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Journal of The Association of Physicians of India ■ Vol. 65 ■ February 2017
ORIGINAL ARTICLE
Prevalence of Cardiovascular Risk Factors
among Diabetic Population and Awareness of
Diabetes among Diabetic Patients: A Population
Based Himalayan Study
Jatinder Mokta1, Kiran Mokta2, Asha Ranjan3, Mehak Garg 4
Abstract
Editorial Viewpoint
Background: To determine the prevalence of modifiable cardiovascular
risk factors among adults with diabetes in the remote Himalayan areas,
at elevation range from 350 meters (1,148ft) to 6900 meters (22,966ft)
above sea level, in the Indian state of Himachal Pradesh.
• Diabetics are at higher
risk for cardiovascular
disease.
Material and Methods: Study was conducted in 21 rural areas of
Himachal Pradesh situated at 2200 to 10,000 feet altitude. Non-pregnant
diabetic adults (>18years) were surveyed, through 32 diabetic camps.
The date and place of the camp was decided one month in advance and
advertised. Detailed history including smoking status, weight, height,
waist circumference, body mass index recorded. Fasting or random blood
glucose, glycated hemoglobin, lipid profile measured and blood pressure
recorded.
Results: Total 909 eligible adult diabetics were surveyed (59.73% male)
with a mean duration of disease 38.14±4.56 months.35.54% adults were
smoker and 67.55% were either overweight or obese 54.04% males and
77.53% females had waist circumference above Indian standards. 78.35%
had A1C >7% and 61.50% had blood pressure measurements above target
(>140/80mmhg). 56.74% had elevated LDL and only 6.32% had all blood
glucose, blood pressure and cholesterol at recommended levels.
Conclusion: High prevalence of modifiable cardiovascular risk factors in
addition to uncontrolled blood glucose is widespread, placing diabetics
at higher risk for cardiovascular disease. Improved disease management
system in addition to public awareness campaign is needed for people
with diabetes in this region of the country.
Introduction
T
ype 2 diabetes mellitus (T2DM)
has emerged as a pandemic
and is associated with increased
c a r d i o va s c u l a r m o r b i d i t y a n d
mortality. India, with >60 million
people with diabetes, has the
second largest diabetic population
of the world. The projection shows
that this number will increase to
100 million by 2030 (>90% T2DM). 1
Although diabetes rates are lower
in rural than urban India, the
overall diabetes burden is higher
in rural India as 68% of India
lives in “Villages”. Nonetheless,
• I m p r o v e d d i a b e t e s
management with public
awareness is needed to
reduce this risk.
t h e p r e va l e n c e o f d i a b e t e s i n
rural areas is increasing rapidly. 2
Increased insulin resistance and
abdominal obesity in conjunction
with unique genes, make Indians
more susceptible to develop
diabetes at younger age and at
l o we r b o d y m a s s i n d e x ( B M I )
compared with Caucasians. 3,4 The
mean life expectancy in India
is 67.3 years for males and 69.6
years for females. The mean age
of death is 56.5 years in diabetics,
a decade earlier than non-diabetic
population in India and coronary
artery disease (CAD) is the most
common cause of death. 5 T2DM
patients, who die early have
significantly higher glycated Hb
(A1C), LDL cholesterol(LDL-C)
and blood pressure(BP) 5 . Better
control of glycemia, LDL-C and BP
(all three parameters) are needed
f o r b e t t e r l o n g - t e r m s u r v i va l
in T2DM patients.6 Himachal
Pradesh situated in the western
1
Professor, 2Associate Professor, 3Senior Resident, 4Junior Resident Department of Medicine, IGMC, Shimla,
Himachal Pradesh
Received: 29.03.2016; Revised: 24.05.2016; Accepted: 27.06.2016
Journal of The Association of Physicians of India ■ Vol. 65 ■ February 2017
Table 1: Demographic profile of 909
patients
Mean duration of
disease
Male
Female
Mean Age
Mean age of male
Mean age of females
Mean BMI (body
mass index)
Mean BMI male
Mean BMI female
% of patients with
BMI>23
% of patients with
BMI<23
% Male patients with
BMI >23
% female patients
with BMI >23
Mean waist
circumference for
male
Mean waist
circumference for
female
% of male patients
with WC >90cm
% of female patients
with WC >80cm
Mean A1C
ABC goal achieved
38.14±4.56 months
(0 month-18 years)
543 (59.73% )
366 (40.27%)
53.00 ± 6.78 years
(26-86 )
54.47 ± 1.59 years
51.84 ± 2.56 years
24.26 ± 2.56 (14-40)
23.83±2.34
24.89±3.67
67.55%
49
% patients
90.00%
80.00%
70.00%
60.00%
78.35%
77.53%
72.05%
61.50%
63.36%
60.74%
54.04%
50.00%
40.00%
35%
30.00%
20.00%
10.00%
0.00%
32.42%
63.36%
72.05%
90.24±16.8 cm
87.94±13.9cm
54.04%
77.53%
8.71±2.034%
6.32%
Himalayas is a mountainous state
with elevation ranging from 350
meters (1,148ft) to 7,000 meters
(22,966 ft) above sea level. 90% of
its population lives in the rural
areas and agriculture is the main
source of income. However, there
is a fast shift from agriculture to
commercial fruit crops in the past
decade. Because of the rapid socioeconomic change and consequent
change in life style, this population
has shown a marked rise in lifestyle
related diseases including T2DM.
Despite of this alarming rise in
T2DM, management provided to
patients is not comprehensive and
consequently mortality is high. This
study was conducted with the aim
to assess the CV risk factors and
awareness among rural diabetic
population of this mountainous
state of Himachal Pradesh.
Fig. 1: Percentage of diabetic patients with CAD risk factors
Material and Method
This study was done in 21 rural
areas of the state, located 35 to
400 kilometers from the capital,
at 2200 to 10,000 feet altitude. 32
diabetic camps were organized
b e t we e n A p r i l 2 0 0 8 t o Au g u s t
2013. The dates and places of
camps were decided one month in
advance and people were informed
through newspapers, pamphlets,
banners, local social workers, local
public representatives and local
health providers. All known and
newly diagnosed T2DM diabetic
adults (males and non- pregnant
females) more than 18years of
age who attended the camp were
included in the study. Non diabetic
participants, T1DM patients, and
diabetic patients with age <18 years
were excluded. Detailed history
(including treatment details,
smoking status, history of CAD
and pre-mature CAD in family),
age, gender, weight, height, waist
circumference (WC), body mass
index (BMI) was and BP recorded.
Fasting (FBS) and/ or random
blood glucose (RBS) level, lipid
profile (done by KONELAB-30
au t omat ic analy zer of Thermo
Fisher Scientific Company,
United States of America) and
A1C (Nycocard HbA1C kit) were
measured. Modified ATP III criteria
given by IDF for South Asians were
used to define obesity (BMI>23Kg/
m2 and WC >90cm males and >80cm
for females). 7 All these patients
were also surveyed for diabetes
awareness through pre-structured
questionnaires (translated for
some patients in Hindi and
local language by interviewer ).
Questionnaire was based to assess
the awareness of patients including
diabetic risk factors, complications,
h e a l t h y l i f e s t yl e , d i e t a r y a n d
pharmacologic management of
diabetes, their personal preferences
for diabetes management and
personal practices, follow up and
disease associated with diabetes.
Results
Total 909 diabetic patients were
surveyed out of which 59.73% were
males and 40.27% females. Mean
duration of disease was 38.14±4.56
months (range: 0 days-288 month).
Demographic profile of the patients
has been tabulated in Table 1. The
mean BMI was 24.26± 5.26 Kg/m 2
(range: 14-40). 32.42% participants
had BMI <23 Kg/m 2. 63.36% males
were either overweight (34.74%) or
obese (29.78%) and 72.05% females
were either overweight (28.22%) or
obese (43.83%). 54.04% males had
WC >90cm where as 77.53% females
had >80 cm. In the present study,
35.53% were smoker (54% male and
8% female) (Figure 1). Average time
spent before television was 2.28
hour/24 hours (0 minute – 6 hours)
50
Journal of The Association of Physicians of India ■ Vol. 65 ■ February 2017
%patients
45.00%
38.50%
40.00%
39.26%
35.00%
30.00%
25.00%
21.65%
20.00%
15.00%
10.00%
6.32%
5.00%
0.00%
A1c <7%
BP<140/80
LDL<100
ABC goal
Fig. 2: Percentage of patients who achieved diabetic management goals
and females spent more time than
males by an hour.
64.36% patients were on oral
hypoglycemic agents (OHAs),
2.31% on insulin and 32.78% on
alternative approaches (herbal,
yoga, ayurvedic drugs and local
indigenous remedies) for diabetes
control. Mean FBS was 153±32.06mg/
dl (70-220) and mean RBS was
266± 19.07mg/dl (110-500). Mean
A1C, estimated in 559 patients,
was 8.71±2.034%. A1C above ADA
target of 7% was found in 78.35%.
Hypertension (including patients
on anti-hypertensive drugs) was
present in 66.33%. The average
systolic BP was 136.41±61.29mmHg
( 1 0 0 - 2 5 0 m m H g ) a n d a ve r a g e
diastolic BP was 88.35±23.54 mmHg
(60-140). BP above ADA target
(140/80 mmHg) was present in
61.50% (559) patients (Figure 1).
Of 711 eligible patients for lipid
lowering therapy (age>40years
plus one risk factor for CAD)
only 10.54 % (75) were on statin
therapy. Lipids were measured in
430 patients with a mean LDL-C
level of 99.69± 32.47 mg/dl. LDL-C
was above ADA target (100mg)
in 60.74%. Only 6.32% achieved
all three ABC goals for diabetes
management (Figure 2). Of total
894 patients, only 12.50% were
a wa r e t h a t c h a n g i n g l i f e s t yl e
(physical inactivity and changed
food habits) was responsible for
the surge of diabetic epidemic in
this country and were aware that
diabetes affects kidney, eyes and
heart. Only 4% diabetic patients
were aware that insulin deficiency
leads to diabetes. 60% had heard
that excess sugar (sweets) intake
leads to diabetes. 78% of were
not aware that diabetes runs in
the family and changing family
environment (healthy food habits
and increased physical activity) is
important in preventing diabetes.
33.01% of patients were on nonpharmacological measures for
diabetes control as they believed
allopathic medicines were hot and
have many side effects. Ayurvedic
medicines, yoga and other herbal
medicines were preferred as they
had no side effects. More than 2/3
(67.94%) of patients believed that
there was no need of continuing
oral hypoglycemic agents once
blood glucose is under control
and used to stop OHAs once blood
glucose normalized. 84% of patients
took two big meals (morning and
evening) with tea 0-2 to 3 times/
day and avoided taking table
sugar and sweets. (They would
avoid sugar in tea but take samosa,
pakoras and salty biscuits with
tea as they believed these didn’t
contain sugar ). Rice, potatoes
and kidney beans were avoided
particularly as they had heard
those to contain sugar. For the fear
of high sugar content, they avoided
taking fruits except papaya. On
asking if taking three meals and
2-3 snacks in between is good for
diabetic patients, all believed it to
be unpractical in the rural settings.
29% believed that exercise has role
in diabetic control but do not take
it regularly. All, except 55 patients
who were on treatment from higher
institutions, had not undergone
eye check up, foot examination,
lipid profile, microalbuminuria
testing because neither their care
providers advised nor they were
aware. They did not know that
hypertension and dyslipidemia are
two co- morbidities associated with
diabetes and their management is
crucial in diabetes management.
They were not aware that CAD is
the most common cause of death in
diabetes and it is common cause of
renal failure, blindness and lower
limb amputations and were not
knowing how to prevent them. All
diabetic patients were reluctant to
use insulin for its potential of habit
formation, they believed.
Discussion
Although each component of
the metabolic syndrome brings
an individual increased CVD risk,
the effect is enhanced when in
combination. Coronary artery
atherosclerosis in diabetic subjects
is more diffuse and severe than
in non-diabetic subjects. Acute
MI in diabetes carries twice the
mortality of that in the general
population and contributing factors
may include coexistent diabetic
cardiomyopathy, autonomic
neuropathy, and adverse
cardiac and metabolic effects of
increased nonesterified fatty acid
levels. 6 The symptoms of angina
may be masked by autonomic
neuropathy. T2DM patients have a
proatherogenic cardiovascular risk
profile which includes impaired
glucose regulation, abdominal
obesity, hypertension, atherogenic
dyslipidemia, microalbuminuria,
and specific proinflammatory
and prothrombotic abnormalities
Journal of The Association of Physicians of India ■ Vol. 65 ■ February 2017
of endothelial cell and vascular
f u n c t i o n s . 6,8 T h e d y s l i p i d e m i a
associated with T2DM is more
complex than simple elevation
of LDL-C levels. The high
atherogenicity associated with
diabetic dyslipidemia is due to
disproportionate amounts of small,
dense LDL particles and small
HDL particles due to their high
susceptibility to oxidation. In
addition there is dysfunctional
adipose tissue or adiposopathy.
DM predisposes individuals to
hypertension by promoting sodium
retention, increasing vascular tone
and by contributing to nephropathy.
Hypertension in T2DM can be
partly a consequence of insulin
resistance and of hyperinsulinemia.
There are significant differences
in the age-related increase in
vascular stiffness in the elastic
arteries of people without
diabetes, compared to those with
diabetes. Their blood vessels age
at an accelerated pace, starting
at an earlier age. There is also
vascular endothelial dysfunction
and, impaired synthesis of NO
which play important role in the
d e ve l o p m e n t a n d p r o g r e s s i o n
of subclinical atherosclerosis.
The relationship between
micro- or macroalbuminuria in
DM and CVD mortality is also
related to its association with
endothelial dysfunction. There is
increasing evidence that low-grade
inflammation is involved in the
pathogenesis of T2DM, dyslipidemia
and atherosclerosis. In DM there is
also high TLC, low serum albumin,
low glomerular filtration rate, high
plasma fibrinogen and elevated
CRP which contribute to premature
atherosclerosis. Hyperglycemia
induce protein glycation, oxidation,
glycoxidation and lipoxidation,
and may mediate vascular damage
in DM. 6,8,9
This study documents a
h i g h p r e va l e n c e o f m o d i f i a b l e
CV risk factors (66% HTN, 60%
dyslipidemia, 78.23% A1C>7% and
35% smokers) among rural adult
diabetic patients of this Himalayan
state. The high prevalence of these
risk factors places them at an
e l e va t e d r i s k f o r C V d i s e a s e s
and higher all cause mortality
and CV disease mortality. 5,10 The
similar high prevalence of these
risk factors has documented in
several other studies. 11,12 Moreover,
poor control of modifiable CV
risk factors in our study suggest
poor diabetic management and
this sub-optimal control of CV
risk factors has consistently seen
in many studies. 13,14 Several recent
studies have shown multiple CV
risk reduction strategy better in
reducing CV related morbidity
and mortality compare to single
risk factor control. 15,16 Therefore,
emphasis should be on multiple
CV risk reduction rather than
glucentric approach in the diabetes
management. However, the benefit
of aggressive control of BP and
cholesterol may exceed than the
aggressive control of blood sugar
in reducing diabetes related deaths
due to CAD and stroke and is
cost- effective. 12,16 Therefore, equal
if not greater focus should be in
controlling these risk factors in
addition to glycemic control by
improving the routine use of antihypertensive and lipid lowering
medicines. 15,16 The proportion of
persons who met all three ABC
goals (6.32%) was much lower
than the proportion that met each
individual ABC goals (21%, 38%
and 39% for A1C, BP and LDL-C
respectively) in our study. The
greatest potential to reduce T2DM,
related complications may lie
in focusing on controlling ABC
g o a l s c o l l e c t i ve l y . 1 5 At t a i n i n g
ABC target will require improved
methods to increase adherence to
prescribed medications, physical
activity, healthy dietary choices
and behavior changes.
By using modified criteria for
obesity for South Asian population,
68% rural adult diabetic patients
are overweight or obese 17 similar
to our study. As more than 2/3,
diabetic patients were obese in this
study, it is better to use “diabesity”
51
as synonym for diabetes in this
hilly state. The high prevalence of
obesity (68%) in the rural diabetic
population in this agriculturist
state was contrary to normal belief
of less obesity because of healthy
life style and simple nutrition. The
high prevalence of obesity found
was expected from changed life
style of physical inactivity and
more consumption of unhealthy
food due to rapid socioeconomic
d e ve l o p m e n t . B o t h m a l e s a n d
females were found obese,
surprisingly, more females were
found to be obese (72% with respect
to BMI and 77%with respect to WC)
than male diabetic patient (63% and
54% respectively). Excess of truncal
obesity is independently associated
with development of diabetes in
Indian women compared to Indian
men 3 and is further supported
in our study as average WC in
women was 87.5cm(normal<80cm)
compare to men with average WC
of 90.8cm (normal<90cms). The
effect of reduced physical activity
and increased leisure activity (TV
watching: female > male by one
hour ) was more pronounced in
female compare to male in this state,
as female used to contribute 60-70%
of agriculture fieldwork in the past
and sudden increase in physical
inactivity due to industrialization
and increased television ownership
in last one decade leads to more
obesity in this gender. Moreover,
cultural shift of consuming excess
fat dense food for one-year post
delivery (average4-6Kg cow ghee)
and physical inactivity for one-year
post-delivery contribute further
for increased obesity in females
in this state. In Indians, WC is
slightly better indicator than body
mass index (BMI) in detecting
obesity and insulin resistance and
directly corresponds with diabetes
rates. 17 As Indians are more prone
to have central obesity and have
more body fat at comparatively
less body weight, 3,4,17-19 use of WC
by Modified ATP III criteria is the
best parameter to be used to detect
obesity in Indian diabetics. 17 This
52
Journal of The Association of Physicians of India ■ Vol. 65 ■ February 2017
is further supported in our study
as 1/3 of diabetic patients had BMI
<23kg/m2 and substantiate the
high risk of diabetes in Indians at
lower BMI levels than Caucasians
in whom 80% of diabetic are either
overweight or obese (BMI>25 and
>30). 18,19
and to community level through
public health campaign. No
doubt, our data show sub-optimal
management of diabetes in this
hilly state of India, but there is
always room for improvement.
Individuals with diabetes may
lack self-management skills and
lifestyle change due to lack of
knowledge and awareness. People
with diabetes should take steps
to improve lifestyle and behavior
to lose weight, increase physical
activity and reduce the number of
calories and fat in the diet and has
positive effect on CV risk factors
reduction. 20 The lower level of
awareness and knowledge about
diabetes and its complications
documented in this study was also
documented in other studies from
India. 21,22
1.
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Conclusion
Diabetes prevalence is increasing
because of ageing population,
urbanization and industrialization.
Most of the burden of diabetes is
due to micro and macro vascular
complications. In order to reduce
diabetes related complications,
it becomes urgent to find ways
t o o ve r c o m e b a r r i e r s t o g o o d
diabetic management and deliver
affordable quality care. Access to
care, diabetes education and self
management skills, knowledge,
behavior and healthy environment,
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