Risk Factor for Diabetes in Different Populations of Manipur

Individuals of both sexes belonging to three different populations were randomly selected and screened for diabetes from different districts of Manipur, which is a small hilly state, situated in the north eastern extreme corner of India sharing an international boundary with Myanmar (Burma). DM was defined according to the American Diabetes Association (ADA) recommendations as FBS>126 mg/dl ororal glucose tolerance test OGTT2>200 mg/dl.


Introduction
Type 2 Diabetes mellitus (DM) is by far the most common metabolic disorder in many populations of the world. It is the third most common health disorder worldwide and fourth leading cause of death. The incidence and prevalence of DM are rapidly increasing worldwide in both developing and developed nations. According to recent analysis the number of adults with DM from 2010 to 2030 would increase 20% in developed countries and 69% in developing countries [1,2]. DM is a disease of insidious onset and the symptoms, when they eventually appear, do not warrant immediate attention and thus remain undiagnosed at onset and even when diagnosed is often ignored by persons afflicted by it [3]. When unmanaged, DM causes damage to many organs and tissues of the body leading to serious complications [4]. The aetiology of diabetes in India is multifactorial and includes genetic factors coupled with environmental influences such as obesity associated with rising living standards, steady urban migration, and lifestyle changes [5]. DM has reached epidemic proportions worldwide, placing a substantial burden on healthcare services. Recent estimates suggest that the prevalence of DM is rising globally, particularly in developing countries [6]. The biggest increase in DM cases is expected in China and India. India currently, have around 40 million cases of DM and these numbers are projected to increase to 87 million by the year 2030 [7]. Anticipating an epidemic like increase in the number of diabetic patients India has been christened as the 'diabetic capital of the world as it is reported that 1 out of 4 individuals will be an Indian diabetic in the world [8,9]. Asian Indians are more prone to type 2 DM at a younger age and premature cardiovascular disease (CVD) remains speculative, there is a growing body of evidence to support the concept of the "Asian Indian Phenotype" [10,11]. A patient who suffers from type 2 DM has a 2-4 times greater risk of death from cardiovascular causes than the patient without DM. The most common cause of death in the diabetic patient is heart disease. In addition, peripheral vascular disease, end-stage renal disease, blindness and amputations are common co-morbidities Shah

Biology and Medicine
in diabetic patients [12]. Thour et al. [13] reported higher prevalence of depression in patients with type 2 diabetes. Kapoor et al. [14] reported that urban environment showed a changing lifestyle and high prevalence of DM among tribal migrating urban tribes as compared to traditional tribes. The aim of present study was to find out associated risk factors, awareness of basic knowledge regarding risk factors, treatment and complications of diabetes among different populations of Manipur.

Subjects
Manipur is a small hilly state, situated in the north eastern extreme corner of India that connects the Indian subcontinent to East Asia and South East Asia as a unique narrow passageway and shares an international boundary with Myanmar (Burma). It is bound by Nagaland in the north, Mizoram in the south, Assam in the west and Burma lies in the east and also isolated from the rest of India, both geographically and economically [15]. The survey was conducted in the given districts of Manipur i.e. Imphal East, Imphal West, Thoubal, Ukhrul and Senapati taking three different populations viz. Manipur Muslims, Meitei (Hindu) and Naga.
Manipuri Muslims comprising 8.32% of the total population according to the 2001 census are mostly migrants who started coming to the state in the middle of the 16th century and they belong to Sheikh, Syed, Pathan or Mughal.

Materials and Methods
A well designed, pre-tested questionnaire was used and a house to house survey was conducted of all the people above the age of 20 years who were interviewed and examined. Informed written consent was obtained. Data on age, sex, occupation, marital status and personal habits were also collected.
Plasma FBS concentration was measured by finger stick with a glucometer. Recent studies have shown that modern handheld glucose measuring devices have excellent technical characteristics and yield results that are similar to the reference laboratory methods. Furthermore, various studies have reported that capillary glucose measurements are as suitable as venous glucose measurements in the diagnosis and detection of type 2 DM in epidemiological studies and may be cost effective in the implementation of pre-screening procedures [16][17][18][19][20][21][22]. The American Diabetes Association (ADA) recommends screening for Type 2 DM by using a verbal or written questionnaire to select high-risk individuals to increase the costeffectiveness of testing undiagnosed individuals [23]. Participants with levels >100 mg/dl subsequently underwent an OGTT2 to confirm the diagnosis of DM. DM was defined according to the ADA recommendations as FBS >126 mg/dl or oral glucose tolerance test OGTT2 >200 mg/dl [24]. Any resident who reported that he/she was a diabetic and on treatment was counted as a diabetic, irrespective of FBS values, and was not tested further.

Family history of diabetes
About 31.25% of the males and 28.43% among females had family history of diabetes. Among Muslims 32.58% of the individuals had family history of diabetes while 67.42% had no family history of diabetes. In case of Meieti and Naga, 25.58 % and 20% respectively had family history of diabetes (Table 1).

Diet and food intake pattern
Analysis of food intake patterns show that the prevalence of diabetes is more among meat eaters than the non-eaters.  Males of the present studied population shows higher intake of meat which includes both white and red meat. Among the different populations, studied Manipuri Muslims and Naga shows higher intake of meat. But the dietary pattern was more fatty and spicy among muslim in comparison to the Meitei and Naga population. Fish is a favorite meat for Meiteis though it was consumed by other two populations also, supplemented with pulses, besides roots and tubers, whereas meat or fish and rice is consumed by all the population taken in the present study.

Overweight
In the present study 33.85% of overweight males had diabetes while among diabetic females 36.27% were overweight. Muslims show highest percentage of overweight diabetic individuals i.e. 36.2% while the least case of overweight diabetic individuals was found among Naga (26.67%) ( Table 2).

Marital status
Among diabetic individuals 90.1% of the males and 94.2% of females were married. Among Muslims only 9.04% of unmarried individuals were found to be diabetic, while 6.98% and 6.67% of unmarried Meitei and Naga respectively were found to be diabetic. and peripheral vascular disease), kidneys (nephropathy), eyes (retinopathy), heart and blood vessels (cardiovascular disease) and gum disease (periodontal disease).The prevalence of cardiovascular and eye disease was found to be highest in comparison to the prevalence of other diseases.

Diabetes awareness
Most of the participants had heard about diabetes but the basic knowledge regarding risk factors, treatment and complications of diabetes was poor. Awareness about risk factor, treatment and long term effects of diabetes was found to be highest among Meitei population (55.81%), followed by Muslim (40.27%) and Naga population (36.67%). Only about 40.82 % of the diabetic individuals reported regular monitoring of blood sugar level. Most of them were on sugar free diet, take insulin or tablets for controlling their blood glucose level.

Discussion
Diabetes mellitus is one of the major non communicable diseases which are growing very fast in this modern era. Diabetes and associated complications pose a major health care burden worldwide and present major challenge to patients, health care systems and national economies. Asia is the major site of a rapidly emerging diabetes epidemic [25]. India and China both are having highest number of diabetes patients in coming years. The smaller countries of the Indian subcontinent like Pakistan, Bangladesh and Srilanka were also witnessing a rapid increase in prevalence of type 2 diabetes [25]. Till date, very little information exists about the prevalence of DM from North-Eastern part of India which also includes Manipur. The present study was so conducted to find out associated risk factors, awareness of basic knowledge regarding risk factors, treatment and complications of diabetes among different populations of Manipur.
The development of type 2 diabetes results from a complex interaction of social, economic, environmental, behavioural, and genetic factors, impacting both genders with different effects for each [26]. Among 294 diabetic individuals taken in the present study, males shows higher incidence of diabetes. Similar findings were reported by various researchers in India regarding female preponderance in Indian diabetics especially by Venkatesham et al. [27] and Ramachandran et al. [28] observed male excess amongst the diabetic person's. A study conducted in Turkey has found high prevalence of type-2 DM among women [29]. About 30.27% of individuals had family history of diabetes. Proper care needs to be taken by siblings of diabetic parents, since family history is one of the important genetic factors that results in the development of DM.
Diet is thought to play an important role in the aetiology of type 2 diabetes [30]. In the present study analysis of food intake patterns shows the prevalence of diabetes is more in meat eaters. Snowdon and Phillips [31] first reported an association between meat intake and diabetes in a study of Seventh Day Adventists, a population with a high proportion of vegetarians. Meat intake was associated with an increased prevalence of diabetes in men and women; and an increased diabetes-associated mortality in men, but not in women. Several subsequent publications have reported an increased risk of diabetes or type 2 diabetes with a high intake of processed meat [32][33][34], red meat [32][33][34] and total meat [32], but the results have not been consistent [35]. Meat is an important source of total and saturated fat and could increase the risk of type 2 diabetes through overweight/obesity [36,37], the metabolic syndrome [38,39] and hyperinsulinaemia and hyperglycaemia [35], although some studies found no association [40,41]. Another possible mechanism may be through the effects of haem-iron derived from meat [34]. Iron can promote oxidative stress by increasing the formation of hydroxyl radicals [42] which can cause damage to tissues, in particular the pancreatic beta cells [42]. Elevated iron status may interfere with glucose metabolism and may reduce pancreatic insulin synthesis and secretion [43] and one study suggested a detrimental effect of red meat intake on glucose metabolism. Higher meat intake is often associated with other unhealthy lifestyles including physical inactivity, overweight, smoking and unhealthy dietary patterns. 33.85% of overweight males had diabetes while in diabetic females 36.27% were overweight. Overweight and obesity are major risk factors for type 2 diabetes and a meta-analysis suggested an approximate 20% increase in type 2 diabetes risk for each unit increase in BMI [44,45]. According to American Diabetes Association, being overweight is a risk factor for developing this disease, but other risk factors such as family history, ethnicity and age also play a role. Unfortunately, too many people disregard the other risk factors for diabetes and think that weight is the only risk factor for type 2 diabetes. Most overweight people never develop type 2 diabetes, and many people with type 2 diabetes are at a normal weight or only moderately overweight.
In the present study overall only 42.18% of diabetic individuals have awareness of basic knowledge regarding risk factors, treatment and complications of diabetes. Deepa Mohan et al. in [46] Chennai observed that even among self-reported diabetic subjects, knowledge about diabetes including awareness of complications of diabetes was poor. This indicates that majority of the patients have not been taught about diabetes by their physicians. Therefore, there is a need to improve the knowledge and awareness about diabetes [47]. Many medical treatments are available to help when diabetes complications occur but self precautionary measures involving a program of healthy, low-fat eating, regular exercise and quitting smoking can help a lot in preventing diabetes complications. Peripheral vascular disease, endstage renal disease, blindness and amputations are reported to be common co-morbidities in diabetic patients [48]. The development of type 2 DM is influenced by lifestyle factors such as poor diet and lack of exercise resulting in high blood glucose levels, blood pressure and obesity. The most effective way to prevent and delay the increasing incidence of type 2 DM is through primary prevention, preventing illness before it occurs. Lifestyle interventions such as dietary and physical activity changes improve health outcomes in people who are at high risk of developing type 2 DM. Type 2 DM can be controlled in its early stages through healthy eating and regular physical activity. However, as the disease progresses, medication such as insulin may be needed [48,49]. American Diabetes Association has also proposed the screening of all the patients aged over 45 years by measuring fasting blood glucose, every three years, in addition to screening patients from high-risk groups and younger patients with HT, obesity, the family history of DM in the first-degree relative, and a family history of gestational DM. Of interest is the prospect of introduction of presymptomatic diagnosis of susceptible individuals using genetic markers, where it is expected to play an essential role in the control and prevention of non-communicable diseases. If this becomes a practical approach, the prevention of the complications will be of appreciable benefit to those prone to DM [50]. The need of the hour, therefore is that large scale epidemiological studies for other populations be undertaken to ascertain the causes of the rising Type 2 DM epidemic in the state of Manipur, either for reducing or if possible, some serious efforts must be taken viz. like concerted preventive measures need to taken by the Government, health planners by discussing it with the general public steps to promote physical activity, changing societal perceptions of health and improving knowledge about their associated risk factors like hyperlipidemia, microalbuminuria and central obesity.

Conflict of Interest
The authors declare no conflict of interest.