Type 2 Diabetes mellitus (T2DM) is often preceded by a state of abnormal blood sugars called as pre diabetic state1. Pre diabetic state depicts the tip of iceberg. It is term coined to include two intermediate conditions- impaired fasting glucose and/or impaired glucose tolerance2. An addition to this duo is elevated glycated haemoglobin has been recently added. Prevalence of this state is rising across the world and it has been estimated that by the year 2030, more than 470 million people will develop pre diabetes3,4. Early diagnosis of pre diabetic state and associated risk factors will help intervene early1,5–7. Several studies have projected the association of T2DM with cardiovascular disease and other metabolic risk factors3,8–10. There is insufficient data of association of various metabolic factors with pre diabetes and hence this study was conducted to understand the association of metabolic risk factors with pre diabetes among adults attending our tertiary care center.

A cross sectional study was conducted on the patient attending the department of medicine. The study was on patients who were more than 20 years attending the outpatient department of Lata Mangeshkar Medical College, Nagpur. The patients with prior history of diabetes mellitus, use of drugs which interfere with the glucose metabolism such as angiotensin converting enzyme inhibitors, angiotensin receptor blockers and thiazide diuretics and use of lipid lowering agents were excluded from the study. A study conducted by Muthunarayanan L et al11 inferred that the prevalence of pre diabetes in their study was 8.5%. Using this, with 95% confidence interval and 4.5% absolute error, we found the minimum sample size to be 148. For our convenience, we included 150 subjects in the present study. We used convenience sampling selection of participants. Before the start of the study permission from institutional ethics committee was taken. Written informed consent and strict confidentially was maintained throughout the study. Data was collected using pretested and pre designed case record form. Case record form has details of demographic particulars like age, gender, detailed clinical history and physical examination details and relevant set of investigations. Standard methods were used to measure height, weight, waist circumference and hip circumference12,13. Body mass index was calculated using the formula and classified based on the Asian adults cut offs14. Gender specific waist: hip ratio cut off was used15. Blood pressure was recorded is sitting position in left arm. Two consecutive readings were taken and average value was considered to diagnose hypertension. Hypertension was classified using the seventh Joint National Committee on prevention, detection, evaluation and treatment guidelines16. Fasting blood glucose, oral glucose tolerance test, serum lipid profile and glycosylated haemoglobin were done based on the standard procedures17,18. A patient was said to be pre diabetic, if any of the three parameters were present. The three parameters were fasting blood sugar between 100 to 125mg/dl, 2 hour plasma glucose between 140 to 199mg/dl and or glycosylated haemoglobin between 5.7 to 6.4%2. Statistical analysis: The data was collected, compiled, and analyzed using EPI info (version 7.2). The qualitative variables were expressed in terms of percentages. The quantitative variables were both categorized and expressed in terms of percentages or in terms of mean and standard deviations. The difference between the two proportions was analyzed using chi-square or Fisher exact test. Student t test was used to test the difference between 2 groups. Binary logistic regression analysis was done for the factors which had p value less than 0.10 on Univariate analysis. Wald’s forward method was used. Nagelkarke R square was used to estimate the variance of the model. Independence of the variables was tested using Hosmer Lemeshaw test. Pearson’s correlation coefficient was used to check the inter variable correlation. All analysis was 2 tailed and the significance level was set at 0.05.

We have included 150 cases in the present study. Table 1: Demographic particulars of the present sample Demographic particulars Frequency Percentage Age group 20 to 30 13 8.67 31 to 40 46 30.67 41 to 50 49 32.67 51 to 60 30 20.00 >60 12 8.00 Gender Male 50 33.33 Female 100 66.67 The mean age of the study subjects was 43.01 ± 10.41 years with female preponderance. The prevalence of the pre diabetes in the present sample was 56%. Table 3: Association of different risk factors with pre diabetic state Risk factors Pre diabetic P value Yes No Mean/Number SD/% Mean/Number SD/% Age 44.33 10.36 41.33 10.31 0.0767 Gender Female 56 66.67 44 66.67 1.000 Male 28 33.33 22 33.33 Body mass index 27.57 2.47 24.94 2.52 <0.001 Waist: hip ratio 0.94 0.03 0.89 0.05 <0.001 Lipid profile Total cholesterol 185.57 34.93 156.42 33.49 <0.001 Triglycerides 183.98 47.50 157.51 29.79 0.0001 Low density lipoprotein 114.07 35.59 100.90 18.72 0.0073 High density lipoprotein 36.85 5.97 40.50 3.15 <0.001 Very low density lipoprotein 36.77 9.49 29.16 5.30 <0.001 Blood pressure Systolic 134.45 12.90 130.39 12.28 0.0527 Diastolic 81.26 7.19 79.88 7.64 0.2571 Univariate analysis of the present sample revealed that body mass index (p<0.001), waist: hip ratio (p<0.001), total cholesterol (p<0.001), triglycerides (0.0001), high density lipoprotein (p<0.001), low density lipoprotein (0.0073) and very low density lipoprotein (p<0.001) were associated with pre diabetic state. Table 4: Binary logistic regression analysis with pre diabetes as outcome variable Risk factor Beta Standard error Wald P value Body mass index 0.590 0.181 10.65 0.0010 Waist: hip ratio 50.03 12.36 16.36 <0.001 Total cholesterol 0.031 0.11 8.20 0.0040 Triglycerides -0.151 0.079 3.62 0.057 High density lipoprotein -0.170 0.072 5.55 0.018 Very low density lipoprotein 0.837 0.398 4.43 0.035 Nagelkarke R square=0.792 Those factors which were having significance value less than 0.10 based on univariate analysis were subjected to binary logistic regression analysis. We found higher body mass index (p=0.0010), higher waist: hip ratio (<0.001), lower high density lipoprotein (p=0.0018) and higher very low density lipoprotein (p=0.035) were significant factors which were associated with pre diabetes.

T2DM is fourth major cause of mortality worldwide and is a significant public health problem among the low and middle income countries. Detection of pre diabetic state is of utmost importance since it will prevent the person from developing diabetes and its associated complications. If metabolic risk factors that affect the pre diabetic state are determined early in the course of disease, lifestyle modifications can help in decreasing the risk of future risks. So, we conducted a study to find the prevalence of pre diabetes and to understand the different predictors associated with it. The prevalence of pre diabetes in our study was 56%. This was higher when compared to studies conducted by Liu C et al19, Al Shafaee et al20, Sethuram K et al21, Gebremedhin G et al22, de Ritter et al23, Christine A et al24, Shahid A et al25 and Muthunarayanan L et al11. This is because our study was a hospital based study and likely to have a bias in selecting the individuals. Hospital cohort is usually high risk with one of more associated co morbidities in them. Higher body mass index (Generalised obesity), higher waist: hip ratio (Centralised obesity), lower HDL and higher VLDL was significant predictors associated with pre diabetic state in the present study. A study conducted by Al Shafaee et al20 reported that for isolated impaired glucose tolerance (IGT) and isolated impaired fasting glucose (IFG) the predictors were male gender, age more than 45 years and higher body mass index. But, combined IFG and IGT (Prediabetes) the predictors were higher age, higher body mass index and low HDL. Another study conducted by Sethuram K et al21 reported on univariate analysis that the mean body mass index, total cholesterol, triglycerides and LDL were significantly higher among pre diabetics when compared to normal individuals. Gebremedhin G22 and colleagues reported that individuals with pre diabetes had higher systolic blood pressure, diastolic blood pressure, higher LDL, cholesterol and triglycerides when compared to normal individuals in their study. Similar findings were inferred by de Ritter et al23, Christine A et al24, Shahid A et al25 and Muthunarayanan L et al11. The study had some limitations. First, it was a hospital based study. Secondly it was a cross sectional study. Studies with follow up status of these factors over the time will have a better quality research. Thirdly, it was a single center study. Multi centeric studies and community based studies will yield better generalizable results. Nonetheless, we conducted one of the pioneer studies in this region on associated risk factors of pre diabetes which will add to the pool of present research.

More than ½ of the patients were pre diabetic in the present study. Higher body mass index (Generalised obesity), higher waist: hip ratio (Centralised obesity), lower HDL and higher VLDL was significant predictors associated with pre diabetic state in the present study. Approach to lifestyle modifications and early identifications of these risk factors will help the patient to stop the transition of disease from pre diabetic state to frank T2DM. It is of utmost important that these factors have to be considered in the management of the patients.

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