Article Text
Abstract
Introduction Type 2 diabetes is characterized by considerable heterogeneity in its etiopathogenesis and clinical presentation. We aimed to identify clusters of type 2 diabetes in Asian Indians and to look at the clinical implications and outcomes of this clustering.
Research design and methods From a network of 50 diabetes centers across nine states of India, we selected 19 084 individuals with type 2 diabetes (aged 10–97 years) with diabetes duration of less than 5 years at the time of first clinic visit and performed k-means clustering using the following variables: age at diagnosis, body mass index, waist circumference, glycated hemoglobin, serum triglycerides, serum high-density lipoprotein cholesterol and C peptide (fasting and stimulated). This was then validated in a national epidemiological data set of representative individuals from 15 states across India.
Results We identified four clusters of patients, differing in phenotypic characteristics as well as disease outcomes: cluster 1 (Severe Insulin Deficient Diabetes, SIDD), cluster 2 (Insulin Resistant Obese Diabetes, IROD), cluster 3 (Combined Insulin Resistant and Deficient Diabetes, CIRDD) and cluster 4 (Mild Age-Related Diabetes, MARD). While SIDD and MARD are similar to clusters reported in other populations, IROD and CIRDD are novel clusters. Cox proportional hazards showed that SIDD had the highest hazards for developing retinopathy, followed by CIRDD, while CIRDD had the highest hazards for kidney disease.
Conclusions Compared with previously reported clustering, we show two novel subgroups of type 2 diabetes in the Asian Indian population with important implications for prognosis and management. The coexistence of insulin deficiency and insulin resistance seems to be peculiar to the Asian Indian population and is associated with an increased risk of microvascular complications.
- diabetes mellitus, type 2
- India
- diabetes complications
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Footnotes
EP and VM contributed equally.
Contributors RMA, VM and EP conceived the study, were involved in the interpretation of data and wrote the first and subsequent drafts of the manuscript. VB, SJ, MKS and ATNN were involved in data retrieval and statistical analyses. RU, RP and CP were involved in the interpretation of data and provided comments on drafts of the manuscript. All authors contributed to revision of the manuscript and approved the final submitted version. VM is the guarantor of this work, and as such had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Funding This research was funded by the National Institute for Health Research (NIHR) (INSPIRED 16/136/102) using UK aid from the UK Government to support global health research. EP holds a Wellcome Trust New Investigator Award (102820/Z/13/Z).
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval The study was approved by the Institutional Ethics Committee of the Madras Diabetes Research Foundation (MDRF) (MDRF/NCT/08-01/2017).
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.