Frequency of prediabetes and influence of various risk


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Frequency of prediabetes and influence of various risk

  1. 1. Int J Diabetes Dev Ctries (April–June 2011) 31(2):65–69DOI 10.1007/s13410-010-0008-9 ORIGINAL ARTICLEFrequency of prediabetes and influence of various riskfactors on the development of prediabetes: a tertiarycare hospital experienceSamiullah Shaikh & Gani Hanif & Kashif & Mona HumeraReceived: 27 June 2010 / Accepted: 1 September 2010 / Published online: 19 April 2011# Research Society for Study of Diabetes in India 2011Abstract The objective of study was to determine the high birth weight child, HDL <35 mg/dl. Considering thefrequency of prediabetes and observe the influence of high frequency of prediabetes in the region, provision ofvarious risk factors on the development of prediabetes at vast educational program to prevent the disease is essentialLiaquat University Hospital, Hyderabad. Descriptive case and as well screening for prediabetes using FBG andseries. Medical outpatient department Liaquat University OGTT, especially for obese subjects and those with otherHospital, Hyderabad. From 01-03-2007 to 31-03-2008. risk factors of diabetes.Total 500 subjects with BMI>25 and aged either 45 yearand above or BMI>25, with an additional risk factor were Keywords Prediabetes . BMI . WHR . IGT . IFG .enrolled for the study.All diagnosed patients of diabetes Triglyceridewere excluded from study. A well designed proformaincluded demographic information, history regarding firstdegree relative with diabetes, gestational diabetes, delivery Introductionof large baby and related investigations. Fasting bloodglucose (FBG)≥100 mg/dl but <126 mg/dl and/or OGTT The incidence and prevalence of type 2 diabetes mellituslevel ≥140 mg/dl but <200 mg/dl was considered predia- (T2DM) have reached epidemic proportions, with furtherbetes. The collected data was analyzed on SPSS version increases appearing inevitable [1]. Unless appropriate16.0. This study comprised of 500 subjects of which 306 action is taken, this will place an impossible economic(61.2%) were male and 194 (38.8%) female. The mean age burden on health systems and on individuals. As a result,of the cases were 49.42±7.73 years. Prediabetes was found major prevention campaigns are needed worldwide. Thesein 147/500(29.4%) cases of which 109 were female and 38 can be of two types: the population approach, in which anwere male. A strong correlation was found between entire population is advised on the benefits of healthy livingprediabetes and BMI, persons with h/o diabetes in first (i.e. increased physical activity and weight control), or thedegree relative, h/o gestational diabetes, h/o delivery of targeting of high-risk individuals [2, 3]. Often the two approaches are combined. In recent years, targeting of high- risk individuals has focused on the identification of thoseS. Shaikh : G. Hanif : Kashif : M. Humera with prediabetes [4].Department of Medicine, Liaquat University of Medical & Health In 1979, the term impaired glucose tolerance (IGT) wasSciences,Jamshoro/Hyderabad, Pakistan coined by the World Health Organization (WHO) and the National Diabetes Data Group [5] to replace an older termS. Shaikh (*) of borderline, chemical or asymptomatic DM coined inH.NO:55, Green Homes, 1965. In 1997, an expert committee from the AmericanQasimabad, Hyderabad, Pakistane-mail: Diabetes Association (ADA) recommended the followinge-mail: criteria for PDM; a fasting blood glucose of 110 to
  2. 2. 66 Int J Diabetes Dev Ctries (April–June 2011) 31(2):65–69<126 mg/dl and/or a postprandial blood glucose of 140 to participants were asked to drink a calibrated dose of 75 g<200 mg/dl 2 h after a 75-g oral glucose challenge [6]. glucose. Two hours later, second plasma sample was drawn The number of prediabetic patients is ever increasing and tested for post load glucose concentrations. Theseworldwide. In 2003, an estimated 314 million people samples were collected in test tubes containing nodeveloped prediabetes. By the year 2025, the number is preservative and were transported within half hour toexpected to increase to 472 million (9% of all adult population) Liaquat University Hospital Laboratory; the method usedworldwide. However, it differs from region to region. was “PAP” enzymatic calorimetric test. IFG was defined asPrevalence was reported at 13.2% of all adult population in having FPG >100 mg/dl but <126 mg/dl. IGT was definedthe south-east Asian region, 10.5% in the European region and as having2h glucose >140 mg/dl but <200 mg/dl. Pre-5.7% of adults in the western Pacific region [7]. diabetes was defined as having IFG and/or IGT [6]. Persons with prediabetes can have mortality 40% greater Another twelve hour fasting blood samples were takenthan the normal population [8]. Coronary heart disease is for HDL cholesterol and triglyceride level and sent to the1.33 times higher than the normal population [9]. Recent same laboratory. All this information was enrolled in well-data have also shown that both lifestyle and pharmacologic designed proforma. Patients with any of variables such astherapy can alter the progression of prediabetes to overt no h/o first degree relative with diabetes, no h/o gestationaldiabetes [10, 11]. diabetes, no h/o delivery of large baby, BMI <25 kg/m2, The objective of the study was to determine the HDL Cholesterol >35 mg/dl and triglycerides <250 mg/dlfrequency of pre-diabetes at Liaquat University Hospital were grouped as one. Patients with any of variables such asHyderabad and to observe the influence of various risk h/o first degree relative with diabetes, h/o gestationalfactors such as sex, BMI, H/O gestational diabetes, first diabetes, h/o delivery of large baby, BMI >25 up to 30 ordegree relative with diabetes and H/O delivery of large >30 kg/m2, HDL Cholesterol <35 mg/dl and triglyceridesbaby with the occurrence of prediabetes. >250 mg/dl were grouped as two.Subjects and methods Data analysisThis descriptive case series study included 500 consecutive Quantitative variables such as age, height, weight, waistcases attending the medical outpatient department of circumferences, waist to hip ratio (WHR), systolic bloodLiaquat University Hospital Hyderabad from 01-03-2007 pressure, diastolic blood pressure, fasting plasma glucoseto 31-03-2008. level and oral glucose tolerance test level were expressed as The study included all persons 45 years or older age with Mean and Standard deviation. Qualitative variables such asBMI 25 kg/m2 or less than 45 years with BMI 25 kg/m2 or sex, subjects with history of first degree relative with diabetes,more, if having another risk factor [6]: with history of gestational diabetes and with history of delivery of large baby, BMI, HDL, triglycerides, prediabetesi. Blood pressure over 140/90 mmHg were expressed as frequency & percent. The qualitativeii. HDL cholesterol 35 mg/dl or less. variables such as sex, h/o of first degree relative with diabetes,iii. Triglyceride level 250 mg/dl or more. h/o gestational diabetes h/o delivery of large baby, BMI, HDL,iv. History of first degree relative with diabetes. triglycerides were compared with the prediabetes byv. History of gestational diabetes. Chi-square test. Statistical analysis was performed by SPSSvi. History of delivery of large baby (weighting more than software version 16.0 (SPSS Inc., Chicago, IL, USA). P value 9 lbs.). of 0.05 was considered statistically Significant. Subjects with known diabetes were excluded from initialenrollment All the patients who met above inclusion criteria Resultsincluded in the study after taking informed consent. Athorough medical history regarding first degree relative This case series study included 500 consecutive subjectswith diabetes were taken, gestational diabetes, delivery of with BMI≥25 of which 306 (61.2%) were male and 194large baby and physical examination including of blood (38.8%) were female. The mean age were 49.42 ±pressure, BMI by measuring height in meters (m) and 7.73 years, height 1.70± 0.06 m, weight 82.32± 8.37,weight in kilogram (kg),waist circumference in centimeters fasting plasma glucose 97.56±19.2 mg/dl, oral glucose(cm) and waist-to-hip ratio (WHR) was carried out and tolerance test 154.74 ± 35.88 mg/dl, HDL cholesterolentered into proforma. After an initial blood sample was 42.60 ± 4.54, and triglycerides 184.4 ± 14.7 mg/dl. h/odrawn for FPG testing after overnight or eight hour fasting, diabetes in first degree relatives was present in 157/500
  3. 3. Int J Diabetes Dev Ctries (April–June 2011) 31(2):65–69 67Table 1 Baseline characteristics of the cases studiedQuantitative Variables Number Mean SD± Age (yrs) 500 49.42 7.73 Weight (kgs.) 500 82.32 8.37 Height (m) 500 1.70 0.06 FBG (mg/dl) 500 97.56 19.2 Oral glucose tolerance test (mg/dl) 500 154.74 35.88 HDL cholesterol (mg/dl) 500 42.6 4.54 Triglycerides (mg/dl) 500 184.4 14.7Qualitative Variables Number Frequency Percentage Sex-Male 500 306 61.2% Female 194 38.8% H/O gestational diabetes 32 6.4% H/O delivery of large baby 32 6.4% H/O diabetes 500 157 31.4% in 1st degree relatives Prediabetes 500 147 29.4% BMI (kg/m2) 500 <25 118 23.6% 25 to30 281 56.2% >30 101 20.2%(31.4%), h/o gestational diabetes in 32(6.4%) and h/o 19/32 female with h/o delivery of high birth weight childdelivery of large baby in 32(6.4%) cases. Prediabetes had prediabetes (p=0.001). 18/34 persons with HDLwas present in 147/500 (29.4%) of which 95 were male <35 mg/dl had prediabetes (p=0.003) and 6/26 withand 52 female. Table 1 explains the baseline character- triglyceride >250 mg/dl had prediabetes (p=0.659). Table 2istics of the cases studied. explains the relation of various risk factors with the Among the 306 male 95 had prediabetes and amongst development of prediabetes.194 females 52 had prediabetes (p=0.316).BMI<25 waspresent 118 cases of which 18 had prediabetes, >25 up to30 was present in 281 persons of which 70 had prediabetes Discussionand 101 persons had BMI>30 kg/m2 of which 60 hadprediabetes (p=001). In 62/147 persons with pre diabetes In this study, frequency of prediabetes was 29.4% which ishad h/o diabetes in first degree relative (p=0.001), 11/32 higher as compared to that reported by the Nationalwith h/o gestational diabetes had prediabetes (p=0.549), Diabetes Prevalence survey of Pakistan which showed thatTable 2 Relation of various riskfactors with the development Variables Number Total N: Prediabetes P valueof prediabetes Sex - Male 306 500 95 0.316 Female 194 52 BMI - <25 118 500 17 0.001 >25–30 281 70 >30 101 60 h/o Diabetes in first degree relative 156 500 86 0.001 h/o gestational diabetes 32 500 11 0.549 h/o delivery of high birth weight child 32 500 19 0.001 HDL <35 mg/dl 34 500 18 0.003 Triglyceride >250 mg/dl 26 500 06 0.659
  4. 4. 68 Int J Diabetes Dev Ctries (April–June 2011) 31(2):65–69over 10% of people in the age group 25 years and above are compared to normal non-diabetics. Several longitudinalsuffering from prediabetes and further that prevalence of cohort studies have demonstrated the association betweenprediabetes among adult population in Sindh was 11.1% obesity and glucose intolerance [20]. Data from NHANES-II[12]. It is because we have enrolled high risk subjects while show that 67% of those with type 2 diabetes have BMI thatNational Diabetes Prevalence survey of Pakistan enrolled meets the criteria for being overweight, and almost half haveall the adults above 25 years irrespective of any risk factor. BMI that meets the definition of obesity [21].While secondary analysis report of New castle Heart In this study, systolic and diastolic blood pressureProject showed that prevalence of prediabetes is 23.4% increased from normal to prediabetes to undiagnosedamong South Asians [13]. Also a study conducted at diabetes. Masoumeh Sadeghi et al. [22] and A. Basit [23]primary health care clinics of Israel to assess the glucose also show same association of blood pressure to prediabetestolerance state in healthy, over-weight Arabs aged above and diabetes. Epidemiological studies report at least 2 fold40 years and showed that 42% had prediabetes [14]. incidence of high blood pressure in diabetes [16].NHANES-III showed that among the overweight adults NHANES-III shows 56.5% hypertensive had prediabetesaged above 45 years, 45.9% had abnormal glucose [13]. In the NHANES II study, the prevalence of hyperten-metabolism, out of these 12.5% had self-reported diabetes, sion, defined as blood pressure >160/95 mmHg among10.8% had undiagnosed diabetes 22.6% had prediabetes individual aged 65 to 74 year, increased with decreasing[15]. NHANES-III shows the severity of problem in glucose tolerance [24]. Approximately 60% of subjectsdeveloped country where people are much more conscious with diabetes, 50.7% of those with IGT, and 38.3% of thoseof their health and take regular medical checkups as with normal glucose were affected [25].compared to our setup where there is no such trend and In this study, HDL cholesterol level decreased frompeople seek medical help when problems like complica- normal to prediabetes to undiagnosed diabetes while thetions arise. It is also estimated that major part of increase in triglyceride level increased. Type 2 diabetics often havediabetes prevalence is occurring in developing countries elevated triglyceride and depressed HDL cholesterol. Itwith the rate of 170% increase and by the year 2025 develops concomitantly with the failure of insulin activity,approximately 75% of all persons with diabetes will be which in turn leads to the release of fatty acids fromliving in developing countries [12]. adipose tissue, increased delivery of free fatty acids to the In this study, the frequency of prediabetes is higher in liver, and increased hepatic synthesis of very low densitymales than in females, NHANES-III also showed that lipoprotein NHANES-III shows high prevalence of predi-higher proportion of male than female had prediabetes abetes 94.9% in dyslipidimics [16]. Dyslipidemia is(55.4% versus 44.6%) [16]. associated with markedly increased cardio vascular risk In this study history of first degree relative with diabetes has among diabetic patients [26].shown a strong association with the prediabetes. In NHANES-III prevalence of prediabetes was high (44.3%) in person withpositive family history of diabetes [16]. Type 2 diabetes Conclusionappears to have strong genetic associations. Studies in twinshave demonstrated that the concordance rate of type 2 diabetes This study showed a meaningful relationship betweenin monozygotic twins range between 34% and 83% [17]. The obesity, dyslipidemia, history of first degree relative withbroad range of observed correlation suggests both a complex prediabetes. Therefore, identifying and mitigating thesegenetic predisposition and an interaction between environ- factors are of great importance to the health of the generalmental and genetic factors in the pathogenesis of type 2 population. The high frequency of prediabetes in this regiondiabetes. People who have one first degree relative suffering makes it necessary to generalise the screening methods offrom prediabetes have a 40% risk of having this disease. If the disease for the population with above risk factors anddiabetes is seen in both parents, the risk is doubled [18]. with early detection of prediabetes and its management In our study h/o gestational diabetes and history of with life style modification can prevent or delay the onsetdelivery of large baby has shown a non-significant of type 2 diabetes in a cost effective way. In addition,association with prediabetes. This is in contrast with the promoting the level of general knowledge on the riskstudy that showed that 36% of women who were diagnosed factors of diabetes or its symptoms and complications canwith gestational diabetes mellitus had persistent abnormal play an effective role in the prevention and control of theglucose tolerance [19]. The reason seems to be enrollment disease. This can be done through the mass media orof small number of patients in our study. distribution of educational pamphlets or books written in A positive association between high BMI with prediabetes simple language. More studies are needed to improve theis seen in this study. Mean weight, BMI, Waist circumference correlation between gestational diabetes or delivery of largeand waist to hip ratio (WHR) were all higher in prediabetes as baby and prediabetes.
  5. 5. Int J Diabetes Dev Ctries (April–June 2011) 31(2):65–69 69Acknowledgements We are grateful to Dr.Ghulam Hussain, in 13. Majeed A, Newnham A, Ryan R, Khunti K, Guthrie C. Preventioncharge Diabetic Clinic of this institute for extensive assistance with and cure of type-II diabetes. BMJ. 2002;325:965– retrieval. We are also thankful to Dr. Irum, Dr. Iftikhar Qazi, 14. Abdul Ghani MA, Sabbah M, Mauti B, Dakwar N, Kashkosh H,postgraduate students for helping us in the collection of the patients Minuchin O, et al. High frequency of pre-diabetes, undiagnosedand conducting statistical analysis. diabetes and metabolic syndrome among over weight Arabs in Israel. Isr Med Assoc J. 2005;7:143–7. 15. Benjamin SM, Valdez R, Geiss LS, Rolka BD, Narayan KM.References Estimated number of adults with prediabetes in the U.S in 2000: opportunities for prevention. Diab Care. 2003;26:645–9. 16. Li C, Ford ES, Zhao G, Mokdad AH. Prevalence of pre-diabetes 1. Alberti G, Zimmet P, Shaw J, et al. Type 2 diabetes in the young: and its association with clustering of cardiometabolic risk factors the evolving epidemic: the International Diabetes Federation and hyperinsulinemia among U.S. adolescents. Diab Care. consensus workshop. Diab Care. 2004;27:1798–811. 2009;32:342–7. 2. Chiasson JL, Brindisi MC, Rabasa-Lhoret R. The prevention of 17. Bener A, Zirie M, Al-Rikabi A. Genetics, obesity, and environ- type 2 diabetes: what is the evidence? Minerva Endocrinol. mental risk factors associated with type-II diabetes. Croat Med J. 2005;30:179–91. 2005;46:302–7. 3. Alberti KG, Zimmet P, Shaw J. International Diabetes Federation: a 18. Yaturu S, Bridges JF, Dhanireddy RR. Preliminary evidence of consensus on type 2 diabetes prevention. Diabet Med. 2007;24:451–63. genetic anticipation in type-II diabetes mellitus. Med Sci Monit. 4. Irons BK, Mazzolini TA, Greene RS. Delaying the onset of type 2 2005;11:262–5. diabetes mellitus in patients with prediabetes. Pharmacotherapy. 19. Russell MA, Phipps MG, Olson CL, Welch HG, Carpenter MW. 2004;24:362–71. Rates of postpartum glucose testing after gestational diabetes 5. National Diabetes Data Group. Classification and diagnosis of mellitus. Obstet Gynaecol. 2006;108:1456–62. diabetes mellitus and other categories of glucose intolerance. 20. Overweight, obesity, and health risk. National Task Force on the Diabetes. 1979;28:1039–57. Prevention and Treatment of Obesity. Arch Intern Med 6. American Diabetes Association. Standards of medical care in 2000;160:898–904. diabetes—2008. Diab Care. 2008;31 suppl 1:S12–54. 21. Virtanen KA, Lozzo P, Hallsten K, Huupponen R, Parkkola R, 7. 18th Congress of the International Diabetes Federation. Paris, France, Janatuinen T. Increased fat mass compensates for insulin 24–29 August 2003. Diabetologia 2003;46 Suppl. 2:A1–471. resistance in abdominal obesity and type-II diabetes: a positron 8. Saydah SH, Loria CM, Eberhardt MS, Brancati FL. Subclinical emitting tomography study. Diabetes. 2005;54:2720–6. states of glucose intolerance and risk of death in the U.S. Diab 22. Sadeghi M, Roohafza H, Shirani S, Poormoghadas M, Kelishad Care. 2001;24:447–53. R, Baghaii A, et al. Diabetes and associated cardiovascular risk 9. Coutinho M, Gerstein HC, Wang Y, Yusuf S. The relations hip factors in Iran: the Isfahan healthy heart programme. Ann Acad between glucose and incident cardiovascular events. A meta Med Singapore. 2007;36:175–80. regression analysis of published data from 20 studies of 95,783 23. Basit A, Hydrie MZI, Ahmed K, Hakeem R. Prevalence of individuals followed for 12.4 years. Diab Care. 1999;22:233–40. diabetes, impaired fasting glucose and associated risk factors in a10. Knowler WC, Barrett-Connor E, Fowler SE, et al. Diabetes rural area of Baluchistan province according to new ADA criteria. Prevention Program Research Group. Reduction in the incidence J Pak Med Assoc. 2002;52:351–60. of type 2 diabetes with lifestyle intervention or metformin. N Engl 24. Geiss LS, Rolka DB, Engelgau MM. Elevated blood pressure J Med. 2002;346:393–403. among U.S. adults with diabetes, 1988–1994. Am J Prev Med.11. Tuomilehto J, Lindstrom J, Eriksson JG, et al. Finnish Diabetes 2002;22:42–8. Prevention Study Group. Prevention of type 2 diabetes mellitus by 25. Bowman L, Armitage J. Diabetes and impaired glucose tolerance: changes in lifestyle among subjects with impaired glucose a review of the epidemiological and trial evidence for their role in tolerance. N Engl J Med. 2001;344:1343–50. cardiovascular risk. Semin Vasc Med. 2002;2:383–90.12. Khuwaja AK. Evidence based care of type-2 diabetes mellitus: 26. International Diabetes Federation IGT/IFG consensus statement. epidemiology, screening, diagnosis and initial evaluation. J Report of an expert consensus workshop. Diabet Med. Liaquat Uni Med Health Sci. 2003;2:63–7. 2002;19:708–23.