Prevention and management of type 2 diabetes: dietary components and nutritional strategies

In the past couple of decades, evidence from prospective observational studies and clinical trials has converged to support the importance of individual nutrients, foods, and dietary patterns in the prevention and management of type 2 diabetes. The quality of dietary fats and carbohydrates consumed is more crucial than is the quantity of these macronutrients. Diets rich in wholegrains, fruits, vegetables, legumes, and nuts; moderate in alcohol consumption; and lower in refined grains, red or processed meats, and sugar-sweetened beverages have been shown to reduce the risk of diabetes and improve glycaemic control and blood lipids in patients with diabetes. With an emphasis on overall diet quality, several dietary patterns such as Mediterranean, low glycaemic index, moderately low carbohydrate, and vegetarian diets can be tailored to personal and cultural food preferences and appropriate calorie needs for weight control and diabetes prevention and management. Although much progress has been made in development and implementation of evidence-based nutrition recommendations in developed countries, concerted worldwide efforts and policies are warranted to alleviate regional disparities

Serum lipids and diabetic retinopathy.

Serum lipids and diabetic retinopathy: A cross-sectional study” by Idiculla et al.,[1] published in IJEM. The authors demonstrate in a hospital-based study from Bangalore that elevated serum lipids are associated with retinal hard exudates formation in type 2 diabetic patients. I was surprised that the authors have not done a literature search to see whether similar studies have been done in Indi

Challenges in Estimation of Glycated Hemoglobin in India

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

Comparison of the world health organization and the International association of diabetes and pregnancy study groups criteria in diagnosing gestational diabetes mellitus in South Indians

We aimed to compare the International Association of Diabetes and Pregnancy Study Groups (IADPSG) and the World Health Organization (WHO) criteria to diagnose gestational diabetes mellitus (GDM) in Chennai, India. Materials and Methods: We reviewed the retrospective data of 1351 pregnant women who underwent screening for GDM at four selected diabetes centers at Chennai (three private and one government). All women underwent an oral glucose tolerance test using 75g glucose load and fasting, 1-h, and 2-h samples were collected. The IADPSG and WHO criteria were compared for diagnosis of GDM. Results: A total of 839 women had GDM by either the IADPSG or the WHO criteria, of whom the IADPSG criteria identifi ed 699 and the WHO criteria also identifi ed 699 women as having GDM. However, only 599/839 women (66.6%) were identifi ed by both criteria. Thus, 140/839 women (16.7%) were missed by both the IADPSG and the WHO criteria. 687/699 (98.2%) of the women with GDM were identifi ed by the WHO criteria. In contrast, each value of IADPSG criteria i.e., fasting, 1 h, and 2 h identifi ed only 12.5%, 14%, and 22%, respectively. Conclusions: A single WHO cut-point of 2 h140 mg/dl appears to be suitable for large-scale screening for GDM in India and other developing countries

Effect of Filarial Infection on Serum Inflammatory and Atherogenic Biomarkers in Coronary Artery Disease (CURES-121)

Helminth infections can potentially confer protection against metabolic disorders, possibly through immunomodulation. In this study, the baseline prevalence of lymphatic filariasis (LF) among subjects without (N = 236) and with (N = 217) coronary artery disease (CAD) was examined as part of the Chennai Urban Rural Epidemiological Study (CURES). The prevalence of LF was not significantly different between CAD− and CAD+ subjects. The LF antigen load and antibody levels indicated comparable levels of infection and exposure between the groups. Within the CAD group, LF+ and LF− subjects had no significant difference in the intimal medial thickness and high-sensitivity C-reactive protein values. However, LF infection was associated with augmented levels of tumor necrosis factor-α and interleukin-6 among CAD+ subjects. The LF infection had no effect on serum adipocytokine profile. In conclusion, unlike type-2 diabetes, there is no association between the prevalence of LF and CAD and also no evidence of protective immunomodulation of LF infection on CAD in the Asian Indian population

Increased Levels of Serum Granulocyte-Macrophage Colony-Stimulating Factor Is Associated with Activated Peripheral Dendritic Cells in Type 2 Diabetes Subjects (CURES-99)

Background: Granulocyte-macrophage colony-stimulating factor (GM-CSF) is a pro-inflammatory cytokine with growth factor–like properties for monocytes and dendritic cells (DCs). In the present study, serum GM-CSF levels and the activation status of DCs were studied in type 2 diabetes mellitus (T2DM) subjects. Methods: Study subjects were recruited from the Chennai Urban Rural Epidemiology Study. Healthy controls (n = 45) and T2DM patients (n = 45) were included in the study. Serum levels of GM-CSF, interleukin-1b, interleukin- 6, and tumor necrosis factor-a were measured. Enumeration of circulating DCs (myeloid [m] and plasmocytoid [p]) and its surface antigen expression were quantified by flow cytometry. Results: The serum GM-CSF levels were significantly higher among diabetes subjects compared with subjects without diabetes and showed a positive correlation with glycated hemoglobin (r = 0.208, P = 0.018). The serum GM-CSF levels were lower in subjects on combined insulin and oral hypoglycemic agents (OHA) treatment (1.09 pg/mL) compared with those taking OHA alone (1.9 pg/mL). The increased GM-CSF levels were associated with the activated phenotype of mDCs and pDCs, as determined by up-regulation of the lineage markers. Conclusion: The activated state of mDCs and pDCs seen among diabetes subjects might be due to the increased levels of GM-CSF and other pro-inflammatory cytokines

Cystatin C and cystatin glomerular filtration rate as markers of early renal disease in Asian Indian subjects with glucose intolerance (CURES-32).

BACKGROUND: The aim of this study was to assess cystatin C (cys-C) as a marker of early diabetic nephropathy and cystatin glomerular filtration rate (cys-GFR) in Asian Indians. METHODS: Five groups of subjects were studied: Group 1, normal glucose tolerance (NGT) and normoalbuminuria (n = 43); group 2, impaired glucose tolerance (IGT) and normoalbuminuria (n = 44); group 3, type 2 diabetes (T2DM) with neither microalbuminuria nor retinopathy (n = 40); group 4, T2DM with microalbuminuria but without diabetic retinopathy (n = 40); and group 5, T2DM with microalbuminuria and any degree of diabetic retinopathy (DR) (n = 42). Subjects were recruited from the Chennai Urban Rural Epidemiology Study (CURES). Microalbumin concentration was assessed in the urine sample by immunoturbidometric assay. cys-C concentrations were measured in serum by a high-sensitivity particle-enhancing nephlometric assay. cys-GFR was calculated by the formula (86.7/cys-C) - 4.2. RESULTS: cys-C levels were highest in group 5 (1.75 +/- 0.12 mg/L) followed by group 4 (1.30 +/- 0.08 mg/L), group 3 (0.98 +/- 0.04 mg/L), group 2 (0.89 +/- 0.03 mg/L), and group 1 (0.79 +/- 0.18 mg/L, P < 0.001). cys-GFR levels were in reverse order going from highest in group 1, followed by groups 2, 3, 4, and 5. cys-C levels were correlated with age, fasting plasma glucose, glycosylated hemoglobin, microalbuminuria, and serum cholesterol. CONCLUSIONS: cys-C levels increase and cys-GFR levels decrease with increasing severity of glucose intolerance and are highest and lowest, respectively, in type 2 diabetes mellitus (T2DM) subjects with microalbuminuria and retinopathy. In T2DM subjects, cys-C and cys-GFR appear to be useful markers of early renal damage

Prevalence and significance of generalized and central body obesity in an urban Asian Indian population in Chennai, India (CURES: 47)

Objectives: To determine the prevalence of generalized and abdominal obesity in urban Asian Indians and compare the association of body mass index (BMI) and waist circumference (WC) with metabolic risk variables. Methods: Subjects were recruited from the Chennai Urban Rural Epidemiology Study (CURES) carried out between 2001 and 2004 and involved 2350/2600 eligible subjects (response rate 90.4%). Anthropometric measurements, lipids and oral glucose tolerance tests were carried out. Generalized obesity (BMIX23 kgm2) and abdominal obesity (WCX90cm in men and X80cm in women) were defined using WHO Asia Pacific guidelines. Results: The age standardized prevalence of generalized obesity was 45.9% (95% CI: 43.9–47.9%), (women: 47.4%; men: 43.2%, P¼0.210), while that of abdominal obesity was 46.6% (95% CI: 44.6–48.6%), (women: 56.2%4 men: 35.1%, Po0.001). Area under the curve for identifying subjects with any three metabolic risk factors using BMI was 0.66, 95% CI: 0.63– 0.69, Po0.001, while, for WC, it was 0.70, 95% CI: 0.66–0.74, Po0.001 for men, and 0.69, 95% CI: 0.65–0.74, Po0.001 for women. Isolated generalized obesity (normal WC, increased BMI) was present in 12.7% of men and 6.1% of women. Isolated abdominal obesity (increased WC, normal BMI) was present in 4.7% of men and 14% of women. Combined obesity was present in 32.6% of men and 43.3% of women. Conclusions: In Asian Indians, the prevalence of combined obesity is high among both sexes, while isolated generalized obesity is more common in men and isolated abdominal obesity more common in women. However, these prevalence rates vary markedly depending on cut points used. WC is a better marker of obesity-related metabolic risk than BMI in women compared to men in this population

Molecular convergence of hexosamine biosynthetic pathway and ER stress leading to insulin resistance in L6 skeletal muscle cells

Augmentation of hexosamine biosynthetic pathway (HBP) and endoplasmic reticulum (ER) stress were independently related to be the underlying causes of insulin resistance. We hypothesized that there might be a molecular convergence of activated HBP and ER stress pathways leading to insulin resistance. Augmentation of HBP in L6 skeletal muscle cells either by pharmacological (glucosamine) or physiological (high-glucose) means, resulted in increased protein expression of ER chaperones (viz., Grp78, Calreticulin, and Calnexin), UDP-GlcNAc levels and impaired insulin-stimulated glucose uptake. Cells silenced for O-glycosyl transferase (OGT) showed improved insulin-stimulated glucose uptake (P\0.05) but without any effect on ER chaperone upregulation. While cells treated with either glucosamine or high-glucose exhibited increased JNK activity, silencing of OGT resulted in inhibition of JNK and normalization of glucose uptake. Our study for the first time, demonstrates a molecular convergence of O-glycosylation processes and ER stress signals at the cross-road of insulin resistance in skeletal muscle

Parental history of type 2 diabetes mellitus, metabolic syndrome, and cardiometabolic risk factors in Asian Indian adolescents

The objective was to study the influence of parental history of type 2 diabetes mellitus on prevalence of the metabolic syndrome (MS) and other cardiometabolic risk factors in Asian Indian adolescents. Adolescents aged 12 to 19 years (N = 321) were recruited from the Chennai Urban Rural Epidemiology Study. Based on parental diabetic status, 3 groups were studied: group 1, offspring of parents with normal glucose tolerance (n = 105); group 2, offspring of 1 diabetic parent (n = 114); and group 3, offspring of 2 diabetic parents (n = 102). Subjects underwent blood pressure and anthropometric measurements as well as an oral glucose tolerance test and a fasting lipid profile. Metabolic syndrome was diagnosed using the International Diabetes Federation definition. Body mass index (P b .001) and waist and hip circumference (P b .05 for group 2 and P b .001 for group 3) were significantly higher in groups 2 and 3 compared with group 1. Highdensity lipoprotein cholesterol was significantly lower in groups 2 and 3 compared with group 1 (P b .05). Serum triglycerides were significantly higher in group 3 (P b .05) compared with the other 2 groups. Adolescents in group 3 (P b .001) and group 2 (P b .05) were significantly more overweight and had more abdominal obesity compared with those in group 1. Impaired fasting glucose and impaired glucose tolerance were also significantly higher in group 3 compared with the other 2 groups. High blood pressure showed an increasing trend from group 1 to group 3 (P for trend b .05). Two metabolic abnormalities were present in 7.6%, 14.9%, and 22.5% of adolescents in groups 1, 2, and 3, respectively (trend χ2: 9.04, P = .003). Prevalence of MS was higher in groups 2 and 3 compared with group 1 but did not reach statistical significance because of small numbers. The cardiometabolic profile of the parents was similar to that of the adolescents. Parental history of type 2 diabetes mellitus increases risk of not only glucose intolerance but also other cardiometabolic risk factors like overweight, low high-density lipoprotein cholesterol, and high blood pressure in Asian Indian adolescents. © 2009 Elsevier Inc. All rights reserved