South Asians

Project title: Should the algorithm for the treatment of type 2 diabetes be different for South Asians.

South Asian people make up four per cent (2,455,964) of the total UK population (61,399,118) and an estimated eight per cent of people with diabetes. In England, there are 200,000 South Asian people with diabetes.

People from South Asia are six times more likely to develop type 2 diabetes than the white members of the UK population, and they are likely to develop it ten years earlier. Also, obesity is rising to epidemic proportions and studies have confirmed the association between obesity and type 2 diabetes.

I intend to evaluate the selection of the best treatment, or combination of treatments for the management of type 2 diabetes in South Asian patients.

This will be done by a systematic review of the most appropriate literature, regarding the treatments of both type 2 diabetes and obesity and considering both their pros and cons.

Objectives of proposed work:

I intend to answer the question as to whether obesity should be treated at an earlier stage, as people of South Asian origin tend to develop diabetes with a lesser degree of obesity at younger ages.

Whether insulin resistant therapies should be focused on more, since evidence exists that South Asians are more insulin resistant than white persons and that insulin resistance may play an important role in the pathogenesis of the disease. Or whether lifestyle and dietary habits should be altered in an effect to prevent obesity.

By carrying out such a project my goal is to reach an algorithm that may be different (i.e. earlier or more intense) in the treatment of type 2 diabetes in South Asians.

There are various existing studies that will aid to answer my question. I will be monitoring various research findings in an attempt to determine the most appropriate treatment, considering the positives and negatives and evaluating the qualitative and quantitative data to support my findings.

Strategic relevance of proposed work (not exceeding 750 characters):

A dramatic increase in the prevalence of type 2 diabetes in South Asians is observed in the UK. While marked cultural and social differences arise within this racial group, South Asians have the unenviable distinction of achieving the highest death rates of coronary heart disease in the UK.

Many South Asians living in the UK are both naive and uneducated about the consequences of type 2 diabetes. My research is intended to cause awareness of type 2 diabetes, its symptoms and treatment. In hope to improve the life style of many South Asian citizens.

The increase of obesity is rising to epidemic proportions, and this can lead problems such as type 2 diabetes. I am hoping that my research will educate the community, allowing them to take appropriate action against the onset of obesity.

5 Details of proposed investigation (Maximum of 5 sides of A4, Arial font 11):

Diabetes is a fascinating, yet devastating disorder that is exploding in incidence and continues to be a major cause of morbidity and mortality throughout the world. Type 2 diabetes occurs either by insufficient production of insulin in the pancreas or a resistance to the action of insulin in the body's cells - especially in muscle, fat and liver cells.

In the past 15 years, our understanding of hyperglycaemia and its consequences has grown dramatically, but with the realisation that there is still so much more to learn. The management of diabetes has been vigorously expanded from trying to just lower blood glucose to normalising blood lipids, blood pressure, coagulation and inflammatory factors.

South Asians are a heterogeneous group of people of Indian, Pakistani, Bangladeshi and Sri Lankan origin, with differing religion, language, culture and rates of diabetes, particularly type 2 diabetes. They live in all areas of the UK, with clustering in certain areas reflecting migration patterns.

Diabetes affects 246 million people worldwide and is expected to affect 380 million by 2025. It is estimated to be the fifth leading cause of mortality in the world. In the UK there are 2.5 million people who have been diagnosed with diabetes. It is estimated that 10 per cent of these people have Type 1 diabetes and 90 per cent have Type 2.

In addition it is estimated that there are half a million more people in the UK who have diabetes but have not yet been diagnosed. The rising prevalence of diabetes represents a serious clinical and financial challenge to the UK's health system, with 10 per cent of the NHS budget currently being spent on diabetes, which works out at around £9 billion a year.

Type 2 diabetes is up to six times more common in people of South Asian descent, and in the UK, people of South Asian origin are the largest ethnic minority who now comprise the majority ethnic group in several urban locations.

Evidence exists that South Asians are more insulin resistant than white persons and that insulin resistance may play an important role in the pathogenesis of the disease.

The prevalence and severity of diabetes varies significantly among populations. While environmental factors are known to greatly influence disease susceptibility, they alone do not fully explain the differences between ethnic groups. Genetic factors often determine an individual's response to the environment, so recognising the role of these factors is essential to our understanding of the molecular mechanisms involved in the causation of diabetes. Epidemiological studies have shown that the prevalence of type 2 diabetes among South Asians is significantly greater than in many other ethnic groups. This increased susceptibility to diabetes is thought, in part at least, to be determined by genetic factors.

Genetic factors are known to play a significant role in the pathogenesis of both Type 1 and Type 2 diabetes. This assertion is truer for type 2 diabetes and is supported by high concordance rates in studies involving monozygotic twins. Type 2 diabetes, however, includes a wide spectrum of clinical disorders, and the extent to which these disorders are influenced by genetic factors varies significantly. Monogenic forms of type 2 diabetes are predominantly due to single gene defects

and account for less than 5 per cent of all cases of type 2. They manifest early, have high phenotypic penetrance and are less influenced by environmental factors. In contrast, the genetics of more common polygenic forms is complex and involves polymorphisms of several genes and a greater gene-environment interaction. These polymorphisms confer only a modest risk to the individual but the effects are often greater at a population level.

A recent addition to the list of type 2 diabetes susceptibility genes is the Transcription Factor 7 Like 2 (TCF7L2). First described in an Icelandic population, and replicated in several other populations, including South Asians, this gene has been shown to have the strongest association with the risk of type 2 diabetes. The exact role of this gene in the pathogenesis of type 2 diabetes, however, remains unknown at present.

Increased visceral fat in South Asians is associated with increased generalised obesity, which is not apparent from their non-obese body mass index. Increased visceral fat is related to dyslipidemia and increased frequency of insulin resistance and may account for the increased prevalence of diabetes mellitus and cardiovascular disease in South Asians.

Additionally, for Caucasians to be obese the Body Mass Index (BMI) will be valued at 30; however South Asians will be obese with a lower BMI, for example 26/27.

Moreover, early protein energy deprivation, as indicated by low weight at birth and at 1 year of age, may induce a state of vulnerability to the development of type 2 diabetes in later life, especially if the quantitative and qualitative aspects of nutrition and altered lifestyles during adult years pose an additional challenge.

The epidemic of type 2 diabetes and the recognition that achieving specific glycaemic goals can substantially reduce morbidity; have made effective treatment of hyperglycaemia a top priority. While the management of hyperglycaemia, the hallmark metabolic abnormality associated with type 2 diabetes, has historically had centre stage in the treatment of diabetes, therapies directed at other coincident features, such as dyslipidmia, hypertension, hypercoagulability, obesity, and insulin resistance, have also been major focus of research and therapy.

The ADA-EASD consensus algorithm emphasises the value of early and intensive treatment with specialist input from the beginning. It proposes that an HbA1C > 7% is a 'call to action' to initiate or change therapy. Treatment should be individualised and holistic, aiming to bring glycaemic control as near to normal as possible where practical, appropriate and free from significant hypoglycaemia.

The structure of the algorithm and selection of therapies is mindful of the long-term progressive nature of type 2 diabetes, the problem of weight control and attendant cardiovascular risk. Lifestyle interventions if embraced and adhered to by the patient offer long-term multifactorial benefits. The commonest modifications, increasing physical activity and changing dietary habits generally to promote weight loss, reduce HbA1C, reduce blood pressure, improve the lipid profile and can benefit other markers of cardiometabolic risk.

Despite being inexpensive such lifestyle changes are personally challenging. They often impinge on the lives of family and friends who do not appreciate the importance of this treatment strategy.

Initial intervention is recommended to include both lifestyle modification and metformin therapy, provided the latter is not contraindicated and titrated for optimum tolerability and efficacy. If glycaemic control is not achieved within 2-3 months or sustained then move promptly to additional medication which is likely to be a sulphonylurea or a thiazolidinedione.

Where oral therapy is inadequate, or hyperglycaemia is marked (e.g. HbA1C > 8.5%) or causing symptoms, then basal insulin therapy is advised. Clear guidance for the initiation and intensification of insulin regimens is given along with opinion on cautions and monitoring.

I intend to answer the question as to whether the algorithm for the treatment of type 2 diabetes should be different for South Asians. People of Asian origin tend to develop diabetes with a lesser degree of obesity at younger ages, suffer longer with complications of diabetes, and die sooner than people in other regions.

Therefore should obesity be treated quicker in South Asians to prevent the onset and complication of type 2 diabetes?

By answering the question as to whether treatment should differ, be quicker, or be more intense I hope to benefit the South Asian community in ways which will alleviate the problems of type 2 diabetes.

Effective programmes need to be established, tailored for each population group and vigorously evaluated. The current situation of “too little and (often) too late” cannot be allowed to continue. Only in this way will the epidemic of diabetes witnessed in South Asians be arrested and reversed.

In order to reach my objectives I will analyse various appropriate literature available to me through Aston library facilities regarding type 2 diabetes in South Asians and evaluate the findings. By doing so, this will enable me to understand the main causes for the higher prevalence of type 2 diabetes in South Asians compared to europids.

Having this information will allow me to further investigate the most appropriate literature regarding treatment for South Asians. Through understanding the main causes of type 2 diabetes in South Asians, will allow me to evaluate the main treatments offered, and whether they are appropriate. For example, if the main cause of the diabetes is due to obesity, then maybe it is obesity that should tackled initially rather than anything else.

Annotated Bibliography.

Books

John R. White, Jr. & R. Keith Campbell. 2008, ADA/PDR Medications for the Treatment of Diabetes, Healthcare business of Thomas Reuters at Montvale, United States.

- A comprehensive drug reference organised into four sections according to therapeutic area. Within each chapter, the information is arranged to allow east reference to the specific area of interest e.g. treatment of type 2 diabetes.

Kamlesh Khunti, Sudhesh Kumar & Jo Brodie. 2009, Diabetes UK and South Asian Health Foundation recommendations on diabetes research priorities for British South Asians, South Asian Health Foundation, Diabetes UK Macleod House 10 Parkway London NW1 7AA United Kingdom.

- Diabetes UK and the South Asian Health Foundation have worked together on this review, whose principal purpose is to highlight the gaps in our understanding of diabetes in the UK-based South Asian population as well as to identify recommendations and priorities for future research areas.

Srikanth Bellary & Anthony H Barnett. 2009, Genetics, South Asian Health Foundation, Diabetes UK Macleod House 10 Parkway London NW1 7AA United Kingdom.

- Describes the genetic influence of diabetes amongst various populations including south Asians; it is therefore a crucial part of my understanding of the higher prevalence among the ethnic group.

Articles

Bajaj M, Banergi MA. 2007, Type 2 diabetes in South Asians: A pathophysiologic focus on the Asian-Indian epidemic: Current Diabetes Reports, Vol. 4, no 3, pp. 213-218.

- This article describes the functional changes associated with diabetes; it therefore provides an insight to the current South Asian diabetes epidemic.
K. Yoon, J. Lee, J. Kim, J. Cho, Y. Choi, S. Ko, P. Zimmet, H. Son, Epidemic obesity and type 2 diabetes in Asia, The Lancet, Vol. 368, Issue 9548, pp. 1681-1688.
- This article focuses on the health consequences of diabetes which threaten to overwhelm health-care systems in the region. Therefore, it is useful as it discusses what types of actions need to be taken, for example, lifestyle changes is the first step.

Tahseen A Chowdhury. 2003, Preventing diabetes in south Asians Too little action and too late, British Medical Journal, Vol. 327.

- This article focuses on the action of “too little and (often) too late”. Thereby it is useful in my research as it gives me some insight into what can be done differently in the management of type 2 diabetes in South Asians.
Clifford J. Bailey, Caroline Day and Ian W. Campbell. 2006, A Consensus Algorithm for Treating Hyperglycaemia in Type 2 Diabetes: Algorithm, British Journal of Diabetes and Vascular Disease, 6(4), pp. 147-148.

- This article describes the algorithm for treating hyperglycaemia in type 2 diabetes. It is therefore the core of my research project and as a result will further my understanding.

Electronic Resources

Adam Brimelow. 2009, ‘Lower' Asian obesity threshold, Available at http://news.bbc.co.uk/1/hi/health/8141335.stm

http://www.pamf.org/southasian/healthy/screening/bodysize.html

This electronic source describes diabetes in terms of body mass index it therefore provides an understanding into the early development of the disease among South Asians.

 

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