Diabetes Care in India

Integrating Polygenic Risk Scores (PRS) for Personalized Diabetes Care: Advancing Clinical Practice with Tailored Pharmacological Approaches

The rising global prevalence of diabetes poses a serious threat to public health, national economies, and the healthcare system. Despite a high degree of disease heterogeneity and advancing techniques, there is still an unclear diagnosis of patients with diabetes compounded by the array of long-term microvascular and macrovascular complications associated with the disease. In addition to environmental variables, diabetes susceptibility is significantly influenced by genetic components. The risk stratification of genetically predisposed individuals may play an important role in disease diagnosis and management. Precision medicine methods are crucial to reducing this global burden by delivering a more personalised and patient-centric approach. Compared to the European population, genetic susceptibility variants of type 2 diabetes mellitus (T2DM) are still not fully understood in other major populations, including South Asians, Latinos, and people of African descent. Polygenic risk scores (PRS) can be used to identify individuals who are more susceptible to complex diseases such as diabetes. PRS is selective and effective in developing novel diagnostic interventions. This comprehensive predictive approach facilitates the understanding of distinct response profiles, resulting in the development of more effective management strategies. The targeted implementation of PRS is especially advantageous for people who fall into a higher-risk category for diabetes. Through early risk assessment and the creation of individualised diabetes treatment plans, the integration of PRS in clinical practice shows potential for reducing the prevalence of diabetes and its complications. Diabetes self-management depends significantly on patient empowerment, with behavioural monitoring emerging as a vital facilitator. The main aim of this review article is to formulate a more structured intervention strategy by advocating for increased awareness of the clinical utility of PRS and counseling among healthcare practitioners, patients, and individuals at risk of diabetes.

Relationship between self-reported impairments and clinical examination of upper extremity in subjects with type 2 diabetes mellitus

BACKGROUND

Upper Extremity Impairments (UEIs) in type 2 DM(Diabetes Mellitus) usually occur after other complications of DM have occurred and can lead to disability and severely impact the quality of life. This study aimed to identify the UEIs by self-reported questionnaire and clinical findings and to investigate whether self-reported impairments conform to clinical findings and whether any vital questions about UEIs can be identified to screen the UEIs quickly in type 2 DM comprehensive assessment.

METHODS

91 medically diagnosed type 2 DM subjects were enlisted at a tertiary care hospital per the inclusion and exclusion criteria to participate in the study. Participants were asked to fill out a self-reported questionnaire regarding UEIs, following which a clinical examination of the upper extremity was performed to identify the UEIs.

RESULTS

85% of the participants self-reported UEIs. Self-reported shoulder pain was reported by n = 34 (37.3%), stiffness by n = 21(23.1%), and hand weakness by n = 24 (26.4%). Clinical examination of shoulder and hand revealed impairments such as hands against the back in n = 30(33%), lift-off sign in 22(24.1%), decreased finger extension in 11(12.1%), and thenar strength in 9(9.9%). Self-reported shoulder pain and hand stiffness were associated with clinically examined decreased shoulder mobility and rotator cuff (RC) tests (p < 0.05). Grip strength, thenar strength, and Phalen's sign decreased significantly with self-reported hand weakness (p < 0.05).

CONCLUSION

Self-reported shoulder pain and stiffness, hand stiffness, and weakness should be used to identify patients with UEIs needing comprehensive assessment and treatment. Significantly self-reported hand impairments can also be an indication to screen shoulder pathologies.

Expert Consensus on Dipeptidyl Peptidase-4 Inhibitor-Based Therapies in the Modern Era of Type 2 Diabetes Mellitus Management in India

India has a high prevalence of type 2 diabetes mellitus (T2DM) with unique clinical characteristics compared to other populations. Despite advancements in diabetes therapy, a significant number of patients in India still experience poor glycemic control and complications. Dipeptidyl peptidase-4 (DPP-4) inhibitors continue to be an important component of T2DM treatment due to their favorable efficacy and tolerability profile. Given the current scenario, there is a need to revisit the role of DPP-4 inhibitors in T2DM management in Indian patients. This consensus paper aims to provide guidance on the utilization of DPP-4 inhibitors in T2DM management from an Indian perspective. A consensus group of 100 experts developed recommendations based on an extensive literature review and discussions. The expert group emphasized the importance of timely glycemic control, combination therapy, and targeting the underlying pathophysiology of T2DM. The combinations of DPP-4 inhibitors with metformin and/or sodium-glucose transport protein-2 inhibitors are rationalized in this paper, considering their complementary mechanisms of action. This paper provides valuable insights for clinicians in optimizing the management of T2DM in the Indian population with the use of DPP-4 inhibitors and proposes an algorithm for selecting DPP-4 inhibitor-based therapies.

Improvement of knowledge following diabetes self-management education with respect to socioeconomic status: A retrospective cohort study among type 2 diabetes in Eastern India

Introduction

We assessed the baseline knowledge and the improvement and retention of knowledge after attending diabetes self-management education (DSME) programs with respect to different socioeconomic status (SES). We also looked into the change in body mass index (BMI), blood pressure, and glycemic parameters after attending the DSME sessions.

Materials and Methods

This was a retrospective, cohort study carried out via chart review based on data collected from manual or electronic medical records (EMR) and questionnaire responses of 160 adult patients with type 2 diabetes (T2D) who attended two DSME sessions with a gap of at least six months.

Results

Baseline knowledge on diabetes was uniform (P = 0.06), irrespective of differences in SES, and DSME sessions significantly improved the knowledge in all socioeconomic classes (P value < 0.05 in each SES group). However, SES did have a significant influence on the finally acquired knowledge of diabetes as was evident from the final score after attending two DSME sessions. A significant number of patients (48.1%) from our cohort either improved or retained their knowledge of diabetes over a mean follow-up of 15.5 months. The BMI of our cohort was significantly reduced from baseline to final follow-up (P = 0.016).

Conclusion

DSME sessions were effective in improving knowledge and awareness among T2D patients, irrespective of socioeconomic classes in Eastern India. The acquired knowledge from DSME sessions was retained over a long time.

Development of a machine learning model to predict risk of development of COVID-19-associated mucormycosis

Aim: The study aimed to identify quantitative parameters that increase the risk of rhino-orbito-cerebral mucormycosis, and subsequently developed a machine learning model that can anticipate susceptibility to developing this condition. Methods: Clinicopathological data from 124 patients were used to quantify their association with COVID-19-associated mucormycosis (CAM) and subsequently develop a machine learning model to predict its likelihood. Results: Diabetes mellitus, noninvasive ventilation and hypertension were found to have statistically significant associations with radiologically confirmed CAM cases. Conclusion: Machine learning models can be used to accurately predict the likelihood of development of CAM, and this methodology can be used in creating prediction algorithms of a wide variety of infections and complications.

Prevalence and risk factors associated with undiagnosed diabetes in India: Insights from NFHS-5 national survey

Background

Undiagnosed diabetes is a significant public health concern in India, considering the accumulative burden of diabetes and its long-term complications. We have estimated the prevalence and factors associated with undiagnosed diabetes in India.

Methods

We used data from the fifth round of the National Family Health Survey (NFHS-5, 2019-21) to estimate undiagnosed diabetes prevalence aged under 50 (15-49) years. A log-binomial model with survey-adjusted Poisson regression was used to estimate the prevalence risk ratio (PR) between undiagnosed diabetes and various factors. Multinomial logistic regression analysis was performed to examine the factors associated with diagnosed diabetes (vs. healthy) and undiagnosed diabetes (vs. healthy). All the analyses were survey-weighted and stratified by gender and reported with 95% confidence intervals.

Results

The prevalence of diabetes for individuals aged 15-49 years was found to be 4.90% (4.80 to 5.00%) from the NFHS-5. Among them, the proportion of individuals with undiagnosed diabetes was 24.82% (24.07 to 25.59%), with higher among males (28.82% (26.45 to 31.30%)) than females (24.22% (23.44 to 25.01%)). The overall prevalence of undiagnosed diabetes was 1.22% (1.18 to 1.26%), with a higher prevalence among males (1.60% (1.46 to 1.76%)) than females (1.17% (1.13 to 1.21%)). Individuals who are middle-aged (45-49), have a higher body mass index (BMI), and are in a lower wealth index group, or live in the southern regions of India are at a higher risk of being undiagnosed for diabetes.

Conclusion

One in every four having diabetes is undiagnosed. The study highlights the need for public health interventions to improve diabetes screening and access to health care, particularly among middle-aged individuals, and those with higher BMI, as well as addressing lifestyle and dietary factors. The findings also reveal disparities in diabetes burden among population subgroups in India, underscoring the need for targeted efforts.

Risk of multiple lower and upper urinary tract problems among male older adults with type-2 diabetes: a population-based study

AIM

This study explores the risk of diabetes-associated lower and upper urinary tract diseases among male older adults aged 45 and above in India.

METHODS

Longitudinal Ageing Study in India (LASI), 2017-2018 data was used in this study. The prevalence of various urinary tract problems and diabetes among male older adults was estimated by background characteristics using bivariate cross-tabulation. In addition, multivariate logistic regression was applied to examine the likelihood of urological disorders associated with diabetes.

RESULT

The prevalence of incontinence was highest among male older adults with diabetes, followed by kidney stones, benign prostatic hyperplasia, and chronic renal failure. Multivariate logistic regression estimation showed that men diagnosed with diabetes were 80% more likely to experience chronic renal failure, 78% more likely to suffer from incontinence, and 37% more likely to suffer from kidney stones than those without diabetes when controlling for various socio-demographic, behavioral, and co-morbidity status of the older adults.

CONCLUSIONS

The study findings suggest that diabetes is associated with multiple urinary complications among male older adults in India and needs more careful investigation of the phenomenon. Independent risk factors such as changes in lifestyle with regular monitoring and diagnosis may help to prevent the progression of diabetes and reduce the risk of diabetes-associated lower and upper urinary tract diseases among male older adults.

Machine learning for predicting diabetic metabolism in the Indian population using polar metabolomic and lipidomic features

AIMS

To identify metabolite and lipid biomarkers of diabetes in the Indian subpopulation in newly diagnosed diabetic and long-term diabetic individuals. To utilize the global polar metabolomic and lipidomic profiles to predict the susceptibility of an individual to diabetes using machine learning algorithms.

MATERIALS AND METHODS

87 individuals, including healthy, newly diabetic, and long-term diabetics on medication, were included in the study. Post consent, their serum was used to isolate polar metabolome and lipidome. NMR and LCMS were used to identify the polar metabolites and lipids, respectively. Statistical analysis was done to determine significantly altered molecules. NMR and LCMS comprehensive data were utilized to generate diabetic models using machine learning algorithms. 10 more individuals (pre-diabetic) were recruited, and their polar metabolomic and lipidomic profiles were generated. Pre-diabetic metabolic profiles were then utilized to predict the diabetic status of the metabolome and lipidome beyond glucose levels.

RESULTS

Mannose, Betaine, Xanthine, Triglyceride (38:1), Sphingomyelin (d63:7), and Phosphatidic acid (37:2) are some of the top key biomarkers of diabetes. The predictive model generated showed the receiver operating characteristic area under the curve (ROC-AUC) as 1 on both test and validation data indicating excellent accuracy. This model then predicted the diabetic closeness of the metabolism of pre-diabetic individuals based on probability scores.

CONCLUSION

Polar metabolic and lipid profile of diabetic individuals is very different from that of healthy individuals. Lipid profile alters before the polar metabolic profile in diabetes-susceptible individuals. Without regard to glucose, the diabetic closeness of the metabolism of any individual can be determined.

Financial burden of seeking diabetes mellitus care in India: Evidence from a Nationally Representative Sample Survey

Background

Diabetes mellitus (DM) is a major public health concern in India, and entails a severe burden in terms of disability, death, and economic cost. This study examined the out-of-pocket health expenditure (OOPE) and financial burden associated with DM care in India.

Methods

The study used data from the latest round of the National Sample Survey on health, which covered 555,115 individuals from 113,823 households in India. In the present study, data of 1216 individuals who sought inpatient treatment and 6527 individuals who sought outpatient care for DM were analysed.

Results

In India, 10.04 per 1000 persons reported having DM during the last 15 days before the survey date, varying from 6.94/1000 in rural areas to 17.45/1000 in urban areas. Nearly 38% of Indian households with diabetic members experienced catastrophic health expenditure (at the 10% threshold) and approximately 10% of DM-affected households were pushed below the poverty line because of OOPE, irrespective of the type of care sought. 48.5% of households used distressed sources to finance the inpatient costs of DM. Medicines constituted one of the largest proportion of total health expenditure, regardless of the type of care sought or type of healthcare facility visited. The average monthly OOPE was over 4.5-fold and 2.5-fold higher for households who sought inpatient and outpatient care, respectively, from private health facilities, compared with those treated at public facilities. Notably, the financial burden was more severe for households residing in rural areas, those in lower economic quintiles, those belonging to marginalised social groups, and those using private health facilities.

Conclusion

The burden of DM and its associated financial ramifications necessitate policy measures, such as prioritising health promotion and disease prevention strategies, strengthening public healthcare facilities, improved regulation of private healthcare providers, and bringing outpatient services under the purview of health insurance, to manage the diabetes epidemic and mitigate its financial impact.

Using 17th century medication for modern diabetes management: Doctors' perceptions of self-medication practices - A qualitative study

Purpose

This study was conducted to explore doctors' perceptions and understanding of the self-medication practices of people living with type 2 diabetes.

Methods

A qualitative research design incorporating 20 semi-structured, face-to-face interviews were conducted with doctors treating people with type 2 diabetes in Mysuru, India, between July 2019 and January 2020. All the interviews were conducted in doctors' clinics, audio-recorded and thematically analyzed.

Results

Three themes were identified from these interviews- i) Doctors' beliefs towards their patients' use of traditional medicine and environmental factors influencing prescription practices, ii) Doctors reported little faith in traditional medicines, iii) Limited strategies implemented by doctors to overcome barriers to self-medications. Doctors reported greater belief in western medications over traditional medications and expressed concern that their patients favored traditional medications over western. Multiple factors such as social media, accessibility of healthcare facilities and pill burden influenced adherence to western medications. Also, lack of knowledge about traditional medications and trust in western medications available under government schemes have influenced prescription practices among doctors. It appears that doctors implemented strategies such as educating patients on the detrimental effects of self-medication and insisting on patients to take only western medications to achieve desired blood glucose levels when managing self-medication practices among people with diabetes.

Conclusion

These results suggest that doctors have limited strategies to implement to prevent self-medication practices among people with diabetes. Increasing knowledge amongst doctors about JAS medication effectiveness and thereby garnering greater trust in generic medications. In addition, efforts should be made to identify the best ways to integrate traditional and western medicine into patient-centered care delivery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-01154-5.

Triangulating evidence for the causal impact of single-intervention zinc supplement on glycaemic control for type 2 diabetes: systematic review and meta-analysis of randomised controlled trial and two-sample Mendelian randomisation

Although previous studies suggested the protective effect of Zn for type 2 diabetes (T2D), the unitary causal effect remains inconclusive. We investigated the causal effect of Zn as a single intervention on glycaemic control for T2D, using a systematic review of randomised controlled trials and two-sample Mendelian randomisation (MR). Four primary outcomes were identified: fasting blood glucose/fasting glucose, HbA1c, homeostatic model assessment for insulin resistance (HOMA-IR) and serum insulin/fasting insulin level. In the systematic review, four databases were searched until June 2021. Studies, in which participants had T2D and intervention did not comprise another co-supplement, were included. Results were synthesised through the random-effects meta-analysis. In the two-sample MR, we used single-nucleotide polymorphisms (SNP) from MR-base, strongly related to Zn supplements, to infer the relationship causally, but not specified T2D. In the systematic review and meta-analysis, fourteen trials were included with overall 897 participants initially. The Zn supplement led to a significant reduction in the post-trial mean of fasting blood glucose (mean difference (MD): −26·52 mg/dl, 95 % CI (−35·13, −17·91)), HbA1c (MD: −0·52 %, 95 % CI: (−0·90, −0·13)) and HOMA-IR (MD: −1·65, 95 % CI (−2·62, −0·68)), compared to the control group. In the two-sample MR, Zn supplement with two SNP reduced the fasting glucose (inverse-variance weighted coefficient: −2·04 mmol/l, 95 % CI (−3·26, −0·83)). From the two methods, Zn supplementation alone may causally improve glycaemic control among T2D patients. The findings are limited by power from the small number of studies and SNP included in the systematic review and two-sample MR analysis, respectively.

Foot Self-Care Behaviour among People with Type 2 Diabetes mellitus Living in Rural Underserved Area of North India: A Community-Based Cross-Sectional Study

The objective of this study was to ascertain the foot self-care behaviour and its associated factors among people with type 2 diabetes mellitus (T2DM) living in the rural resource-constrained health setting of Punjab, North India. A community based cross sectional study was undertaken in the randomly selected underserved rural area of District Fatehgarh Sahib, Punjab, North India. A pre-validated Nottingham Assessment of Functional Footcare (NAFF) scale was administered to assess foot self-care behaviour, and participants were classified based on the percentage of a maximum possible score of 84 on the scale, as poor, if the score was <50%, satisfactory if score 50%-70% and >70% good foot self-care behaviour. A total of 700 participants' responses were recorded. The study results revealed that 84% (588) of the respondents had poor, 16% (112) had satisfactory, and none were following good foot self-care behaviour. An outcome of multivariable logistics regression suggested satisfactory foot self-care behaviour was significantly associated with foot self-care education, with an adjusted odds ratio (aOR) of 2.83 (95%, CI:1.62 - 4.93; p <0.01) among respondents who had received foot self-care education, literate than illiterate (aOR 2.50 95%, CI:1.31- 4.74; p <0.01) and women compared to men (aOR 1.69 95%, CI: 1.06 -2.70; p -0.26). This study revealed that foot self-care behaviours were alarmingly low among people with T2DM living in rural resource-constrained health settings of Punjab, North India, suggesting an urgent need to disseminate foot self-care education to prevent diabetes foot related complications.

One-year trends from the LANDMARC trial: A 3-year, pan-India, prospective, longitudinal study on the management and real-world outcomes of type 2 diabetes mellitus

Introduction

Longitudinal data on management and progression of type 2 diabetes mellitus (T2DM) in India are scarce. LANDMARC (CTRI/2017/05/008452), first‐of‐its‐kind, pan‐India, prospective, observational study aimed to evaluate real‐world patterns and management of T2DM over 3 years.

Methods

Adults (≥25 to ≤60 years old at T2DM diagnosis; diabetes duration ≥2 years at enrolment; controlled/uncontrolled on ≥2 anti‐diabetic agents) were enrolled. The first‐year trends for glycaemic control, therapy and diabetic complications, including those from metropolitan and non‐metropolitan cities are reported here.

Results

Of 6236 enrolled participants, 5654 completed 1 year in the study. Although the overall mean glycated haemoglobin (HbA1c) improved by 0.5% (baseline: 8.1%) at 1 year, only 20% of the participants achieved HbA1c <7%. Participants from metropolitan and non‐ metropolitan cities showed similar decrease in glycaemic levels (mean change in HbA1c: −0.5% vs. −0.5%; p = .8613). Among diabetic complications, neuropathy was the predominant complication (815/6236, 13.1% participants). Microvascular complications (neuropathy, nephropathy and retinopathy) were significantly (p < .0001) higher in non‐metropolitan than metropolitan cities. Hypertension (2623/6236, 78.2%) and dyslipidaemia (1696/6236, 50.6%) continued to be the most commonly reported cardiovascular risks at 1 year. After 1 year, majority of the participants were taking only oral anti‐diabetic drugs (OADs) (baseline: 4642/6236 [74.4%]; 1 year: 4045/6013 [67.3%]), while the proportion of those taking insulin along with OADs increased (baseline: 1498/6236 [24.0%] vs. 1 year: 1844/6013 [30.7%]). Biguanides and sulfonylureas were the most used OADs. The highest increase in use was seen for dipeptidyl peptidase‐IV inhibitors (baseline: 3047/6236 [48.9%]; 1 year: 3529/6013 [58.7%]). Improvement in all glycaemic parameters was significantly (p < .0001) higher in the insulin vs. the insulin‐naïve subgroups; in the insulin‐naïve subgroup, no statistical difference was noted in those who received >3 vs. ≤3 OADs.

Conclusions

First‐year trends of the LANDMARC study offer insights into real‐world disease progression, suggesting the need for controlling risk factors and timely treatment intensification in people with T2DM.

Does engagement in frequent physical activity improve diabetes mellitus among older adults in India? A propensity score matching approach

BACKGROUND AND AIMS

Diabetes is a major chronic condition and was identified as one of the four priority non-communicable diseases that the United Nations targeted because of its increasing disease burden. The present study aims to examine the impact of physical activity on improving diabetes mellitus among older adults in India.

METHODS

This study utilizes data from India's first nationally representative longitudinal ageing survey (2017-18). Descriptive along with bivariate analysis was used to present the preliminary results. Additionally, Propensity score matching (PSM) analysis was used.

RESULTS

About 14% of older adults suffered from diabetes. Eighteen percent of older adults did frequent physical activity. The estimated average treatment effect on the treated (ATT) values in treated and control groups were 0.123 and 0.147, respectively, indicating that the prevalence of diabetes among older adults was reduced by 2.5% points because of frequent physical activity. The average treatment effect on the untreated (ATU) results indicates that among older adults who did not do frequent physical activity, if they did frequent physical activity, the prevalence of diabetes is likely to decrease by 2.2% points.

CONCLUSION

Our findings show that frequent physical activity is associated with a lower risk of diabetes in older adults. The results underscore the need to develop strategies of promoting an active lifestyle by maintaining physical activity to combat the diabetes epidemic in the older population.

The Relationship between Macronutrient Distribution and Type 2 Diabetes in Asian Indians

Asian Indians (AIs) are at increased risk for type 2 diabetes mellitus than other ethnic groups. AIs also have lower body mass index (BMI) values than other populations, so can benefit from strategies other than weight reduction. Macronutrient distributions are associated with improved glycemic control; however, no specific distribution is generally recommended. This study looks at whether a macronutrient distribution of 50:30:20 (percent of total calories from carbohydrates, fats, and protein) is related to diabetes status in AIs. Diet and Hemoglobin A1c (HbA1c) were assessed from convenience sample of AI adults in Maryland. A ratio of actual to needed calories using the 50:30:20 macronutrient distribution was then tested against diabetes status to identify associations. All groups except non-diabetic females, were in negative energy balance. The non-diabetic group consumed larger actual to needed ratios of protein than pre-diabetics and diabetics. However, all groups consumed protein at the lower end of the Acceptable Macronutrient Distribution Range (AMDR), and the quality of all macronutrients consumed was low. Therefore, weight loss may not be the recommendation for diabetes management for AIs. Increasing protein and insoluble fiber consumption, could play a critical role.

Expert Opinion About the Pharmacoeconomic Edge of Low-Cost Dapagliflozin in Type 2 Diabetes Mellitus in Indian Clinical Settings

Background

This study aimed to understand the attitudes, beliefs, and concerns of physicians across India regarding the economic burden of diabetes and subsequently the cost-effectiveness of low-cost dapagliflozin for the management of patients with uncontrolled type 2 diabetes mellitus (T2DM) on background metformin therapy in Indian clinical settings.

Method

A cross-sectional questionnaire survey was conducted among physicians treating people with T2DM with or without complications. The questions covered the general aspects of affordability and adherence to diabetes medications as well as specific details of low-cost dapagliflozin and its cost-effectiveness.

Results

In total, 844 physicians provided a response to the survey questionnaire. The physicians who participated in the study included diabetologists, endocrinologists, cardiologists, consulting physicians, and family physicians. A majority of the physicians (53%) opined that only 10%-30% of their patients can afford the cost of newer antidiabetic medicines, while 25% of the physicians mentioned that <10% of their patients had issues related to affordability. Further, 39% of the physicians opined that 20%-40% of their patients discontinue the medicines due to high cost. Most of the physicians (95%) agreed that due to the low cost of dapagliflozin, it can be used for the primary prevention of heart failure in patients with T2DM in India. Similarly, 98% of the physicians agreed that it can be used for the treatment of heart failure in patients with or without T2DM in India. A majority of these physicians (93%) responded that switching from expensive sodium/glucose cotransporter-2 inhibitors (SGLT2i) to low-cost dapagliflozin is a long-term cost-effective management of T2DM. In total, 98% of the physicians agreed that low-cost dapagliflozin has the characteristics of an ideal SGLT2i because of its metabolic benefits, cardioprotection, nephroprotection, and potential cost-effectiveness.

Conclusion

This survey-based study indicates that dapagliflozin is an effective and cost-saving therapy for patients with T2DM and complications. Low-cost dapagliflozin can revolutionize the treatment of T2DM in the Indian setting.

Social Support, Self-Care Behaviour and Self-Efficacy in Patients with Type 2 Diabetes during the COVID-19 Pandemic: A Cross-Sectional Study

Diabetes mellitus is a major public health issue that considerably impacts mortality, morbidity, and healthcare costs worldwide. The COVID-19 pandemic has created havoc in diabetes management, too, like other spectrums of life. A descriptive, cross-sectional study was adopted to determine the effect of Social Support, Self-Care Behaviour and Self-Efficacy in Type 2 Diabetes Mellitus (T2D) during this COVID-19 pandemic. Two hundred T2D patients who satisfied the inclusion criteria were chosen using a convenient sampling procedure. The tool consists of four sections, including socio-demographic characteristics, Multidimensional Scale of Perceived Social Support (MSPSS), revised Summary of Diabetes Self-Care Activities (SDSCA) Scale and modified Diabetes Management Self-Efficacy Scale (DMS). Descriptive and inferential statistics were used to analyze the obtained data. The mean and SD of diabetic management self-efficacy is 5.74 (1.95) and 4.37 (1.4), respectively, for patients with HbA1c < 6.5% and HbA1c ≥ 6.5%. The self-care activities of the patients who had good glycemic control were 4.31 (2.06) compared to 3.50 (1.73) who did not. The social support received by the patients was 6.13 (2.13) vs. 5.31 (1.67) among patients with glycemic control vs. no control. The results show that social support (p = 0.04), self-efficacy (p =0.01) and self-care activities (p = 0.001) were significantly related to the level of glycemic control of the T2D patients. A significant relationship was also identified between gender (p = 0.036), age (p = 0.001) and education status (p = 0.000) with HbA1c control of the participants. This study demonstrates a significant relationship between social support, self-care behaviours, self-efficacy and glycemic management in T2D patients. During this COVID-19 pandemic, interventions to enhance the self-care activities like exercise and social support to boost their self-efficacy; for better diabetes management, reducing diabetes complications or prolonging their onset are the need of the hour.

Rhino-Orbito-Cerebral Mucormycosis During the Second Wave of Covid-19: The Indian Scenario

Mucormycosis is a life threatening, opportunistic infection often seen in individuals with a weak immune system. With an upsurge of cases of Covid-19, a drastic increase in cases of Rhino-Orbito-Cerebral Mucormycosis is being witnessed at present. This article has been written with the purpose of understanding the factors responsible for it and the challenges it brings along for the Indian health-care system at present. Possible solutions for dealing with these problems have also been included in the manuscript. Google, PubMed and ENT Cochrane databases were searched without a time limit using key words like “Mucormycosis”, “Rhino-cerebral-mucormycosis” in conjunction with “COVID-19” and “SARS CoV-2”. We found 34 articles to be relevant and hence included them to write this review. Rhino-Orbito-Cerebral Mucormycosis is being seen due to coming together of the three entities-the agent, host and environment that constitute the epidemiological triad for this disease in India. Responsible factors are uncontrolled diabetes mellitus, overzealous use of steroids and antibiotics and other environment related issues. The solutions for these problems lie in spreading awareness about prevention of these practices along with early diagnosis and treatment of mucormycosis. To deal effectively with this situation, particularly when there is an existing overload on otolaryngologists and the rest of the health-care system, a multipronged and multilevel collaborative approach is the need of the hour. With effective Standard Operating Procedures and guidelines promoting a multidisciplinary approach for early diagnosis and treatment, we can surely overcome this situation.

Prospective Comparative Observational Study of Safety and Efficacy of Topical Ozone Gas Therapy in Healing of Diabetic Foot Ulcers versus Only Conventional Wound Management

The prevalence of diabetic foot ulcers (DFUs) in India is 11.6%. DFU accounts for major cost expenditure, morbidity, and mortality. 1 Ozone gas has antimicrobial and antioxidant properties. We studied efficacy of topical ozone gas therapy in promoting healing of DFU. This is an observational comparative cohort study, n  = 160, There were two groups of patients namely: those who received Conventional wound management alone C and those who received topical ozone therapy in addition to conventional wound management O + C therapy groups (81 each). Study group, i.e., O + C received five alternate day sessions of ozone therapy by bagging method for 30 minutes each session. Both groups were observed for 30 days for wound healing parameters like reduction of wound surface area, wound diameter, presence and character of discharge, granulation tissue, healing wound edges, microbial negativity, and requirement of revision (re-debridement and/or amputation) surgery. Mean baseline ulcer surface area is 17.43 ± 8.6 cm ² for C and 17.87 ± 9.2 cm ² (range 1–50 cm ² ) in O + C group. Percentage change in ulcer surface after 21 days in O + C group is 32.37% compared with 17.15% in C group, which is statistically significant ( p  = 0.01). Rates of microbial negativity and ulcer healing were significantly faster in ozone group. There was a statistically significant decrease in hospital stay, number of revision surgeries required, and mortality in ozone group. Topical ozone gas was well tolerated. Our study supports the efficacy of ozone therapy in DFU healing and reduction in the chances of infection and revision (re-debridement and/or amputation) surgery. More research is needed for dose, duration, and exposure time standardization.

Diabetes Care in India: A Descriptive Study

CONTEXT

Diabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent and reduce the risk of long-term complications. It requires an array of investigations to provide an accurate picture of the condition and its management accordingly by a qualified doctor.

AIMS

This study was conducted to understand the treatment received by type 2 diabetes (T2DM) patients from various categories of health care professionals and awareness about diabetes reversal by lifestyle modification and prevention of complications.

SETTINGS AND DESIGN

This was a community-based cross-sectional study.

SUBJECTS AND METHODS

The link of the semi-structured questionnaire in Google form with e-consent was sent to all members in the selected groups of "World free of obesity and diabetes" campaign on their personal WhatsApp account.

STATISTICAL ANALYSIS USED

A total of 3082 participants were included, and the data obtained were analyzed using SPSS v26.

RESULTS

The mean age of the participants was 50.26 ± 9.78 years ranging from 18 to 81 years. A total of 35.8% of the study population was diabetic for 1-5 years. A total of 54.9% were started with antidiabetic medication on the same day of diagnosis. Only 1.5% of the patients had complete investigation profile for T2DM, 50.2% of the patients were briefed about hypoglycemia, and only 15.8% of the patients were checked for retinopathy.

CONCLUSIONS

Most doctors, qualified as well as nonqualified, did not follow the standard guidelines for diagnosis, treatment, and patient education regarding T2DM; therefore, it is necessary to train all medical practitioners regarding these guidelines. Diabetes reversal by lifestyle modification must be prescribed as the first line of treatment in patients with T2DM.

Fatty acid desaturase 2 (FADS 2) rs174575 (C/G) polymorphism, circulating lipid levels and susceptibility to type-2 diabetes mellitus

Several factors influence an individual's susceptibility in inter-individual lipid changes and its role in the onset of type-2 diabetes mellitus (T2DM). Considering the above fact, the present investigation focuses on determining the association between fatty acid desaturase 2 (FADS2) rs174575 (C/G) polymorphism, circulating lipid levels and susceptibility to type-2 diabetes mellitus. As per the inclusion and exclusion criteria a total of 429 subjects (non-diabetic-216; diabetic-213) were recruited for the study. Glycemic and lipid profile status were assessed using commercially available kits. Based on the previous reports SNP rs174575 of fatty acid desaturase gene (FADS2) was selected and identified using the dbSNP database. The amplified products were sequenced by means of Sanger sequencing method. Lipid profile status and apolipoprotein levels revealed statistically significant difference between the groups. Three models were assessed namely, recessive model (CC vs CG + GG), dominant model (CC + CG vs GG) and additive model (CC vs CG vs GG). The recessive model, displayed a statistically significant variations between the circulating lipid levels in T2DM. The multivariate model with genotype (G allele carriers), triglyceride (TG) and insulin served as a predictive model. The study results potentiate the functional link between FADS2 gene polymorphism, lipid levels and type-2 diabetes mellitus.

Impact of prediabetes education program on Knowledge, attitude and practice among prediabetic population of south India

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A Prediabetes prevalence of 10.5% alarms the need for prediabetes management programs.

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KAP-PAQ was found to be an efficient tool to conduct KAP survey among prediabetes.

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Implementation of Prediabetes Education Program increased the self management skills among the prediabetes.

Education plays a vital role not only in the management of diabetes but also for the effective prevention of diabetes and its complications. Prediabetes awareness and knowledge is grossly inadequate in India and massive prediabetic screening and management programs are urgently needed. This study was an initiative to conduct education program among the prediabetic subjects after assessment of their knowledge attitude and practice using a newly developed and validated prediabetes questionnaire. A total of 308 prediabetic participants were recruited through prediabetes screening camps conducted in the selected districts of Kerala and Tamilnadu. A newly developed and validated KAP-PAQ Questionnaire was used to analyze the Knowledge Attitude and Practice among the prediabetic population. The impact of Prediabetes Education Program was assessed by administration of questionnaire before and after PEP with an interval period of 30 days. Baseline assessment of knowledge among prediabetics shown that 90% had poor knowledge but after PEP program 43% had average knowledge and 44% could score good knowledge. Baseline assessment of attitude exhibited 30% with negative attitude but after counseling 68% shown positive attitude. Regarding practice assessment 35% had very poor and 52% shown poor practice but after PEP 71% shown good practice and 15% shown very good practice. Baseline KAP survey shows the need for health literacy among the newly diagnosed prediabetics. Prediabetes education program could bring significant improvement in knowledge attitude and practice and KAP-PAQ was found to be an efficient tool to conduct survey among the newly diagnosed prediabetics of south India.

Instruments measuring the quality of life among people living with type 2 diabetes mellitus in India: a systematic review protocol

INTRODUCTION

Type 2 diabetes mellitus affects an individual's quality of life (QoL); and there are multiple instruments that can be used to measure QoL. The purpose of this systematic review is to identify the existing instruments that have been used to measure QoL in people living with diabetes, and to enlist the major domains (such as physical and psychological components) available in the identified instruments. Additionally, we plan to determine the psychometric properties of the identified QoL instruments using COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology.

METHODS AND ANALYSIS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol guideline was followed to report this systematic review protocol. Searches will be conducted on MEDLINE (via PubMed, Web of Science), SCOPUS and CINAHL. Predetermined inclusion/exclusion criteria will be applied to the search results, to include studies with adult individuals diagnosed with type 2 diabetes mellitus, with and without complications, and exclude studies with type 1 diabetes or other clinical illness. Studies conducted outside India will be excluded. Five authors in pairs will independently screen the articles and extract the data that meets the inclusion criteria. The COSMIN criteria will be used to assess the risk of bias of included studies. Narrative synthesis will be performed to analyse the findings of the instruments.

ETHICS AND DISSEMINATION

Ethical permission is not applicable, as this is a systematic review. We intend to disseminate the systematic review findings through a national or international conference and publish the findings in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020180432.

Data on vildagliptin and vildagliptin plus metformin combination in type-2 diabetes mellitus management

It is of interest to evaluate the clinical effectiveness and safety of vildagliptin as monotherapy and combination therapy of vildagliptin and metformin for the management of type 2 diabetes mellitus (T2DM) patients in Indian settings. The study included patients with T2DM (aged >18 years) receiving vildagliptin monotherapy and vildagliptin in combination with metformin therapy of various strengths. Data related to demographics, risk factors, medical history, glycated hemoglobin (HbA1c) levels, and medical therapies were retrieved from medical records. Out of 9678 patients (median age, 52.0 years), 59.1% were men. A combination of vildagliptin and metformin (50/500 mg) was the most commonly used therapy (54.8%), and the median duration of therapy was 24.0 months. The predominant reason for selecting vildagliptin therapy was to improve HbA1c levels (87.8%). A total of 87.5% of patients required dosage up-titration. Vildagliptin therapy was used in patients with T2DM and associated complications (peripheral neuropathy, CAD, nephropathy, retinopathy, autonomous neuropathy, stroke/TIA, and peripheral artery disease). Among 5175 patients who experienced body weight changes, a majority of patients showed a loss of weight (68.6%). The target glycemic control was achieved in 95.3% of patients. The mean HbA1c levels were significantly decreased post-treatment (mean change: 1.34%; p<0.001). Adverse events were reported in 0.4% of patients. Physicians rated the majority of patients as good to excellent on the global evaluation of efficacy and tolerability scale (98.9%, each). Vildagliptin as monotherapy and combination therapy of vildagliptin and metformin was an effective therapy in reducing HbA1c helps in achieving target glycemic control, and was well tolerated in Indian patients with T2DM continuum.

Evaluating Glycemic Control in Patients of South Asian Origin With Type 2 Diabetes Using a Digital Therapeutic Platform: Analysis of Real-World Data

Background

Digital therapeutics are evidence-based therapeutic interventions driven by high-quality software programs for the treatment, prevention, or management of a medical disorder or disease. Many studies in the western population have shown the effectiveness of mobile app–based digital therapeutics for improving glycemic control in patients with type 2 diabetes (T2D). However, few studies have assessed similar outcomes in the South Asian population.

Objective

This study aims to investigate the real-world effectiveness of the Wellthy CARE digital therapeutic for improving glycemic control among the South Asian population of Indian origin.

Methods

We analyzed deidentified data from 102 patients with T2D from India enrolled in a 16-week structured self-management program delivered using the Wellthy CARE mobile app. Patients recorded their meals, weight, physical activity, and blood sugar in the app, and they received lessons on self-care behaviors (healthy eating, being active, monitoring, medication adherence, problem solving, healthy coping, and reducing risks); feedback provided by an artificial intelligence–powered chatbot; and periodic interactions with certified diabetes educators via voice calls and chats. The primary outcome of the program was a change in glycated hemoglobin A_1c (HbA_1c). Secondary outcomes included the difference between preintervention and postintervention fasting blood glucose (FBG) and postprandial blood glucose (PPBG) levels; changes in BMI and weight at the completion of 16 weeks; and the association between program engagement and the changes in HbA_1c, FBG, and PPBG levels.

Results

At the end of 16 weeks, the average change in HbA_1c was –0.49% (n=102; 95% CI −0.73 to 0.25; P<.001). Of all the patients, 63.7% (65/102) had improved HbA_1c levels, with a mean change of −1.16% (n=65; 95% CI −1.40 to −0.92; P<.001). The mean preintervention and postintervention FBG levels were 145 mg/dL (n=51; 95% CI 135-155) and 134 mg/dL (n=51; 95% CI 122-146; P=.02) and PPBG levels were 188 mg/dL (n=51; 95% CI 172-203) and 166 mg/dL (n=51; 95% CI 153-180; P=.03), respectively. The mean changes in BMI and weight were –0.47 kg/m² (n=59; 95% CI −0.22 to −0.71; P<.001) and –1.32 kg (n=59; 95% CI −0.63 to −2.01; P<.001), respectively. There was a stepwise decrease in HbA_1c, FBG, and PPBG levels as the program engagement increased. Patients in the highest tertile of program engagement had a significantly higher reduction in HbA_1c (−0.84% vs −0.06%; P=.02), FBG (−21.4 mg/dL vs −0.18 mg/dL; P=.02), and PPBG levels (−22.03 mg/dL vs 2.35 mg/dL; P=.002) than those in the lowest tertile.

Conclusions

The use of the Wellthy CARE digital therapeutic for patients with T2D showed a significant reduction in the levels of HbA_1c, FBG, and PPBG after 16 weeks. A higher level of participation showed improved glycemic control, suggesting the potential of the Wellthy CARE platform for better management of the disease.

Profile of diabetes patients' chronic illness care in India and its role in their adherence

BACKGROUND AND AIMS

Negligence of illness care in terms of non-adherence may give rise to serious health outcomes in patients with type 2 diabetes mellitus. Considering the importance of both chronic illness care and adherence, the primary purpose of the study is to explore the profile of diabetic patients' chronic illness care and examine its role in their clinical adherence. In addition to this, we have also investigated the major confounding variables in understanding the chronic illness care of diabetic patients.

METHODS

We have conducted this study using a simple retrospective design with one group involving the patients primarily diagnosed with type 2 diabetes (N = 200) in India.

RESULTS

The cluster analysis (k-Means) has yielded three clusters on the basis of five domains of chronic illness care-patient activation, delivery system design, goal setting, problem solving, and follow-up/coordination. The findings further reveal that the profile of chronic illness care plays a significant role in deciding the clinical adherence of patients with type 2 diabetes. The three clusters of diabetes patients, however, are confounded by health risk behaviour.

CONCLUSIONS

These initial findings are suggestive of an association between chronic illness care, clinical adherence, and health risk behaviour of patients with type 2 diabetes. More research on this topic, however, needs to be undertaken involving other important dimensions of health care system like patient-provider relationship and quality of life during hospitalisation. The implications and shortcomings are discussed.

Prevalence of prediabetes, and diabetes in Chandigarh and Panchkula region based on glycated haemoglobin and Indian diabetes risk score

There is a rapid increase in the prevalence of diabetes in India. We wanted to review the status of prediabetes and diabetes in the combined population of Chandigarh and Panchkula region based on both Indian Diabetes Risk Score (IDRS) and Glycated Haemoglobin (HbA1c). A total of 1215 subjects were recruited during the screening process, out of which 444 i subjects have been analysed for the current study on the basis of high risk for IDRS (≥60) and their known diabetes status. This study included 431 subjects having high risk for IDRS (≥60) and 13 known subjects with diabetes (IDRS < 60) which were further analysed for biochemical and anthropometric parameters. The prevalence of diabetes was found to be 12.67% and prediabetes 11.69% in the combined population of Chandigarh and Panchkula. There was an increased level of fasting blood glucose (183.12 ± 68.61), postprandial blood glucose (262.57 ± 96.92), triglyceride (193.84 ± 119.88), very low-density lipoprotein (VLDL) (34.87 ± 15.42) and High Density Lipoprotein(HDL) (4.61 ± 1.39) in the said diabetes population. Mean HDL was found to be decreased in subjects having diabetes. Glucose-induced lipid intolerance study revealed significant alteration in triglyceride, HDL and VLDL. The study has revealed that high prevalence of diabetes in the sampled population when compared with the national average of 8.8%.

1800 121 2096 Diabeteshelp - A toll free helpline for people with diabetes

People with diabetes mellitus require long-term care that is timely, patient-centered, community-based and sustainable. Any deficiency in care increases the risk of developing complications like Diabetic Retinopathy. Patients or their carers also have numerous questions and doubts during this long-period of care. This increases the pressure on health systems that are struggling with a lack of skilled human resources. One option is to provide counseling support using a dedicated helpline. Over the last five years a major initiative to tackle visual impairment due to diabetes was rolled out in India by the Public Health Foundation of India supported by the Queen Elizabeth Diamond Jubilee Trust, UK. One component of the initiative was establishing a toll-free helpline (1800 121 2096) to address the lack of awareness and to empower people with diabetes in Telangana and Andhra Pradesh states in India. Over a 1-year period, the helpline received 4406 calls, making a case for a national service for people with diabetes.

Effect of health education and screening location on compliance with diabetic retinopathy screening in a rural population in Maharashtra

Purpose:

To compare the acceptance of diabetic retinopathy (DR) screening by the proximity of care and health education in rural Maharashtra.

Methods:

Study was done in the public health facilities in four blocks (in two blocks at community health center (CHC) level and in other two blocks at primary health center (PHC) level with the provision of transport from villages to PHCs) over 3 months. Health education was not imparted in one block in each segment. Health education consisted of imparting knowledge on diabetes mellitus (DM) and DR by trained village-level workers. The screening was done using non-mydriatic fundus camera and teleophthalmology supported remote grading of DR.

Results:

In the study period, 1,472 people with known diabetes were screened in four blocks and 86.6% (n = 1275) gradable images were obtained from them. 9.9% (n = 126) were detected having DR and 1.9% (n = 24) having sight-threatening DR (STDR). More people accepted screening closer to their residence at the PHC than CHC (24.4% vs 11.4%; P < 0.001). Health education improved the screening uptake significantly (14.4% vs 18.7%; P < 0.01) irrespective of the place of screening—at CHC, 9.5% without health education vs 13.1% with health education; at PHC, 20.1% without health education versus 31.6% with health education.

Conclusion:

Conducting DR screening closer to the place of living at PHCs with the provision of transport and health education was more effective for an increase in the uptake of DR screening by people with known diabetes in rural Maharashtra.

Prevalence of Vascular Complications Among Type 2 Diabetic Patients in a Rural Health Center in South India

Introduction: Vascular complications are the major cause of morbidity in patients with diabetes mellitus. Screening for these complications is crucial in early detection and tertiary prevention. Hence, this study aimed at finding the prevalence of micro and macrovascular complications and their associated factors in type 2 diabetes mellitus patients in a rural health center by using simple and easily available tools. Methodology: This hospital based cross sectional study was conducted in Rural Health and Training Centre (RHTC) of Sri Ramachandra medical college from Jan 2017 to Aug 2017. All type 2 diabetes patients registered at RHTC were included in the study. By the use of questionnaire, clinical examination and laboratory investigations, the prevalence of macro and microvascular complications and associated factors were ascertained. Multiple logistic regression was used to identify factors associated with vascular complications of diabetes. Results: The study included 390 type 2 diabetes patients. The overall prevalence of macrovascular and microvascular complications in our study population was 29.7% and 52.1%, respectively. Among the macrovascular complications, both coronary artery disease (CAD) and peripheral vascular disease (PVD) had a prevalence rate of 15.1%. Among the microvascular complications, peripheral neuropathy (44.9%) had the highest prevalence followed by nephropathy (12.1%) and diabetic foot (7.2%). Multiple logistic regression analyses showed high HbA1c level, lower education, high postprandial blood sugar, hypertension, abdominal obesity were significantly associated with increased risk of vascular complications of diabetes. Conclusion: This study demonstrated the increased prevalence of vascular complications in Type 2 diabetes patients in rural India. Regular screening to identify those patients at risk could prevent further progression of complications.

Compliance to secondary prevention strategies for coronary artery disease: a hospital-based cross-sectional survey from Ernakulam, South India

OBJECTIVES

The primary objective of the study was to report the compliance to secondary prevention strategies for coronary artery disease (CAD), such as smoking cessation, weight management, low-density lipoprotein (LDL) cholesterol control, blood pressure control, glycaemic control, physical activity and cardiovascular drug therapy from a resource-limited setting.

DESIGN

Analytical cross-sectional survey with data collection using questionnaire administered by study personnel.

SETTING

Institutional-two tertiary care hospitals and two cardiology clinics.

PARTICIPANTS

Patients in the age group of 30-80 years with documented CAD with a minimum of 1 year and a maximum of 6 years of follow-up after diagnosis.

MAIN OUTCOME MEASURES

The main outcome measures were the prevalence of individual compliance to secondary prevention strategies for CAD such as smoking cessation, weight management, LDL cholesterol control, blood pressure control, glycaemic control, physical activity and cardiovascular drug therapy. The secondary outcomes were the association of secondary prevention strategies with age, sex, domicile, socioeconomic status, insurance and type of treatment.

RESULTS

We recruited a total of 1206 patients among whom 879 (72.9%) were males. The median age of patients was 62 (14) years. The compliance to smoking cessation was 93.86% (95% CI 91.66% to 96.06%), ideal body mass index was 63.76% (95% CI 61.05% to 66.47%), blood pressure control was 65.11% (95% CI 62.42% to 67.80%), LDL compliance was 36.50% (95% CI 33.18% to 39.82%), diabetes control was 51.23% (95% CI 46.10% to 56.36%) and adequate physical activity was 39.22% (95% CI 36.46% to 41.98%)respectively. Reported compliance for cardiovascular drugs therapy was 96% for antiplatelets, 89.4% for statins, 68.2% for beta blockers, 37.7% for renin angiotensin aldosterone system blockers, 81.28% for oral hypoglycaemic agents and 22% for insulin therapy.

CONCLUSION

Compliance to secondary prevention strategies for CAD in resource limited settings are moderate. This needs further improvement for better outcomes related to CAD in future.

The Upcoming Epidemic of Heart Failure in South Asia

Currently, South Asia accounts for a quarter of the world population, yet it already claims ≈60% of the global burden of heart disease. Besides the epidemics of type 2 diabetes mellitus and coronary heart disease already faced by South Asian countries, recent studies suggest that South Asians may also be at an increased risk of heart failure (HF), and that it presents at earlier ages than in most other racial/ethnic groups. Although a frequently underrecognized threat, an eventual HF epidemic in the densely populated South Asian nations could have dramatic health, social and economic consequences, and urgent interventions are needed to flatten the curve of HF in South Asia. In this review, we discuss recent studies portraying these trends, and describe the mechanisms that may explain an increased risk of premature HF in South Asians compared with other groups, with a special focus on highly relevant features in South Asian populations including premature coronary heart disease, early type 2 diabetes mellitus, ubiquitous abdominal obesity, exposure to the world's highest levels of air pollution, highly prevalent pretransition forms of HF such as rheumatic heart disease, and underdevelopment of healthcare systems. Other rising lifestyle-related risk factors such as use of tobacco products, hypertension, and general obesity are also discussed. We evaluate the prognosis of HF in South Asian countries and the implications of an anticipated HF epidemic. Finally, we discuss proposed interventions aimed at curbing these adverse trends, management approaches that can improve the prognosis of prevalent HF in South Asian countries, and research gaps in this important field.

Impact of type 2 diabetes variants identified through genome-wide association studies in early-onset type 2 diabetes from South Indian population

The prevalence of early-onset type 2 diabetes (EOT2D) is increasing in Asian countries. Genome-wide association studies performed in European and various other populations have identified associations of numerous variants with type 2 diabetes in adults. However, the genetic component of EOT2D which is still unexplored could have similarities with late-onset type 2 diabetes. Here in the present study we aim to identify the association of variants with EOT2D in South Indian population. Twenty-five variants from 18 gene loci were genotyped in 1,188 EOT2D and 1,183 normal glucose tolerant subjects using the MassARRAY technology. We confirm the association of the HHEX variant rs1111875 with EOT2D in this South Indian population and also the association of CDKN2A/2B (rs7020996) and TCF7L2 (rs4506565) with EOT2D. Logistic regression analyses of the TCF7L2 variant rs4506565(A/T), showed that the heterozygous and homozygous carriers for allele ‘T’ have odds ratios of 1.47 (95% confidence interval [CI], 1.17 to 1.83; p = 0.001) and 1.65 (95% CI, 1.18 to 2.28; p = 0.006) respectively, relative to AA homozygote. For the HHEX variant rs1111875 (T/C), heterozygous and homozygous carriers for allele ‘C’ have odds ratios of 1.13 (95% CI, 0.91 to 1.42; p = 0.27) and 1.58 (95% CI, 1.17 to 2.12; p = 0.003) respectively, relative to the TT homozygote. For CDKN2A/2B variant rs7020996, the heterozygous and homozygous carriers of allele ‘C’ were protective with odds ratios of 0.65 (95% CI, 0.51 to 0.83; p = 0.0004) and 0.62 (95% CI, 0.27 to 1.39; p = 0.24) respectively, relative to TT homozygote. This is the first study to report on the association of HHEX variant rs1111875 with EOT2D in this population.

Study of Neurocognitive Function in Type 2 Diabetes Mellitus Patients Using P300 Event-Related Potential

Background:

Diabetes mellitus is the most prevailing metabolic disease. It causes structural and functional alterations in several organs, including the central nervous system. Altered glucose metabolism, atherosclerosis, and inflammation of blood vessels are seen in diabetes. This may lead to neuronal degeneration and decline in cognition. Event-related potential P300 can detect cognitive decline before the emergence of obvious neurological manifestations.

Objective:

The aim of this study is to assess and compare the P300 latencies in subjects with type 2 diabetes mellitus and in nondiabetic subjects and to determine the influence of type 2 diabetes mellitus on cognitive functions.

Materials and Methods:

In this study our sample size was 248 subjects, with type 2 diabetes mellitus patients (n = 124) and healthy controls (n = 124) between the age group of 31 and 60 years. This cross-sectional comparative study was conducted at SRM Medical College Hospital and Research Centre. The subjects were evaluated by a structured interview and they were assessed with a general health questionnaire to rule out any subpsychiatric illness. Fasting and postprandial blood glucose, HbA1c level, lipid profile, and creatinine were estimated. P300 amplitude and peak latencies were recorded using the standard auditory oddball paradigm.

Results:

The latencies of P300 were significantly increased and the amplitude of P300 was significantly reduced in the diabetic group when compared to the control group (P < .001). P300 latency has a positive correlation with the HbA1c levels (r = 0.136) and the duration of diabetes (r = 0.231).

Conclusion:

Prolongation of P300 latencies and the decreased amplitude in diabetic subjects may suggest the existence of a cognitive decline in individuals with type 2 diabetes compared to healthy individuals.

Suboptimal glycemic control among subjects with diabetes mellitus in India: a subset analysis of cross-sectional wave-7 (2016) data from the International Diabetes Management Practices Study (IDMPS)

OBJECTIVE

To assess the real-world management practices of subjects with type 2 diabetes mellitus (T2DM) and type 1 diabetes mellitus (T1DM) in India.

METHODS

This cross-sectional study was conducted between 7 March 2016 and 15 May 2016 in India as part of the seventh wave (2016) of the International Diabetes Management Practices Study (IDMPS). Adult subjects with T1DM or T2DM visiting physicians during a 2-week recruitment period were included.

RESULTS

A total of 55 physicians included 539 subjects who met eligibility criteria. Of 495 subjects with T2DM, 303 were treated with oral glucose lowering drugs (OGLDs) only, 158 were treated with OGLD + insulin, and 27 received insulin only. Among 44 subjects with T1DM receiving insulin, 13 (29.5%) were also treated with OGLD therapy. The most commonly used insulin regimens were basal alone (69/184; 37.5%) and premixed alone (63/184; 34.2%) in subjects with T2DM, and basal + prandial insulin (24/44; 54.5%) in subjects with T1DM. Proportions of subjects achieving glycemic targets were low [glycated haemoglobin (HbA1c) <7%: T1DM = 7.3% (3/44), T2DM = 25.2% (106/495); as targeted by the treating physician: T1DM = 31.8% (14/44), T2DM = 32.1% (59/185); global target: T1DM = 4.8% (2/42) and T2DM = 1.7% (8/482)]. In subjects with T2DM, HbA1c <7% was noted in 11/22 subjects receiving insulin only and 76/260 receiving only OGLDs. Lack of experience in self-managing insulin dosing, poor diabetes education and failure to titrate insulin dosages were the main reasons for non-achievement of glycemic targets.

CONCLUSION

Timely insulinization, education and empowerment of people with diabetes may help improve glycemic control in India.

Prevalence and Awareness of Stroke and Other Comorbidities Associated with Diabetes in Northwest India

Objectives  The main purpose of this study is to investigate the prevalence of comorbid conditions in diabetic, prediabetic, and nondiabetic individuals. Additionally, the current study examines the levels of awareness of those comorbidities among North Indian population.

Methods  As a part of a national study (Niyantrit Madhumeh Bharat [NMB] screening program), different comorbidity parameters were screened in the northern part of India between April and September 2017. There were 1,215 participants recruited in this study. Biochemical analyses of hemoglobin A1c (HbA1c) were conducted on the study subjects. Subsequently, the study subjects were divided into diabetic, prediabetic, and nondiabetic groups based on their HbA1c results.

Results  The study analysis reveals a higher prevalence of peripheral vascular disease (21.2%), ocular diseases (18%), and hypertension (13.4%) in diabetics with other comorbidities. Furthermore, the study found that a vast majority of the participants were unaware of the presence of hypertension (67.2%), dyslipidemia (84.5%), kidney disease (95.2%), peripheral vascular disease (34.5%), and stroke (95.1%).

Conclusion  The study concluded that in the northern India, the prevalence of multiple comorbid conditions, such as peripheral vascular disease and hypertension, is higher among diabetic population. Also, the level of awareness of diabetic comorbidities is surprisingly low, which has implications for policymakers, health practitioners, and educators of alternate medicine to increase awareness about diabetes, comorbid conditions, health risk, and possible solution at community and rural level, such as periodic screening programs in this population.

Rationale, study design and methodology of the LANDMARC trial: a 3-year, pan-India, prospective, longitudinal study to assess management and real-world outcomes of diabetes mellitus

AIM

India contributes towards a large part of the worldwide epidemic of diabetes and its associated complications. However, there are limited longitudinal studies available in India to understand the occurrence of diabetes complications over time. This pan-India longitudinal study was initiated to assess the real-world outcomes of diabetes across the country.

METHODS

The LANDMARC study is the first prospective, multicentre, longitudinal, observational study investigating a large cohort of people with type 2 diabetes mellitus across India over a period of 3 years. The primary objective of this ongoing study is to determine the proportion of people developing macrovascular diabetes complications over the duration of the study (36 months ± 45 days) distributed over seven visits; the secondary objective is to evaluate microvascular diabetes complications, glycaemic control and time-to-treatment adaptation or intensification. Overall, 6300 participants (aged 25-60 years) diagnosed with type 2 diabetes for at least 2 years will be included from 450 centres across India. Data will be recorded for baseline demographics, comorbidities, glycaemic measurements, use of anti-hyperglycaemic medications and any cardiovascular or other diabetes-related events occurring during the observational study period.

CONCLUSIONS

The LANDMARC study is expected to reveal the trends in complications associated with diabetes, treatment strategies used by physicians, and correlation among treatment, control and complications of diabetes within the Indian context. The findings of this study will help to identify the disease burden, emergence of early-onset complications and dose titration patterns, and eventually develop person-centred care and facilitate public health agencies to invest appropriate resources in the management of diabetes. (Trial Registration No: CTRI/2017/05/008452).

Retinal Vessel Segmentation Using an Entropy-Based Optimization Algorithm

This article presents an algorithm for the segmentation of retinal blood vessels for the detection of diabetic retinopathy eye diseases. This disease occurs in patients with untreated diabetes for a long time. Since this disease is related to the retina, it can eventually lead to vision impairment. The proposed algorithm is a supervised learning method of blood vessels segmentation in which the classification system is trained with the features that are extracted from the images. The proposed system is implemented on the images of DRIVE, STARE and CHASE_DB1 databases. The segmentation is done by forming clusters with the features of patterns. The features were extracted using independent component analysis and the classification is performed by support vector machines (SVM). The results of the parameters are grouped by accuracy, sensitivity, specificity, positive predictive value, false positive rate and are compared with particle swarm optimization (PSO), the firefly optimization algorithm (FA) and the lion optimization algorithm (LOA).

Effect of an Integrated Naturopathy and Yoga Program on Long-Term Glycemic Control in Type 2 Diabetes Mellitus Patients: A Prospective Cohort Study

AIM

Lifestyle is an important risk factor for increasing the prevalence of diabetes in the Indian population. In this study, we evaluate the effects of naturopathy treatment, salt-restricted low-calorie diets, and yoga in long-term glycemic control in patients with type 2 diabetes mellitus.

METHODS

In this prospective, longitudinal, two-arm cohort study, patients with type 2 diabetes mellitus referred from a tertiary care center undergoing a 3-month residential naturopathy treatment were compared with those undergoing only conventional management on glycemic control. Both fasting and postprandial blood glucose (PPBG) levels were assessed at baseline, 3 months following intervention, at 6 months, and 12 months from the study start. Data were analyzed using repeated-measures ANOVA with post hoc Bonferroni correction.

RESULTS

Naturopathy and yoga intervention significantly reduced PPBG levels (P < 0.001), glycated hemoglobin levels (P < 0.001), and reduced requirement for antidiabetic medications (P < 0.008) in the intervention group compared to controls. The effects were more profound immediately following intervention and lasted up to 6 months from the start of the study.

CONCLUSION

The results suggest benefit with an intensive residential naturopathy-based lifestyle intervention program. Randomized controlled trials are needed to further validate the findings.

Efficacy of a Validated Yoga Protocol on Dyslipidemia in Diabetes Patients: NMB-2017 India Trial

Background: Dyslipidemia is considered a risk factor in Type 2 diabetes mellitus (T2DM) resulting in cardio-vascular complications. Yoga practices have shown promising results in alleviating Type 2 Diabetes pathology. Method: In this stratified trial on a Yoga based lifestyle program in cases with Type 2 diabetes, in the rural and urban population from all zones of India, a total of 17,012 adults (>20 years) of both genders were screened for lipid profile and sugar levels. Those who satisfied the selection criteria were taught the Diabetes Yoga Protocol (DYP) for three months and the data were analyzed. Results: Among those with Diabetes, 29.1% had elevated total cholesterol (TC > 200 mg/dL) levels that were higher in urban (69%) than rural (31%) Diabetes patients. There was a positive correlation (p = 0.048) between HbA1c and total cholesterol levels. DYP intervention helped in reducing TC from 232.34 ± 31.48 mg/dL to 189.38 ± 40.23 mg/dL with significant pre post difference (p < 0.001). Conversion rate from high TC (>200 mg/dL) to normal TC (<200 mg/dL) was observed in 60.3% of cases with Type 2 Diabetes Mellitus (T2DM); from high LDL (>130 mg/dL) to normal LDL (<130 mg/dL) in 73.7%; from high triglyceride (>200 mg/dL) to normal triglyceride level (<200 mg/dL) in 63%; from low HDL (<45 mg/dL) to normal HDL (>45 mg/dL) in 43.7% of T2DM patients after three months of DYP. Conclusions: A Yoga lifestyle program designed specifically to manage Diabetes helps in reducing the co-morbidity of dyslipidemia in cases of patients with T2DM.

Consensus Recommendations on GLP-1 RA Use in the Management of Type 2 Diabetes Mellitus: South Asian Task Force

The advent of incretin mimetics such as glucagon-like peptide-1 receptor agonists (GLP-1 RAs) has enriched the armamentarium for diabetes management owing to their glycaemic as well as extra-glycaemic benefits. The approval status and availability of this class of drugs vary widely across the globe. Being a relatively newer class of drug with numerous benefits, several national and international guidelines are working towards addressing clinical questions pertaining to the optimal use of GLP-1 RAs for the management of diabetes. Although the newer class of drugs are associated with significant benefits such as patient-centric approach, these drugs demand the providers to be vigilant and knowledgeable about the medication. The South Asian population is at higher risk of type 2 diabetes mellitus (T2DM) because of their genetic predisposition and lifestyle changes. Hence, prevention and management of T2DM and its associated complications in this population are of paramount importance. The current report aims to present an overview of current knowledge on GLP-1 RAs based on pragmatic review of the available clinical evidence. In addition, this report is a consensus of expert endocrinologists representing South Asian countries including India, Pakistan, Bangladesh, Nepal, Sri Lanka, Afghanistan and the Maldives on essential recommendations related to the use of GLP-1 RAs in a real-world scenario.

A Cross-sectional Retrospective Analysis of Glycemic Burden and Nephropathy in an Indian Population and Formulation of a New Plan Using eGFR/HbA1c Grid Formation

Background Diabetes is a metabolic, non-communicable disease (NCD) that represents one of the major causes of morbidity and mortality worldwide. India has a huge burden of chronic kidney disease (CKD) that is associated with diabetes. Materials and methods Cross-sectional data were collected for a total of 241 patients from the authors' clinic record. A new approach for the management of patients with diabetes was proposed using a grid system, where we need to consider the Hemoglobin A1C (HbA1c) and estimated glomerular filtration rate (eGFR) values of the patient and assign a zone (green, blue, orange or red) and subsequently decide an appropriate treatment according to the assigned zone. Results We found that 20.73% of patients had decreased eGFR and only 31.12% of patients achieved target HbA1c level. A high prevalence of diabetic nephropathy (20.73%) was observed in this study population. A statistically significant difference among the four groups (zones) with respect to age (p <0.001), duration of diabetes (p = 0.024), HbA1c (p <0.001), and eGFR (p <0.001) was found. Conclusion The burden of diabetes and nephropathy is high in low-income countries and can be easily assessed by applying simple tools such as the newly proposed HbA1c/eGFR grid system to identify high-risk and medium-risk patients and adopting treatment according to the assigned zone.

Real-world evidence of glycemic control among patients with type 2 diabetes mellitus in India: the TIGHT study

Objective

To determine glycemic control in adult patients with type 2 diabetes receiving antidiabetic therapy as part of routine healthcare in India.

Research design and methods

This was a retrospective analysis of cross-sectional data of patients with type 2 diabetes receiving oral hypoglycemic agents (OHAs) with or without insulin between 2015 and 2017. We assessed proportion of patients with uncontrolled glycemia and performed logistic regression to evaluate its association with various risk factors and microvascular complications.

Results

A total of 55 639 eligible records were identified; mean age of patients was 54.31 (±11.11) years. One-third of the study population had microvascular complications, predominantly neuropathy. Nearly 76.6% of patients had uncontrolled glycated hemoglobin (HbA1c) ≥7% (53 mmol/mol); 62% of these patients had HbA1c between 7% and 8% (53-64 mmol/mol). Glycemic control from combination of OHAs with or without insulin varied between 14.2% and 24.8%. In multivariate analysis, factors statistically associated with uncontrolled glycemia were obesity (OR: 1.15), hypertension (stage I OR: 1.65 and stage II OR: 2.73) and diabetes duration >5 years (OR: 1.19) (p<0.001). Similarly, the odds of having any microvascular complication increased with duration of diabetes (past 1-2 years, OR: 1.67; 2-5 years, OR: 2.53; >5 years, OR: 4.01; p<0.0001), hypertension (stage I, OR: 1.18 and stage II, OR: 1.34; p<0.05) and uncontrolled HbA1c (OR: 1.28; p<0.0001).

Conclusions

Indian population with type 2 diabetes has a high burden (76.6%) of poor glycemic control. This study highlights the need for early implementation of optimum diabetes pharmacotherapy to maintain recommended glycemic control, thereby reducing burden of microvascular complications.

Evidence-Based Consensus on Positioning of SGLT2i in Type 2 Diabetes Mellitus in Indians

The current diabetes management strategies not only aim at controlling glycaemic parameters but also necessitate continuous medical care along with multifactorial risk reduction through a comprehensive management concept. The sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a group of evolving antidiabetic agents that have the potential to play a pivotal role in the comprehensive management of patients with diabetes due to their diverse beneficial effects. SGLT2i provide moderate glycaemic control, considerable body weight and blood pressure reduction, and thus have the ability to lower the risk of macrovascular and microvascular complications. Some of the unique characteristics associated with SGLT2i, such as reduction in body weight (more visceral fat mass loss than subcutaneous fat loss), reduction in insulin resistance and improvement in β-cell function, as measured by homeostatic model assessment-β (HOMA-β) could be potentially beneficial and help in overcoming some of the challenges faced by Indian patients with diabetes. In addition, a patient-centric approach with individualised treatment during SGLT2i therapy is inevitable in order to reduce diabetic complications and improve quality of life. Despite their broad benefits profile, the risk of genital tract infections, volume depletion, amputations and diabetic ketoacidosis associated with SGLT2i should be carefully monitored. In this compendium, we systematically reviewed the literature from Medline, Cochrane Library, and other relevant databases and attempted to provide evidence-based recommendations for the positioning of SGLT2i in the management of diabetes in the Indian population.Funding: AstraZeneca Pharma India Limited.

Challenges in primary care for diabetes and hypertension: an observational study of the Kolar district in rural India

Background

Chronic diseases have emerged as the leading cause of death globally, and 20% of Indians are estimated to suffer from a chronic condition. Care for chronic diseases poses a major public health challenge, especially when health care delivery has been geared traditionally towards acute care. In this study, we aimed to better understand how primary care for diabetes and hypertension is currently organised in first-line health facilities in rural India, and propose evidence-based ways forward for strengthening local health systems to address chronic problems.

Methods

We used qualitative and quantitative methods to gain insight into how care is organised and how patients and providers manage within this delivery system. We conducted in-depth interviews with the medical doctors working in three private clinics and in three public primary health centres. We also interviewed 24 patients with chronic diseases receiving care in the two sub-sectors. Non-participant observations and facility assessments were performed to triangulate the findings from the interviews.

Results

The current delivery system has many problems impeding the delivery of quality care for chronic conditions. In both the public and private facilities studied, the care processes are very doctor-centred, with little room for other health centre staff. Doctors face very high workloads, especially in the public sector, jeopardising proper communication with patients and adequate counselling. In addition, the health information system is fragmented and provides little or no support for patient follow-up and self-management. The patient is largely left on their own in trying to make sense of their condition and in finding their way in a complex and scattered health care landscape.

Conclusions

The design and organisation of care for persons with chronic diseases in India needs to be rethought. More space and responsibility should be given to the primary care level, and relatively less to the more specialised hospital level. Furthermore, doctors should consider delegating some of their tasks to other staff in the first-line health facility to significantly reduce their workload and increase time available for communication. The health information system needs to be adapted to better ensure continuity of care and support self-management by patients.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3876-9) contains supplementary material, which is available to authorized users.