SUPPLEMENT MEDICINE MEDICAL CHANNEL ABSTRACT 1. MUHAMMAD HANIF GHANI FCPS 2. ASLAM AZIZ GHOURI FCPS 3. AKRAM MUNIR FCPS 4.

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1 Vol. 16, No. 1 ORIGINAL PAPER SUPPLEMENT MEDICINE MEDICAL CHANNEL JANUARY - MARCH 2010 ASSESSMENT OF FASTING BLOOD SUGAR LEVEL IN HIGH RISK NON DIABETIC INDIVIDUALS AND ITS COMPARISION TO FASTING BLOOD SUGAR IN LOW RISK NON DIABETIC INDIVIDUALS 1. MUHAMMAD HANIF GHANI 2. ASLAM AZIZ GHOURI 3. AKRAM MUNIR 4. SONIHA ASLAM MBBS 1. Professor of Medicine, 2. Senior Registrar Medical Unit IV 3. Senior Medical Officer, Department of Medicine, 4. Assistant Professor Department o f Health & Physical Education UNIVERSITY OF SINDH, JAMSHORO Corresponding Author: MUHAMMAD HANIF GHANI Professor of Medicine, POSTAL ADDRESS: 5-OFFICER'S FLATS, GOR, HYDERABAD Phone: Fax: Mobile: hanifmem@hotmail.com ABSTRACT OBJECTIVE: To assess the fasting blood sugar level in high risk non diabetic young individuals and to compare fasting blood sugar level, blood pressure, BMI and waist circumferences in high risk non diabetic young individuals with low risk non diabetic young individuals. METHODOLOGY: This cross sectional comparative study was conducted in department of medical - IV, LUMHS Jamshoro/ Hyderabad from January 2009 to June Total one hundred individual years of age were selected and divided into two groups. Group A: 50 cases of high-risk non-diabetic individuals and Group B: 50 cases of low risk non-diabetic individuals on the basis of same age and gender. RESULTS: In both groups 35 (70%) were males & 15 (30%) were females. 10 % of group A and 2% of group B individuals showed impaired fasting glucose (IFG = 110mg/ dl) while none of individual in both groups had FBS in diabetic range (=126mg/dl). However, only 16 % in group A and 12% in group B individuals exhibited raised blood pressure while 52 % in group A and 26% in group B individuals also represented raised BMI whereas 42% in group A and 36% in group B individuals showed raised WC. CONCLUSION: IFG is strongly associated with family history of type 2 diabetes mellitus. But presence of hypertension and obesity in non-diabetic young individuals emphasize the need for routine health screening for early institution of preventive measure. KEYWORDS: Type 2 diabetes mellitus, impaired fasting glucose, Body mass index INTRODUCTION Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. 1 Impaired glucose tolerance (IGT) is known to increase vascular risk and the risk of developing diabetes. 2 Prevalence of diabetes in adults worldwide was estimated to be 4.0% in 1995 and expected to be 5.4% by the year Its incidence is higher in developing countries than developed countries. 3 Pakistan is estimated to have 7 million people with diabetes. Currently it is 8th in the world according to WHO estimation of prevalence of diabetes and by the year 2025 is expected to be 4th with 15 million people with diabetes, representing a 2 fold increase in caseload (Global Burden WHO 1998). 4 Diabetes prevalence in Pakistan is high, 12% of people above 25 years of age suffer from the condition and 10% have impaired glucose tolerance (IGT). 5 Shera at al have shown prevalence of diabetes in the urban versus the rural areas was 6.0% in men and 3.5% in women against 6.9% in men and 2.5% in women, respectively The Risk factors for the development of type 2 DM include family history of diabetes, high BMI 6, waist circumference 7, race/ ethnicity, previously identified IFG 8 or IGT, history of GDM or delivery of baby over 9 lbs, hypertension 9, HDL cholesterol level =0.90mmol/L (35 mg/dl) and/ or a triglycerides level =2.82mmol/L (250 mg/dl), polycystic ovarian syndrome, the chewing of Arecha catechu (betel) nut 10 and a high prevalence of cigarette smoking in some South Asian populations (Bangladeshis and Pakistanis). 11 Peoples with IGT can reduce the risk of diabetes mellitus by changing their lifestyle as well as reduce their weight. 12 The prevalence of metabolic syndrome in Pakistan according to different definitions is reported to be from 18% to 46%, comparable to the data from other South Asian countries. Thus, metabolic syndrome should be considered as a prime target for preventive medicine. 13 The primary prevention of diabetes is possible by modifying the environmental factors 117

2 influencing diabetogenesis, such as obesity, diet and physical activity. Long-term studies had shown the beneficial effect of life style modification on reducing the risk of diabetes. Prevention (or at least delay) in the development of diabetes is feasible with rigorous lifestyle intervention or drug therapy in people at high risk of diabetes. Exercise levels of 30 minutes per day, plus at least two-monthly dietary advice or education sessions for the first year. 14 The Expert Committee recognized an intermediate group of subjects whose glucose levels, although not meeting criteria for diabetes, are nevertheless too high to be considered normal. This group is defined as shown in the table no. 1 AIMS AND OBJECTIVS - To assess the fasting blood glucose level in high-risk non-diabetic young individuals. - To compare FBS level, blood pressure, body mass index and waist circumferences in high-risk non-diabetic young individuals with low risk non-diabetic young individuals. MATERIAL AND METHOD Setting: This study was conducted in medical unit-iv LUMHS Jamshoro/ Hyderabad. It was designed as Crosssectional comparative study from January 2009 to June One hundred individuals were included in this study, divided into two groups: Group-A (n=50): High-risk non-diabetic young individuals (Family H/O diabetes +ve in 1 st degree relative) Group-B (n= 50): Low risk non-diabetic young individuals (control group: no family H/O diabetes in 1 st degree relative) Inclusion criteria 1. Age years old both male and female. 2. Individuals whose first degree relatives are known case of type-2 diabetes mellitus. Exclusion criteria 1. Known diabetic or hypertensive. 2. Had secondary obesity 3 Pregnant women DATA COLLECTION PROCEDURE: Patients of type-2 diabetes who had come through OPD, emergency and ward were evaluated for young healthy non-diabetic individual of either sex in their family. 50 high-risk young non-diabetic individuals were selected who fulfilled the inclusion criteria mentioned above. A low risk group (control group) of healthy young non-diabetic individual was formed to compare with highrisk group on the basis of same age and TABLE NO.1: CRITERIA FOR IMPAIRED GLUCOSE LEVELS CATEGORY FPG 2-h PG Normal <100 mg/dl (<5.6 mmol/l) <140 mg/dl (<7.8 mmol/l) IFG IGT Age of Individuals mg/dl ( mmol/l) IGT, indicate the need for further evaluation mg/dl ( mmol/l) TABLE: 02 FREQUENCY OF INDIVIDUALS IN RELATION TO AGE AND GENDER (Both groups) Number of Individuals n = 100 Gender Male Female (71%) 20 (29%) (67%) 10 (33%) TABLE: 03 SHOWING BMI (BODY MASS INDEX) IN HIGH AND LOW RISK GROUPS Classification for BMI BMI Results (n = 100) (Normal values) High Risk Low Risk (n = 50) (n = 50) Underweight < Normal weight (48%) 37 (74%) Overweight (20%) 11 (22%) Obesity (class 1) (24%) 02 (4%) Obesity (class 2) (8%) - Extreme obesity (class 3) > sex. This low risk group (control) had no family history of type-2 diabetes in their first-degree relatives. Body weight (to the nearest 0.1 kg) of each individual was measured. BMI was calculated by dividing the weight in Kg by the height in the meter square. Waist circumference was measured by measuring tape midway between the iliac crest and the lower costal margin. Three standard readings for blood pressure of each participant was taken in sitting posture using mercury column sphygmomanometer in relaxed state by comfortably sitting on a chair. The mean of three readings of both systolic and diastolic blood pressure was taken for calculation. A fasting blood glucose level after over night fasting for hours of each participant was done in the pathology laboratory or by glucometer (one touch). Plasma glucose was measured by glucose oxidase method. The data was collected on pre designed Performa (annex). DATA ANALYSIS: The data was evaluated by SPSS version Student t test was applied to compare the means (2 tailed) on 95% confidence interval among the numerical parameters such as age, FBS, blood pressure (SBP and DBP) BMI and waist circumference. Chi square test was applied among the categorical 118

3 variables of family history i.e. obesity, type II DM, and hypertension to calculate frequencies and percentages. P value < 0.05 was considered statistically as significant RESULTS Fifty participants included in each group on the basis of same gender and age. In each group 35 (70%) were males and 15(30%) were females with mean age ± SD (range) ± 5.71 (20-40) in years. Regarding fasting blood sugar (<100mg dl, 5.55 mmol/l), the overall mean ± SD (range) in high and low risk group was 87.4 ± (67-116) mg / dl and 77.7 ± (66-111) mg / dl p = (statistically significant) and there was mean ± SD 90.2 ± mg / dl in males and 81.0 ± mg / dl in females in the high risk group p = <0.03 (statistically significant), whereas mean ± SD in males 80.5 ± mg / dl and 71.4 ± mg / dl in females in low risk group p = 0.05 (statistically significant). However 10% in high risk and 2% in low risk group male individuals had impaired fasting blood sugar level. Regarding systolic blood pressure (<120 mmhg), the overall mean ± SD (range) in high and low risk group was ± (95-140) mmhg and ± (90-135) p = 0.17 and there was mean ± SD ± 11.9 mmhg in males and ± mmhg in females in the high risk group p = <0.63, whereas mean ± SD in males ± mmhg and 109 ± mmhg in females in low risk group p = However in high risk group one (2%) male individual had elevated systolic blood pressure. Regarding diastolic blood pressure (<80mmHg), the overall mean ± SD (range) in high and low risk group was 79.4 ± 8.66 (70-110) mmhg and 76 ± 8.45 (60-100) p = 0.05 (statistically significant) and there was mean ± SD ± 7.48 mmhg in males and ± mmhg in females in the high risk group p = <0.10, whereas mean ± SD in males ± 7.10 mmhg and 73 ± mmhg in females in low risk group p = However in high risk group seven (14%) individuals had elevated diastolic blood pressure. Of which five (71%) were males and two (29%) were females while in low risk group six (12%) individual had elevated diastolic blood pressure, of which four (67%) were males and two (33%) were females. Regarding body mass index ( ), the overall mean ± SD (range) in high and low risk group was ± 5.3 ( ) and 22.5 ± 3.3 ( ) p = (statistically significant) and there was mean ± SD ± 5.45 in males and ± FIGURE: 01 DEMOGRAPHICAL DISTRBUTION OF INDIVIDUALS (High and Low Risk Group) FIGURE: 02 FAMILY HISTORY & RISK FACTORS AMONG HIGH AND LOW RISK GROUP 4.64 in females in the high risk group p = 0.13, whereas mean ± SD in males ± 3.30 and ± 1.79 in females in low risk group p = (statistically significant). However in high risk group twenty six (52%) individuals were obese, of which twenty three (88%) were male and three (12%) were females, while in low risk thirteen (26%) males were obese. Regarding waist circumference (Male<90 cm or 36 inches, Female <80 cm or 32 inches) the overall mean ± SD (range) in high and low risk group was ± (50-106) centimeters and ± 9.12 (60-103) centimeters p = 0.96 and there was mean ± SD ± centimeters in males and ± 6.60 centimeters in females in the high risk group p = 0.09, whereas mean ± SD in males ± and ± 6.99 in females in low risk group p = However in high risk group twenty 21 (42%) individual had increased waist circumference, of which thirteen (62%) were males and eight (38%) were females, while in low risk group eighteen individuals (36%) had increased waist circumference, of which eleven (61%) were males and seven (39%) were females. DISCUSSION Diabetes mellitus is a fast expanding global health problem but more so in the developing countries. Therefore it is of particular interest to study the epidemiological transition of the state and to identify the risk factors in order to recognize the extent of the problem. 15 In this study 05 (10%) individuals of high risk and 01 (2%) individuals of low risk 119

4 group had impaired fasting blood glucose level. Of these 04 were between years age and remaining 02 were between years. In study by Sudha et al, 5.3% individuals of years of age group and 7.7% individuals of years of age group were identified as having IFG level. The prevalence of diabetes in the first degree relatives as well as vertical transmission through more than two generations is commonly seen in Asians Indians and the prevalence of diabetes increases with increasing family history of diabetes. 17 However a study conducted showed prevalence rate of 62% and risk of 73% when both parents had diabetes. 18 The study conducted in Bangladesh have shown 3.5% individuals of years of age and 2,5% individuals of years age group had IFG levels. 15 Present study showed that all individuals with IFG had no any symptoms of diabetes mellitus; this is totally similar to the study by Khan MN et al, in which fasting plasma glucose (FPG) of 859 symptom free adults was checked. Of them, 344(40%) were found to have IFG. In our study out of 6 individuals with IFG, 04 (80%) individuals belonged to urban areas while 02 (20%) individuals belonged to rural areas where as in the study by Shera et al 20.5% individuals of urban areas and 17.8% individuals of rural areas had IGT. 19 Present study showed that all the individuals with IGF were males whereas in another study the male were predominant also i.e. 13.1% were males and 6.2% were females. 21 Comparatively the study carried out by Ramachandran A, showed IFG was more prevalent in women (9.8%) than in men (7.4%). 22 In this study, out of 50 individuals of highrisk group 26 (52%) were obese. Couture S et al conducted a study revealed that 4555 of individuals were identified as having 2 or more risk factors for diabetes. 23 Individuals with impaired fasting glucose (IFG) have a 20 30% chance of developing diabetes over the next 5-10 years. 24 In this study twenty-six (52%) high-risk individuals and thirteen (26%) low risk individuals had raised BMI. The mean ages of both (high risk and low risk) groups were 27 years. However in another study the mean age of raised BMI individual was 30 and the prevalence was recorded as 28.6%. The other reason of such difference of raised BMI in high risk group in present study may be due to life style and socio-economic factors i.e. habits of sleeping at daytime, taking rich fat diet, taking more sugar in tea, drinking soft drink daily, use of sweets and doing no exercise daily. In this study there was significant difference in BMI between high and low risk individuals. However a local study done in Baqai medical university, Karachi by Basit et al in children shown that the children having positive family history for diabetes had slightly higher mean values for BMI. 25 In this study out of twenty-six (52%) of high risk individuals with raised BMI, five (19%) of age group and 04 (15%) of age group had metabolic syndrome. Our study showed that in high risk individuals 48% had normal BMI, 20% were overweight and 32% were obese while in low risk individuals 74% had normal BMI 22% were overweight and 4% were obese. In DAP-WHO study it was shown that 16 % had a BMI <18.5, (underweight), 36.8 % had a BMI between (normal), 44.6% had a BMI (overweight) and 17% were obese with a BMI of > Our study showed that in high risk individuals 2% had elevated SBP and 14% had elevated DBP while in low risk individuals 12% had elevated DBP. In our study in high risk individuals 71% male and 29% female had elevated DBP while in low risk individual 67% male and 33% female had elevated DBP. Until recently, waist circumference demonstrated to be a better predictor of type 2 diabetes than either BMI or waistto-hip ratio however, there is no compelling evidence that waist circumference provides any clinically-meaningful information that is independent of well-known cardio metabolic risk factors. In our study out of 21 individuals of raised WC in high risk group fifteen (71%) had raised BMI and four (19%) had normal BMI. Waist circumference (WC) is an independent risk factor for hypertension and type2 diabetes mellitus in the setting of a developing country. In our study out of 21 individuals of raised WC in high risk group five (24%) had elevated blood pressure while out of 18 individuals of raised WC in low risk individuals three (17%) had elevated blood pressure. However a study done in 2004 proved that waist circumference was an independent determinant for hypertension and diabetes especially in women younger than 40 years of age. CONCLUSION: It is concluded that IFG is related to hypertension and other clinical and metabolic abnormalities such as obesity, hyperlipidemia and family history of DM RECOMMENDATIONS: It is important for family physicians to identify patients with metabolic syndrome and to intervene aggressively to reduce the risk of diabetes and macro vascular disease. There should be screening for type 2 diabetes in adults (< 40 years) with hypertension or hyperlipidemia or obesity. REFERENCES 1. Diagnoses and Classification of Diabetes Mellitus. American Diabetes Association position statement. Diabetes care 2008; 31:S Savage G, Ewing P, Kirkwood H, Carter S. Are undiagnosed IGT/IFG and type 2 diabetes common in heart disease and hypertension?. Br J Diabetes Vasc Dis 2003; 3: Jali Mv, Kambar S. Prevalence of diabetes among the family members of known diabetes. Int J Daib Dev Ctries 2006; 26(2): Diabetes Atlas, Executive Summary, Second Edition. International Diabetes Federation. Electronic version of Diabetes Atlas: Available URL: / 5. Jawd F. Diabetes in Pakistan. Diabetes Voice 2003; 48(2): Tirosh A, Shai I, Tekes-Manova D, Israeli E, Pereg D, Shochat T, et al. Normal fasting plasma glucose level and type 2 diabetes in young men. N Engl J. Med 2005; 353: Stolk RP, Suriyawongpaisal P, Aekplaktorn W, Woodward M, Neal B. Fat distribution is strongly associated with plasma glucose level and diabetes in Thai adults-the Inter Asia Study. Diabetologia 2005; 48: Park Yw, Chang Y, Sung KC, Ryu S, Sung E, Kim Ws. The sequential changes in the fasting plasma glucose level within normoglycemic range predict type 2 diabetes in healthy, young men. Diabetes Res Clin Pract 2006; 73(3): Rehman K, Hashim R, Anwer MS, Qureshi A, Mohammad K. Type 2 diabetes and its association with hypertension and high urinary albumin excretion. Pak J Med Res 2004; 43(4): Ogunkolade WB, Boucher BJ, Bustin SA. Vitamin D metabolism in peripheral blood mononuclear cells is influenced by chewing betel nut (Areca catechu) and vitamin D status. J Clin Endocrinol Metab 2006;91: Eliasson B. Cigarette smoking and diabetes. Progress in Cardiovascular Diseases 2003; 45: Iqbal F, Naz R. Patterns of diabetes mellitus in Pakistan: An overview of the problem. Pakistan J. Med. Res 2005; 44(1): Basit A, Shera AS. Prevalence of Metabolic Syndrome in Pakistan. Metabolic Syndrome and Related Disorders 2008; 6(3): Laaksonen DE, Lindstrom J, Lakka TA et al. Finnish diabetes prevention study. Physical activity in the prevention of type 2 diabetes: the Finnish diabetes 120

5 prevention study. Diabetes 2005; 54: Hussain A, Vaaler S, Sayeed MA, Mahtab H, Ali SM, Khan AK. Type 2 diabetes and impaired fasting blood glucose in rural Bangladesh: a population based study. European Journal of Public Health 2006; 17(3): Iqbal F, Naz R. Patterns of diabetes mellitus in Pakistan: An overview of the problem. Pakistan J. Med. Res 2005; 44(1): Sudha SD, Zantye A, Mokal R, Mithbawkar S, Rane S, Thakur K. To identify the risk factors for high prevalence of diabetes and impaired glucose tolerance in Indian rural population. Int J Diab Dev Ctries 2006; 26 (1): Hussain A, Rahim MA, Khan AK, Ali SM, Vaaler S. Type 2 diabetes in rural and urban population. Diverse prevalence and associated risk factors in Bangladesh. Diabet Med 2005; 22: Khan MN, Dilawar M, Khan FA, Sultana S, Ljaz A, Naeem U, et al. Impaired fasting glucose individuals: their response to oral glucose challenge. Pak J Pathol 2006; 17(4): Shera AS, Jawad F, Maqsood A. Prevalence of diabetes in Pakistan. Diabetes Res Clin Pract 2007; 76(2): Genugten RE, Utzschneider KM, Tong J, Gerchman F, Zraika S, Udayasankar J. Effects of Sex and Hormone Replacement Therapy Use on the Prevalence of Isolated Impaired Fasting Glucose and Isolated Impaired Glucose Tolerance in Subjects With a Family History of Type 2 Diabetes. Diabetes 2006; 55: Ramachandran A, Snehalatha C, Satyavani K, Vijay V. Impaired fasting glucose and impaired glucose tolerance in urban population in India. Diabet. Med 2003; 20: Couture S, Yale JF, Marchand R, Jilwan NA, Champagne F, Strychar I. Diabetes Screening Among High-risk Participants in the Quebec Health Survey. Canadian journal of diabetes 2006; 30(1): Bock G, Man CD, Campioni M, Chittilapilly E, Basu R, Toffolo G, et al. Mechanisms of Fasting and Postprandial Hyperglycemia in People With Impaired Fasting Glucose and/or Impaired Glucose Tolerance. Diabetes 2006; 55: Basit A, Hakeem R, Hydrie ZI, Ahmadani Y, Masood O. Relation between family history, obesity and risk for diabetes & heart disease in Pakistani children. Pak J Med Sci 2004; 20(4):