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Evaluation of the burden of type 2 diabetes mellitus in population of Puducherry, South India
Diabetes & Metabolic Syndrome: Clinical Research & Reviews 5 (2011) 12–16
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Original article
Evaluation of the burden of type 2 diabetes mellitus in population of Puducherry, South India D.R. Bharati a, Ranabir Pal b,*, R. Rekha c, T.V. Yamuna d a
Department of Community Medicine, Mahatma Gandhi Medical College and Research Institute, Pondy-Cuddalore Main Road, Pillayarkuppam, Puducherry - 607402, India Department of Community Medicine, Sikkim-Manipal Institute of Medical Sciences and Central Referral Hospital, 5th Mile Tadong, Gangtok, Sikkim 737 102, India c Mahatma Gandhi Medical College and Research Institute, Pillayarkuppam, Puducherry - 607402, India d Kasturba Gandhi Nursing College, Mahatma Gandhi Medical College and Research Institute ‘‘Campus’’, Pondy-Cuddalore Main Road, Pillayarkuppam, Puducherry - 607402, India b
A R T I C L E I N F O
A B S T R A C T
Keywords: Diabetes mellitus Fasting venous plasma glucose level India
Aims: To find out the prevalence of undiagnosed diabetes mellitus and the correlates among the adult population of Puducherry, South India. Methods: In this population based cross-sectional study in the rural and urban field practice area of Mahatma Gandhi Medical College and Research Institute, Puducherry, by simple random sampling 1013 adults of 30 years and above, not on anti-diabetics drugs were included. Main outcome measures were the prevalence and correlates of undiagnosed diabetes mellitus among the adult population. Predesigned and pre-tested questionnaire was used to elicit the information on family and individual sociodemographic variables. Height, weight, waist and hip circumference, blood pressure were measured and venous blood was collected to measure fasting blood glucose and blood cholesterol. Results: Overall, 10.3% study subjects were diagnosed as diabetic. In univariate analysis age, dilatory habit, tobacco addiction, body mass index, waist hip ratio, hypertension, and total blood cholesterol were found statistically significant. In multivariate logistic regression (LR method) analysis age, residence, education, dietary habit, tobacco addiction, body mass index, waist hip ratio and total blood cholesterol were statistically significant. Conclusions: In our study adults having increased age, urban residence, illiterate, non-vegetarian diet, tobacco addiction, obese and high total blood cholesterol were important correlates. ß 2010 Diabetes India. Published by Elsevier Ltd. All rights reserved.
1. Introduction Diabetes mellitus has reached epidemic proportions worldwide as we enter the new millennium. The World Health Organization (WHO) has commented there is ‘an apparent epidemic of diabetes which is strongly related to lifestyle and economic change’. Over the next decade the projected number will exceed 200 million. Most will have type 2 diabetes, and all are at risk of the development of complications [1]. Diabetes mellitus is a heterogeneous group of diseases that develops insidiously and characterized by a state of chronic hyperglycaemia, resulting from a diversity of etiologies, environmental and genetic, acting jointly [2]. Diabetes mellitus is increasing due to population growth, aging, consequences of industrialization and urbanization, preference of high fat containing fast foods, sedentary life and obesity [3]. Given the enormous public health and economic burden posed by the global epidemic of type 2 diabetes mellitus (T2DM),
* Corresponding author. Tel.: +91 9433247676; fax: +91 3592 231496. E-mail address: [email protected] (R. Pal).
intervention in the pre-diabetes stage of disease to prevent progression to T2DM and its vascular complications seems the most sensible approach. Prudent lifestyle changes have been shown to significantly reduce the risk of progression in individuals with impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). Although lifestyle modifications are notoriously difficult to maintain, there is evidence that intensive intervention results in continued preventive benefit after the stopping of structured counseling [4]. The age adjusted mortality rates among the diabetics are 1.5– 2.5% times higher than general population [5]. It is a chronic, noncommunicable, expensive disease of public health and clinical concern imposes economic burden on the person, family, community and nation as a whole [6]. In the coming years the majority of diabetics will be in India, China and U.S.A. The projection for India is 79,441 million by 2030 from 31,705 million in 2000 [7,8]. The second-stage choice of test for blood glucose remains a problem, as in the last review for NSC. The best test is the oral glucose tolerance test (OGTT), but it is the most expensive, is inconvenient and has weak reproducibility. Fasting plasma glucose would miss people with IGT. Glycated haemoglobin does not
1871-4021/$ – see front matter ß 2010 Diabetes India. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dsx.2010.05.008
D.R. Bharati et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 5 (2011) 12–16
require fasting, and may be the best compromise. It may be that more people would be tested and diagnosed if the more convenient test was used, rather than the OGTT [9]. Diabetes remains a great social and clinical problem. Therefore, there is a need to focus our efforts on prevention of the disease, especially of type 2 diabetes. Type 2 diabetes is characterized by accelerated development of atherosclerotic changes (macroangiopathy). Hyperglycaemia, hypertension, hyperlipidaemia and hyperfibrinogenaemia also play an important role in the development of macroangiopathy. Hyperinsulinaemia, which accompanies the visceral type of obesity, is characteristic of type 2 diabetes. Considering all the abovementioned findings, prevention of type 2 diabetes should be based on the population level, concentrating especially on the groups with increased risk of obesity and/or diabetes (early primary prevention) [10]. The study was undertaken to find out the prevalence of undiagnosed diabetes mellitus and correlates diabetes mellitus among the adult population of rural and urban area of Puducherry, South India. 2. Subjects, materials and methods Settings and design: Population based cross-sectional study was carried out in the rural and urban field practices area of Mahatma Gandhi Medical College and Research Institute, Puducherry. Study period: 1st December 2007–31st May 2008 Participants: 1013 adults 30 years of age and above, not taking any types of anti-diabetic drugs. Interventions: None. Sample size and sampling design: Prevalence rate of diabetes among adults 9.3% was reported from Malwan area of Sindhudurg district of Maharashtra, India by Deo et al. [12]. Considering this prevalence of diabetes mellitus with 5% alpha error, 2% absolute allowable error, 15% for non-response and 10% to nullify design effect, 1013 samples were calculated. All eligible individuals from selected area were identified from electoral roll of election commission of India, followed by preparation of two separate lists of eligible, one for urban area and another for rural area and there after 506 subjects from rural area and 507 subjects from urban area were selected by random sampling method. 201 data (35 were non-respondent and 166 were on treatment) were discarded and finally 812 data (396 data from rural area and 416 data from urban area) were analyzed. Study instrument: The data collection tool used for the study was an interview schedule that was developed at the Institute with the assistance from the faculty members and other experts. This pre-designed and pre-tested questionnaire contained questions relating to the information on family characteristics like residence, type of family, family history of diabetes mellitus, family history of chronic disease, income and personal characteristics like age, sex, education, occupation, and type of food, dietary habit. By initial translation, back-translation, re-translation followed by pilot study the questionnaire was custom-made for the study. The pilot study was carried out at the institute among general subjects following which some of the questions from the interview schedule were modified. Blood pressure as well as anthropometric measurements was taken and venous blood samples were also collected for laboratory investigations. Data collection procedure: Study was approved by Institutional ethics committee and informed consent was obtained from all participants. The health workers informed and motivated the families to participate in the study along with the scope of future intervention, if necessary. All the participants were explained about the purpose of the study and were ensured strict confidentiality, and then informed consent was taken from each of them before the total procedure. The participants were given the
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options not to participate in the study if they wanted. Data regarding family and personal characteristics were recorded by personal interview. Body weight was measured (to the nearest 0.5 kg) in the standing motionless on the bath room scale with feet 15 cm apart, and weight equally distributed on each leg. Height was measured (to the nearest 0.5 cm) by stadeometer in standing position with closed feet, holding their breath in full inspiration and Frankfurt line of vision. Waist and hip circumference was measured by flexible non-stretchable measuring tape in standing. Venous blood samples were taken after 10–12 h fast, there after blood samples were examined in the biochemistry departmental laboratory of Mahatma Gandhi Medical College and Research Institute, Puducherry. A maximum of five visits were conducted for those who could not be contacted during the first visit. Diagnostic criteria of undiagnosed diabetes mellitus: 2006 WHO recommendation used for diagnostic criteria for the diagnosis of diabetes mellitus, WHO/International Diabetes Federation [11] ‘‘Persons with the fasting venous blood plasma glucose level 126 mg/dl and not on treatment were classified as undiagnosed case of Diabetes mellitus’’. Statistical analysis used: Data were analyzed by Epi-Info. 3.4.1 and SPSS version 13th statistical software. Proportion of adult person with diabetes mellitus was presented as percentage. Odds ratio (OR) and 95% confidence interval (95% C.I.) was calculated for each categorical risk factors. Backward LR method was used to perform binary logistic regressions, where presence of diabetes mellitus was used as dependent variable while others as independent variables. p < 0.05 was used as the definition of statistical significance. 3. Results In the present study, Out of 812 adults 30 years of age and above, 306 (37.7%) were males and 506 (62.3%) were females. Overall, 84 (10.3%) study subjects had fasting venous plasma blood glucose level 126 mg/dl. Magnitude of persons with fasting venous blood plasma glucose level 126 mg/dl was 50 (12.0%) in urban and 34 (8.6%) in rural area. The proportion of diabetes mellitus was higher (18.4%) in persons aged 50 years than in persons aged between 30 and 49 years (5.8%), the difference was statistically significant. In fact result of this study shows that magnitude of diabetes mellitus increases as age of the study population increases (Table 1). The proportion of diabetes mellitus was 11.1% in males and 9.9% in females (Table 2). In univariate analysis, probability of having increased risk of diabetes mellitus was significantly higher among adults aged 50 years, having non-vegetarian dietary habit, addicted to tobacco, obese (general and abdominal obesity), hypertensive and whose blood cholesterol were higher than normal (Table 2). The final model of multivariate logistic regression LR method shows the significant correlates of diabetes mellitus were age 50 years and above, urban residence, illiteracy, non-vegetarian dietary habit, tobacco addiction, obesity and having high total blood cholesterol (Table 3). Table 1 The prevalence of diabetes mellitus in different age groups among the study population. Age groups (years)
Study population (%)
Diabetes mellitus (%)
Odds ratio
30–39 40–49 50–59 60–69 70
320 198 142 106 46
8 22 26 20 10
1.00 4.88 6.59 9.07 10.83
(39.4) (24.4) (17.5) (13.1) (5.6)
Chi-square = 38.015, p-value = 0.000.
(2.5) (11.1) (16.9) (18.9) (21.7)
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D.R. Bharati et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 5 (2011) 12–16
Table 2 Correlates of diabetes mellitus among adults: unvariate analysis. Variables
Study population (%)
DM (%)
OR (95% C.I.)
p-Value
1. Age (years) 30–49 50
518 (63.8) 296 (36.2)
30 (5.8) 54 (18.4)
1 3.660 (2.282–5.869)
0.000
2. Sex Female Male
506 (62.3) 306 (37.7)
50 (9.9) 34 (11.1)
1 1.140 (0.719–1.807)
0.577
3. Residential area Rural Urban
396 (48.8) 416 (51.2)
34 (8.6) 50 (12.0)
1 1.455 (0.919–2.302)
0.108
4. Type of family Joint Nuclear
382 (47.0) 330 (53.0)
38 (9.9) 46 (10.7)
1 1.084 (0.689–1.707)
0.726
5. Education Literate Illiterate
374 (46.1) 438 (53.9)
38 (10.2) 46 (10.5)
1 1.038 (0.659–1.633)
0.873
6. Occupation Non-sedentary Sedentary
310 (38.2) 502 (61.8)
26 (8.4) 58 (11.6)
1 1.427 (0.878–2.320)
0.150
7. Dietary habit Vegetarian Non-vegetarian
86 (10.6) 726 (89.4)
2 (2.3) 82 (11.3)
1 5.348 (1.291–22.147)
0.010
8. Alcohol addiction Absent Present
752 (92.6) 60 (7.4)
78 (10.4) 6 (10.0)
1 0.960 (0.400–2.304)
0.927
9. Tobacco addiction Absent Present
736 (90.6) 76 (9.4)
68 (9.2) 16 (21.1)
1 2.620 (1.430–4.798)
0.001
10. Family history of diabetes mellitus Absent Present
680 (83.7) 132 (16.3)
72 (10.6) 12 (9.2)
1 0.844 (0.445–1.604)
0.605
11. Body mass index Normal (IBM < 30) Obesity (BMI 30)
734 (90.4) 78 (9.6)
68 (9.3) 16 (20.5)
1 2.528 (1.382–4.622)
0.002
12. Waist–hip ratio Normal Obesity
338 (41.6) 474 (58.4)
24 (7.1) 62 (12.7)
1 1.896 (1.155–3.112)
0.010
13. Hypertension Absent Present
456 (56.2) 356 (43.8)
30 (6.6) 54 (15.2)
1 2.539 (1.587–4.063)
0.000
14. Total blood cholesterol Normal (<240 mg/dl) High (240 mg/dl)
736 (90.6) 76 (9.4)
64 (8.7) 20 (26.3)
1 3.750 (2.118–6.640)
0.000
Underlined bold values are p < 0.05. Table 3 Correlates of diabetes mellitus among adults: final model—multivariate logistic regression backward stepwise (likelihood ratio) method. Correlates
Standard error
Wald
p-Value
Odds ratio
95% C.I. for OR
1. Age 2. Residence 3. Education 4. Dietary habit 5. Tobacco addiction 6. Body mass index 7. Waist hip ratio 8. Total blood cholesterol Constant
0.269 0.262 0.266 0.738 0.344 0.349 0.274 0.331 1.935
23.877 4.300 4.061 5.598 6.878 6.584 6.118 9.002 53.535
0.000 0.038 0.044 0.018 0.009 0.010 0.013 0.003 0.000
3.714 1.723 1.709 5.738 2.464 2.450 1.970 2.700 0.000
2.194–6.287 1.030–2.880 1.015–2.879 1.350–24.396 1.256–4.833 1.236–4.856 1.151–3.370 1.411–5.166
4. Discussion Among the screened subjects who underwent blood testing, the overall, prevalence of newly diagnosed diabetes was 10.3%. Final model of the multivariate logistic regression showed that the important correlates of diabetes mellitus were higher age,
urban residence, illiteracy, non-vegetarian dietary habit, obesity, tobacco addiction and high total blood cholesterol. The findings were found to be statistically significant, while Menon et al. [21] reported 10.5% in Kerala, 9.1% in Lucknow [8], and 1.4% in Madurai by Ramaiya et al. [13] in the population above 30 years of age.
D.R. Bharati et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 5 (2011) 12–16
This study shows diabetes mellitus rate increases with age. Similar trend is reported by Ramaiya et al. [13], Zargar et al. [14], abu Sayeed et al. [15], Shera et al. [16], Satman et al. [17], Ramachandran et al. [18], Mohan et al. [19], Melidonis et al. [20], Menon et al. [21], Kumar et al. [22], Wang et al. [23]. Magnitude of diabetes mellitus is not significantly different among male and female in this study. Higher magnitude in males was reported by Zargar et al. [14] and Gupta et al. [24] in India, and in migrant Indians in other countries by Beckles et al. [25], Dowse et al. [26], Taylor et al. [27]. Ramachandran et al. [18] in South India observed the female preponderance in Indian diabetic. Swai et al. [28] in Tanzania reported, similar in men and women. In this study, the magnitude of diabetes mellitus is significantly more in urban area than rural area. Similar finding is reported by WHO [5], Sadikot et al. [29], Zargar et al. [14]. No association was reported by abu Sayeed et al. [15]. Illiteracy in this study is significantly associated with diabetes mellitus. Similar finding is reported by Magliano et al. [30]. Occupation shows no association in this study, while positive association is reported by Singh et al. [31] and Mohan et al. [19] in India, Ramaiya et al. [13] in Mauritius, Swai et al. [28] among Indian Muslim of Tanzania and Magliano et al. [30] in Australia. Non-vegetarian dietary habit shows positive association in this study, while Gupta et al. [24] in Indian and Ramaiya et al. [13] in Tanzania, show that prevalence of diabetes mellitus was more in vegetarians. Alcohol addiction is not significantly associated with diabetes mellitus in this study. Similar finding is reported by Singh et al. [31]. Tobacco addiction in this study is significantly associated with diabetes mellitus. Similar finding is reported by Magliano et al. [30] in Australia. Family history of diabetes mellitus is not significantly associated with diabetes mellitus in this study. But positive association is reported by Patandin et al. [32], Shera et al. [16], Satman et al. [17], Mohan et al. [19], Melidonis et al. [20], Menon et al. [21], Kumar et al. [22], Wang et al. [23]. Body mass index in this study is significantly associated with diabetes mellitus. Similar finding is reported by Zargar et al. [14], Patandin et al. [32], Singh et al. [31], Shera et al. [16], Amoah [33], Satman et al. [17], Gupta et al. [34], Mohan et al. [19], Melidonis et al. [20], Menon et al. [21], Katulanda et al. [35], Wang et al. [23] No association is reported by Mohan et al. [36] and Kumar et al. [22]. Hip ratio in this study is significantly associated with diabetes mellitus. Similar finding is reported by Singh et al. [31], Zargar et al. [14] Amoah [33], Satman et al. [17], Gupta et al. [34], Mohan et al. [19], Katulanda et al. [35], Kumar et al. [22]. Hypertension in this study is significantly associated with diabetes mellitus only in univariate analysis but not in multivariate analysis. Positive association is reported by Satman et al. [17], Gupta et al. [34], Mohan et al. [19], Melidonis et al. [20], Shera et al. [37], Magliano et al. [30] Katulanda et al. [35], Wang et al. [23]. This study shows blood cholesterol level is a significant correlates of diabetes mellitus. Similar finding is reported by WHO [5], Amoah [33], Magliano et al. [30], Katulanda et al. [35], Wang et al. [23]. It is an exciting era for patients at risk for developing T2DM. While IFG and IGT continue to be useful in identifying patients at increased risk for both progression to DM and for cardiovascular clinical events, further insights into the mechanisms that lead to impaired glucose metabolism are being discovered. There is now real hope that measures to prevent T2DM can be employed on a population-wide basis, and perhaps such measures may even prevent the cardiovascular clinical consequences of T2DM. Ongoing clinical trials are evaluating newer pharmacotherapies, including angiotensin converting enzyme inhibitors, angiotensin receptor antagonists, metglitinides and thiazolidinediones, to
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prevent both T2DM and cardiovascular events. In combination with lifestyle modification, these therapies offer hope for effective prevention of T2DM and its consequences in high-risk patients, Petersen et al. [38]. The strength of the study was that it was a population based cross-sectional study to find the prevalence of undiagnosed diabetes mellitus among adults in both urban and rural area. Bias was taken care of by random sampling. So far there has been no study done in this field in the state and to the horizon of our knowledge this was one of the recent studies reported from the South India. The limitation of the study was that, we could not include in the study of the prevalence among adolescents. 5. Future directions of the study Recent epidemiologic studies show increasing ‘‘epidemic’’ of diabetes mellitus throughout the world [29]. The prevalences of diabetes and IFG have increased dramatically over the past decade. Yet, a large proportion of cases go undiagnosed, Wang H et al. [22]. We hope to find out that this study should have been repeated at regular interval in our country by multicentre study to find out national prevalence. The key factor to prevent diabetes mellitus that we have to generate awareness among our Peers, Public Health Experts, Health Services Researchers, Healthcare Providers and Planners to consider the higher prevalence and associated risk factors of diabetes mellitus as a public health problem in the developing countries like ‘Diabetic capital’ India. 6. Conclusions In our study we observed that the prevalence of undiagnosed diabetes mellitus was 10.3%. Moreover, adults with the increasing age, urban residence, illiterate, non-vegetarian dietary habit, tobacco addiction and hypercholesterolemia are more likely to develop diabetes mellitus. These findings suggest that this could lay the foundation for the introduction of primary health care with community participation. Ethical approval from authors All the co-authors have seen and approved the final version of the manuscript and it is not currently under active consideration for publication elsewhere, has not been accepted for publication, nor has it been published/reported earlier, in full or in part. All the authors have been personally and actively involved in substantive work leading to the report, and will hold themselves jointly and individually responsible for its content. Financial disclosures We declare that no funding, direct or indirect for our study was received. Acknowledgements We thank the medical officers, interns, social workers and nursing staffs of the Department of Community Medicine of Mahatma Gandhi Medical College and Research Institute for the data collection and the Department of Biochemistry for the ultra structural technical assistance. Conflict of interest statement There are no potential, perceived, or real competing and/or conflicts of interest among authors regarding the article.
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Diabetes & Metabolic Syndrome: Clinical Research & Reviews journal homepage: www.elsevier.com/locate/dsx
Original article
Evaluation of the burden of type 2 diabetes mellitus in population of Puducherry, South India D.R. Bharati a, Ranabir Pal b,*, R. Rekha c, T.V. Yamuna d a
Department of Community Medicine, Mahatma Gandhi Medical College and Research Institute, Pondy-Cuddalore Main Road, Pillayarkuppam, Puducherry - 607402, India Department of Community Medicine, Sikkim-Manipal Institute of Medical Sciences and Central Referral Hospital, 5th Mile Tadong, Gangtok, Sikkim 737 102, India c Mahatma Gandhi Medical College and Research Institute, Pillayarkuppam, Puducherry - 607402, India d Kasturba Gandhi Nursing College, Mahatma Gandhi Medical College and Research Institute ‘‘Campus’’, Pondy-Cuddalore Main Road, Pillayarkuppam, Puducherry - 607402, India b
A R T I C L E I N F O
A B S T R A C T
Keywords: Diabetes mellitus Fasting venous plasma glucose level India
Aims: To find out the prevalence of undiagnosed diabetes mellitus and the correlates among the adult population of Puducherry, South India. Methods: In this population based cross-sectional study in the rural and urban field practice area of Mahatma Gandhi Medical College and Research Institute, Puducherry, by simple random sampling 1013 adults of 30 years and above, not on anti-diabetics drugs were included. Main outcome measures were the prevalence and correlates of undiagnosed diabetes mellitus among the adult population. Predesigned and pre-tested questionnaire was used to elicit the information on family and individual sociodemographic variables. Height, weight, waist and hip circumference, blood pressure were measured and venous blood was collected to measure fasting blood glucose and blood cholesterol. Results: Overall, 10.3% study subjects were diagnosed as diabetic. In univariate analysis age, dilatory habit, tobacco addiction, body mass index, waist hip ratio, hypertension, and total blood cholesterol were found statistically significant. In multivariate logistic regression (LR method) analysis age, residence, education, dietary habit, tobacco addiction, body mass index, waist hip ratio and total blood cholesterol were statistically significant. Conclusions: In our study adults having increased age, urban residence, illiterate, non-vegetarian diet, tobacco addiction, obese and high total blood cholesterol were important correlates. ß 2010 Diabetes India. Published by Elsevier Ltd. All rights reserved.
1. Introduction Diabetes mellitus has reached epidemic proportions worldwide as we enter the new millennium. The World Health Organization (WHO) has commented there is ‘an apparent epidemic of diabetes which is strongly related to lifestyle and economic change’. Over the next decade the projected number will exceed 200 million. Most will have type 2 diabetes, and all are at risk of the development of complications [1]. Diabetes mellitus is a heterogeneous group of diseases that develops insidiously and characterized by a state of chronic hyperglycaemia, resulting from a diversity of etiologies, environmental and genetic, acting jointly [2]. Diabetes mellitus is increasing due to population growth, aging, consequences of industrialization and urbanization, preference of high fat containing fast foods, sedentary life and obesity [3]. Given the enormous public health and economic burden posed by the global epidemic of type 2 diabetes mellitus (T2DM),
* Corresponding author. Tel.: +91 9433247676; fax: +91 3592 231496. E-mail address: [email protected] (R. Pal).
intervention in the pre-diabetes stage of disease to prevent progression to T2DM and its vascular complications seems the most sensible approach. Prudent lifestyle changes have been shown to significantly reduce the risk of progression in individuals with impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). Although lifestyle modifications are notoriously difficult to maintain, there is evidence that intensive intervention results in continued preventive benefit after the stopping of structured counseling [4]. The age adjusted mortality rates among the diabetics are 1.5– 2.5% times higher than general population [5]. It is a chronic, noncommunicable, expensive disease of public health and clinical concern imposes economic burden on the person, family, community and nation as a whole [6]. In the coming years the majority of diabetics will be in India, China and U.S.A. The projection for India is 79,441 million by 2030 from 31,705 million in 2000 [7,8]. The second-stage choice of test for blood glucose remains a problem, as in the last review for NSC. The best test is the oral glucose tolerance test (OGTT), but it is the most expensive, is inconvenient and has weak reproducibility. Fasting plasma glucose would miss people with IGT. Glycated haemoglobin does not
1871-4021/$ – see front matter ß 2010 Diabetes India. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dsx.2010.05.008
D.R. Bharati et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 5 (2011) 12–16
require fasting, and may be the best compromise. It may be that more people would be tested and diagnosed if the more convenient test was used, rather than the OGTT [9]. Diabetes remains a great social and clinical problem. Therefore, there is a need to focus our efforts on prevention of the disease, especially of type 2 diabetes. Type 2 diabetes is characterized by accelerated development of atherosclerotic changes (macroangiopathy). Hyperglycaemia, hypertension, hyperlipidaemia and hyperfibrinogenaemia also play an important role in the development of macroangiopathy. Hyperinsulinaemia, which accompanies the visceral type of obesity, is characteristic of type 2 diabetes. Considering all the abovementioned findings, prevention of type 2 diabetes should be based on the population level, concentrating especially on the groups with increased risk of obesity and/or diabetes (early primary prevention) [10]. The study was undertaken to find out the prevalence of undiagnosed diabetes mellitus and correlates diabetes mellitus among the adult population of rural and urban area of Puducherry, South India. 2. Subjects, materials and methods Settings and design: Population based cross-sectional study was carried out in the rural and urban field practices area of Mahatma Gandhi Medical College and Research Institute, Puducherry. Study period: 1st December 2007–31st May 2008 Participants: 1013 adults 30 years of age and above, not taking any types of anti-diabetic drugs. Interventions: None. Sample size and sampling design: Prevalence rate of diabetes among adults 9.3% was reported from Malwan area of Sindhudurg district of Maharashtra, India by Deo et al. [12]. Considering this prevalence of diabetes mellitus with 5% alpha error, 2% absolute allowable error, 15% for non-response and 10% to nullify design effect, 1013 samples were calculated. All eligible individuals from selected area were identified from electoral roll of election commission of India, followed by preparation of two separate lists of eligible, one for urban area and another for rural area and there after 506 subjects from rural area and 507 subjects from urban area were selected by random sampling method. 201 data (35 were non-respondent and 166 were on treatment) were discarded and finally 812 data (396 data from rural area and 416 data from urban area) were analyzed. Study instrument: The data collection tool used for the study was an interview schedule that was developed at the Institute with the assistance from the faculty members and other experts. This pre-designed and pre-tested questionnaire contained questions relating to the information on family characteristics like residence, type of family, family history of diabetes mellitus, family history of chronic disease, income and personal characteristics like age, sex, education, occupation, and type of food, dietary habit. By initial translation, back-translation, re-translation followed by pilot study the questionnaire was custom-made for the study. The pilot study was carried out at the institute among general subjects following which some of the questions from the interview schedule were modified. Blood pressure as well as anthropometric measurements was taken and venous blood samples were also collected for laboratory investigations. Data collection procedure: Study was approved by Institutional ethics committee and informed consent was obtained from all participants. The health workers informed and motivated the families to participate in the study along with the scope of future intervention, if necessary. All the participants were explained about the purpose of the study and were ensured strict confidentiality, and then informed consent was taken from each of them before the total procedure. The participants were given the
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options not to participate in the study if they wanted. Data regarding family and personal characteristics were recorded by personal interview. Body weight was measured (to the nearest 0.5 kg) in the standing motionless on the bath room scale with feet 15 cm apart, and weight equally distributed on each leg. Height was measured (to the nearest 0.5 cm) by stadeometer in standing position with closed feet, holding their breath in full inspiration and Frankfurt line of vision. Waist and hip circumference was measured by flexible non-stretchable measuring tape in standing. Venous blood samples were taken after 10–12 h fast, there after blood samples were examined in the biochemistry departmental laboratory of Mahatma Gandhi Medical College and Research Institute, Puducherry. A maximum of five visits were conducted for those who could not be contacted during the first visit. Diagnostic criteria of undiagnosed diabetes mellitus: 2006 WHO recommendation used for diagnostic criteria for the diagnosis of diabetes mellitus, WHO/International Diabetes Federation [11] ‘‘Persons with the fasting venous blood plasma glucose level 126 mg/dl and not on treatment were classified as undiagnosed case of Diabetes mellitus’’. Statistical analysis used: Data were analyzed by Epi-Info. 3.4.1 and SPSS version 13th statistical software. Proportion of adult person with diabetes mellitus was presented as percentage. Odds ratio (OR) and 95% confidence interval (95% C.I.) was calculated for each categorical risk factors. Backward LR method was used to perform binary logistic regressions, where presence of diabetes mellitus was used as dependent variable while others as independent variables. p < 0.05 was used as the definition of statistical significance. 3. Results In the present study, Out of 812 adults 30 years of age and above, 306 (37.7%) were males and 506 (62.3%) were females. Overall, 84 (10.3%) study subjects had fasting venous plasma blood glucose level 126 mg/dl. Magnitude of persons with fasting venous blood plasma glucose level 126 mg/dl was 50 (12.0%) in urban and 34 (8.6%) in rural area. The proportion of diabetes mellitus was higher (18.4%) in persons aged 50 years than in persons aged between 30 and 49 years (5.8%), the difference was statistically significant. In fact result of this study shows that magnitude of diabetes mellitus increases as age of the study population increases (Table 1). The proportion of diabetes mellitus was 11.1% in males and 9.9% in females (Table 2). In univariate analysis, probability of having increased risk of diabetes mellitus was significantly higher among adults aged 50 years, having non-vegetarian dietary habit, addicted to tobacco, obese (general and abdominal obesity), hypertensive and whose blood cholesterol were higher than normal (Table 2). The final model of multivariate logistic regression LR method shows the significant correlates of diabetes mellitus were age 50 years and above, urban residence, illiteracy, non-vegetarian dietary habit, tobacco addiction, obesity and having high total blood cholesterol (Table 3). Table 1 The prevalence of diabetes mellitus in different age groups among the study population. Age groups (years)
Study population (%)
Diabetes mellitus (%)
Odds ratio
30–39 40–49 50–59 60–69 70
320 198 142 106 46
8 22 26 20 10
1.00 4.88 6.59 9.07 10.83
(39.4) (24.4) (17.5) (13.1) (5.6)
Chi-square = 38.015, p-value = 0.000.
(2.5) (11.1) (16.9) (18.9) (21.7)
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D.R. Bharati et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 5 (2011) 12–16
Table 2 Correlates of diabetes mellitus among adults: unvariate analysis. Variables
Study population (%)
DM (%)
OR (95% C.I.)
p-Value
1. Age (years) 30–49 50
518 (63.8) 296 (36.2)
30 (5.8) 54 (18.4)
1 3.660 (2.282–5.869)
0.000
2. Sex Female Male
506 (62.3) 306 (37.7)
50 (9.9) 34 (11.1)
1 1.140 (0.719–1.807)
0.577
3. Residential area Rural Urban
396 (48.8) 416 (51.2)
34 (8.6) 50 (12.0)
1 1.455 (0.919–2.302)
0.108
4. Type of family Joint Nuclear
382 (47.0) 330 (53.0)
38 (9.9) 46 (10.7)
1 1.084 (0.689–1.707)
0.726
5. Education Literate Illiterate
374 (46.1) 438 (53.9)
38 (10.2) 46 (10.5)
1 1.038 (0.659–1.633)
0.873
6. Occupation Non-sedentary Sedentary
310 (38.2) 502 (61.8)
26 (8.4) 58 (11.6)
1 1.427 (0.878–2.320)
0.150
7. Dietary habit Vegetarian Non-vegetarian
86 (10.6) 726 (89.4)
2 (2.3) 82 (11.3)
1 5.348 (1.291–22.147)
0.010
8. Alcohol addiction Absent Present
752 (92.6) 60 (7.4)
78 (10.4) 6 (10.0)
1 0.960 (0.400–2.304)
0.927
9. Tobacco addiction Absent Present
736 (90.6) 76 (9.4)
68 (9.2) 16 (21.1)
1 2.620 (1.430–4.798)
0.001
10. Family history of diabetes mellitus Absent Present
680 (83.7) 132 (16.3)
72 (10.6) 12 (9.2)
1 0.844 (0.445–1.604)
0.605
11. Body mass index Normal (IBM < 30) Obesity (BMI 30)
734 (90.4) 78 (9.6)
68 (9.3) 16 (20.5)
1 2.528 (1.382–4.622)
0.002
12. Waist–hip ratio Normal Obesity
338 (41.6) 474 (58.4)
24 (7.1) 62 (12.7)
1 1.896 (1.155–3.112)
0.010
13. Hypertension Absent Present
456 (56.2) 356 (43.8)
30 (6.6) 54 (15.2)
1 2.539 (1.587–4.063)
0.000
14. Total blood cholesterol Normal (<240 mg/dl) High (240 mg/dl)
736 (90.6) 76 (9.4)
64 (8.7) 20 (26.3)
1 3.750 (2.118–6.640)
0.000
Underlined bold values are p < 0.05. Table 3 Correlates of diabetes mellitus among adults: final model—multivariate logistic regression backward stepwise (likelihood ratio) method. Correlates
Standard error
Wald
p-Value
Odds ratio
95% C.I. for OR
1. Age 2. Residence 3. Education 4. Dietary habit 5. Tobacco addiction 6. Body mass index 7. Waist hip ratio 8. Total blood cholesterol Constant
0.269 0.262 0.266 0.738 0.344 0.349 0.274 0.331 1.935
23.877 4.300 4.061 5.598 6.878 6.584 6.118 9.002 53.535
0.000 0.038 0.044 0.018 0.009 0.010 0.013 0.003 0.000
3.714 1.723 1.709 5.738 2.464 2.450 1.970 2.700 0.000
2.194–6.287 1.030–2.880 1.015–2.879 1.350–24.396 1.256–4.833 1.236–4.856 1.151–3.370 1.411–5.166
4. Discussion Among the screened subjects who underwent blood testing, the overall, prevalence of newly diagnosed diabetes was 10.3%. Final model of the multivariate logistic regression showed that the important correlates of diabetes mellitus were higher age,
urban residence, illiteracy, non-vegetarian dietary habit, obesity, tobacco addiction and high total blood cholesterol. The findings were found to be statistically significant, while Menon et al. [21] reported 10.5% in Kerala, 9.1% in Lucknow [8], and 1.4% in Madurai by Ramaiya et al. [13] in the population above 30 years of age.
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This study shows diabetes mellitus rate increases with age. Similar trend is reported by Ramaiya et al. [13], Zargar et al. [14], abu Sayeed et al. [15], Shera et al. [16], Satman et al. [17], Ramachandran et al. [18], Mohan et al. [19], Melidonis et al. [20], Menon et al. [21], Kumar et al. [22], Wang et al. [23]. Magnitude of diabetes mellitus is not significantly different among male and female in this study. Higher magnitude in males was reported by Zargar et al. [14] and Gupta et al. [24] in India, and in migrant Indians in other countries by Beckles et al. [25], Dowse et al. [26], Taylor et al. [27]. Ramachandran et al. [18] in South India observed the female preponderance in Indian diabetic. Swai et al. [28] in Tanzania reported, similar in men and women. In this study, the magnitude of diabetes mellitus is significantly more in urban area than rural area. Similar finding is reported by WHO [5], Sadikot et al. [29], Zargar et al. [14]. No association was reported by abu Sayeed et al. [15]. Illiteracy in this study is significantly associated with diabetes mellitus. Similar finding is reported by Magliano et al. [30]. Occupation shows no association in this study, while positive association is reported by Singh et al. [31] and Mohan et al. [19] in India, Ramaiya et al. [13] in Mauritius, Swai et al. [28] among Indian Muslim of Tanzania and Magliano et al. [30] in Australia. Non-vegetarian dietary habit shows positive association in this study, while Gupta et al. [24] in Indian and Ramaiya et al. [13] in Tanzania, show that prevalence of diabetes mellitus was more in vegetarians. Alcohol addiction is not significantly associated with diabetes mellitus in this study. Similar finding is reported by Singh et al. [31]. Tobacco addiction in this study is significantly associated with diabetes mellitus. Similar finding is reported by Magliano et al. [30] in Australia. Family history of diabetes mellitus is not significantly associated with diabetes mellitus in this study. But positive association is reported by Patandin et al. [32], Shera et al. [16], Satman et al. [17], Mohan et al. [19], Melidonis et al. [20], Menon et al. [21], Kumar et al. [22], Wang et al. [23]. Body mass index in this study is significantly associated with diabetes mellitus. Similar finding is reported by Zargar et al. [14], Patandin et al. [32], Singh et al. [31], Shera et al. [16], Amoah [33], Satman et al. [17], Gupta et al. [34], Mohan et al. [19], Melidonis et al. [20], Menon et al. [21], Katulanda et al. [35], Wang et al. [23] No association is reported by Mohan et al. [36] and Kumar et al. [22]. Hip ratio in this study is significantly associated with diabetes mellitus. Similar finding is reported by Singh et al. [31], Zargar et al. [14] Amoah [33], Satman et al. [17], Gupta et al. [34], Mohan et al. [19], Katulanda et al. [35], Kumar et al. [22]. Hypertension in this study is significantly associated with diabetes mellitus only in univariate analysis but not in multivariate analysis. Positive association is reported by Satman et al. [17], Gupta et al. [34], Mohan et al. [19], Melidonis et al. [20], Shera et al. [37], Magliano et al. [30] Katulanda et al. [35], Wang et al. [23]. This study shows blood cholesterol level is a significant correlates of diabetes mellitus. Similar finding is reported by WHO [5], Amoah [33], Magliano et al. [30], Katulanda et al. [35], Wang et al. [23]. It is an exciting era for patients at risk for developing T2DM. While IFG and IGT continue to be useful in identifying patients at increased risk for both progression to DM and for cardiovascular clinical events, further insights into the mechanisms that lead to impaired glucose metabolism are being discovered. There is now real hope that measures to prevent T2DM can be employed on a population-wide basis, and perhaps such measures may even prevent the cardiovascular clinical consequences of T2DM. Ongoing clinical trials are evaluating newer pharmacotherapies, including angiotensin converting enzyme inhibitors, angiotensin receptor antagonists, metglitinides and thiazolidinediones, to
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prevent both T2DM and cardiovascular events. In combination with lifestyle modification, these therapies offer hope for effective prevention of T2DM and its consequences in high-risk patients, Petersen et al. [38]. The strength of the study was that it was a population based cross-sectional study to find the prevalence of undiagnosed diabetes mellitus among adults in both urban and rural area. Bias was taken care of by random sampling. So far there has been no study done in this field in the state and to the horizon of our knowledge this was one of the recent studies reported from the South India. The limitation of the study was that, we could not include in the study of the prevalence among adolescents. 5. Future directions of the study Recent epidemiologic studies show increasing ‘‘epidemic’’ of diabetes mellitus throughout the world [29]. The prevalences of diabetes and IFG have increased dramatically over the past decade. Yet, a large proportion of cases go undiagnosed, Wang H et al. [22]. We hope to find out that this study should have been repeated at regular interval in our country by multicentre study to find out national prevalence. The key factor to prevent diabetes mellitus that we have to generate awareness among our Peers, Public Health Experts, Health Services Researchers, Healthcare Providers and Planners to consider the higher prevalence and associated risk factors of diabetes mellitus as a public health problem in the developing countries like ‘Diabetic capital’ India. 6. Conclusions In our study we observed that the prevalence of undiagnosed diabetes mellitus was 10.3%. Moreover, adults with the increasing age, urban residence, illiterate, non-vegetarian dietary habit, tobacco addiction and hypercholesterolemia are more likely to develop diabetes mellitus. These findings suggest that this could lay the foundation for the introduction of primary health care with community participation. Ethical approval from authors All the co-authors have seen and approved the final version of the manuscript and it is not currently under active consideration for publication elsewhere, has not been accepted for publication, nor has it been published/reported earlier, in full or in part. All the authors have been personally and actively involved in substantive work leading to the report, and will hold themselves jointly and individually responsible for its content. Financial disclosures We declare that no funding, direct or indirect for our study was received. Acknowledgements We thank the medical officers, interns, social workers and nursing staffs of the Department of Community Medicine of Mahatma Gandhi Medical College and Research Institute for the data collection and the Department of Biochemistry for the ultra structural technical assistance. Conflict of interest statement There are no potential, perceived, or real competing and/or conflicts of interest among authors regarding the article.
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