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Journal of Postgraduate Medicine
Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India
ISSN: 0022-3859 EISSN: 0972-2823
Vol. 47, Num. 1, 2001, pp. 26-28
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Journal of Postgraduate
Medicine, Vol. 47, Issue 1, 2001 pp.26-28
Clinical and Etiological
Profile of Early Onset Diabetes Mellitus: Data From a Tertiary Care Centre in
the Indian Subcontinent
Zargar AH, Bhat MH,
Laway BA, Masoodi AR
Department of Endocrinology, Sher-i-Kashmir Institute
of Medical Sciences, Srinagar - India.
Code Number: jp01006
Abstract
BACKGROUND: Type 2 diabetes mellitus (DM) in youth is
emerging as a serious clinical entity and its incidence has increased over the
years. AIM: To analyse the causes of DM in the age group of <40 years of age.
SETTINGS AND DESIGN: Tertiary care center; retroscpective analysis of data from
January 1990 to December 1999. METHODS AND MATERIAL: Analysis of data of all
the subjects of DM in whom disease started before the 40th birthday. RESULT:
724 subjects were detected to have diabetes mellitus before their 40th birthday.
Of these, 205 had Type 1, 174 had Type 2 and 48 had Fipocalculous pancreatic
diabetes. Males outnumbered in Type 1 and Fipocalculous pancreatic diabetes
while as females in Type 2 diabetes mellitus. Chronic complications were more
common in Type 2 diabetes mellitus. CONCLUSION: Type 2 diabetes mellitus is
becoming an important cause of diabetes in subjects with onset of disease at
younger age.
Till recently, diabetes mellitus (DM) was mainly characterised
into two types. Type 1, a distinct entity, affecting <40 years and Type 2, a
heterogeneous group, characterized by a combination of insulin resistance and/or
insulin deficiency affecting individuals of >40 years of age. In past, Type
1 DM was considered to be rare in adults but same is not considered true at
present. However, Type 2 DM still continues to be the commonest type of DM in
this age group and its prevalence is increasing.2 A surprising observation in
recent years has been the documentation of Type 2 DM in children. There is a
unanimous agreement that Type 2 DM in youth is emerging as a serious clinical
entity and its incidence has increased between 1982 to 1994.3 Fipocalculous
pancreatopathy - a secondary form of DM, mostly seen in tropical countries with
few exceptions is also an important cause of DM in the age group of <40 years.
In the present study, we analysed the causes of diabetes
mellitus in the age group of <40 years of age.
Subjects
and Methods
The present study
consists of analysis of data of all the subjects of DM in whom disease started
before the 40th birthday. From January 1990 to December 1999, 427 subjects were
recognised whose records were complete. These were screened for age, sex and
duration of symptoms related to DM or its complications, actual duration of
DM, family history of DM, episodes of ketoacidosis. Weight, height, body mass
index, blood pressure on admission, presence of neuropathy, nephropathy, retinopathy
were noted. Neuropathy was defined as failure to elicit the knee and/or ankle
reflexes after reinforcement with or without symptoms of neuropathy or gross
sensory disturbance in both feet, in the absence of any other cause of neuropathy.4
Nephropathy was defined as quantitative 24-hour urine protein excretion of >500mg
per 24 hours, in the absence of other renal diseases.5 Retinopathy was established
by an ophthalmologist/endocrinologist and classified as background or proliferative
retinopathy according to Kohner et al classification. Investigations studied
were electrocardiogram, X-ray chest/abdomen, 24-hour urinary protein, creatinine,
serum urea, creatinine, lipid profile and fructosamine (in some cases). Subjects
were clinically classified into three main types of diabetes mellitus:
1. Type 1 DM: Subjects
with an episode of ketoacidosis and requiring insulin for survival or patients
who required insulin within first year of diagnosis for control of hyperglycemia.
2. Type 2 DM: Subjects
without an episode of ketoacidosis, controlled on oral hypoglycemic agents for
more than a year after diagnosis
3. Fipocalculous
pancreatic diabetes (FCPD): Diabetes mellitus with or without pain abdomen with
pancreatic calcification on plain X-ray abdomen.
Observation And
Results
Over a period of a decade, 427 subjects of diabetes
mellitus were evaluated who started the disease before their 40th birthday.
Being a retrospective study, diagnosis of DM was based on previous WHO criteria.6
Out of 427 patients, 205 subjects qualified for the diagnosis of Type 1 DM,
174 qualified for the diagnosis of Type 2 DM and 48 had FCPD making Type 1 DM
as the commonest form of DM before the 40th birthday. Fig.
1 gives the age distribution of three types of DM. As is evident from the
figure, Type 1 DM starts peaking in the
age group of 2nd and 3rd decade whereas FCPD and Type 2 DM peak around 3rd and
4th decade. The sex distribution in three types of DM was not uniform. Males
outnumbered females in both Type 1 (123 vs.82) and FCPD (29 vs.19) whereas females
did so in Type 2 DM (230 vs.130). Family history was positive in 3.4%, 4.2%
and 4.6% in type 1, FCPD and type 2 respectively. Over-all mean body mass index
(BMI) was 16.7 ± 4.70Kg/m2. Only 18% of subjects with Type 2 DM had BMI of >25Kg/m2
whereas none of the patients with Type 1 or FCPD had BMI of >25Kg/m2.
Table 1 gives the
details of chronic complications in three types of DM. Nephropathy, neuropathy
and retinopathy were more common in Type 2 DM, followed by decreasing order
of occurrence in Type 1 and FCPD. Table 2
gives the duration of DM when these subjects were evaluated in Endocrinology
Clinic. Half of the patients with Type 1 DM had duration of disease of <1year.
A reverse sequence was seen in subjects with Type 2 DM. Similarity of trend
was seen between FCPD and Type 1 DM.
Discussion
Type 2 DM is the
commonest type of DM when one estimates the prevalence especially over 40 years
of age. In past, Type 1 DM was considered to affect only children and subjects
<40 years of age. (1) Our study revealed Type 1 DM as the commonest form of
DM seen in the age group of <40 years, accounting for 48% of the cases followed
by 40.01% with Type 2 DM. Type 1 DM is still considered to be the commoner form
of DM in young. The incidence of Type 2 DM in children between 1990 and 1994
in one series was found to be 31%, rest of the subjects had Type 1 DM. Similarly
19% incidence has been reported in other series. (7) Emergence of Type 2 DM
in childhood is a new challenge. At present it has assumed epidemic proportions
in Japan, Canada and North America. Increasing obesity and decreasing physical
activity are the possible explanations for such a change. Fipocalculous pancreatic
diabetes (presently termed as fipocalculous pancreatopathy) affects young people,
mostly in tropical areas but we have reported its presence in the subtropical
regions is equally, also. (8-10) In our study, FCPD constituted 11.04% of the
cases and mostly started in the 3rd decade. Because of their relative young
age, macrovascular complications occur less frequently in them. (9) As is evident
in Fig. 1, both Type 1 and FCPD were more
common in males whereas Type 2 DM was more common in females. In previous observations
also, we have found Type 1 DM and FCPD to be more common in males. (9-11)
In Mexican Americans, Type 2 DM has been found more
frequently in females although the reason may not be clearly related to gender
if one considers the environmental factors. (12) In one of our previous study,
we have documented female predominance in Type 2 DM although only subjects more
than 40 years of age were studied in that survey. (2) We believe in addition
to obesity some genetic factor may be responsible for such an observation. (13)
A strong family history of DM is seen more frequently with Type 2 rather than
Type 1 DM, although exact nature of family descent is not understood except
in maturity onset diabetes of young (MODY).
In our study, only 4.6% of DM had a positive family
history of DM, however, possibility of more undetected asymptomatic cases cannot
be ruled out. In our earlier study, we documented 5% of subjects with FCPD having
a positive family history of DM. (9)
Most of our subjects with Type 1 DM and FCPD were non-obese.
This observation is in agreement with most of the previous studies. (8-9) Obesity
is considered a major contributing factor in Type 2 DM. In one study using a
criteria of BMI>27Kg/M2, 50% of the children were found obese6. 18% of our Type
2 DM subjects had a mean BMI of >25Kg/M2. In our previous study, we found a
mean BMI of 22.35Kg/m2 in males and 23.88Kg/m2 in females. (2)
In this study, chronic complications of DM were seen
more often in Type 2 than Type 1 (Table 2).
We believe this observation is related to longer duration of DM in Type 2 as
compared to Type 1 (6.4 vs. 2.8 years.) and on top of that, the exact duration
of DM is always underestimated in Type 2 DM because of paucity of florid symptoms.
It was previously believed that chronic complications do not occur in subjects
with FCPD but both acute and chronic complications have been documented time
and again. (5,8,9,11,14) Chronic diabetic complications have been demonstrated
mostly to be related to glycaemic status and duration of the disease in most
of the landmark studies. (15)
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