Arti D. Shah

Adipokines and Body Fat Composition in South Asians: Results of the Metabolic syndrome and Atherosclerosis in South Asians Living in America (MASALA) Study

Objective:To investigate whether leptin and adiponectin are associated with body fat composition in a South Asian population independent of metabolic variables.Design:Cross-sectional study.Subjects:150 South Asian men and women, between the ages of 45–79 years, in the San Francisco Bay Area without pre-existing clinical cardiovascular disease.Measurements:Blood samples were obtained to measure glucose metabolism variables, lipid profiles and adipokines. Total body fat was determined using dual-energy X-ray absorptiometry. Abdominal computed tomography was used to measure subcutaneous, visceral and hepatic fat.Results:Average body mass index (BMI) was overweight at 26.1±4.6 kg m−2 and did not differ by sex. However, women had significantly more total body fat (P<0.001) and subcutaneous fat (P<0.001) than men, whereas men had significantly more visceral fat (P<0.001) and hepatic fat (P=0.04) than women. Women had significantly higher levels of adiponectin (P<0.01) and leptin (P<0.01). In sex-stratified analyses, leptin was strongly associated with all-body composition measures in women (P<0.05) as well as in men (P<0.05 except for hepatic fat), whereas there was an insignificant trend towards an inverse association between adiponectin and body composition in both women and men, which was significant in combined bivariate analyses. In multivariate analyses, leptin was strongly associated with all measures of adiposity, including BMI (P<0.001), total body fat (P<0.001), visceral fat (P<0.001) and hepatic fat (P=0.01). However, adiponectins inverse association with adiposity was significantly attenuated by high-density lipoprotein (HDL), triglycerides and insulin resistance. The association between adipokines and diabetes was markedly attenuated after adjusting for body composition.Conclusion:Despite only modestly elevated BMI, South Asians have elevated levels of total and regional adiposity. Leptin is strongly associated with adiposity, whereas adiponectins association with adiposity is attenuated by metabolic variables in South Asians. Adipokines in association with adiposity have an important role in the development of diabetes.

Diabetes and associated complications in the South Asian population.

The rising prevalence of diabetes in South Asians has significant health and economic implications. South Asians are predisposed to the development of diabetes due to biologic causes which are exacerbated by lifestyle and environmental factors. Furthermore, they experience significant morbidity and mortality from complications of diabetes, most notably coronary artery disease, cerebrovascular disease, and chronic kidney disease. Therefore, understanding the pathophysiology and genetics of diabetes risk factors and its associated complications in South Asians is paramount to curbing the diabetes epidemic. With this understanding, the appropriate screening, preventative and therapeutic strategies can be implemented and further developed. In this review, we discuss in detail the biologic and lifestyle factors that predispose South Asians to diabetes and review the epidemiology and pathophysiology of microvascular and macrovascular complications of diabetes in South Asians. We also review the ongoing and completed diabetes prevention and management studies in South Asians.

Less favorable body composition and adipokines in South Asians compared with other US ethnic groups: results from the MASALA and MESA studies.

Background:Small studies have shown that South Asians (SAs) have more total body, subcutaneous, visceral and hepatic fat and abnormal adipokine levels compared with Whites. However, comprehensive studies of body composition and adipokines in SAs compared with other ethnic groups are lacking.Methods:Using harmonized data, we performed a cross-sectional analysis of two community-based cohorts: Mediators of Atherosclerosis of South Asians Living in America (MASALA, n=906) and Multi-Ethnic Study of Atherosclerosis (MESA which included 2622 Whites, 803 Chinese Americans, 1893 African Americans and 1496 Latinos). General linear models were developed to assess the ethnic differences in ectopic fat (visceral, intermuscular and pericardial fat; and hepatic attenuation), lean muscle mass and adipokines (adiponectin and resistin). Models were adjusted for age, sex, site, alcohol use, smoking, exercise, education, household income and body mass index. Ectopic fat models were additionally adjusted for hypertension, diabetes, high-density lipoprotein and triglycerides. Adipokine models were adjusted for subcutaneous, visceral, intermuscular and pericardial fat; and hepatic attenuation.Results:Compared with all ethnic groups in MESA (Whites, Chinese Americans, African Americans and Latinos), SAs had greater intermuscular fat (pairwise comparisons with each MESA group, P<0.01), lower hepatic attenuation (P<0.001) and less lean mass (P<0.001). SAs had greater visceral fat compared with Chinese Americans, African Americans and Latinos (P<0.05) and greater pericardial fat compared with African Americans (P<0.001). SAs had lower adiponectin levels compared with other ethnic groups (P<0.01; except Chinese Americans) and higher resistin levels than all groups (P<0.001), even after adjusting for differences in body composition.Conclusion:There are significant ethnic differences in ectopic fat, lean mass and adipokines. A less favorable body composition and adipokine profile in SAs may partially explain the increased predisposition to cardiometabolic disease. The mechanisms that underlie these differences warrant further investigation.

Correlates of prediabetes and type II diabetes in US South Asians: Findings from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study

PURPOSE In this study, we aim to elucidate the role of sociodemographic, lifestyle, and cultural factors in prediabetes and diabetes in South Asian immigrants to the United States, a population at high risk of type II diabetes. METHODS We performed a cross-sectional analysis of a community-based cohort of 899 South Asians without known cardiovascular disease from the Mediators of Atherosclerosis in South Asians Living in America study. Glycemic status was determined by fasting glucose, 2-hour postchallenge glucose, and use of diabetes medication. We used multinomial logistic regression models to estimate the independent associations of sociodemographic, lifestyle, and cultural factors with prediabetes and diabetes, adjusting for confounders identified using directed acyclic graphs. RESULTS Approximately 33% of participants had prediabetes and 25% had diabetes. In multivariate analyses, an independent correlate of prediabetes was low exercise. Additional covariates associated with diabetes included lower family income, less education, high chronic psychological burden score, and greater time spent watching television; and fasting monthly or annually was inversely associated with diabetes prevalence. CONCLUSIONS We found several modifiable risk factors associated with prediabetes and diabetes that may help guide diabetes prevention interventions for South Asian immigrants to the United States.

Falsely Decreased HbA1c in a Type 2 Diabetic Patient Treated with Dapsone

OBJECTIVE To discuss a case of a falsely low hemoglobin A1c (HbA1c) in a transplant patient treated with dapsone and its implications. HbA1c is widely used as a measure of glycemic control in diabetic patients. With the increasing transplant population, it is important to be mindful of medications used in this population that can affect HbA1c and to use other measures of glycemic control to guide treatment decisions. METHODS We present details of the case and review the relevant literature. RESULTS A 61-year-old patient received a liver transplant in 2012 and subsequently was noted to have a falling HbA1c despite evidence of hyperglycemia based on fingerstick glucose and fructosamine measurements. Review of the medical records revealed that the discordance between HbA1c and fingerstick glucose levels developed after initiation of dapsone therapy. Dapsone may lead to a falsely low HbA1c via several mechanisms. Upon cessation of dapsone therapy, the patients HbA1c returned to pre-dapsone levels. CONCLUSION It is important to be aware of medications commonly used in transplant patients that may lead to a falsely low HbA1c level so that incorrect treatment decisions are not made. Fructosamine correlates with HbA1c and can be used as a measure of glycemic control in transplant patients when HbA1c cannot be used.

INTRAVENOUS CONTRAST IN PATIENTS WITH DIABETES ON METFORMIN: NEW COMMON SENSE GUIDELINES.

Abbreviations: ACR = American College of Radiology AKI = acute kidney injury CT = computed tomography Cr = creatinine DM = diabetes mellitus eGFR = estimated glomerular filtration rate FDA = Food and Drug Administration FDG = fluorodeoxyglucose IV = intravenous

The association between body composition and cystatin C in South Asians: Results from the MASALA study

While South Asians have high rates of obesity and kidney disease, little is known about the effect of regional body composition on kidney function. We investigated the association between body composition measures and cystatin C-based estimated glomerular filtration rate (eGFRcysC) in 150 immigrant South Asians. The inverse association between overall adiposity and eGFRcysC was attenuated by C-reactive protein (CRP), while the association of ectopic fat was completely attenuated by metabolic covariates and CRP. In immigrant South Asians, the associations between overall adiposity and ectopic fat with decreased kidney function are largely explained by metabolic alterations and inflammation.

Patient Self-Management of Diabetes Care in the Inpatient Setting: Con.

Self-management of diabetes by inpatients can be problematic. People with type 1 diabetes often prefer to self-manage their diabetes in the inpatient setting. We report the case of a patient admitted to the surgical service who was self-administering his home insulin, often without telling his nurse or physician. He was aiming for tight glycemic control, which resulted in life-threatening hypoglycemia. While patients can often self-manage their diabetes in the outpatient setting, inpatient management of diabetes is very different. Patients may not be familiar with common scenarios requiring adjustments of insulin therapy. Therefore, we recommend against self-management of diabetes in the hospital. However, the patients should be involved in discussions about management of their diabetes in the hospital to allay their concerns about changes made to their insulin regimens. An example of successful cooperative management is with use of protocols that allow continued use of insulin pumps in the hospital.

Mitral regurgitation and pulmonary edema.

An asymptomatic 88-year-old Asian male with hypertension presented with a right upper lobe infiltrate on chest x-ray. A chest CT (Fig. 1) demonstrated a geographic 3.5 × 2.2-cm ground-glass opacity in the right apex. A 3/6 holosystolic murmur was heard at the apex radiating to the axilla. Transthoracic echocardiography showed a flail posterior mitral valve leaflet secondary to a ruptured chordae tendinae. In patients with a flail posterior mitral valve leaflet, the regurgitant jet is directed towards the right superior pulmonary vein (Fig. 2), causing higher hydrostatic pressures in that location. This may lead to focal edema in the right upper lobe. Prior studies have shown that up to 38% of patients with a ruptured chordae tendinae remain asymptomatic in the subacute to chronic setting despite severe mitral insufficiency. In most cases, surgical repair is highly successful. However, given this patient’s age and his excellent response to medical therapy with an angiotensin receptor blocker, surgery was not performed. In the setting of upper lobe infiltrates where infection and cancer seem unlikely or have been excluded, mitral regurgitation with segmental pulmonary edema should be considered.

Virtual glucose management service: a novel resident educational tool

form of a booklet containing the reflections of others and an area for self-reflection by graduating students. What was tried? Patients, doctors and other health professionals were interviewed and asked only two questions: What are the qualities of a ‘good’ doctor? What are the qualities of a ‘not so good’ doctor? Various themes emerged amongst the different groups and a representative sample of quotations was collated. The booklet, entitled Good Doc, Bad Doc, was created with the aim of producing an aesthetically pleasing end product. The front section of the booklet was dedicated to quotations derived from responses to question 1 (What are the qualities of a ‘good’ doctor?), and the back section contained quotations derived from responses to the questions on the qualities of a ‘bad’ doctor. The centre of the booklet contained an area for self-reflection and the reader was encouraged to consider what he or she thought made a ‘good’ or ‘bad’ doctor at different stages of a career. The aim of the project was to present the booklet to the graduating medical students of 2016 so that they could use it as a tool for self-reflection throughout their careers. The booklet was initially presented to a focus group of final-year medical students. Their response was overwhelmingly positive. It provided an excellent source of discussion among the group, who were eager to see themes in the responses given and used it to reflect on their own practice. The group felt that in reality this tool would be best used at the earliest possible stage of medical school and could be used to track the learner’s maturing views on professional behaviour. They felt that then, once the booklet had proven to be a useful resource, they would be more likely to take it into their work following graduation. What lessons were learned? In light of the input given by the focus group, the booklet was used as originally intended and presented to graduating doctors in 2016. The original focus group will be followed up and the impact of the booklet fully assessed at this time. The development of the original project to introduce the booklet at the beginning of medical school, alongside a discussion on the use of reflective practice, can be planned. The practicability and effectiveness of using this as a tool for self-reflection at an earlier stage will be further evaluated and compared with the original project and its follow-up results. REFERENCE