Effect of internal migration on diabetes and metabolic abnormalities in India - The ICMR-INDIAB study.

AIMS: To assess the effect of migration (rural-to-urban and vice versa) on prevalence of diabetes and metabolic disorders in Asian Indians participating in the Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study. MATERIALS AND METHODS: The ICMR-INDIAB study is a national study on diabetes and associated cardiometabolic disorders in individuals aged ≥20 years from 28 states and 2 union territories of India. Individuals who moved to a different place from their place of birth and had resided in the new location for at least one year were considered as migrants. Anthropometric measurements, blood pressure estimation and a capillary oral glucose tolerance test were performed. RESULTS: Of the 113,043 participants, 66.4% were non-migrant rural dwellers, 19.4% non-migrant urban dwellers, 8.4% rural-urban migrants, 3.8% multiple migrants and 2.0% urban-rural migrants. Weighted prevalence of diabetes was highest in rural-urban migrants followed by urban dwellers, urban-rural migrants and rural dwellers [14.7%, 13.2%, 12.7% and 7.7% respectively (p < 0.001)]. Rural-urban migrants had highest prevalence of abdominal obesity (50.5%) compared to the other three groups. The risk for diabetes was 1.9 times higher in rural-urban migrants than among rural dwellers. Five risk factors [hypertension, abdominal and generalized obesity, physical inactivity and low fruit and vegetable intake] together explained 69.8% (partial population attributable risk) of diabetes among rural-urban migrants and 66.4% among non-migrant urban dwellers. CONCLUSIONS: Rural-to-urban migration is associated with increased risk of developing diabetes and other cardiometabolic abnormalities. Adoption of healthier lifestyle patterns among migrants could help prevent/delay onset of these abnormalities in this population.

Early Intensified Insulin Therapy in Newly Diagnosed Type 2 Diabetes Leads to Sustained Improvement in Glycemic Control and Improved Beta Cell Function.

AIM: Type 2 diabetes (T2D) is a progressive disease characterized by relentless deterioration of pancreatic ß-cell function. Traditionally, insulin is used in later stages of T2DM. This study looks at use of insulin at time of diagnosis of T2DM and its effect on glycemic control and beta cell function. METHODS: This is a prospective observational study conducted in symptomatic newly diagnosed type 2 diabetes adults (>18 years) who presented with glycated hemoglobin (A1C) levels > 9%. For the initial 8 weeks, patients were treated with pre-mix insulin after which they were changed over to oral agents, and followed up for next three years. RESULTS: Amongst 122 study participants, who completed the study, 50% were female and 90% were from rural areas. Average age of participants was 51.4 ± 9.6 years. Baseline mean fasting plasma glucose (FPG), post prandial plasma glucose (PPPG) and A1C were 267 ± 76 mg/dl, 408 ± 101 mg/dl and 11.5 ± 1.4% respectively. At the end of insulin therapy (8 weeks), the mean FPG, PPG and A1C reduced to 107 ± 10 mg/dl, 145 ± 24 mg/dl and 7.3 ± 0.8% respectively all of which were highly significant. The mean post-prandial C-peptide significantly increased from 1.8± 0.6 to 2.8± 0.9 ng/dl. An average of 1.7 kg weight gain and 0.97 episodes of mild to moderate hypoglycemia were observed. At the end of study (156 weeks), the mean FPG, PPG and A1C were 99 ± 14 mg/dl, 152 ± 12 mg/dl and 6.7 ± 0.4%. CONCLUSION: Early insulin therapy in treatment naïve patients with type 2 diabetes results in rapid improvement of glycaemia thus helps to maintain long term normoglycemia and improves ß-cell function.

Comparison of Safety and Efficacy of Glimepiride-Metformin and Vildagliptin- Metformin Treatment in Newly Diagnosed Type 2 Diabetic Patients.

OBJECTIVES: To compare the safety and efficacy of combination of Glimepiride - Metformin with Vildagliptin - Metformin in type 2 diabetic patients with HbA1c between 7.5to10. METHODS: A randomized, prospective, comparative and interventional study was conducted at Indira Gandhi Medical College, Shimla. The level of hemoglobin A1c (HbA1c), fasting blood sugar (FBS) and postprandial blood sugar (PP) were the primary outcomes, whereas, the evidence of hypoglycemia, quality of life and weight gain were recorded as secondary outcomes. 215 patients newly diagnosed with type 2 diabetes mellitus were randomized into Glimepiride-Metformin group (Group1) having 111 patients and Vildagliptin-Metformin group (Group 2) having 106 patients. Patients were followed up at 3 month, 12 month, 24 month and then after completion of 30 month of treatment. RESULTS: A comparable FPG, PPPG and HbA1c were observed from baseline at the end of 12 weeks in both groups. However, at the 130-week endpoint a significantly more pronounced reduction in HbA1c was observed in vildagliptin-metformin (1.96%) arm compared to Glimepiride-metformin (1.67%) arm. A similar significant more pronounced reduction was demonstrated in both FPG (48.25% vs. 41.70%) and PPPG (49.40% vs. 42.95%) in vildagliptin-metformin group compared to Glimepiride-metformin group. The proportion of patients who achieved an A1C < 7% at 130-weeks was 49% in the vildagliptin group and 41% in the Glimepiride group. Statistically significant more weight gain was observed in Glimepiride arm compared to vildagliptin arm (2.09 kg vs. 0.69 kg) and 8-fold lower incidence was observed in vildagliptin group. Conclusion: Vildagliptin -metformin represent a more effective combination in terms of number of patients achieving guidelines recommended A1C target of less than 7% at the end of 30 months, less weight gain, and a lower risk of hypoglycemia in newly diagnosed type 2 diabetic patients with moderate hypoglycemia. CONCLUSIONS: Vildagliptin -metformin represent a more effective combination in terms of number of patients achieving guidelines recommended A1C target of less than 7% at the end of 30 months, less weight gain, and a lower risk of hypoglycemia in newly diagnosed type 2 diabetic patients with moderate hypoglycemia.

Life threatening unilateral pulmonary oedema at moderate altitude.

A-23-year-old medical student, resident of an altitude of 700 meters, developed dyspnea and cough during a temple visit at an altitude of 2200 m within 10 hours of arrival and his symptoms improved on descending and with 100% oxygen. Chest skiagram and CT scan chest revealed soft fluffy shadows on the left side with small right lung and absent right pulmonary artery. Absent right pulmonary artery was responsible for development of pulmonary oedema at moderate altitude.