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Abstract

Aims:

The epidemiology of diabetic patients is well studied in India. However, there is limited data on the epidemiology of diabetes among the rural and urban communities. This study has been designed to understand the geographical pattern and presentation of diabetes in North India.

Methods and Materials:

An observational, multicentre, cross-sectional study was conducted among diabetic patients visiting outpatient clinics of the primary care centres at various cities of Uttar Pradesh state from January 2019 to October 2020. The patients’ epidemiological, demographic and clinical characteristics were collected with the help of a predesigned questionnaire tool. The collected data were analysed using an appropriate statistical test.

Results:

A total of 3,951 patient records had been studied. The median age of diabetics was 50 years, and their median BMI was 26 kg/m² and indicating diabetic patients were obese as per Asian Indian criteria. Patients from rural settings had 59% higher odds of not having received any formal education, and 23% higher odds of any addiction-related history. Odds of heart disease and of stroke were significantly higher in the urban setting than rural setting. Positive history of any addiction was associated with 85% higher odds of heart disease or stroke (P < .05) in the overall adult population. Multiple regression analysis showed age of patient and liquor consumption were associated with a statistically significant association with heart disease.

Conclusion:

There was a discrepancy in presentation of diabetic individuals within the rural and urban communities of India.

Keywords

Diabetes mellitus diabetic comorbidities diabetic epidemiology diabetic demography diabetes in north India

Introduction

Diabetes mellitus (DM) is a type of metabolic disorder of altered carbohydrate metabolism in which hyperglycaemia occurs due to both underutilization of glucose as an energy source as well as overproduction of glucose due to inappropriate gluconeogenesis and glycogenolysis.¹ In the context of escalating global prevalence, DM is regarded as a significant chronic pandemic disease that affects individuals across all ethnic backgrounds and economic strata, regardless of whether they reside in developing or developed nations. DM has also been recognized as ‘public health priority’ in most countries around the world.^2,3 People having DM are at a higher risk of developing various correlated complications, including microvascular and macrovascular complications as well. Due to this, people encounter persistent and tiring contestation with the Medical services.⁴ The medical expenses for the management of diabetes and its related problems impose a substantial financial strain both at the domestic and countrywide scale.^5-8 The world’s diabetes capital may soon be India. After China, it was noted that India had 77 million individuals with diabetes in 2021, and it is anticipated that this number will nearly double, to 134 million by 2045. Taking this into account, the epidemiological evolution of diabetes carries a significant health burden, both socially and economically. Chronicity and the escalating epidemic of diabetes have enduring repercussions on the country’s health and economic well-being. Hence, controlling diabetes and dealing with its complications is a formidable challenge in India, attributable to various obstacles and impediments, including paucity of insight in regard to diabetes, its predisposing aspects, proactive measures, medical services, an underprivileged economic state, medication non-compliance, etc. Together, these issues and difficulties significantly increase the financial risk of diabetes in India. Diabetes in India is a multidimensional problem that includes genomic characteristics along with ecological factors, including obesity connected to an enhanced level of living, a persistent urban trend, and alterations in lifestyle. There is a lot of data available highlighting the diabetes predicament in India.⁹ However, there is limited data on how Indian diabetes patients from both rural and urban communities present in the clinics, as well as the impact of epidemiological factors on health outcomes. Hence, this study was designed to understand the geographical pattern and presentation of diabetes in North India diabetes clinics.

Study Subjects and Design

This was an observational, cross-sectional study, in which data were collected from the patients visiting the outpatient clinic of the primary care centres at cities of Agra, Kanpur, Ghaziabad, and Saharanpur of Uttar Pradesh state, with the help of a predesigned questionnaire in vernacular language (Table 1), from January 2019 to October 2020. This analysis represents the demographic profile of patients and looks into the commonest clinical presentation in a typical outpatient setting of DM, in the north Indian state of Uttar Pradesh.

Table 1.

Predesigned Questionnaires Tool.

1.	उम्र _ _ _ _ _ _ _ _
2.	वजन _ _ _ _ _ _ _
3.	लम्बाई _ _ _ _ _ _ _
4.	सेक्स: पुरुष ☐ स्त्री ☐ अन्य ☐
5.	शिक्षा: अशिक्षित ☐ 12th से कम ☐ ग्रेजुए ☐ पोस्टग्रेजुएट ☐
6.	व्यवसाय: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
7.	निवास स्थान: शहर ☐ क़स्बा/गांव ☐
8.	आपको सबसे पहले डॉयबिटीज़ किस उम्र मैं हुई _ _ _ _
9.	आपको डॉयबिटीज़ का कैसे पता चला ?
	a. पेशाब ज्यादा /बार-बार आता था ☐
	b. मुँह सूख रहा था ☐
	c. वजन कम हो रहा था ☐
	d. बार-बार पेशाब मैं इन्फेक्शन हो रहा था ☐
	e. बहुत कमजोरी महसूस हो रही थी ☐
	f. गुप्तांगो मैं खुजली हो रही थी ☐
	g. ब्लड शुगर की वैसे ही जाँच करवाई थी ☐
	h. आँख या किसी अन्य ऑपरेशन के दौरान पता चला ☐
	i. पेशाब मैं झाग आ रहा था ☐
	j. पैरों मैं जलन/झुनझुनी/चुनचुनी, चींटी सी काटना या सुन्नपन ☐
	k. बार-बार चश्में का नम्बर बदलना ☐
	l. परिवार या निकट सम्बन्धी को डॉयबिटीज़ होना ☐
	m. सम्भोग मैं रूचि ना होना या लिंग में तनाव ना आना ☐
	n. अन्य _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
10.	परिवार में किसी को डॉयबिटीज़ है ? हाँ ☐ नहीं ☐
	यदि हाँ: (a) पिता ☐ (b) माता ☐ (c) भाई/बहिन ☐ (d) दादा/दादी ☐
	(e) नाना/नानी ☐ (f) चाचा/मामा/ताऊ ☐ (g) चचेरे/ममेंरे भाई/बहिन ☐
11.	क्या आपको कोई हृदय सम्बन्धी रोग/हार्टअटैक हुआ है ? हाँ ☐ नहीं ☐
12.	क्या आपको कभी पक्षाघात (फालिस) हुआ है ? हाँ ☐ नहीं ☐
13.	क्या आपको रक्तचाप (BP) की समस्या है ? हाँ ☐ नहीं ☐
14.	क्या आपको गुर्दा (Kidney) सम्बन्धित समस्या है ? हाँ ☐ नहीं ☐
15.	क्या आप धूम्रपान/शराब/गुटखा/तम्बाकू आदि का सेवन करते हैं ? हाँ ☐ नहीं ☐
यदि हाँ: (a) धूम्रपान ☐ (b) शराब ☐ (c) गुटखा/तम्बाकू ☐

Materials and Methods

This was a secondary analysis of randomly selected patients, performed at multiple centres around the city of Agra. The analysis represents urban as well as rural patients, visiting a primary care outpatient setting of DM. For this analysis, clinical variables have been determined from the existing patient records, available on 1st October 2020. We included only those patients who presented to outdoor clinics for the first time as a case of newly diagnosed Type 2 diabetes as per the American Diabetes Association diagnostic criteria. We excluded those who had been diagnosed previously or were taking any treatment or lifestyle modification. We also excluded patients who had type 1 diabetes or were suffering from any other disease.

Statistical Analysis

Descriptive statistics had been used for analysis. The clinical variables were represented as mean values and/or percentages, as applicable. The odds ratio was used to measure the association between exposure and outcome for selected variables. The statistical significance of association was measured using the Chi-squared test for non-parametric variables.

Results

A 3,951 patient records have been included in the analysis. The key demographic aspects were represented in Table 2. 43.9% of the patients were females, and 56.1% were males. The median age of male and female patients was 50 years and 52 years, respectively. The median body mass index (BMI) of 26 kg/m² was suggestive of high prevalence of obesity in patients with DM, as per the Asian Indian criteria. The median BMI was 25.75 kg/m² in male patients and was 26.2 kg/m² in female patients.

Table 2.

Key Demographic Characteristics of Study Population The data in the tables and figures is our own research data, which has been statistically analyzed and reproduced in the form of tables and figures. Please note that we have not used any data/figure/table from any other sources..

	N (%)
Median age	50
Median weight (kg)	67.15
Median BMI (kg/m² )	26
Gender
Male	2215 (56.1)
Female	1736 (43.9)
Education
Number	1122 (33.2)
<12th pass	1067 (31.5)
Graduate	808 (23.9)
Post graduate	387 (11.4)
Residence
Urban	3094 (78.4)
Rural	852 (21.6)

Notes: Values are presented as mean ± standard deviation, median (range), or number (%).

BMI: Body mass index.

The most common presenting symptom was diabetes associated with neuropathy (41%) followed by frequent urination (33.5%), dry mouth (25.9%), and weight loss (22.7%) in the given patient population. Family history of DM was absent in 62.7% cases, while hypertension was the most commonly associated clinical condition in 34.6% of diabetes patients within the studied population. Nearly 1/3rd of the patients had not received any formal education. Only about 1/3rd of the population had a graduate-level or higher education. In the overall population, we did not observe a meaningful association between level of education and addiction (smoking, tobacco, or alcohol consumption); approximately 17% of the population had a history of any addiction, regardless of background educational status as shown in Table 3. 78.4% of the patients were urban residents, whereas 21.6% were from rural setting. A separate analysis was performed, involving adult (≥18 years old) patients from rural and urban areas. The results of this analysis were reported in Table 4. Hypertension (34.6%) was found to be most common comorbidity followed by tobacco use (13.1%) illustrated in Figure 1.

Table 3.

Clinical Features of Study Population.

Presenting Symptoms
Symptoms of neuropathy	1608 (40.7)
Frequent urination	1324 (33.5)
Dry mouth	1023 (25.9)
Weight loss	896 (22.7)
UTI	376 (9.5)
Dullness	1160 (29.4)
Urogenital itching	624 (15.8)
Known surgery	200 (5.1)
Foamy urine	459 (11.6)
Eyesight change	313 (7.9)
Erectile dysfunction	247 (6.3)
Breathlessness or fatigue	4 (0.1)
Poor wound healing	6 (0.2)
Others	37 (0.9)
Family history of diabetes mellitus
Diabetes absent	2477 (62.7)
Not known	82 (2.0)
Diabetes present	1474 (37.4)
• Parents (either father or mother or both)	1045 (70.8)
• Siblings	319 (21.7)
• Grandparents	56 (3.8)
• Cousins	54 (3.7)
Concomitant medical conditions
Hypertension	1366 (34.6)
Tobacco	487 (13.1)
Smoking	257 (7.4)
Alcohol	243 (7.0)
Cardiac disease	129 (3.4)
Chronic kidney disease	89 (2.3)
Stroke	68 (1.7)

Notes: Values are presented as mean ± standard deviation, median (range), or number (%).

UTI: urinary tract infection.

Family history was absent in 2395 (60.6%) population whereas it was present in 1474 (37.4%) reported in Table 3. In the rural subgroup, the odds of having female cases were 27% lower, as compared to urban subgroup. The significantly higher female-proportion in urban subgroup, although possibly indicative of improved diagnosis in females, was still at 45% mark. Patients from rural setting had 59% higher odds of not having any formal education, and 23% higher odds of any addiction-related history. Odds of heart disease and of stroke were significantly higher in the urban patients; the absolute risk for these outcomes differed by 1.5% and 1.2%, respectively, between the two settings. Positive history of any addiction was associated with 85% higher odds of heart disease or stroke (P < .05) in the overall adult population. Importantly, presence of formal education was not linked with a lower probability of addiction in any of the two (urban or rural) settings.

Table 4.

Clinical Presentation of Rural and Urban Adult Patients with Diabetes Mellitus.

	Rural Adults	Urban Adults	Odds Ratio	P Value
Total patients	842	3084	–	–
Age (median, years)	51	50	–	–
BMI (median, kg/m²)	24.9	26	–	–
Females	40%	45%	0.73	<.001
No formal education	40%	26.4%	1.59	<.001
H/o any addiction	21.3%	18.1%	1.23	.03
H/o heart disease	2.1%	3.6%	0.59	.03
H/o stroke	0.8%	2.0%	0.42	.03
H/o hypertension	32.4%	35.3%	0.88	.11
H/o kidney disease	2.4%	2.2%	1.08	.3

Notes: Values are presented as mean ± standard deviation, median (range), or number (%).

BMI: body mass index.

Figure 1.

Diabetes Comorbidities.

Table 5 depicts the results of multiple logistic regression analysis, which looks at how predictors influence the likelihood of heart disease outcome. Independent variables such as age and consumption of liquor were associated with a statistically significant increased risk of heart disease, whereas smoking, tobacco consumption, male gender and no formal education also increased the risk of heart disease but statistically not significantly.

Table 5.

Regression Coefficients Predicting Heart Disease Risk.

	Coefficient B	Standard Error	z	P	Odds Ratio	95% Conf. Interval
Constant	–6.43	0.72	8.91	<.001	0	0-0.01
Age	0.05	0.01	6.07	<.001	1.05	1.03–1.07
BMI	0.01	0.02	0.46	.644	1.01	0.97–1.04
Rural residence	–0.41	0.31	1.34	.181	0.66	0.36–1.21
Smoking	0.17	0.35	0.5	.614	1.19	0.6–2.34
Liquor	0.8	0.33	2.47	.014	2.23	1.18–4.23
Tobacco	0.2	0.35	0.56	.576	1.22	0.61–2.42
Male	0.22	0.21	1.06	.29	1.25	0.83–1.9
No formal education	0.05	0.21	0.25	.805	1.05	0.69–1.61

Notes: Standard multiple linear regression analysis.

Dependent Variable: Heart Disease.

Discussion

Heightening peril of diabetes has been a chief issue for India and as predicted we are soon going to be world capital. To analyse a few points for an increase in incidence of the disease we think that an expeditious cultural and social transformation, namely, increasing age, dietary adjustment, swift urban development, inadequacy of consistent workout routine, obesity and a desk-bound living is the cause for rise in incidence. This study looks into the epidemiology and the prevalence of diabetes amongst the rural and urban communities from the state of Uttar Pradesh and the commonest clinical presentation among Type 2 diabetes mellitus (T2DM) patients.

We found that the median age of diagnosis was 50 years in urban population and 51 years in rural population. Subramani et al. observed a similar pattern among T2DM patients in central India, though it was also observed that a large no. of population had prediabetes.¹⁰ The median BMI in this study was 24.9 kg/m² in rural adults and 26.0 kg/m² in urban population; this difference is attributable to the availability of resources and the lifestyle followed in the urban population. Ganz et al. stated that BMI is powerfully and autonomously allied as a risk factor for being diagnosed with T2DM. The progressive affiliation of BMI category on the risk of T2DM is sturdier for people with a greater BMI relative to individuals with a lesser BMI.¹¹ Boffetta et al. showed that in the Asian population, the association of BMI was strong in persons below age 50 at baseline (P value of interaction < .001) in cohorts from India and Bangladesh.¹²

In this study, we found that patients residing in the rural area had higher odds of not having received a formal education, the prevalence of diabetes though was more in the urban educated community. Shang et al. observed that among the Asian population low educational level was detrimentally linked with the incidence of diabetes.¹³ Seiglie et al. found the opposite for the Western population and concluded that among low-income group countries, the diabetes prevalence was substantial and increased with increasing income groups. On the contrary it is seen in high income countries with BMI as an independent risk factor, the diabetes risk was more in well educated people.¹⁴

In this study, we found the presence of neuropathy to be 41%, similar to the prevalence of peripheral neuropathy of 44.9% in a study conducted by Venguidesvarane AG among 390 rural T2DM patients in South India.¹⁵ The clinical features varies from clinically silent to excruciating neural discomfort. Owing to the danger of foot ulcer (25%) and amputation linked with diabetic peripheral neuropathy, intense screening and treatment in the form of glucose maintenance, routine foot examinations, and pain mitigation are essential.^16-18

In this study, we found a higher odds of developing heart disease and stroke were significantly higher in the urban patients; the absolute risk for these outcomes differed by 1.5% and 1.2%, respectively, between the two settings, this observation is resembling those from Sridhar et al. and Mohan et al.^19,20 In spite of the higher literacy rate, per capita income, and a standard of living in urban areas amongst all others, people were identified as nescient of their concomitant ailments.

A diabetes prevention program should be planned for control of lifestyle risk factors through various healthcare prevention strategies among urban and rural settings, as well as detection of diabetes should be done through health camps, and effective treatment should be provided on a regular basis for better control of diabetes and its complications. Some national policies, such as food policies, health policies, disease prevention policies, as well as drug policies for cost-effectiveness and ease of access to essential drugs, should be strengthened in urban and rural settings to slow the further progression of diabetes across different geographies of India.²¹

Limitation

The study has some limitations. First, the responses to questionnaires were subjective and may have a so-called possibility of response bias. Second, the sample size was too small to interpret the results on a large scale.

Conclusion

This descriptive study shows majority of diabetes patients were obese, residing in an urban setting. Rural diabetes patients were associated with a higher odds of not having any formal education and addiction history compared to urban diabetes. There was a higher incidence of heart disease or stroke among patients with positive history of any addiction. A formal patient education and support program, especially targeting rural population, would help in mitigating these disparities among urban and rural diabetes populations. Taking into account the immense load of diabetes on healthcare systems, patients and families across the globe, more evidence is needed, ideally in the form of registry studies, to more precisely quantify the burden of diabetes in India.

Footnotes

Author Contributions

All authors have equally contributed to the preparation of the manuscript and meet all authorship criteria of the rules made by editor of journal. The manuscript represents an honest work by all authors.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Ethical Approval

Ethical Approval was taken from the institutional ethics committee for conducting this study.

Informed Consent

Written informed consent for the article to be published (including images, case history and data) was obtained from the patient for publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

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A Multicentric Study from North India to Evaluate and Compare Epidemiological,Demographic and Clinical Characteristics of Diabetic Patients and Associated Comorbidities

Abstract

Aims:

Methods and Materials:

Results:

Conclusion:

Keywords

Introduction

Study Subjects and Design

Materials and Methods

Statistical Analysis

Results

Diabetes Comorbidities.

Discussion

Limitation

Conclusion

Footnotes

Author Contributions

Declaration of Conflicting Interests

Ethical Approval

Informed Consent

Funding

References