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Mohan V.,Madras Diabetes Research Foundation | Seedat Y.K.,University of KwaZulu - Natal | Pradeepa R.,Madras Diabetes Research Foundation
International Journal of Hypertension | Year: 2013

Aim. To review the available literature on burden of diabetes mellitus (DM) and hypertension (HTN) and its coexistence in Southeast Asian (SEA) and the African (AFR) regions and to suggest strategies to improve DM and HTN prevention and control in primary health care (PHC) in the two regions. Methods. A systematic review of the papers published on DM, HTN, and prevention/control of chronic diseases in SEA and AFR regions between 1980 and December 2012 was included. Results. In the year 2011, SEA region had the second largest number of people with DM (71.4 million), while the AFR region had the smallest number (14.7 million). Screening studies identified high proportions (>50%) of individuals with previously undiagnosed HTN and DM in both of the SEA and AFR regions. Studies from both regions have shown that DM and HTN coexist in type 2 DM ranging from 20.6% in India to 78.4% in Thailand in the SEA region and ranging from 9.7% in Nigeria to 70.4% in Morocco in the AFR region. There is evidence that by lifestyle modification both DM and HTN can be prevented. Conclusion. To meet the twin challenge of DM and HTN in developing countries, PHCs will have to be strengthened with a concerted and multipronged effort to provide promotive, preventive, curative, and rehabilitative services. © 2013 Viswanathan Mohan et al.


Narayan K.M.V.,Emory University | Echouffo-Tcheugui J.B.,Emory University | Mohan V.,Emory University | Ali M.K.,Madras Diabetes Research Foundation
Health Affairs | Year: 2012

Continued increases in the prevalence of and disproportionate health spending associated with type 2 diabetes argue for policies focused on preventing that condition and treating it appropriately, even as we strive to improve coordination of care for coexisting chronic diseases. This article argues that four policy paradigm shifts will be necessary to achieve that specific emphasis on type 2 diabetes: conceptually integrating primary and secondary prevention along a clinical continuum; recognizing the central importance of early detection of prediabetes and undiagnosed diabetes in implementing cost-effective prevention and control; integrating community and clinical expertise, and resources, within organized and affordable service delivery systems; and sharing and adopting evidence-based policies at the global level. © 2012 Project HOPE-The People-to-People Health Foundation, Inc.


Sandeep S.,Madras Diabetes Research Foundation
The Journal of the Association of Physicians of India | Year: 2011

The aim of the study was to assess the association of Insulin Resistance [IR] assessed by Homeostasis Assessment model (HOMA-IR) with cardiovascular risk factors in subjects with Normal Glucose Tolerance [NGT] in Asian Indians. This cross-sectional study recruited subjects from the Chennai Urban Rural Epidemiology Study [CURES] an epidemiological study in a representative population of Chennai [formerly Madras], in South India. We included 1550 subjects with normal glucose tolerance, ie, fasting plasma glucose < 100 mg/dl [5.6 mmol/L] and 2 hour post load plasma glucose < 140 mg/dl [7.8 mmol/L]. IR was calculated using the homeostasis assessment model (HOMA-IR) using the formula: fasting insulin (1IU/mL) fasting glucose (mmol/L)/22.5. Metabolic syndrome [MS] was defined based on modified Adult Treatment Panel III (ATP III) guidelines. HOMA-IR was found to be significantly associated with systolic blood pressure (beta = 0.100, p < 0.001), diastolic pressure (beta = 0.094, p < 0.001), total cholesterol (beta = 0.068, p = 0.005), serum triglycerides (beta = 0.105, p < 0.001), LDL cholesterol (beta = 0.118, p < 0.005), and HDL cholesterol (beta = -0.060, p < 0.001) even after adjusting age, gender and BMI. Subjects with family history of type 2 diabetes had significantly higher HOMA-IR [p = 0.011] compared to those without family history. In relation to physical activity, subjects with heavy grade activity had significantly lower HOMA-IR values compared to the light grade activity [p < 0.001] Subjects with generalized obesity [p < 0.001] and abdominal obesity [p < 0.001] had significantly higher HOMA-IR which remained statistically significant even after adjusting for age and gender. There was a linear increase in the mean values of HOMA IR with increase in number of components of MS [p for trend < 0.001] Among Asian Indians who are known to have high risk of premature coronary artery disease and diabetes, a significant association exists between insulin resistance with cardiovascular risk factors even among NGT subjects.


Anjana R.M.,Madras Diabetes Research Foundation
Journal of diabetes science and technology | Year: 2011

Currently available estimates of diabetes prevalence in India are based on published data derived from very few studies. The Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study is a community-based survey conceived with the aim of obtaining the prevalence rates of diabetes in India as a whole, covering all 28 states, the National Capital Territory of Delhi, and two of the union territories in the mainland of India, with a total sample size of 124,000 individuals. A stratified multistage sampling design has been used. In all study subjects, a structured questionnaire was administered and anthropometric parameters and blood pressure were measured. Fasting capillary blood glucose was first determined using a glucose meter. An oral glucose load was then administered to all subjects except those with self-reported diabetes, and the 2 h post-load capillary blood glucose was estimated. In every fifth subject, a fasting venous sample was collected for measurement of lipids and creatinine, a resting 12-lead electrocardiogram was performed, and dietary assessment questionnaire was administered. In all diabetic subjects, an additional diabetes questionnaire was used and a fasting venous sample drawn for glycated hemoglobin. All biological samples collected were analyzed in a central laboratory. All data collected were stored electronically. Quality control was achieved through multiple tiers of checks. The ICMR-INDIAB study is the first of its kind attempting to provide accurate and comprehensive state- and national-level data on diabetes prevalence in India. © 2011 Diabetes Technology Society.


Mohan V.,Madras Diabetes Research Foundation | Shah S.,The Mutual | Saboo B.,Dia Care Clinic
Journal of Association of Physicians of India | Year: 2013

Background: According to the ICMR - INDIAB study, there are 62.4 million people living with diabetes in India. Type 2 diabetes (T2DM) is a progressive disease and hampers the quality of life of the patients due to micro and macrovascular complications. There are few studies on the status of glycemic control in the country. Such data would be useful to allocate health resources and plan measures for instituting better control of diabetes. Methods: The A1chieve study was an observational study of patients 66,726 with T2DM who were initiated, on or switched to, insulin analogues, alone or in combination with oral glucose lowering drugs at the discretion of their physician in accordance with local, routine clinical practice. This study reports on the participants in India from the A1chieve study. Results: Baseline data of A1chieve study in 20,554 Indian T2DM patients showed that the mean HbA1c was 9.2%. Diabetes control was worse in those with longer duration of diabetes (9.9 ± 5.5 years). Use of insulin was clearly suboptimal showing evidence of clinical inertia. The prevalence of both macrovascular and microvascular complications was high due to poor glycemic control. The prevalence of neuropathy was the most common complication followed by cardiovascular (23.6%), renal (21.1%) and eye (16.6%) complications. The prevalence of foot ulcer was 5.1%. Many patients had multiple complications. Conclusion: Glycemic control in India is poor and this has resulted in a high prevalence of complications. This emphasizes the fact that effective control of T2DM is urgently needed to prevent or reduce the risk of developing the complications of diabetes in Indian T2DM patients. © SUPPLEMENT TO JAPI.


Anuradha S.,Madras Diabetes Research Foundation | Radha V.,Madras Diabetes Research Foundation | Mohan V.,Madras Diabetes Research Foundation
Clinical Genetics | Year: 2011

Variants in hepatocyte nuclear factor 4A (HNF4A) cause maturity onset diabetes of the young (MODY 1). The objective of the study was to screen the coding and the promoter regions of HNF4A mutations in 87 unrelated South Indian subjects with clinically diagnosed MODY with severe forms of diabetes referred to a tertiary diabetes centre. In addition, we looked at the association of common polymorphisms in HNF4 A gene in subjects with MODY (n = 199), early onset type 2 diabetes (T2DM) (n = 505), late onset T2DM (n = 287) and normal glucose tolerance (NGT) (n = 247). We identified three novel mutations in the P2 promoter region of HNF4A, namely -1009 G/C, -129 T/C and -79 C/T. Co-segregation with diabetes was noted with the -1009 G/C and -129 T/C in one MODY family. We also studied eight single nucleotide polymorphisms (SNPs) of HNF4A gene. The frequency of the minor allele of the rs2144908 was significantly higher in subjects with MODY (p < 0.01) and that of rs736823 was significantly higher in early onset T2DM (p = 0.001). Minor allele frequency of rs1884614 and rs2071197 was significantly lower in early onset T2DM when compared to NGT subjects (p < 0.01). Minor allele frequency of Val255Met was significantly lower in MODY, early onset T2DM and late onset T2DM compared to NGT subjects (p < 0.01). This is the first report of MODY 1 mutations from India and shows that 3.4% of clinically diagnosed MODY subjects have MODY 1. In addition, we report SNPs of HNF4A that are both susceptible to, and protective against, MODY and early onset T2DM. © 2010 John Wiley & Sons A/S.


Unnikrishnan R.,Madras Diabetes Research Foundation | Mohan V.,Madras Diabetes Research Foundation
Diabetes Technology and Therapeutics | Year: 2013

Glycated hemoglobin (HbA1c) is the most widely accepted index of long-term glycemic control. However, there are some clinical situations that make the accurate measurement of HbA1c difficult. Although some of these situations are general, others are more specific to some parts of the world like India. These conditions include hemoglobinopathies such as thalassemias and structural hemoglobin (Hb) variants such as HbS and HbD, as well as iron-deficiency anemia and the use of certain drugs. Because of the relatively frequent occurrence of some of these conditions in some parts of India, it is important that they are looked for when evaluating an inappropriately high or low HbA1c level. Alternative indices may have to be used for assessing glycemic control in these cases. © 2013 Mary Ann Liebert, Inc.


Gokulakrishnan K.,Madras Diabetes Research Foundation | Velmurugan K.,Madras Diabetes Research Foundation | Ganesan S.,Madras Diabetes Research Foundation | Mohan V.,Madras Diabetes Research Foundation
Metabolism: Clinical and Experimental | Year: 2012

The objective was to assess the association of insulin-like growth factor binding protein-1 (IGFBP-1) with insulin resistance (IR), type 2 diabetes mellitus (T2DM), and metabolic syndrome (MS) in Asian Indians. Fifty subjects with normal glucose tolerance (NGT) and 50 with T2DM were randomly selected from the Chennai Urban Rural Epidemiology Study. Insulin-like growth factor binding protein-1 was measured by sandwich enzyme-linked immunosorbent assay. Serum insulin was estimated using Dako (Glostrup, Denmark) kits. Insulin resistance was calculated using the homeostasis model assessment. Subjects with T2DM had significantly decreased levels of IGFBP-1 (21.7 ± 3.5 ng/mL) compared with NGT subjects (34.4 ± 7.6 ng/mL, P <.001). The IGFBP-1 was significantly lower in NGT subjects with IR as measured by the homeostasis model assessment (25.5 ± 6.5 ng/mL) compared with NGT subjects without IR (40.7 ± 9.5 ng/mL, P <.001). On regression analysis, IR showed a significant association with IGFBP-1 even after adjusting for age, sex, body mass index, and glycated hemoglobin (β = -3.714, P <.001). Type 2 diabetes mellitus was significantly associated with IGFBP-1 even after adjusting for age, sex, and body mass index (β = -12.798, P <.001). The IGFBP-1 levels decreased with increasing number of metabolic abnormalities (P for trend <.001). Logistic regression analysis showed that IGFBP-1 had a strong negative association with MS even after adjusting for age and sex (odds ratio, 0.942; 95% confidence interval, 0.914-0.971; P <.001). Among Asian Indians, lower levels of circulating IGFBP-1 are seen in subjects with IR, T2DM, and MS. © 2012 Elsevier Inc. All rights reserved.


Mohan N.,Madras Diabetes Research Foundation | Monickaraj F.,Madras Diabetes Research Foundation | Balasubramanyam M.,Madras Diabetes Research Foundation | Rema M.,Madras Diabetes Research Foundation | Mohan V.,Madras Diabetes Research Foundation
Journal of Diabetes and its Complications | Year: 2012

A role for vascular endothelial growth factor (VEGF) has been clearly implicated in the pathogenesis of proliferative diabetic retinopathy (PDR). However, other molecules and mechanisms may be operating independently, or in conjunction with VEGF in the pathogenesis of this disease. Therefore, we made an attempt to comparatively investigate the levels of angiogenic and angiostatic factors in vitreous, plasma and postmortem retinal tissue of subjects with Proliferative Diabetic Retinopathy (PDR) compared to control subjects. The vitreous and plasma concentrations of VEGF, EPO (Erythropoietin) and PEDF (Pigment Epithelium Derived Factor) were measured using Enzyme Linked Immunosorbent Assay (ELISA) and the postmortem retinal tissue was subjected to Western blot analysis. The mean vitreous and plasma levels of VEGF and EPO in patients with PDR were significantly (p < 0.001) higher than those in subjects without diabetes. Conversely, the vitreous and plasma levels of PEDF were significantly (p < 0.001) lower in the PDR patients compared to control subjects. Multivariate logistic-regression analyses indicated that EPO was more strongly associated with PDR than VEGF. The protein expression of the VEGF and EPO in the retinal tissue was significantly higher in PDR and diabetes without complication groups compared to controls. Compared to controls, the protein expression of PEDF was significantly lower in retinal tissues from diabetes patients without complications and in patients with PDR. The fact that the vitreous and plasma levels and the retinal tissue protein expression of EPO were strongly associated with PDR implies a definite role of 'hypererythropoietinemia' in neovascularization processes. © 2012 Elsevier Inc. All rights reserved.


Ranjani H.,Madras Diabetes Research Foundation | Sonya J.,Madras Diabetes Research Foundation | Anjana R.M.,Madras Diabetes Research Foundation | Mohan V.,Madras Diabetes Research Foundation
Diabetes Technology and Therapeutics | Year: 2013

Aim: This study was designed to determine the prevalence of glucose intolerance (prediabetes or diabetes) in children and adolescents in urban South India. Subjects and Methods: Children (6-11 years old) and adolescents (12-19 years old) (n=1,519; 777 boys and 742 girls) were randomly selected from residential apartments representing the 10 corporation zones of Chennai city. Height, weight, waist circumference, body fat percentage, and blood pressure were measured using standardized techniques. Investigations included oral glucose tolerance test (OGTT), lipid profile, and fasting insulin. Insulin resistance (IR) was assessed by homeostasis model assessment (HOMA-IR). Results: The overall prevalence of glucose intolerance was 3.7% but was higher in girls compared with boys (4.2% vs. 3.2%, P<0.001) and increased to 12.7% in girls with abdominal obesity. On univariate regression, the following risk factors showed significant association with glucose intolerance in girls: adolescent age group (odds ratio [OR] 2.94; confidence interval (CI) 1.12, 7.76), waist circumference (OR 4.45; CI 1.95, 10.14), body mass index (OR 2.73; CI 1.32, 5.65), acanthosis nigricans (OR 2.35; CI 1.14, 4.83), family history of diabetes (OR 2.52; CI 1.07, 5.92), and HOMA-IR (OR 9.30; CI 3.59, 24.12). On multivariate analysis, only family history of diabetes (OR 4.11; CI 1.28, 13.22; P=0.018) and HOMA-IR (OR 11.22; CI 4.19, 30.05; P<0.001) remained significant. In boys only HOMA-IR (OR 5.19; CI 1.54, 17.44; P=0.008) was associated with glucose intolerance. Conclusions: The prevalence of glucose intolerance is high in Asian Indian adolescents, particularly in girls with abdominal obesity. © Copyright 2013, Mary Ann Liebert, Inc. 2013.

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