|Year : 2018 | Volume
| Issue : 2 | Page : 104-108
Effect of regular treatment, follow-up, and lifestyle practices in diabetic patients with ocular manifestations attending a tertiary care hospital in Puducherry, India
Nivedha S Raman, Amod Hansdak
Department of Ophthalmology, Pondicherry Institute of Medical Sciences, Puducherry, India
|Date of Submission||25-Sep-2018|
|Date of Acceptance||24-Oct-2018|
|Date of Web Publication||13-Dec-2018|
Department of Ophthalmology, Pondicherry Institute of Medical Sciences, Puducherry
Source of Support: None, Conflict of Interest: None
Background: The last few decades have witnessed the growth of diabetes mellitus which is affecting all sections of the society. Complications of diabetes and its management present a still further challenge to health care providers.
Methods: A hospital-based cross-sectional study was conducted at Pondicherry Institute of Medical Sciences, India, to find out the treatment and follow-up of patients with diabetes mellitus and also to estimate ocular manifestations among the study subjects.
Results: Regular treatment was found among 80% while regular follow-up was seen in 55.7% of the diabetic patients. Two-thirds of the patients were on oral hypoglycemic agents only. 18.6% of the patients tested their blood glucose levels once a month. Visit to an ophthalmologist was made in the last 12 months by 32.9% of them. Ocular manifestations were present in both vegetarians 80% and non-vegetarians 76% respectively. Diabetics practicing sedentary lifestyle had more ocular manifestations 87% as compared to 62.5% in those who did not exercise. Ocular manifestation was also higher among those with elevated blood glucose levels 74.4% in comparison to 61.3% among those with normal blood glucose levels.
Conclusion: This study highlights the importance of regular treatment and follow-up by patients with diabetes in relation to development of ocular manifestations. Exercise in diabetes is a key factor in delaying complications such as retinopathy.
Keywords: Diabetes mellitus, lifestyle practices, ocular manifestations
|How to cite this article:|
Raman NS, Hansdak A. Effect of regular treatment, follow-up, and lifestyle practices in diabetic patients with ocular manifestations attending a tertiary care hospital in Puducherry, India. J Curr Res Sci Med 2018;4:104-8
|How to cite this URL:|
Raman NS, Hansdak A. Effect of regular treatment, follow-up, and lifestyle practices in diabetic patients with ocular manifestations attending a tertiary care hospital in Puducherry, India. J Curr Res Sci Med [serial online] 2018 [cited 2019 Mar 19];4:104-8. Available from: http://www.jcrsmed.org/text.asp?2018/4/2/104/247495
| Introduction|| |
Diabetes mellitus (DM) as a disease has become a major cause of concern for health-care providers as the burden from this disease is consuming a large share of the resources for people across the globe. Type 2 DM is associated with irreversible risk factors such as age, genetics, race, and ethnicity and reversible factors such as diet, physical activity, and smoking. Dietary habits and sedentary lifestyle are the major factors for rapidly rising incidence of DM among developing countries. Recently, it has been identified that in type 2 diabetics, elevated glycosylated hemoglobin (HbA1c) level is also considered as one of the leading risk factors for developing microvascular and macrovascular complications. Type 2 DM requires insulin or oral hypoglycemic agents (medication that helps lower blood sugar), if diet and exercise alone fail to lower blood glucose. The key to proper control is balancing the glucose and the insulin in the blood which can be achieved by adjusting diet, activity, and taking medication., Recent studies by Nathan et al. have shown a significant decrease in HbA1c levels in type 2 DM patients treated with insulin. Better blood glucose control had been found to correlate most with a lower rate of diabetic retinopathy.,
Many cross-sectional as well as prospective and retrospective studies have found significant association between physical inactivity and type 2 DM. It was found that the diabetes incidence rate remained higher in less active men and women from all BMI groups. Physical activity improves abnormal glucose tolerance, prevents progression of diabetes, and also increases fat metabolism, thereby reducing insulin resistance and increasing its activity.,,, The role of diet in the etiology of type 2 DM was proposed by several workers as mentioned earlier, who observed that the disease was almost confined to rich people who consumed oil, flour, and sugar in excessive amounts. As with carbohydrates, the association between dietary fats and type 2 DM was also consistent. Many prospective studies have found relations between fat intake and subsequent risk of developing type 2 DM. The objectives of the study were to document the effect of regularity of treatment and follow-up with ocular manifestations and the lifestyle practices in diabetic patients with ocular morbidity.
| Materials and Methods|| |
The ophthalmology department of Pondicherry Institute of Medical Sciences is situated in Puducherry providing specialist services to both urban and rural population from the surrounding cities, towns, and villages. A cross-sectional study was conducted in 2017 where patients with diabetes reporting to the department in the months of August and September were included in the study. Inclusion criteria for the study participants were (a) patients who were diagnosed with type 2 DM, (b) ages between 18 and 80 years, and (c) both males and females. Patients with other systemic comorbidities such as hypertension, leprosy, and ocular pathologies unrelated to diabetes were not included in the study. Convenient sampling technique was used to collect the data. These study participants were interviewed by the investigator using a predesigned structured questionnaire. The interview was conducted in the outpatient service area as well as in the wards for admitted patients.
The questionnaire had questions related to the diagnosis of diabetes, treatment details, follow-up, ocular manifestations of the patient with respect to diet and exercise, and the last checkup by ophthalmologist. The patients were further examined by the consultant as part of routine eye examination done by the department. Following the collection of this information, the proformas were checked for completeness and then entered into EpiData. Data were analyzed and expressed as percentages and simple proportions.
| Results|| |
In this study, a total of 70 diabetes patients were studied after using the inclusion and exclusion criteria for selection. The treatment of diabetes with respect to treatment modality is shown in [Figure 1]. Here, we find that two-thirds 67.1% (47) of the patients were on oral hypoglycemic drugs while 27.1% (19) were on both oral hypoglycemic drugs as well as injectable insulin. Only 2.9% (2) of the patients were not on any form of treatment. With regard to regularity of treatment, it was found that most 80% (56) of the patients were regular, but 20% (14) of them were irregular in taking treatment. Patient follow-up was also asked where more than half 55.7% (39) were regular whereas 44.3% (31) of them were not regular in follow-up.
The frequency of blood sugar measurement was assessed and is depicted in [Figure 2]. Majority of them 42.8% (30) had their blood sugar tested occasionally while 24.3% (17) had it tested once in 3 months and only 18.6% (13) had it tested once a month. The type of blood sugar test done was also asked, and it was found that 61.4% (43) did random blood sugar testing while the rest 38.6% (27) had fasting blood sugar test done. Blood sugar values for 55.7% (39) were increased and it was normal for 44.3% (21) of the study participants. Ocular manifestations among the study participants with respect to blood glucose levels are given in [Table 1]. Almost three-fourths 74.4% (29) of diabetics with elevated blood glucose levels had ocular manifestations in comparison to 61.3% (19) of diabetics with normal blood glucose levels.
|Figure 2: Distribution of participants based on the frequency of blood glucose measurement|
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|Table 1: Distribution of ocular manifestations in participants based on blood glucose levels|
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The last visit made by these diabetic patients to the ophthalmologist is shown in [Table 2]. Visit to an ophthalmologist in the past 12 months was made by 32.9% (23) of the study participants which was followed by 14.3% (10) in the past 1–2 years and also 14.3% (10) in the past 2–3 years. Among the study participants, 28.6% (20) of them had never visited an ophthalmologist.
|Table 2: Distribution of participants based on their last visit to an ophthalmologist|
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Lifestyle practices of the diabetic patients were enquired into which revealed that 71.4% (50) of them were non-vegetarian as compared to 28.6% (20) who were vegetarians. Majority of them 65.7% (46) did not do any exercise whereas 17.1% (12) did it occasionally and another 17.1% (12) did exercises regularly. Distribution of ocular manifestations among the study participants based on diet is shown in [Table 3]. Both vegetarians 80% (12) and non-vegetarians 76% (38) had higher number of ocular manifestations. This finding need to be treated with caution as the number of vegetarians is less than non-vegetarians. Distribution of ocular manifestations among the study participants based on their exercise is given in [Table 4]. Here, we find that most of the participants who do not do exercise had higher number 87% (40) of ocular manifestations as compared to those who did exercise 62.5% (15).
|Table 3: Distribution of ocular manifestations in participants based on diet|
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|Table 4: Distribution of ocular manifestations in participants based on exercise|
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| Discussion|| |
In this study, we found that 67.1% of the patients were on oral hypoglycemics while 27.1% were on both oral hypoglycemics and insulin. In the study done by Maureen regarding blood glucose monitoring among diabetic patients, it was found that 65% used oral agents while 29% used insulin. Most patients treated on oral agents or diet alone never monitored their blood glucose while one-fourth of the patients treated on insulin never monitored their blood glucose. According to Park et al., HbA1c levels improved with combination of insulin and oral hypoglycemic drugs such as metformin. More than half 55.7% of the study participants were regular for follow-up whereas 46.3% of them were irregular in follow-up. In the study conducted by Rihah et al., 67% of the patients followed up regularly in the hospital. About a third (35%) of the patients visited ophthalmology clinic after more than 11 years of DM and a quarter (25%) of the patients presented in the later stage of diabetic retinopathy. Regular blood testing every month was done by 18.6% of the study participants in this study while 24.3% had tested their blood sugar once in 3 months. Ocular manifestation was seen to be more 74.4% among those who had an elevated blood glucose level as compared to those with normal blood glucose levels 61.3%. A study by Balasubramaniyan et al. showed that about 88.6% of people with diabetes tested their blood sugar at least once in every 3 months. Among the study participants, 28.6% of them never visited a ophthalmologist whereas 14.3% visited before 2–3 years.
Diet preference among the people with diabetes in this study did not show very different findings as both vegetarians and non-vegetarians had high number of ocular manifestations 80% and 76%, respectively. Observational studies by Kahleova and Pelikanova show that the prevalence of type 2 diabetes is 1.6–2 times lower in vegetarians than in the general population. Clinical interventional trials demonstrated that vegetarian diets lead to a greater weight loss and greater reduction in fasting plasma glucose, HbA1c, blood lipids, and hypoglycemic medication than a conventional hypocaloric diet in participants with type 2 diabetes. Many reasons have been cited for suspecting that a vegan diet could decrease the major complications of DM including diabetic retinopathy. It is recommended that vegan diet and exercise strategy for treating diabetes are a safe and a “low-tech” approach which requires more emphasis from researchers and practitioners today. Observational studies have shown that individuals adopting vegetarian diets are half as likely to get diabetes as compared with nonvegetarians. There was quite a marked difference between those who practiced sedentary lifestyle in comparison to those who engaged in exercise where ocular manifestation was found in 87% and 62.5% of the people with diabetes, respectively. The present study findings are much higher as compared to the study done by Dharmastuti et al. in Indonesia where it was found that the prevalence of diabetic retinopathy for sedentary persons was 41.9% as compared to 39.2% who did moderate exercise and 32.7% who did vigorous physical activity. A study by Gupta et al. showed that significant improvement in clinical signs and symptoms along with plasma glucose and HbA1c in the diabetic patients after dietary interventions and lifestyle modifications was advised.
| Conclusion|| |
DM today needs to be a given high priority by health planners and also researchers due to its unrelenting burden for mankind as a whole. The main findings of this study are that ocular manifestations among diabetes are higher among those who are not on regular treatment and follow-up, which include control of blood glucose levels. Lifestyle practices such as diet and exercise do play a major role in the development of complications such as diabetic retinopathy.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Sami W, Ansari T, Butt NS, Hamid MRA. Effect of diet on type 2 diabetes mellitus: A review. Int J Health Sci (Qassim) 2017;11:65-71.
Wolf AM, Conaway MR, Crowther JQ, Hazen KY, L Nadler J, Oneida B, et al.
Translating lifestyle intervention to practice in obese patients with type 2 diabetes: Improving control with activity and nutrition (ICAN) study. Diabetes Care 2004;27:1570-6.
Diabetes Control and Complications Trial Research Group, Nathan DM, Genuth S, Lachin J, Cleary P, Crofford O, et al.
The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-86.
Nathan DM, McKitrick C, Larkin M, Schaffran R, Singer DE. Glycemic control in diabetes mellitus: Have changes in therapy made a difference? Am J Med 1996;100:157-63.
Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK prospective diabetes study (UKPDS) group. Lancet 1998;352:837-53.
The relationship of glycemic exposure (HbA1c) to the risk of development and progression of retinopathy in the diabetes control and complications trial. Diabetes 1995;44:968-83.
Weinstein MC, Toy EL, Sandberg EA, Neumann PJ, Evans JS, Kuntz KM, et al.
Modeling for health care and other policy decisions: Uses, roles, and validity. Value Health 2001;4:348-61.
Davies R, Roderick P, Raftery J. The evaluation of disease prevention and treatment using simulation models. Eur J Oper Res 2003;150:53-66.
Charokopou M, Sabater FJ, Townsend R, Roudaut M, McEwan P, Verheggen BG, et al.
Methods applied in cost-effectiveness models for treatment strategies in type 2 diabetes mellitus and their use in health technology assessments: A systematic review of the literature from 2008 to 2013. Curr Med Res Opin 2016;32:207-18.
Tucker DM, Palmer AJ. The cost-effectiveness of interventions in diabetes: A review of published economic evaluations in the UK setting, with an eye on the future. Prim Care Diabetes 2011;5:9-17.
Cole G, Leonard B, Hammond S, Fridinger F. Using “stages of behavioral change” constructs to measure the short-term effects of a worksite-based intervention to increase moderate physical activity. Psychol Rep 1998;82:615-8.
Danaei G, Finucane MM, Lu Y, Singh GM, Cowan MJ, Paciorek CJ, et al.
National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: Systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2·7 million participants. Lancet 2011;378:31-40.
Seidell JC. Dietary fat and obesity: An epidemiologic perspective. Am J Clin Nutr 1998;67:546S-50S.
Peterson DB, Lambert J, Gerring S, Darling P, Carter RD, Jelfs R, et al.
Sucrose in the diet of diabetic patients – Just another carbohydrate? Diabetologia 1986;29:216-20.
Harris MI, National Health and Nutrition Examination Survey (NHANES III). Frequency of blood glucose monitoring in relation to glycemic control in patients with type 2 diabetes. Diabetes Care 2001;24:979-82.
Park CY, Kang JG, Chon S, Noh J, Oh SJ, Lee CB, et al.
Comparison between the therapeutic effect of metformin, glimepiride and their combination as an add-on treatment to insulin glargine in uncontrolled patients with type 2 diabetes. PLoS One 2014;9:e87799.
Ghanma RA, Abudabat MM. First presentation of diabetic patients to ophthalmology clinic (A survey of two peripheral hospitals in Jordon). J R Med Services 2017;24:12-7.
Balasubramaniyan N, Ganesh Kumar S, Ramesh Babu K, Subitha L. Awareness and practices on eye effects among people with diabetes in rural Tamil Nadu, India. Afr Health Sci 2016;16:210-7.
Kahleova H, Pelikanova T. Vegetarian diets in the prevention and treatment of type 2 diabetes. J Am Coll Nutr 2015;34:448-58.
McCarty MF. Favorable impact of a vegan diet with exercise on hemorheology: Implications for control of diabetic neuropathy. Med Hypotheses 2002;58:476-86.
Barnard ND, Katcher HI, Jenkins DJ, Cohen J, Turner-McGrievy G. Vegetarian and vegan diets in type 2 diabetes management. Nutr Rev 2009;67:255-63.
Dharmastuti DP, Agni AN, Widyaputri F, Pawiroranu S, Sofro ZM, Wardhana FS, et al.
Associations of physical activity and sedentary behaviour with vision-threatening diabetic retinopathy in indonesian population with type 2 diabetes mellitus: Jogjakarta eye diabetic study in the community (JOGED.COM). Ophthalmic Epidemiol 2018;25:113-9.
Gupta A, Agarwal NK, Byadgi PS. Clinical assessment of dietary interventions and lifestyle modifications in Madhumeha (type- 2 diabetes mellitus). Ayu 2014;35:391-7.
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