Shriraam Mahadevan

Are the current Indian growth charts really representative? Analysis of anthropometric assessment of school children in a South Indian district.

Background: India currently is posed by the double threat of thinness and overweight/obesity among children. Different growth charts have taken different population and give different cut-off points to assess these conditions. Objective: The objective of this study is to assess the anthropometry of school children, 5-18 years of age and thereby estimate the prevalence of childhood thinness, overweight and obesity. To analyze how the study population compares with that of Agarwals growth chart. Materials and Methods: The anthropometric measurements of all the students who were studying from 1st to 12th standards were taken from 27 randomly selected Government and private schools. Prevalence of thinness, overweight and obesity were assessed using two standards – Indian standard given by Agarwal and International Standards given by International Obesity Task Force (IOTF). Results: The prevalence of thinness, overweight and obesity among 18,001 students enrolled as per Indian standard were 12.2%, 9.5% and 3% and as per International standard were 15.3%, 8.1% and 2.6% respectively. The mean and the 95th percentile values of body mass index for both boys and girls at all ages in this study are falling short of Agarwals and IOTF values. Using international cut-offs as well as Indian cut-offs given by Agarwal, underestimate the prevalence of obesity among boys and girls of all age groups. Conclusion: This study shows that under and over-nutrition among school children is in almost equal proportions. There is an underestimation of obesity among children whenever an Indian or an International growth chart is used. Thus, this study brings out the need for a really representative growth chart.

Knowledge of hypoglycemia and its associated factors among type 2 diabetes mellitus patients in a Tertiary Care Hospital in South India

Introduction: Hypoglycemia being the rate limiting complication in the attainment of strict glycemic control in diabetes management, in this study, we intended to study the knowledge of its symptoms, target blood levels during treatment and ways of prevention among type 2 diabetes patients attending Outpatient Department (OPD) of a medical college hospital. Materials and Methods: Every fifth patient attending the OPD during the 4 months between March and June 2013 was interviewed using a questionnaire. Results: The study included 366 type 2 diabetic patients, of which 76.5% were females. The target fasting and postprandial blood glucose levels while on treatment was known to 135 (36.9%) and 126 (34.4%) patients, respectively. The common symptoms of hypoglycemia known to the study subjects were dizziness (81.4%), weakness (73.8%), and drowsiness (72.1%). Overall, 242 (66.1%) diabetic patients had good knowledge on hypoglycemia (knowledge of at least three symptoms of hypoglycemia together with at least one precipitating factor and at least one remedial measure). Higher age, illiteracy, low socioeconomic status were associated with poor knowledge whereas treatment with insulin along with oral hypoglycemic agents was associated with good knowledge on hypoglycemia. Sex and duration of disease were not associated with knowledge on hypoglycemia. Conclusion: Although the knowledge on symptoms of hypoglycemia, precipitating factors, remedial measures are high in this study, the target blood levels, complications were known to just a third of them. There is a knowledge gap on important aspects of hypoglycemia among type 2 diabetic patients.

National health programs in the field of endocrinology and metabolism - Miles to go

The endocrine and metabolic diseases of childhood obesity, diabetes mellitus, hypertension, iodine deficiency disorders, vitamin D deficiency, and osteoporosis are major public health problems. Different programs including National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke address these problems although some are yet to be addressed. National surveys have shown high prevalence of these disorders and their risk factors. Most of the programs aim at awareness raising, lifestyle modification, (primary prevention) and screening (secondary prevention) for the disease conditions as these are proven to be cost-effective compared to late diagnosis and treatment of various complications. Urgent concerted full scale implementation of these programs with good coordination under the umbrella of National Rural Health Mission is the need of the moment. The referral system needs strengthening as are the secondary and tertiary levels of health care. Due attention is to be given for implementation of these programs in the urban areas, as the prevalence of these conditions is almost equal or even higher among urban poor people where primary and secondary prevention measures are scarcely available and treatment costs are sky-high.

Estimation of magnesium in patients with functional hypoparathyroidism

Context: It is evident that about 30-50% of patients with Vitamin D deficiency (VDD) do not manifest develop secondary hyperparathyroidism (SHPT). A number of theories have been proposed to explain this lack of SHPT, including hypomagnesemia. Settings and Design: Retrospective review of laboratory database. Materials and Methods: We evaluated the differences in serum magnesium (Mg) levels among those with VDD with or without SHPT. A retrospective review of 6255 laboratory data of bone mineral profiles performed in the period of 2007–2013. After excluding patients with hypercalcemia, renal dysfunction/unknown kidney function and primary hypothyroidism, the remaining 1323 patient data were analyzed. SHPT was defined as serum parathyroid hormone >65 in those with VDD. Statistical Analysis Used: ANOVA and Wilcoxon tests as appropriate to compare means. Multivariate logistic regression to analyze relation between variables and outcome of SHPT. Results: We noted that 55% patients (n = 727) had VDD, and among those who had VDD, 23% (n = 170) were hypocalcemic (corrected serum calcium <8.5). Patients with VDD who did not exhibit SHPT were 56% (n = 407). The mean (±standard deviation) serum Mg levels in the entire cohort (n = 1323) was 1.94 ± 0.26 mg/dl and 1.95 ± 0.26 mg/dl in VDD cohort and 2 ± 0.31 mg/dl in the VDD-hypocalcemic cohort. There was no statistical difference in the Mg levels among those with SHPT compared to those without SHPT (P = 0.14). Serum calcium and phosphorus were lower in those with SHPT (P = 0.06 and P < 0.001, respectively). In multivariate logistic regression, serum calcium (P = 0.043), phosphorus (P < 0.001) and severe VDD (P < 0.001) independently correlated with occurrence of SHPT in VDD. Conclusions: Serum Mg levels did not explain the functional hypoparathyroidism seen in about half of the patients with VDD. A low normal serum calcium and phosphorus levels are more likely to be associated with VDD patients who develop SHPT.

Does fasting or postprandial state affect thyroid function testing

Background: Thyroid stimulating hormone (TSH) levels vary with the time of the day and probably in relation to food. In this study, we addressed the question of whether a fasting or non-fasting sample would make a clinically significant difference in the interpretation of thyroid function tests. Materials and Methods: Fifty seven adult ambulatory patients were selected from our laboratory database and were divided into Group A [Normal free thyroxine (T4) and TSH], Group B (subclinical hypothyroid with increased TSH and normal free T4) and Group C (overt hypothyroid with low free T4 and high TSH). Thyroid functions (free T4 and TSH) were done in fasting state and 2 hours postprandially. Results: TSH was suppressed in all subjects after food irrespective of the fasting levels. Free T4 values did not change significantly. This resulted in reclassification of 15 out of 20 (75%) subjects as subclinical hypothyroidism (SCH) based on fasting values whose TSH values were otherwise within range in the postprandial sample. This may have an impact on the diagnosis and management of hypothyroidism especially where even marginal changes in TSH may be clinically relevant as in SCH and in pregnancy. Conclusion: TSH levels showed a statistically significant decline postprandially in comparison to fasting values. This may have clinical implications in the diagnosis and management of hypothyroidism, especially SCH.

Resistance to Thyroid Hormone - A Novel Mutation in THRβ-Gene from India

To the Editor: Resistance to Thyroid Hormone (RTH) is a dominantly inherited disorder (OMIM#188,570) caused by heterozygous mutations in the THRβ-gene (OMIM*190,160) with an incidence of 1 in 40,000 [1, 2]. Among 183 families investigated, THRβ-gene mutations have been identified in 85 % and among them, 28 % occurred de novo [1]. A 6.5-y-old boy of eastern Indian descent, born of nonconsanguineous parentage was evaluated for goiter of 6–8 mo duration. The history suggested normal growth and development and good scholastic performance. Height was 121 cm (75–97 centile) and weight was 19.5 kg (25–50 centile). He had a 20 g diffuse soft goiter (Fig. 1). Pulse rate was 68 bpm, BP 104/64 mmHg (>95 centile) and bone age 5.5–6 y (Greulich & Pyle chart). His audiological assessment was normal. Neuropsychological assessment revealed good attention span, adequate construction, and memory functions with IQ (Binet Kamat) score 95. Thyroid function test of the patient, his parents and siblings are shown in Table 1. Peripheral blood DNA was sequenced on Illumina sequencing platform and analysed using Picard and GATK-Lite toolkit. A heterozygous mis-sense variation in chromosome 3, exon 10 of the THRβ-gene (c.1357C > C/T (p. P453S) was detected. Mutation testing in parents or sibling was not performed. The P453S codon variant seen in the index patient has previously been reported in 2 kindreds [3]. One of the kindred reported an autosomal dominant presentation of RTH in a 22 y femalewith 3 out of 5 affected familymembers harbouring the mutation [3]. Our case is the first report of the THRβmutation from India and has a novel polymorphic variation in THRβ resulting in codon P453S. Although the mutation in the index patient has occurred in a known Bcodon hot spot^ (codons 429–460) resulting in a previously reported altered amino-

Reported hypoglycemia in Type 2 diabetes mellitus patients: Prevalence and practices-a hospital-based study

Introduction: Hypoglycemia tops the list of hurdles in preventing tight glycemic control in diabetic patients. It is even considered as a cardiovascular risk factor. However, it continues to be a neglected complication with very limited epidemiological data in our country. Aim: To study the self-reported prevalence of hypoglycemia among type 2 diabetic patients and the practices adopted by them during and after the episodes to manage and avert future occurrences. Materials and Methods: It is a questionnaire-based cross-sectional study done using systematic random sampling selecting every 5th patient attending the diabetic Out-Patient (OP) in a tertiary medical college hospital. Results: There were 366 participants with median age of 60 years. Around 96% reported any one symptom of hypoglycemia, but 78% had eaten following the episode and got relieved of the symptoms. Weakness (76.2%) and dizziness (74%) were the most common symptoms reported by the patients. A quarter of them reported having severe attacks requiring somebodys assistance. Most patients resorted to timely meals (85%) to avert future attacks. Patients who took insulin along with oral hypoglycemic agents (OHAs) were at a higher risk (OR = 2.3) for hypoglycemia compared to patients taking only OHAs (P < 0.01). Conclusion: The reported prevalence of hypoglycemia among type 2 diabetes patients is quite high. This finding reiterates the importance of enquiring and educating every diabetic patient about hypoglycemic episodes during every health visit.

Is body mass index a good indicator of obesity

The obesity epidemic has become the most blatantly visible public health problem globally. Industrialization, urbanization, and globalizations have resulted in the adoption of proobesity lifestyle. The incidence of non-communicable diseases (NCDs) is increasing at alarming rates globally. As of 2014, more than 1.9 billion adults 18 years and older were classified as overweight and more than 600 million as obese. Combined overweight and obesity account for more deaths worldwide than underweight [1–3]. Obesity and its associated twin diabetes together comprise a major public health problem. The term diabesity is being used frequently to better describe the current twin epidemic [4]. Body mass is the simplest and the most widely used parameter for measuring obesity. Body mass index (BMI) is calculated by dividing body weight in kilograms by height in meters squared (BMI=kg/m). It is the epidemiological and clinical parameter used to define obesity in most of the studies. According to the World Health Organization (WHO), a BMI of greater than or equal to 25 is classified as overweight and a BMI of greater than or equal to 30 is classified as obese. This is the most useful population-level measure of overweight and obesity. It does not measure the body fat directly and hence is an indirect measure of obesity [3]. Hence, it has several drawbacks. A person’s body fat composition changes with age and increases as the person gets older. This is not necessarily reflected by the person’s weight and height. Furthermore, the correspondence between BMI and body differs for bothmen and women. For example, a man and woman of the same height and weight may have the same BMI but women have higher body fat composition compared to men. Taking the debate one step further, several long-term studies have shown that individuals classified as overweight with respect to their BMI, by and large, had the same or in some instances better health profile outcomes as compared to those who had a normal BMI. These and other such studies have opened a new avenue for the researchers to look into the intrinsic limitations of BMI in differentiating adipose tissue from lean body mass [5, 6]. It is a well-accepted fact that central or abdominal fat is far more likely to be associated with chronic metabolic disorders rather than the overall excess weight reflected by BMI; several studies have reported a higher incidence of metabolic abnormalities in Indian population. The same studies have further gone on to document a higher incidence of cardio-metabolic abnormalities in Indians for any given level of BMI [7, 8] Considering these observations, the WHO had lowered BMI cutoffs for overweight and obesity in Asians to 23 and 27 kg/ m, respectively, mainly for public health action [9]. However, evidence used to establish this classification was obtained from only limited numbers of prevalence studies, not from more conclusive incidence or mortality data. This has generated debate about the appropriateness of ethnic-specific cutoff points for defining obesity. A pertinent question which arises then is Bdoes BMI above the cutoffs currently defined for overweight and obesity result in detrimental health consequences?^ The answer is not a simple yes as the literature is replete with contradictions. A pooled analysis showed a reasonably strong association of higher BMI with diabetes and atherosclerotic Int J Diabetes Dev Ctries (April–June 2016) 36(2):140–142 DOI 10.1007/s13410-016-0506-5

Fasting practices in Tamil Nadu and their importance for patients with diabetes.

Religious practices and cultural customs related to eating habits have a significant impact on lifestyle and health of the community. The Ramadan fasting in Muslims and its influence on various metabolic parameters such as diabetes have been reasonably studied. However, literature related to Hindu religious customs related to fasting and food patterns during various festivals and its effect on diabetes are scarce. This article is an attempt to describe the Hindu religious customs related to fasting and food practices from the State of Tamil Nadu (South India) and to raise the awareness among physicians about its relationship with diabetes which may help in managing their diabetic patients in a better way.

A systematic review on normative values of trimester-specific thyroid function tests in Indian women

Background: Small cross-sectional studies are published on the trimester-specific normal ranges of thyrotropin and thyroxine levels in Indian women from various parts of the country. Objective: We sought to review the published literature on thyroid function tests in normal pregnant Indian women to see if the pooled data from various studies can define normative data and hypothyroidism in pregnancy. Methods: We retrieved 56 studies from online databases with detailed search using multiple search terms. Unanimously eight studies were finalized. Results: Data of 2703 pregnant women (age 16–45 years; 966 were in the first trimester, 1072 in their second trimester, and 1037 women in their third trimester) were analyzed. All eight studies included singleton pregnancies from the northern and eastern part of India with seven studies being cross-sectional in nature. The exclusion criteria in all studies included those with historical/clinical evidence of thyroid dysfunction, those with family history of thyroid dysfunction, infertility and those with history of recurrent miscarriages (usually >3). Ultrasound evidence of thyroid disease, urinary iodine assessment, and thyroid antibodies were included as additional exclusion criteria in two, three, and four studies, respectively. None of the studies included the outcome of pregnancy as part of follow-up. As part of the pooled data analysis, the 5th–95th centile values of normal TSH extended from 0.09 to 6.65 IU/mL in the first trimester, 0.39–6.61 IU/mL in the second trimester, and 0.70–5.18 IU/mL in the third trimester. The FT4 levels (5th–95th centile values) extended from 8.24 to 25.74 pmol/L in the first trimester, 6.82–26.0 pmol/L, and 5.18–25.61 pmol/L in the third trimester. Conclusions: With due limitations imposed by the quality of the available studies, the current review suggests that upper normal limit of TSH values can extend up to 5–6 IU/mL in pregnancy.