Karnataka, India SANJAY KAMBAR*, PRAVEEN GS**, AVINASH KAVI**, NIKHIL P HAWAL**, RAVINDRA NR**
ABSTRACT Background: Diabetes mellitus and its complications have huge burdens globally especially in developing countries. A cross-sectional study was aimed to assess the socioeconomic burden of diabetes mellitus among the urban population of North Karnataka, India. Methodology: A detailed history was elicited regarding diabetes mellitus, including disease duration, care seeking behavior, treatment compliance and management of complications. Results: In this study, males (60.76%) outnumbered females (39.24%) with male-to-female ratio of 1.54:1. Most of the participants (40%) belonged to Class IV socioeconomic status. Majority of diabetics had duration of more than five years (70.86%) and hypertension as common comorbidity (26.15%). Majority of the diabetics (40.77%) had single consultation in the past one year and spent half day for the consultation (60.77%). Most of the diabetics (63.08%) spent less than ` 100 for consultation, less than ` 200 for investigations (81.54%) with annual cost of medication being less than ` 2,500 (71.54%). About 55.38% skipped laboratory investigations due to the cost, 80% opted for the government hospital, 55.08% financed their own treatment. Conclusion: Diabetes exerts a heavy economic burden on society. This burden is related to health system costs incurred by society in managing the disease. Keywords: Diabetes mellitus, socioeconomic burden, health insurance
D
iabetes is rapidly emerging as a major healthcare problem in India, especially in urban areas. The mortality and morbidity of diabetes is very high due to poor management and noncompliance to global treatment guidelines. The prevalence of type 2 diabetes has been steadily increasing in urban areas from a low of 2.1% reported in early 1970, to a whopping 11.6% in 1996, in the adult population. The World Health Organization (WHO) estimates that there were 19.4 million persons with diabetes in India in 1995 and that this number is likely to be 57.2 million 2025. Moreover, there is an equally large pool of persons with impaired glucose tolerance (IGT), many of whom will go on to develop type 2 diabetes in the future. The rapid increase in population, increased longevity and high ethnic susceptibility to diabetes, coupled with rapid urbanization and changes from traditional lifestyles, will most likely trigger a diabetes epidemic. The more obvious ill
*Associate Professor and Specialist in Diabetes, Diabetes Centre KLES Dr Prabhakar Kore Hospital and MRC, Belgaum, Karnataka **Postgraduate Dept. of Community Medicine Jawaharlal Nehru Medical College, KLE University, Belgaum, Karnataka Address for correspondence Dr Sanjay Kambar Associate Professor and Specialist in Diabetes, Diabetes Centre KLES Dr Prabhakar Kore Hospital and MRC Belgaum - 590 010 Karnataka
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Asian Journal of Diabetology, Vol. 16, No.1, January-March 2013
effects of urban life are emotional stress, loss of family structure, congested traffic, noise, environmental pollution and these affect people from all incomes. Good health is a prerequisite to successful human endeavor and therefore core to economic growth and activity. Economic loss due to chronic ill health is associated not merely with the cost of care but takes a heavy toll in terms of loss in productivity. The per capita expenditure on healthcare in India is only 6.4% of the average world spending, while India accounts for 23.5% of the world’s disability-adjusted life years (DALYs) lost due to diabetes. Diabetic complications account for 60% of diabetes related healthcare costs (direct cost) and almost 80-90% of indirect costs. This increase of over five times in a decade amounts to about one-sixth of India’s gross domestic product (GDP). The majority of healthcare expenditure was private (4% of GDP) with only 0.9% of GDP spent on public healthcare. Therefore, careful planning based on health economic assessments is necessary in order to maximize the use of funds for the treatment and prevention of diabetes. METHODOLOGY The present cross-sectional study was conducted in the urban block of Khasbag, which is a field practice area of Jawaharlal Nehru Medical College, Belgaum, Karnataka. It was a cross-sectional study
nt
de
d
ye
plo
em
Un
e
ffic
O
job
ed
Se
rs
he
y plo
Ot
em
lf-
Occupation
Figure 1. Distribution of study population according to occupation. 40
40 35 30 25 20 15 10 5 0
34.62
15.38 6.15
3.85
Class I
Class II Class III Class IV Socioeconomic status
Class V
Figure 2. Distribution of study population according to socioeconomic status. 70 60 50 40 30 20 10 0
63.08
26.15
ur
at
Ne
op tin
6.15
op
hy
e as ise
ar td
Re
ion ns
He
rte
16.15
at hy Ne ph ro pa No thy co m pli ca tio ns
11.54
9.23
pe
In this study, males (60.76%) outnumbered females (39.24%) with male-to-female ratio of 1.54:1. Most of the males (35.38%) were aged between 45-60 years, whereas females (17.69%) belonged to the age group of 60-75 years. In the age group of 15-30 years 1.54% were males and 0.77% were females. With regard to the occupation most of the diabetics were self-employed (44.62%) followed by 36.92% with other occupation predominantly house wife, 14.62% with office job and 3.85% were unemployed (Fig. 1). In this study, majority of the diabetics (73.08%) had completed school education followed by intermediate or pre-university (13.85%) and graduation (3.85%). 9.23% of the diabetics were illiterates.
14.62
Hy
RESULTS
36.92
3.85
0
u St
Distribution (%)
The study participants were interviewed in their households. Written informed consent was obtained from all the participants. The data was collected using predesigned and pretested proforma. Data regarding demographic profile like age, sex, place of residence, education status, marital status, socioeconomic status and type of family were recorded. Information of total monthly income of the family in rupees was obtained as well as the family size. Per capita monthly income in rupees was calculated, and then the family was classified using modified BG Prasad’s classification.A detailed history was elicited regarding diabetes mellitus, including disease duration, care seeking behavior, treatment, compliance and complication and its management. The results were expressed in ratios and proportions and analyzed using SPSS version 10.0. The study was approved by the Ethical and Research Committee of Ethics Committee, Jawaharlal Nehru Medical College, KLE University Belgaum, Karnataka, India.
44.62
45 40 35 30 25 20 15 10 5 0
Distribution (%)
extended over a period of six months from March 2012 to August 2012. The sample size was 130. The population of Urban Health Centre (UHC) is about 6,000. Line listing of all the diabetic patients was done using the family folders of UHC, Khasbag, which includes the detailed health information of every member in the family residing in that area. One hundred thirty study participants were selected using simple random sampling technique. All patients diagnosed with diabetes mellitus residing in UHC Khasbag area for more than 1-year duration were recruited for the study.
Distribution (%)
ORIGINAL STUDY
Complications
Figure 3. Distribution of study population according to complications.
In this study, most of the participants (40%) belonged to Class IV socioeconomic status based on modified BG classification, while 34.62% belonged to Class III, 15.38% to Class II, 6.15% to Class I and 3.85% to Class V (Fig. 2). Most number of diabetics with duration of more than five years (70.86%) were reported in this study followed by 16.15% with 3-5 years duration and 5.38%
Asian Journal of Diabetology, Vol. 16, No.1, January-March 2013
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ORIGINAL STUDY Table 1. Distribution of Study Population according to the Amount Spent on Treatment per Month in the Past One Year Details of expenditure Consultation
Investigations
Medication
Expenditure in rupees
No. of patients
Percentage (%)
<100
82
63.08
100-300
37
23.46
>300
11
8.46
<200
106
81.54
200-500
15
11.54
>500
09
6.92
<2,500
93
71.54
2,500-5,000
29
22.31
>5,000
08
6.15
with 1-3 years duration. In the present study majority (63.08%) of the participants had no complications and 36.92% diabetics had complications. Among them 26.15% had hypertension, 16.15% had neuropathy, 11.54% had retinopathy, 9.23% had heart disease and 6.15% had nephropathy (Fig. 3). In the present study majority (90.77%) of the patients followed allopathic treatment regimen followed by 6.92% who had ayurvedic and 2.31% who had homeopathic medicine. In this study, 9.23% diabetics required admission for the treatment of diabetes during the last one year. In this study, majority of the diabetics (40.77%) had single consultation in the past one year followed by no consultation (27.69%) and twice (20.77%). However, 10.77% of the diabetics had more than two consultations in the past one year. In this study, most of the diabetics (60.77%) spent half day for the consultation to the doctor followed by one day (36.15%) and more than one day (3.08%). In this study, with regard to consultation costs most of the diabetics (63.08%) spent less than ` 100 followed by ` 100-300 (23.46%) and more than ` 300 (8.46%). The investigations during the past one year amounted to less than ` 200 among 81.54%, ` 200-500 among 11.54% and more than ` 500 among 6.92% diabetics. The cost of medication was less than ` 2,500 in 71.54% cases, ` 2,500-5,000 among 22.31% and more than ` 5,000 among 6.15% diabetics (Table 1). In this study majority of the diabetics (55.38%) skipped laboratory investigations due to the cost followed by consultation (17.69%) and medication (3.08%).
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Study population
Asian Journal of Diabetology, Vol. 16, No.1, January-March 2013
In this study most of the diabetics (55.08%) financed their own treatment followed relatives (33.08%), health insurance (10.77%) and loan (3.08%). DISCUSSION Healthcare delivery in India is provided either by doctors in the health centers, clinics, district, municipal and tertiary teaching hospitals run by the central and state governments; or through private practicing general practitioners, specialists in their clinics, nursing homes or large corporate hospitals. The quality and cost of care varies considerably from place-to-place, depending on the available resources, training and interest in diabetes of the treating doctor and the patientsâ&#x20AC;&#x2122; ability to pay for it. Generally, care provided in government institutions is free or at low subsidized cost. These institutions are crowded, ill-equipped and have scant resources. Those seeking medical care in the private sector pay for everything on their own, as there is limited or no reimbursements. When uniformly good quality care is accessible to all, the disease outcome is at least not predetermined by his/her socioeconomic status.2 The Bangalore Urban District (BUD) Diabetes Study estimated the annual direct cost for routine care in Bangalore, India, in 1998 to be about 191 US dollars, the mean direct cost per hospitalization for a diabetes related episode was about 208 US dollars. Health resources in India and other developing countries are very limited with only 5% of GDP, (USD 23 per capita) being spent on healthcare. With regard to the occupation most of the diabetics were self-employed (44.62%) followed by 36.92% with other occupation predominantly house wife, 14.62% with office job and 3.85% were unemployed. In this
ORIGINAL STUDY study, majority of the diabetics (73.08%) had completed school education followed by intermediate or pre-university (13.85%) and graduation (3.85%). In this study, 9.23% of the diabetics were illiterates. The level of education is an important determinant of how quickly a diagnosis will be made and education appears to have a major affect on diabetes prognosis. In this study, most of the participants (40%) belonged to Class IV socioeconomic status based on modified BG classification, the others being 34.62% in Class III and 15.38% in Class II. However, 6.15% diabetics belonged to Class I and 3.85% to Class V. A study from Bangalore reported similar findings in regards to occupation, educational status and socioeconomic status. In this study, 9.23% diabetics required admission for the treatment of diabetes during the last one year. As well-known, persons with diabetes use higher healthcare resources compared to nondiabetics. The costs varied considerably depending on the duration, reason and place. Also the cost of hospitalization was higher for person with multiple complications. In the present study majority (90.77%) of the patients followed allopathic treatment regimen followed by 6.92% who took ayurvedic and 2.31% who took homeopathic medicine. In this study, most of the diabetics (90%) had glycemic control with diet and oral hypoglycemics, whereas 10% had diet and insulin. In this study, majority of the diabetics (40.77%) had single consultation in the past one year followed by no consultation (27.69%) and twice (20.77%). However, 10.77% of the diabetics had more than two consultations in the past one year. A study by Rayappa et al from Bangalore reported almost similar findings.10 In this study, majority of the diabetics (55.38%) skipped laboratory investigations due to the cost followed by who had no consultation (17.69%) and (3.08%) who had no medication. To prevent diabetic complications, it is crucial that proper monitoring be carried out, firstly to assess response to treatment and secondly to detect any complications. In the given socioeconomic situation in India, the lack of proper healthcare infrastructure and support for chronic illness; the rampant ignorance and absence of clear cut, even barely minimum, guidelines on protocols for care and monitoring, at the primary level means that diabetes care at this level is poor. This study shows that the uneducated, unemployed people, especially those living in semi-urban or
urban areas, who cannot afford or do not have access to even bare minimum healthcare facilities, are likely to be diagnosed late, are likely to develop or have at presentation, diabetes related complications because of delay in diagnosis and/or improper treatment. This has remarkable socioeconomic significance, since those who will need more advance/more expensive care for diabetes related complications, are often the ones who can ill afford such care. CONCLUSION Diabetes exerts a heavy socioeconomic burden on society. This burden is related to health system costs incurred by society in managing the disease, indirect costs resulting from productivity losses due to patient disability and premature mortality, time spent by family members accompanying patients when seeking care, and intangible costs (psychological pain to the family and loved ones). There is emerging evidence that diabetes education, awareness and improving motivation for self-care improves care, reduces complications and may thus reduce overall economic costs of diabetes.
Acknowledgment Authors are thankful to Mr. MD Mallapur, Biostatistician of Jawaharlal Nehru Medical College, KLE University, Belgaum, Karnataka for his valuable comments and technical support. The co-operation and support of staff of Community Medicine, Jawaharlal Nehru Medical College, KLE University, Belgaum, Karnataka is greatly acknowledged.
SUGGESTED READING 1. Ahuja MMS. Epidemiological studies on diabetes mellitus in India. In: Epidemiology of Diabetes in Developing Countries. Ahuja MMS (Ed.), Interprint: New Delhi 1979:p.29-38. 2. Ramachandran A, Snehlata C. NIDDM in India and Indian: Is it increasing? Bull IDF 1995;40:27-9. 3. Ramaiya KL, Kodali VR, Alberti KG. Epidemiology of diabetes in Asians of the Indian subcontinent. Diabetes Metab Rev 1990;6(3):125-46. 4. Zimmet P. Challenges in diabetes epidemiology - from West to the rest. Diabetes Care 1992;15:232-52. 5. King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025: prevalence, numerical estimates, and projections. Diabetes Care 1998;21(9):1414-31. 6. Kapur A, Shishoo S, Ahuja MMS, Sen V, Mankame K. Diabetes Care in India - Patientsâ&#x20AC;&#x2122; Perceptions Attitudes and Practices (DIPPAP - 1 Study) Int J Diab Dev Countries 1998;18:124-30.
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ORIGINAL STUDY 7. Huizinga MM, Rothman RL. Addressing the diabetes pandemic: a comprehensive approach. Indian J Med Res 2006;124(5):481-4. 8. World Bank. World Development Report 1993: Investing in Health. World Development Indicators. Oxford University Press: Oxford 1993:p.213-4. 9. The Economics of Diabetes and Diabetes Care - A Report of Diabetes Health Economics Study Group. Gruber W, Lander T, Leese B, Songer T, Williams R (Eds.), An IDF, WHO Publication; 1997. 10. Rayappa PH, Raju KNM, Kapur A, Bjork S, Sylvist C, Kumar KMD. The impact of socio-economic factors on diabetes care. Int J Diab Dev Countries 1999;19:7-16. 11. Rayappa PH, Raju KNM, Kapur A, Bjork S, Sylvist C, Kumar KMD. Economic costs of diabetes care - The Bangalore Urban District Diabetes Study. Int J Diab Dev Countries 1999;19:87-96. 12. Peters DH, Yazbeck SA, Sharma RR, Ramana GNV, Pritchett LH, Wagstaff A. A better health systems for Indiaâ&#x20AC;&#x2122;s poor: Findings analysis and options. World
13.
14.
15. 16.
17.
Bank; 2002. Available from: http://www1.worldbank. org/publications/pdfs/15029overview.pdf. Kirigia JM, Sambo HB, Sambo LG, Barry SP. Economic burden of diabetes mellitus in the WHO African region. BMC International Health and Human Rights 2009;9:6. Misra A, Pandey RM, Devi JR, Sharma R, Vikram NK, Khanna N. High prevalence of diabetes, obesity and dyslipidaemia in urban slum population in northern India. Int J Obes Relat Metab Disord 2001;25(11): 1722-9. Insurance Worker. 2010;LIII (6):28. Qiao Q, Hu G, Tuomilehto J, Nakagami T, Balkau B, Borch-Johnsen K, et al; DECODA Study Group. Ageand sex-specific prevalence of diabetes and impaired glucose regulation in 11 Asian cohorts. Diabetes Care 2003;26(6):1770-80. Bhaskaran VP, Rau NR. Satyashankar, Acharya RR, Metgud CS, Koshy T. A study of the direct costs incurred by type-2 diabetes mellitus patients for their treatment at a large tertiary-care hospital in Karnataka, India. J Acad Hospital Admin 2003;15(2):
Me Lord I Am Not Guilty d rre refe on e b ti ay r ac se m HS fo a c The k to D bac
Pr
oc
ee
d
How can I be summoned. Itâ&#x20AC;&#x2122;s the DHS who should do the inquiry against the chemist
The IV fluid had fungus in the bottle
Question: Can somebody complain about irregularities in the functioning of the chemist in a hospital to State Medical Council? No. In a case DMC/DC/F14/574/2009 dated 19.06.2009, the Council dismissed a complaint regarding growth of fungus in a glucose bottle found in the chemist in Saroj Hospital Delhi. The complaint was referred back to Directorate of Health Services (DHS) for investigations. Dr. K K Aggarwal
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Asian Journal of Diabetology, Vol. 16, No.1, January-March 2013
CLINICAL STUDY
A Hospital-based Observational Study of Type 2 Diabetic Subjects from India MAYUR PATEL*, INA M PATEL*, YASH M PATEL*, SURESH K RATHI**
ABSTRACT Aim: The aim of this study was to describe the profile of the subjects with type 2 diabetes mellitus (T2DM) to obtain a clear picture from Western India, that would help in management of diabetes. Methods: An observational study was conducted with newly diagnosed 622 type 2 diabetic subjects attending Dept. of Diabetology, All India Institute of Diabetes and Research and Yash Diabetes Specialties Centre (Swasthya), Ahmedabad during the period from August 2006 to January 31, 2009. Subjects completed an interviewer-administered comprehensive questionnaire, which included variables such as sociodemographic presenting symptoms, risk profile (hypertension, obesity, dyslipidemia and glycemic status), family history of diabetes, physical activity and behavioral profile. Blood pressure, body mass index (BMI), glycosylated hemoglobin (HbA1C) and fasting lipid profile were measured. Descriptive and bivariate analyses were carried out using SPSS version 11.5. Results: A total of 622 T2DM cases with mean age (years) 47.7 ± 10.9 were studied. Of these, 384 (62%) were male. The majority of T2DM subjects were obese (68%) and 67% had positive family history of diabetes. Renal dysfunctions and vision impairment were found in 10% (62/622) and 9% (57/622), respectively in T2DM subjects. The mean HbA1C level was 9.02% ± 1.67 and good glycemic control (HbA1C level <7%) was achieved only in 7.4% T2DM subjects. The Chi-square (χ2) analysis showed that higher BMI (≥25 kg/m2) is significantly associated with hypertension among T2DM subjects (p < 0.01). There were statistically significant differences between male and female study subjects with respect to mean age, BMI, waist and hip circumference and mean low-density lipoprotein (LDL) level (p < 0.05). Conclusions: The present study revealed that obesity, family history of diabetes, dyslipidemia, uncontrolled glycemic status, sedentary lifestyles and hypertension were more prevalent in T2DM subjects. Hence, the overall risk profile was very poor and needs improvement. The characterization of this risk profile will contribute in defining more effective and specific strategies for screening and controlling T2DM in Western India. Keywords: Type 2 diabetes mellitus, obesity, polyuria, glycemic status, dyslipidemia, India
T
blindness, kidney failure and neuropathy. T2DM is also associated with 4-fold increase risk of cardiovascular events and risk factor for doubling the risk of cardiovascular death.5-7
*All India Institute of Diabetes and Research, Narainpura, Ahmedabad, Gujarat **SBKS Medical Institute and Research Centre, Piparia, Vadodara, Gujarat Address for correspondence Dr Suresh Kumar Rathi F-102, Aalekh Complex, 8, Amravati Society, Near Yash Complex Gotri Road, Vadodara, Gujarat - 390 021 E-mail: rathisj@yahoo.com
The prevalence of T2DM has been rising worldwide and globally more than 180 million people are suffering from it. In particular, developing countries are facing an epidemic of T2DM.8,9 The major global burden comes from India and China, where more than 75% of diabetic subjects will live in 2025.4 India, like many other developing countries, has witnessed a rapid epidemiological transition in the last two decades. Coupled with this, there has been a dramatic improvement of the Indian economy in terms of per capita income. These dramatic changes have had a great impact on urbanization and lifestyle of the Indians and as a result diabetes mellitus has become the main public health problem. It is amenable to change through early recognition at the individual level and surveillance at the population level. Studies showed that India is facing 3-fold rise of prevalence of diabetes in urban (from 5% to 15%) as well as in rural (2% to 6%) areas.10,11 India had the largest number of the diabetic subjects with
ype 2 diabetes mellitus (T2DM) is a chronic, debilitating disease characterized by insulin resistance, impaired insulin secretion and hyperglycemia. It is the most prevalent metabolic condition and one amongst major health and socioeconomic problems worldwide.1-3 It represents more than 90% of total prevalence of diabetes in the world4 and is responsible for 9% of the global mortality corresponding to four million deaths per year. Since, the onset is insidious, there is an average delay of 3-5 years in diagnosis. By the time, the condition is diagnosed, minimal changes responsible for micro- and macrovascular complications are already present. This issue is further compounded by untreated diabetes because of ignorance or inaccessibility to treatment. Untreated diabetes may result in limb amputation,
Asian Journal of Diabetology, Vol. 16, No.1. January-March 2013
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CLINICAL STUDY 31.7 million cases of T2DM in India.3,12 This is further compounded by the epidemic of obesity and increase in the cost of diabetes management by 2-folds.13 Therefore, prevention is also important from monetary point of view. Misra et al reported that increasing awareness of risk factors and how to prevent them should be emphasized in the population.14 Apart from this, the lifestyle modifications (physical exercise, diet control, etc.) are appropriate measures in prevention of diabetes. Furthermore, to control and prevent T2DM epidemic, it must be approached in an appropriate, socioeconomically and culturally relevant manner but very little data are available from western part of India to support this and for prevention of diabetes it is also vital to know the profile of diabetics. To describe the profile of type 2 diabetic subjects from Western India. METHODS A hospital-based observational study was conducted during August 2006 to January 2009 in Ahmedabad district of Gujarat State. Ahmedabad is the largest district of Gujarat with an approximate population of 5 million. The city is famous for medical tourism because of its wide network of cost-effective tertiary care hospitals catering the population of not only from Gujarat but also from neighboring states and even from abroad. To be included in this study, subjects had to be newly diagnosed cases of diabetes mellitus (diagnosed within last 6 months), attending the Dept. of Diabetology, All India Institute of Diabetes and Research and Yash Diabetes Specialties Centre (Swasthya) during the study period for first time and willing to participate in the study. A sample size of 660 was decided so as to study at least 20% of newly diagnosed cases, based on the data review of the Dept. of Diabetology, which revealed that at least 100 subjects (newly diagnosed) presented every month, hence during the study period there would be 3,000 subjects. The calculated minimum sample size was inflated by 10% to account for anticipated dropouts. After satisfying the case definition and obtaining informed consent (written consent from literate subjects and a verbally informed consent from illiterate subjects), 709 subjects were enrolled through simple random sampling method. After explaining the details of the study, a comprehensive case history was recorded on a semi-structured, close-ended proforma. The basic data on age, sex, education, occupation,
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Asian Journal of Diabetology, Vol. 16, No.1, January-March 2013
smoking and tobacco chewing status, alcohol consumption, diet and physical activity were collected from all the subjects. All subjects were also interviewed regarding history of hypertension and other comorbid conditions and a general physical examination was done. All anthropometric measurements were recorded using standardized procedures. These subjects also underwent various clinical tests like urinalysis (first morning urine sample for evaluation of microalbuminuria), blood tests for complete hemogram, plasma glucose, glycosylated hemoglobin (HbA1C), renal function tests and lipid levels. The blood samples were collected after ensuring 12 hours of overnight fasting. Total cholesterol (TC), triglycerides (TG) and highdensity lipoprotein cholesterol (HDL-C) levels were estimated in serum. Low-density lipoprotein cholesterol (LDL-C) was calculated using the Friedewald formula (LDL-C [mg/dl] = Non-HDL-C - TG/5).15 For analysis, the current smokers and ex-smokers were categorized in the ‘ever smoker’ group. Similarly, the current tobacco chewer and ex-tobacco chewer were categorized in the ‘ever tobacco chewer’ group. Ever smoker and ever tobacco chewer groups were considered as tobacco user. Current alcohol users were defined as subjects who had consumed alcohol at least once in last 1-month period. The main occupational level was divided into three categories: Low (e.g., skilled workers, household workers and retired); medium (e.g., desk jobs) and high (e.g., professionals and businessmen). Physical activity was categorized as sedentary (sitting, standing and driving for most of the day, cooking, light cleaning, light yard work, slow walking and other major activities involve sitting); moderate (an occupation that includes lifting, lots of walking or other activities that keep you moving for several hours qualifies as moderately active) and heavy (heavy manual labor, a very active lifestyle, dancer or very active sports played for several hours almost daily, an elite athlete in training or an extremely active lifestyle - both at work and at play and sport or activity lasting for several hours, almost daily). Blood pressure (BP) was recorded, after the subjects had rested for at least five minutes. Two readings were taken five minutes apart and mean of two was considered as the BP. Hypertension was diagnosed based on drug treatment for hypertension or if the BP was >130/80 mmHg according to Joint National Committee-7 (JNC-7) criteria.16,17 The diagnosis of diabetes mellitus was done using criteria established by the American Diabetes Association.18 Either a fasting plasma glucose (FPG) level >7.0 mmol/l or ≥126 mg/dl after a minimum
CLINICAL STUDY 12-hour fast, or 2-hour post glucose level (oral glucose tolerance test [OGTT]) >11.1 mmol/l or ≥200 mg/dl on more than one occasion, with symptoms of diabetes. In the absence of information from medical records, self-reported cases were confirmed by establishing the criteria of regular treatment with antidiabetic drugs or by performing a 2-hour OGTT. Impaired glucose tolerance (IGT) was defined as FPG level of 100 mg/dl (5.6 mmol/l) but <126 mg/dl (7.0 mmol/l) or 2-hour OGTT of ≥140 mg/dl (7.8 mmol/l) but <200 mg/dl (11.1 mmol/l). National Cholesterol Education Program (NCEP) guidelines were used for definition of dyslipidemia19 as presence of ≥1 abnormal serum lipid concentration like hypercholesterolemia, high LDL-C, hypertriglyceridemia and low HDL-C. Body mass index (BMI) values were defined according to the recommendations of Indian Council of Medical Research (ICMR) for Indians. A study subject was considered to be obese if BMI was ≥25 kg/m2, overweight when BMI was 23-24.9 kg/m2.20 The criteria for glycemic status were <7% (good control), 7-8% (suboptimal control), 8-9% (inadequate control) and >9% (uncontrolled).21 The study protocol was approved by the Institutional Review Board (IRB) of All India Institute of Diabetes and Research.
Table 1. Sociodemographic Characteristics of the Type 2 Diabetic Subjects from India Characteristics Age (years) (mean ± SD)
Number (n = 622)
Percentages (%)*
47.70 ± 10.94
Upto 40
164
27
41-48
170
27
49-55
150
24
>55
138
22
Male
384
62
Female
238
38
Never married
22
4
Ever married
600
96
521
84
Sex
Marital status
Religion Hinduism Islam
51
8
Christianity
19
3
Others
31
5
Education
Statistical Analysis
Nil
03
1
Data were entered in Excel sheet and cleaned, validated and analyzed using SPSS version 11.5. Quantitative variables were summarized using mean and standard deviation while categorical variables were tabulated using frequencies and percentages. Student t-test was used to test the significance of differences between mean values of two continuous variables. Chi-square (x2) test was carried out to test the difference between two or more groups. The probability (p) level of < 0.05 was considered significant.
Primary school
18
3
Secondary school
105
17
College
420
67
Professionals (CA, MBBS, etc.)
76
12
Low
281
45
Medium
112
18
High
229
37
RESULTS A sample of 709 diabetic subjects was enrolled. Of 709 study subjects, 622 had T2DM. Hence, further analysis was performed on 622 T2DM subjects. Sociodemographic: Sociodemographic characteristics of the study sample are shown in Table 1. Eightyfour percent (521/622) of the subjects were Hindus and almost all study subjects were literate. The sample comprised of 384 males and 238 females. Type 2 diabetics were evenly distributed in the study sample in four quartiles of age with mean age 47.70 ± 10.94 years. Around a third of the study sample had high level of occupation (37%).
Occupation level
*All percentages rounded to whole numbers.
Presenting complaints/symptoms: The study subjects had classic diabetic symptoms such as nocturia 44% (273/622), polyuria 31% (192/622) and polydypsia 23% (145/622). However, 9% (57/622) study subjects presented with vision impairment (Table 2). Behavioral profile: Our findings showed that 28% (173/622) subjects had some form of habits; 9% (56/622) subjects were smoker, 20% (121/622) subjects were chewing tobacco and 8% (51/622) subjects were consuming alcohol. A large number of study subjects (84%) reported sedentary lifestyle (Table 3).
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CLINICAL STUDY Table 2. Presenting Symptoms of Type 2 Diabetic Subjects from India Characteristics Nocturia (Yes)
(n = 622) 273
Percentages (%)* 44
Polyuria (Yes)
192
31
Polydipsia (Yes)
Table 3. Profile of Clinical and Other Associated Factors of Type 2 Diabetic Subjects from India Characteristics
Number (n = 622)
HbA1C (mean ± SD)
9.02 ± 1.67
Percentages (%)*
145
23
Glycemic status
Vision impairment (Yes)
5
79
<7% (good control)
46
7
Itching of private parts (Yes)
50
8
Tingling (Yes)
136
22
7-8% (suboptimal control)
159
26
Weight loss (Yes)
165
27
8-9% (inadequate control)
163
26
Weakness (Yes)
365
59
>9% (uncontrolled)
254
41
Leg pain (Yes)
155
25
Burning micturition (Yes)
68
11
417
67
Skin complaint (Yes)
59
10
Numbness (Yes)
39
6
Underweight (<18.5 kg/m2)
11
1
H/O impotence (Yes)
28
5
Normal (18.5-22.9 kg/m2)
99
16
Overweight (23.0-24.9 kg/m2)
92
15
420
68
62
10
487
78
289
47
Acute
446
72
Subacute
145
23
Insidious
31
5
Sedentary
525
84
Moderate
89
14
Heavy
8
1
Diet control
103
17
Other diabetic treatments
219
35
56
9
*All percentages rounded to whole numbers.
Risk profile: Very few study subjects (7%) had good glycemic control (HbA1C <7%). Two-thirds of the study population had positive family history for diabetes. Our findings showed a mean BMI of 27.06 ± 4.57. According to BMI, only 16% of the studied sample was of normal weight; the majority was either over weight (23.0-24.9 kg/m2) or obese (BMI ≥ 25 kg/m2). Microalbuminuria was found in 10% (62/622) T2DM subjects. Dyslipidemia and hypertension among T2DM was 78% and 47%, respectively (Table 3). There were statistically significant differences between male and female study subjects with respect to mean age (male = 46.93 ± 11.11, female = 48.95 ± 10.53), mean BMI (male = 26.47 ± 4.34, female = 28.02 ± 4.78), mean waist circumference (male = 93.12 ± 10.47, female = 88.96 ± 9.53), mean hip circumference (male = 98.46 ± 8.83, female = 101.69 ± 12.52) and mean LDL level (male = 119.20 ± 31.23, female = 127.73 ± 38.15) at p < 0.05 (Table 4). BMI was significantly associated with hypertension among T2DM subjects (p < 0.001) (Table 5). DISCUSSION Diabetes mellitus is a major public health problem worldwide. Its prevalence is on the rise in many parts of the developing world and India is no exception. Individuals with T2DM are considered as high priority as they are potential candidates for rapid evaluation to prevent and halt the progression of the complications. This study presents observational data from large number of subjects with diabetes attending Dept. of
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Asian Journal of Diabetology, Vol. 16, No.1, January-March 2013
Family history of diabetes Present BMI group
Obese (≥25.0
kg/m2)
Microalbuminuria Lipid Dyslipidemia Hypertension Present Mode of onset
Physical activity
(excluding diet) (Yes) Smoking (Yes) Years of tobacco smoking (mean ± SD) Tobacco chewing (Yes) Years of tobacco chewing (mean ± SD) Alcohol (Yes) Years of alcohol drinking (mean ± SD)
11.46 ± 9.27 121
20
12.37 ± 8.61 51 9.68 ± 7.64
*All percentages rounded to whole numbers.
8
CLINICAL STUDY Table 4. Study Population Characteristics, Clinical and Laboratory Findings by Sex among Type 2 Diabetic Subjects from India Characteristics
Mean ± SD
Table 5. Factors Associated with Hypertension among T2DM Subjects from India Factors
P value
Hypertension Yes
No
Male
Female
Age
46.93 ± 11.11
48.95 ± 10.53
0.026
Upto 40
67
97
BMI
26.47 ± 4.34
28.02 ± 4.78
0.000
41-48
73
97
93.12 ± 10.47
88.96 ± 9.53
0.000
49-55
74
76
>55
75
63
≥25 kg/m2
222
198
<25 kg/m2
67
135
Sedentary
246
279
Moderate to heavy
43
54
Dyslipidemia
220
267
Normal
69
66
Positive
205
212
Negative
84
121
<7% (good control)
24
22
7-8% (suboptimal control)
65
94
8-9% (inadequate control)
86
77
>9% (uncontrolled)
114
140
Waist circumference (cm)
HIP circumference (cm) 98.46 ± 8.83 101.69 ± 12.52
0.000
SBP (mmHg)
128.30 ± 16.43
129.60 ± 17.54
0.354
DBP (mmHg)
84.87 ± 9.13
83.41 ± 9.19
0.054
9.07 ± 1.74
8.93 ± 1.55
0.333
194.82 ± 39.24
201.00 ± 46.98
0.079
HDL (mg/dl)
41.17 ± 5.28
40.91 ± 6.10
0.575
LDL (mg/dl)
119.20 ± 31.23
127.73 ± 38.15
0.003
Triglycerides (mg/dl)
182.49 ± 123.31
169.87 ± 140.23 0.242
Lipid profile Cholesterol (mg/dl)
VLDL (mg/dl)
36.04 ± 18.46
32.03 ± 12.62
P value
6.86
0.076
21.25
0.000
0.21
0.659
1.4
0.242
3.7
0.054
5.449
0.142
Age (years)
Blood pressure
HBA1C
X2
0.004
BMI
Physical activity
Lipid profile
Family history (diabetes)
Glycemic status
Diabetology, All India Institute of Diabetes and Research and Yash Diabetes Specialties Centre, Ahmedabad. To the best of our knowledge, no such type of profiles has been reported from Western India. Nonetheless, literature regarding prevalence of diabetes is available from South and North India.22-26 Our main motivation for this analysis was to obtain the risk profile so that we can prevent or decrease the burden of T2DM in Western India. This study found that T2DM is a major burden in Western India, which is consistent with a study by Simon.4 Our study population had a negligible proportion of illiterate T2DM subjects. This finding was expected given that our sample was drawn from a tertiary care hospital located in an urban area. Many factors like family history of diabetes mellitus, age, overweight/obesity, hypertension and lack of physical exercise have already been identified.27 In the present study, most subjects with T2DM were found to be
obese. This complements various studies.28-31 Obesity was also associated with family history of diabetes in Indian population.32 Dyslipidemia and hypertension were also related with family history of diabetes through BMI.30,33 This study also identified BMI as predictor for hypertension among T2DM subjects and the role of BMI has been previously described.27 Our study could not demonstrate significant association between physical activity, dyslipidemia and controlled glycemic status with hypertension among T2DM subjects. However, age and family history of diabetes are marginally significant.
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CLINICAL STUDY Although diet control is the cornerstone in the management of T2DM but only 17% of the studied sample was on diet therapy. Achieving good glycemic control in diabetes subjects has proven a real challenge to the healthcare providers. It has been documented in studies that self care among T2DM subjects improved glycemic control and reduced complications.34,35 In this study, only 7% subjects had good glycemic control, which is different from various studies such as a Swedish survey, which found that 34% of type 2 diabetic subjects had good glycemic control,36 study by Al-Maskari et al, which found that 38% T2DM of subjects had good glycemic control37 and study by AlKaabi et al, which reported 31% of subjects had good glycemic control.21 The possible explanation may be that our study sample consisted of newly- diagnosed T2DM subjects drawn from a tertiary care hospital and nonadherence to interventions may have contributed to uncontrolled glycemic status38 and these subjects may have had T2DM since many years as evident from the complications such as renal dysfunction in 9% and vision impairment in 10% subjects of T2DM. LIMITATIONS Several potential limitations should be considered in interpreting the results of this study. First, the study is limited by cross-sectional design so temporality (cause-and-effect relationships) cannot be established but it can provide a clear snapshot of the current situation and may help in developing improvement in management and in designing future studies to explore further. Second, this is a hospital-based study from a urban set up, which may not be representative and applicable to general population. However, this could provide a reasonably precise and reliable estimate of risk profile of T2DM in Western India. Lastly, we tried our level best to include newly diagnosed subjects but we are not sure that all subjects were newly diagnosed because we have relied on the subjects. CONCLUSION AND RECOMMENDATION The present study is directed at providing the profile of the T2DM subjects from Western India as an impetus for further exploration of the sociocultural and subjectrelated factors affecting the outcomes of T2DM care that in turn will lead to redefining of the diabetes control and preventive strategies. The present study revealed that obesity, family history of diabetes, dyslipidemia, uncontrolled glycemic status, sedentary lifestyles and
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Asian Journal of Diabetology, Vol. 16, No.1, January-March 2013
hypertension were highly prevalent in T2DM subjects. Hence, the overall risk profile was very poor. The findings of this study also provide an early indication for development of complications of T2DM. Based on our findings, we recommend that appropriate management of T2DM subject requires a number of steps. ÂÂ
Uncontrolled glycemic status, dyslipidemia and vision impairment should be taken care by conducting early screening for complications, frequent check-ups and follow-ups.
ÂÂ
Lifestyle modification interventions like control of body weight through diet and exercise should be emphasized for prevention of T2DM.
ÂÂ
Early approach for prevention of onset and progression of diabetic complications can be achieved with reduction in HbA1C level.
Acknowledgment The authors would like to express their sincere thanks to all the subjects who participated in the study and Dr BD Mankad for his expert opinion. We would also like to thank Drs Prakash J Shah and WQ Shaikh for reviewing the manuscript. It is uncourteous if authors would not thank Mr Diwakar Sharma for statistical assistance. The study was supported by All India Institute of Diabetes and Research, Ahmedabad, Gujarat, India. REFERENCES 1. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27(5):1047-53. 2. Aguilar-Salinas CA, Reyes-Rodríguez E, OrdóñezSánchez ML, Torres MA, Ramírez-Jiménez S, DomínguezLópez A, et al. Early-onset type 2 diabetes: metabolic and genetic characterization in the mexican population. J Clin Endocrinol Metab 2001;86(1):220-6. 3. Mudaliar S. New frontiers in the management of type 2 diabetes. Indian J Med Res 2007;125(3):275-96. 4. Simon D. Epidemiological features of type 2 diabetes. Rev Prat 2010;60(4):469-73. 5. Delavari A, Alikhani S, Nili S, Birjandi RH, Birjandi F. Quality of care of diabetes mellitus type II patients in Iran. Arch Iran Med 2009;12(5):492-5. 6. Turner RC, Millns H, Neil HA, Stratton IM, Manley SE, Matthews DR, et al. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom Prospective Diabetes Study (UKPDS: 23). BMJ 1998;316(7134):823-8. 7. Tzoulaki I, Molokhia M, Curcin V, Little MP, Millett CJ, Ng A, et al. Risk of cardiovascular disease and all
CLINICAL STUDY cause mortality among patients with type 2 diabetes prescribed oral antidiabetes drugs: retrospective cohort study using UK general practice research database. BMJ 2009;339:b4731.
The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA 2001;285(19):2486-97.
8. Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med 1998;15(7):539-53.
20. Misra A, Chowbey P, Makkar BM, Vikram NK, Wasir JS, Chadha D, et al; Concensus Group. Consensus statement for diagnosis of obesity, abdominal obesity and the metabolic syndrome for Asian Indians and recommendations for physical activity, medical and surgical management. J Assoc Physicians India 2009;57:163-70.
9. Zimmet P. The burden of type 2 diabetes: are we doing enough? Diabetes Metab 2003;29(4 Pt 2):6S9-18. 10. Ebrahim S, Kinra S, Bowen L, Andersen E, Ben-Shlomo Y, Lyngdoh T, et al. The effect of rural-to-urban migration on obesity and diabetes in India: a cross-sectional study. PLoS Med 2010;7(4):e1000268. 11. Mohan V, Deepa M, Deepa R, Shanthirani CS, Farooq S, Ganesan A, et al. Secular trends in the prevalence of diabetes and impaired glucose tolerance in urban South India-the Chennai Urban Rural Epidemiology Study (CURES-17). Diabetologia 2006;49(6):1175-8. 12. Deepa M, Pradeepa R, Rema M, Mohan A, Deepa R, Shanthirani S, et al. The Chennai Urban Rural Epidemiology Study (CURES) - study design and methodology (urban component) (CURES-I). J Assoc Physicians India 2003;51:863-70. 13. Ramachandran A, Ramachandran S, Snehalatha C, Augustine C, Murugesan N, Viswanathan V, et al. Increasing expenditure on health care incurred by diabetic subjects in a developing country: a study from India. Diabetes Care 2007;30(2):252-6. 14. Misra A, Khurana L. The metabolic syndrome in South Asians: epidemiology, determinants, and prevention. Metab Syndr Relat Disord 2009;7(6):497-514. 15. Chen Y, Zhang X, Pan B, Jin X, Yao H, Chen B, et al. A modified formula for calculating low-density lipoprotein cholesterol values. Lipids Health Dis 2010;9:52. 16. Reddy KS, Prabhakaran D, Chaturvedi V, Jeemon P, Thankappan KR, Ramakrishnan L, et al. Methods for establishing a surveillance system for cardiovascular diseases in Indian industrial populations. Bull World Health Organ 2006;84(6):461-9. 17. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289(19):2560-72. 18. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2006;29 Suppl 1:S43-8. 19. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of
21. Al-Kaabi J, Al-Maskari F, Saadi H, Afandi B, Parkar H, Nagelkerke N. Assessment of dietary practice among diabetic patients in the United arab emirates. Rev Diabet Stud 2008;5(2):110-5. 22. Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V, Das AK, et al; Diabetes Epidemiology Study Group in India (DESI). High prevalence of diabetes and impaired glucose tolerance in India: National Urban Diabetes Survey. Diabetologia 2001;44(9):1094-101. 23. Kutty VR, Soman CR, Joseph A, Pisharody R, Vijaya kumar K. Type 2 diabetes in southern Kerala: variation in prevalence among geographic divisions within a region. Natl Med J India 2000;13(6):287-92. 24. Ramachandran A, Jali MV, Mohan V, Snehalatha C, Viswanathan M. High prevalence of diabetes in an urban population in south India. BMJ 1988;297(6648):587-90. 25. Ramachandran A, Snehalatha C, Latha E, Vijay V, Viswanathan M. Rising prevalence of NIDDM in an urban population in India. Diabetologia 1997b;40(2): 232-7. 26. Misra A, Pandey RM, Devi JR, Sharma R, Vikram NK, Khanna N. High prevalence of diabetes, obesity and dyslipidaemia in urban slum population in northern India. Int J Obes Relat Metab Disord 2001;25(11):1722-9. 27. van Tilburg J, van Haeften TW, Pearson P, Wijmenga C. Defining the genetic contribution of type 2 diabetes mellitus. J Med Genet 2001;38(9):569-78. 28. Mayer-Davis EJ, Costacou T. Obesity and sedentary lifestyle: modifiable risk factors for prevention of type 2 diabetes. Curr Diab Rep 2001;1(2):170-6. 29. Lieberman LS. Dietary, evolutionary, and modernizing influences on the prevalence of type 2 diabetes. Annu Rev Nutr 2003;23:345-77. 30. Bener A, Al-Suwaidi J, Al-Jaber K, Al-Marri S, Elbagi IE. Epidemiology of hypertension and its associated risk factors in the Qatari population. J Hum Hypertens 2004;18(7):529-30. 31. Musaiger AO, Al-Mannai MA. Social and lifestyle factors associated with diabetes in the adult Bahraini population. J Biosoc Sci 2002;34(2):277-81. 32. Habib SS, Aslam M. Lipids and lipoprotein(a) concentrations in Pakistani patients with type 2 diabetes mellitus. Diabetes Obes Metab 2004;6(5):338-43.
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CLINICAL STUDY 33. Ramachandran A, Snehalatha C, Satyavani K, Sivasankari S, Vijay V. Cosegregation of obesity with familial aggregation of type 2 diabetes mellitus. Diabetes Obes Metab 2000;2(3):149-54.
35. Heisler M, Piette JD, Spencer M, Kieffer E, Vijan S. The relationship between knowledge of recent HbA1c values and diabetes care understanding and selfmanagement. Diabetes Care 2005;28(4):816-22.
34. Ramachandran A, Snehalatha C, Mary S, Mukesh B, Bhaskar AD, Vijay V; Indian Diabetes Prevention Programme (IDPP). The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia 2006;49(2):289-97.
37. Al-Maskari F, El-Sadig M. Prevalence of risk factors for diabetic foot complications. BMC Fam Pract 2007;8:59.
36. Holmström IM, Rosenqvist U. Misunderstandings about illness and treatment among patients with type 2 diabetes. J Adv Nurs 2005;49(2):146-54.
38. Kim N, Agostini JV, Justice AC. Refill adherence to oral hypoglycemic agents and glycemic control in veterans. Ann Pharmacother 2010;44(5):800-8.
Doc You Are Guilty: To render gracious services I was his insurance which paid for my fee
Pr
oc
ee
d
On legal grounds, yes, but on moral and ethical grounds, you should not have charged
This doctor charged surgical fee from me, I am a qualified specialist
Lesson: MCI Chapter 4.4 says “a physician should consider it a pleasure and privilege to render gracious services to all physicians and their immediate family dependents. If this word ( should ) would have been shall, it would have been mandatory and not doing so would have become a professional conduct. However, the word “should” makes it a recommendation, therefore, one cannot charge a doctor with professional misconduct for charging fee from another doctor or their immediate family dependents but it does amount to immoral act on the part of the doctor who charged another doctor. Whether it is mediclaim, public sector or any other reimbursement agency, the doctor should not charge their fee on principle. In the case of investigations and procedures, the doctors should waive off their part of professional fee. For example, in a CT scan, there will always be some portion of reading charges which the doctor should waive off.
Dr. K K Aggarwal
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Asian Journal of Diabetology, Vol. 16, No.1, January-March 2013
CASE REPORT
Tuberous Xanthoma in Diabetes Mellitus SONIA JAIN*, AP JAIN**
ABSTRACT Xanthoma is a deposition of cholesterol in the soft tissues. It is an uncommon presentation of hypercholesterolemia and/or diabetes mellitus (DM). We are reporting a case of 60-year-old female who presented with multiple xanthomas over extensor tendons of both hands and elbows. Her investigations revealed raised triglycerides, very high plasma cholesterol, very lowdensity lipoprotein (VLDL) and low-density lipoprotein (LDL) levels. Fasting and postprandial sugar levels were also increased. A work-up for cardiovascular involvement was normal and biopsy from one of the nodules showed the xanthoma cells. Keywords: Xanthomatosis, familial hypercholesterolemia, diabetes mellitus
X
anthomatosis is a cutaneous manifestation of lipidosis in which the plasma lipoproteins and free fatty acids are changed quantitatively and there is accumulation of lipids in large foam cells in the tissues.1 It is associated with abnormalities of cholesterol metabolism.2 There are five types of xanthomas based on clinical presentation. We are reporting here a case of tuberous xanthoma, which occurs due to familial heterozygous hypercholesterolemia (type II a) and usually presents as nodules localized to extensor surfaces of elbows, knees, knuckles and buttocks.3 Familial heterozygous hypercholesterolemia occurs as a result of inheritance of single abnormal allele for the low-density lipoprotein (LDL) receptor.3 Fredrickson classified familial hyperlipidemia into five main types based on the changes in plasma lipoprotein spectrum and other associated changes.4 CASE REPORT A 60-year-old female patient presented with history of gradually enlarging nodules over both hands and elbows since one year, not associated with pain or itching. The family history was insignificant and none of the family members including parents had similar lesions. However, they could not be investigated because of their unavailability. On examination, she had an average built with height of 145 cm and weight of 60 kg. Her body mass index (BMI) was 17.4. Her blood pressure was 140/90 mmHg and her other vital *Associate Professor Dept. of Skin and VD, MGIMS, Sewagram, Wardha, Maharashtra **Associate Professor Dept. of Medicine, MGIMS, Sewagram, Wardha, Maharashtra Address for correspondence Dr Sonia Jain A-13, Dhanvantri Nagar, MGIMS, Sewagram, Wardha, Maharashtra - 442 102 E-mail: soniapjain@rediffmail.com
parameters were normal. On cutaneous examination, multiple yellowish colored papules and nodules were found on the dorsum of fingers of both hands at interphalangeal joints (Fig. 1) and extensor aspect of both elbows (Fig. 2). Examination of the eyes revealed sclerotic changes in the retinal vessels and arcus corneae. Hair, nail, mucosae as well as palms and soles were normal. Laboratory investigations like complete blood count (CBC), erythrocyte sedimentation rate (ESR), blood sugar, lipid profile and skin biopsy were carried out. She was not taking any medications before coming to the hospital. She was found to have raised blood sugar and lipid levels. Her cholesterol was increased 6-folds (Table 1). Electrocardiogram (ECG), treadmill test (TMT) and echocardiography were done to look for the cardiovascular effects of hypercholesterolemia and they proved to be normal. The chest X-ray was normal, while that of hands and elbows showed multiple soft tissue swellings corresponding to cutaneous lesions
Figure 1. Subcutaneous nodules over the extensor aspect of hands.
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CASE REPORT diabetes. Xanthomas occur anywhere on the body, but particularly on the extensor surfaces of the limbs and the buttocks. The papules are discrete and domeshaped but may coalesce to form plaques and nodules when they are called tuboeruptive. Tuboeruptive lesions occur mainly over the elbows.3 Tuberous xanthomas are found localized to the extensor surface of the elbows, knees, knuckles and buttocks.3 Plane xanthomas typically develop in skin folds, especially in the palmar creases (xanthoma striatum palmare) and on the upper eyelids (xanthelasma palpebrum).3 Figure 2. Xanthomas over the extensor aspect of the elbows.
Table 1. Blood Investigations Patient’s value
Normal value
Total cholesterol (mg/dl)
923
150-250
LDL cholesterol (mg/dl)
314
100-160
HDL cholesterol (mg/dl)
255
30-60
VLDL cholesterol (mg/dl)
354
10-30
Triglycerides (mg/dl)
231
50-150
FBS (mg/dl)
159
80-120
PP2BS (mg/dl)
234
180-200T
FBS = Fasting blood sugar; PP2BS = 2-hour postprandial blood sugar.
and normal underlying bones. Biopsy from one of the nodules showed normal epidermis and aggregates of xanthoma cells separated by fibrocollagenous bundles in the dermis. DISCUSSION Xanthomas may be seen either as a primary disorder or secondary to various acquired systemic diseases like hypothyroidism, biliary cirrhosis, diabetes mellitus, nephrotic syndrome, monoclonal gammopathy and intake of drugs like β-blockers, diuretics.5 DM is a common cause of hypertriglyceridemia and the eruptive xanthomas may be the first sign of untreated DM.6 Dyslipidemias in DM usually occur in young insulinresistant diabetics. Insulin is necessary for the normal clearing action of lipoprotein lipase on triglycerides. In this case too, DM was detected for the first time. The decreased lipoprotein lipase activity in insulindependent diabetes results in the accumulation of serum triglycerides, the levels of which are occasionally highly elevated to produce eruptive xanthomas.1 Frequently, the underlying problem is uncontrolled
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Eruptive xanthoma variant presents with sudden onset of crops of small, pruritic, red-yellow papules on an erythematous base, most commonly over buttocks, shoulders and extensor surfaces of extremities; may spontaneously resolve over weeks.2 Tendinous xanthomas are asymptomatic, slowly enlarging subcutaneous nodules attached to tendons, ligaments, fascia and periosteum with normal overlying skin.2 Extensor tendons of the hands, feet including Achilles tendons are involved more frequently. Our patient was treated for DM with tablet metformin 500 mg twicedaily and for altered lipid levels with atorvastatin 40 mg and fenofibrate 160 mg once-daily with dietary restrictions of cholesterol and saturated fatty acids. REFERENCES 1. Errors in metabolism. In: Andrew’s Diseases of the Skin: Clinical Dermatology. 9th edition, James, Berger, Elston, Odom (Eds.), WB Saunders Company: Philadelphia 2000:p.648-81. 2. Black MM, Gawkrodger DJ, Seymour CA, Weismann K. Metabolic and nutritional disorders. In: Textbook of Dermatology, Champion. 6th edition, Burton, Burns, Breathnach (Eds.), Blackwell-Science: Oxford 1998: p.2577-677. 3. White LE. Xanthomatoses and lipoprotein disorders. In: Fitzpatrick’s Dermatology in General Medicine. 7th edition, Wolff, Goldsmith, Katz, Gilchrest, Paller, Leffell (Eds.), McGraw-Hill: New York, NY 2008:p.1272-80. 4. Mahajan VK, Sharma NL, Sood S. Xanthoma tendinosum and familial hypercholesterolemia. Indian J Dermatology 2003;48(2):116-8. 5. Pandhi D, Grover C, Reddy BS. Type IIa hyperlipoproteinemia manifesting with different types of cutaneous xanthomas. Indian Pediatr 2001;38(5):550-3. 6. Binić I, Janković A. Eruptive xanthomas associated with diabetes mellitus. Chinese Medical Journal 2009;122(17):2074-5.
SYMPOSIUM ON NUTRITION AND HEALTH
Diet for Indian Diabetics SHILPA S JOSHI
ABSTRACT With modernization, the traditional diets have continued and some western dietary snacks/meals have been added. Due to this, diets have become hypercaloric. Keywords: Diabetes, medical nutrition therapy, insulin sensitivity, hypocaloric diet, glycemic index
D
iabetes care is complex and requires that many issues beyond glycemic control be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes output.1 Medical nutrition therapy (MNT) is an integral component of diabetes management and training. Diet plays a major role in regulating carbohydrate, fat and protein homeostasis in patients with diabetes. Furthermore, proper dietary management is required for safe and effective use of insulin and oral hypoglycemic agents. GOALS OF MNT FOR DIABETICS2 Goals of MNT that apply to individuals with diabetes: ÂÂ
Achieve and maintain: Blood glucose levels in the normal range or as close to normal as is safely possible. A lipid and lipoprotein profile that reduces the risk for vascular disease. Blood pressure levels in the normal range or as close to normal as is safely possible.
ÂÂ
To prevent, or at least slow, the rate of development of the chronic complications of diabetes by modifying nutrient intake and lifestyle.
ÂÂ
To address individual nutrition needs, taking into account personal and cultural preferences and willingness to change.
ÂÂ
To maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence.
GOALS OF MNT THAT APPLY TO SPECIFIC SITUATIONS ÂÂ
For youth with type 1 diabetes, youth with type 2 diabetes, pregnant and lactating women, and older adults with diabetes, to meet the nutritional needs of these unique times in the life cycle.
ÂÂ
For individuals treated with insulin or insulin secretagogues, to provide self-management training for safe conduct of exercise, including the prevention and treatment of hypoglycemia and diabetes treatment during acute illness.
TRADITIONAL INDIAN DIETS Traditionally Indian diets are high in carbohydrates, moderate in fats and proteins. These diets evolved as a part of agrarian culture, which also involved lot of physical activity. With modernization, the traditional diets have continued and some western dietary snacks/meals have been added. Due to this, diets have become hypercaloric. To add to the problem, modernization has led to sedentary lifestyle, which actually demands decreased caloric intake. All these factors have led to increase in prevalence of obesity and type 2 diabetes. DIET IN DIABETES For practical purpose the major division of type 1 and type 2 diabetes provides means of classifying dietary management issues. The goals of therapy of two groups are similar in most respects. To maintain normal blood sugars and lipid profiles, diabetic patients should aim for a prudent diet with right proportions of carbohydrates, fats and proteins.
Calories Consultant Nutritionist, Mumbai Diet and Health Centre, Mumbai
The primary nutrition goals for persons with type 2 diabetes are to achieve and maintain normal blood
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SYMPOSIUM ON NUTRITION AND HEALTH glucose and lipid levels. A number of strategies can be implemented to achieve these goals. Learning new lifestyle behaviors and attitudes are essential.3,4 Weight loss appears to improve glucose uptake, increase insulin sensitivity and normalize hepatic glucose production. Weight loss may be most beneficial soon after type 2 diabetes is diagnosed, when insulin secretion is still adequate. A hypocaloric diet, however, has been shown to have an important regulatory effect on glucose control in persons with type 2 diabetes, independent of any effects from weight loss.5,6 When calories are restricted, hyperglycemia improves more rapidly than with weight loss. Furthermore, when calories are increased after weight reduction, glucose levels increase despite no regain of weight. This suggests that caloric intake is more important than weight. A genetic predisposition to obesity and possible impaired metabolic and appetite regulation make it difficult to lose and, more importantly, to maintain Table 1. Methods for Determining Caloric Requirements of Adults* 1. Caloric requirements of adults: Obese or very inactive adults, chronic dieters (20 kcal/kg) Adults older than 55 years of age, active women, sedentary men (28 kcal/kg) zz Active men or very active women (30 kcal/kg) zz Thin or very active men (40 kcal/kg) zz zz
2. Harris-Benedict equation for determining caloric requirements of adults: (Measure of resting energy expenditure [REE]) zz zz
omen: REE = 655 + 9.63 W (kg) + 1.83 H (cm) - 4.73 A (year) W Men: REE = 66 + 13.73 W (kg) + 5.3 H (cm) - 6.83 A (year) – Obese adults: W = ([actual W – DBW] × 0.25) + DBW – Activity factors: Restricted, 1.1; sedentary, 1.2; aerobic activity = 3×/week,1.3; 5×/week, 1.5; 7×/week, 1.6; true athlete, 1.7 (REE × activity factor = total caloric requirements)
W = Weight; H = Height; A = Age; DBW = Desired body weight *Adapted from Kraus, Mahan Nutrition Therapy for Diabetes Mellitus and Hypoglycemia of Non-Diabetic Sign, Food. Nutrition and Diet Therapy-200;34:771.
For children (upto 12 years) 1,000 kcal + Age × 100 kcal for girls 1,000 kcal + Age × 125 kcal for boys Adapted from Raghuram TC, Pasricha S and Sharma RD. Diet and Diabetes, NIN, 1991.
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weight loss. Because of the psychological and physiologic impact of dieting, individuals should be encouraged to attain and maintain a reasonable body weight. Emphasis should be on blood glucose control, a nutritionally adequate intake and moderate caloric restriction (250-500 kcal less than the average daily intake as calculated from nutrition assessment), rather than weight loss.
Carbohydrates Carbohydrates should provide 50-60% of energy intake. Generally in Indian diet carbohydrate provide 60-65% of total calories. Diabetics need to restrict carbohydrate intake, but they can alter the type of carbohydrate in their diet. Unrefined carbohydrates, with natural fiber intact, have distinct advantages over highly refined versions because of their other benefits such as a lower glycemic index, greater satiety and cholesterol-lowering properties. Refined carbohydrates contain simple sugars and cause a rapid rise in blood sugar, e.g., maida and maida products, sugar, jaggery, honey, etc. Refined carbohydrate though not as severely restricted as in past should make up <1/3 of total carbohydrates. Since, the blood sugar level depends mainly on carbohydrates, it is important to distribute the intake of carbohydrates in accordance to need and pharmacological therapy. Under certain circumstances, especially with low fiber intake, high-carbohydrate, low-fat diets can worsen blood glucose control, increase serum triglyceride concentrations and lower high-density lipoprotein (HDL) cholesterol concentrations.7,8 The fiber content of the diet appears critical in preventing these problems.9,10
Glycemic Index Different carbohydrates raise the blood sugar to variable extents. It is therefore important to know, while recommending a diet for a diabetic, what is extent rise in blood sugar with different foods. The glycemic index indicates the extent of rise in blood sugar in response to a food in comparison with the response to an equivalent amount of glucose. The glycemic index is therefore useful in planning diets for diabetics. Generally, cereals like wheat and rice and root vegetables such as potato, carrots have a high glycemic index (45-55%). Legumes and lentils such
SYMPOSIUM ON NUTRITION AND HEALTH Table 2. Glycemic Index of Common Foods Item
Glycemic index
Cereal products Bread Millets Rice (White) Wheat (Paratha)
Glycemic index
Fruits 70 71 72 70
Breakfast snacks Pongal Pesarattu Upma Idli Chole Sprouted green gram Sundal
Item
55 60 75 80 65 60 80
Dairy products Milk Ice-cream Curds
33 36 36
Miscellaneous Groundnuts Potato chips Tomato soups
13 51 38
Apple Banana Orange
39 69 40
Vegetables Brown beans Frozen beans Potato Sweet potato Yam Beetroot
79 51 70 48 51 64
Dried legumes Soyabeans Rajmah Bengal gram Green gram Black gram
43 29 47 48 48
Sugars Fructose Glucose Maltose Sucrose Honey
20 100 105 59 87
Source: Jenkins, et al. Am J Clin Nutr 1981;34:362. Raghuram, et al. Diabetes Bull 1987;7:64. Dilwari, et al. Diet, Digestion and Diabetes 1987.
as dried beans, peas, green gram and Bengal gram have a low glycemic index (30-40%) and are beneficial to diabetics in moderate amounts. Bengal gram helps additionally of atherosclerosis by reducing serum cholesterol and triglyceride levels. The glycemic index of various common Indian foods is given in Table 2. One has to remember that though certain foods such as groundnuts, milk and ice cream have a low glycemic index, they are not good for diabetics since they have a high fat content. They have a high caloric value and excessive consumption of such foods is likely to increase the body weight leading to obesity. Similarly, fructose, in view of its effects on serum lipids, is not recommended. The glycemic response of different foods is influenced by the physical form, nature of cooking, etc. For example, consumption of
ground rice raises the blood sugar to a greater extent than of ungrounded rice. Similarly, the glycemic response is higher with cooked than with raw food.
Glycemic Load Glycemic load is a ranking system for carbohydrate content in a food portion based on their glycemic index and carbohydrate content of food. Foods high in glycemic load causes more rapid glucose and insulin response. In clinical management of diabetes, lowering dietary glycemic load improves hyperglycemia, dyslipidemia. Increased dietary glycemic load is also associated with low HDL and elevated fasting triglyceride.11 Foods which are low in glycemic load are legumes, beans, channa dal, etc.
Resistant Starches Resistant starch is any starch that is not digestible in small intestine but passes into large bowel. Here resistant starch becomes a good substrate for fermentation, which gives rise to short-chain fatty acid production. The differing rate of absorption between resistant starches and digestible starches are thought to denote their different metabolic response. Resistant starch intake is associated with several changes in metabolism and may confer some health benefits. Resistant starch seems to decrease postprandial glycemic and insulinemic response, lowers plasma cholesterol and triglyceride, improves whole body insulin sensitivity, increases satiety and decreases fat storage.12 The rich source of resistant starch is raw corn starch.
Fiber Dietary fiber is that part of food that is not digested by the gut and is considered as unavailable carbohydrate. It is not a single entity, but consists of a wide range of complex carbohydrates. Fiber present in vegetables, fruits, legumes and fenugreek seed is soluble in nature and more effective in controlling blood sugar and serum lipids than the insoluble fiber present in cereals and millets. However, longterm consumption of insoluble fiber also improves glucose tolerance. Diets containing high dietary fiber can reduce blood sugar, serum cholesterol and relieve constipation. In addition, dietary fiber is beneficial in the
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SYMPOSIUM ON NUTRITION AND HEALTH Table 3. Dietary Fiber Content of Some Common Indian Foods Food
caloric value and low glycemic index and therefore, diabetics should consume such foods liberally.
Dietary fiber (g/100 g)
The dietary fiber consist of some common Indian foods is given in Table 3.
Rice
7.6
Wheat
17.6
Sorghum
14.3
Bajra
20.3
Although soluble fiber (from legumes, oats, fruits and some vegetables) is capable of inhibiting glucose absorption from the small intestine, the clinical significance of this effect is probably insignificant.3
Ragi
18.6
Cereals and millets
Pulses and legumes Green gram dal
13.5
Black gram dal
14.3
Red gram dal
14.1
Bengal gram dal
13.6
Nuts and oilseeds Groundnut
6.1
Coconut dry (copra)
8.9
Roots and tubers Sweet potato
7.3
Potato
4.0
Yam
5.3
Fruits Banana
2.5
Mango
2.3
Vegetables Amaranth
3.4
Palak
5.0
Brinjal
2.0
Ridge gourd
5.7
Snake gourd
1.8
Bottle gourd
2.8
Yellow pumpkin
0.5
Source: BS Narasinga Rao, Nutrition Foundation of India Bulletin 1988;9(4).
prevention and treatment of several diseases such as cardiovascular disease and colon cancer. Excess dietary fiber may cause gastrointestinal symptoms such as flatulence (gas formation) and diarrhea. It may also interfere with the absorption of minerals such as iron, calcium and zinc. Intake of 25 g of dietary fiber per 1,000 calories is considered to be optimum for a diabetic. High-fiber foods have a low
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Diets containing 20 g/day of soluble fibers may be capable of modestly reducing fasting circulating total and low-density lipoprotein (LDL) cholesterol when administered in conjunction with a diet containing at least 50% carbohydrate.13 Fiber is only one of many components of food that influence the glycemic response. Beans have lower glycemic indices than any other group of carbohydrate-rich foods. The low glycemic response to beans is probably related to their high soluble fiber content, food form (usually eaten as cooked rather than in bakery products) and naturally occurring starch blockers (inhibitors of digestive enzymes responsible for hydrolysis of starch). Finally, fiber fermentation products such as short-chain fatty acids are absorbed from the colon into the portal vein; in the liver, they may directly affect glucose metabolism.14 Fiber has emerged as a major dietary component in the management of diabetes. It has therapeutic value and may reduce the prevalence of diabetes. The American Diabetic Association (ADA) currently recommends 20-35 g/day.
Proteins The adult recommended dietary intake (RDI) of 0.8 g protein/kg body weight meets metabolic and nutritional needs. Though current ADA recommendations allow 10-20% of energy intake as protein, a more conservative recommendation of 10-15% of total energy needs as protein. Protein of high biologic value should be given consideration, though protein should be included from both animal and vegetable sources. Greater emphasis should on vegetable sources of protein, particularly the cereals and legumes, which are recommended for diabetes from other considerations. Current research indicates that soy protein diets reduce hyperfiltration in diabetic individuals and
SYMPOSIUM ON NUTRITION AND HEALTH substituting soy protein for animal protein should be considered as a preventive measure for diabetic individuals.15
in several tissues, decreasing glucose transport into muscle and adipose tissue and decreasing activities of insulin-stimulated processes.
Indian diets are very poor in protein. The so-called nonvegetarians in Indian do not consume nonveg >3 times a week. Plant based proteins like legumes, sprouts and dal are consumed in very small quantity as are milk and milk product.
There is a growing consensus that diets for diabetic individuals should include only modest amounts of saturated fat but could include moderate levels of monounsaturates. If triglycerides and very LDLs are elevated, a moderate increase in monounsaturated fat intake may be liberalized to include upto 20% of calories with a more moderate intake of carbohydrate.17 However, increased monounsaturated fat intake may enhance insulin resistance and in obese individuals, may perpetuate or aggravate the obesity.
At present, there is no evidence that protein requirements increase or decrease in persons with uncomplicated diabetes, so the recommended dietary allowance (RDA) for protein intake â&#x20AC;&#x201C; 0.8 g/ kg/day â&#x20AC;&#x201C; for nondiabetic adults is also appropriate for adults with diabetes.
Fats Fats are concentrated source of energy. Fat intake generally should not exceed 30% of energy. Most importantly, saturated fats, because of their atherogenic potential, should be held at a maximum of 10% of energy needs e.g., ghee, butter, coconut and coconut oil. Polyunsaturates, with their tendency to lower HDL cholesterol values and their susceptibility to oxidation, should also be held under 10%. However, upto 35% of energy from fat can be used for nonobese individuals with acceptable serum triglyceride values if the additional fat comes from monounsaturated sources such as peanut or olive oils or rice bran oil. Cholesterol intake, though less influential than saturated fats on serum lipid values, should be held under 300 mg/day; recommended <200 mg/day. These recommendations are consistent with those of the American Heart Association and other groups.9,16 Excessive fat intake contributes to obesity, insulin resistance, hypertension and atherosclerotic cardiovascular disease. Maintaining serum lipid levels is one of the most important goals in diabetic management. Hyperlipidemia, common in type 2 diabetics, is a major risk factor for cardiovascular disease. Epidemiologic evidence indicates that highfat diets contribute to atherosclerosis. In fact, almost all risk factors for cardiovascular disease occur more frequently in diabetics. Hyperlipidemia, glycosylated lipoproteins, platelet dysfunction, arterial wall changes, hyperinsulinemia, hypertension and obesity are correlated with atherosclerosis in diabetics. High-fat diets cause insulin resistance and impaired intracellular glucose metabolism. Highfat diets decrease the number of insulin receptors
The World Health Organization (WHO) recommendation for the general population is 3-7% of energy from polyunsaturates. High intakes of polyunsaturates have been suggested to be potentially damaging, relating to increased production of lipid peroxides.10 Polyunsaturated fats are present in sunflower oil, kardi oil and safflower. Certain essential fatty acids of the w-3 class lower serum cholesterol moderately but lower serum triglyceride levels markedly.18 These w-3 fatty acids, popularly known as fish oils, may also decrease platelet aggregation, which may potentially reduce the cardiovascular disease risk in diabetes. Initially, fish oil supplementation in individuals with noninsulin-dependent diabetes appeared to improve their insulin sensitivity. The most potentially beneficial effects of w-3 fatty acids are on plasma triglycerides, commonly elevated in type 2 diabetic patients. In pharmacologic quantities, w-3 fatty acids reduce elevated plasma cholesterol and triglyceride concentrations and blood pressure. Vegetarian sources of w-3 fatty acids are flax seed oil, rajmah, urad dal, etc.
Alcohol Because of its potential hypoglycemic effects, heavy alcohol use is not recommended in the diabetic population. In diabetics, alcohol induces fasting by inhibiting gluconeogenesis. If should be ingested with a meal. provokes hypertriglyceridemia and concurrent medications.
hypoglycemia consumed, it Alcohol also interacts with
Alcoholic beverages provide 7 kcal/g, similar to fat and metabolized much the same. This may result
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SYMPOSIUM ON NUTRITION AND HEALTH in excessive energy intake without corresponding nutritive value. For insulin-dependent diabetes, the caloric value should be counted in the meal plan. In the noninsulin-dependent diabetic diet, alcohol is best substituted as a fat exchange. Individuals may not be aware of the effects of alcohol and should be provided with at least the following guidelines: a) Potential or concurrent intake should be discussed with the physician and nutrition counselor; b) alcohol should be consumed slowly and with food to lessen hypoglycemic episodes; c) identification should be worn indicating diabetic diagnosis since the symptoms of insulin reaction and intoxication are similar; d) drinking to the extent of impaired judgment or operating a motor vehicle should be avoided; and e) poorly controlled diabetics should abstain from alcohol use and of course pregnant women, diabetic or not, should not use alcohol.4
Vitamin and Minerals There appears to be no justification for routinely prescribing vitamin and mineral supplements for most persons with diabetes.19 Antioxidant therapies, such as probucol, vitamin E and vitamin C, are currently being studied.20
Micronutrients Two minerals commonly mentioned in relation to diabetes are chromium and magnesium. Chromium deficiency has been related, hypothetically, to development of diabetes in humans for many years, but persuasive studies in Western people are not available for recommendation of chromium supplementation for diabetic individuals.
polyols (sorbitol, mannitol or xylitol) are acceptable in modest amounts in the diabetic meal plan. Fructose as a natural component of foods is sweeter than other sugars and is metabolized without the use of insulin, thus producing less hyperglycemia. Though fructose may increase an already high blood glucose level in poorly controlled diabetics, its effects is minimal in those with adequate control. Substituting fructose or sucrose or glucose lowers average blood glucose levels, producing a glycemic response of 20% and 33%, respectively. The polyols are formed by partial hydrolysis and hydrogenation of edible starches. Polyols also produce a lower glycemic response than sucrose and other carbohydrates. Alternative sweeteners, noncaloric, are an acceptable means of checking the amounts of excess refined sugars in the diet. Though adequately safe, to avoid excesses of any one type, a multiple-type approach is recommended. Each sweetener has its distinctive taste, advantages and risks.
‘Free’ Foods The foods listed under ‘Use as Desired’ are relatively very low in kilocalories and do not need to be calculated in the meal plan. ADI of Various Sweeteners21 Sweetener
Acceptable daily intake (mg/kg body weight)
Acesulfame potassium
0-9
Aspartame
0-40
Cyclamate
0-7
Saccharin
0-5
Sucralose
0-15
Sweeteners Traditionally, diabetic individuals have been advised to curtail intake of foods that aggravate hyperglycemia, increase serum triglyceride concentrations and foster additional weight gain. Often, these same foods contain excessive amounts of fat and calories contributing to poor metabolic control. Recently, the ADA and others have eased their restrictions on the use of sweets in the diet. There are two basic categories of sweeteners: Nutritive (caloric containing) and nonnutritive (noncaloric). Nutritive sweeteners, such as fructose found in fruits and common sugar alcohols, the
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Used as Desired Beverages Coffee
Thin butter milk
Decaffeinated coffee
Nimboo pani
Tea
Jaljeera
Water
Salads
Carbonated water
Kurmura
Club soda
Diet soda
Mineral water
Cucumber
Tonic water, sugar-free
Lettuce
Seltzers, sugar-free
SYMPOSIUM ON NUTRITION AND HEALTH The foods listed under ‘Use in Limited Amount’ contain <20 kcal/serving. They do not need to be calculated in the meal plan unless the total sum of their use exceeds 20 kcal per meal or a total of 60 kcal maximum distributed throughout the day. Artificially sweetened foods and beverages are limited because of a general restriction on the quantity of artificial sweeteners used rather than their caloric contribution. REFERENCES 1. American Diabetes Association. Standards of medical care in diabetes - 2007. Diabetes Care 2007;30 Suppl 1:S4-S41. 2. Bantle JP, Wylie-Rosett J, Albright AL, Apovian CM, Clark NG, Franz MJ, et al. Nutrition recommendations and interventions for diabetes - 2006: a position statement of the American Diabetes Association. Diabetes Care 2006;29(9):2140-57.
insulin-dependent diabetes mellitus. N Engl J Med 1988;319(13):829-34. 9. Anderson JW, Geil PB. Nutritional management of diabetes mellitus. In: Modern Nutrition in Health and Disease. 8th edition, Shils MW, Olson JA, Shike M (Eds.), Lea & Febiger: Philadelphia 1994:p.1259-86. 10. A nderson JW, Gustafson NJ. Dr. Anderson’s High-Fiber Fitness Plan. University Press of Kentucky, Lexington, KY 1994:p.1. 11. L iu S, Manson JE, Buring JE, Stampfer MJ, Willett WC, Ridker PM. Relation between a diet with a high glycemic load and plasma concentrations of high-sensitivity C-reactive protein in middle-aged women. Am J Clin Nutr 2002;75(3):492-8. 12. H iggins JA. Resistant starch: metabolic effects and potential health benefits. J AOAC Int 2004;87(3):761-8. 13. Nuttall FQ. Dietary fiber in the management of diabetes. Diabetes 1993;42(4):503-8.
3. American Diabetes Association. Nutrition recommendations and principles for people with diabetes mellitus (Position Statement). Diabetes Care 1999c;22(Suppl 1):S42.
14. Anderson JW, O’Neal DS, Riddell-Mason S, Floore TL, Dillon DW, Oeltgen PR. Postprandial serum glucose, insulin, and lipoprotein responses to high- and low-fiber diets. Metabolism 1995;44(7):848-54.
4. Franz MJ, Horton ES Sr, Bantle JP, Beebe CA, Brunzell JD, Coulston AM, et al. Nutrition principles for the management of diabetes and related complications. Diabetes Care 1994;17(5):490-518.
15. Anderson JW, Blake JE, Turner J, Smith BM. Effects of soy protein on renal function and proteinuria in patients with type 2 diabetes. Am J Clin Nutr 1998;68(6 Suppl):1347S-1353S.
5. Kelley DE, Wing R, Buonocore C, Sturis J, Polonsky K, Fitzsimmons M. Relative effects of calorie restriction and weight loss in noninsulin-dependent diabetes mellitus. J Clin Endocrinol Metab 1993;77(5):1287-93.
16. Anderson JW. Professional Guide to High-Fiber Fitness Plan. HCF Nutrition Fdn Lexington, KY 1995:p.1.
6. Wing RR, Blair EH, Bononi P, Marcus MD, Watanabe R, Bergman RN. Caloric restriction per se is a significant factor in improvements in glycemic control and insulin sensitivity during weight loss in obese NIDDM patients. Diabetes Care 1994;17(1):30-6.
18. Connor WE. Diabetes, fish oil, and vascular disease. Ann Intern Med 1995;123(12):950-2.
7. Garg A, Bantle JP, Henry RR, Coulston AM, Griver KA, Raatz SK, et al. Effects of varying carbohydrate content of diet in patients with non-insulin-dependent diabetes mellitus. JAMA 1994;271(18):1421-8. 8. Garg A, Bonanome A, Grundy SM, Zhang ZJ, Unger RH. Comparison of a high-carbohydrate diet with a high-monounsaturated-fat diet in patients with non-
17. N utrition recommendations and principles for people with diabetes mellitus. Diabetes Care 1994;17(5):519-22.
19. Mooradian AD, Failla M, Hoogwerf B, Maryniuk M, Wylie-Rosett J. Selected vitamins and minerals in diabetes. Diabetes Care 1994;17(5):464-79. 20. Reaven PD, Herold DA, Barnett J, Edelman S. Effects of Vitamin E on susceptibility of low-density lipoprotein and low-density lipoprotein subfractions to oxidation and on protein glycation in NIDDM. Diabetes Care 1995;18(6):807-16. 21. www.isabru.org/about_sweeteners-safety.html.
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LIGHTER READING
He asked her what was wrong and she replied, “I wanted to buy a red rose for my mother. But I only have seventy-five cents, and a rose costs two dollars.” The man smiled and said, “Come on in with me. I’ll buy you a rose.” He bought the little girl her rose and ordered his own mother’s flowers. As they were leaving he offered the girl a ride home. She said, “Yes, please! You can take me to my mother.” She directed him to a cemetery, where she placed the rose on a freshly dug grave. The man returned to the flower shop, cancelled the wire order, picked up a bouquet and drove the two hundred miles to his mother’s house.”
LAUGH A WHILE
—Ms Ritu Sinha
A young blonde was on vacation in the depths of Louisiana. She wanted a pair of genuine alligator shoes in the worst way, but was very reluctant to pay the high prices the local vendors were asking. After becoming very frustrated with the “no haggle” attitude of one of the shopkeepers, the blonde shouted, “Maybe I’ll just go out and catch my own alligator so I can get a pair of shoes at a reasonable price!” The shopkeeper said, “By all means, be my guest. Maybe you’ll luck out and catch yourself a big one!” Determined, the blonde turned and headed for the swamps, set on catching herself an alligator. Later in the day, the shopkeeper is driving home, when he spots the young woman standing waist deep in the water, shotgun in hand. Just then, he sees a huge 9 foot alligator swimming quickly toward her. She takes aim, kills the creature and with a great deal of effort hauls it on to the swamp bank. Lying nearby were several more of the dead creatures. The shopkeeper watches in amazement. Just then the blonde flips the alligator on it’s back, and frustrated, shouts out, “Damn it, this one isn’t wearing any shoes either!” —GM Singh
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Asian Journal of Diabetology, Vol. 16, No.1, January-March 2013
“Life’s battles don’t always go to the stronger or faster man, but sooner or latter the man who wins, is the man who thinks he can.” —Vince Lombardi
“A successful man is one who can lay a firm foundation with the bricks others have thrown at him.” —David Brinkley
TB Skin Test Also known as: Purified Protein Derivative; PPD; Mantoux; Latent tuberculosis infection test to help determine whether or not you may have been exposed to and become infected with the Mycobacterium tuberculosis bacteria.!!
Allergy Testing Allergies are hypersensitivities, overreactions of the immune system to substances that do not cause reactions in most people. Allergen specific IgE testing - Immunoassay and line blot tests are blood tests that are used to screen for type 1 allergen-specific IgE antibodies. —Navin Dang, Dr Arpan Gandhi
Dr. Good and Dr. Bad SITUATION: A diabetic wanted to know can be fast?
You can do it
With restrictions
©IJCP Academy
A man stopped at a flower shop to order some flowers to be wired to his mother who lived two hundred miles away. As he got out of his car he noticed a young girl sitting on the curb sobbing.
QUOTE
A Bouquet for Mother
LAB UPDATE
AN INSPIRATIONAL STORY
Lighter Side of Medicine
LESSON: In general, fasting is not recommended for
people with diabetes. The practice increases the risk for both hypoglycemia from lack of food and hyperglycemia resulting from cutting back too far on medication in attempts to avoid hypoglycemia. Hyperglycemia can also occur if patients overeat after sundown. Dr KK Aggarwal
The Asian Journal of
DIABETOLOGY Information for Authors
Manuscripts should be prepared in accordance with the ‘Uniform requirements for manuscripts submitted to biomedical journals’ compiled by the International Committee of Medical Journal Editors (Ann. Intern. Med. 1992;96: 766-767).
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The title should be of no more than 80 characters and should represent the major theme of the manuscript. A subtitle can be added if necessary.
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A short title of not more than 50 characters (including inter-word spaces) for use as a running head should be included.
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The name, telephone and fax numbers, e-mail and postal addresses of the author to whom communications are to be sent should be typed in the lower right corner of the title page.
The boxed checklist will help authors in preparing their manuscript according to our requirements. Improperly prepared manuscripts may be returned to the author without review. The checklist should accompany each manuscript.
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A list of abbreviations used in the paper should be included. In general, the use of abbreviations is discouraged unless they are essential for improving the readability of the text.
Authors may provide on the checklist, the names and addresses of experts from Asia and from other parts of the World who, in the authors’ opinion, are best qualified to review the paper.
Summary - The summary of not more than 200 words. It must convey the essential features of the paper. - It should not contain abbreviations, footnotes or references.
The Asian Journal of Diabetology disapproves of the submission of the same articles simultaneously to different journals for consideration as well as duplicate publication and will decline to accept fresh manuscripts submitted by authors who have done so.
Covering letter The covering letter should explain if there is any deviation from the standard IMRAD format (Introduction, Methods, Results and Discussion) and should outline the importance of the paper. Principal/Senior author must sign the covering letter indicating full responsibility for the paper submitted, preferably with signatures of all the authors. Articles must be accompanied by a declaration by all authors stating that the article has not been published in any other Journal/Book. Authors should mentioned complete designation and departments, etc. on the manuscript. Manuscript Three complete sets of the manuscript should be submitted and preferably with a CD; typed double spaced throughout (including references, tables and legends to figures). The manuscript should be arranged as follow: Covering letter, Checklist, Title page, Abstract, Keywords (for indexing, if required), Introduction, Methods, Results, Discussion, References, Tables, Legends to Figures and Figures. All pages should be numbered consecutively beginning with the title page. Note: Please keep a copy of your manuscript as we are not responsible for its loss in the mail. Manuscripts will not be returned to authors. Title page Should contain the title, short title, names of all the authors (without degrees or diplomas), names and full location of the departments and institutions where the work was performed, name of the corresponding authors, acknowledgment of financial support and abbreviations used.
1. Introduction - The introduction should state why the study was carried out and what were its specific aims/objectives. Methods - These should be described in sufficient detail to permit evaluation and duplication of the work by others. - Ethical guidelines followed by the investigations should be described. Statistics -
The following information should be given:
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The statistical universe i.e., the population from which the sample for the study is selected.
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Method of selecting the sample (cases, subjects, etc. from the statistical universe).
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Method of allocating the subjects into different groups.
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Statistical methods used for presentation and analysis of data i.e., in terms of mean and standard deviation values or percentages and statistical tests such as Student’s ‘t’ test, Chi-square test and analysis of variance or non-parametric tests and multivariate techniques.
1. Confidence intervals for the measurements should be provided wherever appropriate. 2. Results 3. These should be concise and include only the tables and figures necessary to enhance the understanding of the text. Discussion This should consist of a review of the literature
Asian Journal of Diabetology, Vol. 16, No.1, January-March 2013
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and relate the major findings of the article to other publications on the subject. The particular relevance of the results to healthcare in India should be stressed, e.g., practicality and cost.
Figures -
Two complete sets of glossy prints of high quality should be submitted. The labelling must be clear and neat.
References
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All photomicrographs should indicate the magnification of the print.
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Special features should be indicated by arrows or letters which contrast with the background.
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The back of each illustration should bear the first author’s last name, figure number and an arrow indicating the top. This should be written lightly in pencil only. Please do not use a hard pencil, ball point or felt pen.
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Color illustrations will be accepted if they make a contribution to the understanding of the article.
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Do not use clips/staples on photographs and artwork.
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Illustrations must be drawn neatly by an artist and photographs must be sent on glossy paper. No captions should be written directly on the photographs or illustration. Legends to all photographs and illustrations should be typed on a separate sheet of paper. All illustrations and figures must be referred to in the text and abbreviated as ‘Fig.’.
These should conform to the Vancouver style. References should be numbered in the order in which they appear in the texts and these numbers should be inserted above the lines on each occasion the author is cited (Sinha12 confirmed other reports13,14...). References cited only in tables or in legends to figures should be numbered in the text of the particular table or illustration. Include among the references papers accepted but not yet published; designate the journal and add ‘in press’ (in parentheses). Information from manuscripts submitted but not yet accepted should be cited in the text as ‘unpublished observations’ (in parentheses). At the end of the article the full list of references should include the names of all authors if there are fewer than seven or if there are more, the first six followed by et al., the full title of the journal article or book chapters; the title of journals abbreviated according to the style of the Index Medicus and the first and final page numbers of the article or chapter. The authors should check that the references are accurate. If they are not this may result in the rejection of an otherwise adequate contribution. Examples of common forms of references are: Articles Paintal AS. Impulses in vagal afferent fibres from specific pulmonary deflation receptors. The response of those receptors to phenylguanide, potato S-hydroxytryptamine and their role in respiratory and cardiovascular reflexes. Q. J. Expt. Physiol. 1955;40:89-111. Books Stansfield AG. Lymph Node Biopsy Interpretation Churchill Livingstone, New York 1985. Articles in Books Strong MS. Recurrent respiratory papillomatosis. In: Scott Brown’s Otolaryngology. Paediatric Otolaryngology Evans JNG (Ed.), Butterworths, London 1987;6:466-470. Tables - These should be typed double spaced on separate sheets with the table number (in Roman Arabic numerals) and title above the table and explanatory notes below the table. Legends - These should be typed double spaces on a separate sheet and figure numbers (in Arabic numerals) corresponding with the order in which the figures are presented in the text. - The legend must include enough information to permit interpretation of the figure without reference to the text.
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Asian Journal of Diabetology, Vol. 16, No.1, January-March 2013
Please complete the following checklist and attach to the manuscript: 1. Classification (e.g. original article, review, selected summary, etc..)_____________________________ 2. Total number of pages _______________________ 3. Number of tables ___________________________ 4. Number of figures __________________________ 5. Special requests ___________________________ 6. Suggestions for reviewers (name and postal address) Indian 1.___________ Foreign 1.______________ 2.___________ 2.______________ 3.___________ 3.______________ 4.___________ 4.______________ 7. All authors’ signatures_______________________ 8. Corresponding author’s name, current postal and e-mail address and telephone and fax numbers ___________________________________________ ___________________________________________ ___________________________________________
For Editorial Correspondence Dr K.K. Aggarwal Group Editor-in-Chief
Asian Journal of Diabetology
E-219, Greater Kailash, Part-1 New Delhi - 110 048 E-mail: editorial@ijcp.com, Website: www.ijcpgroup.com