RESULTS AND ANALYSIS
ANALYSIS OF BMI IN CASES WITH NORMAL AND ABNORMAL THYROID PROFILE
Out of 20 patients with abnormal thyroid profile, 45% (9/20) were overweight and 30% (6/20) were obese. There was no significant correlation between BMI and abnormal thyroid profile (p > 0.05).
Fan W et al observed in their study that obese individuals have normal levels of thyroxine(T4) and thyroid stimulating hormone(TSH) but, increased levels of triiodothyronin(T3) in a minority of subjects.81 The findings contradict with Process et al who in their study found that besides known parameters such as age and drugs, thyroid-function tests can also be altered by diabetes mellitus and obesity.55
SUMMARY
SUMMARY
This study aimed at estimating the prevalence of thyroid dysfunction in type 2 Diabetes mellitus patients and also to find out it’s correlation with various risk factors. The study sample included 100 type 2 diabetic patients presented in the outpatients department. Each patient was assessed clinically and by laboratory investigations.
Primary observations regarding thyroid profile in patients with type 2 diabetes mellitus. In the present study, 20%(20 nos) of patients with type 2 diabetes mellitus had abnormal thyroid profile.
In patients with abnormal thyroid profile(20 nos), most common abnormality was subclinical hypothyroidism(55%) followed by subclinical hyperthyroidism(25%).
Our study showed significant correlation between abnormal thyroid profile and gender, duration of diabetes and family history of diabetes.
In persons with abnormal thyroid profile, 70% were females and 30% were males. This is statistically significant. The prevalence of thyroid abnormalities is more common in females than in males.
No significant correlation was found between altered thyroid profile and age, type of treatment, SHT and BMI.
Additional observations in the study group of type 2 diabetes mellitus subjects:
In the present study, patients ranged from 35 to 79 years of age.
Maximum number of patients were in the age group between 41 to 60yrs (58%).
Majority (82%) of patients were on regular treatment and 18%
were on irregular treatment.
44% patients were having family history of diabetes mellitus and 56% had no family history.
Majority (80%) of the diabetic patients were overweight and obese.
CONCLUSION
CONCLUSION
♦ Prevalence of thyroid dysfunction is more common among type 2 diabetes mellitus patients than in general population.
♦ Prevalence of thyroid dysfunction in patients with type 2 diabetes mellitus is higher in females than in males
♦ There is no significant correlation between age, duration of diabetes, family history of diabetes and BMI.
♦ Routine screening for thyroid dysfunction in type 2 diabetes
mellitus patients may be justified especially in females because the progression to overt thyroid dysfunction is associated with significant morbidity including the adverse effects on glycemic control, lipid profile, bone mineral density and cardiovascular events.
LIMITATIONS
• Study population was small.
• Associated thyroid autoimmunity was not evaluated due to
constraints.So it was not able to refine the spectrum of thyroid dysfunction in type 2 diabetics.
• Follow up study was not done. So the natural history of subclinical thyroid dysfunction and its effect on various parameters could not be assessed.
ANNEXURES
BIBLIOGRAPHY
BIBLIOGRAPHY
1. Peter H Bennett, William C Knowlap. Definition, diagnosis and classification of diabetes. Joslin’s diabetes mellitus 14th edition,2005: 331-337.
2. Alvin C .Powers. Diabetes mellitus. Harrison’s principles of internal medicine 17th edition,2008: 2275-2304.
3. IDF Diabetes atlas 4th edition, 2009.
4. WHO(2003), Tech. Rep. Ser., N 916.
5. WHO(2002), Health situation in the South East Asia Region 1998-2000, New Delhi.
6. International Diabetes Federation, 20th October 2009, Montreal.
7. UN. 83rd plenary meeting, 20th December 2006. 61st session;
Agenda 113.
8. Donald M Barnett, Leo P. Krall. History of diabetes. Joslin’s diabetes mellitus 14th edition,2005: 1-17.
9. Porter R. The greatest benefit to mankind, al medical history of humanity. New York: WW Norton, 1997:71.
10. Schadewaldt H. The history of diabetes mellitus. In: Van Englehardt D, ed. Diabetes, its medical and cultural history. Berlin:
Springer Verlag, 1987:43–100.
11. Langerhans P. Beitrage zur mikroskopischen Anatomie der Bauchspeicheldruse. Med Diss (Berlin), 1869.
12. Morrison H. Translation and introductory essay. Langerhans P.
Contributions to the microscopic anatomy of the pancreas. Bull Inst Hist Med 1937;5:259–269.
13. Minkowski O. Historical development of the theory of pancreatic diabetes (introduction and translation by R. Levine). Diabetes 1989;38:1–6.
14. De Meyer J. Contribution l'ude de la pathogie du diabete pancreatique. Archive Internationale de Physiologie 1909:121–180.
15. Banting FG, Best CH. The internal secretion of the pancreas. J Lab Clin Med 1922;7:251–266.
16. Savage PJ, Bennion LJ, Bennett PH. Normalization of insulin and glucagon secretion in ketosis-resistant diabetes mellitus with prolonged diet therapy. J Clin Endocrinol Metab 1979;49:830–833.
17. Agner T, Damm P, Binder C. Remission in IDDM: prospective study of basal C-peptide and insulin dose in 268 consecutive patients. Diabetes Care 1987;10:164–169.
18. Gavin JR III, Alberti KGMM, Davidson MB, et al. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997;20:1183–1197
19. WHO Consultation Group. Definition, diagnosis and classification of diabetes mellitus and its complications, 2nd ed. Part 1: Diagnosis and classification of diabetes mellitus WHO/NCD/NCS/99.
Geneva: World Health Organisation, 1999:1–59.
20. Turner RC, Cull CA, Frighi V, et al. Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes mellitus: progressive requirement for multiple therapies (UKPDS 49). UK Prospective Diabetes Study (UKPDS) Group. JAMA 1999;281:2005–2012.
21. Dabelea D, Pettitt DJ, Jones KL, et al. Type 2 diabetes mellitus in minority children and adolescents. An emerging problem.
Endocrinol Metab Clin North Am 1999;28: 709-29.
22. American Diabetes Association 2007, Criteria for the diagnosis of diabetes mellitus. Diabetes care, Volume 30, Supplement 1, anuary 2007.
23. Howard BV. Pathogenesis of diabetic dyslipidemia. Diabetes Rev 1995;3:423–432.
24. Siegel RD, Cupples A, Schaefer EJ, et al. Lipoproteins, apolipoproteins, and low-density lipoprotein size among diabetics in the Framingham offspring study. Metabolism 1996;45:1267–
1272.
25. Robert H. Eckel. The metabolic Syndrome. Harrison’s principles of internal medicine 17th edition,2008:1509-1514.
26. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High
Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001; 285:2486–2497.
27. J, Larry Jameson, Anthony P. Weetman. Disorders of thyroid gland. Harrison’s principles of internal medicine 17th edition, 2008: 2224-2247.
28. Thyroid and Antithyroid drugs. Katzung Basic clinical pharmacology 10th edition,2007: 618-634.
29. Physiological effects of thyroid hormones. William F. Ganong Review of medical physiology 22nd edition: 317-332.
30. P.Reed Lorson, F. Davies. Quantitation of serum thyroid hormone concentration. Williams textbook of Endocrinology 11th edition:
299-332.
31. Nikhil Tandon. API Text book of medicine 8th edition:1002-1010 32. Chidakel A, Mentuccia D, Celi FS: Peripheral metabolism of
thyroid hormone and glucose homeostasis. Thyroid 2005; 15:899-903.
33. Gregory A. Brent, P. Reed Larsen, Terry F. Davies.
Hypothyroidism and thyroiditis. Williams textbook of Endocrinology 11th edition: 377-409.
34. Huber G, Staub J-J, Meier C, et al: Prospective study of the spontaneous course of subclinical hypothyroidism: prognostic value of thyrotropin, thyroid reserve, and thyroid antibodies. J Clin Endocrinol Metab 2002; 87:3221-3226
35. Kvetny J, Heldgaard PE, Bladbjerg EM, et al: Subclinical hypothyroidism is associated with a low-grade inflammation, increased triglyceride levels and predicts cardiovascular disease in males below 50 years. Clin Endocrinol (Oxf.) 2004; 61: 232-238 36. Cappola AR, Fried LP, Arnold AM, et al: Thyroid status, clinical implications. Ann Intern Med 2003; 139:205-213.
39. Faber J, Galloe AM: Changes in bone mass during prolonged subclinical hyperthyroidism due to L-thyroxine treatment: a meta-analysis. Eur JEndocrinol 1994; 130:350-356.
40. R. Sathish,V. Mohan. Diabetes and Thyroid disease-A Review. Int J of Diabetes in Developing countries 2003;23; 120-123.
41. Schlienger JL, Anceau A, Chabrier G, North ML,. Stephan F.
Effect of diabetic control on the level of circulating thyroid hormones. Diabetologia. 1982;22;486-8
42. Donckier JE. Endocrine diseases and diabetes. In: Textbook of Diabetes mellitus. Pickup JC, Williams G (eds), Blackwell Publishing Company, Chichester, 2003: 27.1– 27.25.
43. Coiro V, Volpi R, Marchesi C, et al. Influence of residual C-peptide secretion on nocturnal serum TSH peak in well-controlled diabetic patients. Clin. Endocrinal. 1997;47:305-10.
44. Kalmann R, Mourits M. Diabetes Mellitus: a risk factor in patients with Grave’s orbitopathy. Br. J. Ophthalmol. 1999; 83: 463-465.
45. Taylor R, Muculloch A, Zeuzem S, Gray P, Clark F, Alberti G.
Insulin secretion, adipocyte insulin binding and insulin sensitivity in thyrotoxicosis. Acta Endorcinol. 1985;109:96-103.
46. Ahren B, Lundquist I, Hedner P, Valdemassan S, Scheroten B.
Glucose tolerance and insulin and C-peptide responses after various insulin secretions stimuli in hyperthyroid and hypothyroid subjects before and after treatment diab. Res. Clin. Practice.
1985;2:95-103.
47. Randin J, Tappy L, Scazziga B, Jequier E, Felber J. Insulin sensitivity and exogenous insulin clearance in Grave's disease.
Measurements by the glucose clamp technique and continuous glucose calorimetry. Diabetes. 1986;35:178-81.
48. Bech K, Damsbo P, Eldrup E, et al. Beta cell function and glucose and lipid oxidation in Grave's disease. Clin. Endocrinol. 1996;44:
59-66.
49. Dimitriadis G, Raptis S A. Thyroid hormone excess and glucose intolerance. Exp Clin. Endocrinol. Diabetes. 2001; 109: S225-S239.
50. Holness M, Sugden M. Continued glucose output after refeeding contributes to glucose intolerance in thyroid disease. Biochem. J.
1987;247:801-4.
51. Mokuno T, Uchimura K, Hayashi R, et al. Glucose transporter concentration in hyper and hypothyroid rat livers. J. Endocrinol.
1999;160:285-9.
52. Haber R, Wilson C, Weinstein S, Pritsker A, Cushman S. Thyriod hormone increases the partitioning of glucose transporters to the plasma membrane in ARL 15 cells. Amer. J. Physiol. 1995; children and adolescents with type 1 diabetes mellitus. Diab. Med.
2002; 19:70-3.
55. Celani MF, Bonati ME, Stucci N. Prevalence of abnormal thyrotropin concentrations measured by a sensitive assay in patients with Type 2 diabetes mellitus. Diabetes Res 1994; 27: 15-25.
56. Proces S, Delgrange E,Vander Borght TV, Jamart J, Donckier JE.
Minor alterations in thyroid-function tests associated with diabetes mellitus and obesity in outpatients without known thyroid illness.
Acta Clin Belg. 2001 Mar-Apr; 56(2):86-90.
57. Roderick E. Warren, Petros Perros, Moffat J. Nyirenda, Brian M.
Frier. Serum Thyrotropin is a better predictor of future thyroid Dysfunction than Thyroid Autoantibody status in biochemically euthyroid patients with Diabetes: Implications for Screening.
Thyroid. 2004, 14(10): 853-857.
58. Vondra K, Vrbikova J, Dyorakova K. Thyroid gland diseases in adult patients with diabetes mellitus. Minerva Endocrinol. 2005 Dec;30(4):217-36
59. Abdel Rahman, Nusier MK, Amari FL et al. Thyroid dysfunction in patients with type 2 diabetes mellitus in Jordan. Saudi Med J.
2004 Aug;25(8):1046-50.
60. Perros P, Mc Crimmon RJ, Shaw G, Frier BM, Frequency of thyroid dysfunction in diabetic patients, value of annual screening.
Diabet Med 1995;12:622-627.
61. Smithson MJ. Screening for thyroid dysfunction in a community population of diabetic patients. Diabet Med 1998; 15 (2): 148-50.
62. Zdrojewicz Z, Humpich G, Januszewski A, Adamek J. The assessment of thyroid gland function in patients with non-insulin
dependent diabetes mellitus(type 2). Wiad Lek.1999;52(1-2): 35-41.
63. Parr JH. The effect of long-term metabolic control on free thyroid hormone levels in diabetics during insulin treatment. Ann Clin Biochem. 1987 Sep; 24 (Pt 5):466-9.
64. Chubb SA, Davis WA, Inman Z, Davis DME.Prevalence and progression of subclinical hypothyroidism in women with type 2 diabetes: the Fremantle Diabetes Study. Clin Endocrinol (Oxf).
2005 Apr;62(4):480-6.
65. Wild S, Rogli G, Green A. Global prevalence of diabetes estimates for the year 2000 and projection for 2030. Diabetes Care, 2004; 27:
1047-53.
66. Kapur A., Snehlatha C., Ramchandran A., Vijay V., Mohan V., Das A.K., Rao P.V., Yajnik C.S., Prasanna Kumar K.M., Jyotsna Nair: High prevalence of diabetes and impaired glucose tolerance in India. National Urban diabetes survey. Diabetologia 2001; Vol.
44: 1094 –1101.
67. Arthur M.Michalek, Martin C.Mahoney, Donald Calebaugh:
Hypothyroidism and Diabetes Mellitus in an American Indian Population. Journal of family practice 2000 July; 49:638-640.
68. Jali MV, Mohan V, Ramchandran A, Snehlatha C and Viswanathan M; High Prevalence of diabetes in an Urban population in South India. BMJ Sept 1988; Vol. 297: p- 587-590.
69. Flatau E.; Trougouboff P.; Kaufman N.; Reichman N.;
Luboshitzky R. Prevalence of hypothyroidism and diabetes mellitus in elderly kibbutz members. European Journal of Epidemiology, Volume 16, Number 1, January 2000 , pp. 43-46(4).
70. Tattersal R.B., Fojans S, Arbor A: Prevalence of Diabetes and Glucose Intolerance in offsprings of 37 conjugal Diabetic parents.
Diabetes 1975, 24:452-462.
71. Vishwanthan M, Mohan V, Snehlatha C, Ramchandran A: High prevalence of type 2 Diabetes among the offspring of conjugal type 2 parents in India. Diabetologia, 1985, 28:907-910.
72. Asha A, Pradeepa R, Mohan V. Evidence for Benefits from diabetes education program. Int J Diab Dev Countries 2004; 24:96-102(4).
73. Kaur K, Singh MM, Kumar,Walia I. Knowledge and self-care practices of diabetics in a resettlement colony of Chandigarh.
Indian J Med Sci. 1998;52:3417.
74. Mc Larty DG, Kitange, Chuwa LM: Prevalence of Diabetes and impaired glucose tolerance in rural Tanzania 1989, 22: 871-74.
85. Yon Gik Kim, Youngsoo Shin, Younsoo Park. Prevalence of Diabetes and impaired glucose tolerance in Yonchon country, South Lorea, Diabetic care 1994, 545-48.
76. D.H. Akbar, M.M.Ahmed, J. Al-Mughales. Thyroid dysfunction African diabetic population. J Diabetes Complications 1995; 9:37-41.
80. Muz Nez A, Gonzez Sarmiento E, Ergueta Mart P, Escorial Miguel C, Crespo Pinilla J, Mara n Cabello A. Thyroid function study in
patients with diabetes mellitus. An Med Interna. 1990 Jun;
7(6):291-3.
81. Fan W, Dinulescu DM, Butler AA, et al. The central melanocortin system can directly regulate serum insulin levels. Endocrinology 2000;141:3072–3079
RECOMMENDATIONS
Biochemical tests of thyroid functions are readily available and relatively inexpensive. So, a baseline thyroid function test to be done in all type 2 diabetic patients at first visit especially in females.
Longitudinal studies are needed to find out the incidence of thyroid dysfunction in type 2 diabetes mellitus patients and to determine the need of regular screening for thyroid dysfunction during follow up and its cost effectiveness.
Follow up thyroid function test to be done to assess the progression of subclinical thyroid dysfunction in type 2 diabetics because of associated morbidity of overt thyroid dysfunction in these patients.