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Das S, Swain s and Tripathy S. Diabetic Complications in Indian scenario : An Update. In
Gupta Pritam Ed. Medicine Update, Vol. 28,The Association of Physicians of India, Mumbai;
Evangel Publishing,2018: 225-237
Diabetic Complications in Indian Scenario:
An Update
Authors:
Prof.Dr.Sidhartha Das,
MD, FRCP (GLASG), FRCP (EDIN), FRCP (LONDON), FICP
Senior Consultant in Medicine and Diabetes,
Senior most Professor P.G.Department of Medicine,
Dean & Principal
S.C.B.Medical College, Cuttack – 753007, India
Dr.Santosh Kumar Swain, MD
Assistant Professor, P.G.Department of Medicine,
S.C.B.Medical College, Cuttack – 753007, India
Dr.Saroj Kumar Tripathy, MD
Associate Professor, P.G.Department of Medicine,
S.C.B.Medical College, Cuttack – 753007, India
1
DIABETIC COMPLICATIONS IN INDIAN SCENARIO: AN UPDATE
Sidhartha Das, Santosh Kumar Swain, Saroj Kumar Tripathy
Introduction
Diabetes mellitus is now a global pandemic. The global prevalence of diabetes is estimated to
increase, from 8.8% in 2015 to 10.4% by the year 2040.1 India, China and USA will be the
countries with major diabetic population in the year 2040.1 Rapid socio-economic development,
demographic shift, rapid urbanization and lifestyle changes have led to explosive increase in the
prevalence of diabetes mellitus (DM) over the past four decades. Little is understood regarding the
lower age of onset of DM in India, diabetes occurring at lower BMI, complications differing from
western population, more severity of complications in Asians specifically in Indians.2 Lack of
awareness regarding the disease has led to diabetes mellitus getting diagnosed later in the course
of the disease, when one or two of the complications have already set in. The experience of Indian
diabetics and its management might be different from those in the western world.
Diabetes in India
According to the Diabetes Atlas published by the International Diabetes Federation (IDF), there
are an estimated 69.2 million persons with diabetes in India in 2015 and this number is predicted
to rise to almost 123.5 million people by 2040, by which time every fifth diabetic patient in the
world would be an Indian.1 As compared to the Europeans, DM appears a decade earlier and late
diagnosis of this disease in our part of the world seriously affects the youth in their most
productive years. Many of the diabetics at the time of diagnosis present with micro and macro-
vascular complications. India with its large number of diabetics faces huge economic burden.
Regarding the difference of Indian diabetics from the western world few attributes are very
important. In Asia specially in India the prevalence of diabetes is increasing rapidly and the
diabetes phenotype appears to be different from that in the United States and Europe with an onset
at a lower BMI and younger age, greater visceral adiposity and reduced capacity of insulin
secretion. It is becoming increasingly apparent that DM in other ethnic groups (Asians, Africans
and Latin Americans) has a different, but yet undefined pathophysiology. In these groups, diabetes
mellitus that is ketosis prone (often obese) or ketosis resistant (often lean) is commonly seen.” 2
Regarding the complications, the two landmark studies of UKPDS in Type 2 DM and DCCT in
Type 1 DM have made it clear that tight control of hyperglycemia reduces the risk of
complications in diabetes especially vascular complications to a great extent. In India a steep rise
in the prevalence of DM and consequently its complications needs timely intervention in the form
of primary and secondary prevention which will unburden the health care facilities in India. The
diabetic complications can be acute or chronic. Acute complications of hyperglycemia are DKA
(Diabetic Ketoacidosis) and HHS (Hyperglycemic Hyperosmolar State). The chronic
complications are represented in Table-1. (Ref: 3)
2
Complications in Type 2 DM
The long term complications of diabetes mellitus are illustrated in Figure-1.
Macrovascular Complications:
Coronary Artery Disease (CAD)
Diabetes mellitus, Type 2 in particular, is a progressive macrovascular disease with
universally established excessive predilection for coronary arteries irrespective of race,
ethnicity, gender or geography. The presentation of CAD in a diabetic is more severe and with a
higher complication rate than in a non-diabetic. A diabetic subject may present as a case of
myocardial infection (MI) or sudden cardiac death without any history of cardiac complaints.
The CAD occurrence has a two to three decades earlier presentation in diabetic patients as
compared to their nondiabetic counterparts. Women diabetes patients are possibly more prone
to develop CAD than men with diabetes.4
In Indians the overall cardio vascular mortality is predicted to have risen by 103 % in men and
90 % in woman between 1985 to 2015.1 A subject of great concern is that 52 % of the CAD death
in India occurred in people aged below 70 years while the same was just 22 % in the developed
countries.4 Another study from Eastern India in a tertiary care hospital revealed that the diabetics
with CAD had a higher prevalence of multivessel disease along with more extensive involvement
as compared to nondiabetic cohort.5
The multifactorial pathogenesis of CAD in diabetes is governed by various risk factors like
traditional risk factors viz. gender , increased total or LDL-c, decreased HDL-c, smoking and
diabetes itself .Several novel risk factors proposed for CAD like apolipoproteins A1 & B,
microalbuminuria , plasminogen activator inhibitor -1 (PAI-1), prothrombin fragment 1 and 2,
accelerated platelet activity and platelet aggregation, tissue plasminogen activator, fibrinogen,
vascular and cellular adhesion molecules , lipoprotein (a) and Insulin Resistance(IR).
An urban South Indian study in patients of DM with CAD from India revealed a significant
finding of increased platelet activation. Collagen induced GP IIb / IIIa binding was significantly
higher among diabetic subjects with CAD (p <0.05) and without CAD (P<0.05) and non diabetic
subjects with CAD (P< 0.05) compared to nondiabetic subjects without CAD. Regression
analysis showed collagen induced GP IIb / IIIa binding to be significantly associated with CAD
[odds ratio (OR) : :1.029 , P=0.025] and diabetes (OR : 1.037, P =0.007).6
A significant postprandial hypertriglyceridimia and significant delay in postprandial
triglyceride clearance following a standardized fat meal challenge in patients with Type-2 DM,
particularly those with the macrovascular disease was found in another recent study from New
Delhi. Persistent postprandial hypertriglyceridimia may result in a pro-atherogenic environment
leading to Atherosclerosis (AS) and Macro Vascular Disease (MVD) in T2 DM. 7
3
In the Chennai Urban Population Study (CPUS NO 5) the prevalence of CAD was 11% in the
total population and the prevalence of CAD among diabetic subjects was 21.4%, 14.9 % among
impaired glucose tolerance (IGT) and 9.1% among those with normal glucose tolerance (NGT).
The prevalence of CAD in Bikaner study was 25.8% and from North Delhi study was 7% in T2
DM patients.8,9 A multicentric study conducted by Diabetes India (CINDI) had revealed that the
prevalence of CAD in newly diagnosed subjects with Type 2 DM was 6%.10 Incidence of
cardiovascular disease among subjects with diabetes was 5-6 cases /1000 person years according
to an 11 year follow up study from south India.11
A North Delhi study regarding the prevalence of cardiovascular risk factor in the Type 2 DM
without manifestation of overt CAD found that 28.9 % had silent CAD. This study observed,
high LDL-c level and greater carotid intima –media thickness (CIMT) are particularly important
parameters that can predict if a patient with Type 2 DM is at risk for silent ischemia.12
The prevalence of CAD amongst diabetics in India is presented in Table 2 ( Ref: 8,9,10)
Cerebro vascular disease (CVD):
Diabetes is an independent risk factor for stroke. In patients with DM there is recurrent stroke
associated with higher mortality, with a female preponderance. The UKPDS study revealed 2.6%
patients developed stroke on a follow up of 7.9 years with the prevalence of recognized DM in
patients with acute stroke approximating 8% to 20% and unrecognized DM is estimated to the
between 6% to 42%.13 The prevalence of stroke is more than double in diabetic subjects
compared to the general population. The Indian studies conducted during 1970-80s revealed
incidence of stroke in diabetics varied from 0.5% - 9%. In 2011, our study from Cuttack showed
the prevalence of DM was 38.75% among stroke patients. The same study depicted the
relationship of carotid plaque, Intima Media Thickness (IMT), Resistivity index (RI), Pulsatility
index (PI) in Asian-Indian patients with acute ischemic stroke with and without type-2 DM.
These findings are elaborated in Table 3 and Table 4 (Ref:14). The mean CIMT of diabetic
subjects was significantly higher than nondiabetic counterparts as showed in the CUPS study.
The prevalence of carotid atherosclerosis was 20% in diabetic subjects as compared to 1%
among nondiabetics.15 In the same population, arterial stiffness was also greater and endothelial
dysfunction was also severe among diabetic subjects than non diabetic counterparts in the CUPS
Study.16 Another study from South India Endocrine Centre documented 1.12% of diabetics had a
diagnosis of cerebrovascular disease at the time of presentation.17 Further, studies from India had
revealed that DM is a more common a cause for cerebral infarction (22.1%) than cerebral
haemorrhage (6.35%).18 The data on stroke and CVD in India is inadequate.
Incidence of DM amongst patients with CVD is presented in Table 5. (Ref: 19)
Peripheral Vascular Disease (PVD):
4
Diabetes presenting with PVD is a major risk factor for lower limb amputation and also
invariably associated symptomatic cardiovascular disease and cerebrovascular disease. It is an
underdiagnosed and undertreated entity in several countries including India. A fourfold increase
in prevalence is seen in people with DM than in non diabetics. PVD in T2 DM typically involves
the arteries below the knee such as anterior tibial, posterior tibial and peroneal arteries showing
arterial stenosis and occlusion due to atherosclerotic changes in diabetic subjects. The increased
prevalence of PVD in patients with diabetes is attributed to added risk factors like smoking,
hypertension and hyperlipidemia.
An estimated 20% of symptomatic PVD patients had diabetes as revealed by the Framingham
Heart Study. The prevalence rate of PVD in Indian subjects is lower than that in other ethnic
groups. There is a striking difference in the prevalence of CAD and PVD in India, despite both
being macrovascular disease. CAD occurs at a much younger age and at high rates while PVD
appears to show opposite trend, i.e. lower prevalence and occurrence at older age groups. The
different trend of these two complications may be attributable to the differences in risk factors.
In Asians the prevalence of PVD ranges from 3% to 6%. The first population based study in
South India (CUPS) reported that the prevalence of PVD was 6.3% among diabetics compared to
2.7% among non-diabetics.20 The prevalence of PVD was 3.9% and 4% in another South Indian
clinic based study which included 18 patients with gangrene.21, 22 The reported prevalence rate of
PVD in type 2 Diabetics in a study conducted in Bikaner (Rajasthan) was 28% and North Delhi
was 7.4%.8,9 The most recent study from South India showed prevalence rate 7.6% (Female
11.8%, Male 5.1%) and crude incidence 17 / 1000 patient years with progression of PVD seen in
16.5% cases.23
Type 2 DM and Metabolic Syndrome:
There is sparse data on the prevalence of metabolic syndrome (MS) amongst Indian diabetic
patients. Basing on the NCEP ATP III guidelines a study conducted on urban Indian diabetic
population reported that the prevalence of MS in 77.2% of patients which was significantly
higher in females(87.71%) as compared to males(19.33%) (p<0.0001). This study clearly depicts
that in the urban Indian diabetics MS is highly prevalent. So it should be identified by regular
screening to avert or delay the progression to type 2 diabetes and its related morbidity and
mortality.24
Microvascular Complications in Type 2 DM
The microvascular complications of DM include retinopathy, nephropathy and neuropathy.
The microvascular disease also can contribute to diabetic cardiomyopathy, exacerbation of limb
ischemia in diabetic foot. Hyperglycemia, hypertension and possibly lipid abnormalities provide
a solid medium for microangiopathy. Multiple pathogenic sequences may be triggered viz
5
advanced glycation end products (AGE) formation, protein kinase C (PKC) activation and
increased flux through the polyol (sorbitol) and hexosamine pathways, all of which culminate in
oxidative stress resulting in pathological vascular remodeling, altered vascular tone, changes in
the basement membrane and permeability. The subsequent pathogenic changes are peculiar to the
concerned target tissues. The mesangium shows an abnormal extracellular matrix (ECM)
accumulation in diabetic nephropathy. Ischemia due to acellular capillaries coupled with
neovascularization triggered by vascular endothelial growth factor (VEGF) results in diabetic
retinopathy (DR).25
In New Delhi a recent study done on the coagulation profile in diabetes and its possible
association with diabetic microvascular complications revealed that diabetic retinopathy was
associated with decreased protein S and increased VWF levels. Diabetic nephropathy was
associated with increased PAI-1 and VWF levels whereas diabetic neuropathy did not show any
significant relationship with any of the haemostatic variables. So, for the development of
microvascular complications of diabetes mellitus a hypercoagulable state as indicated by
decreased fibrinolysis and increased coagulability is responsible.26
It has been reported that some associations have also been noted between different diabetic
microvascular complications. The presence of diabetic retinopathy itself may reveal that the
patients are at risk of diabetic neuropathy and nephropathy. The CURE study identified some
common risk factors like age, glycosylated hemoglobin, duration of diabetes and serum
triglycerides for these microvascular complications. The association between retinopathy and
nephropathy was stronger than the association with neuropathy was also proved in the CURE
study.27
Diabetic Retinopathy (DR):
A potentially sight threatening microvascular complication of diabetes is DR and is also an
important preventable cause of blindness. DR is one of the hallmark of the disorder and
considered as most specific complication of diabetes. Nonproliferative DR (NPDR) and
proliferative DR (PDR) are the two major forms of opthalmological complications in T2 DM.
The forms which can lead to blindness are PDR and diabetic macular edema (DME). The risk of
DR is strongly influenced by disease duration, glycemic status and blood pressure control. The
younger age of onset especially for type 2 DM may be an added risk for DR. A patient with
history of more than 15 years DM is affected by DR in 60% and with a history of more than 25
years of diabetes is affected to the tune of 90%.28
In western population the prevalence of DR at diagnosis varies from 20% - 50% as compared
to 5%-7.3% in Indians. In India the prevalence varies from clinic based studies to population
6
based studies. The population based studies show that nearly 1 in every 5 diabetic individuals
may have DR which is much lower than that reported from west.
The first population based study to document DR in Indian population was the Chennai Urban
Rural Epidemiological Study (CURES), which revealed an overall prevalence 17.6% (among
known diabetics 20.8% and 5.1% in newly detected diabetic subjects). Prevalence of DME in the
total diabetic population was 5.0%. A 5 year increase in duration of diabetes, increases the risk
of DR by 1.89 times and for every 2% increase in HbA1C, the risk of DR increases by factor of
1.75 times was revealed by this study.27 A familial aggregation study documented that familial
clustering of DR was three times higher in siblings of type 2 diabetic subjects with DR compared
to those without DR.29 A study carried out in rural Tamilnadu, The Chunampet Rural Diabetes
Prevention Project study (CRDPP Study) showed that the prevalence of DR also increases
significantly with duration of diabetes. The prevalence of DR was seen in 6.6% even among
diabetic subjects with less than one year duration. According to a South India study conducted
recently on prevalence and risk factors for DR in Asian Indians with younger age of onset
revealed prevalence of DR in 52.7% in type 2 DM patients. The age and gender adjusted
prevalence of DR, DME, PDR in type 2 DM were 65.8%, 12.7% and 9.3% respectively.28
The overall prevalence of DR in different parts of India as per different studies are
presented in Table -6 and Table- 7. (Ref :8,9,10,30)
Diabetic Neuropathy and Diabetic Foot:
Nearly 50% of all diabetic subjects are affected by diabetic neuropathy (DN) and is
considered to be the main cause for morbidity. The severity and duration of hyperglycemia
governs the intensity and extent of diabetic neuropathy. Both type-1 and type-2 diabetes have an
equal frequency of affection. The prevalence of neuropathy varies from 19% to 33% (clinic
based studies) and 13 to 31% (population based studies).30 In an observational study at a tertiary
care centre from Cuttack the clinical diabetic neuropathy were in the following order of
frequency: distal symmetrical sensorimotor neuropathy, cranial mononeuropathy,
mononeuropathy multiplex and autonomic neuropathy.31 In the low body weight groups of type 2
DM the incidence of peripheral neuropathy was common.32
A North-East Indian study on young diabetic patients documented peripheral neuropathy
to be common (43.5%) in patients with Fibrocalculous Pancreatic Disease(FCPD).33 The CURES
population based study reported the age-standardized prevalence of neuropathy to be 13.1%
(Known diabetic(KD): 13.6% vs. 11.2% in Newly Detected DM(NDD) whereas the crude
prevalence rate was 26.1% (KD: 27.8%, NDD 19.5%.34 The prevalence rate of diabetic
neuropathy in different studies is presented in Table-8. (Ref: 8,9,10,30)
7
Though vasculopathy, infections and peripheral neuropathy are traditionally blamed for
diabetic foot (DF), the common cause of diabetic foot problem in India is peripheral neuropathy.
In India, 24% of hospital admission and 35% of total hospital days are due to foot problems.
Diabetic foot ulcers are common and estimated to affect 15% of all diabetic individuals during
their lifetime. Diabetic foot ulcer precedes almost 85% of amputations. According to a
multicentric study from India studying on pattern and cause of amputation in diabetic patients
infection in 90% of cases results in amputation in diabetic patients. The prevalence of neuropathy
was 82% (high) and 35% had PVD in this study.35 The prevalence of neuropathy was 15% (n =
193) and PVD was 3% (n=64) in another multicentric study in India. Infections were present in
7.6% (n=100) of patients. In the different centres of India the infection rate varied from 6% -11%
in DF. Studies have revealed that a minor or major amputation has to be performed in 3% of the
patients.36
Diabetic Nephropathy:
The chronic kidney disease (CKD) which often goes unrecognized most of the times are
closely related to hypertension and DM. An epidemiological study by Indian CKD Registry
established under the aegis of Indian Society of Nephrology (ISN) had made certain pertinent
observations. CKD Registry has documented DM as the cause of CKD in 31.2% of patients.
CKD also leads to CVD as disease progress: in 0.7% in Stage1 CKD to 48.5% in stageV CKD.37
The SEEK (Screening and Early Evaluation of kidney disease) study reported a high prevalence
of CKD 17.4% (Urban 25.5 vs. Rural 9.4%). The main causes of CKD were DM and
hypertension.38 Nephropathy developed in 20.4% of subjects with type 2 DM over years.
According to a recent study from Jhansi, incidence of nephropathy in newly diagnosed type 2
DM was 17.34% (52/300) and the most important associated factor contributing to development
of nephropathy was hypertension.39
The prevalence of nephropathy according to different studies are: CURE study
(microalbuminuria 26.9%, overt proteinuria 2.2%), CRDPP study in Tamilnadu 24.3%, 30.2% in
Bikaner study (Rajasthan), microalbuminuria in 41% patients in North Delhi study.8,9,40 Various
population based studies has also observed familial clustering of nephropathy. In individuals with
a family history of ESRD there was three to nine fold greater risk for development of ESRD
which suggest a genetic component apart from environmental and host factors.
In our own study from Cuttack there was a greater degree of IR and Beta cell dysfunction and
atherosclerosis in diabetics than non-diabetic CKD patients. 38 Another study from our institute
revealed that proteinuria is common and more related to glycemic status. Improvement in
8
proteinuria can be achieved with strict glycemic control. Microalbuminuria in type-2 DM was
found to be a marker of generalized vascular endothelial dysfunction.38
Other complications in Type-2 DM:
There are several other complications which also occur in long standing type 2 DM patients
besides the micro and macrovascular complications. The spectrum of chronic complications of
DM are illustrated in Figure-2.
(A) Non coronary cardiac complications :
Diabetic cardiomyopathy and heart failure (HF), cardiovascular autonomic neuropathy (CAN)
and sudden cardiac death (SCD) can occur in addition to CAD. Cardiomyopathy is seen in one
third of the diabetic patients. Diastolic dysfunction usually precedes systolic dysfunction. Early
degenerative changes in the conducting system give rise to heart blocks. DM is an independent
risk factor for Congestive Cardiac Failure (CCF) in the elderly and every 1% increase in the
HbA1C increases the risk of CCF by 15%. Prevalence of DM in people with CCF is estimated to
be around 20% compared to 4-6% in control population. Poor glycemic control and longer
duration of diabetes increases the risk of HF in diabetic subjects. In 50-70% of long standing
diabetic subjects there is co-existence of CAN in Indian studies.41
(B) Hypertension :
Globally in 40-60% of patients with type 2 DM, hypertension coexists. The prevalence of
hypertension in newly detected type 2 DM was 39% in the HDS-1(Hypertension in Diabetes
Study) report. Indian studies showed that about half of the diabetic patients have coexisting
hypertension. Recently, the cross-sectional study Screening Indias twin epidemic (SITE)
conducted in 10 Indian states reported that DM and hypertension coexist in 20.6% of patients.42
(C) Chronic Liver disease :
The etiology of chronic liver disease with and without DM studied by Amarpurkar et al (2002)
from India compared and found higher evidence of nonalcoholic steatohepatitis (NASH), NASH with
cirrhosis of liver and cryptogenic cirrhosis in diabetic subjects than non diabetic counterparts.43 In our
study constituting 42 patients of NASH, it was observed that the development of NASH was a decade
earlier than the western population was likely due to the early onset of Type2 DM in our population.
19(45.2%) out of 42 patients had DM 45, which was very high as compared to study conducted prior
by Bacon et al and Amarpurkar, where the incidence of DM was 21% and 22% respectively.43,44 IR
and dyslipidemia rather than the glycemic status were determinant factors that had positive
correlation with the higher histo-pathological grades of NASH.45
9
(D)Infections :
There is an increased susceptibility for various acute and chronic infections leading to
increased morbidity and mortality in DM. Diabetes is an independent risk factor for tuberculosis
(TB) and there is a three fold higher risk of developing TB. Worldwide data suggests that
diabetes is found in 15% of all tuberculosis and 21% of smear positive TB. 46 The prevalence of
TB among diabetic populations in India according to different studies are 14% (Bhutia 1975),
4.5% (Bhalkar 1975), 12% (Nanda & Tripathy, 1968), 14% (Deshmukh et al, 1966), 5.9% (Patel
JC, 1989), etc. A study revealed that in urban areas increased prevalence of DM is associated
with 15.2% greater Smear-positive TB incidence compared to rural areas. The study predicted
that in India 18.4% (12.5% - 29.9%) of people with pulmonary TB (both smear-positive and
smear-negative) have diabetes and that in the smear-positive group diabetes prevalence is 23.5%
(12% - 44%).47 Another study revealed that 36% of cases suffer from multidrug resistant TB
(MDR-TB) amongst diabetics compared to 10% in non diabetics (p<0.01) and out of these 36%
of MDR TB patients 23% never received antitubercular drugs. Death from active TB accounted
for 14% in the diabetic group and 1% of nondiabetic group. The incidence of extrapulmonary TB
was 20% in diabetic compared to 5% in the non diabetic group.48 In a south Indian study
conducted recently on diabetes prevalence among a cohort of TB cases registered under RNTCP
revealed DM prevalence was 25.3% (95% CI 22.6 – 28.5) and that of pre-diabetes was 24.5%
(95% CI 20.4-27.6).49 The most common infection seen in diabetes is urinary tract infection
(UTI) and is also a common cause of hospital admission. Symptomatic UTI was reported to be
14% in mostly menopausal diabetic women in an Indian series.50 In another study, the prevalence
of UTI was found to be 9%. In a study from north India, mortality related to UTI in diabetic
patients was 2.4%.51 Klebsiella was the commonest organism isolated in another Indian study in
11.6% of diabetic patients presenting with pneumonia.50 Mortality due to bronchopneumonia in
diabetes was 17.4% in an Indian study. The detail infections caused in a diabetic are represented
in Table-9. (Ref: 52)
Conclusion
In the post insulin era due to decline of acute complications and infections in diabetes, the
chronic complications more so macrovascular diseases like CAD, CVD and PVD have come to the
forefront. Though macrovascular complications are more common in Type 2 DM it is also a major
cause of morbidity and mortality in Type 1 DM as well. Macrovascular Disease has been seen to
forerun the development of hyperglycemia by decades suggesting a likelihood of atherosclerosis
and DM sharing a common soil for growth and development in individuals.53 Amongst
macrovascular complication PVD is less common in Indians than Western diabetics.
10
Diabetes care in the Indian context has to start from the roots to prevent the complications.
Identification of the high risk category for development of Type 2 DM like age > 40 years, positive
family history of DM, increased abdominal fat (waist circumference in males > 90cm, females>
85cm), prediabetes and people with sedentary life style is important. Targeting the modifiable risk
factors like obesity, physical inactivity, dyslipidemia, HTN and changing the dietary habits will be
of immense help in controlling DM and its complications. This has to be achieved through creating
awareness regarding DM regular health checkups and catching them young and treating them
properly.
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Table-1 (Ref: 3)
Chronic Complications in DM
Microvascular
Complications
Macrovascular
Complications
Others
Eye disease :
Retinopathy
(Proliferative/Non Proliferative)
Macular edema
Coronary heart disease Gastrointestinal
( Gastroparesis, diarrhea)
Genitourinary
(uropathy/sexual
dysfunction)
Neuropathy:
Sensory and motor
(mono and polyneuropathy)
Autonomic
Peripheral arterial disease Dermatologic
Infectious
Nephropathy Cerebrovascular disease Cataracts
Glaucoma
Periodontal disease
Hearing loss
Table-2 (Ref: 8, 9, 10, 67)
Prevalence of CAD amongst Diabetics in India
Author Year Place Prevalence
15
ICMR*67 1985-90 Multicentric 8.1% Male
4.7% Female
V. Mohan (CUPS-5) 16 2001 Chennai (Population
based)
21.4
Gupta PB67 2001 Surat 19%
Gupta S67 2001 Nagpur 33.5%-Male
21.5%-Female
PODIS** 61 2001 Multicentric 4.5%
Ramachandran et al67 2002 Chennai 11.5%
Phatak S 55 2002 Ahmedabad 20.2%-Male
26.1%-Female
J. Ahmad et al 66 2007 Aligarh 37.7%
R. Chawla 92012 New Delhi 7%
A. A. Sosale et al 10 2014 Multicentric 6%
(Newly detected DM)
R.P. Agarwal et al82014 Bikaner 25.8%
*ICMR – Indian Council of Medical Research
**PODIS – Prevalence of Diabetes in India Study
Table- 3 (Ref: 14)
Intima media thickness (IMT) of common carotid artery (CCA) distribution
in relation to co-morbidity among patients and controls
IMT In mm CASES CONTROL p-VALUE
OVERALL MEAN
IMT
0.88±0.19(N=80) 0.60±0.09(N=40) 0.000
IMT IN DIABETES 0.90±0.16(N=31) 0.64±0.11(N=14) 0.013
IMT IN HTN 0.88±0.16(N=53) 0.65±0.10(N=14) 0.006
IMT IN SMOKERS 0.93±0.20(N=49) 0.63±0.06(N=17) 0.000
IMT is a dependable marker of atherosclerosis.
Table- 4 (Ref: 14)
Pulsatility Index (CCA) distribution in relation to
co-morbidities among patients and controls
PI in mm Pts. with Ischemic Stroke Control P-value
16
Overall Mean PI 1.71±0.18mm (N=80) 1.53±0.11(N=40) 0.000
PI in Diabetes 1.76±0.20mm (N=31) 1.49±0.09 (N=18) 0.000
PI in HTN 1.69±0.18mm (N=53) 1.49±0.09 (N=18) 0.000
PI in Smokers 1.82±0.22 (N=49) 1.49±0.09 (N=18) 0.000
Resistivity Index distribution in relation
to co-morbidities among patients and controls
RI in mm Pts. with Ischemic Stroke Control P-value
Overall Mean RI 0.76±0.05(N=80) 0.61±0.06(N=40) 0.000
RI in Diabetes 0.76±0.04(N=31) 0.59±0.06(N=18) 0.000
RI in HTN 0.76±0.04(N=53) 0.59±0.06(N=18) 0.000
RI in Smokers 0.77±0.04(N=49) 0.59±0.06(N=18) 0.000
Table- 5 (Ref: 19)
Incidence of DM amongst Patients with Cerebro-Vascular Disease
(prior to the last decade of the past century)
Place / Country %
Study from 11 Countries 2-28
North Carolina , USA 13.9
Michigan, USA 18.3
Africa 4-8
Hong Kong 33.5
Das S, Cuttack 8.0
Bombay 14.2
Pondicherry 32
Toole, Janway, Choi 28
Even in patients with TIA or VBI, the incidence of DM was as high as
28 and 20% respectively.
Table – 6 (Ref: 8,9,10,30)
Prevalence of Diabetic Retinopathy in India (Clinic Based Studies)
Author / Year (References) Type of Study Place Prevalence (%)
Rema et al 1996 63 Clinic based Chennai 34.1
Ramachandran et al 1999 55 Clinic based Chennai 23.7
Pradeepa et al 201134 Clinic based South India 37.9
17
Chawla et al 2012 9Clinic based North Delhi 21.2
Agarwal et al 2014 62 Clinic based Bikaner 32.5
Sosale et al 2014 10 Clinic based 14 centres 6.1
(Newly detected DM)
Table – 7 (Ref: 8, 9, 10, 30)
Prevalence of Diabetic Retinopathy in India (Population Based Studies)
Author / Year (References) Type of Study Place Prevalence (%)
Dandona et al, 1999 59 Population Hyderabad 22.4
Narendran et al, 2002 60 Population Palakkad 26.8
Rema et al (CURES), 2005 27 Population Chennai 17.6
Raman et al, 2009 64 Population Chennai 18
Vaz et al, 201158 Population Goa (Rural) 15.4
Mohan et al,2012(CRDPP) 54 Population Chunampet 18.2
Table - 8 (Ref: 8, 9,10,30)
Prevalence of Diabetic Neuropathy in India
Author (References) Year Type of Study City Prevalence(%)
Ramachandran et al 55 1999 Clinic based Chennai 27.5
Ashok et al 56 2002 Clinic based Chennai 19.1
Chanda et al 57 2006 Clinic based Bengaluru 64.1
Pradeepa et al34 2011 Clinic based Chennai 33.1
Chawla et al 92012 Clinic based North Delhi 15.3
Sosale et al 10 2014 Clinic based Multicentric 13.15
(Newly detected DM)
Agarwal RP et al 82014 Clinic based Bikaner 26.8
Pradeepa et al 34 2008 Population
(CURES 55)
Chennai 13.1
Vaz et al 58 2011 Population Goa (Rural) 60
Mohan et al 54 2012 Population
(CRDPP)
Chunampet
(Tamil Nadu)
30.9
18
Table - 9 (Ref: 52)
Infections in DM
Infections Risk (Proven association)
Tuberculosis 3-6 fold
Bacteriuria in females 4 fold
Malignant otitis externa 100 %
Emphysematous cystitis 80 %
Necrotising cellulitis 75 %
Emphysematous pyelonephritis 72 %
Acute papillary necrosis 57 %
Mucormycosis 42 %
Emphysematous cholecystitis 38 %
Perinephric Abscess 36 %
Figure -1
Figure-2
19
20