Thilak Priyantha Weerarathna

Osteoporosis and cardiovascular risk among premenopausal women in Sri Lanka.

We examined the association between bone mineral density (BMD) and cardiovascular risk in a group of premenopausal women selected from the Southern province of Sri Lanka. One hundred six previously healthy premenopausal volunteers (aged 30-54 yr) were recruited by open invitations. Subjects with previous history of diabetes, hypertension, epilepsy, chronic renal or liver disease, hyperlipidemia, ischemic heart disease, endocrine diseases, or prolonged inflammatory conditions were excluded. Subjects who were taking medications that can affect bone density, blood sugar, serum lipids, or blood pressure (BP) were also excluded. Women with the history of previous fractures were not excluded. BMDs in the spine, hip, and total body (TB) were measured using a Hologic Discovery scanner (Hologic Inc, Bedford, MA). BP, fasting glucose, and fasting lipids were also measured. Independent of body mass index (BMI) and age, TB bone mineral content (BMC) and spine BMD showed inverse and significant correlations with total cholesterol (TC), low density cholesterol, and the ratio between TC and high density lipoprotein cholesterol (r ranged from -0.24 to -0.27, p<0.05 for all). The highest mean lipid levels were seen among the women in the lowest third of spine BMD, whereas women in the upper third of spine BMD had the lowest lipid levels. The number of women with metabolic syndrome in the 3 tirtiles of spine BMD was not significantly different. Fasting glucose or BP had no association with either BMD or BMC. In conclusion, our data demonstrates an association, independent of age and BMI, between BMD and BMC or lipid levels among previously healthy, premenopausal women. This may explain the high cardiovascular risk seen in women with osteoporosis in old age.

Correlation between changes of blood pressure with insulin resistance in type 2 diabetes mellitus with 4 weeks of pioglitazone therapy.

OBJECTIVE: To examine effects of pioglitazone (PIO) on systolic, diastolic, pulse and mean blood pressures (SBP, DBP, PP and MP, respectively) in type 2 diabetes mellitus (T2DM). MATERIALS AND METHODS: One hundred and six normotensive patients with T2DM with mean fasting blood glucose (FBS; 183 ± 6 mg/dl) were randomly divided into two groups. Test group was treated with 15 mg of PIO in addition to metformin 500 mg three times per day in both groups. SBP, DBP, PP and MP and fasting insulin, FBS and lipid profiles were measured before and after PIO therapy. RESULTS: There was a significant reduction in SBP (123 ± 2 vs. 118 ± 2 mmHg, P < 0.05), PP (41 ± 1 vs. 37 ± 1 mmHg, P < 0.05), and MP (95 ± 1 vs. 91 ± 1, P < 0.05). Clinical reduction in DBP was observed but not significant (82 ± 2 vs. 81 ± 1 mmHg, P > 0.05). There was a significant correlation between decline in SBP and DBP with respective baseline values (r = 0.76, P < 0.001 and r = 0.62, P < 0.001, respectively). Changes in PP and MP strongly correlated with baseline values (r = 0.51, P < 0.05 and r = 0.56, P < 0.05, respectively). There was a parallel reduction of FBS (183 ± 2 vs. 121 ± 3, P < 0.001) but reduction in IR or lipid profiles was not significant in test group. Changes in BP were not significant in control group ( P > 0.05). CONCLUSION: PIO treatment of T2DM showed early reduction of SBP and MP within first 4 weeks. Results suggest that pharmacodynamic effects of PIO mainly affect the systolic component. We hereby suggest that reduction of BP by PIO is independent from mechanisms of changes in IR and dyslipidaemia in normotensive diabetic patients.

Significant correlation between BMI/BW with insulin resistance by McAuley, HOMA and QUICKI indices after 3 months of pioglitazone in diabetic population

Twenty-four patients of type 2 diabetes with fasting blood glucose (FBG) > 7 mmol/l (126 mg/dl) were randomly selected on one (if the patient is symptomatic) or two occasions (if the patient is asymptomatic). Patients were treated with 15 mg of PIO daily and investigated for BW, BMI, FBG, fasting insulin (FI) and triglycerides (TG). IR was calculated by McAuley (McA), homeostasis model assessment (HOMA) and QUICKI indices at baseline and repeated after 3 months.

Effects of high-dose parenteral vitamin D therapy on lipid profile and blood pressure in patients with diabetic nephropathy: A randomized double-blind clinical trial

AIMS Aim of this study was to determine the effect of high dose vitamin D given to patients with early diabetic renal disease on systolic and diastolic blood pressure, total cholesterol (TC), low-density lipoproteins (LDL), triglycerides (TG) and high density lipoproteins (HDL) in a randomized controlled trial MATERIALS AND METHOD: Patients with early diabetic nephropathy were recruited. Selected patients were allocated to two groups by Block randomization method. Treatment group received 50,000 IU of vitamin D3 intramuscularly and the control group was given an equal volume of distilled water (0.25mL) monthly for six months. Blood and urine were collected at the baseline for biochemical analyses and blood pressure was measured. After six months all the measurements done at the baseline were repeated. RESULTS Of 155 patients invited, 85 were randomly assigned to two groups. No significant differences were found between treatment and control groups at the baseline. Vitamin D therapy significantly reduced DBP, total cholesterol and LDL but the between group differences were not significant. There was an increase in HDL cholesterol level in the treatment group while there was no change in the control group Between groups difference was significant (P=<0.001). CONCLUSIONS There was a significant improvement of serum HDL level with six months therapy of high dose vitamin D in patients with early diabetic nephropathy.

Is risk factor-based screening good enough to detect gestational diabetes mellitus in high-risk pregnant women? A Sri Lankan experience

Background: There is a long lasting dilemma over the ideal screening and diagnostic method in gestational diabetes mellitus (GDM). Even though universal screening is commonly practiced, selective screening based on risk factors is also practiced in some center. The aim of this study is to evaluate the most appropriate method to screen GDM in high-risk pregnant women in Sri Lanka. Methods: This study was a clinic-based, cross-sectional study conducted in a tertiary referral center, Sri Lanka. All women underwent 75 g oral glucose tolerance test at 24–28 weeks of gestation. Diagnosis of GDM was made according to the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) and World Health Organization (WHO) criteria. Results: With universal screening using IADPSG criteria, 23.2% (105/452) were found to have GDM and with risk factor-based screening 20.1% (91/452) were detected to have GDM. The prevalence of GDM dropped to 18.1% when GDM was diagnosed using the WHO criteria with universal screening approach. It was further dropped to 15.7% when the WHO criteria were used along with risk factors-based screening approach. Conclusions: The IADPSG criteria labeled considerably higher number of women as having GDM compared to the WHO criteria. With regards to the screening methods, the risk-based screening had a lower detection rate of GDM; however, it reduced the necessity of screening of women by around 20%.

Cardiovascular risk assessment in type 2 diabetes mellitus: comparison of the World Health Organization/International Society of Hypertension risk prediction charts versus UK Prospective Diabetes Study risk engine.

Introduction Patients with type 2 diabetes mellitus (T2DM) are at higher risk of developing cardiovascular diseases, and assessment of their cardiac risk is important for preventive strategies. Purpose The Ministry of Health of Sri Lanka has recommended World Health Organization/International Society of Hypertension (WHO/ISH) charts for cardiac risk assessment in individuals with T2DM. However, the most suitable cardiac risk assessment tool for Sri Lankans with T2DM has not been studied. This study was designed to evaluate the performance of two cardiac risk assessments tools; WHO/ISH charts and UK Prospective Diabetes Study (UKPDS) risk engine. Methods Cardiac risk assessments were done in 2,432 patients with T2DM attending a diabetes clinic in Southern Sri Lanka using the two risk assessment tools. Validity of two assessment tools was further assessed by their ability to recognize individuals with raised low-density lipoprotein (LDL) and raised diastolic blood pressure in a cohort of newly diagnosed T2DM patients (n=332). Results WHO/ISH charts identified 78.4% of subjects as low cardiac risk whereas the UKPDS risk engine categorized 52.3% as low cardiac risk (P<0.001). In the risk categories of 10%–<20%, the UKPDS risk engine identified higher proportions of patients (28%) compared to WHO/ISH charts (7%). Approximately 6% of subjects were classified as low cardiac risk (<10%) by WHO/ISH when UKPDS recognized them as cardiac risk of >20%. Agreement between the two tools was poor (κ value =0.144, P<0.01). Approximately 82% of individuals categorized as low cardiac risk by WHO/ISH had higher LDL cholesterol than the therapeutic target of 100 mg/dL. Conclusion There is a significant discrepancy between the two assessment tools with WHO/ISH risk chart recognizing higher proportions of patients having low cardiac risk than the UKPDS risk engine. Risk assessment by both assessment tools demonstrated poor sensitivity in identifying those with treatable levels of LDL cholesterol and diastolic blood pressure.

Targeting postprandial blood sugar over fasting blood sugar: A clinic based comparative study

INTRODUCTION Recent studies indicate that modulation of post prandial blood sugar (PPBS) plays an important role in the long term glycemic control. Measurement of PPBS is more convenient for patients attending outpatient clinics than fasting blood sugar (FBS) as the former needs only two hours of fasting from the last meal. OBJECTIVE To assess the value of PPBS monitoring in optimization of long term glycemic control among diabetic patients attending an outpatient clinic. METHODS A total of 240 patients with type 2 diabetes (T2DM) attending an out-patient medical clinic were randomized to either PPBS or FBS monitoring. Those who selected to PPBS-group underwent blood sugar measurement 2-h after last meal on the day of their clinic visits and those in the FBS group underwent blood sugar measurement after fasting overnight (8-10h) in the morning of their clinic visits. Treating team was asked to optimize the anti-diabetic medications based on the available PPBS or FBS results. All patients were followed up monthly for six months. Glycemic control was assessed with glycosylated hemoglobin (HbA1c) at baseline and six months later. RESULTS Baseline characteristics of the two arms including age, gender, and duration of T2DM were not significantly different. Mean HbA1c (SD) of FBS and PPBS arms at baseline were 7.20 (0.45), and 7.33 (0.43) and were not significantly different (P=0.115). During the study period, HbA1c dropped by 0.20 in FBS arm compared to 0.25 drop in PPBS arm (p=0.59). Incidence of hypoglycemia was similar in FBS (2.42%) and PPBS arms (2.70%). CONCLUSION Monitoring of PPBS is a safe and effective alternative to FBS to optimize glycemic control in managing patients with T2DM attending outpatient clinics.

Prevalence of low HDL cholesterol and its associations among Sri Lankan patients with diabetes mellitus on statin therapy

AIMS We aimed to study the prevalence and associations of suboptimal high density lipoproteins level, a characteristic feature in diabetic dyslipidemia among patients under statin therapy. MATERIALS AND METHODS From a database of 2416 patients, data on age, gender, duration of diabetes, body mass index (BMI) and waist circumference (WC), low density lipoproteins (LDL), triglyceride, high density lipoproteins (HDL) were obtained. Prevalence of suboptimal HDL (<40mg/dL in males and <50mg/dL in females) and its association with gender, age, duration of diabetes, BMI and WC were studied. RESULTS The mean (SD) age of the sample (n=2416) was 53 (10) years and 64.2% of them (n=1550) were males. Prevalence of suboptimal HDL was 17.6%. Regression analysis revealed female gender, (OR 7.73, 95% CI 5.99-9.97) younger age (OR 0.98, 95% CI 0.97-0.99), higher BMI (OR1.05. 95% CI 1.00-1.2) and LDL level over 100mg/dL (OR 1.004, 95% CI 1.00-1.007) had significant associations with suboptimal HDL. CONCLUSIONS Every sixth diabetic patient on statins has suboptimal HDL level. Females, younger and obese diabetic individuals should be more focused on achieving optimal HDL cholesterol levels.

Prevalence and associations of non-alcoholic fatty liver disease (NAFLD) in Sri Lankan patients with type 2 diabetes: A single center study

BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is one of the most common causes for chronic liver disease in Asians. It occurs more commonly in patients with type 2 diabetes mellitus (T2DM). However, data on prevalence and associations of NAFLD among Sri Lankans with diabetes are lacking. The main aim of this study is to investigate the prevalence and factors associated with NAFLD in a cohort of diabetic patients. METHODS Total of 233 patients with type 2 diabetes mellitus, followed up at a diabetes center in Southern Sri Lanka, were recruited by convenience sampling method. Each of them underwent a detailed medical history, physical examination, laboratory investigations and abdominal ultrasonography(USS). The diagnosis of NAFLD was made according to the established criteria using USS. RESULTS The overall prevalence of NAFLD based on USS was 62.6% with no significant gender difference. Compared to USS, elevation in AST and ALT levels, based on NHANES III criteria, occurred only in 42% (98/234). The patients with NAFLD (56.7 ± 8.9) were significantly younger and had higher BMI and waist circumference, and raised AST and ALT than those without NAFLD. Binary logistic regression showed that the use of pioglitazone, higher BMI, and waist circumference were independently and significantly associated with NAFLD. CONCLUSIONS NAFLD is common in Sri Lankan patients with T2DM and central and global obesity are significant associations. Use of pioglitazone seemed to be protective against the development of NAFLD. These findings underscore the need for weight management as a preventive measure of NAFLD in T2DM patients.

Association of Self-Reported Dietary and Drug Compliance with Optimal Metabolic Control in Patients with Type 2 Diabetes: Clinic-Based Single-Center Study in a Developing Country

Introduction Influence of dietary and drug compliance of patients with diabetes on attainment of optimal metabolic (glucose and lipid) control remains underexplored in developing countries. Materials and methods Self-reported dietary and drug compliance score of 0–10, glycosylated hemoglobin (HbA1c), and low-density lipoprotein (LDL) levels were obtained from patients with diabetes. HbA1c <7% and LDL <100 mg/dL were used to define optimal glucose and lipid control, respectively. Proportions achieving each and both optimal parameters were estimated. Regression analysis was used to study the association of age, gender, age of onset and the duration of diabetes, self-reported dietary, and drug compliance scores with achievement of both parameters. Results Mean (SD) age and duration of diabetes of 207 patients were 55 (10) and 10 (03) years. Optimal glucose and LDL control were achieved by 30% and 62%, and 23% had achieved both. Regression analysis revealed significant association of self-reported high dietary compliance with achievement of both targets. Conclusions Findings highlight the suboptimal glucose and lipid control among patients with diabetes. Significant association of better dietary compliance with control of both parameters emphasizes the value of proper dietary adherence in achieving the optimal metabolic control among patients with diabetes.