CME INDIA Presentation by Dr. N. K. Singh, MD, FICP, Diabetologist Physician, Director – Diabetes and Heart Research Centre (DHRC), Dhanbad, Chairman – RSSDI Jharkhand, Editor – CME INDIA.

Ensure Happy Deepawali years ahead

• The young Indian population is fast adapting to a new lifestyle – this has never happened in the history of mankind. No wonder we are in the midst of a tsunami like situation with increasing diabetes and associated complications in younger population in India that isभारत.
• To detect the young diabetics, one new paper has uniquely suggested to lower the screening age to 25, instead of 30 in India.

What could be the perfect Deepawali Gift?

• Genetic and environmental factors, change in lifestyle, age, smoking habits, increased alcohol consumption, screen time, parental conflicts, improper sleep, education, and stress are predisposing young adults to diabetes.
• This is exacerbated with diabetic comorbid conditions. Childhood obesity is a great matter of concern that accounts for 80%-85% of the risks of developing T2DM.
• The very exciting fact is that the risk of diabetes in young adults can be managed by routine physical activity and adopting a healthy and balanced diet, which focuses on the increased intake of dietary fibre.
• Worth a million as Diwali message is the fact that young diabetes patients are amenable to reversal to a greater extent by intensive lifestyle intervention because of reduced risk factors as compared to the aged group.

Screen early, Reduce screening age in India

• Diabetes, if it remains untreated/undetected in the early stage of life, may become more complicated in the later stage of life.
• Young diabetes often remains undetected as aged people continue to be tested for multiple health problems.
• Identification of the young diabetics is the crux of the matter.
• Find them and do appropriate intervention in time as one fourth of the young adult population in India is at a high risk of developing it.

Eminent Diabetologists from India pave the way

• Drs Anoop Misra , Ambady Ramachandran, Banshi Saboo, Jothydev Kesavadev, Arvind Sosale, Shashank Joshi, Ashok Kumar Das at el in an original article, published recently in Diabetes & Metabolic Syndrome: Clinical Research & Reviews journal, suggest to do screening of young population at an early age of 25 years in non-pregnant adults instead of 30 years as currently stipulated. (1)

Background

• Ehtisham et al. from the UK in the year 2000 identified eight girls with T2D, aged 9-16 years who were of Pakistani, Indian or Arabic origin. This paper is supposed to be the earliest description of youth onset T2DM. They were all overweight and had a family history of diabetes in at least two generations.
• One of the earliest studies was from south India in 2003.
• In 2004  Anoop Misra et al reported a high prevalence of insulin resistance in urban Asian Indian children which was closely associated with obesity; specifically excess body fat, abdominal adiposity, and excess truncal subcutaneous fat.
• Abdominal adiposity and family history of diabetes emerged as strong risk factors in these studies for T2D in young.

Path Ahead

• National Control Program for Diabetes and related diseases in India slowly took concern.
• Screening for diabetes has been set at age 30 years or more. In the final National Control Program for Prevention and of Cancer, Diabetes, Cardiovascular Disease and Stroke (NPCDCS) document it is clearly mentioned – “Non-Communicable Disease (NCD) clinic at district hospital shall screen persons above the age of 30 years for diabetes, hypertension, cardiovascular diseases and common cancers and identify individuals who are at a high risk of developing NCDs warranting further investigation/action. (2)
• Such recommendations were based on the premise that an increasing number of young adults were being diagnosed with diabetes, particularly in urban areas.
• This is a decade story, since then diabetes in India has shown a rising trend as the authors take concern.
• New date from different parts of India shows an increasing trend in the number of young diabetic patients.

USPSTF note is worth to ponder

• Data from United States Preventive Services Task Force (USPSTF), for persons with recently diagnosed (not screen-detected) diabetes, interventions improved health outcomes; for obese or overweight persons with prediabetes, interventions were associated with reduced incidence of diabetes and improvement in other intermediate outcomes. (3)

What is the screening age in US?

• Screening age for diabetes in the USA is 35 years as stated in draft document. (4)
• This recommendation applies to non-pregnant adults aged 35 to 70 years seen in primary care settings who have overweight or obesity and no symptoms of diabetes.
• Asian American ethnicity has been given special emphasis for screening at a younger age and at a lower BMI.

Why we should consider screening for diabetes in India at a younger age?

• Authors (1) recommend screening as early as 25 years vs. 30 years.
• This in the recent perspective of observational data collected from tertiary care centers, which show an average prevalence of 2.76% young T2DM in patients aged 30 years or below.
• All these numbers are showing a rising trend in the last one decade.
• It is also important to note that 77.6% of these cases have a BMI of 23 kg/m2.

CME INDIA Learning Points

• As commented by authors more robust data are required to make any more policy changes in future.
• The statement of USPSTF that screening for diabetes should be done at an earlier age in Asian Americans is more applicable for Asian Indians.
• As this unique and timely paper concludes – It  is becoming clearer that screening for T2D should be started at 25 years of age for non-pregnant adults in India and should be particularly targeted towards overweight and obese individuals and those with a family history of diabetes. Waist circumference and BMI can be used as simple tools to triage this further.

CME INDIA Tail Piece

Yoga benefit in decreasing diabetic risks

References:

1. Anoop Misra, Ambady Ramachandran, Banshi Saboo, Jothydev Kesavadev, Arvind Sosale, Shashank Joshi, Ashok kumar Das,Screening for diabetes in India should be initiated at 25 years age,Diabetes & Metabolic Syndrome: Clinical Research & Reviews,Volume 15, Issue 6,2021,102321,ISSN 1871-4021,https://doi.org/10.1016/j.dsx.2021.102321.
2. Operational Guidelines for National Program for Prevention and Control of Cancer D. Cardiovascular disease and Stroke. file:///C:/Users/DR%20ANOOP% 20MISRA/Downloads/Operational%20Guidelines%20of%20NPCDCS% 20(Revised%20-%202013-17)_1%20(2)pdf
3. Jonas DE, Crotty K, Yun JDY, Middleton JC, Feltner C, Taylor-Phillips S, et al. Screening for prediabetes and type 2 diabetes: updated evidence report and systematic review for the US preventive Services Task Force. JAMA 2021;326(8):744e60.
4. Force USPST, Davidson KW, Barry MJ, Mangione CM, Cabana M, Caughey AB, et al. Screening for prediabetes and type 2 diabetes: US preventive Services Task Force recommendation statement. JAMA 2021;326(8):736e43. [17] Misra A, et al. Ethnic-Specific Criteria for Classification of Body Mass Index: A Perspective for Asian Indians and American Diabetes Association Position Statement. Diabetes Technol Ther 2015;17(9):667e71.
5. Zhao L, Zhang F, Ding X, Wu G, Lam YY, Wang X, et al. Gut bacteria selectively promoted by dietary fibers alleviate type 2 diabetes. Science (2018) 359:1151–PubMed Abstract | Google Scholar
6. Galisteo M, Duarte J, Zarzuelo A. Effects of dietary fibers on disturbances clustered in the metabolic syndrome. J Nutr Biochem (2008) 19:71–84.PubMed Abstract | Google Scholar
7. Brennan CS. Dietary fibre, glycaemic response, and diabetes. Mol Nutr Food Res (2005) 49:560–70.
8. Srivastava Vinod, Patil Suchitra, Sharma Guruprasad, Manasa Krishna, Pannu Viraaj, Singh Amit, Nagendra Hongasandra R.Prevalence of Diabetes and Its Determinants in the Young Adults Indian Population-Call for Yoga Intervention .Frontiers in Endocrinology 2020;11:846 URL=https://www.frontiersin.org/article/10.3389/fendo.2020.507064  DOI=10.3389/fendo.2020.507064 .ISSN=1664-2392  

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