Clinical profile and incidence of microvascular complications of childhood and adolescent onset type 1 and type 2 diabetes seen at a tertiary diabetes center in India.

AIM: To study the clinical characteristics and incidence of microvascular complications among childhood and adolescent onset type 1 (T1DM) and type 2 diabetes (T2DM) seen at a tertiary care diabetes center in India. METHODS: From our electronic medical records, we retrieved clinical and biochemical details of 4555 individuals with childhood and adolescent onset diabetes (diagnosed below the age of 20 years) seen between 1992 and 2017. T1DM was diagnosed if there was history of ketoacidosis or fasting C-peptide <0.3 PMol/mL and stimulated C-peptide <0.6 PMol/mL or if insulin treatment was required from the time of diagnosis. T2DM was diagnosed based on absence of ketosis, or fasting C-peptide ≥0.6 PMol/mL and stimulated >1.0 PMoL/mL, or response to oral hypoglycemic agents for more than 2 years. We calculated the incidence rates of retinopathy (presence of at least one definite microaneurysm by retinal photography), nephropathy (urinary albumin excretion ≥30 µg/mg of creatinine) and neuropathy (vibration perception threshold ≥20 V) per 1000 person-years of follow up. RESULTS: Among the 4555 individuals with childhood and adolescent-onset diabetes, 71.4% had T1DM, 19.5% T2DM and 9.1% other forms of diabetes. Age at first visit and duration of diabetes were significantly higher in T2DM when compared to T1DM. The age adjusted incidence of retinopathy was 52.9/1000 person years (Confidence Intervals [CI]: 42.9-62.8) in T1DM and 49.8/1000 person years (CI 30.8-68.8) in T2DM; nephropathy, 6.2 (CI 3.3-9.0) and 13.8 (CI 5.6-22.0); and neuropathy, 8.8(CI 3.6-14.0) and 24.0 (CI 9.8-38.2) in T1DM and T2DM, respectively. CONCLUSION: The incidence of microvascular complications is high among childhood and adolescent-onset T1DM and T2DM and these calls for more aggressive control of diabetes.

Importance of controlling diabetes early--the concept of metabolic memory, legacy effect and the case for early insulinisation.

Most of the microvascular complications of diabetes are related to the degree and the length of exposure to hyperglycaemia. New data from the follow-up studies of the Diabetes Control and Complications Trial-the Epidemiology of Diabetes Intervention and Complications Study (DCCT-EDIC), and the United Kingdom Prospective Diabetes Study (UKPDS) emphasize the role of glycemic control early in the course of the disorder and its value in prevention of later complications. The phenomenon of ongoing beneficial effects on diabetic complications after a period of improved glycemic control even if followed by a return to usual (often poorer) metabolic control has been described as representing "metabolic memory" by the DCCT/EDIC investigators and as a "legacy effect" by the UKPDS investigators. This article reviews these concepts and explores the role of early use of insulin as a tool to achieve good glycemic control in type 2 diabetes.

Future risk of diabetes among Indians with metabolic and phenotypic obesity: Results from the 10-year follow-up of the Chennai Urban Rural Epidemiology Study (CURES-158).

AIM: To investigate the risk of type 2 diabetes (T2DM) among the combinations of BMI categories and metabolic syndrome in Asian Indians. MATERIALS AND METHODS: Individuals from the Chennai Urban Rural Epidemiology Study cohort (n = 1,368), free of diabetes at baseline were stratified by BMI and metabolic health as metabolically healthy non-obese (MHNO), metabolically healthy obese (MHO), metabolically obese non-obese (MONO) and metabolically obese obese (MOO). Phenotypic obesity was defined as BMI ≥ 25 kg/m2 and metabolic obesity as presence of any two of the metabolic abnormalities: hyperglycemia, high blood pressure, high triglyceridemia or low HDL cholesterol. Hazard ratios for progression to diabetes were estimated using Cox proportional hazard regression. RESULTS: During median 9.1 years of follow-up, incident cases of diabetes were highest among MOO-45.1%, followed by MONO-41.3%, MHO-27.1% and MHNO-15.9%. Incidence rates of diabetes among MOO, MONO, MHO and MHNO were 57.8, 50.9, 30.4 and 18.1 per 1000 person years, respectively. Hazard ratio for diabetes development were 1.71 in MHO, 2.87 in MONO, and 3.39 in MOO compared with MHNO. CONCLUSIONS: Increased BMI and metabolic risk factor clustering independently contribute to the increased risk of T2DM in obese individuals. Screening for metabolic abnormalities should be performed routinely in clinic to identify high-risk individuals and institute appropriate preventive measures.

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.

Elevated glycated hemoglobin predicts macrosomia among Asian Indian pregnant women (WINGS-9).

AIM: The aim of this study was to determine the optimal glycated hemoglobin (HbA1c) cut point for diagnosis of gestational diabetes mellitus (GDM) and to evaluate the usefulness of HbA1c as a prognostic indicator for adverse pregnancy outcomes. METHODS: HbA1c estimations were carried out in 1459 pregnant women attending antenatal care centers in urban and rural Tamil Nadu in South India. An oral glucose tolerance test was carried out using 75 g anhydrous glucose, and GDM was diagnosed using the International Association of the Diabetes and Pregnancy Study Groups criteria. RESULTS: GDM was diagnosed in 195 women. Receiver operating curves showed a HbA1c cut point of ≥ 5.0% (≥31 mmol/mol) have a sensitivity of 66.2% and specificity of 56.2% for identifying GDM (area under the curve 0.679, confidence interval [CI]: 0.655-0.703). Women with HbA1c ≥ 5.0% (≥31 mmol/mol) were significantly older and had higher body mass index, greater history of previous GDM, and a higher prevalence of macrosomia compared to women with HbA1c < 5.0% (<31 mmol/mol). The adjusted odds ratio for macrosomia in those with HbA1c ≥ 5.0% (≥31 mmol/mol) was 1.92 (CI: 1.24-2.97, P = 0.003). However, other pregnancy outcomes were not significantly different. CONCLUSION: In Asian Indian pregnant women, a HbA1c of 5.0% (31 mmol/mol) or greater is associated with increased risk of macrosomia.

Comparison of maternal and fetal outcomes among Asian Indian pregnant women with or without gestational diabetes mellitus: A situational analysis study (WINGS-3).

AIM: To compare the existing maternal and fetal outcomes in Asian Indian women with or without gestational diabetes mellitus (GDM) before the development of the Women in India with GDM Strategy (WINGS) GDM model of care (MOC). MATERIALS AND METHODS: Records of pregnant women were extracted retrospectively from three maternity centers in Chennai. GDM was diagnosed using the International Association for Pregnancy Study Groups criteria or the Carpenter and Coustan criteria. Demographic details, obstetric history, antenatal follow-up, treatment for GDM, and outcomes of delivery were collected from the electronic medical records. RESULTS: Of the 3642 records analyzed, 799 (21.9%) had GDM, of whom 456 (57.1%) were treated with insulin and medical nutrition therapy (MNT), 339 (42.4%) with MNT alone, and 4 (0.5%) with metformin. Women with GDM were older than those without (28.5 ± 4.5 vs. 27.1 ± 4.5 years; P < 0.001) and had higher mean body mass index at first booking (26.4 ± 5.2 kg/m(2) vs. 25.2 ± 5.1 kg/m(2); P < 0.001). Rates of cesarean section (26.2% vs. 18.7%; P < 0.001), preeclampsia (1.8% vs. 0.8%; P = 0.04), and macrosomia (13.9% vs. 10.8%; P = 0.02) were significantly higher among women with GDM. In women with GDM treated with insulin and MNT, emergency cesarean section (16.2% vs. 36.6%; P < 0.0001), preeclampsia (0.7% vs. 3.2%; P = 0.015), and macrosomia (9.9% vs. 18.6%; P = 0.0006) were significantly lesser compared to those treated with MNT alone. CONCLUSION: Pregnancy outcomes were in general worse in GDM women. Treatment with insulin was associated with a significantly lower risk of complications. However, in countries with limited access to insulin and other medicines may lead to poor follow-up and management of GDM. Data from this retrospective study will form the basis for the development of the WINGS GDM MOC, which will address these gaps in GDM care in low-resource settings.