This study aimed to determine the frequency of prediabetes and observe the influence of various risk factors on the development of prediabetes. The study found that 29.4% of subjects had prediabetes. Several risk factors were strongly correlated with prediabetes, including high BMI, family history of diabetes, history of gestational diabetes, history of delivering a high birth weight baby, low HDL cholesterol, and high triglycerides. The results suggest screening those with risk factors can help identify individuals at high risk of developing diabetes.

1. Int J Diabetes Dev Ctries (April–June 2011) 31(2):65–69
DOI 10.1007/s13410-010-0008-9
ORIGINAL ARTICLE
Frequency of prediabetes and influence of various risk
factors on the development of prediabetes: a tertiary
care hospital experience
Samiullah Shaikh & Gani Hanif & Kashif & Mona Humera
Received: 27 June 2010 / Accepted: 1 September 2010 / Published online: 19 April 2011
# Research Society for Study of Diabetes in India 2011
Abstract The objective of study was to determine the high birth weight child, HDL <35 mg/dl. Considering the
frequency of prediabetes and observe the influence of high frequency of prediabetes in the region, provision of
various risk factors on the development of prediabetes at vast educational program to prevent the disease is essential
Liaquat University Hospital, Hyderabad. Descriptive case and as well screening for prediabetes using FBG and
series. Medical outpatient department Liaquat University OGTT, especially for obese subjects and those with other
Hospital, Hyderabad. From 01-03-2007 to 31-03-2008. risk factors of diabetes.
Total 500 subjects with BMI>25 and aged either 45 year
and 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 Triglyceride
were excluded from study. A well designed proforma
included demographic information, history regarding first
degree relative with diabetes, gestational diabetes, delivery Introduction
of large baby and related investigations. Fasting blood
glucose (FBG)≥100 mg/dl but <126 mg/dl and/or OGTT The incidence and prevalence of type 2 diabetes mellitus
level ≥140 mg/dl but <200 mg/dl was considered predia- (T2DM) have reached epidemic proportions, with further
betes. The collected data was analyzed on SPSS version increases appearing inevitable [1]. Unless appropriate
16.0. 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. These
in 147/500(29.4%) cases of which 109 were female and 38 can be of two types: the population approach, in which an
were male. A strong correlation was found between entire population is advised on the benefits of healthy living
prediabetes and BMI, persons with h/o diabetes in first (i.e. increased physical activity and weight control), or the
degree 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 those
S. 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) was
Sciences,
Jamshoro/Hyderabad, Pakistan coined by the World Health Organization (WHO) and the
National Diabetes Data Group [5] to replace an older term
S. Shaikh (*) of borderline, chemical or asymptomatic DM coined in
H.NO:55, Green Homes,
1965. In 1997, an expert committee from the American
Qasimabad, Hyderabad, Pakistan
e-mail: shaikh135@hotmail.com Diabetes Association (ADA) recommended the following
e-mail: shaikhsamiullah@yahoo.com criteria for PDM; a fasting blood glucose of 110 to

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. These
worldwide. In 2003, an estimated 314 million people samples were collected in test tubes containing no
developed prediabetes. By the year 2025, the number is preservative and were transported within half hour to
expected to increase to 472 million (9% of all adult population) Liaquat University Hospital Laboratory; the method used
worldwide. However, it differs from region to region. was “PAP” enzymatic calorimetric test. IFG was defined as
Prevalence was reported at 13.2% of all adult population in having FPG >100 mg/dl but <126 mg/dl. IGT was defined
the 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 taken
than the normal population [8]. Coronary heart disease is for HDL cholesterol and triglyceride level and sent to the
1.33 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 as
therapy can alter the progression of prediabetes to overt no h/o first degree relative with diabetes, no h/o gestational
diabetes [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/dl
frequency of pre-diabetes at Liaquat University Hospital were grouped as one. Patients with any of variables such as
Hyderabad and to observe the influence of various risk h/o first degree relative with diabetes, h/o gestational
factors such as sex, BMI, H/O gestational diabetes, first diabetes, h/o delivery of large baby, BMI >25 up to 30 or
degree relative with diabetes and H/O delivery of large >30 kg/m2, HDL Cholesterol <35 mg/dl and triglycerides
baby with the occurrence of prediabetes. >250 mg/dl were grouped as two.
Subjects and methods Data analysis
This descriptive case series study included 500 consecutive Quantitative variables such as age, height, weight, waist
cases attending the medical outpatient department of circumferences, waist to hip ratio (WHR), systolic blood
Liaquat University Hospital Hyderabad from 01-03-2007 pressure, diastolic blood pressure, fasting plasma glucose
to 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 as
BMI 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, prediabetes
i. Blood pressure over 140/90 mmHg
were expressed as frequency & percent. The qualitative
ii. 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 by
v. History of gestational diabetes.
Chi-square test. Statistical analysis was performed by SPSS
vi. 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 initial
enrollment
All the patients who met above inclusion criteria Results
included in the study after taking informed consent. A
thorough medical history regarding first degree relative This case series study included 500 consecutive subjects
with diabetes were taken, gestational diabetes, delivery of with BMI≥25 of which 306 (61.2%) were male and 194
large 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 cholesterol
entered into proforma. After an initial blood sample was 42.60 ± 4.54, and triglycerides 184.4 ± 14.7 mg/dl. h/o
drawn for FPG testing after overnight or eight hour fasting, diabetes in first degree relatives was present in 157/500

3. Int J Diabetes Dev Ctries (April–June 2011) 31(2):65–69 67
Table 1 Baseline characteristics of the cases studied
Quantitative 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 14.7
Qualitative 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 child
delivery of large baby in 32(6.4%) cases. Prediabetes had prediabetes (p=0.001). 18/34 persons with HDL
was present in 147/500 (29.4%) of which 95 were male <35 mg/dl had prediabetes (p=0.003) and 6/26 with
and 52 female. Table 1 explains the baseline character- triglyceride >250 mg/dl had prediabetes (p=0.659). Table 2
istics 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 was
present 118 cases of which 18 had prediabetes, >25 up to
30 was present in 281 persons of which 70 had prediabetes Discussion
and 101 persons had BMI>30 kg/m2 of which 60 had
prediabetes (p=001). In 62/147 persons with pre diabetes In this study, frequency of prediabetes was 29.4% which is
had h/o diabetes in first degree relative (p=0.001), 11/32 higher as compared to that reported by the National
with h/o gestational diabetes had prediabetes (p=0.549), Diabetes Prevalence survey of Pakistan which showed that
Table 2 Relation of various risk
factors with the development Variables Number Total N: Prediabetes P value
of 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. 68 Int J Diabetes Dev Ctries (April–June 2011) 31(2):65–69
over 10% of people in the age group 25 years and above are compared to normal non-diabetics. Several longitudinal
suffering from prediabetes and further that prevalence of cohort studies have demonstrated the association between
prediabetes 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 that
National Diabetes Prevalence survey of Pakistan enrolled meets the criteria for being overweight, and almost half have
all 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 pressure
Project showed that prevalence of prediabetes is 23.4% increased from normal to prediabetes to undiagnosed
among 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 prediabetes
tolerance state in healthy, over-weight Arabs aged above and diabetes. Epidemiological studies report at least 2 fold
40 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 prediabetes
aged 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 among
10.8% 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 subjects
developed country where people are much more conscious with diabetes, 50.7% of those with IGT, and 38.3% of those
of 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 from
people seek medical help when problems like complica- normal to prediabetes to undiagnosed diabetes while the
tions arise. It is also estimated that major part of increase in triglyceride level increased. Type 2 diabetics often have
diabetes prevalence is occurring in developing countries elevated triglyceride and depressed HDL cholesterol. It
with 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 from
living 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 density
males 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 with
positive family history of diabetes [16]. Type 2 diabetes Conclusion
appears to have strong genetic associations. Studies in twins
have demonstrated that the concordance rate of type 2 diabetes This study showed a meaningful relationship between
in monozygotic twins range between 34% and 83% [17]. The obesity, dyslipidemia, history of first degree relative with
broad range of observed correlation suggests both a complex prediabetes. Therefore, identifying and mitigating these
genetic predisposition and an interaction between environ- factors are of great importance to the health of the general
mental and genetic factors in the pathogenesis of type 2 population. The high frequency of prediabetes in this region
diabetes. People who have one first degree relative suffering makes it necessary to generalise the screening methods of
from prediabetes have a 40% risk of having this disease. If the disease for the population with above risk factors and
diabetes 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 onset
delivery 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 risk
study that showed that 36% of women who were diagnosed factors of diabetes or its symptoms and complications can
with gestational diabetes mellitus had persistent abnormal play an effective role in the prevention and control of the
glucose tolerance [19]. The reason seems to be enrollment disease. This can be done through the mass media or
of 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 the
is seen in this study. Mean weight, BMI, Waist circumference correlation between gestational diabetes or delivery of large
and waist to hip ratio (WHR) were all higher in prediabetes as baby and prediabetes.

5. Int J Diabetes Dev Ctries (April–June 2011) 31(2):65–69 69
Acknowledgements We are grateful to Dr.Ghulam Hussain, in 13. Majeed A, Newnham A, Ryan R, Khunti K, Guthrie C. Prevention
charge Diabetic Clinic of this institute for extensive assistance with and cure of type-II diabetes. BMJ. 2002;325:965–6.
data 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, undiagnosed
and 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 a
10. 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.