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Table of Content - Volume 13 Issue 2 - February 2020
A study of co-relation of vitamin D level and risk factors in a patient of diabetes mellitus
Nidhi J Thula1, Jagdishkumar V Patel2*
1Assistant Professor, 2Assistant Professor, Department of Medicine, B J Medical College and Civil Hospital, Asarwa, Ahmedabad, Ahmedabad. Email: drjagdishvpatel@gmail.com
Abstract Background: Vitamin D insufficiency has long been suspected as a risk factor for type 1 Diabetes based on animal and human observational studies. The study under discussion was undertaken to determine the correlation of Vitamin D level to the other risk factor of Diabetes, glycemic control, and duration of Diabetes and treatment of Diabetes. Materials and Methods: A study of co-relation of Vitamin D level and other risk factors of Diabetes in patients attending the outpatient department and indoor department of civil hospital, Ahmedabad was done using Vitamin D level in year 2017-2019. All the patients and the control subjects underwent a through clinical examination. The following investigations were done HbA1c, S cholesterol, S triglyceride estimation, Fasting blood sugar after an overnight fast, Post prandial blood sugar 2 hours after lunch and Vitamin D level estimation in all subjects. Results: Patient with well controlled Diabetes (HbA1c < 7) had a mean Vitamin D level 28.48(ng/ml) which was on higher side as compared to patient with poorly controlled Diabetes. In control group one subject had deficient Vitamin D, 11 having insufficient and 18 had adequate level of Vitamin D. Hypovitaminosis D is 4.12 times more common in diabetic patient as compared to age and gender matched control. In our study 73% diabetic patient had insufficient Vitamin D level as compared to 40% in control group. In our study mean Vitamin D level in diabetic patients was 24.25(ng/ml) and in control group 32.21(ng/ml). Conclusion: Vitamin D deficiency appears to be detrimental to beta-cell function, and leads to glucose intolerance in animal models and humans, consequently type 2 Diabetes. In our study we found that Vitamin D co-related with other risk factors of Diabetes. Vitamin D deficiency was common in patients with Diabetes Mellitus and deficiency was much more in patients having more than one risk factor for Diabetes. Vitamin D deficiency is associated with poor Glycemic control. Key Words: Diabetes mellitus, Vitamin D deficiency, HbA1C, BMI, Cholesterol
INTRODUCTION Diabetes is now emerging as a world wide epidemic. Type 2 Diabetes mellitus is the predominant form of Diabetes worldwide, accounting for 90% of cases globally. Although our current methods of treating Type 2 Diabetes Mellitus and its complications have improved, prevention of the disease is preferable. Indeed, epidemiologic data suggest that 9 out of 10 cases of type 2 Diabetes could be attributed to habits and forms of modifiable behavior. Recent evidence suggests that Vitamin D and calcium have also been suspected as modifiers of Diabetes risk. Vitamin D insufficiency has long been suspected as a risk factor for type 1 Diabetes based on animal and human observational studies. More recently, there is accumulating evidence to suggest that altered Vitamin D and calcium homeostasis may also play a role in the development of Type 2 Diabetes Mellitus. The study under discussion was undertaken to determine the correlation of Vitamin D level to the other risk factor of Diabetes, glycemic control, duration of Diabetes and treatment of Diabetes.
MATERIAL AND METHODS A study of co-relation of Vitamin D level and other risk factors of Diabetes in patients attending the outpatient department and indoor department of civil hospital, Ahmedabad was done using Vitamin D level in year 2017-2019. This is a descriptive case control study with total number of 60 patients and 30 controls. INCLUSION CRITERIA:
EXCLUSION CRITERIA
CONTROL A random sample of 30 patients 19 male and 11 female was selected. The criteria for inclusion were:
All the patients and the control subjects underwent a thorough clinical examination with special emphasis on Symptoms: Body ache, Depression, Bone pain, weakness, Tingling and numbness in feet and hands, Burning sensation in hands and feet, Blurring of vision, Polyuria/Polydypsia. Duration of Diabetes. Treatment received : OHA and/or insulin. General Examination was done specially looking for Height, Weight, Body Mass Index, features of hyperlipidemia, Blood Pressure. Cardiovascular, respiratory and Central Nervous system examination was done to exclude any clinical abnormality. The following investigations were done HbA1c, S cholesterol and S triglyceride estimation, Fasting blood sugar after an overnight fast, Post prandial blood sugar 2 hours after lunch. Vitamin D level estimation in all subjects.
OBSERVATION AND RESULTS
Figure 1: Age and sex wise distribution of Diabetic cases
Table 1: Mean Age in various study groups of diabetic patients
Table 2: Relationship between duration of Diabetes and Vitamin D level
Table 3: Gender Distribution and Vitamin D level:
Table 4: BMI distribution in Diabetic patient and control:
Table 5: Co-relation of BMI and Vitamin D Level in Diabetic Patients
Table 6: ANOVA test (analysis of variance) for correlation between BMI and mean Vitamin D level
F value of ANOVA test is 4.78 and corresponding p value is 0.012 (<0.05) suggest significant difference of Vitamin D level in obese, pre-obese and healthy diabetic patient and shows inverse correlation between BMI and Vitamin D level. This is probably explained by as Vitamin D is fat soluble vitamin and stored in adipose tissue. Blum et al showed that the concentration of Vitamin D in fat is approximately ten times higher than in the blood stream. In patient of obesity it becomes difficult for body to retrieve stored vitamin because it is less bio-available when it imbedded in deeper adipose tissue. Also Vitamin D metabolizing enzyme has been demonstrated in human adipose tissue, the expression level of 25-hydroxy cyp2j2 and 1α hydroxylase cyp27b1 is decreased in adipose tissue of obese subject.
Table 7: Comparison of BMI in various Study Groups
Table 8: Comparison of HbA1c and Vitamin D in Diabetic Patients.
Study done by pittas et al and Schwalfenberg et al shows inverse co-relation between HbA1c and Vitamin D level. In our study, mean value of HbA1C in diabetic was 7.64 as compared to 5.56 of control group. Mean value of HbA1C in study carried out by Kyong et al was 7.62 as compared to 5.3 of control group. This value is almost similar to our finding. Mean value of HbA1c in study carried out by JA Sugden et al was 7.5 as compared to 5.4 of control group. Mean value of HbA1C in study by Vinereanu et al, and Mohammd et al was 8 which were higher than control group.
Table 9: Mean HbA1C level according to Vitamin D levels
Table 10: Comparison between Vitamin D level and HBA1C in various study groups
In our study mean HbA1c in patients with hypovitaminosis D was 7.7 which was higher than HbA1c of 7.4 in patient having Vitamin D in normal range. In study done by Krugs’ et al mean HbA1c was 7.1 in patients with normal Vitamin D level and mean HbA1c of 8.1 in patients with hypovitaminosis D. Table 11: Comparison between Mode of Treatment and Vitamin D level
Table 12: Age distribution and Vitamin D level
Inverse relationship between age of patient and Vitamin D level is demonstrated in the study. Patient with age < 60 having mean Vitamin D level of 26.4 much higher than mean Vitamin D level of 22 in patient with age more than 60. This could be explained by decreased capacity in old people tp produce Vitamin D, decreased capacity of intestine to absorb dietary Vitamin D.9,10 Table 13: Co-relation of Hypertension and Vitamin D level in Diabetic Patients
In our study 25 patients were hypertensive having mean Vitamin D level of 22.75 as compared to mean Vitamin D level of 25.18 in non-hypertensive diabetic patient. Thus Vitamin D level having inverse correlation with blood pressure. Many studies have been conducted in order to establish a relationship between hypertension and Vitamin D levels. A recent review article demonstrates that eight out of ten observational studies and three randomized controlled trials strongly support an inverse relation between Vitamin D level and blood pressure.11 1.25-OH-D decreases the production of renin in the kidneys, as well as decreasing the inflammatory factors involved in chronic heart disease, including C-reactive protein and IL-10.12 This modulation occurs by way of suppressing renin gene expression via VDR, and low calcitriol concentrations may result in an up-regulation of the renin-angiotensin system.13-15 Table 14: Co-relation of cholesterol and Vitamin D level in diabetic patients
In our study mean Vitamin D is significantly lower 17.33 in patients with cholesterol > 240, as compared to mean Vitamin D levels of 25.18 in patients having cholesterol level between 200-240 and mean Vitamin D level of 24.81 in patients having cholesterol level <200. Mean cholesterol level of our 60 diabetic patient was 202.
Table 15: Co-relation of triglyceride and Vitamin D level in diabetic patients
Mean triglyceride level in 60 diabetic patient was 174. Out of 60, 27 patient had triglyceride level < 150 with mean Vitamin D level of 24.11. While 15 patients had triglyceride level between 151-199 with mean Vitamin D level of 28.33, and 18 patients had triglyceride level of >200 with mean Vitamin D level of 21.01. No linear co-relation was established in our study between Triglyceride and Vitamin D level. Table 16: Prevalence of Vitamin D deficiency in diabetic patient
In our study 5 patients were Vitamin D deficient (<10), 39 patient had insufficient Vitamin D level (10-30), and 16 patient had Vitamin D level of normal range. Thus total 44 out of 60 [73.3%] diabetic patients had hypovitaminosis D. In control group 1 subject had deficient Vitamin D, 11 having insufficient and 18 had adequate level of Vitamin D. Thus 12 control out of 30 [40%] had hypovitaminosis D. Table 17: Calculation of odds ratio of hypovitaminosis D in diabetic patients
Odd ratio=4.12, suggest that hypovitaminosis D is 4.12 times more commen in diabetic patient as compared to age and gender matched control. Table 18: Prevalence of hypovitaminosis D in various study groups
In our study 73% diabetic patient had insufficient Vitamin D level as compared to 40% in control group, which is comparable to study done by Barissova Am et al 70% in case and 46% in control group. In study done by krugs et al and Daga et al 91% diabetic patient were having hypovitaminosis D which was more than control group. Table 19: Mean Vitamin D level in various study groups
In our study mean Vitamin D level in diabetic patients was 24.25 and in control group 32.21. In study done by Ja Sudgen et al mean Vitamin D level in diabetic patients was 16.6 which was lower than our study, but in control group level was comparable to our study.
Table 20: Z test for correlation between Vitamin D level and Diabetes
Z test value 2.77, and corresponding p value <0.005. This shows relation between Diabetes and hypovitaminosis D although not causal but a definite and important association. The correlation further warrants larger prospective studies addressing hypovitaminosis D and Diabetes association.
DISCUSSION The mean age of diabetic patients was 58.6 years and controls was 57.4 years. The male to female ratio was 1.33:1 in diabetic group and 1.31: 1 in controls. 22 patients out of 60 had Diabetes duration of 5 years. 27 patients had duration of Diabetes between 6 to 10 years, while 11 patients had Diabetes duration more than 10 years. Mean Vitamin D of patients with Diabetes duration between 6 to 10 years was 22.27(ng/ml), of < 5 year was 25.88(ng/ml) and patient with Diabetes duration > 10 was 25.61(ng/ml). Male had mean Vitamin D level of 24.93 and female patients had 23.95(ng/ml). 38 patients were in over weight group and only 9 controls were in over weight group. Mean BMI of diabetic patients was 27.14(kg/m2) as compared to 22.77(kg/m2) of control group. Diabetic patient with BMI<25 had mean Vitamin D level of 28.71(ng/ml) whereas mean Vitamin D level was 22.66(ng/ml) in pre-obese and 20.41(ng/ml) in obese diabetic patients. Patient with well controlled Diabetes (HbA1c < 7) had a mean Vitamin D level 28.48(ng/ml) which was on higher side as compared to patient with poorly controlled Diabetes. In our study, mean value of HbA1C in diabetic was 7.64 as compared to 5.56 of control group. In our study mean HbA1c in patients with hypovitaminosis D was 7.7 which was higher than HbA1c of 7.4 in patient having Vitamin D in normal range. Patient on OHA having Vitamin D level on higher side as compared to patient on insulin. Hypertensive patients had mean Vitamin D level of 22.75(ng/ml) as compared to mean Vitamin D level of 25.18(ng/ml) in non-hypertensive diabetic patient. Mean Vitamin D is significantly lower 17.33(ng/ml) in patients with cholesterol > 240(mg/l), as compared to mean Vitamin D levels of 25.18(ng/ml) in patients having cholesterol level between 200-240(mg/l) and mean Vitamin D level of 24.81(ng/ml) in patients having cholesterol level <200(mg/l). Mean cholesterol level of our 60 diabetic patient was 202.63(mg/l). Mean triglyceride level in 60 diabetic patient was 174(mg/l). 5 patients were Vitamin D deficient (<10), 39 patient had insufficient Vitamin D level (10-30), and 16 patient had Vitamin D level of normal range. In control group 1 subject had deficient Vitamin D, 11 having insufficient and 18 had adequate level of Vitamin D. Hypovitaminosis D is 4.12 times more common in diabetic patient as compared to age and gender matched control. In our study 73% diabetic patient had insufficient Vitamin D level as compared to 40% in control group. In our study mean Vitamin D level in diabetic patients was 24.25(ng/ml) and in control group 32.21(ng/ml).
CONCLUSION Vitamin D is a hormone of multiple importance to the body and its role in various disease processes is being appreciated. The present study evaluated the co-relation between Vitamin D level and other risk factors of Diabetes Mellitus. Vitamin D deficiency appears to be detrimental to beta-cell function, and leads to glucose intolerance in animal models and humans, consequently type 2 Diabetes. Vitamin D and its related metabolic and immune pathways may be involved in the pathogenesis of Diabetes at environmental and genetic levels. Studies on Vitamin D supplementation on prevention of Diabetes are inconclusive. In our study we found that Vitamin D co-related with other risk factors of Diabetes. Vitamin D deficiency was common in patients with Diabetes Mellitus and deficiency was much more in patients having more than one risk factor for Diabetes. Vitamin D deficiency is associated with poor Glycemic control. Further prospective study are required to encertain the role of Vitamin D deficiency in pathogenesis of Diabetes Mellitus. REFERENCE
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