Objective: The objective of the study was to assess the prevalence of thyroid disorders among diabetics in Central India.
Methods: This study was conducted as a cross-sectional comparative study at the department of medicine, tertiary care center in Central India on a total of 100 diabetic patients admitted at the study area during the study period of 1 year. Cases in the study group with diabetes and control group (non-diabetic) were enrolled as per inclusion and exclusion criteria in 1:1 ratio. All the patients in both the groups were subjected to the estimation of thyroid function tests, that is, T3, T4, and TSH levels after overnight fasting.
Results: Mean age of patients in the study group was 55.7±10.1 years whereas that of the control group was 53.9±10.6 years. Overall, thyroid dysfunctions were noted in 31% of cases in the study group and 12% of cases in the control group (p&lt;0.05). The most common thyroid dysfunction was hypothyroidism, particularly subclinical hypothyroidism (19% and 8% in the study group and control group, respectively). Thyroid dysfunctions were associated with increased HbA1c in our study group (p&lt;0.05).
Conclusion: Thyroid dysfunctions are observed in higher proportions of cases with diabetes as compared to non-diabetes. All the parameters of thyroid function tests including T3 and T4 levels as well as TSH levels are found to be altered in higher number of diabetics. Poor glycemic control among diabetics is one of the important determinants of thyroid dysfunction in patients with diabetes

MELWANI, VEENA

TOMAR, MUKESH SINGH

TRIVEDI, ANSHULI

English

Innovare Academic Sciences: E-Journals

Vol 15, Issue 3, 2022Online - 2455-3891 Print - 0974-2441ASSESSMENT OF THYROID DYSFUNCTIONS IN PATIENTS WITH TYPE II DIABETES MELLITUS IN CENTRAL INDIAMUKESH SINGH TOMAR1, VEENA MELWANI2*, ANSHULI TRIVEDI31Department of Medicine, BIMR Hospital, Gwalior, Madhya Pradesh, India. 2Department of Community Medicine, AIIMS, Bhopal, Madhya Pradesh, India. 3Department of Community Medicine, Gandhi Medical College, Bhopal, Madhya Pradesh, India. ABSTRACTObjective: The objective of the study was to assess the prevalence of thyroid disorders among diabetics in Central India.Methods: This study was conducted as a cross-sectional comparative study at the department of medicine, tertiary care center in Central India on a total of 100 diabetic patients admitted at the study area during the study period of 1 year. Cases in the study group with diabetes and control group (non-diabetic) were enrolled as per inclusion and exclusion criteria in 1:1 ratio. All the patients in both the groups were subjected to the estimation of thyroid function tests, that is, T3, T4, and TSH levels after overnight fasting.Results: Mean age of patients in the study group was 55.7±10.1 years whereas that of the control group was 53.9±10.6 years. Overall, thyroid dysfunctions were noted in 31% of cases in the study group and 12% of cases in the control group (p<0.05). The most common thyroid dysfunction was hypothyroidism, particularly subclinical hypothyroidism (19% and 8% in the study group and control group, respectively). Thyroid dysfunctions were associated with increased HbA1c in our study group (p<0.05).Conclusion: Thyroid dysfunctions are observed in higher proportions of cases with diabetes as compared to non-diabetes. All the parameters of thyroid function tests including T3 and T4 levels as well as TSH levels are found to be altered in higher number of diabetics. Poor glycemic control among diabetics is one of the important determinants of thyroid dysfunction in patients with diabetes.Keywords: Hypothyroidism, Hyperthyroidism, Thyroid disorders, diabetes, Central India.INTRODUCTIONDiabetes mellitus and thyroid disorders, particularly hypothyroidism, are common endocrine disorders observed in clinical practice [1]. Due to rapid increase in the prevalence of diabetes in India, India is described as diabetes capital of the world [2]. Diabetes is a single most endocrine disorder which is known to affect every organ system in body and is known to influence the thyroid functions through some common endocrine pathways [3]. Thyroid disorders among diabetics have been associated with adverse clinical outcomes [4].Hypothyroidism is the most common thyroid disorder in general population and is estimated to affect one in 10 adults in India [5,6]. However, the prevalence of hypothyroidism has been reported to be much higher in diabetics as compared to general population ranging from 12% to 23% [4]. Studies have shown that deranged blood glucose or uncontrolled hyperglycemia affects serum thyroxine (T4) as well as triiodothyronine (T3) levels affecting thyroid functions and thyroid hormones play an important role in regulation of glucose metabolism [7]. The studies assessing the prevalence of thyroid dysfunctions among diabetics in Indian settings are scarce. The present study was, therefore, conducted to assess the prevalence of thyroid disorders among diabetics in Central India.METHODSThis study was conducted as a cross-sectional comparative study at the department of medicine, tertiary care center in Central India on a total of 100 diabetic patients admitted at the study area during the study period of 1 year, that is, January 1, 2019–December 31, 2019. All the patients with diagnosed type 2 diabetes admitted at our institute and giving consent for the study were included as the study group whereas all the patients with previous history of thyroid surgery, thyroid disorders, pregnant women, sepsis, heart failure, on corticosteroids therapy, on antithyroid drugs, and seriously ill patients were excluded from the study. A sex- and age-matched healthy non-diabetic control admitted in ward with other condition and meeting the inclusion and exclusion criteria except for the presence of diabetes were enrolled in 1:1 ratio.The patients in the study and control group were subjected to detailed history taking including sociodemographic variables, clinical history (including symptoms of diabetes and thyroid dysfunction), duration of treatment, complications, and drug history. All the patients were then subjected to detailed general and systemic examination and findings were documented. Diabetes workup was done for both the groups which included FBS, PPBS, and HbA1c. All the patients in both the groups were subjected to the estimation of thyroid function tests, that is, T3, T4, and TSH levels after overnight fasting. Apart from this, LFT and lipid profile were also assessed.Normal range of T3, T4, and TSH was:1.	 T3	–	0.8–2.1	ƞgm/ml2. T4 – 5–13 µgm/dl3. TSH – 0.4–5.5 µIU/ml.Thyroid disorders were described as:1. Euthyroid – A state of normal thyroid function, documented biochemically by normal TSH and T3 and T4 levels2. Overt hypothyroidism – A form of thyroid dysfunction manifested biochemically by an elevated TSH and decreased T3 and T4 level3. Subclinical hypothyroidism – A form of hypothyroidism wherein TSH is elevated but the T3 and T4 level is within normal©	2022	The	Authors.	Published	by	Innovare	Academic	Sciences	Pvt	Ltd.	This	is	an	open	access	article	under	the	CC	BY	license	(http://creativecommons.org/licenses/by/4.0/)	DOI:	http://dx.doi.org/10.22159/ajpcr.2022v15i3.44009.	Journal	homepage:	https://innovareacademics.in/journals/index.php/ajpcrResearch Article Email: drmelwaniveena@gmail.comReceived: 29 December 2021, Revised and Accepted: 05 February 202266Asian J Pharm Clin Res, Vol 15, Issue 3, 2022, 65-68 Tomar et al.4. Overt hyperthyroidism – A form of thyroid dysfunction manifested biochemically by a decreased TSH and increased T3 and T4 level5. Subclinical hyperthyroidism – A form of hyperthyroidism wherein TSH is decreased but the T3 and T4 level is within normal.RESULTSA total of 100 cases were enrolled in each group, that is, study group (patients with type II diabetes) and control group.Mean age of patients in the study group was 55.7±10.1 years whereas that of the control group was 53.9±10.6 years. Two groups were comparable with respect to age, gender, comorbidities, and anthropometric variables. However, FBS, PPBS, and HbA1c were significantly higher in the study group as the study group comprised diabetic patients and the control group comprised non-diabetic patients (p<0.05).Polyuria was the predominant feature observed in 21% of cases in the study group followed by polydipsia (18%). Duration of diabetes was more than 10 years in 55% of cases and the most common diabetic complication observed in patients with diabetes was neuropathy in 27% of cases.In the present study, we documented that thyroid hormones, that is, T3, T4, as well as TSH were deranged in significantly higher proportions Hypothyroid  (n=23)Hyperthyroid  (n=8)pDuration of diabetes (years)<5 11 (15.9) 2 (8.7) 0 0.095–10 23 (33.3) 7 (30.4) 2 (25)10–15 28 (40.6) 7 (30.4) 3 (37.5)>15 7 (10.1) 7 (30.4) 3 (37.5)ComplicationsStroke 2 (2.9) 1 (4.3) 0 0.32Retinopathy 8 (11.6) 5 (21.7) 2 (25) 0.35Nephropathy 9 (13) 7 (30.4) 3 (37.5) 0.07Neuropathy 15 (21.7) 9 (39.1) 3 (37.5) 0.21FBS<126 24 (34.8) 6 (26.1) 2 (25) 0.67>126 45 (65.2) 17 (73.9) 6 (75)Mean 167.5±54.2 192.3±48.3 194.4±51.0PPBS<140 9 (13) 2 (8.7) 1 (12.5) 0.86>140 60 (87) 21 (91.3) 7 (87.5)Mean 209±84.3 254.2±91.2 242.3±89.6HbA1c6.5–7.5 27 (39.1) 3 (13) 1 (12.5) 0.03*>7.5 42 (60.9) 20 (87) 7 (87.5)Mean 7.8±3.9 8.7±2.1 8.3±2.3??? Frequency (n=100), n (%)Clinical featuresPolydipsia 18 (18)Polyphagia 12 (12)Polyuria 21 (21)Delayed wound healing 7 (7)Duration of diabetes (years)<5 13 (13)5–10 32 (32)10–15 38 (38)>15 17 (17)ComplicationsStroke 3 (3)Retinopathy 15 (15)Nephropathy 19 (19)Neuropathy 27 (27)Baseline variables Study group  (n=100)Control group  (n=100)pT3	(ƞg/ml)<0.8 19 5 0.001*0.8–2.1 76 93>2.1 5 2Mean 1.2±0.45 1.36±0.6T4	(µg/dl)<5 20 7 0.001*5–13 73 90>13 7 3Mean 7.23±2.7 9.1±2.5TSH	(µIU/ml)<0.4 7 3 0.001*0.4–5.5 69 88>5.5 24 9Mean 4.9±2.2 3.1±1.6T4: Thyroxine, T3: Triiodothyronine, TSH: Thyroid-stimulating hormoneBaseline variables Study group  (n=100)Control group  (n=100)pAge (years) 55.7±10.1 53.9±10.6 0.22GenderMale 69 72 0.64Female 31 28ComorbiditiesHypertension 23 21 0.73Arthritis 3 4 0.70None 77 78 0.71Addiction historySmoking 25 26 0.87Alcohol 2 4 0.41None 73 73 1BMI	(kg/m2) 24.9±7.4 23.3±8.9 0.17Waist circumference (cm) 84.2±15.5 82.6±13.7 0.44Waist–hip ratio 0.89±0.26 0.85±0.24 0.26FBS<126 32 100 0.001*>126 68 0Mean 179.3±51.87 116.3±28.39PPBS<140 12 100 0.001*>140 88 0Mean 239.3±89.9 124.56±56.8HbA1c<6.5 0 100 0.001*>6.5 100 0Mean 8.4±2.5 5.9±1.6Table 1: Comparison of baseline variables between the groups Table 3: Distribution according to thyroid function testsTable 4: Association of thyroid dysfunctions with duration of diabetes, complications, and glycemic control among diabeticsTable 2: Distribution according to clinical features and complications among diabetics (study group)*Statistically significant. BMI: ???, FBS: ???, PPBS: ???, HbA1c: ???Euthyroid  (n=69)Statistical analysisData were compiled using MS Excel and statistical analysis was done using Statistical Package for the Social Sciences for Windows (version 20.0). Categorical variables were expressed as  frequency  (percentage),  whereas  continuous  variables  were expressed  as  mean  and  standard  deviation.  Categorical  variables between the groups were compared using Chi-square test whereas continuous  variables  were  compared  using  independent  t-test.  In the  study  group,  association  of  thyroid  dysfunctions  with  diabetes characteristics in the study group was assessed using Chi-square test. p<0.05 was considered statistically significant.67Asian J Pharm Clin Res, Vol 15, Issue 3, 2022, 65-68 Tomar et al.of cases in the study group (i.e., diabetic patients) as compared to the control group (p<0.05).Overall, thyroid dysfunctions were noted in 31% of cases in the study group and 12% of cases in the control group. The most common thyroid dysfunction was hypothyroidism, particularly subclinical hypothyroidism (19% and 8% in the study group and control group, respectively). The prevalence of thyroid dysfunctions was observed in significantly higher proportions of cases in the study group as compared to the control group (p<0.05).DISCUSSIONIndia is experiencing a rapid demographic transition due to rapid urbanization and westernization. As the risk factors associated with non-communicable diseases are increasing such as lack of physical activity, unhealthy diet, sedentary lifestyle, tobacco, and alcohol addiction, the prevalence of diabetes is increasing rapidly to such a level that it has been considered as impending pandemic and India is considered as diabetic capital of the world [2]. It is well known that diabetes is associated with microvascular as well as macrovascular complications. Apart from this, diabetes is known to affect every organ and thyroid is no exception [3,4]. Our study aimed to assess the prevalence of thyroid disorders in cases with diabetes and compare it with patients without diabetes. We reported significantly higher prevalence of thyroid disorders in diabetics (31%) as compared to the control group (12%), the most common form of thyroid disorder being subclinical hypothyroidism. Our study findings were concordant with the findings of Yadav et al., in which the prevalence of subclinical hypothyroidism was documented to be higher in type 2 diabetes with estimated prevalence of 14.1% [4]. Our study findings were also supported by the findings of Hussain et al., where the authors reported thyroid dysfunctions in 21% of cases with diabetes, of them majority, that is, 42% had hypothyroidism and 36% had subclinical hypothyroidism [1]. Similar findings were documented by Demitrost et al., in which 31.2% of cases with diabetes had thyroid dysfunctions, of them 16.3% had subclinical hypothyroidism, 11.4% had hypothyroidism, whereas 2% and 1.5% had subclinical and overt hyperthyroidism, respectively [8].The thyroid hormones, that is, both T3 and T4, have antagonistic action against insulin and potentiate the action of insulin indirectly [9]. However, thyrotropin-releasing hormone release is decreased in diabetes, which could be the fact associated with the low level of thyroid hormones in diabetics [10]. In our study, T3, T4, as well as TSH levels were deranged (particularly revealing hypothyroid picture) in significantly higher proportions of cases with diabetes as compared to the control group. Similarly, Pasupathi et al. reported significantly higher T4 and lower TSH in diabetes cases as compared to controls, but the difference in T3 levels between the groups was statistically insignificant (p>0.05) [11]. However, Udiong et al. reported significantly higher derangement in T4 levels in diabetes as compared to controls [12].In our study, though the duration of diabetes did not affect the thyroid profile, we reported significant association of thyroid dysfunction with poor glycemic control as revealed by HbA1c levels. The findings of our study were supported by the findings of Ogbonna et al., in which the risk of thyroid dysfunctions was reported to be 4.3 times higher in cases with elevated HbA1c levels as compared to patients with good glycemic control (HbA1c<7%) [13]. Similarly, Ardekani et al. also reported significantly higher rate of thyroid disorders in diabetics with higher HbA1c levels [14]. However, Bazrafshan et al. reported a significant positive correlation between HbA1c and TSH levels [15]. This could be attributed to chronic hyperglycemia-induced adverse effect on the hypothalamopituitary axis, which abolishes the TSH peak [16]. Thyroid dysfunction, particularly hypothyroidism in diabetes, may alter the glucose metabolism along with reduced production of glucose in hepatocytes and present with hypoglycemia [17,18]. In contrast, hyperthyroidism reduces the half-life of insulin contributing to hyperglycemia [19]. Thus, thyroid dysfunctions may alter the glycemic control leading to increased HbA1c levels indicating raised HbA1c levels to correlate with thyroid dysfunction.CONCLUSIONThyroid dysfunctions are observed in higher proportions of cases with diabetes as compared to non-diabetes. All the parameters of thyroid function tests including T3 and T4 levels as well as TSH levels are found to be altered in higher number of diabetics. Poor glycemic control among diabetics is one of the important determinants of thyroid dysfunction in patients with diabetes.AUTHORS’ CONTRIBUTIONSAll the authors have contributed to the preparation and editing of this research article.CONFLICTS OF INTERESTNone.AUTHORS’ FUNDINGNone.REFERENCES1. Hussain T, Barik BS, Nayak AR, Das S, Khadanga UK, Yadav VS, et al. Prevalence and predictors of thyroid dysfunction among patients with type 2 diabetes mellitus attending a tertiary care hospital in an urban area of Bhubaneswar, Odisha. Thyroid Res Pract 2019;16:26-35.2. Joshi SR, Parikh RM. India; the diabetes capital of the world: Now heading towards hypertension. J Assoc Phys India 2007;55:323.3. Kutty BM, Raju TR. New vistas in treating diabetes--insight into a holistic approach. Indian J Med Res 2010;131:606-8.4. Yadav A, Yadav GA, Narsingrao KK, Kumar LN, Yadav GS. Prevalence of thyroid disorders among patients with diabetes in rural South India. Diabetes Metab Syndr Clin Res Rev 2021;15:885-9.5. Unnikrishnan AG, Kalra S, Sahay RK, Bantwal G, John M, Tewari N. Prevalence of hypothyroidism in adults: an epidemiological study in eight cities of India. Indian J Endocrinol Metab 2013;17:647-52.6. Hoogendoorn EH, Hermus AR, de Vegt F, Ross HA, Verbeek AL, Kiemeney LA, et al. Thyroid function and prevalence of anti-thyroperoxidase antibodies in a population with borderline sufficient iodine intake: influences of age and sex. Clin Chem 2006;52:104-11.7. Hage M, Zantout MS, Azar ST. Thyroid disorders and diabetes mellitus. J Thyroid Res 2011;2011:439463.8. Demitrost L, Ranabir S. Thyroid dysfunction in type 2 diabetes mellitus: A retrospective study. Indian J Endocrinol Metab 2012;16 Suppl 2:S334-5.9. Johnson JL, Duick DS. Diabetes and thyroid disease: A likely combination. Diabetes Spec 2002;15:140-2.Fig. 1: Thyroid dysfunctions between the groups68Asian J Pharm Clin Res, Vol 15, Issue 3, 2022, 65-68 Tomar et al.10. Suzuki Y, Nanno M, Gemma R, Tanaka I, Taminato T, Yoshimi T. The mechanism of thyroid hormone abnormalities in patients with diabetes mellitus. Nihon Naibunpi Gakkai Zasshi 1994;70:465-70.11. Pasupathi P, Bakthavathsalam G, Saravanan G, Sundaramoorthi R. Screening for thyroid dysfunction in the diabetic/non-diabetic population. Thyroid Sci 2008;3:1-6.12. Udiong CE, Udoh AE, Etukudoh ME. Evaluation of thyroid function in diabetes mellitus in Calabar, Nigeria. Indian J Clin Biochem 2007;22:74-8.13. Ogbonna SU, Ezeani IU. Risk factors of thyroid dysfunction in patients with type 2 diabetes mellitus. Front Endocrinol 2019;10:440.14. Ardekani MA, Rashidi M, Shojaoddiny A. Effect of thyroid dysfunction on metabolic response in type 2 diabetic patients. Iran J Diabetes Obes 2010;2:20-6.15. Bazrafshan HR, Ramezani A, Salehi A, Shir AA, Mohammadian S, Faraj EM, et al. Thyroid dysfunction and its relation with diabetes mellitus (NIDDM). J Gorgan Univ Med Sci 2000;2:5-11.16. Gursoy NT, Tuncel E, Erturk E, Imamoglu S. The relationship between the glycemic control and the hypothalamus-pituitary-thyroid axis in diabetic patients. Turk J Endocrinol Metab 1999;4:163-8.17. Okajima F, Ui M. Metabolism of glucose in hyper- and hypothyroid rats in vivo. Glucose-turnover values and futile-cycle activities obtained with 14C-and 3H-labelled glucose. Biochem J 1979;182:565-75.18. Leong KS, Wallymahmed M, Wilding J, MacFarlane I. Clinical presentation of thyroid dysfunction and Addison’s disease in young adults with type 1 diabetes. Postgrad Med J 1999;75:467-70.19. Maxon HR, Kreines KW, Goldsmith RE, Knowles HC. Long-term observations of glucose tolerance in thyrotoxic patients. Arch Intern Med 1975;135:1477-80.

ASSESSMENT OF THYROID DYSFUNCTIONS IN PATIENTS WITH TYPE II DIABETES MELLITUS IN CENTRAL INDIA

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ASSESSMENT OF THYROID DYSFUNCTIONS IN PATIENTS WITH TYPE II DIABETES MELLITUS IN CENTRAL INDIA

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