Department of Anthropology, University of Delhi, Delhi 110007, IndiaIndia
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Background: Diabetes Mellitus (DM) has become a major health issue all over the world. Lifestyle factors may affect the health of the patients with diabetes directly or indirectly. Family history of diabetes was given importance in various studies of this aspect of metabolic syndrome. Aim: The present study was conducted to find out the effect of lifestyle indicators and family history of diabetes among the diabetic Muslim population of Manipur. Materials and Methods: Cross-sectional method was used for the study in which individuals of both sexes in the age group from 20-45 years. The respondents were taken from two districts in Manipur. Information was gathered by using a structured proforma. Results: Chi-square test showed significant p-values for stress level, family history, physical activity and Quality of Life (QoL) of the participants. All these lifestyle indicators including breakfast habit and family history of diabetes were found to be significant except quality of life on multinomial logistic regression analysis. Conclusion: Lifestyle had greatly influenced on the life of the diabetic Muslim people of Manipur in which it needed to give more awareness to them.
Keywords: Diabetes mellitus; Family history; Lifestyle; Manipur
Diabetes mellitus, a metabolic disease is increasing rapidly in almost all regions of the world. India stands at the topmost position in the world with the highest number of people with diabetes mellitus of about 31.7 million in the year 2000 followed by China with 20.8 million in second and the United States 17.7 million in the third place.1 The maximum increase of the prevalence of diabetes in India will contribute largely to the global increase from 171 million in 2000 to 366 million in 2030.1 India is experiencing an alarming increase in the incidence 2 3 4 and prevalence of type 2 diabetes mellitus (T2DM)2 both in rural3 and urban areas4 with higher prevalence in South than in North India.5 A higher risk of diabetes has been reported from few Southern and North-eastern states while several northern and central states were at lower risk after adjusting for individual characteristics and place of residence.6
have diabetes. Two to three times higher risk of developing glucose intolerance is associated
8,9
8,10 with individuals with no family history of the disease. The causes of type 2 diabetes are quite complex, family medical history provides valuable genomic information. Hence, this informa-
tion represents the combination of inherited genetic susceptibilities and shared environmental and behavioural factors.11
Physical inactivity is also another major behavioural risk factor of type 2 diabetes. Sedentary habits of the individuals developed higher prevalence of the disease.12 Quality of life of people with diabetes is seriously threatened.13 The present study was therefore conducted to examine whether these lifestyle indicators affected the diabetic Muslim population of Manipur.
All the participants studied were from Muslim community of Imphal-East district and Thoubal district and were under medical supervision. A cross-sectional research method was used. Among a total of 400 participants, 200 were diabetics and 200 were non-diabetics of both sexes. The purpose of the study and techniques to be used were explained to each participant. Only those participants who gave written consent were included for the study. Ethical permission was taken from Institutional Ethical Committee (IEC) prior to the fieldwork. Direct interview method was used. Detailed information of the participants was collected using standardized proforma. Stress level of the participants was assessed by using standardized questionnaires given by Canadian Mental Health Association (CMHA).14 Total stress level was calculated and classified according to its cut-off points (14-22=considerably above average, 10-13=above average, 9-0=average). QoL was assessed by using the World Health Organization (WHO) Quality of life-BREF (WHOQL-BREF) questionnaire.15 Statistical analysis of all the data collected were
N: Number of participants.
Table 1. Distribution of participants under different Considerably above average 80(40.0%) Above average 49(24.5%) N: Number of participants. ***p<0.001.
Table 2. Cross tabulation of different stress levels.
N=Number of participants.
***p<0.001.
Table 3. Cross tabulation of family history of diabetes.
analysed by using 17.0 version of SPSS. Cross tabulations were carried out to find out the frequencies, percentages and chisquare values. Risk factors of the variables were determined by using multinomial logistic regression.
The basic characteristics of the population under study are displayed in Table 1. The numbers of subjects were 200 each for both males and females. Mean values of age, height and weight were more for the patients with type 2 diabetes. Table 2 shows cross tabulation of different stress levels among patients with type 2 diabetes and non-diabetic participants. All the stress level percentages were higher among patients with type 2 diabetes as compared to non-diabetic participants. Chi-square value was found to be statistically significant at p<0.001. Distribution of patients with type 2 diabetes according to family history of diabetes has been displayed in Table 3. Maximum number of diabetic subjects (60%) was found to have a family history of type 2 diabetes mellitus and 4.5% subjects had type 1 family history of this disease. But the corresponding values were comparatively less among non-diabetic participants. Statistical significance was found for this factor at p<0.001 .
Table 4 displays the cross tabulation of physical activity status. It was found from the study that more number of patients with type 2 diabetes were physically inactive as compared to non-diabetics. Most of the non-diabetics were found to be physically more active (98%). However, 77% patients with type 2 diabetes were active for physical activity. Marked differ-
Sex Male (N=200) Female (N=200)
Age (years) 41.2±4.16 32.8±6.97 40.6±4.79 31.8±6.90 Height (centimetre) 160.1±5.10 158.6±5.53 151.8±4.64 149.7±5.24 Weight (kilogram) 63.3±8.78 60.1±9.52 61.6±9.84 52.8±10.04
characteristics.
24(12.0%) 104(26.0%) 29(14.5%) 78(19.5%) 61.7*** Average 71(35.5%) 147(73.5%) 218(54.5%) Total 200(100.0%) 200(100.0%) 400(100.0%)
Type 1 9(4.5%) 1(0.5%) 10(2.5%) Type 2 120(60.0%) 41(20.5%) 161(40.3%) 78.2*** Not applicable 71(35.5%) 158(79.0%) 229(57.3%) Total 200(100.0%) 200(100.0%) 400(100.0%)
ence with statistically significance (p<0.001) was also observed for physical activity status among patients with type 2 diabetes and non-diabetic participants. In the present study, maximum subjects had their breakfast regularly (93% diabetic and 98% non-diabetic). Five percent diabetic and 1% non-diabetic took breakfast irregularly. Two percent diabetic and 1% non-diabetic were not taking breakfast at all. The differences in the various categories were found statistically non-significant (Table 5).
The median of the total score of QoL was calculated and it was found to be 77. It was categorized as <77 as low quality of life and ≥77 as good quality of life. It was found from the scores of quality of life of the participants (Table 6) that 54.5%
N: Number of participants.
***p<0.001.
Table 4. Cross tabulation of physical activity status.
N: Number of participants.
Table 5. Cross tabulation of breakfast consumption pattern.
Low quality of life 133(66.5%) Good quality of life 67(33.5%)
N: Number of participants.
***p<0.001.
CI: Confidence Interval.
0ª: Reference (normal).
Diabetic: Dependent category.
Non-diabetic: Reference category.
Table 7. Multinomial logistic regression of various lifestyle indicators.
of them had low QoL out of which proportionately larger number were diabetic (66.5%). Only 42.5% non-diabetics had low quality of life. Good quality of life was comparatively more in number among non-diabetics (33.5% diabetic and 57.5% nondiabetic). The difference in distribution of participants in the quality of life categories was statistically significant (p<0.001) .
Multinomial logistic regression of lifestyle indicators and family history of diabetes was found out to the risk factors for each category as given in Table 7. The patients under the categories of considerably above average level of stress and above average level of stress were 6.9 times and 3.8 times more risk of having diabetes respectively. Patients with family history of
Inactive 46(23.0%) 4(2.0%) 50(12.5%) Active 154(77.0%) 196(98.0%) 350(87.5%) 40.3*** Total 200(100.0%) 200(100.0%) 400(100.0%)
Irregular 10(5.0%) 2(1.0%) 12(3.0%) Absent 4(2.0%) 2(1.0%) 6(1.5%) 6.3 Regular 186(93.0%) 196(98.0%) 382(95.5%) Total 200(100.0%) 200(100.0%) 400(100.0%)
85(42.5%) 218(54.5%) 115(57.5%) 182(45.5%) 23.2*** Total 200(100.0%) 200(100.0%) 400(100.0%)
Considerably above average 6.9 (3.6, 13.3) Stress level Above average 3.8 (2.0, 7.4) Average 0ª Type 1 diabetes mellitus 20.5 (2.2, 186.7)
Not applicable 0ª Inactive 13.2 (4.2, 41.6)
Active 0ª Irregular 6.5 (0.9, 43.9) Breakfast Absent 8.1 (1.4, 45.5) Regular 0ª Low quality of life 1.5 (0.9, 2.5)
Good quality of life 0ª
type 1 and type 2 diabetes mellitus were 20.5 times and 7.1 times more likely to have risk of diabetes respectively. Those patients who were less active in physical activity were 13.2 times more at risk to develop diabetes compared to the active group. Irregular breakfast consumers and none breakfast consumers were 6.5 times and 8.1 times more at risk of developing diabetes respectively. Patients with low quality of life had 1.5 times more risk to suffer from diabetes.
Stress level, physical inactivity, breakfast consumption pattern, quality of life, etc. do indicate the health status of an individual. The present study was conducted to determine whether these indicators affected the health of the diabetic and non-diabetic Muslim population of Manipur. It was observed from the present study that most of the patients with diabetes were found to have stress and it was identified as one of the risk factor of diabetes. This was consistent with the results of earlier studies16 and was suggestive of direct or indirect negative impact of stress on blood glucose level through the release of stress hormones or by disrupting self-care practices.
Indian population were commonly seen to have familial aggregation of diabetes with a high prevalence among very close relatives and was transmitted vertically through more than two generations.17 A study conducted among the South Indian population showed the development of diabetes to be earlier among the subjects with family history of diabetes as compared to subjects without family history. Further, it was demonstrated by which study that glucose intolerant subjects with family history were 7 years younger than subjects without a family history of diabetes.18
In a self-reported study among US adults, family history of diabetes was shown to be a significant predictor of diabetes. The study estimated that those adults with a family history of diabetes on their parents or siblings had four times more risk of having diabetes than adults without a family history of the disease, after adjusting for gender, age, race, and body mass index (BMI).19
The risk of type 2 diabetes was six times higher among the women with family history of diabetes as compared with individuals without a family history of the disease.10 Furthermore, the study conducted by Centre for Disease Control and Prevention (CDC)20 demonstrated that the risk of having diabetes among adults with two diabetic parents was more than twice.
In the present study, it was clearly found that patients with type 2 diabetes had 60% type 1 and 4.5% type 2 family histories of diabetes respectively. However, the risk of developing diabetes was more among those who had type 1 diabetes family history. Similarly, in a recent clinic based study among patient with diabetes of Western Indian population, it was reported that 57.7% had positive family history out of which 37.0% had single
parent with diabetes, 10.5% had both parents with diabetes and 26.7% had near relatives suffering with diabetes which showed high familial aggregation of T2DM in the Western Indian population.21
Sedentary lifestyle adversely affected the health of the people that might contribute to the increase in body weight, a major risk factor of diabetes. Maintaining exercise regularly and active physical work could contribute in improving the health of the diabetic patient. Regular physical exercise whether aerobic or resistance was proved to be effective in the reduction of degree of obesity and the incidence of metabolic results such as 22 23 type 2 diabetic individuals.22 Wing et al.23 suggested walking as a form of exercise and prescribed an increment of exercise. In the present study, it was found that the percentage of physically inactive individuals was more among diabetics as compared to non-diabetics and the difference between the two was also statistically significant. Moreover, it was marked that the physically inactive persons were 13 times more likely to be at risk of diabetes. This finding was consistent with the study by Dowse et al,24 that there was an association between physical inactivity and risk of non-insulin dependent diabetes mellitus and impaired glucose tolerance.
The present study among the Muslims of Manipur showed relative risk between irregular or absence of breakfast consumption and diabetes. Maximum percentage of patients with diabetes had regular breakfast and very few them did not consume breakfast at all. The risk of diabetes was found 8.1% on patients not taking breakfast and 6.5% among regular consumers. This result was consistent with a large prospective study by Mekary et al,25 that the risk of type 2 diabetes might be decreased among men by breakfast consumption. Breakfast omission was associated with an increased risk of type 2 diabetes mellitus in men even after adjustment for BMI which needed further studies to elucidate this association in women and in other ethnic and racial groups and to conduct an in-depth analysis of specific breakfast foods.
Marked significant difference in the QoL between patients with diabetes and non-diabetic participants was revealed in the present study. However, in multinomial logistic regression analysis, it showed less difference and statistically non-significant. It could be due to social conditions and lifestyle of the people which adversely affected their physical and psychological domains. Similarly, this type of difference was found in Health Related Quality of Life (HRQoL) of both genders in a study con- 26 27 ducted in Iran.26 Eljedi et al27 in their study on the diabetic patient living in refugee camps in the Gaza strip analyzed HRQoL in comparison with gender and age matched non-diabetic controls from the same camps. They reported that all the domains of the WHOQL-BREF was negatively affected by diabetes and its complications that had greatest effects on the physical health and psychological domains but the effects was weaker for the social relationships and environmental domains. Further, interactions between gender and disease status between diabetic patients and
non-diabetic were also strong. However, this finding could not be explained fully because the situation of the female patient was worse which showed the evidence for gender inequalities.28
Another study29 found the deterioration of the QoL of patients with type 2 DM by the presence of depression. This finding resulted on the conclusion that the QoL of the subject could be made better by treating depression.
The family history of diabetes as well as lifestyle indicators such as stress level, physical activity, breakfast consuming pattern and quality of life among Muslim males and females of Manipur played crucial role in the life of patients with diabetes. The present study demonstrated these parameters as risk factors of this metabolic disease. Thus, there is a need to make efforts for improving the lifestyle which might help in the reduction of this disease.
The authors are thankful to all the participants of the Muslim community of Imphal-East district and Thoubal district for their full cooperation in the present study. Nilupher Feroz is grateful to the University Grants Commission for financial assistance during the study under the Non-NET fellowship scheme.
The authors declare that they have no conflicts of interest.
The participants have been properly, made aware about the objectives, relevance and purpose of the research study. The participants have been told that the anthropological information collected from them will be utilized for the real purpose of research and academic activities. They are also made to understand that no money will be charged from them for any of the tests, and they can withdraw from the study at any time, but will keep getting counselling benefits till the duration of the project.
All the participants consciously gave their consent to participate in the above research study.