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ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 94-98

Assessment of risk of type 2 diabetes mellitus in tuberculosis patients using Indian diabetes risk score in rural area of Chittoor district: A cross-sectional study


Department of Community Medicine, Sri Venkateswara Institute of Medical Sciences, Sri Padmavathi Medical College for Women, Tirupati, Andhra Pradesh, India

Date of Submission26-Aug-2020
Date of Decision14-Feb-2021
Date of Acceptance19-May-2021
Date of Web Publication20-Dec-2021

Correspondence Address:
Dr. Chandrasekhar Vallepalli
Department of Community Medicine, Sri Venkateswara Institute of Medical Sciences, Sri Padmavathi Medical College for Women, Tirupati - 517507, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrntruhs.jdrntruhs_139_20

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  Abstract 


Background: In India, there was an estimated 2.69 million new tuberculosis (TB) cases with 449,700 deaths in 2018 and it continues to be a major public health problem. Diabetes mellitus (DM) and poor glycemic control triple the risk of TB and adversely affect TB treatment outcomes. This study aimed to determine the risk of type 2 DM among TB patients registered under RNTCP using the Indian Diabetes Risk Score (IDRS).
Materials and Methods: This was a community-based cross-sectional study conducted among 60 TB patients of rural field practice area of a medical college. A pretested semi-structured questionnaire with IDRS was used for the data collection. TB patients were categorized into low-risk, medium-risk, and high-risk categories of developing diabetes using the IDRS. Necessary statistical tests like simple proportions and Chi-square test were applied to test for association between categorical variables.
Results: Of 60 TB patients, 19 (31.7%) were in high-risk category; 36 (60%) were in the medium risk category and 5 (8.3%) were in low-risk category of developing DM.
Conclusion: Routine DM screening of TB patients in the community using IDRS is the most cost-effective tool where there are limited resources and infrastructure and also provides an early opportunity to decrease the twin burden of TB-DM.

Keywords: Diabetes mellitus, IDRS, risk factors, tuberculosis


How to cite this article:
Vallepalli C, Srisai O, Nagaraj K. Assessment of risk of type 2 diabetes mellitus in tuberculosis patients using Indian diabetes risk score in rural area of Chittoor district: A cross-sectional study. J NTR Univ Health Sci 2021;10:94-8

How to cite this URL:
Vallepalli C, Srisai O, Nagaraj K. Assessment of risk of type 2 diabetes mellitus in tuberculosis patients using Indian diabetes risk score in rural area of Chittoor district: A cross-sectional study. J NTR Univ Health Sci [serial online] 2021 [cited 2022 Jan 24];10:94-8. Available from: https://www.jdrntruhs.org/text.asp?2021/10/2/94/332848




  Introduction Top


Globally in 2018, there was an estimated 10.0 million incident cases of tuberculosis (TB), equivalent to 130 cases per 100,000 population. TB is one of the top 10 causes of death and the leading cause from a single infectious agent Mycobacterium TB. In India, there was an estimated 2.69 million new TB cases with 449,700 deaths in 2018. Globally, the number of individuals with diabetes mellitus (DM) is projected to rise from 425 million in 2017 to 629 million by 2045 and 80% of whom will be residing in low-income and middle-income countries where TB burden is highest. Risk of developing active TB disease is higher among people affected by risk factors such as undernutrition, diabetes, smoking, and alcohol consumption.[1],[2]

A systematic review of studies conducted at multiple settings showed that screening of patients with TB for DM also yielded high prevalence of diabetes ranging from 1.9% to 35%.[3] A literature search in various studies in India done in Bhopal, Gwalior, Telangana, Kerala, and Tamil Nadu revealed a diabetes prevalence of 11.9%, 15.5%, 11.5%, 44%, and 25.3% among TB patients, respectively.[4],[5],[6],[7],[8] DM and poor glycemic control triple the risk of TB and adversely affect TB treatment outcomes such as treatment failure, relapse, multidrug-resistant TB, and death.[9],[10] The SDG and End TB Strategy targets set for 2030 cannot be met without intensified research and development.

Thus this study aimed to determine the risk of type 2 DM among TB patients registered under RNTCP using the Indian Diabetes Risk Score (IDRS) and to identify the factors associated with high risk of developing type 2 DM among TB patients of Chittoor district, Andhra Pradesh, India.


  Materials and Methods Top


This was a community-based observational cross-sectional study conducted in rural field practice area of Community Medicine Department of SVIMS Sri Padmavathi Medical College for Women in Tirupati, Andhra Pradesh, India for a period of 2 months from July to August 2019 among patients with a confirmed diagnosis of TB as per RNTCP guidelines and currently receiving DOTS therapy from Designated Microscopy Centre (DMC) of rural field practice area.

A total of 83 TB patients were currently registered in the rural health training center under the RNTCP and receiving DOTS therapy, of which 23 TB patients were excluded from the study, that is, who are less than 18 years of age, who are already diagnosed as DM and who refused to participate in the study. So, a total sample size of 60 TB patients was obtained.

Madras Diabetes Research Foundation[11] developed IDRS––Indian Diabetes Risk Score––A simplified form of score for screening undiagnosed Diabetics was a validated questionnaire which includes four variables like age, family history of diabetes, physical activity, and waist circumference measurement. An IDRS value ≥60 had the optimum sensitivity (72.5%) and specificity (60.1%) for determining undiagnosed diabetes with a positive predictive value of 17.0%, negative predictive value of 95.1%, and accuracy of 61.3%. IDRS is the most cost-effective tool which can be used by any healthcare professional with minimal training in the hospital or community for detecting active DM or pre-diabetes where there are limited resources and infrastructure.

Data were collected from TB patients at their houses using a pretested semi-structured questionnaire with prevalidated IDRS questionnaire which includes socio-demographic profile including age, gender, education, occupation, socio-economic status, physical activity, and personal habits such as dietary pattern, smoking, and alcohol consumption were noted. TB history including type of TB, type of treatment, duration of treatment along with family history of TB and DM were taken. Anthropometry including height, weight, and waist circumference were measured and noted in the study questionnaire.

Data analysis

Data were entered in MS Excel Sheet 2010 and the outcomes were expressed in numbers and percentages based on low (<30), medium (30–50), and high risk (≥60) of developing diabetes using the IDRS risk score. The minimum score is 0 and the maximum score is 100. Continuous variables were summarized as frequency, mean and standard deviation. Necessary statistical tests like simple proportions and Chi-square test were applied using MedCalc statistical software to test for association between categorical variables and P value less than 0.05 was considered as statistically significant.

Ethical clearance

The study was approved by the Institutional Ethics Committee (IEC No. 914) of Sri Venkateswara Institute of Medical Sciences, Tirupati on 09 July 2019.


  Results Top


A total of 60 TB patients who were taking treatment in RHTC of a medical college participated in the study. The mean age of the study population was 41.02 years with a standard deviation of 15.01 years. Of 60 TB patients, 19 (31.7%) were in the high-risk category, 36 (60%) were in medium-risk category, and 5 (8.3%) were in low-risk category of developing DM, as shown in [Table 1].
Table 1: Distribution of Tuberculosis Patients Based On Indian Diabetes Risk Score (IDRS)

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The majority (38.4%) of the study population belongs to 18 to 35 years age group. Prevalence of high risk of DM was 70.6% in the age group more than 50 years. About 36 (60%) were males and 24 (40%) were females, as depicted in [Table 2].
Table 2: Socio-Demographic Variables in Relation to Risk of Diabetes Mellitus in Tuberculosis Patients

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Among the study population 26.7% were smokers and 38.3% were having habit of alcohol intake. The prevalence of high risk of diabetes among smokers and who are consuming alcohol was 62.5% and 47.8% respectively. Majority (56.7%) of the study population belongs to no exercise and sedentary work group as shown in [Table 3].
Table 3: Life-Style Factors and Anthropometry in Relation to Risk of Diabetes Mellitus Among Tuberculosis Patients

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Among the study population 16.7% were having a positive family history of DM. All the TB patients with both parents family history of diabetes were in the high-risk IDRS category. Among the study population 15% were having a positive family history of TB and there was 33.3% prevalence of high risk of diabetes observed among them, as shown in [Table 4].
Table 4: Various Factors Associated With the Risk of Diabetes Mellitus Among the Tuberculosis Patients

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  Discussion Top


Among the study population, 31.7% (19/60) were at high risk of developing DM and 60% (36/60) were at medium risk of DM. Only about 8.3% (5/60) were at low risk of developing DM. However, the prevalence of DM among TB patients in various other studies was Nagar et al.[4] (12.39%); Agarwal et al.[5] (15.5%); Viswanathan et al.[8] (25.3%); and Balakrishnan et al.[7] (44%).

In this study, age of the study participants ranged between 18 and 78 years with a mean age of 41.02 ± 15.01 SD. In this study, prevalence of high risk of DM was 70.6% in the age group more than 50 years and there was a statistically significant association (P < 0.0001) found between risk of diabetes and increasing age. Similar findings were observed in the studies done by Nagar V, et al.[4]; Agarwal AK, et al.[5]; Viswanathan V, et al.[8]; Siddiqui A, et al.[12] and Shivakumar S, et al.[13]

Prevalence of high risk of diabetes was higher among smokers (62.5%) compared to non-smokers (20.5%) and there was a statistically significant association (P = 0.006) found between smoking and risk of DM in the TB patients. This was similar to the studies done by Viswanathan V, et al.[8]; Siddiqui A, et al.[12] and Shivakumar S, et al.[13] Prevalence of high risk of diabetes was 47.8% among TB patients who consume alcohol and there was statistical significant association (P = 0.038) found between alcohol intake and risk of DM. Similar findings were observed in a study done by Siddiqui A, et al.[12] (P < 0.001).

The majority (56.7%) of the study population belongs to sedentary type of physical activity and there was a statistically significant association (P = 0.003) between physical activity and risk of DM in the study group. This was in similar to the study done by Viswanathan V, et al.[8] In the present study, 16.7% of the TB patients were having a positive family history of DM and there was a statistically significant association (P = 0.024) found between family history of diabetes and risk of DM. This was similar to the studies done by Agarwal AK, et al.[5] and Viswanathan V, et al.[8]

Prevalence of high risk of diabetes in the pulmonary TB patients was 32.7%, whereas it was 20% in the extrapulmonary TB patients and there was a statistically significant association (P = 0.028) found between type of TB and risk of DM. In a study conducted by Nagar V, et al.[4] showed that 69.7% were pulmonary TB and 30.3% were extrapulmonary TB and pulmonary TB patients (15.3%) had more prevalence of diabetes as compare to extrapulmonary TB (5.5%) and the difference was statistically significant (P = 0.0001). Similar results were found in a study done by Viswanathan V, et al.[8]

About 37.5% of the females were having abnormal waist circumference (≥0.80 cm) and there was a statistically significant association (P = 0.002) with the risk of DM. This was against the study done by Agarwal AK, et al.[5] which showed that Waist circumference in both genders (male: 87.73 ± 6.74; female 82.06 ± 5.8) were found significantly higher in normoglycemic TB patients when compared to dysglycemic TB patients (P < 0.05). Another study done by Viswanathan V, et al.[8] showed that the mean waist circumference of men differed significantly (P < 0.001) whereas this was not observed among women (P = 0.485).

Limitations

Sample size in this study is smaller and biochemical analysis including fasting blood glucose and lipid profile were not done, which gives more valid data regarding prevalence of diabetes and metabolic syndrome in relation to TB.


  Conclusion Top


The present study revealed a 31.7% TB patients with high risk of developing DM. The study showed that various factors such as age 50 years and above, smoking, alcohol intake, sedentary activity, positive family history of DM, pulmonary type of TB, and abnormal waist circumference had a statistically significantly association between TB and DM. Although there was an established association between TB and DM, this study revealed the importance of early identification of risk factors associated with type 2 DM in TB patients in the community using simple IDRS screening tool to halt the twin burden of TB-DM.

Acknowledgements

We are thankful to Indian Council of Medical Research - Short Term Studentship Program for giving us an opportunity to conduct this research study. (ICMR STS Reference ID: 2019-00831).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Global Tuberculosis Report 2019. Geneva: World Health Organization; 2019. Available from: https://www.who.int/tb/publications/global_report/en/. [Last accessed 2019 Oct 18].  Back to cited text no. 1
    
2.
International Diabetes Federation. The IDF Diabetes Atlas, 8th Edition 2017. http://www.diabetesatlas.org/. [Last accessed 2019 Jan 21].  Back to cited text no. 2
    
3.
World Health Organization 2017. Guidance Document - Nutritional Care and Support for TB patients in India: Central TB Division. Tbcindia.gov.in. Available from: https://tbcindia.gov.in/index1.php?lang=1&level=3&sublinkid=4731&lid=3277. [Last accessed 2019 Jan 21].  Back to cited text no. 3
    
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Nagar V, Gour D, Pal DK, Singh AR, Joshi A, Dave L. A study on prevalence of diabetes and associated risk factors among diagnosed tuberculosis patients registered under revised National tuberculosis control programme in Bhopal District. J Family Med Prim Care 2018;7:130-6.  Back to cited text no. 4
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5.
Agarwal AK, Gupta G, Marskole P, Agarwal A. A study of the patients suffering from tuberculosis and tuberculosis-diabetes comorbidity in revised National tuberculosis control program centers of Northern Madhya Pradesh, India. Indian J Endocr Metab 2017;21:570-6.  Back to cited text no. 5
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Gutta L, Rajender, Meghana S, Rani J. Study on prevalence of diabetes mellitus in patients with pulmonary tuberculosis. Int J Intg Med Sci 2016;3:303-8.  Back to cited text no. 6
    
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Balakrishnan S, Vijayan S, Nair S, Subramoniapillai J, Mrithyunjayan S, Wilson N, et al. High diabetes prevalence among tuberculosis cases in Kerala, India. PLoS One 2012;7:e46502.  Back to cited text no. 7
    
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Viswanathan V, Kumpatla S, Aravindalochanan V, Rajan R, Chinnasamy C, Srinivasan R, et al. Prevalence of diabetes and pre-diabetes and associated risk factors among tuberculosis patients in India. PLoS One 2012;7:e41367.  Back to cited text no. 8
    
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Rifat M, Milton A, Hall J, Oldmeadow C, Islam M, Husain A, et al. Development of multidrug resistant tuberculosis in Bangladesh: A case-control study on risk factors. PLoS One 2014;9:e105214.  Back to cited text no. 9
    
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Mohan V, Deepa R, Deepa M, Somannavar S, Datta M. A simplified Indian diabetes risk score for screening for undiagnosed diabetic subjects. J Assoc Physicians India 2005;53:759-63.  Back to cited text no. 11
    
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Siddiqui A, Khayyam K, Siddiqui N, Sarin R, Sharma M. Diabetes prevalence and its impact on health-related quality of life in tuberculosis patients. Trop Med Int Health 2017:22:1394-404.  Back to cited text no. 12
    
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Shivakumar S, Chandrasekaran P, Kumar A, Paradkar M, Dhanasekaran K, Suryavarshini N, et al. Diabetes and pre-diabetes among household contacts of tuberculosis patients in India: Is it time to screen them all? Int J Tuberc Lung Dis 2018:22:686-94.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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