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Lontchi-Yimagou E, Dasgupta R, Anoop S, Kehlenbrink S, Koppaka S, Goyal A, Venkatesan P, Livingstone R, Ye K, Chapla A, Carey M, Jose A, Rebekah G, Wickramanayake A, Joseph M, Mathias P, Manavalan A, Kurian ME, Inbakumari M, Christina F, Stein D, Thomas N, Hawkins M. An Atypical Form of Diabetes Among Individuals With Low BMI. Diabetes Care 2022; 45:1428-1437. [PMID: 35522035 PMCID: PMC9184261 DOI: 10.2337/dc21-1957] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 03/28/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetes among individuals with low BMI (<19 kg/m2) has been recognized for >60 years as a prevalent entity in low- and middle-income countries (LMICs) and was formally classified as "malnutrition-related diabetes mellitus" by the World Health Organization (WHO) in 1985. Since the WHO withdrew this category in 1999, our objective was to define the metabolic characteristics of these individuals to establish that this is a distinct form of diabetes. RESEARCH DESIGN AND METHODS State-of-the-art metabolic studies were used to characterize Indian individuals with "low BMI diabetes" (LD) in whom all known forms of diabetes were excluded by immunogenetic analysis. They were compared with demographically matched groups: a group with type 1 diabetes (T1D), a group with type 2 diabetes (T2D), and a group without diabetes. Insulin secretion was assessed by C-peptide deconvolution. Hepatic and peripheral insulin sensitivity were analyzed with stepped hyperinsulinemic-euglycemic pancreatic clamp studies. Hepatic and myocellular lipid contents were assessed with 1H-nuclear magnetic resonance spectroscopy. RESULTS The total insulin secretory response was lower in the LD group in comparison with the lean group without diabetes and the T2D group. Endogenous glucose production was significantly lower in the LD group than the T2D group (mean ± SEM 0.50 ± 0.1 vs. 0.84 ± 0.1 mg/kg · min, respectively; P < 0.05). Glucose uptake was significantly higher in the LD group in comparison with the T2D group (10.1 ± 0.7 vs. 4.2 ± 0.5 mg/kg · min; P < 0.001). Visceral adipose tissue and hepatocellular lipids were significantly lower in LD than in T2D. CONCLUSIONS These studies are the first to demonstrate that LD individuals in LMICs have a unique metabolic profile, suggesting that this is a distinct entity that warrants further investigation.
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Affiliation(s)
| | - Riddhi Dasgupta
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
| | - Shajith Anoop
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
| | | | | | | | - Padmanaban Venkatesan
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
| | - Roshan Livingstone
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
| | - Kenny Ye
- Albert Einstein College of Medicine, Bronx, NY
| | - Aaron Chapla
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
| | - Michelle Carey
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Arun Jose
- Department of Biochemistry, Christian Medical College, Vellore, Vellore, India
| | - Grace Rebekah
- Department of Biostatistics, Christian Medical College Vellore, Vellore, India
| | | | - Mini Joseph
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
| | | | | | - Mathews Edatharayil Kurian
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
| | - Mercy Inbakumari
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
| | - Flory Christina
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
| | | | - Nihal Thomas
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, Vellore, India
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Suvarna P, Shruti K, Maruti D, Charudatta J. Diabetes in the Kokan region of India. World J Diabetes 2019; 10:37-46. [PMID: 30697369 PMCID: PMC6347652 DOI: 10.4239/wjd.v10.i1.37] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 12/20/2018] [Accepted: 01/04/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND BKL Walawalkar Hospital is situated near the village of Dervan in the Kokan region of the state of Maharashtra in India. A survey of 2200 surrounding villages showed 51.8% adults had body mass index (BMI) below <18.5 kg/m2 and only 4.5% were overweight. A survey of 11521 adolescent girls from rural schools showed 64% prevalence of thinness. In the same region, government survey reported the prevalence of diabetes around 7%, and 70% prevalence of leanness. This reinforced the fact that the overall population of Kokan is lean. Hence, we decided to investigate body composition of diabetic people from our hospital clinic by carrying out a clinic-based case control study.
AIM To study body composition of diabetics in a rural clinic of Kokan.
METHODS In a case-control study, 168 type 2 diabetic patients (102 men) attending the outpatient department at a rural hospital and 144 non-diabetic controls (68 men) in the Chiplun area of the Kokan region were recruited. History of diabetes (age of onset, duration), anthropometric measurements (height, weight, waist and hip circumference) were recorded. Body composition was measured by bioimpedance using the TANITA analyzer.
RESULTS More than 45% of diabetic subjects had a 1st degree family history of diabetes, and more than 50% had macrovascular complications. The average BMI in diabetic subjects was 24.3 kg/m2. According to World Health Organization standards, prevalence of underweight was 8% and that of normal BMI was around 50%. Underweight and normal diabetic subjects (men as well as women) had significantly lower body fat percentage, higher muscle mass percentage, lower visceral fat and lower basal metabolic rate when compared to their overweight counterparts.
CONCLUSION The diabetic population in Kokan has near normal body composition, and BMI has considerable limitations in assessing body composition and it also lacks sensitivity for assessing risk for diabetes in this population. High prevalence of family history of diabetes may point towards genetic predisposition. Leanness is an inherent characteristic of this population and its metabolic significance needs further investigations with a larger sample size.
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Affiliation(s)
- Patil Suvarna
- Department of Medicine, BKL Walawalkar Hospital and Rural Medical College, Sawarde, Taluka-Chiplun, Maharashtra 415606, India
| | - Kadam Shruti
- Department of Medicine, BKL Walawalkar Hospital and Rural Medical College, Sawarde, Taluka-Chiplun, Maharashtra 415606, India
| | - Desai Maruti
- Statistics Unit, Regional Centre for Adolescent Health and Nutrition, BKL Walawalkar Hospital and Rural Medical College, Taluka-Chiplun, Maharashtra 415606, India
| | - Joglekar Charudatta
- Statistics Unit, Regional Centre for Adolescent Health and Nutrition, BKL Walawalkar Hospital and Rural Medical College, Taluka-Chiplun, Maharashtra 415606, India
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Abstract
PURPOSE OF REVIEW Overweight and obesity are well-established risk factors for type 2 diabetes. However, a substantial number of individuals develop the disease at underweight or normal weight. In this review, we discuss the epidemiology of type 2 diabetes in non-overweight adults; pose questions about etiology, pathophysiology, diagnosis, and prognosis; and examine implications for prevention and treatment. RECENT FINDINGS In population-based studies, the prevalence of type 2 diabetes ranged from 1.4-10.9%. However, the prevalence of type 2 diabetes in individuals with BMI < 25 kg/m2 ranged from 1.4-8.8%. In countries from Asia and Africa, the proportion of individuals with diabetes who were underweight or normal weight ranged from 24 to 66%, which is considerably higher than the US proportion of 10%. Impairments in insulin secretion, in utero undernutrition, and epigenetic alterations to the genome may play a role in diabetes development in this subgroup. A substantial number of individuals with type 2 diabetes, particularly those with recent ancestry from Asia or Africa, are underweight or normal weight. Future research should consist of comprehensive studies of the prevalence of type 2 diabetes in non-overweight individuals; studies aimed at understanding gaps in the mechanisms, etiology, and pathophysiology of diabetes development in underweight or normal weight individuals; and trials assessing the effectiveness of interventions in this population.
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Affiliation(s)
- Unjali P Gujral
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Room 7040-L, Atlanta, GA, 30322, USA.
- Emory Global Diabetes Research Center, Emory University, Atlanta, GA, USA.
| | - Mary Beth Weber
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Room 7040-L, Atlanta, GA, 30322, USA
- Emory Global Diabetes Research Center, Emory University, Atlanta, GA, USA
| | - Lisa R Staimez
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Room 7040-L, Atlanta, GA, 30322, USA
- Emory Global Diabetes Research Center, Emory University, Atlanta, GA, USA
| | - K M Venkat Narayan
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Room 7040-L, Atlanta, GA, 30322, USA
- Emory Global Diabetes Research Center, Emory University, Atlanta, GA, USA
- School of Medicine, Emory University, Atlanta, GA, USA
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Dasgupta R, Naik D, Thomas N. Emerging concepts in the pathogenesis of diabetes in fibrocalculous pancreatic diabetes. J Diabetes 2015; 7:754-61. [PMID: 25707547 DOI: 10.1111/1753-0407.12280] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 01/16/2015] [Accepted: 02/10/2015] [Indexed: 12/17/2022] Open
Abstract
Fibrocalcific pancreatic diabetes (FCPD) is a rare form of diabetes affecting people in the tropics and presenting with unique clinical and radiological features. The onset of diabetes usually follows the first few episodes of abdominal pain and develops by the second or third decade of life. Endocrine and exocrine pancreatic insufficiency, brittle glycemic control, and insulin-requiring, ketosis-resistant diabetes are the novel characteristics of FCPD. The etiopathogenetic mechanisms leading to FCPD remain unknown. Although defects in insulin secretion are the major contributors, growing evidence towards a possible role for insulin resistance and body composition abnormalities have added a new dimension to the disease pathogenesis. Deciphering the key pathogenetic mechanisms may have a profound effect on therapeutic strategies in future studies on FCPD.
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Affiliation(s)
- Riddhi Dasgupta
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
| | - Dukhabandhu Naik
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
| | - Nihal Thomas
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
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Barma PD, Ranabir S, Prasad L, Singh TP. Clinical and biochemical profile of lean type 2 diabetes mellitus. Indian J Endocrinol Metab 2011; 15:S40-S43. [PMID: 21847453 PMCID: PMC3152194 DOI: 10.4103/2230-8210.83061] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Type 2 diabetes mellitus is the most prevalent form of diabetes worldwide. In western countries majority of the cases are obese. The scenario may be different in certain parts of India. Various studies have reported a high prevalence of lean type 2 diabetes mellitus with a body mass index < 19 kg/m(2). MATERIALS AND METHODS We evaluated 100 cases of lean type 2 diabetes mellitus (62 males and 38 females). RESULTS AND CONCLUSION The mean duration of diabetes was 51.7 months (range 5-180 months). The glycemic control was poor according to standard guidelines. The majority of them showed response to oral hypoglycemic agents. Secondary failure to oral hypoglycemic agents was seen in 27 patients. The prevalence of microvascular complications was much higher than macrovascular complications. Neuropathy was the commonest complication seen in 70%, followed by retinopathy in 25%. Only 12 patients had hypertension, one had coronary artery disease and two had cerebrovascular accident. Lipid profile was not significantly deranged in our patients.
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Affiliation(s)
- Punyakrit Deb Barma
- Department of Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India
| | - Salam Ranabir
- Department of Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India
| | - Lallan Prasad
- Department of Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India
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Das S, Mishra RK, Samal KC, Mishra KC, Tripathy BB. Insulin and Glycaemic Response to Common Carbohydrate Diets in Undernourished Diabetics. ACTA ACUST UNITED AC 2009. [DOI: 10.3109/13590849109084137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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8
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Low bodyweight Type 2 diabetes in India: Clinical characteristics and pathophysiology. Diabetes & Metabolic Syndrome: Clinical Research & Reviews 2009. [DOI: 10.1016/j.dsx.2009.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Samal KC, Kanungo A, Sanjeevi CB. Clinicoepidemiological and biochemical profile of malnutrition-modulated diabetes mellitus. Ann N Y Acad Sci 2002; 958:131-7. [PMID: 12021092 DOI: 10.1111/j.1749-6632.2002.tb02955.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Malnitrition-modulated diabetes mellitus ((MMDM) was previously known as protein-deficient diabetes mellitus (PDDM). Its clinical picture is similar to that of type 1 diabetes, but it develops over a background of chronic malnutrition from childhood. In spite of severe hyperglycemia, ketonuria never occurs. MMDM patients are extremely lean and require high doses of insulin-over 2.0 U/kg/day for good glycemic control. Even when optimally controlled, these patients maintain their leanness. Infections of the skin and soft tissues and pulmonary tuberculosis are often seen, whereas micro- and macrovascular complications are rare, even after long-term follow-up. Ultrasonographic evaluation of the abdomen clearly differentiates MMDM from fibrocalculous pancreatic diabetes. Absence of ketonuria and ketosis despite very severe hyperglycemia in emaciated young subjects is the most significant marker of MMDM.
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Affiliation(s)
- K C Samal
- Department of Endocrinology, SCB Medical College, Cuttack, Orissa, India.
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Goswami R, Kochupillai N, Gupta N, Kukreja A, Lan M, Maclaren NK. Islet cell autoimmunity in youth onset diabetes mellitus in Northern India. Diabetes Res Clin Pract 2001; 53:47-54. [PMID: 11378213 DOI: 10.1016/s0168-8227(01)00235-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We characterised a consecutive cohort of 132 youth onset diabetic individuals (age at onset<30 years, mean duration of disease 5.5+/-6.0 years) from North India, by serological determination of the determination of the islet cell autoantibodies, GAD(65) and IA2, and clinically for coexisting autoimmune thyroid disease, malnutrition and pancreatic calcification. Five types of diabetes were delineated: Type 1 (37%), ketosis resistant (32%), Type 2 (13%), fibrocalculous pancreatopathy (11%) and autoimmune polyglandular syndrome (7%). C-peptide response to glucagon was assessed in a representative subset of 50 patients with Type 1, ketosis resistant, and autoimmune polyglandular syndrome. A total of 22.4% of Type 1 and 30% of autoimmune polyglandular syndrome subjects showed both GAD(65) plus IA-2 autoantibody positivity, significantly more than the 4.7% positivity shown by the ketosis resistant type. However, GAD(65) antibody positivity alone was seen in 38% of ketosis resistant subjects which was significantly more than the 14.2 and 10% positivity seen in Type 1 and autoimmune polyglandular groups, respectively. The fibrocalculous pancreatopathy group showed GAD(65) plus IA-2 autoantibody positivity in 14.2% and GAD(65) autoantibody alone positivity in 7.1%. 26 and 60%, respectively, of the Type 1 and autoimmune polyglandular syndrome groups had thyroid microsomal autoantibody positivity. Type 1 showed significantly less C-peptide response to glucagon when compared to the ketosis resistant and autoimmune polyglandular syndrome groups. The controls and Type 2 diabetic individuals tested negative for islet cell autoimmunity markers. These findings demonstrate a role of islet cell autoimmunity in the pathogenesis of four out of the five clinical types of youth onset diabetes seen in North India.
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Affiliation(s)
- R Goswami
- Department of Endocrinology and Metabolism, All India Institute of Medical Science, 110029, New Delhi, India
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11
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Goswami R, Jaleel A, Kochupillai NP. Insulin antibody response to bovine insulin therapy: functional significance among insulin requiring young diabetics in India. Diabetes Res Clin Pract 2000; 49:7-15. [PMID: 10808058 DOI: 10.1016/s0168-8227(00)00130-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The majority of young diabetics in India prefer to use low-cost bovine insulin for economic reasons. Therefore, the question of insulin antibody response to bovine insulin and its functional significance is still relevant in the Indian context. We assessed insulin antibody response in 52 young diabetics (type 1, n=25, malnutrition modulated form of diabetes, n=19 and fibrocalculous pancreatopathy (FCP) n=8) on bovine insulin therapy (mean duration 3.0+/-2.1 years) using an internationally standardised in-house radioligand assay. The functional significance of insulin antibody was assessed by calculating their affinity constant, maximum binding capacity and total insulin binding power by Scatchard analysis (type 1, n=14, malnutrition modulated form of diabetes, n=11). All the patients treated with bovine insulin showed high titers of insulin antibodies with S.D. score ranging from 5.1 to 42.0. No significant difference was observed in the mean S.D. score of insulin antibodies in the three diabetic groups. The mean daily insulin dose, maximum insulin binding capacity and total insulin binding power were significantly higher in type 1 when compared to the malnutrition modulated form of diabetes (36+/-8 vs. 26+/-11 IU/day, P<0.05; 9. 7+/-7.8 vs. 4.0+/-3.9 nmol/l, P=0.03 and 59+/-29 vs. 29+/-43, P=0.01, respectively). Insulin antibodies S.D. score and its affinity did not show significant relationship with daily insulin dose and glycemic control (HbAl) at admission. Only 24+/-7% variations in daily insulin requirement were accounted for by total insulin binding power. There was a significant inverse relationship between insulin antibody S.D. score and duration of insulin therapy (r=-0. 4172, P<0.0004). To conclude, insulin antibody response following bovine insulin therapy is not different among type 1, malnutrition modulated form of diabetes and FCP diabetes. The insulin antibody response to bovine insulin therapy does not contribute significantly to increase in daily insulin requirement in bovine insulin treated insulin requiring young diabetics.
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Affiliation(s)
- R Goswami
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
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12
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Singh AK, Bhatia E, Dabadghao P, Bhatia V, Gellert SA, Colman PG. Role of islet autoimmunity in the aetiology of different clinical subtypes of diabetes mellitus in young north Indians. Diabet Med 2000; 17:275-80. [PMID: 10821293 DOI: 10.1046/j.1464-5491.2000.00267.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIMS To determine the role of islet autoimmunity in the aetiology of different clinical subtypes of diabetes mellitus in young north Indian patients by measuring islet autoantibodies. METHODS In a cross-sectional study, 145 young patients with diabetes (onset < 30 years) were subdivided into the following categories: Type 1 diabetes (n = 83), malnutrition-modulated diabetes mellitus (MMDM, n = 31) and fibro-calculous pancreatic diabetes (FCPD, n = 31). MMDM subjects presented with emaciation and severe insulin-requiring but ketosis-resistant diabetes, while FCPD was associated with idiopathic chronic calcific pancreatitis. Antibodies to glutamic acid decarboxylase (GADA) and IA-2 (IA-2 A) were detected by immunoprecipitation of 35S-labelled recombinant antigens and cytoplasmic islet cell antibody (ICA) by indirect immunofluorescence. RESULTS GADA were present in a significant proportion (23%) of patients with MMDM. In contrast, IA-2 A was increased only among patients with Type 1 diabetes (22%), but not MMDM (3%, P < 0.05). Among patients with a duration of diabetes < 2 years, GADA and/or IA-2 A were found in 61% of Type 1 diabetic and 37% of MMDM patients (P < 0.01). MMDM patients who were positive for GADA had a shorter duration of diabetes, but did not differ in their age at onset of diabetes, body mass index, fasting plasma C-peptide, or frequency of thyroid microsomal and parietal cell antibodies. FCPD subjects had the lowest prevalence of autoantibodies: IA-2 and ICA were absent, while GADA were present in 7% (P < 0.05 vs. Type 1 diabetes). CONCLUSIONS GADA, though not IA-2 A, were present in a substantial proportion of patients with the MMDM variant of diabetes, suggesting that islet autoimmunity may play a role in its pathogenesis. In contrast, none of the islet antibodies was increased in subjects with FCPD, making it likely that it is a secondary type of diabetes.
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Affiliation(s)
- A K Singh
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute, Lucknow, India
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13
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al-Amin AN, Ahrén B. Relation between malnutrition and development of diabetes mellitus. INTERNATIONAL JOURNAL OF PANCREATOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PANCREATOLOGY 1999; 26:125-30. [PMID: 10732288 DOI: 10.1385/ijgc:26:3:125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- A N al-Amin
- Department of Medicine, Lund University, Malmö, Sweden
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14
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Sanjeevi CB, Kanungo A, Shtauvere A, Samal KC, Tripathi BB. Association of HLA class II alleles with different subgroups of diabetes mellitus in Eastern India identify different associations with IDDM and malnutrition-related diabetes. TISSUE ANTIGENS 1999; 54:83-7. [PMID: 10458326 DOI: 10.1034/j.1399-0039.1999.540109.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Genetic studies of Malnutrition related diabetes are few. We have analyzed HLA class II gene polymorphism in different types of diabetes mellitus patients from Cuttack in Eastern India. Patients with insulin-dependent diabetes mellitus (IDDM), non-insulin-dependent diabetes mellitus (NIDDM) and malnutrition-related diabetes mellitus (MRDM), which is subdivided into protein-deficient diabetes mellitus (PDDM) and fibrocalculous pancreatic diabetes (FCPD), were studied and their associations with autoantibody markers. IDDM and PDDM were associated with DR3 and DQ2 but not DR4 and DQ8. FCPD was positively associated with DQ9 (A*0201-B*0303). The association of DQ9 with FCPD suggests differences in the genetic background for susceptibility between IDDM and MRDM in the Cuttack population. There is no association seen between HLA-DR-DQ and NIDDM patients from Eastern India. Clinical classification of diabetes into IDDM, NIDDM and MRDM does not identify the underlying pathological mechanisms. Presence of autoantibodies to IDDM autoantigens in clinical MRDM and NIDDM identifies the slow-onset form of IDDM. Due to the absence of autoantibody assays for diagnosis of IDDM in India, slow onset IDDM is not diagnosed and the patients are classified as NIDDM or MRDM. Our study demonstrates that the presence of GAD65 antibody and DR3-DQ2 positivity in MRDM and NIDDM patients in Eastern India would suggest the presence of slow-onset IDDM. Our data would indicate alternatively that MRDM can coexist with IDDM in these patients and malnutrition could be one of the reasons for the slower onset in IDDM-prone individuals.
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Affiliation(s)
- C B Sanjeevi
- Department of Molecular Medicine, Karolinska Hospital, Stockholm, Sweden.
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15
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Abstract
The disease process in classical Type 1 diabetes patients (IDDM) is believed to be autoimmune. In contrast, the disease process in classical Type 2 diabetes patients (NIDDM) is not autoimmune and a decreased sensitivity to insulin action is the main abnormality. The clinical distinction of Type 1 diabetes versus Type 2 diabetes is recognized to be imperfect and has limitations. There is a group of individuals (Type 1 1/2 diabetes), who present like typical NIDDM, but have some of the immunological and clinical features of IDDM. We review the current medical literature on Type 1 1/2 diabetes with special reference to its clinical characteristics, natural history and pathophysiology. Since the distinction between these two forms of diabetes may have important therapeutic implications especially with regards to the benefits of insulin therapy in patients with Type 1 1/2 diabetes and because of the need for uniformity in its diagnosis we recommend that both clinical plus biochemical criteria (the presence of ICA and/or GAD Ab, HLA typing and tests to quantify beta cell function) be used to make a diagnosis. Comparative studies in the area of cytokine production, T cell reactivity and autoantibody clustering between classic Type 1 diabetes and Type 1 1/2 diabetes patients are needed as are studies with the animal model of Type 1 1/2 diabetes, Psammomys obesus.
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Affiliation(s)
- R Juneja
- Department of Veteran Affairs Puget Sound Health Care System, University of Washington, Endocrinology, Seattle 98108, USA.
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Dabadghao P, Bhatia E, Bhatia V, Jayaraj K, Colman PG. Islet-cell antibodies in malnutrition-related diabetes mellitus from north India. Diabetes Res Clin Pract 1996; 34:73-8. [PMID: 9031808 DOI: 10.1016/s0168-8227(96)01336-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The etiology of malnutrition-related diabetes mellitus (MRDM)--protein-deficient pancreatic diabetes (PDPD) and fibro-calculous pancreatic diabetes (FCPD)-is unclear. We studied the role of autoimmunity against pancreatic islet cells in the etiology of these two subtypes of MRDM by measuring islet-cell antibodies (ICA) in 23 patients with PDPD, 25 with FCPD and 62 with Type 1 diabetes. Three patients (13%) with PDPD had detectable ICA. Including a patient with a high titre of ICA (> 80 JDF units). The frequency of ICA in patients with PDPD was significantly lower than subjects with Type 1 diabetes (22/62, 35%; P < 0.05). Among patients studied at onset. ICA prevalence was lower in the PDPD patients (1/7, 14%) compared to subjects with Type 1 diabetes (8/20, 40%). No patient of FCPD had detectable ICA (P < 0.001 vs. Type 1 diabetes subjects). We conclude that autoimmunity may play a role in the etiology of some patients with the PDPD subtype of MRDM. However, FCPD is unlikely to have an autoimmune etiology.
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Affiliation(s)
- P Dabadghao
- Department of Endocrinology, Sanjay Gandhi Postgraduate, Institute of Medical Sciences, Lucknow, India
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18
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Rao RH, Menon RK. Chronic malnutrition impairs insulin sensitivity through both receptor and postreceptor defects in rats with mild streptozocin diabetes. Metabolism 1993; 42:772-9. [PMID: 8510523 DOI: 10.1016/0026-0495(93)90248-m] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The effect of coexisting chronic malnutrition on insulin sensitivity in mild diabetes was studied in rats. Food intake was restricted over an 8-week period to 50% of ad libitum intake by pair-feeding 4-week-old littermate rats injected with streptozocin ([STZ] 40 mg/kg intraperitoneally) at 8 weeks. Significantly greater glucose intolerance and hypoinsulinemia were seen in response to a glucose load in the malnourished diabetic group (P < .00005), suggesting that chronic malnutrition significantly accentuated beta-cell dysfunction from STZ. Significantly greater insulin resistance was also seen, with the percentage rate constant for glucose disappearance after a bolus of insulin being markedly impaired (P < .0001) in the malnourished diabetic group (1.5% +/- 0.2% x min-1 [SE]) compared with ad libitum-fed diabetic and normal rats (3.6% +/- 0.6% x min-1 and 4.7% +/- 0.7% x min-1, respectively; P < .01). Insulin binding to receptor in liver plasma membranes was altered by malnutrition (P < .00005), with the affinity of binding being significantly reduced compared with that of ad libitum-fed diabetic controls (P < .0001) at both the high-affinity site (3.9 +/- 0.2 v 13.7 +/- 3.3 x 10(-7) x mol/L-1) and low-affinity site (2.7 +/- 0.4 v 20.1 +/- 3.8 x 10(-5) x mol/L-1). During a constant glucose and insulin infusion (1.67 mU/kg/min), glucose clearance was significantly lower in malnourished rats (5.3 +/- 0.7 v 8.6 +/- 1.7 mL/gk/min, P < .01).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R H Rao
- Department of Medicine, University of Pittsburgh School of Medicine, PA
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Abstract
The effect of moderate chronic undernutrition on insulin receptors was studied in male rats, pair-fed 60% of the daily food intake of ad libitum-fed littermates, for 8 weeks. Body weights of undernourished rats were consistently found to be 35% to 40% less than control littermates, with no period of growth arrest at any point in the 8-week study. The binding-displacement curves of labeled insulin to hepatocyte receptors in the two groups in the presence of unlabeled insulin were significantly different (P = .0258 after repeated measures ANOVA). Significantly lower binding was observed in hepatocytes from the undernourished group (P less than .01) at all unlabeled insulin concentrations less than 20 nmol/L. In the absence of any unlabeled insulin, specific binding was reduced from 8.8% +/- 0.7%, (mean +/- SE) in controls, to 7.4% +/- 0.3% in undernourished rats (P less than .01). Half-maximal specific hormone binding to hepatocytes was achieved at a free insulin concentration of 362 nmol/L in the control group, compared with 447 nmol/L in the undernourished group, reflecting an increase of approximately 20%. The hypoglycemic response to intravenous insulin (0.1 U/kg body weight) was tested in a parallel experiment involving seven paired littermate rats, and found to be significantly impaired in the undernourished group (P = .0041 by repeated measures ANOVA).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R H Rao
- Department of Medicine, University of Pittsburgh School of Medicine, PA
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Ramaiya KL, Kodali VR, Alberti KG. Epidemiology of diabetes in Asians of the Indian subcontinent. DIABETES/METABOLISM REVIEWS 1990; 6:125-46. [PMID: 2091908 DOI: 10.1002/dmr.5610060302] [Citation(s) in RCA: 55] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Asians from the Indian subcontinent have received greater attention in diabetes studies because of their migration in large numbers. The prevalence of non-insulin-dependent diabetes mellitus (NIDDM) in migrant Indians is higher than that in the population residing in the Indian subcontinent and is also usually higher than in the other racial groups in the host country. However, before drawing any conclusions with reference to the high prevalence of NIDDM in the migrant Indians, careful comparisons are required with more up-to-date information available from the Indian subcontinent itself. Recent data from India indeed indicate that the prevalence rates have either been underestimated in the past or are rising. The problem is compounded by the different diagnostic criteria used for defining diabetes. Some of the possible factors which cause variations in the rates of NIDDM in this population are discussed.
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Affiliation(s)
- K L Ramaiya
- Hindu Mandal Hospital, Dar es Salaam, Tanzania
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Abdulkadir J, Mengesha B, Welde Gebriel Z, Keen H, Worku Y, Gebre P, Bekele A, Urga K, Taddesse AS. The clinical and hormonal (C-peptide and glucagon) profile and liability to ketoacidosis during nutritional rehabilitation in Ethiopian patients with malnutrition-related diabetes mellitus. Diabetologia 1990; 33:222-7. [PMID: 2112100 DOI: 10.1007/bf00404800] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Cases of malnutrition-related diabetes mellitus conforming to the description of the protein deficient pancreatic diabetes type in Ethiopian patients were compared with Type 1 (insulin-dependent) and Type 2 (non-insulin-dependent) diabetic. Fourteen of 39 malnutrition-related diabetes mellitus patients had fat malabsorption compared with only two of ten Type 1 diabetic patients and one of nine control subjects. Xylose absorption was normal favouring a pancreatic cause for the malabsorption. Plasma C-peptide during oral glucose tolerance test was significantly lower than that in Type 2 diabetic patients and normal control subjects (p less than 0.01 to 0.001) and was also consistently but not significantly higher than in Type 1 diabetic patients. Glucagon secretion patterns were similar in malnutrition-related and Type 1 diabetic patients. Of 23 new malnutrition-related diabetic patients treated with glibenclamide after nutritional rehabilitation and insulin treatment, only three responded, 14 were unresponsive but remained ketosis free for over eight days while another six developed ketoacidosis or significant ketonuria within two to six days during the trial. Sixteen unselected Type 1 diabetic patients who discontinued their insulin therapy all developed frank ketoacidosis after a mean of 5.5 days. The similarity of the malnutrition-related and Type 1 diabetes mellitus in age of onset, insulin requirement for diabetic control and appearance of ketosis-proneness in some cases, together with the similarity of C-peptide and glucagon secretion patterns suggest that the protein deficient pancreatic diabetes variant of malnutrition-related diabetes mellitus may be Type 1 diabetes mellitus modified by the background of malnutrition rather than an aetiologically separate entity.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J Abdulkadir
- Department of Internal Medicine, Faculty of Medicine, Addis Ababa University, Ethiopia
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Abstract
Although Asians are known to have an excess of Type 2 diabetes when compared with Europids, the relative prevalence of Type 1 diabetes in Asians remains controversial. The Coventry Diabetes Study enumerated all adult diabetic subjects in the electoral ward of Foleshill (population 10,304) by a house-to-house survey. Residents treated with insulin were classified as having either Type 1 or Type 2 diabetes on the basis of plasma C-peptide concentration and their diabetic history. Insulin treatment was received by 22% of Europids and 12% of Asians with previously diagnosed diabetes. Diabetic history was available for all and C-peptide for 69% of insulin-treated subjects. The age adjusted prevalence of Type 1 diabetes was 0.16 (95% CI 0.6-3.3)% in Europids and 0.12 (95% CI 0.4-2.7)% in Asians. Asians were found to have a significantly higher age at diagnosis (26 (range 19-34) vs 18 (6-29) years, p less than 0.05) than Europids, and all were born outside of the United Kingdom. No Type 1 diabetes was diagnosed under 19 years of age in Asians while 5 of the 8 Europid subjects with Type 1 diabetes were diagnosed under this age. Type 1 diabetes does occur in Asians born outside the UK but either commences later in life or, if of earlier onset, precludes migration to the UK.
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Affiliation(s)
- D Simmons
- Sheikh Rashid Diabetes Unit, Radcliffe Infirmary, Oxford, UK
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Abstract
Seven undernourished and seven obese, insulin-requiring type 2 diabetic subjects, who were matched for age, sex, and duration of diabetes, were subjected to oral glucose tolerance tests. Although fasting glucose and free insulin levels were similar in both groups, glucose tolerance was markedly worse in the undernourished subjects, with a mean incremental glucose area (+/- SE) of 22.8 +/- 2.3 mmol/l.h vs. 12.4 +/- 1.3 in the obese diabetic subjects (P less than 0.001). The incremental insulin response (area under the curve) to oral glucose in the undernourished group (39.3 +/- 7.9 mU/l.h) was 50% lower than the response in both the obese group (89.2 +/- 19.9, P less than 0.001) and a group of non-diabetic, normal weight-for-height subjects (77.1 +/- 5.7, P less than 0.01). Peak insulin levels were similarly reduced to approximately half the levels seen in the obese and control groups (P less than 0.01). Undernutrition is known to impair both glucose tolerance and insulin secretory reserve by reducing the beta cell number, size, and granulation. It is concluded that chronic undernutrition accentuates beta cell dysfunction in undernourished diabetics, leading to increased glucose intolerance.
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Affiliation(s)
- R H Rao
- Division of Endocrinology and Metabolism, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad
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Ramachandran A, Mohan V, Snehalatha C, Bharani G, Chinnikrishnudu M, Mohan R, Viswanathan M. Clinical features of diabetes in the young as seen at a diabetes centre in south India. Diabetes Res Clin Pract 1988; 4:117-25. [PMID: 3125028 DOI: 10.1016/s0168-8227(88)80006-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
This study reports on the clinical pattern of 545 consecutive young diabetic patients with age at onset below 30 years attending a diabetes centre in Southern India. Three hundred and fourteen patients (57.7%) were classified as having non-insulin-dependent diabetes of the young (NIDDY), 119 (22%) as insulin-dependent diabetes (IDDM) and 28 (5%) as malnutrition-related diabetes (MRDM); 4% fibrocalculous pancreatic diabetes and 1% protein-deficient pancreatic diabetes. The remaining 84 patients could not be classified into any of the above categories. A positive family history of diabetes was more common in NIDDY compared to the other groups (P less than 0.001). While 40.3% of patients with IDDM had age at onset below 15 years, the other types of diabetes were rarely seen in patients younger than this. Body mass index (BMI) did not reliably indicate the MRDM forms of diabetes as 70% of patients with IDDM also had a BMI of less than 18, one of the criteria recommended for the diagnosis of MRDM. C-peptide levels in MRDM were intermediate between the IDDM and NIDDY groups. Microvascular complications were present in all the groups of young diabetics. The frequency was higher in NIDDY patients who also had a longer duration of diabetes. There was an increasing prevalence of complications with increasing duration of diabetes.
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Abdulkadir J, Mengesha B, Gebriel ZW, Gebre P, Beastall G, Thompson JA. Insulin-dependent ketosis-resistant diabetes in Ethiopia. Trans R Soc Trop Med Hyg 1987; 81:539-43. [PMID: 3328338 DOI: 10.1016/0035-9203(87)90398-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Anthropometric, clinical and biochemical findings were compared in 30 rural (group A), 18 urban insulin-requiring (group B) and 45 urban oral-agent-responsive (group C) newly diagnosed diabetics. Mean ages at onset were 28.3 +/- 12.0, 25.6 +/- 14.5 and 42.1 +/- 10.5 years respectively. The differences between A and C and between B and C were significant. Group A were poor and malnourished, with body mass index (BMI) 15.9 +/- 1.9 and 17.2 +/- 3.7 kg/m2 for males and females respectively, presented with a long history of classical diabetes without ketoacidosis and required insulin in modest doses. 3 of 10 cases had excess stool fat but none of 13 unselected cases had pancreatic calcification. Group C were better nourished, with BMI 22.6 +/- 2.8 and 22.4 +/- 4.5 kg/m2, and responded to oral agents. Group B, with BMI 17.2 +/- 2.6 and 18.6 +/- 3.1 kg/m2, required insulin for control but had C-peptide levels above 0.02 nmol/1 in 10 of 15 cases. Anthropometric indices for males, but not for females, were significantly lower in group A than in group B or C. There were significant differences in levels of glucose between A and B and A and C, free fatty acids between A and C and B and C, insulin between A and B and A and C and C-peptide between A and C and B and C. Of the 3 groups the rural type most closely resembled the tropical variants.
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Affiliation(s)
- J Abdulkadir
- Department of Internal Medicine, Faculty of Medicine, Addis Ababa University, Ababa, Ethiopia
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Bodansky HJ, Beverley DW, Gelsthorpe K, Saunders A, Bottazzo GF, Haigh D. Insulin dependent diabetes in Asians. Arch Dis Child 1987; 62:227-30. [PMID: 3494431 PMCID: PMC1778292 DOI: 10.1136/adc.62.3.227] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Type 1 diabetes is said to be extremely rare in children in India, where diabetes treated with insulin may be due to chronic pancreatic disease or malnutrition. To see whether typical type 1 diabetes occurred in Asian children in the United Kingdom, all known Asian children with diabetes in industrial West Yorkshire were ascertained. A total of 17 such children were studied; of these, seven were from three multiplex families and two fathers from these families had diabetes. All children were ketosis prone and developed diabetes while resident in the UK. There were significant increases in HLA-B8 and HLA-DR3 and increases in HLA-DR4 and HLA-DR3/DR4, while HLA-B15 was absent. Islet cell antibodies, either IgG or complement fixing, were present in four of 18 subjects tested, all of whom had disease of short duration. The prevalence of type 1 diabetes in Asian children aged 15 years or less in West Yorkshire was 36/100,000, assuming complete ascertainment. It is concluded that typical type 1 diabetes may occur in Asian children and this condition may be more common in families who have migrated to the UK.
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Vannasaeng S, Nitiyanant W, Vichayanrat A, Ploybutr S, Harnthong S. C-peptide secretion in calcific tropical pancreatic diabetes. Metabolism 1986; 35:814-7. [PMID: 3528743 DOI: 10.1016/0026-0495(86)90221-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Serum C-peptide levels were measured during a glucagon stimulation test in ten normal nonobese controls and 54 diabetic patients with recent onset of diabetes under 30 years of age. Diabetic patients were comprised of 13 CTPD, 23 IDDM, and 18 NIDDM. As similar to IDDM patients, serum C-peptide concentrations did not rise significantly (P greater than 0.05) in response to glucagon administration in CTPD-patients. Mean baseline and peak serum C-peptide concentrations in CTPD-patients were significantly lower (P less than 0.001) than the values in normal controls and NIDDM patients, but were significantly higher (P less than 0.05) than those in IDDM patients. We conclude that CTPD patients have partial C-peptide reserve, which may protect against ketosis and contribute to ketosis resistance in CTPD. Our results also suggest that CTPD patients require insulin treatment. Neither baseline nor peak C-peptide levels after glucagon could discriminate CTPD from IDDM and CTPD from NIDDM.
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Abstract
The syndrome known as tropical diabetes seems to be distinct from the two main types common in developed countries. Major pancreatic exocrine disease may or may not be present, and within these two groups there are clinical and biochemical variants. For these conditions the term malnutrition-related diabetes has been proposed. Although malnutrition is a plausible unifying factor, there is a good case for retaining the term tropical diabetes until there is more information on clinical and biochemical features and on aetiology.
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Keen H, Ng Tang Fui S. The definition and classification of diabetes mellitus. CLINICS IN ENDOCRINOLOGY AND METABOLISM 1982; 11:279-305. [PMID: 6754159 DOI: 10.1016/s0300-595x(82)80017-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Martin FI, Simeanova L. Insulin secretion in non-obese (J-type) diabetics in Papua New Guinea. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 1979; 9:260-2. [PMID: 111657 DOI: 10.1111/j.1445-5994.1979.tb04135.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Nine of ten non-obese non-ketotic diabetics attending Port Moresby General Hospital had detectable C-peptide in plasma. All had received insulin for at least two months at the time of study. It is concluded that many non-obese non-ketotic young diabetics in Papua New Guinea retain pancreatic insulin secretion and so resemble the maturity onset diabetics of "Western" countries.
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Vormittag W, Weninger M. [Heterogeneity of diabetes mellitus and dermatoglyphics (author's transl)]. HUMANGENETIK 1974; 22:45-58. [PMID: 4837290 DOI: 10.1007/bf00338134] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Alford FP, Kiss ZS, Martin FI, Pearson MJ, Willis MF, Yeomans ND. "Type J" diabetes in New Guinea--studies of insulin release and insulin sensitivity. AUSTRALASIAN ANNALS OF MEDICINE 1970; 19:111-7. [PMID: 5427443 DOI: 10.1111/imj.1970.19.2.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Lal BH, Bahl AL, Mathur KP, Chugh RN, Bhalla AS. Clinical patterns and complications of diabetes mellitus in India. Postgrad Med J 1968; 44:223-8. [PMID: 5648667 PMCID: PMC2466365 DOI: 10.1136/pgmj.44.509.223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The records of 274 diabetics attending an outpatient clinic in New Delhi have been reviewed and the patients classified into four main types. The relationship of the disease to nutritional, socio-economic and environmental factors has been discussed. The incidence of complications in the various types is reported and the differences between them analysed.
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Chhetri MK, Chowdhury ND, Pal K, Bimal D. Clinical experience with phenformin timed disintegration capsules in Indian diabetics. Postgrad Med J 1966; 42:770-7. [PMID: 5981053 PMCID: PMC2466113 DOI: 10.1136/pgmj.42.494.770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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