INTRODUCTION:

Diabetes mellitus is a heterogenous disorder characterised by hyperglycaemia, insulin deficiency and insulin resistance with increasing economic and health burden throughout the world. American diabetes association defines diabetes as a metabolic disease characterised by hyperglycaemia resulting from defects in insulin secretion, insulin action or both.¹People with diabetes spend up to 8000 hours per year managing their diabetes outside medical setting ².This disease often requires various daily tasks such as checking blood glucose levels as well as coherence to many complicated medical regimens ³.

Diabetes is often accompanied by risk factors such as obesity, hypertension, hypercoagulability, systemic inflammation and dyslipidaemia, which increases cardio vascular death rates.⁴India is the epicentre of diabetes mellitus and in 2017 it was found that India is the second largest country having 73 million diabetic patients after china.⁵.An average Indian exhausts around 5-30% of his house hold earnings on the management of diabetes alone which increases the burden of the nation.^6-8 There is a strong evidence shown by various randomised trials that lifestyle interventions like healthy diet, physical activity and weight loss decreases risk of developing type 2 diabetes ^9-12. Recently it has been postulated that dietary modification can preserve B cell mass thereby reversing the progression of type 2 diabetes mellitus.^13-15It has been shown that inspite of maintaining blood glucose levels below a threshold for diabetes treatment some people develop micro and macro vascular complications from prediabetes even before onset of type 2 diabetes mellitus.^16,17. Around 10% prediabetic subjects develop type 2diabetes each year.¹⁸

The aim of our study was to determine the relationship between vitamin D and physical activity on glycaemic control in type 2 DM patients.

Subjects and Methods:

This is an observational cohort study which was conducted at SDH Hospital Sopore during November 2019 to December 2020 among diabetic patients aged 40 years and above .A total of 450 patients were registered for the study who agreed and gave consent to take part in this study of which 50 lost follow up and finally 400 were assessed.(200 cases and 200 control subjects).Subjects were screened and randomised by schedule of permuted block randomisation with block size 4 was used drug allotment. Subjects diagnosed with DM and taking oral anti diabetics were considered to have DM. Type2 DM diagnosis was made in accordance with the world health organisation criteria where patients having fasting blood glucose level greater than 126mg/dl and post prandial glucose greater than 200mg/dl were considered to be diabetic.¹⁹The inclusion criteria were: (1)subjects diagnosed with T2DM (2) taking oral medications for around 1 year. (3) ≥ 40 years old (4) formal written informed consent.

Serum measurement of vitamin D:

Trained expertise collected blood samples and measured vitamin D levels . using kit (DXI kit Beckman Coulter machine) and the samples were then assayed using radioimmunoassay (RIA) technique.

Questionnaire:

The questionnaire comprise information about socio-demographic profile including age, sex,, education level, BMI, and, family history of diabetes, type of diabetes, co-morbid hypertension, and diabetic complications. Information on physical activity, and smoking habits were also collected.

Statistical analysis:

Categorical variables were summarised as percentages. Continuous variables were summarised as mean and standard deviation. Unpaired t-test was used to analyse the difference of two means. Chi-square test was used to analyse the relationship between two categorical variables. Two-sided p-values were reported and p-value < 0.05 was considered statistically significant.

RESULTS:

Table 1 shows the comparison of socio-demographic characteristics between diabetic and control subjects. There was significant difference between patients of diabetes and control group vis - a –vis vitamin D levels, physical activity, smoking, family history and hypertension. The difference was statistically significant also. Neither educational status nor monthly income seemed to play any significant role in the genesis of DM, also when case and control groups were compared the difference was not statistically significant in both the parameters.

Table 1: Comparison of socio-demographic and clinical characteristics between case and control groups.

Parameters

Total (n=400)

Cases n= 200

Control n= 200

P -value

Age

40-49

50-59

60-69

100

250

120

130

0.49

Gender

Male

Female

150

250

120

130

0.30

Education status.

Illiterate

Intermediate

College

120

230

125

105

0.318

BMI(kg/m²)

Normal

Overweight

Obese

210

110

100

0.041

Physical activity.

Yes

130

270

140

130

<0.000001

Smoking

Yes

120

280

130

150

0.029

Family history of DM.

Yes

220

180

120

100

0.044

Hypertension(mmHg)

Yes

180

220

100

120

0.044

Monthly income

< 15000

>15000

150

250

130

120

0.30

Table 2 shows the biochemistry values of the 2 groups. Vitamin D levels were lower in the Diabetic group when compared to the control group. Mean vitamin D levels being 20ng/ml in the diabetic patients when compared to 50ng/ml in the control groups (p < 0.0000001). In participants with T2DM, BMI, fasting glucose level, HbA1c, LDL, triglycerides, uric acid and blood pressure were higher when compared to the control group.

Table 2: Comparison of biochemical values of subjects with type 2 DM and control subjects.

Parameters	Case(n=200) Mean ± SD	Control(n=200 Mean ± SD	P-value
Blood glucose(Fasting)	177mg/dl ± SD 353	93. ± SD 12.77	0.00001
HbA1c	5.93%	5.86%	0.0001
Triglycerides	240.3mg/dl	134.5mg/dl	0.00001
HDL	19.75mg/dl	44.5mg/dl	0.025
LDL	154.5mg/dl	85.5mg/dl	0.026
Vit D	15ng/ml	43.95ng/ml	0.0000001
Calcium	6.02mg/dl	8.42mg/dl	0.155
Creatinine	0.96mg/dl	0.41mg/dl	0.04
Urea	30mg/dl	35mg/dl	0.59
Uric acid	4.25mg/dl	3.65mg/dl	0.75

DISCUSSION:

Growing burden of diabetes is a major concern in Indian population. With an alarming increase in diabetes cases India will be labelled as diabetes hub of the world. With the changing trend in lifestyle vis -a vis lack of physical exercise , sedentary life style, urbanisation, advancing age, dietary habits etc. has resulted in increasing incidence of DM. A large portion of health care expenditure by the patients affect the health care infrastructure because of financial burden.²⁰In India it is largely the private sector which spends approximately 68% of financial cost for delivering health care services for diseases in both rural and urban population.²¹Type 2 DM accounts for around more than 90% of all diabetes. This type includes individuals who have relative insulin deficiency and peripheral insulin resistance. Sometimes initially and lately throughout their life time they become dependent on insulin therapy to survive. There are many etiologies of type 2 DM, although the specific ones are unknown. Most of the patients with type 2 DM are obese or overweight. Type 2 DM is mostly missed on diagnosis for many years because symptoms develop gradually and are not severe enough initially and go unnoticed by the patient. Even though not severe in the beginning micro and macrovascular complications do start commencing from the initial stages of disease. Diabetic ketoacidosis, one of the serious complications rarely occurs in association with stress like infection or with some drugs like steroids, antipsychotics etc.^22,23

In our study vitamin D levels were low in diabetes mellitus group when compared to control group. Earlier studies have shown that lower vitamin D levels in diet than required can lead to the development of DM type 2. ²⁸ Vitamin D deficiency has been related to the development of DM through many ways such as homeostasis in phosphorous and calcium metabolism, insulin secretion regulation, alteration of cytokine expression, intonation of adipocyte function.²⁸ There are many studies which relate occurrence of diabetes mellitus type 2 with vitamin D deficiency.^24-31As postulated by meta-analysis done by Pittas et al. it suggests that binding of vitamin D to beta cell receptors facilitated by calcium causes regulation of insulin secretion.³²Thus deficiency of vitamin D can cause impaired insulin secretion in patients with type 2 DM. Vitamin D also stimulates the insulin receptor expression so its deficiency can cause insulin resistance.^33,34 Vitamin D also acts as a hormone and regulates many gene functions directly or indirectly which influence large number of physiological functions. In our study there was negative correlation between Vitamin D and HbA1c levels. Previous studies have shown same results.³⁵Normal blood glucose levels can be obtained in type2 DM patients if their plasma vitamin D levels are maintained at normal. Also progression of type 2 DM can be slowed down in high risk subjects if optimal plasma levels of vitamin D are maintained.²⁶

There is increasing risk of developing type 2 DM with advancing age, inadequate physical activity and obesity.³¹It also occurs frequently in those with dyslipidaemia and hypertension. In our study subjects with type 2 DM had higher levels of triglycerides and LDL when compared to control group. Also blood pressure was slightly higher in DM group. In a longitudinal study contrary to association of vitamin D with type 2 DM, no correlation was found between vitamin D levels and type I DM.³⁶

BMI ³25 kg/m²is a risk factor type 2 DM.³⁷In our study physical activity was seen less in type 2 DM patients when compared to control group. Moderate physical activity like brisk walking showed beneficial results in subjects with pre diabetes.³⁸Moderate intensity physical activity decreases insulin resistance and reduces abdominal fat in children and adults.^39,40Besides aerobic activity, resistance training can be included in regular physical activity which can help to prevent Type2 diabetes.

CONFLICT OF INTEREST:

There was no conflict of interest among authors

CONCLUSION:

Vitamin D , physical activity, smoking, family history of DM seem to be contributing factors to the rising burden of DM in Indian population. Therefore there is a dire need to recognize causative factors responsible for the rising incidence of this disease which eventually escalates the economic burden on individual level and by and large the global burden of this disease.

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Received on 01.06.2021 Modified on 18.08.2021

Research J. Pharm. and Tech 2022; 15(10):4697-4700.

DOI: 10.52711/0974-360X.2022.00788