Type 2 Diabetes in South Asian: Epidemiology, Risk Factors and Prevention Gundu HR Rao, V Mohan
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1Type 2 Diabetes in South Asians: Epidemiology, Risk Factors and Prevention
2Type 2 Diabetes in South Asians: Epidemiology, Risk Factors and Prevention
EditorsV Mohan MD FRCP(UK) FRCP(Glasg) PhD DSc FNASc Chairman and Chief Diabetologist, Dr Mohan’s Diabetes Specialities Centre President and Director, Madras Diabetes Research Foundation 4, Conran Smith Road, Gopalapuram Chennai (India)Gundu HR Rao PhD Professor and Director, Thrombosis Research Laboratory Medicine and Pathology Lillehei Heart Institute, University of Minnesota Minneapolis, Minnesota (USA)
3Published by
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Type 2 Diabetes in South Asian: Epidemiology, Risk Factors and Prevention
© 2007, V Mohan, Gundu HR Rao
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and the publisher.
This book has been published in good faith that the material provided by editors is original. Every effort is made to ensure accuracy of material, but the publisher, printer and editors will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters to be settled under Delhi jurisdiction only.
First Edition:2007
9788180619366
Typeset at JPBMP typesetting unit
Printed at Ajanta Offset4
5Contributors 9Foreword
Epidemiology is an essential part of study of any widespread disease. It is meant to assess the frequency of the disorder in a population along with studies on its etiology. The data emerging from study of epidemiology is most valuable for setting up a programe for prevention.
The attention on epidemiology of diabetes mellitus is most vital at the present juncture in view of the surging pandemic with blood chilling figures for projected future prevalence rates of diabetes in developing countries, particularly in South Asia.
Following the landmark observation of Joslin [1921] that the rising frequency of diabetes in a community deserved to be considered as epidemic, several efforts were made by various groups to assess its epidemiology. The procedures adopted were not quite scientific until the work of Wilkerson and Krall published in 1947.
In India attempts at study of prevalence were made during mid ‘60s of the last century by urine examinations followed by blood sugar estimation in positive cases in exhibitions, and melas at Bombay, Hyderabad, Varanasi and in different ways at Delhi, Chandigarh, Pondicherry and Sarojini nagar [rural]. Randomized house to house testing by estimation of urine and plasma glucose, fasting and post glucose, were conducted only towards the fag end of the 1960s almost simultaneous by us at Cuttack and OPGupta and his colleagues at Ahmedabad. These efforts were followed by the ICMR Collaborative Study in six centers coordinated by MMS Ahuja in 1971. In the absence of WHO directions [1980] and the coinage of the world impaired glucose tolerance we [1971] classified those with abnormal plasma glucose either as hyperglycemia [chemical diabetes] or diabetes [overt diabetes].
In the present era it is the laborious work at the Diabetes Research Centre and the Madras Diabetes Research Foundation and Dr Mohan’s Diabetes Specialities Centre in Chennai, which have extensively contributed to the Epidemiology of this expansive disorder.
Who else but V Mohan, the architect of such studies as Chennai Urban Population Study [CUPS] and Chennai Urban Rural Epidemiology Study [CURES] covering urban, semi-urban and rural populations assessing a formidable variety of parameters for diagnosis of diabetes and its associates, is more competent to edit a book on “Type 2 Diabetes in South Asians – Epidemiology, Risk Factors and Prevention”. I congratulate him and Dr Gundu Rao for their stupendous effort of presenting us a large volume of data on our own and neighboring countries of the Indians subcontinent.
10Dr Mohan has spent valuable time for the purpose at the peak period of his productive research. The volume may be considered as a benevolent gift to all of us from this highly gifted scientist. It will serve as a supplement to the RSSDI Textbook of Diabetes Mellitus, Second Edition, to be published shortly within this year of which Dr Mohan is an editor.
The contents are comprehensive. Selection of topics and assignment to authors has been impeccable. It is due to his popularity and respectability that Dr Mohan has been able to collect contributions from the top barons of the various topics discussed.
At the fag end of my life, I am extremely delighted to see the school boy whom I first saw with his illustrious father M Viswanathan, decades ago ride the crest of fame by dint of his high level of intellect, perseverance, painstaking effort, broad heart and wide outlook.
I close with my high recommendation for the book to find a place in the shelves of all institutions, libraries and personal collections of those dealing with diabetes. I wish the book resounding success and congratulate Dr Mohan and Dr Gundu Rao on their efforts to bring out this book.
BB Tripathy
Cuttack [Orissa], India
11Preface
It gives me great pleasure to write the foreword for the book on Type 2 Diabetes in South Asians: Epidemiology, Risk Factors and Prevention published under the Aegis of “South Asians Society of Atherosclerosis and Thrombosis (SASAT)”. SASAT has been contributing extensively to the network of scientists working in the area of cardiovascular disease, diabetes and atherosclerosis. It has brought out several excellent books related to this field in the past. As India has become the “Diabetic Capital” of the world, Dr Gundu Rao and I felt a book on diabetes in Indians (or South Asians) would be a useful contribution to the world literature on diabetes. It has been known for at least 3 decades that South Asians have an increased susceptibility to Type 2 diabetes. This has been variously called as the “South Asian Phenotype” or “Asian Indian Phenotype” or “Asian Indian Paradox”. Basically what this refers to is the fact that high prevalence rates of diabetes are seen in people from South Asia (India, Pakistan, Bangladesh, Nepal and in addition Sri Lanka), despite low rates of obesity as defined using body mass index. South Asians also seem to have a peculiar body phenotype characterized by increased waist circumference, waist hip ratio, excessive body fat, increased plasma insulin levels, insulin resistance and a characteristic dyslipidemia with a low HDL cholesterol and increased triglyceride levels. They are also known to have excess amounts of visceral fat. All these predispose them not only to diabetes but also to premature coronary artery disease. Some studies have shown that LP(a) levels are also increased in Indians. There could also be unique genetic markers which makes Indians more susceptible to diabetes. Surprisingly, there is no book dedicated to Type 2 diabetes in South Asians. Hence we thought that we would invite people who have contributed to the study of epidemiology of Type 2 diabetes and its complications in South Asians to contribute a book devoted to this subject. This is the basis for the present book. We do not claim that the book is exhaustive and there could be several gaps in the knowledge. Unfortunately, some of the invited authors who were supposed to write on specific aspects of diabetes in South Asians did not send their contributions in time. We hope that in the next edition of the book we would be able to make up for this and present a more comprehensive picture of diabetes in South Asians and make it more international in its perspective. However if the book stimulates interest in the subject of diabetes in South Asians and more specifically leads to increased research on diabetes in South Asians, I think the purpose of this book would have been achieved. I thank all the authors for their excellent contributions.
12A special word of thanks to Dr Deepa Raj, Dr Ranjit Unnikrishnan I and Mr K Gokulakrishnan of MDRF for the editorial assistance and to Ms G Malarvizhi and Ms M Muthu Valli Nayaki of MDRF for their secretarial help. If there are any errors in the book, do let us know so that we would be able to correct these in the subsequent editions of the book. Any suggestions from our readers are also most welcome.
V Mohan
131415
16Introduction
South Asians have a very high incidence of coronary artery disease. To create awareness, develop educational and preventive programs, we started a society (South Asian Society on Atherosclerosis and Thrombosis, SASAT) in 1993. Since then, we have been organizing international conferences on “Atherosclerosis and Thrombosis” in India, every other year. We have published two monographs on this subject. At the time we were finalizing the second monograph, “Coronary Artery Disease: Risk Promoters, Pathophysiology and Prevention” Professor Seedat from South Africa, reminded me of a great need for such a monograph on Diabetes Mellitus. According to a World Health Organization estimate, India ranks number one in the prevalence of adult onset diabetes.
Since there is a need for a reference book on this subject, I readily agreed to facilitate the publication of a book on Diabetes Mellitus. I needed an expert in this field to collaborate with me on this project. I approached Dr V Mohan, Director, Madras Diabetes Research Foundation, Chennai, India. He graciously accepted to work with me on this project. He and his associates have significantly contributed to development of this book. The book chapters have been arranged into two sub areas: Risk Factors and Prevention. Each contributor is a national or an international expert in the area of his or her specialty. We sincerely thank all the authors for their valuable contribution to this project. We hope this book will serve as a valuable source of reference for researchers and students.
We thank Prof Seedat, who requested me to facilitate the publication of this monograph. I thank Dr Mohan and his associates for their valuable contribution to this project. We also thank KOS pharmaceuticals Inc, USA, Novartis Pharmaceuticals Corporation, USA and Prof Sandip Mukherjee (Cardiovascular Division, Yale University School of Medicine), for partial financial support of this project. I dedicate this book to Dr PR Krishnaswamy, Medical Director, Sagar Appolo Hospitals, Bangalore, who kindled that little lamp of knowledge inside me, four decades ago. His inspiration and continued encouragement has kept me busy exploring the biochemical mechanisms underlying human disease. This is the third monograph SASAT has published with the help of Jaypee Brothers Medical Publishers, New Delhi, India. We thank the publishers of this book for the excellent job they have done.