Reference equations for evaluation of spirometry function tests in South Asia, and among South Asians living in other countries.

BACKGROUND: There are few data to support accurate interpretation of spirometry data in South Asia, a major global region with a high reported burden of chronic respiratory disease. METHOD: We measured lung function in 7453 healthy men and women aged ≥18 years, from Bangladesh, North India, South India, Pakistan and Sri Lanka, as part of the South Asia Biobank study. First, we assessed the accuracy of existing equations for predicting normal forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1) and FEV1/FVC ratio. Then, we used our data to derive (n=5589) and internally validate (n=1864) new prediction equations among South Asians, with further external validation among 339 healthy South Asians living in Singapore. RESULTS: The Global Lung Initiative (GLI) and National Health and Nutrition Examination Survey consistently overestimated expiratory volumes (best fit GLI-African American, mean±sd z-score: FEV1 -0.94±1.05, FVC -0.91±1.10; n=7453). Age, height and weight were strong predictors of lung function in our participants (p<0.001), and sex-specific reference equations using these three variables were highly accurate in both internal validation (z-scores: FEV1 0.03±0.99, FVC 0.04±0.97, FEV1/FVC -0.03±0.99) and external validation (z-scores: FEV1 0.31±0.99, FVC 0.24±0.97, FEV1/FVC 0.16±0.91). Further adjustment for study regions improves the model fit, with highest accuracy for estimation of region-specific lung function in South Asia. CONCLUSION: We present improved equations for predicting lung function in South Asians. These offer the opportunity to enhance diagnosis and management of acute and chronic lung diseases in this major global population.

Glycemic index of a nutritional supplement designed for people with chronic kidney disease.

The study was carried out to measure the glycemic index (GI) of an oral food supplement for people with CKD as well as on patients on maintenance dialysis. The study was conducted as per international protocols for testing GI, was approved by the local institutional ethics committee, and was registered with the Clinical Trial Registry of India (CTRI). This was a crossover randomized controlled study which enrolled 15 participants between the ages of 18 and 45 years. The participants were randomly allotted to one group that consumed either the reference food (27.5 g of glucose monohydrate) or 118 g of the nutritional supplement which contained 25 g of available carbohydrates. Fasting capillary blood samples as well as blood samples at different time intervals as per the GI protocol, after consumption of either the supplement or the reference food were taken from the participants. Each testing day was separated by a 3-day washout period. GI was calculated from the incremental area under the blood glucose response elicited by the nutritional supplement as a percentage of the response after the consumption of 25 g of glucose (27.5 g of glucose monohydrate) by the same participant using a standard formula. The GI of the nutritional supplement was calculated to be 10.3 ± 2.0 which is considered to be low as per international GI testing standards. The product was created to supplement the diet of people with CKD at different stages and to help prevent the progression from CKD to ESRD as well as the risk for CVD. This product was found to have a low GI which is desirable for people with CKD as well as diabetics in general who are at risk for developing CKD.

Cost-effectiveness of a Stepwise Approach vs Standard Care for Diabetes Prevention in India.

Importance: A stepwise approach that includes screening and lifestyle modification followed by the addition of metformin for individuals with high risk of diabetes is recommended to delay progression to diabetes; however, there is scant evidence regarding whether this approach is cost-effective. Objective: To estimate the cost-effectiveness of a stepwise approach in the Diabetes Community Lifestyle Improvement Program. Design, Setting, and Participants: This economic evaluation study included 578 adults with impaired glucose tolerance, impaired fasting glucose, or both. Participants were enrolled in the Diabetes Community Lifestyle Improvement Program, a randomized clinical trial with 3-year follow-up conducted at a diabetes care and research center in Chennai, India. Interventions: The intervention group underwent a 6-month lifestyle modification curriculum plus stepwise addition of metformin; the control group received standard lifestyle advice. Main Outcomes and Measures: Cost, health benefits, and incremental cost-effectiveness ratios (ICERs) were estimated from multipayer (including direct medical costs) and societal (including direct medical and nonmedical costs) perspectives. Costs and ICERs were reported in 2019 Indian rupees (INR) and purchasing power parity-adjusted international dollars (INT $). Results: The mean (SD) age of the 578 participants was 44.4 (9.3) years, and 364 (63.2%) were men. Mean (SD) body mass index was 27.9 (3.7), and the mean (SD) glycated hemoglobin level was 6.0% (0.5). Implementing lifestyle modification and metformin was associated with INR 10 549 (95% CI, INR 10 134-10 964) (INT $803 [95% CI, INT $771-834]) higher direct costs; INR 5194 (95% CI, INR 3187-INR 7201) (INT $395; 95% CI, INT $65-147) higher direct nonmedical costs, an absolute diabetes risk reduction of 10.2% (95% CI, 1.9% to 18.5%), and an incremental gain of 0.099 (95% CI, 0.018 to 0.179) quality-adjusted life-years per participant. From a multipayer perspective (including screening costs), mean ICERs were INR 1912 (INT $145) per 1 percentage point diabetes risk reduction, INR 191 090 (INT $14 539) per diabetes case prevented and/or delayed, and INR 196 960 (INT $14 986) per quality-adjusted life-year gained. In the scenario of a 50% increase or decrease in screening and intervention costs, the mean ICERs varied from INR 855 (INT $65) to INR 2968 (INT $226) per 1 percentage point diabetes risk reduction, from INR 85 495 (INT $6505) to INR 296 681 (INT $22 574) per diabetes case prevented, and from INR 88 121 (INT $6705) to INR 305 798 (INT $23 267) per quality-adjusted life-year gained. Conclusions and Relevance: The findings of this study suggest that a stepwise approach for diabetes prevention is likely to be cost-effective, even if screening costs for identifying high-risk individuals are added.

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

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

Gestational Diabetes Mellitus Postpartum Follow-Up Testing: Challenges and Solutions.

One in every 4 pregnancies is affected by hyperglycemia, of which 90% is gestational diabetes mellitus (GDM). Women with GDM are at a high risk of developing both short- and long-term complications. Various studies have shown the heightened risk of type 2 diabetes among women with GDM. Despite clear evidence from published literature about the substantial risk that GDM imposes on women after delivery, rates of postpartum follow up have been low in most parts of the world. Several reasons, such as lack of awareness among health-care professionals and patient-related barriers, such as emotional stress and adjusting to motherhood, have been cited as reasons for poor follow-up rates. To address these issues and come up with solutions to improve postpartum follow-up rates, it is important to understand these barriers both from the patient and the health-care system points of view. In this review, we have summarized some of the key issues contributing to the low postpartum follow-up rates and have discussed possible strategies to tackle them. Use of proactive reminder systems, such as postal service, telephone call, short messaging service and e-mail, recall registries for GDM and utilization of mobile health technology are some of the key strategies that have been discussed in this review. A brief note on the Women in India with GDM Strategy project, which developed a model of care for GDM in resource-constrained settings and adopted several strategies that led to a 95.8% postpartum follow up, has also been presented.

Slowing the diabetes epidemic in the World Health Organization South-East Asia Region: the role of diet and physical activity

The nutrition transition occurring in the World Health Organization South-EastAsia Region, as a result of rapid urbanization and economic development, hasperhaps made this region one of the epicentres of the diabetes epidemic. Thisreview attempts to evaluate the role of diet and physical inactivity in the South-EastAsia Region in promoting this epidemic and points to strategies to slow it downby lifestyle modification. The emerging new food-production technologies andsupermarkets have made energy-dense foods more easily available. This includesrefined carbohydrate foods like those with added sugars, and refined grainsand unhealthy fats. In addition, increased availability of modern technology andmotorized transport has led to decreased physical activity. South Asian diets tendto be based on high-carbohydrate foods, with a predominance of refined grains.All of these accentuate the risk of diabetes in people of this region, who alreadyhave a unique “south Asian phenotype”. However, there is increasing evidencethat altering diet by replacing refined cereals like white rice with whole grains (e.g.brown rice) and increasing physical activity can help to prevent diabetes in highrisk individuals. An urgent, concerted effort is now needed to improve diet qualityand encourage physical activity, by introducing changes in policies related to foodand built environments, and improving health systems to tackle noncommunicablediseases like diabetes.