attributable to diabetes globally in 2000 was estimated Since last year the Diabetes Research Centre, However, diabetes is rarely perceived as a …
Editorial
Tsunami Induced Hyperglycemia and Diabetes Mortality - Two studies from South India
Shashank R Joshi
S
tress affects everyone and its subtypes namely work-related stress, home stress and post-traumatic stress disorders PTSD are all health hazards Stress and its comorbid diseases are responsible for a large proportion of disability worldwide The World Health Organization WHO Global Burden of Disease Survey estimates that mental disease, including stress-related disorders, will be the second leading cause of disabilities by the year 2020 Although the term stress is used in a wide variety of contexts, it has consistently been demonstrated that individuals with stress and related disorders experience impaired physical and mental functioning, more work days lost, increased impairment at work, and a high use of healthcare services The disability caused by stress is just as great as the disability caused by workplace accidents or other common medical conditions such as hypertension, diabetes, and arthritis1 Natural calamities like earthquakes and tidal wave tsunamis have been known to cause PTSD and impact diseases like diabetes though such reports are scant The Great
Hanshin-Awaji Earthquake worsened glycemic control in Japanese diabetics in 19952 Similar results were seen in a rural community in Northern China where influence of earthquake was noted on quality of life with type 1 diabetes3 A tidal wave swept South-East Asia on 26th December 2004 which was a natural disaster Tamil Nadu coast was badly ravaged and this led to hardship and mental stress Since last year the Diabetes Research Centre, Chennai established in a village twice a week Tsunami OPD for diabetic patients In this issue of JAPI, Ramachandran et al in two populations, one affected by tsunami n1184 and other control n1176, each more than thousand patients use Harvard trauma questionnaire and score as well as glucose tolerance test Stress score was significantly higher in tsunami population Although the total prevalence of diabetes was similar control 100; tsunami population 105 prevalence of undetected diabetes 57 vs 38; Z 954, P 0001 and impaired glucose tolerance 98 vs 83; Z 1283, P 0001 were higher in the tsunami area Stress score was higher in women and in the young in the tsunami area Population affected by tsunami was
Dept of Endocrinology, Seth G S Medical College
and KEM Hospital, Mumbai 400 012 JAPI VOL 54 FEBRUARY 2006
under high stress and also showed a high prevalence of undetected diabetes and impaired glucose tolerance4 Stress induced hyperglycemia is a well-known feature of General Adaptation Syndrome arousal, resistance, exhaustion, but it is known to reverse If a subpopulation of Tsunami or earthquake affected persons turns diabetic after PTSD, then further studies are warranted to study affected/non affected groups with reference to anxiety-depression scale Earthquake survivors, terrorism affected and such groups can be subjected to retrospective cohort studies The neuroendocrine response to stress now is well studied and is a complex interplay of neuro peptides, cortisol-cortisone axis, epinephrine and other catecholamines as well as several other hormones Currently there are more than 150 published papers of stress and hyperglycemia which have yielded variable results Stress still remains an poorly studied component in Asian Indian population and the current study needs a long term follow up to know its long term effects Traditionally Indian systems like yoga has always aimed at stress modulation and need to be revisited
Asian Indians have higher prevalence rates of diabetes, premature coronary artery disease [CAD] and cardiovascular disease [CVD] mortality compared to other ethnic groups5 Diabetes is one of the leading causes for morbidity and mortality worldwide In recent years India has witnessed a rapidly exploding epidemic of diabetes6 At present there are over 32 million diabetic individuals in India and these numbers are predicted to increase to nearly 80 million by the year 2030 7 Environmental and lifestyle changes resulting from industrialization and migration to urban environment from rural settings may be responsible to a large extent, for this epidemic of Type 2 diabetes in Indians In addition, there is also strong evidence that Indians have a stronger genetic predisposition to diabetes8 It is also been shown that a typical Asian Indian phenotype with higher percentage of body fat and increased waist to hip ratio or any given body mass index BMI which predisposes to diabetes and the metabolic syndrome9 Earlier studies have shown that Indians have a high mortality rate due to diabetes The number of deaths attributable to diabetes globally in 2000 was estimated at 32 million, almost 6 of
world mortality10 A recent report published by the Indian Council of Medical
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Research ICMR, reported that in India, mortality due to diabetes has increased from 095 lakh deaths/ year in 1998 to 109 lakh deaths/ year in 200411 There are very few population-based studies on mortality rates in India and virtually none comparing diabetic and non-diabetic subjects However, information on mortality rate and cause of death due to diabetes is available from some retrospective hospital-based and autopsy studies12-14 There is therefore a need for such studies in India as there is a paradigm shift in the health problems in the country, from communicable disease to non-communicable diseases NCDs, which includes diabetes, cardiovascular diseases CVD, hypertension and obesity However, diabetes is rarely perceived as a major contributor to mortality, largely because routine mortality statistics are based on death certificates where diabetes is often omitted as primary or secondary cause of death It is a great challenge to study the mortality rates among diabetic individuals as it leads to other disease conditions, which subsequently become the cause of death According to the
World Health Organization study13 there are about five times as many deaths indirectly attributable to diabetes as directly attributable in established market economies With this scenario of the diabetes burden, it is important to study the mortality rates due to diabetes using population based Indian data to know the real dimensions of the problem and work towards preventive measures The population based study done by Dr Mohan and his group following the cohort from the famous Chennai Urban Population Study is an important mortality study conducted in diabetic and non-diabetic subjects from India 15 Of the 1262 individuals who responded at baseline, 1140 individuals [903] could be followed annually for six years since 1997 The overall mortality rate was higher in diabetic, compared to non-diabetic, subjects [189 vs53 per 1000 person years] Cardiovascular and renal diseases were the commonest causes of death among diabetic subjects, whereas mortality due to gastrointestinal, respiratory, lifestyle-related and unnatural causes were observed only among nondiabetic subjects The hazards ratio for all cause mortality for diabetes was 36, and even after adjusting for age the ratio was 19
demonstrating that in urban India, mortality rates are two-fold higher in people with diabetes compared to non-diabetic subjects It was surprising to note that waist circumference and triglyceride levels, which are markers of obesity and CAD, are found to be lower among the non-survivors compared to the survivors Few studies have shown that compared to host populations, migrant Indians have higher mortality rates in diabetic subjects compared with non-diabetic subjects5 Hence data on mortality in diabetic individuals are extremely important and this study conducted by
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Mohan et al 15 is an important study from India Ramachandran et al study once again highlight the connection of stress and diabetes where evidence base has been a little conflicting but gathering momentum The current emerging evidence suggest both a more direct role as well as an indirect role of stress mediated via cortisol axis in the visceral fat, the cortisol - cortisone shuttle Thus in this issue two landmark studies both from Chennai from wellknown diabetes centers are published One highlights the impact of Tsunami and Tsunami related stress on hyperglycemia, undetected diabetes and impaired glucose
tolerance and shows us the contribution of stress in diabetes which is so illrecognised This should re-emphasize the point that lifestyle modifications should integrate stress management including Yoga as a part of comprehensive metabolic care The second study highlights the burden of diabetes and its impact on mortality The burden of diabetes is not just due to diabetes itself but the vascular burden and mortality it will contribute To reduce mortality due to diabetes early detection of diabetes and tight control of blood glucose, pressure, lipids and other athero-thrombotic factors is needed
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1 2 Kalia M Assessing the economic impact of stress the modern day hidden epidemic Metabolism 2002;51Suppl 1:49-53 Kirizuka K, Nizhizaki H, Kohriyama K, et al Influences of The Great Hanshin-Awaji Earthquake on glycemic control in diabetic patients Diabetes Res Clin Pract 1997;36:193-6 Salman S, Sengul AM, Salman F, et al Influence of earthquake on the quality of life of patients with type 1 diabetes Psychiatry Clin Neurosci 2001;55:165 Ramachandran A, Snehalatha C, Yamuna A, et al Stress and Undetected Hyperglycemia in Sourthern Indian Coastal Population Affected by Tsunami J
Assoc Physicians Ind 2006;54:109-12 Ma S, Cutter J, Tan CE, Chew SK, Tai ES Associations of diabetes mellitus and ethnicity with mortality in a multiethnic Asian population: data from the 1992 Singapore National Health Survey Am J Epidemiol 2003;158:543 52 Ramachandran A, Snehalatha C, Latha E, Vijay V, Viswanathan M Rising prevalence of NIDDM in an urban population in India Diabetologia 1997;40:232-37 Wild S, Roglic G, Green A, Sicree R, King H Global prevalence of diabetes: estimates for the year 2000 and projections for 2030 Diabetes Care 2004;27:104753 Radha V, Vimaleswaran KS, Deepa R, Mohan V The genetics of diabetes mellitus Indian J Med Res 2003;117:225-38 Joshi SR Metabolic Syndrome - Emerging clusters of the Indian phenotype J Assoc Physicians Ind 2003;51:445-6 Sridhar CB, Ahuja MM Pattern of mortality amongst diabetics in North India Indian J Pathol Bacteriol 1966;9:222-227 Zargar AH, Wani AI, Masoodi SR, Laway BA, Bashir MI Mortality in diabetes mellitus–data from a developing region of the world Diabetes Res Clin Pract 1999; 43:67-74 Bhansali A, Chattopadhyay A, Dash RJ Mortality in diabetes: a retrospective analysis from a tertiary care hospital in North India
Diabetes Res Clin Pract 2003; 60:11924 Murray CJ, Lopez AD The Global Burden of Disease Harvard University Press, 1996 Sicree RA, Ram P, Zimmet P, Cabealawa S, King H Mortality and health service utilization amongst Melanesian and Indian diabetics in Fiji Diabetes Res Clin Pract 1985;1:227-34 Mohan V, Shanthirani CS, Deepa M, Deepa R, Unnikrishnan RI, Datta M Mortality Rates Due to Diabetes in a Selected Urban South Indian Population - The Chennai Urban Population Study [CUPS - 16] J Assoc Physicians Ind 2006; 54:113-7
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JAPI VOL 54 FEBRUARY 2006
Source:dredf.org
