Lifestyle and clinical risk factors in relation with the prevalence of diabetes in the Indonesian urban and rural populations: The 2018 Indonesian Basic Health Survey

Aims

To investigate the differences between Indonesian urban and rural populations in the association of lifestyle and clinical factors with diabetes prevalence.

Methods

Using database of the 2018 Indonesian Basic Health Survey, which was conducted in April-May 2018, non-pregnant respondents aged ≥15 years old with available blood glucose data (n urban = 17,129, n rural = 16,585) were included in this study. The diagnosis of diabetes was based on the combination of known diabetes, i.e., a previous history of diabetes or use of anti-diabetes medication, and unknown diabetes based on blood glucose criteria. We performed logistic regression analyses separately for the urban and rural populations to examine the association of lifestyle and clinical factors with prevalent diabetes.

Results

Indonesian urban population was less physically active, had a lower proportion of adequate fruit and vegetable intake, and had higher individuals with obesity than rural population. Although there were no differences in the total prevalence of diabetes between the two populations (10.9 % vs. 11.0 %, for urban and rural, respectively), the prevalence of known diabetes was twice higher in urban than in rural population (3.8 % vs. 1.9 %). Physical activity was associated with lower risk of diabetes, especially in the urban population [prevalence OR (95 %CI): 0.91 (0.85; 0.98) for urban and 0.94 (0.89; 1.00) for rural). Obesity, hypertension, and dyslipidemia were risk factors for prevalent diabetes in both populations.

Conclusions

Indonesian rural population showed relatively better lifestyle and clinical profiles compared to their urban counterparts. However, no differences were observed between the two populations in the relation between risk factors and diabetes. Special attention needs to be addressed to the high prevalence of undiagnosed and untreated diabetes in Indonesia.

Prevalence and associated factors of female sexual dysfunction among type 2 diabetes patients in Indonesia: A systematic review and meta-analysis

BACKGROUND AND AIMS

Female sexual dysfunction (FSD) is a neglected chronic complication of diabetes. However, there is a scarcity of data in Indonesia, which is currently ranked as the 5th in the world for the number of people with Type 2 Diabetes (T2D). Our study aims to analyze the prevalence and factors of FSD among T2D patients in Indonesia.

METHOD

Literature searching was performed in PubMed/Medline®, CINAHL®, Embase®, Proquest®, Scopus®, local journals and libraries. All studies in searching keywords "sexual", "diabetes" and "Indonesia" with Medical Subject Headings (MeSH) terms were included, without time or language restriction. Pooled prevalence and odds ratio of associated factors of FSD were analyzed using STATA.

RESULTS

Ten studies comprised 572 females with T2D were included in this review. The pooled prevalence of FSD reached 52% (95% CI = 0.49-0.56; I2 93.9%, p < 0.001). After removing one study that was conducted with an unstandardized questionnaire cut-off value, the pooled prevalence of FSD was 62% (95% CI = 0.58-0.66; I2 68.7%, p = 0.001). Age more than 45 years old and or menopause, and the use of antihypertensives were associated with FSD. While Hemoglobin A1c (HbA1c) is only correlated with a desire for sexual dysfunction.

CONCLUSION

FSD was prevalent among T2D patients in Indonesia and was associated with age more than 45 years old, menopause, and the use of antihypertensive medications.

The role of high fat diet on serum uric acid level among healthy male first degree relatives of type 2 diabetes mellitus

First-degree relatives (FDR) of type 2 diabetes mellitus have increased risk of developing insulin resistance-related disorders including hyperuricemia. We investigated metabolic profile and serum uric acid (SUA) metabolism in response to high-fat diet among healthy male FDR in comparison to those without family history of diabetes. A total of 30 FDR and 30 non-FDR subjects completed a 5-days-hypercaloric diet with fat added to regular daily intake. Despite similar insulin response, FDR displayed different changes in SUA compared to non-FDR subjects (0.26 ± 0.83 mg/dL vs - 0.21 ± 0.78 mg/dL, p = 0.028). In subgroup analyses stratified by body mass index and waist circumference, significant different SUA changes between FDR and non-FDR subjects were only found in obese (0.48 ± 0.87 mg/dL vs - 0.70 ± 0.71 mg/dL, p = 0.001) and centrally obese (0.59 ± 0.83 mg/dL vs - 0.55 ± 0.82 mg/dL, p = 0.011) subgroups. In multivariate analysis, visceral adiposity seemed mediating the different response in SUA metabolism between FDR and non-FDR subjects induced by short-term obesogenic diet.

Risk factors of severe hypoglycemia among patients with type 2 diabetes mellitus in outpatient clinic of tertiary hospital in Indonesia

This study aimed to describe risk factors of severe hypoglycemia in type 2 diabetes mellitus (T2DM) patients in a tertiary care hospital in Indonesia. This study was a retrospective cohort study in the Endocrinology Outpatient Clinic of Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia. All subjects more than 18 years old who had been visiting the clinic for at least a year were included. Subjects were interviewed whether they had any severe hypoglycemia events within the past year, while data on risk factor variables of severe hypoglycemia was taken from medical records one year before data collection. We recruited 291 subjects, among whom 25.4% suffered at least one episode of severe hypoglycemia within one year. History of severe hypoglycemia (OR 5.864, p ≤ 0.001), eGFR less than 60 mL/min/1.73m2 (OR 1.976, p = 0.028), and insulin use (OR 2.257, p = 0.021) were associated with increased risk of severe hypoglycemia. In conclusion, history of previous severe hypoglycemia, eGFR less than 60 mL/min/1.73m2, and insulin use were associated with severe hypoglycemia.

Differential effect of ramadan fasting on intercellular adhesion molecule-1 (ICAM-1) in diabetes mellitus and non-diabetes mellitus patients

Background

The month of Ramadan is a holy month for Muslims. During this month, Muslims do not eat, drink, or smoke from sunrise to sunset. Patients with type 2 diabetes mellitus (T2DM) will also fast from dawn to dusk, creating a unique opportunity to study the effects of dietary changes during fasting period. One of the interesting results of Ramadan fasting is its effect on endothelial dysfunction, measured using Intercellular Adhesion Molecule-1 (ICAM-1) as a biological marker of endothelial function.

Aim

To determine the changes ICAM-1 levels in T2DM and non-DM patients during Ramadan fasting.

Methods

A retrospective cohort study was performed on 26 T2DM patients and 21 non-DM, age-matched patients (aged 19-60 years). Measurement of metabolic parameters (systolic and diastolic blood pressure, total calorie intake, and intensity of physical activity), anthropometry (body weight, body mass index (BMI) and abdominal circumference), total dietary intake, and laboratory analysis (blood glucose fasting, HbA1c, lipid profile, ICAM-1) were done at 4 weeks before (T0) and 14 days after Ramadan fasting (T1).

Result

The median ICAM-1 level in T2DM patients at T0 was 340.9 (193-505) ng/mL and at T1 was 312.3 (158-581) ng/mL, while the ICAM-1 level in non-DM patients at T0 was 482 (305-653) and at T1 was 398.4 (202-526) ng/mL. There was no significant difference of ICAM-1 level between study groups at both T0 and T1 (p > 0.05). Both T2DM and non-DM patients had lower ICAM-1 level following Ramadan fasting. However, only non-DM patients had significantly lower post Ramadan ICAM-1 (p = 0.008).

Conclusion

There was a significant decrease in ICAM-1 level in both T2DM and non-DM patients after Ramadan fasting.

Defining the optimum HOMA-IR cut-off value for insulin resistance among ARV-treated HIV patients in Indonesia

BACKGROUND AND AIMS

HIV-infected patients who are treated with anti-retroviral (ARV) drugs are prone to develop insulin resistance. This study aims to determine the cut-off value of HOMA-IR score in ARV-treated HIV patients in Indonesia.

METHODS

A cross-sectional study was conducted among 234 adults with HIV who received ARV therapy in HIV Integrated Care Unit of Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia. The duration of HIV diagnosis, duration of ARV therapy, metabolic syndrome status, and calculated HOMA-IR were obtained in this study. HOMA-IR cut-off point was calculated using ROC curve analysis, along with the specificity, sensitivity and likelihood ratio (LR).

RESULTS

Among 234 subjects, 58% of subjects were on second-line ARV therapy. The prevalence of metabolic syndrome was 23.9%. The obtained HOMA-IR cut-off value was 2.705 with sensitivity and specificity approaching 70%, PPV 40.9%, NPV 87.6%, with positive LR of 2.15 and negative LR of 0.48. The insulin resistance prediction from the obtained HOMA-IR cut-off value was at moderate strength. Based on this cut-off value, 39.7% of the subjects experienced insulin resistance.

CONCLUSIONS

Using the new proposed HOMA-IR cut-off point for HIV patient in Indonesia, the prevalence of insulin resistance among HIV-infected patients treated with ARV in Indonesia using optimum HOMA-IR cut-off value of 2.705 was 39.7%.

Increased intestinal-fatty acid binding protein in obesity-associated type 2 diabetes mellitus

BACKGROUND

Obesity is a traditional risk factor for type 2 diabetes mellitus (T2DM). However, recent studies reported that metabolically unhealthy obesity (MUO) exerts a higher risk of developing T2DM than metabolically healthy obesity (MHO) because of its higher state of insulin resistance. This may happen due to metabolic endotoxemia through gut dysbiosis and increased intestinal permeability. Our study aimed to know the association of intestinal permeability using intestinal fatty acid-binding protein (I-FABP) with obesity-related T2DM patients in Indonesia.

METHODS

This was a cross-sectional study that recruited 63 participants with obesity defined using body mass index (BMI) classification for the Asia-Pacific population (BMI ≥25 kg/m2). All participants were then grouped into T2DM and non-T2DM based on American Diabetes Association (ADA) diagnostic criteria. The I-FABP levels were measured using the enzyme-linked immunosorbent assay method.

RESULTS

The I-FABP level of T2DM group was higher compared to non-T2DM group, namely 2.82 (1.23) ng/mL vs. 1.78 (0.81) ng/mL (p<0.001; mean difference 1.033 with 95% CI 0.51-1.55). This difference was not attenuated even after adjustment for age. The fitted regression model using linear regression was: i-FABP = 1.787+1.034*(DM) (R2 = 18.20%, standardized ß = 0.442, p<0.001).

CONCLUSIONS

This study underscores the association of intestinal permeability with T2DM in people with obesity and supports the evidence of the potential role of intestinal permeability in the pathogenesis of obesity-related T2DM.

The urgency in proposing the optimal obesity cutoff value in Indonesian population: A narrative review

In developing nations such as Indonesia, obesity and central obesity have emerged as major public health issues. Many studies have revealed that morbidity and death from obesity-related diseases are already significant in some "Asian" communities at low body mass index (BMI) levels. A recent study showed that the obesity prevalence in Indonesia is underestimated when using the current BMI cutoff (obese ≥ 27.0). Indonesia faced an increase in obesity-related chronic diseases despite having a lower obesity prevalence than developed countries, which may be explained by the underestimation of obesity levels in Indonesia. This creates a huge global health problem, as well as an economic burden. Another recent study on the Indonesian population depicted the new proposed cutoff of waist circumference (WC), which is lower than the World Health Organization (WHO) standard for detecting the early detection of type 2 diabetes mellitus (T2DM), one of the comorbidities and a strong correlation with obesity. An analysis of 58 studies in 2021 that included Indonesian adult subjects revealed enormous differences and ambiguities in defining obesity cutoffs values among Indonesian researchers. Additionally, we advocate adding the Edmonton Obesity Staging System (EOSS) staging to the anthropometric classification for a better clinical evaluation of obesity. Considering the urgency of obesity determination in Indonesia for clinical application and study purposes, this review highlights the need to revise the optimal cutoff value for obesity to warrant early prevention and control of diabetes complications.

Adherence to the healthy lifestyle guideline in relation to the metabolic syndrome: Analyses from the 2013 and 2018 Indonesian National Health Surveys

In this study, we aimed to investigate differences in lifestyle factors and prevalence of metabolic syndrome (MetS) in the Indonesian population between 2013 and 2018. In addition, we investigated whether adherence to the 2015-released national healthy lifestyle guideline (‘GERMAS’) is associated with MetS in different sex, age, urban/rural, and BMI categories. We performed cross-sectional analyses in individuals aged >15 of the 2013 (n = 34,274) and 2018 (n = 33,786) Indonesian National Health Surveys. A stratified, multi-stage, systematic random sampling design and the probability proportional to size method were used to select households in the 34 provinces across the country. MetS was defined according to the Joint Interim Statement Criteria, and adherence to ‘GERMAS’ guideline was defined as fulfilling the national healthy lifestyle recommendations of ≥150 min/week physical activity (PA), ≥5 portions/day fruit and vegetable (FV), no smoking (NS), and no alcohol consumption (NA). We examined the associations of each lifestyle factor with MetS using logistic regression categorised by sex, age groups, urban/rural, and BMI, and adjusted for sociodemographic factors. We observed that men who adhered to the guideline had lower odds ratio of MetS [OR(95%CI) associated with PA: 0.85(0.75–0.97); NA: 0.75(0.56–1.00)] than non-adherent men. Middle-aged adults who adhered to the guideline had lower OR of MetS [PA: 0.85(0.72–1.01); FV: 0.78(0.62–0.99); NA: 0.66(0.46–0.93)] than non-adherent adults <45 years. The adherent urban population had lower OR of MetS [FV: 0.85(0.67–1.07); NA: 0.74(0.52–1.07)] than the non-adherent urban population. Those with overweight or obesity who adhered to the guideline had relatively lower odds of MetS than those who did not. In conclusion, in this nationally representative study, adherence to the ‘GERMAS’ guideline may confer cardiometabolic health benefits to several groups of the Indonesian population, particularly men, middle-aged, those with overweight and obesity, and potentially urban population.

Factors Affecting Mortality of Critical Limb Ischemia 1 Year after Endovascular Revascularization in Patients with Type 2 Diabetes Mellitus

BACKGROUND

Chronic limb ischemia (CLI) is strongly associated with increased mortality in diabetes patients.

OBJECTIVE

The aim of this study was to evaluate factors affecting mortality within 1 year after endovascular revascularization in CLI patients.

METHODS

This retrospective cohort study was based on medical records from the Integrated Cardiovascular Centre of Dr. Cipto Mangunkusumo National General Hospital, a tertiary care hospital in Jakarta, Indonesia. The study included 199 CLI patients with type 2 diabetes mellitus (T2DM) who underwent endovascular revascularization from January 2008 to June 2018. The patients were followed up for 1 year after endovascular revascularization. Kaplan-Meier and Cox proportional hazard analysis was used to analyze the data.

RESULTS

1-year survival probability was 58.8%. Cox proportional hazard analysis showed that duration of diabetes (HR 3.52; 95% CI 1.34-9.22), anemia (HR 2.59; 95% CI 1.47-4.56), and smoking (HR 2.49; 95% CI 1.46-4.27) were significantly associated with mortality within 1 year after endovascular revascularization.

CONCLUSIONS

In T2DM patients with CLI, duration of diabetes, anemia and smoking were associated with a higher risk of mortality within 1 year post endovascular revascularization

Effect of calorie restriction diet on levels of C reactive protein (CRP) in obesity: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

Chronic inflammation in obese patients can be managed through a calorie-restricted diet, characterized by reduced C - reactive protein (CRP). This study aims to assess the role of such diet on CRP.

METHODS

Literature searches were performed using search engines. Randomized controlled trials were included. Calorie-restricted diets in combination with non-diet interventions were excluded.

RESULTS

Calorie restriction decreased CRP in obese patients with a mean difference of -0.22 (95% CI -0.40 to -0.04, p 0.006).

CONCLUSIONS

Calorie-restricted diet reduces CRP. Diet administration >12 weeks had a beneficial effect.

Cardiovascular disease prediction model for Indonesian adult population with prediabetes and diabetes mellitus: The Bogor Cohort study of Noncommunicable Diseases Risk Factors

BACKGROUND AND AIMS

This study aims to develop a predictive model of cardiovascular events in dysglycemia among the Indonesian adult population.

METHODS

This is a retrospective cohort study conducted on subjects over 25 years in the "The Bogor Cohort Study of Noncommunicable Diseases Risk Factors" from 2011 to 2018. Data associated with age, gender, blood pressure, body mass index, waist circumference, blood glucose, cholesterol, smoking habits, family history of cardiovascular disease, and physical activity were obtained. Cardiovascular events in six years were observed; this included coronary heart disease, stroke, or all-cause cardiovascular mortality. Cox proportional hazards regression models were used to determine independent predictors of cardiovascular events.

RESULTS

A total of 1085 subjects with prediabetes and diabetes mellitus were included in this study, with 73.5% female. The cumulative incidence of cardiovascular events in six years was 9.7%. Predictors of cardiovascular events were age ≥45 years (HR = 2.737; 95% CI 1.565-4.787) and hypertension (HR = 2.580; 95% CI 1.619-4.112).

CONCLUSIONS

Age ≥45 years and hypertension were predictors of cardiovascular events in six years among the adult Indonesian population with prediabetes and diabetes, necessitating targeted intervention among these subjects.

Association between Statin Use and Poor Outcomes in COVID-19 Patients with Diabetes Mellitus: A Systematic Review

BACKGROUND AND AIMS

Diabetes mellitus, cardiovascular diseases, obesity, and dyslipidaemia are considered risk factors for more severe forms of COVID-19 infection. Statins have been widely used in such patients to prevent the occurrence of cardiovascular events and the associated mortality. However, statin use has been suggested to promote a more severe form of infection. This review aims to investigate the association between statin use and poor outcomes in COVID-19 patients with diabetes.

METHODS

Literature search was performed in PubMed, CENTRAL, Scopus, and pre-print databases (MedRxiv and BioRxiv), and studies published up to March 6th, 2021 have been reviewed. Selected studies were then assessed for risk of bias with the Newcastle Ottawa Scale.

RESULT

Four studies were included in the final analysis; all were retrospective studies. Two studies reported a decreased risk of mortality with statin use, while one study reported opposite findings. The other one did not find a significant association between statin use and poor COVID-19 outcomes.

CONCLUSION

Available data suggest that statins may be safely administered to diabetic COVID-19 patients as the majority of evidence signifies statins to confer benefits and improve clinical outcomes in COVID-19 patients.

Characteristics of Diabetic Foot Ulcer Patients Pre- and During COVID-19 Pandemic: Lessons Learnt From a National Referral Hospital in Indonesia

Background:

Diabetic foot ulcer (DFU) is one of the most terrifying diabetic complications for patients, due to the high mortality rate and risk for amputation. During the COVID-19 pandemic, many diabetic patients limited their visits to the hospital, resulting in delays for treatment especially in emergency cases.

Objective:

This study aimed to compare the characteristics of patients with DFU pre- and during COVID-19 pandemic period. Methods: This study was a retrospective cohort study using foot registry data. We compared our patients’ characteristics pre-COVID-19 pandemic period (1 March 2019-28 February 2020) and during COVID-19 pandemic period (1 March 2020-28 February 2021).

Results:

Cohorts of 84 and 71 patients with DFU pre- and during COVID-19 pandemic period, respectively, were included in this study. High infection grade (66.7% vs 83.1%, P = .032), osteomyelitis event (72.6% vs 87.3%, P = .04), leukocyte count (15 565.0/μL vs 20 280.0/μL, P = .002), neutrophil-to-lymphocyte ratio (7.7 vs 12.1, P = .008), waiting time-to-surgery (39.0 h vs 78.5 h, P = .034), and number of major amputation (20.2% vs 39.4%, P = .014) were significantly higher during the COVID-19 pandemic period.

Conclusion:

During the COVID-19 pandemic, patients with DFU had more severe infection, higher proportion of osteomyelitis, longer waiting time for getting surgical intervention, and higher incidence of major amputation.

The role of Intestinal-Fatty Acid Binding Proteins and Chitinase-3-Like Protein 1 across the spectrum of dysglycemia

BACKGROUND AND AIMS

Recent studies underlie the importance of intestinal permeability and chronic inflammation in the pathogenesis of T2DM. Our study compared the concentrations of FABP2 and YKL40 as markers of intestinal permeability and inflammation among normoglycemia, prediabetes and T2DM.

METHODS

We recruited 122 participants (45 normoglycemic, 26 prediabetes, and 51 T2DM) of whom we measured the fasting serum levels of FABP2 and YKL-40 using ELISA method.

RESULTS

The levels of FABP2 were significantly higher in the T2DM group [2.890 (1.880-4.070)] in comparison to both prediabetes [2.025 (1.145-2.343), p = 0.0085] and normoglycemia group [1.72 (1.250-2.645), p = 0.011]. The levels of YKL-40 were also significantly higher in the T2DM group [68.70 (44.61-166.6)] in comparison to both prediabetes [28.85 (20.64-41.53), p < 0.0001] and normoglycemia group [28.64 (19.25-43.87), p < 0.001].

CONCLUSIONS

Our study observed that the levels of FABP2 and YKL-40 were highest in the T2DM group supporting the available evidences on the role of intestinal permeability disruption and chronic low-grade inflammation in the pathogenesis of T2DM.

Impact of diabetes mellitus on COVID-19 clinical symptoms and mortality: Jakarta's COVID-19 epidemiological registry

Background and aims

While the higher prevalence of diabetes mellitus (DM) at younger age in Indonesia might contribute to the relatively higher COVID-19 mortality rate in Indonesia, there were currently no available evidence nor specific policy in terms of COVID-19 prevention and management among DM patients. We aimed to find out the association between diagnosed diabetes mellitus (DM) with COVID-19 mortality in Indonesia.

Methods

We performed a retrospective cohort study using Jakarta Province’s COVID-19 epidemiological registry within the first 6 months of the pandemic. All COVID-19 confirmed patients, aged >15 years with known DM status were included. Patients were assessed for their clinical symptoms and mortality outcome based on their DM status. A multivariate Cox-regression test was performed to obtain the relative risk (RR) of COVID-19 mortality in the diagnosed DM group.

Results

Of 20,481 patients with COVID-19, 705 (3.4%) had DM. COVID-19 mortality rate in DM group was 21.28%, significantly higher compared to 2.77% mortality in the non-DM group [adjusted RR 1.98 (CI 95% 1.57–2.51), p < 0.001]. In addition, COVID-19 patients with DM generally developed more symptoms.

Conclusions

DM is associated not only with development of more COVID-19 clinical symptoms, but also with a higher risk of COVID-19 mortality. This finding may provide a basis for future policy regarding COVID-19 prevention and management among diabetes patients in Indonesia.

Triglyceride/Glucose Index (TyG Index) as a marker of glucose status conversion among reproductive-aged women in Jakarta, Indonesia: The Bogor cohort study (2011-2016)

BACKGROUND AND AIMS

Reproductive-aged women are prone to type 2 diabetes mellitus. This study aims to evaluate the optimal cut off point of Triglyceride/Glucose Index for predicting glucose status conversion among women of reproductive age.

METHODS

This study involved normoglycemic and prediabetes women aged 20-49 years from the Bogor Non-Communicable Diseases Cohort Study (West Java, Indonesia) conducted from 2011 to 2016. Statistical analysis was performed using Receiver Operating Characteristics curve analysis with STATA version 15.

RESULTS

Among prediabetes subjects (n = 371), the cut-off point of TyG index for regression from prediabetes to normoglycemic subjects was <4.51 [sensitivity, specificity, AUC (95%CI) 83.9%, 80.1%, 0.913 (0.875-0.943), respectively] and the cut-off point for progression from prediabetes to diabetes was >4.54 [80.0%, 73.1%, 0.858 (0.807-0.900)]. Among normoglycemic subjects (n = 1300), the cut-off point of TyG index for progression to prediabetes and diabetes were >4.44 [80.1%, 71.1%, 0.834 (0.812-0.854)] and >4.47 [80.6%, 80.8%, 0.909 (0.890-0.926)] respectively.

CONCLUSION

Based on sample of subjects evaluated between 2011 and 2016, TyG index appears to be a promising marker for glucose status conversion among reproductive-aged women in Jakarta, Indonesia.

The associations of leptin and adiponectin with the metabolic syndrome in an Indonesian and a Dutch population

BACKGROUND AND AIMS

At the same BMI, Asian populations develop cardiometabolic complications earlier than Western populations. We hypothesized that a different secretion of the adipocyte-derived hormones leptin and adiponectin plays a role and investigated the associations of the two hormones with the metabolic syndrome (MetS) in an Indonesian and a Dutch population.

METHODS AND RESULTS

We performed cross-sectional analyses of the Netherlands Epidemiology of Obesity Study (n = 6602) and the SUGAR Scientific Programme Indonesia-Netherlands Study (n = 1461). We examined sex-stratified associations of leptin and adiponectin with MetS, using multivariate logistic regression including adjustment for total body fat. The mean (SD) leptin (mcg/L) were 4.7 (6.0) in Indonesian men, 18.6 (12.0) in Indonesian women, 9.1 (7.7) in Dutch men, and 23.4 (17.4) in Dutch women. The mean (SD) adiponectin (mg/L) were 5.7 (5.4), 7.5 (7.1), 6.6 (3.3), and 11.3 (4.9), respectively. Within the same BMI category, leptin concentrations were similar in the two populations, whereas adiponectin was lower in the Indonesian population. Per SD of leptin, adjusted prevalence odds ratios (ORs, 95%CI) of MetS were 0.9 (0.6-1.2) in Indonesian men, 1.1 (0.9-1.4) in Indonesian women, 2.2 (1.6-2.8) in Dutch men, and 1.2 (1.0-1.5) in Dutch women. Per SD of adiponectin, the ORs were 0.9 (0.7-1.2), 0.8 (0.7-1.0), 0.6 (0.6-0.8), and 0.4 (0.4-0.5), respectively.

CONCLUSIONS

Despite lower adiponectin levels, adiponectin was not related to the MetS in the Indonesian population and can not explain their increased cardiometabolic risk at the same BMI.

Non-vascular contributing factors of diabetic foot ulcer severity in national referral hospital of Indonesia

PURPOSE

Diabetic foot ulcer (DFU) is a common chronic complication of type 2 diabetes mellitus (T2DM) in Indonesia, with a prevalence of 7.3%. However, the characteristics of these patients remain unclear. We investigated the characteristics of patients with DFU without peripheral arterial disease (PAD) and analyzed non-vascular factors related to severity of DFU in a tertiary care national referral hospital in Indonesia.

METHODS

This was a cross-sectional study including 123 hemodynamically stable DFU patients without PAD recruited from Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia from 2010-2015.

RESULTS

DFU patients were predominantly over 50 years old (75.6%) and diagnosed with T2DM for 5 years with poor glycemic control (82.7%) and peripheral neuropathy (91.3%). Most patients had anemia (86.7%), leukocytosis (84.6%), and were undernourished, as characterized by a low lipid profile (90.8%) and hypoalbuminemia (83.7%). Most had extensive size of ulcer at the initial visit, with a median size of 16.23 (2.92-60.16) cm2. Ulcers were mostly located of the forefoot (62.5%) and were caused by mechanical trauma (46.2%). Bivariate analysis revealed that significant factors for the development of DFU were related to DFU size, including duration of T2DM (p = 0.04), leukocyte levels (p =  < 0.01), and thrombocyte levels (p =  < 0.01). Multivariate analysis showed leucocyte (p = 0.03) and thrombocyte (p = 0.023) had significantly correlated with DFU severity.

CONCLUSION

Leucocyte and thrombocyte may be the greatest contributing non-vascular factors for severity of DFU in Indonesia.

Severe Hypercalcemia as Rare Manifestation of Acute Lymphoblastic Leukemia in Adolescent

Background: Hypercalcemia is a rare manifestation of acute lymphoblastic leukemia (ALL). Several studies reported that severe hypercalcemia is very uncommon in pediatric ALL, but there is no report regarding ALL in adolescence and young adult (AYA) which comprises distinct entity with diverse prognosis.

Clinical Case: A 18-year-old male presented with prolonged fever, general weakness, fatigue, pale and decrease of body weight for 3 months. He also complained visual disturbances which progressively worsened for 1 month. On admission, systemic examination showed that he was alert, had tachycardia, proptosis of both eyes and splenomegaly. There was neither lymphadenopathy nor thyroid/parathyroid abnormality. Initial laboratory investigation revealed pancytopenia (hemoglobin of 6.8 g/dl, hematocrit of 19.1%, white blood cell count of 3.8 x 10⁹/L with platelets of 58 x 10⁹/L and no blast). There was severe hypercalcemia of 18 mg/dL, hypomagnesemia 1.14 mg/dL, with normal phosphorus level. His serum creatinine level slightly increased to 1.3 mg/dL with filtration rate of 79 ml/min/1.73 m². Bone marrow evaluation showed blast cells infiltration, consistent with ALL type L3. Leukemia phenotyping revealed B cell-lineage with aberrant exp CD5. CT scan orbita and brain showed bilateral retrobulbar mass and diffuse lytic lesion in skeletal bones due to leukemic cells infiltration. Patient was treated with supplemental oxygen, hydration targeting natriuresis, loop diuretic and steroid. The serum calcium level remained high, thus bisphosphonate was given. There was progressive decline of serum calcium level after therapy. The patient is then prepared to start chemotherapy.

Discussion: Hypercalcemia is associated with both PTH or PTH-independent mechanism, including malignancy. It complicates 5–20% of malignancy, but only 0.6–4.8% reported in leukemia. Hypercalcemia in malignancy may present due to: (1) direct invasion of cancer cells to bone and (2) secretion of humoral PTH-related peptide (PTHrP) which mimics PTH. Severe hypercalcemia without inadequate treatment is fatal. Initial treatment of hypercalcemia includes hydration, loop diuretic, calcitonin and bisphosphonate targeting decline of serum calcium level of 3–9 mg/dL in 24–48 hours. The main treatment of leukemia-related hypercalcemia is chemotherapy. Several cases of pediatric ALL reported normocalcemia after starting induction phase of chemotherapy and exerted good prognosis.

Conclusion: Hypercalcemia should be investigated in leukemia patients and vice versa. The main aim of therapy is to normalize the serum calcium level and treat underlying causes. In adolescent ALL, adequate treatment of hypercalcemia helps achieving better outcome.

Non-MAS Non-APS Rare Case: Co-Occurrence of Graves’ Disease (GD), Latent Autoimmune Diabetes in Adult (LADA), Systemic Lupus Erythematosus (SLE), and Ulcerative Colitis (UC)

Background: Advancement in medical technology has allowed us to diagnose complicated autoimmune diseases. There is a growing report of multiple autoimmunity co-occurence. Multiple Autoimmune Syndrome (MAS) is a combination of at least three autoimmune diseases, whereas Autoimmune Polyendocrine Syndromes (APS) comprise autoimmunity that involves multiple endocrine gland. Case Illustration: A 47-year old female came with chief complaint of palpitation. She had a history of systemic lupus erythematosus in the last three years, after suffering from malar rash, alopecia, and polyarthritis. Her 24-hour urine protein was 1575 mg. She routinely consumes methylprednisolone, hydroxychloroquine, and mycophenolic acid. She also experienced hematochezia and the biopsy from colonoscopy revealed chronic colitis with crypt destruction. She was diagnosed with ulcerative colitis and was treated with mesalazine. Since last year, her blood glucose was consistently high, accompanied with polydipsia and polyuria. She was treated with metformin, despite persistent increase in her A1C, as well as fasting and random blood glucose. We performed GAD65 test which came back positive, hence we diagnosed her with latent autoimmune diabetes in adult. In the past three months, she experienced palpitations, tremor, diarrhea, diaphoresis, and unexplainable weight loss. No exophthalmos was found, but she complained of an enlargement around her neck. We run thyroid hormone test, her TSHs was <0.003 (0.35-4.94 μIU/mL) and FT4 was 4.17 (0.70-1.48 ng/mL). Her ultrasound revealed diffuse enlargement of both thyroid with increased vascularization. We diagnosed her with Graves’ disease and treated her with methimazole and propranolol. Discussion: This case highlighted the rare co-occurrence of four autoimmune diseases. The underlying genetic predisposition of individual with autoimmune disease, will make them prone to develop multiple defect in their self-tolerance mechanism. However, the strict criteria of APS or MAS constrained us from putting all her autoimmunities into one big umbrella. Based on epidemiological data, hyperthyroidism in female productive age, with diffuse thyroid enlargement, is commonly due to Graves’ disease. However, this diagnosis needs to be further evaluated with thyroid scintigraphy and confirmed with TSH-receptor antibody test. Conclusion: Improvement in medical diagnostic tools as well as better understanding of the underlying pathophysiology will make it inevitable to find more autoimmunity co-occurrence in the future. In order to keep up with this progress, the traditional classification of APS or MAS should be reviewed to allow clinician to see the case in one big entity. Keywords: GD, LADA, SLE, UC

Carotid Intima Media Thickness in Graves Disease: Comparing Overt Hyperthyroid and Remission State

Background/Objective: Hyperthyroid has been associated with increased cardiovascular event. Carotidintima media thickness (CIMT) is oftenly measured to evaluate the risk of cardiovascularevent. The aim of this study is to measure CIMT in Graves’ disease and to comparebetween subjects in overt hyperthyroidism and remission state. Methods: Our study was a cross-sectional study performed at the outpatient endocrinologyclinic of Dr. Cipto Mangunkusumo Hospital, a tertiary care hospital in Jakarta, Indonesia. Graves’ disease subjects were recruited, of whom then grouped into overthyperthyroidism (clinical signs and symptoms of hyperthyroidism, low THS, highthyroxine levels, treatment naïve of within 3 months of treatments) and remission state(no clinical signs and symptoms of hyperthyroidism, normal THs and thyroxine levels,without any anti thyroid drugs for at least 6 months). CIMT measurements wereperformed by trained physician on both right and left artery carotid arteries using anultrasound equipped with software that automatically measured the CIMT. We alsomeasured lipid profile, fasting blood glucose, and ECG. Results: We recruited 49 Graves’ disease subjects, of whom 32 and 17 subjects werein overt hyperthyroidism and remission state respectively. Median CIMT in overthyperthyroidism and remission state were 0,473 mm and 0,488 mm respectively, p:0,109. Among clinical and laboratory risk factors, only age which had an independentcorrelation with CIMT in Graves disease. (r: 0,371; p:&lt;0,0001). Discussion: Our is the first study that measured CIMT among subjects with Graves’disease in remission and overt hyperthyroidism state, of which we observed nodifferences. This might be due to the fact that the atherosclerosis risk factors were notdistributed evenly on both group, of which subjects were older in the remission group. Ithas been reported that there are increasing CIMT along with aging (0,003-0,010 mm peryear). Furthermore, in remission state we need to take metabolic and physical changesinto consideration, such as increasing weight as much as 2,5% from prior weight alongwith increasing total cholesterol and LDL-cholesterol which both can affect CIMT levels. Conclusions:

There are no significant differences in CIMT between overt hyperthyroid andremission state in Graves’ disease. Keywords: carotid intima media thickness, Graves’ disease, overt hyperthyroid, remission.

The impact of Ramadan fasting on Fetuin-A level in type 2 diabetes mellitus

BACKGROUND/AIMS

Ramadan fasting creates changes in lifestyle, causing biochemical alterations that affect glucose metabolism and insulin sensitivity. This study aims to assess the impact of Ramadan fasting on glycemic control and Fetuin-A, a glycoprotein that affects insulin resistance, in patients with type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

This was a prospective study done among 37 patients with T2DM from Internal Medicine Polyclinic in a hospital in Jakarta, Indonesia. Anthropometric data as well as Hemoglobin A1c (HbA1c), Fasting Blood Glucose (FBG), and Fetuin-A levels of the subjects were measured in three time points: before, during, and after Ramadan fasting. A bivariate analysis was done to see the effect of Ramadan fasting on those parameters.

RESULTS

Ramadan fasting reduced Fetuin-A levels [median (minimum-maximum), 5.35 (2.91-7.81) vs. 3.22 (2.35-5.60) mg/dl; p = 0.039] four weeks after the end of Ramadan compared to pre-Ramadan. After two weeks of Ramadan fasting, we found a significant reduction in body weight, BMI, FBG, and HbA1c levels which rebounded to baseline level after Ramadan.

CONCLUSION

Ramadan fasting was associated with a significant decrease in Fetuin-A level post Ramadan.

A pilot study of red complex and three genera subgingival microbiome in periodontitis subjects with and without diabetes, evaluated by MinION platform

Background: Subgingival niche is one biofilm habitat containing rich microbiota, which plays an active role in maintaining the health of periodontal tissue and determining host response. As such, a study of changing subgingival biofilms is important for understanding the effect of a systemic condition. In this study, we compared the occurrence of six bacteria cohabiting in the subgingival area of periodontitis subjects, with (DP, n = 8) and without (NDP, n = 4) diabetes.

Methods: The six genus and species of targeted bacteria were confirmed by 16S rRNA amplicon sequencing on MinION nanopore platform. Descriptive statistic was used to describe the obtained data.

Results: We found that the six genus and species of targeted bacteria were detected but in different quantities in either group's periodontal pocket. Our data showed that Tannerella forsythia was the most abundant species in subgingival biofilms of the DP group of the red complex bacteria. In contrast, Aggregatibacter sp., which belongs to the phylum of proteobacteria, was present at a relatively lower level. In contrast, Fusobacterium sp., which belongs to orange complex bacteria, showed relative similarities in subgingival biofilms of both groups tested, while Veillonella sp., were abundant in the DP groups. 

Conclusions: Our data show that the diversity of classic periodontopathogens increased in the subgingival niche of periodontitis subjects with diabetes. It is the first study in Indonesia to apply MinION-based, full-length 16S rRNA amplicon sequencing in periodontitis patients with and without diabetes.

Impact of Sodium Butyrate Treatment in LPS-Stimulated Peripheral Blood Mononuclear Cells of Poorly Controlled Type 2 DM

Type 2 diabetes mellitus (T2DM) is associated with chronic low-grade inflammation, which is marked by the dysregulation of innate and adaptive immune responses. Therefore, reducing inflammation, possibly through an immunoregulatory agent, may play a role in T2DM treatment. Butyrate is the most potent short-chain fatty acid (SCFA), and it exerts anti-inflammatory properties by inhibiting histone deacetylase activity. As an immunoregulatory agent, sodium butyrate can inhibit nuclear factor kB (NF-kB) activation and reduce the production of pro-inflammatory cytokines in immune cells. The aim of the study was to measure the level of plasma butyrate in poorly controlled T2DM and normoglycemic participants and to compare the response of peripheral blood mononuclear cells (PBMCs) to sodium butyrate treatment between the groups by measuring production of the following cytokines: tumor necrosis factor (TNF)-α, interleukin (IL)-6, interferon (IFN)-γ, IL-13, and IL-10. The in vitro study examined the PBMCs of 15 participants with poorly controlled T2DM and 15 normoglycemic participants. PBMCs were cultured with the following stimulations for two days at a temperature of 37°C and 5% CO₂: 100 ng/mL lipopolysaccharide (LPS), 1 mM sodium butyrate, or a combination of 100 ng/mL LPS and 1 mM sodium butyrate. Plasma butyrate was measured using gas chromatography-mass spectrometry, and cytokines from culture supernatant were analyzed using magnetic beads multiplex assay. Plasma butyrate levels in participants with poorly controlled T2DM did not significantly differ from those in normoglycemic participants (p = 0.105). Compared to treatment with an LPS-stimulated PBMC culture, treatment with 1 mM sodium butyrate reduced the levels of TNF-α (p < 0.039) and IFN-γ (p < 0.038) in normoglycemic participants. The same general trend was seen in PBMC from participants with poorly controlled T2DM, but higher variability appeared to preclude statistical significance. These data suggest that butyrate may modulate inflammatory cytokine production in human PBMCs, but more research is needed to determine if butyrate is anti-inflammatory in poorly controlled T2DM.

High admission blood glucose independently predicts poor prognosis in COVID-19 patients: A systematic review and dose-response meta-analysis

AIMS

To investigate the prognostic value of admission blood glucose (BG) in predicting COVID-19 outcomes, including poor composite outcomes (mortality/severity), mortality, and severity.

METHODS

Eligible studies evaluating the association between admission fasting BG (FBG) and random BG (RBG) levels with COVID-19 outcomes were included and assessed for risk of bias with the Quality in Prognosis Studies tool. Random-effects dose-response meta-analysis was conducted to investigate potential linear or non-linear exposure-response gradient.

RESULTS

The search yielded 35 studies involving a total of 14,502 patients. We discovered independent association between admission FBG and poor COVID-19 prognosis. Furthermore, we demonstrated non-linear relationship between admission FBG and severity (Pnon-linearity < 0.001), where each 1 mmol/L increase augmented the risk of severity by 33% (risk ratio 1.33 [95% CI: 1.26-1.40]). Albeit exhibiting similar trends, study scarcity limited the evidence strength on the independent prognostic value of admission RBG. GRADE assessment yielded high-quality evidence for the association between admission FBG and COVID-19 severity, and moderate-quality evidence for its association with mortality and poor outcomes.

CONCLUSION

High admission FBG level independently predicted poor COVID-19 prognosis. Further research to confirm the prognostic value of admission RBG and to ascertain the estimated dose-response risk between admission FBG and COVID-19 severity are required.

The Impact of the Indonesian Chronic Disease Management Program (PROLANIS) on Metabolic Control and Renal Function of Type 2 Diabetes Mellitus Patients in Primary Care Setting

BACKGROUND

Indonesia through its government National Health Insurance System has launched a non-communicable and chronic disease management program named Indonesian Chronic Disease Management Program (PROLANIS), with Type 2 Diabetes Mellitus (T2DM) and hypertension as the main focus. However, study that evaluates the clinical impact of PROLANIS in patients with T2DM is still scarce to this date. This study aims to evaluate the metabolic control and renal function of PROLANIS participants with T2DM every six month within the first 18-months of implementation.

METHODS

This study was a retrospective cohort study conducted at Wates sub-district, East Java using secondary data from PROLANIS group report from April 2018 to October 2019. The study population was T2DM patients who voluntarily joined the PROLANIS group in April 2018. The six-month-evaluation included metabolic parameters [body mass index (BMI), blood pressure, hemoglobin A1C, total cholesterol, high-density lipid, low-density lipid, and triglyceride (TG)] and renal parameters [blood urea nitrogen (BUN), creatinine serum, and urinary microalbumin]. Paired t-test and wilcoxon signed-rank test was used for the analysis, and the P-value was adjusted using Bonferroni correction. A P-value < .0015 was considered statistically significant, while a P-value between .0015 and .003 was considered as marginally significant.

RESULTS

A total of 30 participants were included in the analysis. Following the PROLANIS implementation, the only parameter of metabolic control that showed significant improvement was TG serum level (P < .001). Despite the worsening status of other metabolic parameters, the changes were not statistically significant except for BMI that was marginally significant (P = .002). From renal function, only BUN serum level was significantly deteriorated (P < .001), while the others did not significantly change.

CONCLUSION

PROLANIS implementation in our study population seems to be ineffective. Future study with more primary healthcare centers needs to be done to scrutinize the clinical impact of this program nationwide.

The impact of Ramadan fasting on metabolic profile among type 2 diabetes mellitus patients: A meta-analysis

BACKGROUND AND AIMS

Majority of Muslims with type 2 diabetes mellitus (T2DM) fasted during Ramadan regardless of possible risk of complication. This systematic review aims to assess the impact of Ramadan fasting on metabolic profile and hypoglycemia event among T2DM patients.

METHODS

Literature searching was conducted on December 2019 at PUBMED, Medline (EBSCOhost), and ProQuest databases using the following keywords: Ramadan fasting, type 2 diabetes mellitus, glycemic and lipid profile, anthropometry measurements, and hypoglycemia. Observational studies in adults and published in English which analyze the glucose parameters, lipid profile, and hypoglycemia among T2DM patients during Ramadan were included in the analysis. All studies were assessed for its risk of bias using New-Castle Ottawa Scale. The heterogeneity of the studies was analyzed using I² (square) test and the overall mean difference between studied parameters before and after Ramadan fasting was calculated using Weighted Mean Difference (WMD) test using Stata 13.

RESULTS

A total of 28 observational studies that were conducted in Middle Eastern, African, and Asian countries were included. This review found decrease in FPG level by -15.28 (95% CI -17.22, -13.34) mg/dl, HbA1c by -0.27 (95% CI -0.32, -0.22)%, total cholesterol by -12.88 (95% CI -14.68, -11.09) mg/dL, LDL-C by -4.42 (95% CI -6.17, -2.66)mg/dl, HDL-C by -1.09 (95% CI -1.71 - 0.47) mg/dL, triglyceride by -2.47 (95% CI -3.69 - 1.24) mg/dL and decreased anthropometry measurement. No studies reported fatal hypoglycemia event.

CONCLUSIONS

Ramadan fasting resulted in slight improvement of overall metabolic profile and anthropometry among T2DM patients with relatively low incidence of hypoglycemia.

Obesity as a predictor for a poor prognosis of COVID-19: A systematic review

BACKGROUND AND AIMS

COVID-19 is an emerging pandemic due to droplet infection of 2019-novel coronavirus (2019-nCoV). Due to its rapid transmission and high case-fatality rate, recognition of its risk and prognostic factor is important. Obesity has been associated with impaired immune system, increasing the susceptibility for 2019-nCoV infection. We aimed to study the impact of obesity to the prognosis and disease severity of COVID-19.

METHODS

A systematic search and handsearching was conducted in four databases: Cochrane, MEDLINE, EMBASE, and PubMed. The identified articles were screened using the chosen eligibility criteria. We obtained three retrospective cohort studies (Wu J et al., Lighter J et al., and Simonnet A et al.) to be critically appraised using Newcastle Ottawa Scale.

RESULTS

The findings of all included studies were consistent in stating the contribution of obesity as a risk factor to increase the requirement for advanced medical care. Study with the highest quality, Simonnet A et al., reported an increase need of invasive mechanical ventilation in COVID-19 patients with body mass index higher than 35 kg/m2, OR: 7.36 (1.63-33.14; p = 0.021). This is associated with a higher mortality rate in obese population infected with COVID-19.

CONCLUSION

Obesity is an independent risk and prognostic factor for the disease severity and the requirement of advanced medical care in COVID-19. This systematic review highlights a particularly vulnerable group - obese, and emphasises on the importance of treatment aggression and disease prevention in this population group.

Diagnosing metabolic syndrome in a multi-ethnic country: is an ethnic-specific cut-off point of waist circumference needed?

The definition of Metabolic Syndrome (MS) required an ethnic-specific cut-off point for waist circumference (WC). We aim to assess the optimal ethnic-specific WC cut-off point for MS in Indonesia, a multi-ethnic country. Three population-based studies in Indonesia were included for analysis [Flores (n = 1227, Floresian), Depok (n = 904, Sundanese), and Jakarta (n = 1574, Javanese)]. All subjects were 25–65 years old. The receiver operator characteristic curve analysis and Youden index method was used to determine the optimal cut-offs of WC to predict two or more risk factors of MS. In Flores, the cut-offs were 80 cm (Sensitivity and Specificity, AUC, 84% and 73%, 0.86) and 77 cm (86% and 68%, 0.85), for men and women, respectively. While in Depok, the values were 87 cm (87% and 67%, 0.85) and 79 cm (94% and 54%, 0.79), for men and women, respectively. While in Jakarta, the values were 83 cm (92% and 60%, 0.85) and 81 cm (84% and 60%, 0.77), for men and women, respectively. The optimal WC cut-off values for MS were different in those three ethnicities, and in general were lower than the currently used cut-off points for Asian population.

The implementation of community-based diabetes and hypertension management care program in Indonesia

Since 2010, Indonesian government has initiated a chronic disease management program, Prolanis (Program Pengendalian Penyakit Kronis) targeted for diabetes and hypertension. The program is continued at the commencement of universal health coverage (UHC) in 2014. “This study aimed to report the utilization and cost of the implementation of Prolanis in Indonesia from 2014 to 2016, or two years since the commencement of Indonesian universal health coverage.” Secondary data analysis was performed using publicly available data and data obtained from the national health insurance agency (BPJS); while data on disease prevalence were collected from basic national health survey. There was an increase trend of Prolanis participants, from around 11,000 participants in 2014 to more than 250,000 in 2016. More than 70% of participants were adults living in Java, however, the acceptance rate was very low in other area. Across different activities in Prolanis, physical activity was the most participated ones. In comparison to other regions, regions in Java were the most active area. The total expenditure for Prolanis program in 2016 increased almost triple from the annual cost in 2014. However, the cost per person was actually decreased more than 50%. Within two years of UHC implementation, there were increase covered participants and total costs, but cost per individual was decreased and there was significant difference in of cost between Java and outside Java. Further study and routine monitoring-evaluation process by health authority is needed to assess whether the cost difference would affect the service quality.

The Effect of Helminths on Granulocyte Activation: A Cluster-Randomized Placebo-Controlled Trial in Indonesia

BACKGROUND

Eosinophils are a prominent cell type in the host response to helminths, and some evidence suggests that neutrophils might also play a role. However, little is known about the activation status of these granulocytes during helminth infection.

METHODS

We analyzed the expression of eosinophil and neutrophil activation markers in peripheral blood by flow cytometry and measured serum levels of eosinophil granule proteins in 300 subjects residing in an area endemic for soil-transmitted helminths (STH). The data generated are on samples before and after 1 year of 3-monthly albendazole treatment.

RESULTS

Anthelmintic treatment significantly reduced the prevalence of STH. While eosinophil numbers were significantly higher in STH-infected compared to uninfected subjects and significantly decreased following albendazole treatment, there was no effect exerted by the helminths on either eosinophil nor neutrophil activation. Although at baseline eosinophil granule protein levels were not different between STH-infected and uninfected subjects, treatment significantly reduced the levels of eosinophil-derived neurotoxin (EDN) in those infected at baseline.

CONCLUSIONS

These results show that besides decreasing eosinophil numbers, anthelmintic treatment does not significantly change the activation status of eosinophils, nor of neutrophils, and the only effect seen was a reduction in circulating levels of EDN.

CLINICAL TRIALS REGISTRATION

http://www.isrctn.com/ISRCTN75636394.

Helminth infections drive heterogeneity in human type 2 and regulatory cells

Helminth infections induce strong type 2 and regulatory responses, but the degree of heterogeneity of such cells is not well characterized. Using mass cytometry, we profiled these cells in Europeans and Indonesians not exposed to helminths and in Indonesians residing in rural areas infected with soil-transmitted helminths. To assign immune alteration to helminth infection, the profiling was performed before and 1 year after deworming. Very distinct signatures were found in Europeans and Indonesians, showing expanded frequencies of T helper 2 cells, particularly CD161+ cells and ILC2s in helminth-infected Indonesians, which was confirmed functionally through analysis of cytokine-producing cells. Besides ILC2s and CD4+ T cells, CD8+ T cells and γδ T cells in Indonesians produced type 2 cytokines. Regulatory T cells were also expanded in Indonesians, but only those expressing CTLA-4, and some coexpressed CD38, HLA-DR, ICOS, or CD161. CD11c+ B cells were found to be the main IL-10 producers among B cells in Indonesians, a subset that was almost absent in Europeans. A number of the distinct immune profiles were driven by helminths as the profiles reverted after clearance of helminth infections. Moreover, Indonesians with no helminth infections residing in an urban area showed immune profiles that resembled Europeans rather than rural Indonesians, which excludes a major role for ethnicity. Detailed insight into the human type 2 and regulatory networks could provide opportunities to target these cells for more precise interventions.

The prevalence of metabolic syndrome and its association with body fat distribution in middle-aged individuals from Indonesia and the Netherlands: a cross-sectional analysis of two population-based studies

BACKGROUND

The prevalence of metabolic syndrome varies among populations with different ethnicities. Asian populations develop metabolic complications at lower amounts of adiposity than western populations. The role of abdominal obesity in the metabolic differences between the two populations is poorly understood.

OBJECTIVES

Our objectives were to estimate the prevalence of metabolic syndrome and the relative contribution of its components in the Indonesian and the Dutch population, as well as to examine the associations of overall and abdominal obesity with metabolic syndrome.

METHODS

In this cross-sectional study of middle-aged adults in the Netherlands Epidemiology of Obesity Study (n = 6602) and the Indonesian National Health Surveillance (n = 10,575), metabolic syndrome was defined by the unified IDF and AHA/NHLBI criteria. We performed logistic and linear regressions to examine associations of BMI and waist circumference with the metabolic syndrome, mutually adjusted for waist circumference and BMI.

RESULTS

The prevalence of metabolic syndrome was 28% and 46% in Indonesian men and women, and 36% and 24% in Dutch men and women. The most prominent components were hypertension (61%) and hyperglycemia (51%) in the Indonesian, and hypertension (62%) and abdominal obesity (40%) in the Dutch population. Per SD in BMI and waist circumference, odds ratios (ORs, 95% CI) of metabolic syndrome were 1.5 (1.3-1.8) and 2.3 (1.9-2.7) in Indonesian men and 1.7 (1.2-2.5) and 2.9 (2.1-4.1) in Dutch men. The ORs of metabolic syndrome were 1.4 (1.2-1.6) and 2.3 (2.0-2.7) in Indonesian women and 1.0 (0.8-1.3) and 4.2 (3.2-5.4) in Dutch women.

CONCLUSION

More Indonesian women than men have metabolic syndrome, whereas the opposite is true for the Dutch population. In both the Indonesian and the Dutch populations, hypertension is the primary contributor to the prevalence of metabolic syndrome. In both populations, abdominal adiposity was more strongly associated with metabolic syndrome than overall adiposity.

Visceral adiposity index and lipid accumulation product as a predictor of type 2 diabetes mellitus: The Bogor cohort study of non-communicable diseases risk factors

OBJECTIVES

Lipid accumulation product (LAP) index and Visceral Adiposity Index (VAI) are simple calculations to measure fat accumulation and visceral fat respectively. We aim to study the use of LAP index and VAI as diagnostic parameter and predictor of T2DM.

METHODS

We analysed the baseline and longitudinal data from the Indonesian Ministry of Health Cohort Study of Non-communicable Diseases Risk Factors in West Java, comprising 846 men and 2437 women aged 25-65 years. At baseline, the odds ratio for the diagnosis of prediabetes and T2DM among subjects with high LAP Index and VAI was analysed using logistic regression analysis. In the longitudinal analysis, LAP index and VAI as predictor of prediabetes and T2DM was analysed with cox regression analysis.

RESULT

Worsening glycemia status was associated with an increased LAP index and VAI (p < 0.001). Subjects with high VAI had an increased OR of having T2DM in both men [OR, 95%CI, 2.29(1.15-4.56), p = 0.018] and women [1.95(1.49-2.54), p < 0.001)]. Association of high LAP with T2DM was found only in women [OR, 95%CI, 2.11(1.16-1.52), p < 0.001]. In terms of T2DM prediction, only women [RR, 95% CI, 2.59 (1.05-6.39), p = 0.038)], with high VAI had an increased risk of T2DM in the future. High LAP index was not associated with an in increased risk of T2DM in the future in both sexes.

CONCLUSION

High LAP index was associated with an increased risk of T2DM diagnosis in women but it could not predict the development of T2DM. High VAI was associated with an increased risk of T2DM diagnosis in both sexes, however, it could only predict the development of T2DM in women.

Determinant of postprandial triglyceride levels in healthy young adults

BACKGROUND

Fasting lipid profile does not necessarily illustrate the exact lipid dynamic in 24 h as human spends most of their time in postprandial state. Postprandial triglyceride (TG) has been reported to have advantages compared to fasting TG in terms of practicality and ability to predict cardiovascular events. This study aims to assess the determinant of postprandial TG in healthy young adults.

METHODS

This is a quasy-experimental study that involved 200 healthy young adults. This study compared fasting with postprandial TG and analyzed the relationship between postprandial TG with various demographic and metabolic parameters after ingestion of standardized high fat liquid meal.

RESULT

There was an upward trend from fasting TG to 2 h postprandial TG and 4 h postprandial TG. There was strong correlation between fasting TG and 2 h postprandial TG with 4 h postprandial TG (r = 0.731; p < 0.0001 dan r = 0.669; p < 0.0001, respectively). Whereas body mass index (BMI) and age showed weak correlation with 4 h postprandial TG (r = 0.141; p < 0.0001 dan r = 0.0747; p < 0.0001), fasting TG was the strongest predictor of 4 h postprandial TG (r = 0.669, B = 1.722 (95% CI 1.552 to 1.892), p < 0.0001).

CONCLUSION

Fasting TG was the strongest determinant of 4 h postprandial TG in healthy young adults. We also observed strong correlation between 4 h postprandial TG and fasting TG. Hence, 4 h postprandial TG might potentially replaced fasting TG when measurement of fasting TG is not feasible.

Visceral adiposity index as a predictor for type 2 diabetes mellitus in Asian population: A systematic review

BACKGROUND

Visceral Adiposity Index (VAI) is a formula to estimate visceral fat accumulation which has been reported to have a better prediction for type 2 diabetes mellitus (T2DM) in Caucasian population. This systematic review is proposed to inquire whether VAI can be used as a predictor of T2DM in Asian population with different body composition compared to the Caucasian.

METHODS

All studies performed in Asia and published in English on VAI prediction on the incidence of T2DM were included. The search keywords used in Pubmed and Cochrane database were visceral adiposity index, VAI and T2DM.

RESULTS

Seven included studies, of which six studies were conducted in China and one in Iran. Four studies were prospective cohorts and the other three were cross-sectional. The largest study population were 7639 subjects, while the longest observation period was 15 years. This study found that VAI can be used as a predictor of T2DM in Asian population with better prediction values compared to Caucasian population. The reported odds ratio or hazard ratio ranged from 1.2 to 3.6.

CONCLUSIONS

VAI is a practical formula used to estimate the accumulation of visceral fat which can be used as a predictor for T2DM in Asian population.

Prevalence of Atopy following Mass Drug Administration with Albendazole: A Study in School Children on Flores Island, Indonesia

BACKGROUND

In many rural areas of tropical countries such as Indonesia, the prevalence of soil-transmitted helminths (STH) infections remains high. At the same time, the burden of allergic disorders in such rural areas is reported to be low and inversely associated with helminth infections. To reduce the morbidity and transmission of helminth infections, the world health organization recommends preventive treatment of school children by providing mass drug administration (MDA) with albendazole. Here, we had an opportunity to evaluate the prevalence of skin reactivity to allergens before and after albendazole treatment to get an indication of the possible impact of MDA on allergic sensitization.

METHODS

A study was conducted among 150 school children living in an area endemic for STH infections. Before and 1 year after anthelminthic treatment with albendazole, stool samples were examined for the presence of STH eggs, skin prick tests (SPT) for cockroach and house dust mites were performed, blood eosinophilia was assessed, and total immunoglobulin E (IgE) and C-reactive protein (CRP) were measured in plasma.

RESULTS

Anthelminthic treatment significantly reduced the prevalence of STH from 19.6 before treatment to 6% after treatment (p < 0.001). Levels of total IgE (estimate: 0.30; 95% CI 0.22-0.42, p < 0.0001), CRP (estimate: 0.60; 95% CI 0.42-0.86, p = 0.006), and eosinophil counts (estimate: 0.70; 95% CI 0.61-0.80, p < 0.001) decreased significantly. The prevalence of SPT positivity increased from 18.7 to 32.7%. Multivariate analysis adjusted for confounding factors showed an increased risk of being SPT positive to any allergen (OR 3.04; 95% CI 1.338-6.919, p = 0.008).

CONCLUSIONS

This study indicates that 1 year of MDA with albendazole was associated with a reduced prevalence of STH infections. This study shows that the prevalence of allergic sensitization increases after 1 year of albendazole treatment. Placebo-controlled and larger studies are needed to further substantiate a role of deworming treatment in an increased risk of allergic sensitization.

Effect of Anthelmintic Treatment on Insulin Resistance: A Cluster-Randomized, Placebo-Controlled Trial in Indonesia

Background

Emerging evidence suggests that helminth infections are associated with lower insulin resistance (IR). Current deworming programs might remove this helminth-associated protective effect. Therefore, we evaluated the anthelmintic treatment effect on changes in IR.

Methods

We conducted a double-blind, household-cluster-randomized, placebo-controlled clinical trial on Flores island, Indonesia, an area endemic for soil-transmitted helminths (STHs). All subjects received 4 rounds of albendazole or matching placebo with 3-month intervals, for 3 consecutive days. The primary outcome was the change in homeostatic model assessment of IR in those aged >16 years. An intention-to-treat analysis was performed involving all subjects and ad hoc in the helminth-infected subjects.

Results

We examined 797 (in 329 households) and 872 (in 353 households) subjects, who were assigned randomly into the albendazole and placebo arms, respectively. Albendazole was associated with a significant reduction in STH prevalence, total immunoglobulin E (IgE), and eosinophil count. Whereas albendazole had no effect on IR (estimated treatment effect, 0.006 [95% confidence interval, -.010 to .021]; P = .48) at the community level, it was associated with a significant increase in IR (estimated treatment effect, 0.031 [95% confidence interval, .004 to .059]; P = .04) (P value for interaction = .01) among helminth-infected subjects as detected by microscopy. Pathway analysis suggested that this might in part be due to an increased body mass index or a reduced eosinophil count.

Conclusions

Anthelmintic treatment reduces STH prevalence, total IgE, and eosinophil count but has no effect on IR at the community level. In helminth-infected subjects, treatment significantly increases IR, highlighting the need for metabolic health monitoring with ongoing deworming programs.

Clinical Trials Registration

ISRCTN 75636394.

The effect of three-monthly albendazole treatment on Th2 responses: Differential effects on IgE and IL-5

Helminth parasites induce a strong Th2 response, characterized by high levels of IgE and elevated signature cytokines such as IL-5. As many global deworming programmes are underway, there is concern that this might lead to emergence of Th1-mediated pathologies when the counterbalancing helminth-induced Th2 response is absent. Therefore, we assessed the effect of deworming on Th2-mediated responses in a household-clustered randomized controlled trial in Indonesia. Total plasma IgE and whole-blood IL-5 responses to mitogen phytohaemagglutinin (PHA) were measured in 1494 and 682 subjects, respectively, at baseline, 9 and 21 months after three-monthly single-dose treatment with albendazole or placebo. Anthelmintic treatment did not result in complete removal of helminth infections in the community. However, treatment significantly decreased IgE levels in albendazole- compared to placebo-treated subjects. IL-5 responses to PHA were not significantly affected by anthelmintic treatment and tended to increase in albendazole-treated subjects, indicating that intensive treatment of helminth parasites has different outcomes on B-cell (IgE levels) and T-cell (IL-5) responses. The data shows that 2 years of deworming can have differential effects on responses typified as Th2-mediated, which needs to be taken into account when examining the impact of helminths on noncommunicable diseases.

Helminth infections and type 2 diabetes: a cluster-randomized placebo controlled SUGARSPIN trial in Nangapanda, Flores, Indonesia

Background

Insulin resistance is a strong predictor of the development of type 2 diabetes mellitus. Chronic helminth infections might protect against insulin resistance via a caloric restriction state and indirectly via T-helper-2 polarization of the immune system. Therefore the elimination of helminths might remove this beneficial effect on insulin resistance.

Methods/Design

To determine whether soil-transmitted helminth infections are associated with a better whole-body insulin sensitivity and whether this protection is reversible by anthelmintic treatment, a household-based cluster-randomized, double blind, placebo-controlled trial was conducted in the area of Nangapanda on Flores Island, Indonesia, an area endemic for soil-transmitted helminth infections. The trial incorporates three monthly treatment with albendazole or matching placebo for one year, whereby each treatment round consists of three consecutive days of supervised drug intake. The presence of soil-transmitted helminths will be evaluated in faeces using microscopy and/or PCR. The primary outcome of the study will be changes in insulin resistance as assessed by HOMA-IR, while the secondary outcomes will be changes in body mass index, waist circumference, fasting blood glucose, 2 h-glucose levels after oral glucose tolerance test, HbA1c, serum lipid levels, immunological parameters, and efficacy of anthelmintic treatment.

Discussion

The study will provide data on the effect of helminth infections on insulin resistance. It will assess the relationship between helminth infection status and immune responses as well as metabolic parameters, allowing the establishment of a link between inflammation and whole-body metabolic homeostasis. In addition, it will give information on anthelmintic treatment efficacy and effectiveness.

Trial registration

This study has been approved by the ethical committee of Faculty of Medicine Universitas Indonesia (ref: 549/H2.F1/ETIK/2013), and has been filed by the ethics committee of Leiden University Medical Center, clinical trial number: ISRCTN75636394. The study is reported in accordance with the CONSORT guidelines for cluster-randomised trials.