Clinical profile of diabetes in the young seen between 1992 and 2009 at a specialist diabetes centre in south India

Performance of European prediction models for classification of type 1 and type 2 diabetes in Indians

AIM

We aimed to determine the performance of European prediction models in an Indian population to classify type 1 diabetes(T1D) and type 2 diabetes(T2D).

METHODS

We assessed discrimination and calibration of published models of diabetes classification, using retrospective data from electronic medical records of 83309 participants aged 18-50 years living in India. Diabetes type was defined based on C-peptide measurement and early insulin requirement. Models assessed combinations of clinical measurements: age at diagnosis, body mass index(mean = 26.6 kg/m2), sex(male = 64.9 %), Glutamic acid decarboxylase(GAD) antibody, serum cholesterol, serum triglycerides, and high-density lipoprotein(HDL) cholesterol.

RESULTS

67955 participants met inclusion criteria, of whom 0.8 % had T1D, which was markedly lower than model development cohorts. Model discrimination for clinical features was broadly similar in our Indian cohort compared to the European cohort: area under the receiver operating characteristic curve(AUC ROC) was 0.90 vs. 0.90 respectively, but was lower in the subset of young participants with measured GAD antibodies(n = 2404): and an AUC ROC of 0.87 when clinical features, sex, lipids and GAD antibodies were combined. All models substantially overestimated the likelihood of T1D, reflecting the lower prevalence of T1D in the Indian population. However, good model performance was achieved after recalibration by updating the model intercept and slope.

CONCLUSION

Models for diabetes classification maintain the discrimination of T1D and T2D in this Indian population, where T2D is far more common, but require recalibration to obtain appropriate model probabilities. External validation and recalibration are needed before these tools can be used in non-European populations.

Sex-Based Differences in Clinical Profile and Complications among Individuals with Type 2 Diabetes Seen at a Private Tertiary Diabetes Care Centre in India

This study aimed to compare the clinical and biochemical profiles as well as the complications in males and females with type 2 diabetes (T2DM) presenting to a private tertiary diabetes care centre in India. This is a retrospective study, conducted between 1 January 2017 and 31 December 2019, and included 72,980 individuals with T2DM, aged ≥ 18 years (age and sex-matched-males-36,490; females-36,490). Anthropometric measurements, blood pressure, fasting plasma glucose (FPG), post-prandial plasma glucose (PPPG), glycated haemoglobin (HbA1c), lipids, urea, and creatinine were measured. Retinopathy was screened using retinal photography, neuropathy using biothesiometry, nephropathy measuring urinary albumin excretion, peripheral vascular disease (PVD) using Doppler, and coronary artery disease (CAD) based on the history of myocardial infarction and/or drug treatment for CAD and/or electrocardiographic changes. Obesity (73.6% vs. 59.0%) rates were significantly higher in females compared to males. FPG, PPPG, and HbA1c were higher among younger age groups among both sexes, with males having higher values compared to females. However, after the age of 44 years, control of diabetes was worse among females. In addition, only 18.8% of the females achieved glycemic control (HbA1c < 7%) compared to 19.9% in males (p < 0.001). Males had higher prevalence of neuropathy (42.9% vs. 36.9%), retinopathy (36.0% vs. 26.3%), and nephropathy (25.0% vs. 23.3%) compared to females. Males had 1.8- and 1.6-times higher risk of developing CAD and retinopathy compared to females. Hypothyroidism (12.5% vs. 3.5%) and cancers (1.3% vs. 0.6%) were significantly higher in females compared to males. In this large sample of T2DM seen at a chain of private tertiary diabetes centres, females had higher prevalence of metabolic risk factors and poorer diabetes control compared to males, emphasizing the need for better control of diabetes in females. However, males had higher prevalence of neuropathy, retinopathy, nephropathy, and CAD compared to females.

Clinical and biochemical profile of childhood-adolescent-onset type 1 diabetes and adult-onset type 1 diabetes among Asian Indians

AIM

To compare the clinical and biochemical profile and prevalence of complications among childhood/adolescent-onset (CAO; onset of diabetes< 20 years of age) and adult-onset (AO; onset of diabetes- ≥ 20 years of age) type 1 diabetes (T1D), seen at a tertiary care diabetes center in south India.

METHOD

Data of 5578 individuals with T1D, diagnosed based on a history of diabetic ketoacidosis or ketonuria, fasting C-peptide < 0.3 pmol/mL and stimulated C-peptide values < 0.6 pmol/mL, and requirement of insulin right from the time of diagnosis, presenting to our center between 1991 and 2021, were retrieved from our electronic medical records. Retinopathy was assessed by retinal photography, chronic kidney disease (CKD) by urinary albumin excretion ≥ 30 µg/mg of creatinine and/or eGFR < 60 mL/min, and neuropathy by vibration perception threshold >= 20v on biothesiometry.

RESULTS

Overall, 3559 (63.8%) of individuals with T1D, belonged to CAO group and 2019 (36.2%) to AO category. AO had higher prevalence of all microvascular complications compared to CAO at every diabetes duration interval, even after adjusting for A1c. Among the AO group, prevalence of retinopathy, CKD, and neuropathy was higher in the GAD negative group. Among CAO there were no differences between the GAD negative and GAD positive groups with respect to prevalence of complications of diabetes.

CONCLUSION

AO with T1D had higher prevalence of microvascular complications compared to CAO. Among AO, GAD negative individuals had higher percentage of retinopathy and CKD compared to GAD positive group.

Use of Ferulic Acid in the Management of Diabetes Mellitus and Its Complications

Diabetes mellitus, a metabolic disease mainly characterized by hyperglycemia, is becoming a serious social health problem worldwide with growing prevalence. Many natural compounds have been found to be effective in the prevention and treatment of diabetes, with negligible toxic effects. Ferulic acid (FA), a phenolic compound commonly found in medicinal herbs and the daily diet, was proved to have several pharmacological effects such as antihyperglycemic, antihyperlipidemic and antioxidant actions, which are beneficial to the management of diabetes and its complications. Data from PubMed, EM-BASE, Web of Science and CNKI were searched with the keywords ferulic acid and diabetes mellitus. Finally, 28 articles were identified after literature screening, and the research progress of FA for the management of DM and its complications was summarized in the review, in order to provide references for further research and medical applications of FA.

A systematic review of the prevalence, risk factors and screening tools for autonomic and diabetic peripheral neuropathy in children, adolescents and young adults with type 1 diabetes

AIMS

We aimed to estimate the prevalence of Diabetic peripheral neuropathy (DPN) and Cardiac autonomic neuropathy (CAN) in youth with type 1 diabetes; identify key risk factors; identify the most useful tests for the diagnostic evaluation of DPN and CAN; identify key treatment options for DPN and CAN.

METHODS

A systematic search was performed including studies published in the last 15 years. PICO framework was used in the selection process and evidence was assessed using the GRADE system.

RESULTS

A total of 758 studies were identified and a final number of 49 studies were included in this systematic review. According to moderate-high level quality studies, the prevalence of probable DPN, ranged between 13.5 and 62%; subclinical DPN between 22 and 88%; confirmed DPN between 2.6 and 11%. The Michigan Neuropathy Screening Instrument was the tool with higher sensitivity and specificity for detecting DPN, which needs to be confirmed by nerve conduction velocity. The prevalence of CAN was 4-39%. Specific treatment options for DPN or CAN in patients younger than 25 years are not available. Key risk factors for DPN and CAN are hyperglycemia/HbA1c, age, diabetes duration, the presence of other microvascular complications, waist/height ratio, lipid profile and blood pressure. For CAN, additional risk factors were cigarette smoking, BMI and total daily insulin.

CONCLUSIONS

Prevalence of neuropathy in youth with type 1 diabetes varies depending on different screening methods and characteristics of the study populations. However, the assessed studies confirmed a relatively high prevalence of subclinical neuropathy, reiterating the importance of early identification of risk factors to prevent this complication.

Frequency and association of self-reported oral cancer among individuals with type 2 diabetes at a tertiary care diabetes centre in South India - A retrospective study

AIM

To assess the frequency of self-reported oral cancer and associated factors among individuals with type 2 diabetes (T2D) at a tertiary care diabetes centre in South India.

METHODS

Individuals with T2D who reported that they had oral cancer were included from the Diabetes Electronic Medical Records (DEMR) database. To assess the association of oral cancer with T2D, a retrospective nested case-control study design was adopted. Individuals with T2D and oral cancer diagnosed after the diagnosis of T2D (n = 78) were considered 'cases', while T2D without oral cancer were considered 'controls' (312) [in a ratio of 1:4 for cases and controls]. The cases and controls were matched for age, gender and duration of diabetes. Logistic regression was used to model predictors of oral cancer in T2D patients.

RESULTS

Oral cancer was reported in 78 out of 379,138 (0.02%) individuals with T2D registered at the centre. Logistic regression analysis showed that a HbA1c value ≥ 9% had a significant association with oral cancer with an odds ratio of 2.3 (95% CI: 1.2-4.6) after adjusting for confounding factors. Among individuals with T2D, higher frequency of oral cancer prevalence and risk was observed among those who used any form of tobacco (32.6%, OR = 2.52, 95% CI: 1.5-4.3), consumed alcohol (29.2%, OR = 2.01, 95% CI: 1.2-3.3), and those with hypertension (23.9%, OR = 2.05, 95% CI: 1.2-3.6) and hypertriglyceridemia (24.7%, OR = 1.66, 95% CI: 1.01-2.7). Significant independent predictors of oral cancer among T2D were tobacco use (OR = 2.06, 95% CI: 1.1-4.00), high HbA1c (OR = 1.3, 95% CI: 1.03-1.5), hypertension (OR = 2.3, 95% CI: 1.3-4.2) and insulin use (OR = 1.8, 95% CI: 1.03-3.2).

CONCLUSIONS

Regular dental check-ups as part of the follow-up for individuals with T2D will identify and diagnose oral cancer earlier. Further research is required to assess the physiological and biological mechanisms leading to oral cancer in individuals with T2D.

Clinical Profile of Long-Term Survivors and Nonsurvivors with Type 1 Diabetes in India

Objective: To compare the clinical profile of long-term survivors and nonsurvivors with type 1 diabetes (T1D) in India. Research Design and Methods: This is a retrospective study of 76 individuals with T1D who had survived for at least 40 years ("survivors") and 51 individuals with T1D who had died with shorter duration of diabetes ("non-survivors"), from diabetes clinics in different cities of India. Prevalence of complications in both groups and causes of death of the nonsurvivors were analyzed. Retinopathy was diagnosed by retinal photography; chronic kidney disease (CKD) by urinary albumin excretion (micro-or macroalbuminuria) and estimated glomerular filtration rate; peripheral vascular disease (PVD) by doppler measurement of ankle-brachial pressure index; coronary artery disease (CAD) based on history of myocardial infarction or coronary revascularization, and neuropathy by biothesiometry. Results: Mean glycated hemoglobin (8.4% ± 1.5% vs. 10.7% ± 2.2%, P < 0.001), serum low-density lipoprotein cholesterol (91 ± 29 mg/dL vs. 107 ± 22 mg/dL, P = 0.004), and systolic blood pressure (135 ± 16 mmHg vs. 153 ± 37 mmHg, P = 0.003) were lower, and high-density lipoprotein cholesterol (51 ± 11 mg/dL vs. 43 ± 15 mg/dL, P = 0.002) higher, among survivors compared to nonsurvivors. Diabetic retinopathy, CKD, neuropathy, PVD, and CAD were more frequent among nonsurvivors. CAD [25.5%] and renal failure [23.5%] were the most frequent causes of death. Conclusions: In this first report of long-term survivors with T1D from India, we report that survivors had better glycemic and blood pressure control, more favorable lipid profiles and lower prevalence of complications compared to nonsurvivors. However, there could be other protective factors as well, which merit further studies.

Spectrum of Phenotypes and Causes of Type 2 Diabetes in Children

Several factors, including genetics, family history, diet, physical activity, obesity, and insulin resistance in puberty, appear to increase the risk of type 2 diabetes in youth. Youth-onset type 2 diabetes is often thought of as a single entity but rather exists as a spectrum of disease with differences in presentation, metabolic characteristics, clinical progression, and complication rates. We review what is currently known regarding the risks associated with developing type 2 diabetes in youth. Additionally, we focus on the spectrum of phenotypes of pediatric type 2 diabetes, discuss the pathogenic underpinnings and potential therapeutic relevance of this heterogeneity, and compare youth-onset type 2 diabetes with type 1 diabetes and adult-onset type 2 diabetes. Finally, we highlight knowledge gaps in prediction and prevention of youth-onset type 2 diabetes.

Retrospective analysis (2009-2017) of factors associated with progression and regression of non-alcoholic fatty liver disease (Hepatic steatosis) in patients with type 2 diabetes seen at a tertiary diabetes centre in Southern India

AIM

To identify the profiles and factors associated with progression/regression of ultrasound-derived hepatic steatosis with type 2 diabetes mellitus seen at a tertiary diabetes center in southern India.

METHODS

Participants were individuals with type 2 diabetes mellitus with at least two consecutive ultrasound measurements available. Hepatic steatosis was assessed using high-resolution B-mode ultrasonography. Admittedly ultrasonography has lower sensitivity and specificity, however, it is the only modality available in a routine clinical setting to screen for hepatic steatosis. Progression or regression of hepatic steatosis was assessed after a mean follow-up of 3.0 ± 2.1 years and correlated with clinical and biochemical parameters.

RESULTS

A total of 1835 participants with type 2 diabetes mellitus were studied, of whom 88.6% had some form of hepatic steatosis at baseline which included mild steatosis (grade 1) in 982 (53.5%), moderate steatosis (grade 2) in 628 (34.2%) and severe steatosis (grade 3) in 15 (0.8%). Hepatic steatosis progression, regression or no change in grade of hepatic steatosis were seen in 21.5%, 26.6% and 51.9% of participants. Increase in body weight, body mass index, glycated haemoglobin, serum triglycerides and gamma glutamyl transferase were the factors associated with progression of hepatic steatosis, whereas regression showed reduction in body weight, body mass index, fasting plasma glucose and glycated haemoglobin.

CONCLUSION

Among South Indian type 2 diabetes patients with hepatic steatosis, severity of steatosis progressed in 1/3rd while it regressed in 1/4th. These retrospective data need proper ascertainment in controlled studies.

Profiles of Intraday Glucose in Type 2 Diabetes and Their Association with Complications: An Analysis of Continuous Glucose Monitoring Data

Aims: To identify profiles of type 2 diabetes from continuous glucose monitoring (CGM) data using ambulatory glucose profile (AGP) indicators and examine the association with prevalent complications. Methods: Two weeks of CGM data, collected between 2015 and 2019, from 5901 adult type 2 diabetes patients were retrieved from a clinical database in Chennai, India. Non-negative matrix factorization was used to identify profiles as per AGP indicators. The association of profiles with existing complications was examined using multinomial and logistic regressions adjusted for glycated hemoglobin (HbA1c; %), sex, age at onset, and duration of diabetes. Results: Three profiles of glycemic variability (GV) were identified based on CGM data-Profile 1 ["TIR Profile"] (n = 2271), Profile 2 ["Hypo"] (n = 1471), and Profile 3 ["Hyper"] (n = 2159). Compared with time in range (TIR) profile, those belonging to Hyper had higher mean fasting plasma glucose (202.9 vs. 167.1, mg/dL), 2-h postprandial plasma glucose (302.1 vs. 255.6, mg/dL), and HbA1c (9.7 vs. 8.6; %). Both "Hypo profile" and "Hyper profile" had higher odds of nonproliferative diabetic retinopathy ("Hypo": 1.44, 1.20-1.73; "Hyper": 1.33, 1.11-1.58), macroalbuminuria ("Hypo": 1.58, 1.25-1.98; "Hyper": 1.37, 1.10-1.71), and diabetic kidney disease (DKD; "Hypo": 1.65, 1.18-2.31; "Hyper": 1.88, 1.37-2.58), compared with "TIR profile." Those in "Hypo profile" (vs. "TIR profile") had higher odds of proliferative diabetic retinopathy (PDR; 2.84, 1.65-2.88). Conclusions: We have identified three profiles of GV from CGM data. While both "Hypo profile" and "Hyper profile" had higher odds of prevalent DKD compared with "TIR profile," "Hypo profile" had higher odds of PDR. Our study emphasizes the clinical importance of recognizing and treating hypoglycemia (which is often unrecognized without CGM) in patients with type 2 Diabetes Mellitus.

Diagnosis, treatment and prevention of type 2 diabetes mellitus in children and adolescents

During the last two decades, there have been several reports of an increasing incidence of type 2 diabetes mellitus (T2DM) in children and adolescents, especially among those belonging to minority ethnic groups. This trend, which parallels the increases in prevalence and degree of pediatric obesity, has caused great concern, even though T2DM remains a relatively rare disease in children. Youth T2DM differs not only from type 1 diabetes in children, from which it is sometimes difficult to differentiate, but also from T2DM in adults, since it appears to be an aggressive disease with rapidly progressive β-cell decline, high treatment failure rate, and accelerated development of complications. Despite the recent research, many aspects of youth T2DM still remain unknown, regarding both its pathophysiology and risk factor contribution, and its optimal management and prevention. Current management approaches include lifestyle changes, such as improved diet and increased physical activity, together with pharmacological interventions, including metformin, insulin, and the recently approved glucagon-like peptide-1 analog liraglutide. What is more important for everyone to realize though, from patients, families and physicians to schools, health services and policy-makers alike, is that T2DM is a largely preventable disease that will be addressed effectively only if its major contributor (i.e., pediatric obesity) is confronted and prevented at every possible stage of life, from conception until adulthood. Therefore, relevant comprehensive, coordinated, and innovative strategies are urgently needed.

Impact of age at type 2 diabetes mellitus diagnosis on mortality and vascular complications: systematic review and meta-analyses

AIMS/HYPOTHESIS

Few studies examine the association between age at diagnosis and subsequent complications from type 2 diabetes. This paper aims to summarise the risk of mortality, macrovascular complications and microvascular complications associated with age at diagnosis of type 2 diabetes.

METHODS

Data were sourced from MEDLINE and All EBM (Evidence Based Medicine) databases from inception to July 2018. Observational studies, investigating the effect of age at diabetes diagnosis on macrovascular and microvascular diabetes complications in adults with type 2 diabetes were selected according to pre-specified criteria. Two investigators independently extracted data and evaluated all studies. If data were not reported in a comparable format, data were obtained from authors, presented as minimally adjusted ORs (and 95% CIs) per 1 year increase in age at diabetes diagnosis, adjusted for current age for each outcome of interest. The study protocol was recorded with PROSPERO International Prospective Register of Systematic Reviews (CRD42016043593).

RESULTS

Data from 26 observational studies comprising 1,325,493 individuals from 30 countries were included. Random-effects meta-analyses with inverse variance weighting were used to obtain the pooled ORs. Age at diabetes diagnosis was inversely associated with risk of all-cause mortality and macrovascular and microvascular disease (all p < 0.001). Each 1 year increase in age at diabetes diagnosis was associated with a 4%, 3% and 5% decreased risk of all-cause mortality, macrovascular disease and microvascular disease, respectively, adjusted for current age. The effects were consistent for the individual components of the composite outcomes (all p < 0.001).

CONCLUSIONS/INTERPRETATION

Younger, rather than older, age at diabetes diagnosis was associated with higher risk of mortality and vascular disease. Early and sustained interventions to delay type 2 diabetes onset and improve blood glucose levels and cardiovascular risk profiles of those already diagnosed are essential to reduce morbidity and mortality. Graphical abstract.

Treatment regimens and glycosylated hemoglobin levels in youth with Type 1 and Type 2 diabetes: Data from SEARCH (United States) and YDR (India) registries

OBJECTIVE

To compare treatment regimens and glycosylated hemoglobin (A1c) levels in Type 1 (T1D) and Type 2 diabetes (T2D) using diabetes registries from two countries-U.S. SEARCH for Diabetes in Youth (SEARCH) and Indian Registry of youth onset diabetes in India (YDR).

METHODS

The SEARCH and YDR data were harmonized to the structure and terminology in the Observational Medical Outcomes Partnership Common Data Model. Data used were from T1D and T2D youth diagnosed <20 years between 2006-2012 for YDR, and 2006, 2008, and 2012 for SEARCH. We compared treatment regimens and A1c levels across the two registries.

RESULTS

There were 4003 T1D (SEARCH = 1899; YDR = 2104) and 611 T2D (SEARCH = 384; YDR = 227) youth. The mean A1c was higher in YDR compared to SEARCH (T1D:11.0% ± 2.9% vs 7.8% ± 1.7%, P < .001; T2D:9.9% ± 2.8% vs 7.2% ± 2.1%, P < .001). Among T1D youth in SEARCH, 65.1% were on a basal/bolus regimen, whereas in YDR, 52.8% were on once/twice daily insulin regimen. Pumps were used by 16.2% of SEARCH and 1.5% of YDR youth with T1D. Among T2D youth, in SEARCH and YDR, a majority were on metformin only (43.0% vs 30.0%), followed by insulin + any oral hypoglycemic agents (26.3% vs 13.7%) and insulin only (12.8% vs 18.9%), respectively.

CONCLUSION

We found significant differences between SEARCH and YDR in treatment patterns in T1D and T2D. A1c levels were higher in YDR than SEARCH youth, for both T1D and T2D, irrespective of the regimens used. Efforts to achieve better glycemic control for youth are urgently needed to reduce the risk of long-term complications.

Clinical profile and incidence of microvascular complications of childhood and adolescent onset type 1 and type 2 diabetes seen at a tertiary diabetes center in India

AIM

To study the clinical characteristics and incidence of microvascular complications among childhood and adolescent onset type 1 (T1DM) and type 2 diabetes (T2DM) seen at a tertiary care diabetes center in India.

METHODS

From our electronic medical records, we retrieved clinical and biochemical details of 4555 individuals with childhood and adolescent onset diabetes (diagnosed below the age of 20 years) seen between 1992 and 2017. T1DM was diagnosed if there was history of ketoacidosis or fasting C-peptide <0.3 PMol/mL and stimulated C-peptide <0.6 PMol/mL or if insulin treatment was required from the time of diagnosis. T2DM was diagnosed based on absence of ketosis, or fasting C-peptide ≥0.6 PMol/mL and stimulated >1.0 PMoL/mL, or response to oral hypoglycemic agents for more than 2 years. We calculated the incidence rates of retinopathy (presence of at least one definite microaneurysm by retinal photography), nephropathy (urinary albumin excretion ≥30 μg/mg of creatinine) and neuropathy (vibration perception threshold ≥20 V) per 1000 person-years of follow up.

RESULTS

Among the 4555 individuals with childhood and adolescent-onset diabetes, 71.4% had T1DM, 19.5% T2DM and 9.1% other forms of diabetes. Age at first visit and duration of diabetes were significantly higher in T2DM when compared to T1DM. The age adjusted incidence of retinopathy was 52.9/1000 person years (Confidence Intervals [CI]: 42.9-62.8) in T1DM and 49.8/1000 person years (CI 30.8-68.8) in T2DM; nephropathy, 6.2 (CI 3.3-9.0) and 13.8 (CI 5.6-22.0); and neuropathy, 8.8(CI 3.6-14.0) and 24.0 (CI 9.8-38.2) in T1DM and T2DM, respectively.

CONCLUSION

The incidence of microvascular complications is high among childhood and adolescent-onset T1DM and T2DM and these calls for more aggressive control of diabetes.

The changing face of paediatric diabetes

The purpose of this review is to provide an update on the changing face of paediatric type 1 diabetes and type 2 diabetes. Paediatric diabetes is on the rise, with extensive research dedicated to understanding its pathophysiology, comorbidities and complications. As obesity continues to increase among all youth, differentiating between type 1 diabetes and type 2 diabetes has become increasingly difficult but remains important for optimising treatment, anticipating complications and predicting disease risk. Novel treatments are emerging, with the ultimate goal being to achieve glycaemic control, limit weight gain, improve quality of life and reduce comorbidities. In this review, we focus on updates regarding the epidemiology, clinical presentation, comorbidities and complications of paediatric type 1 diabetes and type 2 diabetes and conclude with current and emerging treatments.

Clinical Profile of Elderly Patients (Over 90 Years) with Type 2 Diabetes Seen at a Diabetes Center in South India

Background: The current life expectancy in India is <70 years. Type 2 diabetes mellitus (T2DM) is known to reduce life expectancy by 6-8 years. Hence elderly people with T2DM in India would be rare. We report on the clinical profile of Asian Indian patients with T2DM who lived beyond 90 years of age and compared them with T2DM patients aged 50 to 60 years. Methods: From the diabetes electronic medical records of >470,000 diabetes patients, we identified T2DM patients who had lived ≥90 years and compared them with those in the 50-60 years age group, matched for gender and duration of diabetes. Clinical data included age at last visit, age at diagnosis, duration of diabetes, family history, smoking and alcohol, details of medications, body mass index (BMI), and blood pressure. Biochemical data included fasting and postprandial plasma glucose, glycated hemoglobin, fasting and stimulated C-peptide levels, lipid profile, and renal function studies. Assessment of retinopathy, nephropathy, neuropathy, coronary artery disease (CAD), and peripheral vascular disease (PVD) was also done. Results: A total of 325 T2DM patients aged ≥90 years and 278 T2DM patients aged between 50 and 60 years were selected for the study. Patients aged ≥90 years had higher systolic blood pressure (P < 0.001) and lower BMI (P < 0.001) than those between 50 and 60 years. Prevalence of retinopathy (29.7% vs. 53.5%) and macroalbuminuria (3.7% vs. 16.0%) was lower in the ≥90 years T2DM patients than in the 50-60 years age group. However, prevalence of neuropathy (89.8% vs. 50.8%), PVD (13.5% vs. 2.0%), and CAD (60.3% vs. 32.0%) was higher among the ≥90 years patients. Eighty-five percent of the T2DM aged ≥90 years were on oral hypoglycemic agents (OHAs), (of whom 64.9% were on sulfonylurea), 12% were on insulin, and 3% on diet alone. Among the 50-60 years old, 87.8% were on OHAs and 12.2% on insulin. Conclusions: This is the first report on the clinical profile of Asian Indians with T2DM aged ≥90 years, and significant differences are seen in their clinical profile compared with younger T2DM patients.

Clinical features, biochemistry and HLA-DRB1 status in children and adolescents with diabetes in Dhaka, Bangladesh

AIMS

Little information is published on diabetes in young people in Bangladesh. We aimed to investigate the demographic, clinical, and biochemical features, and HLA-DRB1 alleles in new cases of diabetes affecting Bangladeshi children and adolescents <22 years of age.

METHODS

The study was conducted at Bangladesh Institute of Research and Rehabilitation of Diabetes, Endocrine and Metabolic Disorders (BIRDEM) in Dhaka. One hundred subjects aged <22 years at diagnosis were enrolled. Demographic characteristics, clinical information, biochemical parameters (blood glucose, HbA1c, C-peptide, and autoantibodies against glutamic acid decarboxylase 65 (GADA) and islet antigen-2 (IA-2A) were measured. High-resolution DNA genotyping was performed for HLA-DRB1.

RESULTS

Eighty-four subjects were clinically diagnosed as type 1 diabetes (T1D), seven as type 2 diabetes (T2D), and nine as fibrocalculous pancreatic disease (FCPD). Of the 84 with T1D, 37 (44%) were males and 47 (56%) females, with median age at diagnosis 13 years (y) (range 1.6-21.7) and peak age at onset 12-15 years. 85% of subjects were assessed within one month of diagnosis and all within eleven months. For subjects diagnosed with T1D, mean C-peptide was 0.46 ± 0.22 nmol/L (1.40 ± 0.59 ng/mL), with 9 (10.7%) IA-2A positive, 22 (26%) GADA positive, and 5 (6%) positive for both autoantibodies. Analysis of HLA-DRB1 genotypes revealed locus-level T1D association (p = 6.0E-05); DRB1*04:01 appeared predisposing (p < 3.0E-06), and DRB1*14:01 appeared protective (p = 1.7E-02).

CONCLUSIONS

Atypical forms of T1D appear to be more common in young people in Bangladesh than in European populations. This will be helpful in guiding more specific assessment at onset and potentially, expanding treatment options.

Clinical characteristics, types and complications of diabetics with young age at the onset (14-25 years)

AIMS

To determine the distribution, clinical features and complications of the different types of diabetes in young age.

METHODS

The records of children and adolescents with age at the onset of DM (14-25 years) between January 2017 and August 2018, were reviewed. Clinical and laboratory characteristics of the patients at diagnosis and type of diabetes were recorded.

RESULTS

Out of 80 patients (48 males, 32 females), 53 had type 1 DM (66.2%) and 27 had type 2 DM (33.8%). Mean age at the onset of diabetes was 19.75 ± 4.01 years for type 1 DM and 21.37 ± 3.08 years for type 2 DM. Family history of DM was more common in type 2 DM (62.9% of parents, p = 0.000389). Mean BMI in type 2 DM (25.03 ± 5.88 kg/m2) was higher than in type 1 DM (p = 0.009). Osmotic symptoms were more common in type 1 DM (73.06%, p = 0.00151).

CONCLUSION

Osmotic symptoms and ketosis were more common in young age type 1 DM. Family history of DM was more common in parents of type 2 DM.

Clinical profile of nonalcoholic Fatty liver disease among young patients with type 1 diabetes mellitus seen at a diabetes speciality center in India

OBJECTIVE

To estimate the prevalence and clinical profile of nonalcoholic fatty liver disease (NAFLD) among young type 1 diabetes mellitus (T1DM) patients at a tertiary care diabetes center in India.

METHODS

Electronic medical records of T1DM patients (age at first diagnosis of T1DM ≤25 years) registered between January 1992 and May 2013 who had undergone ultrasonography and denied history of any alcohol intake (n = 736) were reviewed. NAFLD was diagnosed if there was any degree of fatty liver. Retinopathy was initially assessed by direct and indirect ophthalmoscopy and later by retinal photography. Nephropathy was diagnosed if urine protein excretion was >500 mg/day, and neuropathy was diagnosed if a patient's vibration perception threshold on biothesiometry was ≥20 V.

RESULTS

A total of 204/736 (27.7%) T1DM patients had NAFLD. Compared to T1DM subjects without NAFLD those with NAFLD had higher body mass index (BMI) (18.9 ± 4.2 vs. 20.2 ± 4.7 kg/m2, P<.001), waist circumference (67.9 ± 13.2 vs. 71.9 ± 13.3 cm, P<.05), systolic blood pressure (110 ± 15 vs. 116 ± 18 mm Hg, P<.001) and diastolic blood pressure (72 ± 9 vs. 74 ± 10 mm Hg, P<.05), while fasting blood glucose (201 ± 101 vs. 183 ± 101 mg/dL, P<.05) and alkaline phosphatase (419 [12.5] vs. 315 [15.8], P<.001) levels were lower in patients with T1DM with NAFLD. Multiple logistic regression analysis showed a significant association between NAFLD and retinopathy (odds ratio [OR]: 2.01, 95% confidence interval [CI]: 1.13-3.43; P = .017, after adjusting for sex, duration of diabetes, overweight/obesity, hypertension, fasting plasma glucose, nephropathy, and nephropathy (OR: 1.89, 95% CI: 1.02-3.50; P = .042), after adjusting for sex and fasting plasma glucose.

CONCLUSIONS

This study suggests that NAFLD is also seen among T1DM patients and that it has an independent and significant association with retinopathy and nephropathy.

Prevalences and Management of Diabetes and Pre-diabetes among Korean Teenagers and Young Adults: Results from the Korea National Health and Nutrition Examination Survey 2005-2014

The rapid increases in childhood obesity and physical inactivity are linked to the incidence of diabetes among young individuals. However, few studies have evaluated the prevalence of diabetes among this population. Therefore, we used Korea National Health and Nutrition Examination Survey (KNHANES) data to evaluate the prevalence and management of diabetes and pre-diabetes among young Koreans. We evaluated KNHANES data (2005-2014) from 10-29-year-old individuals. Individuals were considered eligible if they had completed the health examination and the health interview survey, and we excluded individuals with missing data regarding fasting glucose or glycated haemoglobin levels. Among the 100,101 potentially eligible individuals who participated in KNHANES (2005-2014), we included 83,577 (37,677 male and 45,900 female) individuals. The overall prevalences of diabetes and pre-diabetes among 10-19-year-old individuals were 0.2% and 11.9%, respectively. Among 20-29-year-old individuals, the prevalences of diabetes and pre-diabetes were 0.9% and 9.6%, respectively. The overall rates of diabetes awareness during the study period were 36.6% for 10-19-year-old individuals and 50.8% for 20-29-year-old individuals. However, the prevalence of diabetes and pre-diabetes had noticeably increased at the 2013-2014 KNHANES: 0.6% and 25.9% among 10-19-year-old individuals, and 0.8% and 19.2% among 20-29-year-old individuals. The prevalence of diabetes and pre-diabetes is rapidly increasing among Korean teenagers and young adults. Pre-emptive interventions to diagnose and treat diabetes and pre-diabetes are needed to improve glycaemic control among this population.

Distinct Predictors and Comorbidities in Early Onset Type 2 Diabetes Mellitus Among Asian Indians

BACKGROUND

The incidence of type 2 diabetes mellitus (T2DM) is increasing worldwide, and the age of disease onset is falling. Although there is rising prevalence of early onset T2DM in India, little is known about their clinical characteristics and cardiovascular risks profiles. The aim of this study was to address this knowledge gap by comparing the characteristics of early onset T2DM and usual onset T2DM patients from our clinic population in India.

METHODS

We studied the clinical and biochemical parameters of 98 consecutive early onset T2DM patients of age <45 and <5 years of disease duration and compared those parameters with 86 consecutive usual onset T2DM patients of age >50 years and similar disease duration.

RESULTS

There was a strong component of family history of T2DM in early onset T2DM patients; however, no difference was observed in body mass index or waist circumference between the groups. When compared with usual onset group, the early onset T2DM patients were more hypertriglycedemic, with higher total cholesterol, higher total cholesterol/high-density lipoprotein (HDL) ratio, higher low-density lipoprotein levels, and lower HDL cholesterol. Early onset T2DM patients showed significantly worse glycemic control and rapid decline in insulin secretion compared with usual onset T2DM patients.

CONCLUSIONS

Our results demonstrate that early onset T2DM in Asian Indians appears to be a disease phenotype with adverse risk factors having poor glycemic control and longer disease duration demanding strategies for novel clinical management.

Anthropometric indicators as predictor of pre-diabetes in Indian adolescents

Introduction

In India, there are approximately 41 million diabetics to date. Impaired glucose tolerance or pre-diabetes may occur as early as adolescence.

Objective

To find out the cut-off values of body mass index (BMI) and waist circumference to predict pre-diabetes in adolescents in north India.

Methods

A cross-sectional study was conducted among 526 students aged 17–19 years, in the Institute of Paramedical Sciences, Chatrapati Shahuji Maharaj University, Kanpur. A pre-tested questionnaire was used and the diagnostic criteria of the American Diabetic Association were applied. Receiver operating characteristic(ROC) analysis was used to assess the cut-offs of BMI and waist circumference for predicting prediabetes.

Results

ROC analysis showed that BMI is a good predictor of prediabetes for both boys and girls.Area under the ROC curve was 0.828 for boys and 0.838 for girls, respectively. The cut-off values of BMI for predicting prediabetes were identified as ≥22.8 kg/m² in boys and ≥20.5 kg/m² in girls. Upon ROC analysis for waist circumference, it was observed that it was a good predictor of prediabetes both for boys (area under the curve 0.804) and girls (area under the curve 0.795). The cut-offs for waist circumference for predicting prediabetes were found to be ≥82.5 cm for boys and ≥80.3 cm for girls.

Conclusion

BMI and waist circumference estimation can be done for early detection of prediabetes in adolescents for further diagnostic evaluation and management.

Vascular and Endothelial Function in Youth with Type 2 Diabetes Mellitus

PURPOSE OF REVIEW

This review aims to discuss the burden of type 2 diabetes in youth and summarize the studies that have utilized noninvasive techniques to assess early vascular disease in youth with type 2 diabetes.

RECENT FINDINGS

Noninvasive imaging modalities provide researchers with tools to investigate the vasculature in adolescents with type 2 diabetes. The data published to date consistently show adolescents with type 2 diabetes have greater vascular thickness and stiffness and worse endothelial function compared to their obese and lean peers. As the prevalence of type 2 diabetes continues to increase adolescent youth, there is concern adolescents with type 2 diabetes are at risk to develop early onset cardiovascular disease and complications. Future studies need to address treatments that have the potential to improve or reverse vascular dysfunction and decrease the rate of cardiovascular disease and complications.

Incidence of complications in young-onset diabetes: Comparing type 2 with type 1 (the young diab study)

BACKGROUND

There is little data on the incidence of diabetes complications in young onset type 1 diabetes (T1DM) and type 2 diabetes (T2DM) in non European populations.

METHODS

From a tertiary diabetes centre, Chennai, India, we recruited 108 T1DM (defined by abrupt onset of symptoms or diabetic ketoacidosis, absent insulin reserve requiring insulin treatment) and 90 T2DM participants (defined by absence of ketosis, good beta-cell reserve, and good response to oral agents) who were diagnosed between the ages of 10 and 25years, and without any evidence of diabetes complications at diagnosis. We estimated the incidence of various complications (median follow up of five years); retinopathy was defined by presence of at least one definite microaneurysm by retinal photography, nephropathy by urinary albumin excretion ⩾30μg/mg of creatinine, neuropathy by vibration perception threshold ⩾20V on biothesiometry, peripheral vascular disease by an ankle-brachial index <0.9, and ischemic heart disease (IHD) by history of myocardial infarction or coronary revascularization or Q waves on ECG or on drug treatment for IHD.

RESULTS

The mean ages at diagnosis of T1DM and T2DM participants were 17.1±4.2vs. 21.6±3.6years respectively. The incidence of various complications reported in numbers/1000 person years of follow up of T1DM and T2DM were: retinopathy 77.4vs. 78.0/1000 person years, nephropathy, 62.0vs. 58.8, neuropathy 7.8 vs. 13.9 and ischemic heart disease 1.2vs. 5.4. In Cox regression analysis, after adjustment for age, glycated hemoglobin, systolic blood pressure and serum cholesterol, T2DM participants had 2.11 times (95%CI: 1.27-3.51) higher risk of developing any diabetes complication, compared to T1DM.

CONCLUSIONS

Young-onset T2DM have a more aggressive disease course than T1DM.

Replication of genome-wide association signals in Asian Indians with early-onset type 2 diabetes

AIMS

To evaluate the association of 87 genetic variants previously associated with type 2 diabetes mellitus (T2DM) in genome-wide association studies of populations of European ancestry in an Asian Indian population with early-onset type 2 diabetes mellitus (EOT2DM).

METHODS

The study groups comprised of 877 type 2 diabetes individuals, 436 individuals with EOT2DM (age at diagnosis below 35 years), 441 individuals with older T2DM (diagnosis at 35 years or greater) and controls with normal glucose tolerance (NGT) (n = 400 younger than 35 years; n = 438 older than 35 years). The participants were genotyped for 87 SNPs from 44 genes and 27 intergenic loci. Associations were tested using logistic regression.

RESULTS

All the variants in TCF7L2 and CDKN2A/2B showed study-wide significance (p < 1.4 × 10^-4) with T2DM, but only rs7903146, rs12243326, rs12255372 of TCF7L2 and rs7020996 of CDKN2A/2B showed study-wide significance (p < 1.4 × 10^-4) with EOT2DM in this population. In addition, an intergenic SNP on chromosome 1 (rs10493685) was also shown to be study-wide significant (p = 7.1 × 10^-6). Several additional SNPs previously associated with T2DM reached borderline significance in this study, but may have been limited by relatively low sample numbers. Various other SNPs of T2DM were not associated with EOT2DM.

CONCLUSIONS

Some of the variants in TCF7L2 and CDKN2A/2B associated with T2DM are associated with EOT2DM as well. An intergenic SNP on chromosome 1p31 showed association only with early-onset T2DM in this Asian Indian population. The lack of association with many other SNPs of T2DM may be a reflection of the lack of power of the study, sample size, differences in the frequencies of genetic polymorphisms in different ethnic groups, effect sizes, as well as ancestral differences in pattern of LD between the genetic variants involved in early- and late-onset T2DM.

Postpartum development of type 1 diabetes in Asian Indian women with gestational diabetes

AIM

To study the postpartum conversion of gestational diabetes mellitus (GDM) to different types of diabetes among Asian Indian women.

MATERIALS AND METHODS

Using data from electronic medical records, 418 women with GDM seen at a tertiary diabetes care center for diabetes in Chennai in South India between 1991 and 2014 were evaluated for development of diabetes postpartum.

RESULTS

Of the 418 GDM women followed up postpartum, 388 progressed to diabetes. Of these 359 (92.5%) developed type 2 diabetes (T2DM) and 29 women (7.5%) developed type 1 diabetes (T1DM). The median time to development of T1DM was 2 years (interquartile range 2 [IQR]) while for T2DM it was 5 years (IQR 6). Women who developed T1DM had significantly lower mean body mass index (BMI) (20.4 ± 2.8 vs. 27.5 ± 4.4 kg/m², P = 0.001), and higher fasting plasma glucose (222 ± 105 vs. 165 ± 62 mg/dl P = 0.008) and glycated hemoglobin levels (10.2 ± 2.7 vs. 8.5 ± 2.1% P < 0.001) compared to those who developed T2DM. Glutamic acid decarboxylase (GAD) autoantibodies were present in 24/29 (82.7%) of women who developed T1DM.

CONCLUSION

A small but significant proportion of women with GDM progress to T1DM postpartum. Measurement of GAD antibodies in leaner women with more severe diabetes could help to identify women who are likely to develop T1DM and thus prevent their presentation with acute hyperglycemic emergencies after delivery.

Registry of Youth Onset Diabetes in India (YDR): Rationale, Recruitment, and Current Status

BACKGROUND

With the aim of addressing the relative scarcity of information on youth-onset diabetes in India, the Indian Council of Medical Research (ICMR) decided to establish the Registry of People with Diabetes with Young Age at Onset (YDR) in 2006. The major objectives of YDR are to generate information on disease pattern or types of youth-onset diabetes including their geographical variations within India and to estimate the burden of diabetes complications.

METHODS

YDR is an observational multicenter clinic based registry enlisting physician diagnosed diabetes in individuals below 25 years of age. Diabetes was classified using symptom based clinical criteria. YDR data collection is coordinated through regional collaborating centers and their interacting reporting centers across India. A baseline and an annual follow-up proformas are used to obtain information on sociodemographic details, clinical profile, and anthropometric and laboratory measurements of the patients.

RESULTS

In phase 1, the registry has enrolled 5546 patients, in which type 1 diabetes mellitus (T1DM) was the most prevalent (63.9%), followed by youth-onset type 2 diabetes mellitus (T2DM) (25.3%).

CONCLUSION

This registry provides a unique opportunity to study the natural history of youth-onset diabetes in India.

Childhood and Youth Onset Diabetes: A Single Centre Experience

OBJECTIVES

To identify proportion of various types of diabetes and differences between type 1 and type 2 diabetes in patients with youth onset diabetes (onset below 25 completed years of age). In addition, concurrent autoimmune diseases in type 1 diabetes were studied in a subset of patients.

METHODS

A total of 577 patients (192 girls) with diabetes onset at median age of 14 y (range 1 mo-25 y) with median duration of 1 y (range day of diagnosis- 43 y) were included. Clinical details, investigations and complications were recorded in a proforma. Diabetes was classified using clinical criteria supported by laboratory tests of C peptide and anti GAD-65 antibody in a subset of patients.

RESULTS

Type 1 diabetes accounted for 368/421 (87.4 %) patients with age of onset <18 y and 99/156 (63.5 %) of patients with onset between 19 and 25 y of age. Proportion of type 2 diabetes was 36/421 (8.5 %) and 41/156 (26.2 %) in these two groups. Older age at onset, diabetes in one or both parents, absence of ketosis /weight loss and presence of acanthosis were significant predictors of type 2 diabetes. Hypothyroidism (TSH >10) and biopsy proven celiac disease was found in 11.6 and 9.7 % of type 1 diabetes patients respectively.

CONCLUSIONS

Type 1 diabetes is the most common type of diabetes in youth, however, a significant proportion of youth have type 2 diabetes. In these patients a combination of clinical factors, biochemical parameters and course over few months helps to guide the diagnosis.

Increased serum levels of novel T cell cytokines IL-33, IL-9 and IL-17 in subjects with type-1 diabetes

The role of adaptive immune cytokines in the pathogenesis of type-1 Diabetes Mellitus (T1DM) is well known. Even though reports on the serum levels of both Th-1 and Th-2 cytokines are available, those on newly described T cell cytokines such as IL-17, IL-33 and IL-9 in T1DM are scarce. We therefore measured the serum levels of both T cell polarizing (IL-33 and IL-12) and T cell effector (IFN-γ, IL-4, IL-10, IL-17 and IL-9) cytokines in T1DM subjects with and without microvascular (retinopathy and nephropathy) complications (MVC). All the tested cytokines were significantly elevated in T1DM subjects except for IFN-γ (which failed to attain statistical significance) with no significant difference between those with and without MVC. From the serum cytokine analysis, no apparent Th polarization could be determined for the T1DM subjects.

Diabetes complications in childhood and adolescent onset type 2 diabetes-a review

Diabetes mellitus is one of the most common endocrine disorders in children. Earlier, diabetes in children was almost exclusively type 1 diabetes. Recently, the scenario has changed and increasing numbers of children and adolescent T2DM are being diagnosed. As the epidemic of T2DM shifts to children and adolescents, there is an increased risk of development of micro and macrovascular complications. This could potentially affect the economy of the nation apart from posing a large burden to the individual and his or her family. Prevention and treatment are especially important, given the fact that onset at an early age increases the risk of developing micro and macrovascular complications due to increased duration of exposure to hyperglycemia and other metabolic abnormalities. Diagnosing children and adolescents with T2DM early and instituting good control of all risk factors could yield good results in the prevention of long term complications of diabetes. This review focuses on the prevalence of complications of diabetes among children and adolescents with T2DM.

Epidemiology of microvascular complications of diabetes in South Asians and comparison with other ethnicities

Type 2 diabetes mellitus is widely prevalent in South Asians, and has a significant effect on health, as well as the economies of South Asian countries, particularly when the disease is associated with complications. There are certain characteristics associated with the South Asian phenotype that make South Asians especially prone to diabetes, as well as its complications. Microvascular complications cause considerable morbidity and mortality. There are significant differences in the epidemiology of microvascular complications between South Asians and people of other races. There is evidence of higher prevalence of nephropathy and retinopathy in South Asians compared with Caucasians; however, recent studies indicate that this trend seems to be leveling off. Importantly, diabetic neuropathy occurs less frequently in South Asians compared with Caucasians. These observations have important implications in managing South Asian patients with diabetes and microvascular complications.

Bariatric Surgery: A Potential Treatment for Type 2 Diabetes in Youth

Type 2 diabetes, once referred to as "adult-onset" diabetes, has now emerged as a formidable threat to the health of obese adolescents. Although there is growing evidence regarding the epidemiology of type 2 diabetes in youth and its multisystem health consequences, treatment options have lagged and progression of disease occurs even with aggressive medical therapy. Increasing interest in the application of bariatric surgery for adolescents with type 2 diabetes has evolved in part because of the evidence demonstrating improvement or remission in many adults with diabetes after surgery. Here, we review the burden of type 2 diabetes in youth including its associated complications, discuss the outcomes and complications of bariatric surgery in adolescents with diabetes, and conclude with recommendations for future research and options for refinement of the use of bariatric surgery in this patient population.

Chronic Endotoxemia in Subjects with Type-1 Diabetes Is Seen Much before the Onset of Microvascular Complications

Background

Lipopolysaccharide (LPS)/Endotoxin is hypothesized to play an important role in chronic inflammation associated with Type-1 diabetes (T1DM) and its complications. Endotoxin core antibodies (EndoCAb), LPS binding protein (LBP) and soluble CD14 (sCD14) act as modulators of LPS induced activation of innate immune system in vivo. For the present study we estimated the levels of LPS and its translocation markers in T1DM subjects with and without microvascular complications (MVC) and correlate them with clinical parameters of T1DM and serum inflammatory cytokine levels (TNF-α, IL-6, IL-1β and GM-CSF).

Methods

A total of 197 subjects (64 normal glucose tolerance (NGT) subjects, 97 T1DM subjects without MVC and 36 with MVC) were included in this study and the levels of serum LPS, its translocation markers and cytokines measured by immunoassays.

Results

Compared to NGT, T1DM subjects (both with and without MVC) had significantly higher levels of LPS, reduced levels of LBP and EndoCAb along with significant increase in the levels of IL-1β, IL-6, TNF-α and GM-CSF (p<0.05). No significant change was seen in the levels of these biomarkers between T1DM subjects with and without MVC.

Conclusions

Decreased levels of EndoCAb and LBP suggest sustained endotoxin activity in T1DM subjects even before the onset of microvascular complications.

Diabetes in India: what is different?

PURPOSE OF REVIEW

The purpose of this study was to review the epidemiology and pathogenesis of diabetes in Asian Indians with a particular focus on 'Asian Indian type 2 diabetes phenotype'.

RECENT FINDINGS

The prevalence of diabetes is rapidly increasing among Asian Indians, particularly in the past two decades. The diabetes rates in urban India now exceed that seen in Indians migrated to developed nations. Urbanization, changes from traditional healthier diets to high-refined carbohydrate intake, and sedentary lifestyle have contributed to this steep increase in the prevalence of diabetes in India. Type 2 diabetes among Asian Indians is characterized by onset at a younger age, greater abdominal obesity despite relatively lower BMI, greater insulin resistance, and early decline in beta cell function. Asian Indians are also at a higher risk for premature coronary artery disease.

SUMMARY

The clinical profile of type 2 diabetes in Asian Indians differs from Caucasians with higher central obesity, increased inflammatory markers such as high sensitive C-reactive protein, greater insulin resistance, early loss of beta cell function, and a higher risk of coronary artery disease. Mechanistic studies are needed to characterize the pathophysiology of the Asian Indian phenotype.

Identification of Genetic Variants of Gestational Diabetes in South Indians

BACKGROUND

This study examined the association in a South Indian population with gestational diabetes mellitus (GDM) of type 2 diabetes risk variants that have previously conferred susceptibility to GDM in other populations.

SUBJECTS AND METHODS

The study groups comprised 518 women with GDM and 910 pregnant women with normal glucose tolerance (NGT). Women with GDM were recruited from a tertiary diabetes center in Chennai, in south India, and NGT women were selected from antenatal clinics also in Chennai. Genomic DNA was isolated from whole blood using the phenol chloroform method. Twelve previously reported GDM-associated single nucleotide polymorphisms (SNPs) in or near nine loci were genotyped using the MassARRAY™ system (Sequenom, San Diego, CA).

RESULTS

Among the 12 SNPs genotyped, 11 SNPs were in Hardy-Weinberg equilibrium and had a call rate of >95%. Of the 11 SNPs previously associated with GDM in other populations, significant association was observed only with the rs7754840 and rs7756992 SNPs of the CDK5 regulatory subunit associated protein 1-like 1 (CDKAL1) gene in this population. The minor alleles of the SNPs rs7754840 and rs7756992 showed significant susceptibility to GDM with an odds ratio of 1.34 (95% confidence interval, 1.12-1.60; P = 0.0013) and 1.45 (95% confidence interval, 1.21-1.72; P = 0.00004), respectively.

CONCLUSIONS

The rs7754840 and rs7756992 SNPs of the CDKAL1 gene were found to be associated with GDM in this south Indian population. This is the first study describing genetic susceptibility of GDM in Asian Indians.

Insulin sensitivity and secretion in youth onset type 2 diabetes with and without visceral adiposity

AIM

To investigate insulin sensitivity and insulin secretion patterns among Asian Indian youth without and with type 2 diabetes (T2DM-y defined as onset of diabetes at or below 25 years) with normal and high visceral fat (VF) levels.

METHODS

We recruited 74 T2DM-y individuals, within 18 months of diagnosis and compared them to 77 age-matched controls with normal glucose tolerance (NGT). Using L4/L5 abdominal CT images, VF levels were categorized as normal or high according to their median values. Oral glucose tolerance tests (glucose and insulin measures) were used to derive Matsuda index, insulin resistance (HOMA-IR) and oral disposition index (DIo). Relationships between measures of insulin sensitivity and secretion and T2DM-y by VF level were assessed using standardized multinomial regression models.

RESULTS

Participants were categorized into four groups: NGT-normal VF; NGT-high VF; T2DM-normal VF, and T2DM-high VF. Among NGTs, those with high VF had significantly lower insulin sensitivity (0.013 vs.0.019 pM(-1)) and Matsuda index (10.2 vs.13.8), than normal VF. When compared, T2DM-high VF had lowest insulin sensitivity (0.009 vs.0.019, 0.013, 0.012 pM-1; p<0.001), Matsuda index (6.4 vs. 13.8, 10.2, 8.6; p<0.001), OGIS120 (305 vs. 396, 382, 316; p<0.001) and DIo (0.48 vs. 3.75, 3.20, 0.55 mmol/L; p<0.001). At every category of 2 h PG values, NGT-high VF had lower DIo than NGT-normal VF participants. In standardized multinomial models, that included DIo and Matsuda index adjusted for age, gender, BMI, and leptin, DIo (Odds ratio: 0.001; 95%Confidence interval: 0.000-0.020), matsuda index (0.26; 0.07-0.93), age (2.92; 1.18-7.19) and leptin (3.17; 1.12-8.99) were associated with high VF among T2DM.

CONCLUSION

Lower DIo and Matsuda index, younger age and higher leptin were independently associated with high visceral fat among T2DM participants. Also, lower DIo was seen with increasing 2 h PG values even among normal glucose tolerant individuals.

Diabetes in the young: a population-based study of South Asian, Chinese and White people

AIMS

Rates of diabetes mellitus in the young have not been quantified on a population level, particularly in South Asian and Chinese populations, which bear high rates of diabetes. We determined the incidence of diabetes (Type 2 diabetes and diabetes using insulin only) and rates of hospitalizations among South Asian, Chinese and White people aged 5-29 years with newly diagnosed diabetes.

METHODS

People with newly diagnosed diabetes (1997-2006) in British Columbia, Canada were identified using population-based administrative data and pharmacy databases. Age-standardized incidence rates were calculated for people with diabetes prescribed insulin only and those with Type 2 diabetes. They were followed for up to 8 years for all hospitalizations and diabetes-related complications.

RESULTS

There were 712 South Asians, 498 Chinese and 6176 White people aged 5-29 years with diabetes. Most youth with diabetes had Type 2 diabetes (South Asian 86.4%; Chinese 87.1% and White 61.8%). The incidence of diabetes on insulin only was highest in White people compared with the other groups. The incidence of Type 2 diabetes was highest in South Asians, particularly in 20-29-year-olds, with rates 2.2 times that of White people and 3.1 times that of Chinese people. Hospitalization and diabetes-related complications were uncommon in all groups.

CONCLUSION

The incidence of Type 2 diabetes is higher than previously estimated among youth and is now surpassing diabetes on insulin only. Significant reductions in Type 2 diabetes screening ages in South Asians need to be considered and prevention efforts are urgently required in childhood and adolescence. Global estimates need to consider the epidemic of Type 2 diabetes in the young.

Type 2 diabetes in youth in South Asia

People of South Asian origin are at a high risk of developing diabetes compared to that of other ethnic groups. Recent evidence suggests an emerging epidemic of youth-onset type 2 diabetes (T2DM) in the region, in parallel with the childhood obesity epidemic. Many risk factors such as foetal and early-life influences, the South Asian phenotype, family history of diabetes and environment factors are responsible for the early occurrence of T2DM in South Asia. The high risk supports the need for the opportunistic screening of children and adolescents for diabetes in South Asian countries. Early detection, lifestyle modification, weight reduction and drugs are central to the care of children with T2DM. Both population-based preventive strategies and interventions targeting children and adolescents with obesity and impaired glucose tolerance are required to combat the epidemic of youth-onset T2DM in South Asia.

Prevalence and risk factors for diabetic retinopathy in Asian Indians with young onset type 1 and type 2 diabetes

AIM

To assess the prevalence and risk factors for diabetic retinopathy (DR) in people with young onset type 1 (T1DM-Y) and type 2 diabetes (T2DM-Y).

METHODS

T1DM-Y(n=150) and T2DM-Y(n=150) participants, age between 10 and 25 years at diagnosis, had a complete clinical evaluation, biochemical assessment, and four field digital retinal colour photography. The Early Treatment Diabetic Retinopathy Study grading system was used to grade DR. Proliferative diabetic retinopathy (PDR) and diabetic macular edema (DME) were considered as sight threatening DR.

RESULTS

The prevalence of any DR was 53.3% [95% CI 45.3-61.3] in T1DM-Y (duration of diabetes: 12.4±7.4 years) and 52.7% [44.7-60.7] in T2DM-Y (11.8±8.3 years). The age and gender adjusted prevalence of DR, DME and PDR was 62.5%, 10% and 7.3% in T1DM-Y, whereas it was 65.8%,12.7% and 9.3% in T2DM-Y respectively. In multivariable logistic regression, diabetes duration [Odds ratio (OR) 1.99 per 5 years; CI 1.42-2.79], waist circumference [1.28 per 5 cm;1.05-1.56] and microalbuminuria [2.39 per 50 μg;1.07-5.31] were associated with DR in T1DM-Y, and diabetes duration [2.21 per 5 years; 1.61-3.02], diastolic blood pressure [1.54 per 5 mmHg;1.18-2.02], Glycated hemoglobin [1.37 per %;1.07-1.75] and lower stimulated C-peptide [1.54 per 0.5 pmol/ml;1.15-2.05;] were associated with DR in T2DM-Y.

CONCLUSION

Over half of the people with young-onset diabetes, regardless of type, have retinopathy within 10-12 years of diabetes duration, emphasizing the need for regular eye screening and aggressive control of glucose and blood pressure to prevent DR.

Clinical profile of long-term survivors and nonsurvivors with type 2 diabetes

OBJECTIVE

To compare clinical profile of long-term survivors and nonsurvivors with type 2 diabetes (T2DM).

RESEARCH DESIGN AND METHODS

After conducting a retrospective survey of >200,000 case records, we identified T2DM survivors (>40 years of duration) and age at diagnosis and sex-matched T2DM nonsurvivors. Prevalence of complications and causes of death were analyzed. Retinopathy was diagnosed by retinal photography. Microalbuminuria and macroalbuminuria, peripheral vascular disease based on ankle-brachial index <0.9, coronary artery disease based on history of myocardial infarction or coronary revascularization, and neuropathy based on vibration perception threshold >20 V were compared in both groups.

RESULTS

The mean duration of diabetes of survivors (n = 238) was 43.7 ± 3.9 years, and that of the nonsurvivors (n = 307), at time of death, was 22.4 ± 11.0 years (P < 0.001). Nonsurvivors had significantly higher systolic and diastolic blood pressures, plasma glucose, HbA1c, serum cholesterol, LDL cholesterol, and triglycerides and lower HDL cholesterol compared with long-term survivors (P < 0.001 for all parameters except systolic blood pressure, which was P = 0.027). Myocardial infarction (46.4%) and renal failure (16.6%) were the most common causes of death. Prevalence of most complications was higher among survivors because of longer duration and older age, as follows, for survivors versus nonsurvivors: retinopathy, 76 vs. 62%; microalbuminuria, 39.1 vs. 27.3%; macroalbuminuria, 8.4 vs. 23.7%; neuropathy, 86.5 vs. 63.5%; peripheral vascular disease, 23.1 vs. 11.4%; and coronary artery disease, 44.5 vs. 40.7%.

CONCLUSIONS

Long-term survivors with T2DM had better glycemic and blood pressure control and more favorable lipid profiles.

Associations of β-cell function and insulin resistance with youth-onset type 2 diabetes and prediabetes among Asian Indians

AIM

This study examined β-cell function and insulin resistance (homeostasis model assessment-insulin resistance [HOMA-IR]) in Asian Indian youth with type 2 diabetes mellitus (T2DM-Y) and prediabetes.

SUBJECTS AND METHODS

Eighty-two subjects with non-insulin-requiring type 2 diabetes and age of onset below 25 years were recruited within 18 months of diagnosis and compared with age- and sex-matched subjects with prediabetes (n=31) and normal glucose tolerance (NGT) (n = 83). Body mass index (BMI) and waist circumference were measured, and blood samples were taken in the fasting state and after 30, 60, 90, and 120 min of an oral glucose load for assessment of plasma glucose and insulin levels. Insulin sensitivity/resistance measures was calculated by using the reciprocal of the fasting insulin, the HOMA-IR equation, and the composite whole body insulin sensitivity index (Matsuda Index), and β-cell function was calculated by the oral disposition index (DIo).

RESULTS

T2DM-Y and prediabetes subjects had higher BMI, waist circumference, and fasting insulin than NGT subjects (P<0.05 for each). The 30-min insulin levels were lower in T2DM-Y and higher in prediabetes subjects compared with NGT (57 and 140 vs. 129 μIU/mL, P<0.001). The T2DM-Y group had greater insulin resistance (HOMA-IR, 1.87 vs. 0.97; P<0.05) and lower β-cell function (DIo, 0.36 vs. 3.28; P<0.001) than NGT. In separate models, the Matsuda Index and DIo were independently associated with prediabetes and T2DM-Y (P<0.05). However, when both were included together, only DIo remained associated with T2DM-Y, whereas both DIo and Matsuda Index were associated with prediabetes (P<0.05). When controlled for adiposity (BMI and waist circumference), an association was observed but in opposite directions, with waist being positively associated with prediabetes (P = 0.016) and BMI negatively associated with T2DM-Y (P = 0.009).

CONCLUSIONS

Among Asian Indians, β-cell dysfunction appears to be more strongly associated with T2DM-Y than insulin resistance.

Prevalence of glucose intolerance among children and adolescents in urban South India (ORANGE-2)

AIM

This study was designed to determine the prevalence of glucose intolerance (prediabetes or diabetes) in children and adolescents in urban South India.

SUBJECTS AND METHODS

Children (6-11 years old) and adolescents (12-19 years old) (n=1,519; 777 boys and 742 girls) were randomly selected from residential apartments representing the 10 corporation zones of Chennai city. Height, weight, waist circumference, body fat percentage, and blood pressure were measured using standardized techniques. Investigations included oral glucose tolerance test (OGTT), lipid profile, and fasting insulin. Insulin resistance (IR) was assessed by homeostasis model assessment (HOMA-IR).

RESULTS

The overall prevalence of glucose intolerance was 3.7% but was higher in girls compared with boys (4.2% vs. 3.2%, P<0.001) and increased to 12.7% in girls with abdominal obesity. On univariate regression, the following risk factors showed significant association with glucose intolerance in girls: adolescent age group (odds ratio [OR] 2.94; confidence interval (CI) 1.12, 7.76), waist circumference (OR 4.45; CI 1.95, 10.14), body mass index (OR 2.73; CI 1.32, 5.65), acanthosis nigricans (OR 2.35; CI 1.14, 4.83), family history of diabetes (OR 2.52; CI 1.07, 5.92), and HOMA-IR (OR 9.30; CI 3.59, 24.12). On multivariate analysis, only family history of diabetes (OR 4.11; CI 1.28, 13.22; P=0.018) and HOMA-IR (OR 11.22; CI 4.19, 30.05; P<0.001) remained significant. In boys only HOMA-IR (OR 5.19; CI 1.54, 17.44; P=0.008) was associated with glucose intolerance.

CONCLUSIONS

The prevalence of glucose intolerance is high in Asian Indian adolescents, particularly in girls with abdominal obesity.

Clinical profile and complications of childhood- and adolescent-onset type 2 diabetes seen at a diabetes center in south India

OBJECTIVE

This study describes the clinical characteristics of childhood- and adolescent-onset type 2 diabetes mellitus (CAT2DM) seen at a diabetes center in southern India.

RESEARCH DESIGN AND METHODS

Between January 1992 and December 2009, 368 CAT2DM patients were registered. Anthropometric measurements were done using standardized techniques. Biochemical investigations included C-peptide measurements and glutamic acid decarboxylase antibody assay wherever feasible. Retinopathy was diagnosed by retinal photography; microalbuminuria, if urinary albumin excretion was between 30 and 299 mg/μg of creatinine; nephropathy, if urinary albumin excretion was ≥300 mg/μg; and neuropathy, if vibration perception threshold on biothesiometry was ≥20 V.

RESULTS

The proportion of CAT2DM patients, expressed as percentage of total patients registered at our center, rose from 0.01% in 1992 to 0.35% in 2009 (P<0.001). Among the 368 cases of CAT2DM, 96 (26%) were diagnosed before the age of 15 years. The mean age at first visit and age at diagnosis of the CAT2DM subjects were 22.2±9.7 and 16.1±2.5 years, respectively. Using World Health Organization growth reference charts, 56% of boys and 50.4% of girls were >85(th) percentile of body mass index for age. Prevalence rates of retinopathy, microalbuminuria, nephropathy, and neuropathy were 26.7%, 14.7%, 8.4%, and 14.2%, respectively. Regression analysis revealed female gender, body mass index >85(th) percentile, parental history of diabetes, serum cholesterol, and blood pressure to be associated with earlier age at onset of CAT2DM.

CONCLUSIONS

CAT2DM appears to be increasing in urban India, and the prevalence of microvascular complications is high. Female predominance is seen at younger ages.

Rare and common variants: twenty arguments

Genome-wide association studies have greatly improved our understanding of the genetic basis of disease risk. The fact that they tend not to identify more than a fraction of the specific causal loci has led to divergence of opinion over whether most of the variance is hidden as numerous rare variants of large effect or as common variants of very small effect. Here I review 20 arguments for and against each of these models of the genetic basis of complex traits and conclude that both classes of effect can be readily reconciled.