- Email: [email protected]
Prevalence of diabetes mellitus and related conditions in Asian Indians living in the United States
The high prevalence of infection with H. pylori in our population could be a result of the high mean age of our study population. Elderly patients have a higher risk to be infected with these bacteria because hygiene status was lower in their youth. A reason for the protective effect of infection with H. pylori on vitamin B12 deficiency in cardiovascular patients could be the way the bacteria works on the gastric mucosa. Apparently, more gastric acid is produced as a reaction of the stomach in the presence of the bacteria. Therefore, more vitamin B12 could be released from its protein binding in the patient’s diet. This leads to higher amounts of free vitamin B12, and all available intrinsic factors will come into play in this situation. Our study population used a lot of concomitant medication, which could lead to confounding in the associations that we studied. Nonsteroidal anti-inflammatory drugs are known to cause similar damage to the stomach as acetylsalicylic acid.13 The Dutch elderly population frequently used vitamin preparations, which resulted in a maximum daily vitamin intake.14,15 With use of a vitamin B preparation, a low daily dietary intake of vitamin B12 can be compensated.16,17 However, the number of patients using nonsteroidal anti-inflammatory drugs or vitamin preparations did not differ between vitamin B12 deficient and nondeficient patients. 1. Ranganath LR, Baines M, Roberts NB. Homocysteine and thiol metabolites in
vitamin B12 deficiency. Clin Sci (Lond) 2001;100:111–116.
2. Hankey GJ, Eikelboom JW. Homocysteine and vascular disease. Lancet 1999;354:407– 413. 3. Peterson JC, Spence JD. Vitamins and progression of atherosclerosis in hyper-homocyst(e)inaemia. Lancet 1998;351:263. 4. Verheugt FWA, Gersh BJ. Aspirin beyond platelet inhibition. Am J Cardiol 2002;90:39 – 41. 5. Verheugt FWA. Aspirin, the poor man’s statin. Lancet 1998;351:227–228. 6. Verheugt FWA. In search of a super-aspirin for the heart. Lancet 1997;349: 1409 –1410. 7. Petty GW, Brown RD, Whisnant JP, Sicks JD, O’Fallon WM, Wiebers DO. Frequency of major complications of aspirin, warfarin, and intravenous heparin for secondary stroke prevention. Ann Intern Med 1999;130:14 –22. 8. Lanas A, Serrano P, Bajador E, Esteva F, Benito R, Sainz R. Evidence of aspirin use in both upper and lower gastrointestinal perforation. Gastroenterology 1997;112:683– 689. 9. Weil J, Colin-Jones D, Langman M, Lawson D, Logan R, Murphy M, Rawlins M, Vessey MP, Wainwhright P. Prophylactic aspirin and risk of peptic ulcer bleeding. BMJ 1995;310:827– 830. 10. Willems FF, Aengevaeren WRM, Boers GHJ, Blom HJ, Verheugt FWA. Coronary endothelial function in hyperhomocysteinemia: improvement after treatment with folic acid and cobalamin in patients with coronary artery disease. J Am Coll Cardiol 2002;40:766 –772. 11. Laheij RJF, van Oijen MGH, Paloheimo LI, Jansen JBMJ. Vitamin B12 deficiency and gastric functioning in patients with cardiovascular disease (abstr). Gut 2002;51(suppl III):A152. 12. Van Asselt DZB, de Groot LCPGM, van Staveren WA, Blom HJ, Wevers RA, Biemond I, Hoefnagels WH. The role of cobalamin intake and atrophic gastritis in mild cobalamin deficiency in older Dutch subjects. Am J Clin Nutr 1998;68:328 –334. 13. Day RO, Henry DA, Muirden KD, Yeomans ND, Brooks PM, Stiel D, Prichard PJ. Non-steriodal anti-inflammatory drug (NSAID) induced upper gastrointestinal haemorrhage and bleeding. Med J Aust 1992;157:810 – 812. 14. Carmel R. Mild cobalamin deficiency in older Dutch subjects. Am J Clin Nutr 1999;69:738 –739. 15. Naurath HJ, Joosten E, Riezler R, Stabler SP, Allen RH, Lindenbaum J. Effects of vitamin B12, folate, and vitamin B6 in elderly people with normal serum concentrations. Lancet 1995;346:85– 89. 16. Seal EC, Metz J, Flicker L, Melny J. A randomized, double-blind, placebocontrolled study of oral vitamin B12 supplementation in older patients with subnormal or borderline serum vitamin B12 concentrations. J Am Geriatr Soc 2002;50:146 –151. 17. Loew D, Wanitschke R, Schroedter A. Studies on vitamin B12 status in the elderly—prophylactic and therapeutic consequences. Int J Vitam Nutr Res 1999;69:228 –233.
Prevalence of Diabetes Mellitus and Related Conditions in Asian Indians Living in the United States Rajesh Venkataraman, MD, MPH, Navin C. Nanda, MD, Gurpreet Baweja, Naresh Parikh, MD, and Vishal Bhatia, MD This study is the first attempt to evaluate the prevalence of diabetes mellitus and related conditions in Asian Indians living in the United States. A community-based survey of 1,046 Asian Indian immigrants living in and around the Atlanta metro area of Georgia was conducted and found an overall prevalence of diabetes mellitus of 18.3% (22.5% in men and 13.6% in women). This prevalence of diabetes mellitus in Asian Indians is much higher than in whites, blacks, and Hispanics living in the From the Division of Cardiovascular Disease, The University of Alabama at Birmingham, Birmingham, Alabama. Dr. Nanda’s address is: The University of Alabama at Birmingham, Heart Station/ Echocardiography Laboratories, 619 South 19th Street, SW-S102, Birmingham, Alabama 35249. E-mail: [email protected]. Manuscript received April 2, 2004; revised manuscript received and accepted June 16, 2004. ©2004 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 94 October 1, 2004
United States.
MD,
䊚2004 by Excerpta Medica, Inc. (Am J Cardiol 2004;94:977–980)
any studies have reported that Asian Indians have an unusually high prevalence of diabetes M mellitus. This high prevalence of diabetes in mi1,2
grant Asian Indians has been shown to be much higher than the population residing in India and is also higher than the other racial groups in the host countries.2 Asian Indians now constitute 1% (1.9 million) of the United States population3 and are one of the fastest growing minority groups. No study has examined and compared the prevalence of diabetes mellitus in Asian Indians with other racial groups in the United States. This study examined the prevalence of diabetes mellitus and its association with other co-morbid medical conditions in Asian Indians living in Atlanta, Georgia. ••• 0002-9149/04/$–see front matter doi:10.1016/j.amjcard.2004.06.048
977
no” response for the presence of diabetes mellitus and related co-morbid Total Diabetics Nondiabetics medical conditions, including hyperCharacteristics (n ⫽ 1,046) (n ⫽ 192) (n ⫽ 854) tension, hypercholesterolemia, myocardial infarction, coronary intervenMen 51% 62.5% 51% Women 49% 37.5% 49% tional procedures, history of dialysis, Mean age (yrs)* 52.8 ⫾ 11.3 57.2 ⫾ 9.5 51.9 ⫾ 11.4† and stroke. We also elicited a similar 2 26.1 ⫾ 4.7 26.4 ⫾ 4.5 26.0 ⫾ 4.7 Mean body mass index (kg/m )* response for a family history of diabeHypertension 23.7% 45.2% 18.9%† tes mellitus, myocardial infarction, and Hypercholesterolemia 18.5% 27.3% 16.4%† Myocardial infarction 6.5% 16.3% 4.3%† stroke. The questionnaire itself was Coronary artery intervention 10.7% 21% 8.4%† worded in simple laymen’s language † History of dialysis 2.7% 8.4% 1.4% and was also translated into the verStroke 2.9% 5.2% 2.2%‡ † nacular language spoken by the surFamily history of diabetes mellitus 22.7% 53.1% 14% veyed subjects (Gujarati). Diabetes *Figures are mean ⫾ SD. and other co-morbid conditions were † p ⬍0.001, independent sample t test between diabetic and nondiabetic groups. ‡ self-reported by the subjects. Nonmedp ⬍0.05, independent sample t test between diabetic and nondiabetic groups. ical personnel were trained by local physicians to conduct the survey under their supervision. A 5% (n ⫽ 10) random sample of participants reporting diabetes were conTABLE 2 Prevalence of Co-morbid Conditions in Diabetic tacted, and their medical records were traced with their Men and Women consent and were found to have type 2 diabetes mellitus. Men Women Analysis of this data for the prevalence of stroke in Asian Co-morbid Condition (n ⫽ 120) (n ⫽ 72) p Value Indians has been previously reported elsewhere.4 Hypertension 26.3% 21% NS Data are reported as percent for discrete variables Hypercholesterolemia 20.7% 16.1% NS and mean ⫾ SD for continuous variables. Descriptive Myocardial infarction 8.2% 4.7% 0.07 statistics were computed for all variables and comCoronary artery 11.2% 10% NS pared between diabetics and nondiabetics with chiintervention square (discrete variables) and t tests (continuous variHistory of dialysis 3.7% 1.6% NS Stroke 3.7% 1.7% NS ables). We performed cross tabulations for diabetes with other co-morbid medical conditions and reported odds ratios. A multivariable logistic regression model was constructed with diabetes as the dependent variTABLE 3 Cross Tabulation of Diabetes and Co-morbid able and male sex, stroke, hypertension, hypercholesConditions terolemia, myocardial infarction, coronary artery interventions, history of dialysis, and family history of Confidence Co-morbid Condition Odds Ratio Interval p Value diabetes as independent variables. Statistical analyses were done using SPSS version 11.1 (SPSS Inc., ChiHypertension ⬎3.5 2.5–4.9 ⬍0.001 cago, Illinois) for Windows (Microsoft, Redmond, Myocardial infarction 4.3 2.6–7.1 ⬍0.001 Hypercholesterolemia 1.9 1.3–2.7 ⬍0.001 Washington). All tests were 2 tailed; a p value of Coronary artery 2.9 1.9–4.4 ⬍0.001 ⬍0.05 was considered statistically significant, and all intervention confidence intervals reported are 95%. A total number Stroke 2.4 1.1–5.9 0.029 of 1,046 subjects were surveyed (537 men and 509 History of dialysis 6.5 3–13.9 ⬍0.001 Family history of diabetes 6 4.2–8.4 ⬍0.001 women). Mean age of the subjects was 52.8 ⫾ 11.3 mellitus years (range 17 to 87). The overall prevalence of diabetes was 18.3% for the total surveyed population. The mean age of parAsian Indians living in Atlanta and nearby counties in ticipants reporting diabetes was significantly higher Georgia were surveyed during religious congregations at than those without diabetes (Table 1). The prevalence the Bochasanwasi Shri Akshar Purushottam Swami- of diabetes in those ⱖ20 years of age was 18.1%, in narayan Sanstha temple. Bochasanwasi Shri Akshar Pu- those ⬎45 years of age was 21.6%, and in those ⱖ65 rushottam Sanstha is a prominent sect of Hindu religion years of age was 24.8%. There was no significant and an international sociospiritual organization that con- difference in the body mass index (body weight in ducts humanitarian work through a worldwide network. kilograms divided height in meters squared) between All participants were originally from the state of Gujarat, both groups. The mean age of diabetic men and a state in the western part of India and are Hindus by women was also significantly higher than nondiabetreligion. Abstinence from alcohol, tobacco, and strict ics. The prevalence of diabetes was higher in men adherence to a vegetarian diet are the norm in this par- compared with women (p ⬍0.001); however, among ticular community. Participants were asked to fill out a diabetic men and women, there were no significant questionnaire, which was designed by the authors. The differences in the prevalence of co-morbid conditions questionnaire was composed of demographic character- (Table 2). Myocardial infarction, hypertension, coronary aristics, anthropometric profile (height, weight) and a “yes/ TABLE 1 Baseline Characteristics of Participants
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TABLE 4 Multiple Logistic Regression Analysis Co-morbid Condition Age Men Family history of diabetes Hypertension Myocardial infarction
Adjusted Odds Ratio (95% CI) 1.02 1.7 5.9 2.7 3.9
(1.009–1.36) (1.2–2.5) (4.1–8.4) (1.9–3.9) (2.2–2.7)
p Value ⬍0.001 0.004 ⬍0.0001 ⬍0.0001 ⬍0.001
CI ⫽ confidence interval.
FIGURE 1. Prevalence of diabetes in men and women in our study sample.
tery interventions, history of dialysis, hypercholesterolemia, and stroke showed significant associations with the presence of diabetes mellitus (Table 3). More than 1 in 2 diabetics reported a family history of diabetes, and this was significantly higher than in nondiabetics. Forward logistic regression showed that a family history of diabetes was the strongest independent predicting factor for diabetes (Table 4). Age, male gender, myocardial infarction, and hypertension were also independent predictive factors for diabetes. So far, no studies have examined the prevalence of diabetes mellitus in Asian Indian immigrants in the United States. The National Health and Nutrition Examination Survey (NHANES III)5,6 reported the prevalence of diabetes in whites, blacks, and Hispanics living in the United States. Asian Indians were not categorized separately in this study. The NHANES III showed an overall crude diabetes prevalence of 5.3% in persons living in the United States aged ⱖ20 years of age. They found a higher prevalence of diabetes in Hispanics (9.3%) and blacks (8.2%) compared with whites (4.8%) in the ⱖ20 years age group. The prevalence of diabetes in Asian Indian immigrants ⱖ20 years of age in our study was almost twice that of Hispanics and 4 times that of whites, as reported by NHANES III. In the elderly population, NHANES III reported that the prevalence of diabetes mellitus in the 60- to 74-year age group was 24.4% in Hispanics and 20.9% in blacks, which is similar to the prevalence of diabetes in Asian Indians in the same age group in our study (24.8%). In contrast, the prevalence of diabetes in whites in the 60- to 74-year age group in the previously mentioned study was only 11.3%. Another study, which examined the prevalence of diabetes in elderly Hispanics and blacks, also reported a high prevalence of diabetes among this population in the ⱖ65-year age group.7 Bastida et al8 sur-
veyed a sample of 849 Hispanic men and women aged ⬎45 years in south Texas and reported a 25.9% prevalence of diabetes. They also showed a progressive increase in the prevalence of diabetes in Hispanics from 41 years of age through 70 years of age, similar to our results (Figure 1). •••
In our study, the overall prevalence of diabetes in Asian Indians ⱖ20 years was higher than all other racial groups in the United States. However, in the elderly age group, the prevalence of diabetes in Asian Indians was similar to the prevalence of diabetes in elderly Hispanics and elderly blacks. The prevalence of diabetes mellitus in Asian Indians ⱖ20 years of age in our study is much higher than in Asian Indian immigrants in the United Kingdom, Singapore, Mauritius, Fiji, and South Africa.2,9 –14 In these countries, the prevalence of diabetes in AsianIndian immigrants has ranged from 6% to 15%. The prevalence of diabetes in migrant Asian Indians in the previously mentioned studies was much higher than in the other racial groups in their host countries,2 which is similar to the results seen in our study. A study performed by the Indian Council of Medical Research showed the overall prevalence of diabetes in India to be 1.73%; however, the prevalence varied from 2% in rural areas to up to 33% in urban areas.2,15 A study done by Ramachandran et al1 by sampling urban Indians aged ⬎20 years in 6 major cities showed that the prevalence of diabetes in urban areas was 13.9% with a maximum prevalence seen in subjects aged between 60 and 69 years of age (29.1%). Our study also showed a high prevalence of diabetes in the 60 to 69 years age group (32%) (Figure 1). The overall prevalence of diabetes in Asian Indians in our study appears similar to the prevalence seen in urban India, supporting the view that populations undergoing acculturation changes from a traditional to a modern lifestyle have a higher prevalence of type 2 diabetes mellitus. 1. Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V, Das AK. High prevalence of diabetes and impaired glucose tolerance in India: national urban diabetes survey. Diabetologia 2001;44:1094 –1101. 2. Ramaiya KL, Kodali VRR, Alberti KGMM. Epidemiology of diabetes in Asians of the Indian subcontinent. Diabetes/Metab Rev 1990;6:125–146. 3. U.S. Census Bureau, Census 2000, Special tabulations. 4. Baweja G, Nanda NC, Parikh N, Bhatia V, Venkataraman R. Prevalence of stroke and associated risk factors in Asian Indians living in the state of Georgia, United States of America. Am J Cardiol 2004;93:267–269. 5. Harris MI, Flegal KM, Cowie CC, Eberhardt MS, Goldstein DE, Little RR, Wiedmeyer HM, Byrd-Holt DD. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults: the Third National Health and Nutrition Examination Survey, 1988-1994. Diabetes Care 1998;21:518 –524. 6. Mokdad AH, Ford ES, Bowman BA, Nelson DE, Engelgau MM, Vinicor F, Marks JS. Diabetes trends in the U.S.:1990-1998: The Third National Health and Nutrition Examination Survey, 1988-1994. Diabetes Care 2000;23:1278 –1283. 7. Black SA, Ray LA, Markides KS. The prevalence and health burden of self-reported diabetes in older Mexican Americans: findings from the Hispanic established populations for epidemiologic studies of the elderly. Am J Public Health 1999;89:546 –552. 8. Bastida E, Cu’ellar I, Villas P. Prevalence of diabetes mellitus and related conditions in a south Texas Mexican American sample. Commun Health Nurs 2001;18:75– 84. 9. Beckles GLA, Miller GJ, Kirkwood BR, Alexis SD, Carson DC, Byam NTA. High total and cardiovascular mortality in adults of Indian descent in Trinidad unexplained by major coronary risk factors. Lancet 1986;i:1298 –1300.
BRIEF REPORTS
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10. Dowse GK, Gareeboo H, Zimmet PZ, Alberti KGGM, Tuomilehto J, Fareed D, Brissonnette LG, Finch CF. The high prevalence of non-insulin-dependent diabetes mellitus and impaired glucose intolerance in Indian, Creole and Chinese Mauritians. Diabetes 1990;39:390 –396. 11. Thai AC, Yeo PB, Lun KC, Hughes K, Wong KW, Sothy SP, Lui KF, Ng WE, Cheah JS, Phoon WO, Lim P. Changing prevalence of diabetes mellitus in Singapore over a ten-year period. J Med Assoc Thai 1987;2:63– 67. 12. Omar MAK, Seedat MA, Dyer RB, Rajput MC, Motala AA, Joubert SM. The prevalence of diabetes mellitus in a large group on Indians. S Afr Med J 1985;67:924 –926.
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13. Marine N, Vinik AI, Edelstein I, Jackson WPU. Diabetes, hyperglycaemia and glycosuria among Indians, Malays and Africans (Bantu) in Cape Town, South Africa. Diabetes 1969;18:840 – 857. 14. Zimmet P, Taylor R, Ram P, King H, Sloman G, Raper LR, Hunt R. Prevalence of diabetes and impaired glucose tolerance in the biracial (Melanesian and Indian) population of Fiji: a rural-urban comparison. Am J Epidemiol 1983; 118:673– 688. 15. Gupta OP, Joshi MH, Dave SK. Prevalence of Diabetes in India. In: Levine R, Luft R, Miller M, Bennett P, eds. Advances in Metabolic Disorders. New York: Academic Press, 1978;147–163.
OCTOBER 1, 2004
vitamin B12 deficiency. Clin Sci (Lond) 2001;100:111–116.
2. Hankey GJ, Eikelboom JW. Homocysteine and vascular disease. Lancet 1999;354:407– 413. 3. Peterson JC, Spence JD. Vitamins and progression of atherosclerosis in hyper-homocyst(e)inaemia. Lancet 1998;351:263. 4. Verheugt FWA, Gersh BJ. Aspirin beyond platelet inhibition. Am J Cardiol 2002;90:39 – 41. 5. Verheugt FWA. Aspirin, the poor man’s statin. Lancet 1998;351:227–228. 6. Verheugt FWA. In search of a super-aspirin for the heart. Lancet 1997;349: 1409 –1410. 7. Petty GW, Brown RD, Whisnant JP, Sicks JD, O’Fallon WM, Wiebers DO. Frequency of major complications of aspirin, warfarin, and intravenous heparin for secondary stroke prevention. Ann Intern Med 1999;130:14 –22. 8. Lanas A, Serrano P, Bajador E, Esteva F, Benito R, Sainz R. Evidence of aspirin use in both upper and lower gastrointestinal perforation. Gastroenterology 1997;112:683– 689. 9. Weil J, Colin-Jones D, Langman M, Lawson D, Logan R, Murphy M, Rawlins M, Vessey MP, Wainwhright P. Prophylactic aspirin and risk of peptic ulcer bleeding. BMJ 1995;310:827– 830. 10. Willems FF, Aengevaeren WRM, Boers GHJ, Blom HJ, Verheugt FWA. Coronary endothelial function in hyperhomocysteinemia: improvement after treatment with folic acid and cobalamin in patients with coronary artery disease. J Am Coll Cardiol 2002;40:766 –772. 11. Laheij RJF, van Oijen MGH, Paloheimo LI, Jansen JBMJ. Vitamin B12 deficiency and gastric functioning in patients with cardiovascular disease (abstr). Gut 2002;51(suppl III):A152. 12. Van Asselt DZB, de Groot LCPGM, van Staveren WA, Blom HJ, Wevers RA, Biemond I, Hoefnagels WH. The role of cobalamin intake and atrophic gastritis in mild cobalamin deficiency in older Dutch subjects. Am J Clin Nutr 1998;68:328 –334. 13. Day RO, Henry DA, Muirden KD, Yeomans ND, Brooks PM, Stiel D, Prichard PJ. Non-steriodal anti-inflammatory drug (NSAID) induced upper gastrointestinal haemorrhage and bleeding. Med J Aust 1992;157:810 – 812. 14. Carmel R. Mild cobalamin deficiency in older Dutch subjects. Am J Clin Nutr 1999;69:738 –739. 15. Naurath HJ, Joosten E, Riezler R, Stabler SP, Allen RH, Lindenbaum J. Effects of vitamin B12, folate, and vitamin B6 in elderly people with normal serum concentrations. Lancet 1995;346:85– 89. 16. Seal EC, Metz J, Flicker L, Melny J. A randomized, double-blind, placebocontrolled study of oral vitamin B12 supplementation in older patients with subnormal or borderline serum vitamin B12 concentrations. J Am Geriatr Soc 2002;50:146 –151. 17. Loew D, Wanitschke R, Schroedter A. Studies on vitamin B12 status in the elderly—prophylactic and therapeutic consequences. Int J Vitam Nutr Res 1999;69:228 –233.
Prevalence of Diabetes Mellitus and Related Conditions in Asian Indians Living in the United States Rajesh Venkataraman, MD, MPH, Navin C. Nanda, MD, Gurpreet Baweja, Naresh Parikh, MD, and Vishal Bhatia, MD This study is the first attempt to evaluate the prevalence of diabetes mellitus and related conditions in Asian Indians living in the United States. A community-based survey of 1,046 Asian Indian immigrants living in and around the Atlanta metro area of Georgia was conducted and found an overall prevalence of diabetes mellitus of 18.3% (22.5% in men and 13.6% in women). This prevalence of diabetes mellitus in Asian Indians is much higher than in whites, blacks, and Hispanics living in the From the Division of Cardiovascular Disease, The University of Alabama at Birmingham, Birmingham, Alabama. Dr. Nanda’s address is: The University of Alabama at Birmingham, Heart Station/ Echocardiography Laboratories, 619 South 19th Street, SW-S102, Birmingham, Alabama 35249. E-mail: [email protected]. Manuscript received April 2, 2004; revised manuscript received and accepted June 16, 2004. ©2004 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 94 October 1, 2004
United States.
MD,
䊚2004 by Excerpta Medica, Inc. (Am J Cardiol 2004;94:977–980)
any studies have reported that Asian Indians have an unusually high prevalence of diabetes M mellitus. This high prevalence of diabetes in mi1,2
grant Asian Indians has been shown to be much higher than the population residing in India and is also higher than the other racial groups in the host countries.2 Asian Indians now constitute 1% (1.9 million) of the United States population3 and are one of the fastest growing minority groups. No study has examined and compared the prevalence of diabetes mellitus in Asian Indians with other racial groups in the United States. This study examined the prevalence of diabetes mellitus and its association with other co-morbid medical conditions in Asian Indians living in Atlanta, Georgia. ••• 0002-9149/04/$–see front matter doi:10.1016/j.amjcard.2004.06.048
977
no” response for the presence of diabetes mellitus and related co-morbid Total Diabetics Nondiabetics medical conditions, including hyperCharacteristics (n ⫽ 1,046) (n ⫽ 192) (n ⫽ 854) tension, hypercholesterolemia, myocardial infarction, coronary intervenMen 51% 62.5% 51% Women 49% 37.5% 49% tional procedures, history of dialysis, Mean age (yrs)* 52.8 ⫾ 11.3 57.2 ⫾ 9.5 51.9 ⫾ 11.4† and stroke. We also elicited a similar 2 26.1 ⫾ 4.7 26.4 ⫾ 4.5 26.0 ⫾ 4.7 Mean body mass index (kg/m )* response for a family history of diabeHypertension 23.7% 45.2% 18.9%† tes mellitus, myocardial infarction, and Hypercholesterolemia 18.5% 27.3% 16.4%† Myocardial infarction 6.5% 16.3% 4.3%† stroke. The questionnaire itself was Coronary artery intervention 10.7% 21% 8.4%† worded in simple laymen’s language † History of dialysis 2.7% 8.4% 1.4% and was also translated into the verStroke 2.9% 5.2% 2.2%‡ † nacular language spoken by the surFamily history of diabetes mellitus 22.7% 53.1% 14% veyed subjects (Gujarati). Diabetes *Figures are mean ⫾ SD. and other co-morbid conditions were † p ⬍0.001, independent sample t test between diabetic and nondiabetic groups. ‡ self-reported by the subjects. Nonmedp ⬍0.05, independent sample t test between diabetic and nondiabetic groups. ical personnel were trained by local physicians to conduct the survey under their supervision. A 5% (n ⫽ 10) random sample of participants reporting diabetes were conTABLE 2 Prevalence of Co-morbid Conditions in Diabetic tacted, and their medical records were traced with their Men and Women consent and were found to have type 2 diabetes mellitus. Men Women Analysis of this data for the prevalence of stroke in Asian Co-morbid Condition (n ⫽ 120) (n ⫽ 72) p Value Indians has been previously reported elsewhere.4 Hypertension 26.3% 21% NS Data are reported as percent for discrete variables Hypercholesterolemia 20.7% 16.1% NS and mean ⫾ SD for continuous variables. Descriptive Myocardial infarction 8.2% 4.7% 0.07 statistics were computed for all variables and comCoronary artery 11.2% 10% NS pared between diabetics and nondiabetics with chiintervention square (discrete variables) and t tests (continuous variHistory of dialysis 3.7% 1.6% NS Stroke 3.7% 1.7% NS ables). We performed cross tabulations for diabetes with other co-morbid medical conditions and reported odds ratios. A multivariable logistic regression model was constructed with diabetes as the dependent variTABLE 3 Cross Tabulation of Diabetes and Co-morbid able and male sex, stroke, hypertension, hypercholesConditions terolemia, myocardial infarction, coronary artery interventions, history of dialysis, and family history of Confidence Co-morbid Condition Odds Ratio Interval p Value diabetes as independent variables. Statistical analyses were done using SPSS version 11.1 (SPSS Inc., ChiHypertension ⬎3.5 2.5–4.9 ⬍0.001 cago, Illinois) for Windows (Microsoft, Redmond, Myocardial infarction 4.3 2.6–7.1 ⬍0.001 Hypercholesterolemia 1.9 1.3–2.7 ⬍0.001 Washington). All tests were 2 tailed; a p value of Coronary artery 2.9 1.9–4.4 ⬍0.001 ⬍0.05 was considered statistically significant, and all intervention confidence intervals reported are 95%. A total number Stroke 2.4 1.1–5.9 0.029 of 1,046 subjects were surveyed (537 men and 509 History of dialysis 6.5 3–13.9 ⬍0.001 Family history of diabetes 6 4.2–8.4 ⬍0.001 women). Mean age of the subjects was 52.8 ⫾ 11.3 mellitus years (range 17 to 87). The overall prevalence of diabetes was 18.3% for the total surveyed population. The mean age of parAsian Indians living in Atlanta and nearby counties in ticipants reporting diabetes was significantly higher Georgia were surveyed during religious congregations at than those without diabetes (Table 1). The prevalence the Bochasanwasi Shri Akshar Purushottam Swami- of diabetes in those ⱖ20 years of age was 18.1%, in narayan Sanstha temple. Bochasanwasi Shri Akshar Pu- those ⬎45 years of age was 21.6%, and in those ⱖ65 rushottam Sanstha is a prominent sect of Hindu religion years of age was 24.8%. There was no significant and an international sociospiritual organization that con- difference in the body mass index (body weight in ducts humanitarian work through a worldwide network. kilograms divided height in meters squared) between All participants were originally from the state of Gujarat, both groups. The mean age of diabetic men and a state in the western part of India and are Hindus by women was also significantly higher than nondiabetreligion. Abstinence from alcohol, tobacco, and strict ics. The prevalence of diabetes was higher in men adherence to a vegetarian diet are the norm in this par- compared with women (p ⬍0.001); however, among ticular community. Participants were asked to fill out a diabetic men and women, there were no significant questionnaire, which was designed by the authors. The differences in the prevalence of co-morbid conditions questionnaire was composed of demographic character- (Table 2). Myocardial infarction, hypertension, coronary aristics, anthropometric profile (height, weight) and a “yes/ TABLE 1 Baseline Characteristics of Participants
978 THE AMERICAN JOURNAL OF CARDIOLOGY姞
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TABLE 4 Multiple Logistic Regression Analysis Co-morbid Condition Age Men Family history of diabetes Hypertension Myocardial infarction
Adjusted Odds Ratio (95% CI) 1.02 1.7 5.9 2.7 3.9
(1.009–1.36) (1.2–2.5) (4.1–8.4) (1.9–3.9) (2.2–2.7)
p Value ⬍0.001 0.004 ⬍0.0001 ⬍0.0001 ⬍0.001
CI ⫽ confidence interval.
FIGURE 1. Prevalence of diabetes in men and women in our study sample.
tery interventions, history of dialysis, hypercholesterolemia, and stroke showed significant associations with the presence of diabetes mellitus (Table 3). More than 1 in 2 diabetics reported a family history of diabetes, and this was significantly higher than in nondiabetics. Forward logistic regression showed that a family history of diabetes was the strongest independent predicting factor for diabetes (Table 4). Age, male gender, myocardial infarction, and hypertension were also independent predictive factors for diabetes. So far, no studies have examined the prevalence of diabetes mellitus in Asian Indian immigrants in the United States. The National Health and Nutrition Examination Survey (NHANES III)5,6 reported the prevalence of diabetes in whites, blacks, and Hispanics living in the United States. Asian Indians were not categorized separately in this study. The NHANES III showed an overall crude diabetes prevalence of 5.3% in persons living in the United States aged ⱖ20 years of age. They found a higher prevalence of diabetes in Hispanics (9.3%) and blacks (8.2%) compared with whites (4.8%) in the ⱖ20 years age group. The prevalence of diabetes in Asian Indian immigrants ⱖ20 years of age in our study was almost twice that of Hispanics and 4 times that of whites, as reported by NHANES III. In the elderly population, NHANES III reported that the prevalence of diabetes mellitus in the 60- to 74-year age group was 24.4% in Hispanics and 20.9% in blacks, which is similar to the prevalence of diabetes in Asian Indians in the same age group in our study (24.8%). In contrast, the prevalence of diabetes in whites in the 60- to 74-year age group in the previously mentioned study was only 11.3%. Another study, which examined the prevalence of diabetes in elderly Hispanics and blacks, also reported a high prevalence of diabetes among this population in the ⱖ65-year age group.7 Bastida et al8 sur-
veyed a sample of 849 Hispanic men and women aged ⬎45 years in south Texas and reported a 25.9% prevalence of diabetes. They also showed a progressive increase in the prevalence of diabetes in Hispanics from 41 years of age through 70 years of age, similar to our results (Figure 1). •••
In our study, the overall prevalence of diabetes in Asian Indians ⱖ20 years was higher than all other racial groups in the United States. However, in the elderly age group, the prevalence of diabetes in Asian Indians was similar to the prevalence of diabetes in elderly Hispanics and elderly blacks. The prevalence of diabetes mellitus in Asian Indians ⱖ20 years of age in our study is much higher than in Asian Indian immigrants in the United Kingdom, Singapore, Mauritius, Fiji, and South Africa.2,9 –14 In these countries, the prevalence of diabetes in AsianIndian immigrants has ranged from 6% to 15%. The prevalence of diabetes in migrant Asian Indians in the previously mentioned studies was much higher than in the other racial groups in their host countries,2 which is similar to the results seen in our study. A study performed by the Indian Council of Medical Research showed the overall prevalence of diabetes in India to be 1.73%; however, the prevalence varied from 2% in rural areas to up to 33% in urban areas.2,15 A study done by Ramachandran et al1 by sampling urban Indians aged ⬎20 years in 6 major cities showed that the prevalence of diabetes in urban areas was 13.9% with a maximum prevalence seen in subjects aged between 60 and 69 years of age (29.1%). Our study also showed a high prevalence of diabetes in the 60 to 69 years age group (32%) (Figure 1). The overall prevalence of diabetes in Asian Indians in our study appears similar to the prevalence seen in urban India, supporting the view that populations undergoing acculturation changes from a traditional to a modern lifestyle have a higher prevalence of type 2 diabetes mellitus. 1. Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V, Das AK. High prevalence of diabetes and impaired glucose tolerance in India: national urban diabetes survey. Diabetologia 2001;44:1094 –1101. 2. Ramaiya KL, Kodali VRR, Alberti KGMM. Epidemiology of diabetes in Asians of the Indian subcontinent. Diabetes/Metab Rev 1990;6:125–146. 3. U.S. Census Bureau, Census 2000, Special tabulations. 4. Baweja G, Nanda NC, Parikh N, Bhatia V, Venkataraman R. Prevalence of stroke and associated risk factors in Asian Indians living in the state of Georgia, United States of America. Am J Cardiol 2004;93:267–269. 5. Harris MI, Flegal KM, Cowie CC, Eberhardt MS, Goldstein DE, Little RR, Wiedmeyer HM, Byrd-Holt DD. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults: the Third National Health and Nutrition Examination Survey, 1988-1994. Diabetes Care 1998;21:518 –524. 6. Mokdad AH, Ford ES, Bowman BA, Nelson DE, Engelgau MM, Vinicor F, Marks JS. Diabetes trends in the U.S.:1990-1998: The Third National Health and Nutrition Examination Survey, 1988-1994. Diabetes Care 2000;23:1278 –1283. 7. Black SA, Ray LA, Markides KS. The prevalence and health burden of self-reported diabetes in older Mexican Americans: findings from the Hispanic established populations for epidemiologic studies of the elderly. Am J Public Health 1999;89:546 –552. 8. Bastida E, Cu’ellar I, Villas P. Prevalence of diabetes mellitus and related conditions in a south Texas Mexican American sample. Commun Health Nurs 2001;18:75– 84. 9. Beckles GLA, Miller GJ, Kirkwood BR, Alexis SD, Carson DC, Byam NTA. High total and cardiovascular mortality in adults of Indian descent in Trinidad unexplained by major coronary risk factors. Lancet 1986;i:1298 –1300.
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10. Dowse GK, Gareeboo H, Zimmet PZ, Alberti KGGM, Tuomilehto J, Fareed D, Brissonnette LG, Finch CF. The high prevalence of non-insulin-dependent diabetes mellitus and impaired glucose intolerance in Indian, Creole and Chinese Mauritians. Diabetes 1990;39:390 –396. 11. Thai AC, Yeo PB, Lun KC, Hughes K, Wong KW, Sothy SP, Lui KF, Ng WE, Cheah JS, Phoon WO, Lim P. Changing prevalence of diabetes mellitus in Singapore over a ten-year period. J Med Assoc Thai 1987;2:63– 67. 12. Omar MAK, Seedat MA, Dyer RB, Rajput MC, Motala AA, Joubert SM. The prevalence of diabetes mellitus in a large group on Indians. S Afr Med J 1985;67:924 –926.
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13. Marine N, Vinik AI, Edelstein I, Jackson WPU. Diabetes, hyperglycaemia and glycosuria among Indians, Malays and Africans (Bantu) in Cape Town, South Africa. Diabetes 1969;18:840 – 857. 14. Zimmet P, Taylor R, Ram P, King H, Sloman G, Raper LR, Hunt R. Prevalence of diabetes and impaired glucose tolerance in the biracial (Melanesian and Indian) population of Fiji: a rural-urban comparison. Am J Epidemiol 1983; 118:673– 688. 15. Gupta OP, Joshi MH, Dave SK. Prevalence of Diabetes in India. In: Levine R, Luft R, Miller M, Bennett P, eds. Advances in Metabolic Disorders. New York: Academic Press, 1978;147–163.
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