Genetics and environment have both been implicated in the exponential rise in the prevalence of diabetes mellitus that affects 65.1 million people, and leads to a mortality of 1 million people every year in India. This method is useful in areas where the number of healthcare providers and drug providers is limited, and can be replicated in many parts of the world. Neuropathy was diagnosed if vibratory perception threshold at the great toe, measured by biothesiometry, exceeded mean + 2 sd of a healthy non-diabetic study population aged 20-45 years (cut point > or = 20 V). American Diabetes Association criteria were used to determine the prevalence of diabetes and standard operational definitions were used to define the diabetic complications. Blood glucose measurements were obtained after informed consent by trained staff using a reflectance photometer instrument. The higher incidence of diabetes in urban population has been reported by other workers, but the steep male: female difference seems to be due to social and cultural factors, discussed earlier by the authors . The prevalence of diabetic retinopathy (24.1 vs.
neuropathy (60%), CHD (32.3%) and cataract (20%), retinopathy (15.4%), peripheral vascular disease (11.5%) and cerebrovascular accidents (CVAs) (6.9%). 86.5% were normal (random blood sugar [RBS] 200 mg/dl). Though the primary source of data has been an OPD- based registry, it has been buttressed by inputs from other stakeholders such as physicians, paediatricians and insulin wholesalers as well as retailers. Regression analysis showed age (P < 0.0001), glycated haemoglobin (P = 0.001) and duration of diabetes (P = 0.045) to be significantly associated with neuropathy. In prediction, India along with China account for nearly a third of the estimated 300 million adult diabetics by the year 2025.(6) Recent surveys indicate that diabetes now affects a staggering 10-16% of urban population and 5-8% of rural population in India, while the actual epidemic is believed to be transpiring in the rural areas.(7,8) Indians are susceptible to premature onset of DM which in turn leads to rapid progression of chronic vascular complications, incurring heavy burden on health care systems in India. A log transformation was applied, and bimodality was tested using the Hartigan's dip test. The figures reported may be extrapolated to the country. Hence, this study was undertaken in an attempt to study the prevalence of DM and its associated complications in a rural setting in the state. A community-based study was conducted in a rural setting having a population of 6,500 and catered to by Rural Health and Training centre in Goa, India. The current cross-sectional study was formulated to screen individuals for diabetes and to obtain the trends of distribution of blood glucose by age and gender. The rural: urban population ratio of Karnal District is similar to that of the rest of India. The minimum sample size required was calculated using the formula N = (1.96)2 pq/L2 wherein P = 12% and allowable error L = 15% of P based on pilot study findings. The study subjects were interviewed face-to-face using a semi-structured questionnaire for baseline demographic data and details related to diabetes and complications. Five districts out of the 72 districts in the state were selected based on concerns about programming including the population in the districts, grant amount, and the location of existing infrastructure. This issue cannot be ignored while planning any public health strategy. Blood glucose estimation was done using the Folin-Wu method. Minnesota criterion was used to define coronary heart disease (CHD).(10) Peripheral vascular disease (PVD)(11) was defined as presence of definite history of intermittent claudication or/if one or more of the peripheral pulses were absent on both the feet or/presence of an ulcer or amputation. The nodal centers were Secondary Care Hospitals affiliated with the project. Diabetic neuropathy(12) was defined as a bilateral absence of ankle jerks and/or bilateral distal sensory loss or any other severe neurological deficit. Diabetic retinopathy(13) was defined based on fundoscopy findings. Data was analyzed using SPSS version 14.0 and Chi-square test, χ2 - Trend used for analyzing the associations. A camp-based approach was followed. The present study selected an overall of 1,266 individuals aged 20 years and above to participate in the study. Among them 609 were males and 657 were females respectively. Among the total participants, 130 (10.3%) subjects had DM with females (12%) showing a significantly higher prevalence compared to males (8.4%) (P = 0.032). Age, gender, and RBS values were obtained from the people who underwent screening. The prevalence of associated diabetic complications is shown in . Among the diabetics, the prevalence of CHD, peripheral vascular disease, CVA, retinopathy, cataract and neuropathy were 32.3%, 11.5%, 6.9%, 15.4%, 20% and 60% respectively.
The various complications were found to be significantly associated with DM. For analysis, data were available at the end of the study period for 45,318 subjects, 44.4% of whom were male and 55.6% female. Diabetics were fourteen times [P= 0.0001, OR= 14.18; 95% CI: 8.42-23.89) more likely to have CHD than the non-diabetics. The difference was found to be statistically significant. PVD prevalence was significantly higher [15/130] (11.5%) among diabetics and among these about two (2/15) (13.3%) were amputated and four (26.7%) were having an ulcer. Of the women, 2647 (10.5%) were prediabetic and 621 (2.5%) diabetic. CVA prevalence was 6.9% and diabetics were 42 times more likely to acquire strokes and TIA’s than non-diabetics (OR = 42.17; 95% CI: 8.40-285.88).
Diabetic retinopathy and cataract prevalence was 15.4% and 20% respectively. Diabetic incurred a 22 times higher chance of having retinopathy (OR = 22.77; 95% CI: 9.56-55.47) and were six times more likely to have cataract [OR= 5.92; 95% CI: 3.40-10.28] compared to non-diabetics. Among persons aged 41–60 years, 2049 (4.5%) were prediabetic and 736 (1.6%) were diabetic, whereas, of the subjects aged above 60 years, 762 (1.7%) were prediabetic and 222 (0.5%) were diabetic. The various diabetic complications prevalence in relation to duration of DM is shown in . The prevalence of diabetic complications in relation to duration of diabetes when studied showed a rising trend. A statistically significant association was observed between the various complications and duration of DM. The mean RBS of the females was 115.13 ± 35.34 mg/dl and 115.95 ± 39.38 mg/dl in the males.
The common complications among the diabetics were neuropathy (60%), CHD (32.3%) and cataract (20%) while the other significant complications included retinopathy (15.4%), PVD (11.5%) and CVA (6.9%). In a South India, a similar high prevalence of CHD (30.3%) among the diabetics was revealed by Ramachandran et al.(18) Yet in another study Ramachandran et al(19) reported a prevalence of 0.9% and 61.9% for stroke and neuropathy respectively among the diabetes subjects while the prevalence of PVD was 4.1%. Around 17.2% of diabetics had cataract as a complication in a study (Mohan V et al) carried out in Southern India.(20) Rema M et al(21) reported a retinopathy prevalence of 34.1% among diabetics, in South India. Bimodality was tested using the Hartigan’s dip test, and the dip statistic (D) was 0.0162 with a simulated P < 0.001. Ramachandran et al(18) in their study on prevalence of vascular complications of type 2 diabetes in an urban set up also observed a similar upsurge in trend in the prevalence of diabetic complications with increasing duration of DM. Persons having diabetes for more than ten years were comparatively less in number in the study population which could be either due to ‘survivor’ bias or reflection of a lower prevalence of DM a decade earlier. The prevalence of DM and its associated complications was higher among the diabetic individuals in the rural setting of Goa, India. With a view to providing information, education and enhancing awareness on diabetes with a special focus on gestational diabetes, 899,960 people in rural areas were approached. Also, community awareness programmes need to be implemented to percolate the knowledge about the diabetic complications, the available screening facilities for their early detection, treatment and care in the rural population. 12. Dyck PJ. Besides, women in certain areas are more likely to participate in their decisions on health and participate in the camp activities because of the constraints of work for men. In: Gries F A, Cameron N E, Low P A, Ziegler D, editors. Textbook of Diabetic neuropathy. New York: Thieme; 2003. The overall prediabetes to diabetes ratio was 4:1 in the sample, with an alarming 6:1 ratio among people aged below 40 years, and 3:1 among subjects aged 41 and above. 170–75. 14. Deo SS, Zantye A, Mokal R, Mithbawkar S, Rane S, Thakur K. In a large-scale urban study in India, Ramachandran et al. observed a diabetes prevalence of 12.1%. Int J Diabetes Dev Ctries. 2006;26:19–23.