Key words : lung volumes, flow rates,diabetes mellitus
Diabetes is the most common metabolic disorder and its prevalence
is increasing in several parts of the world, especially in developing
countries like India. Recent epidemiological data showed
that the prevalence of diabetes in India
is 8-10 %. According to WHO survey, India
will be the world's diabetes capital. It has been estimated
that 2.4% of rural population and 8.4% of urban population is
affected by diabetes (1). Western interference has lead to
loss in physical activity and changes in food pattern from traditional
unprocessed natural ingredients to highly refined energy dense
fatty and sugary fast foods. These two core factors are responsible
for the high incidence of diabetes in the years to come (2).
Diabetes mellitus precipitate certain systemic diseases that
affects the eye, kidney, nervous system and heart. There is
a higher incidence of systemic complications including nephropathy,
retinopathy, neuropathy etc. (3). The respiratory diseases
associated with diabetes may results in changes in pulmonary
volumes, diffusion and elastic properties of the lung as well
as the performance of respiratory muscle. In addition to lung
disease, chest wall disorder, obesity, neuromuscular diseases,
pleural diseases can also cause a similar restrictive pattern
of pulmonary function (3). The prevalence of disease is increasing
rapidly due to rapid change in life style. Life style factors
such as diet, physical activity and mental stress have direct
as well as confounding impact on glucose metabolism and insulin
sensitivity and therefore could influence the development of
Although a lot of research work is being carried out on diabetes
mellitus (DM) its relation with respiratory function is to be
traced out and hence the present study was undertaken to assess
the lung functions in diabetic patients taking oral medication
and insulin administration from this region of Kerala. The
oral medication and insulin administered patient were separately
categorized to assess the alterations in respiratory functions
associated with the treatment. The study also expected to throws
some light into the aspects of body mass index (BMI), Body surface
area (BSA), Waist-Hip Ratio (WHR) and anthropometric measurements
of DM patients. A survey on disease related with eye, foot,
mouth ulcer, kidney problems in DM patients were also carried
out along with the study based on the questionnaire.
Screening was done for diabetes and only subjects with proven
diabetes mellitus were considered for the present study. The
patients were undergoing treatment under medical practitioner
in OPD/Ward with oral medication and insulin therapy. Random
selection of patients were carried out for the sole purpose
of studying lung function using Pulmonary function test (PFT)
and categorized on the basis of severity of disease (oral medication
and insulin treatment). Twenty subjects who administered oral
hypoglycemic drug (Group I) and 20 subjects taking insulin (Group
II) were selected from Medical Centre, Kottayam. Age, height,
weight, body surface area (BSA), body mass index (BMI) and waist-hip
ratio were measured. Only male subjects were selected for the
study. Statistical package employed was Students t-test. Age
and height matched forty subjects without any health ailment
were selected as normal controls for the present study. Lung
function tests were, carried out with Vitallograph Compact II
Mean physical characteristics of oral pills used subjects were
age 51.25 years, height - 1.64 m, weight 66.5 kg, BMI - 24.7,
waist - 90.25 cm, hip 91.85 cm, chest 91.13 cm, waist -hip ratio
0.98, BSA - 1.72. Mean physical characteristics of insulin administered
patients were age 50.8 years, height-1.64 m, weight-65.9 kg,
BMI - 24.9, waist - 90.75 cm, Hip - 91.75 cm, chest - 91.5 cm,
waist-hip ratio - 0.99, BSA - 1.71 (Table I).
| Table I
click to see full view
Table I: The anthropometric measurements of diabetic patients.
A significant reduction in FEV1/FVC% (P<0.01)
was observed in oral pills used subjects and insulin administered
subjects compared to control (Table II). Significant decrease
(P<0.05) in FEF25-75% in Group I subjects was
observed as compared to normal control. FMFT showed a significant
increase (P<0.005) in Group 11 subjects in comparison to
normal controls (Table III).
| Table II
click to see full view
Table II: Comparison of lung volumes between Group I and
Group II with controls.
| Table III
click to see full view
Table III: Comparison of flow rates between Group I and Group
II with controls.
In present study, the ancillary observation of parameters related
to oral pills used patients and insulin-administered patients
were collected on the basis of questionnaire (Table IV). From
the questionnaire, Group I patients used diabetic pills. Among
Group I subjects, 1-2 pills were taken by 7 patients, 3-4 pills
were taken by 9 patients per day and 4-5 pills were taken by
2 patients per day.
Among group I patients, sugar level of 5 patients were under
the range of 80-120 mg, 6 patients were belong to a range of 121-220
mg and 7 were belong to a range of' 221-320. But in insulin administered
group, 2 patients were belong to the range of 80-120 mg, 11 patients
were belong to the range of 121-220 mg and only one patient shows
the range of 221-320 mg.
| Table IV
click to see full view
Table IV: Ancillary observations of parameters related with
diabetic patients based on questionnaire.
Duration of diabetes mellitus in Group I patients, 16 were
exposed to diabetes for period of 1-10 years and only
one patient belong to the period of 11-20 years. Duration of
diabetes in Group II patients, 13 subjects were exposed to diabetes
for a period of 1-10 years and 6 patients were placed in the
period of 11-20 years and only one subject were between 21-30
years of age group.
Among the patients in Group I the diet control were strictly
followed by 10 patients and in Group II patients about 17 patients
showed diet control. Among group I patients, 12 subjects show
family history of diabetes. In Group II, 13 patients show family
history of diabetes. 2 patients in Group I and 3 patients in
Group II shows eye defects. Among Group I patients, 6 patients
exhibit hypertension and in Group II, 5 patients exhibit high
blood pressure. Only one patient shows allergy in both Group
I and Group II patients. About 4 of Group I patients and 3
of insulin administering patients exhibit cardiopulmonary disease.
The prediction quadrant based on lung function test, 2 oral
pills used patients and 2 insulin administered patients shows
restrictive diseases. 2 patients among Group I had restrictive
and obstructive disease (combined). 4 patients in Group II have
obstructive disease, 16 patients of Group I and 14 patients
in Group II were normal.
Diabetes mellitus is an important non-communicable chronic
disease of global importance. This is characterised by increased
sugar levels in the blood due to absolute or relative deficiency
of insulin hormone. Nutrition plays an important role in the
maintenance of good health. The diet of an Indian is rich in
carbohydrates with almost an equal distribution of protein and
fats (5). Due to the defect in the insulin secreted P-cell,
hormonal level changes which adversely affects the glucose metabolism
that lead to permanent diabetes mellitus with characteristic
symptoms (4). Niranjan et al. (6) reported that there is a
higher incidence of retinopathy, neuropathy, nephropathy etc.
together with diabetes. They further shows that lung volumes,
septal tissue volume, diffusing capacity were significantly
reduced in both NIDDM and LDDM patients as compared to normals.
It is clear from the present study that body mass index (BMI)
of Group I and Group II patients were 24.7 and 24.9 (Table I).
The over weight range for BMI starts from 25 onwards. So, the
patients can be considered to be over weight. Waist-Hip ratio
of both Group I and Group II diabetic patients were overweight.
Obesity is a well recognised risk factor for diabetes. Increase
in BMI to 25 and above increase the risk of diabetes significantly
(7). Waist-Hip ratio, a measure of upper body adiposity was
also observed above the permissible limit in the present study.
Body mass index (BMI) is used as an index of obesity even minimal
excess of BMI has been seen to be risk factor for the development
of NLDDM used subjects (8). Similar observations were also
reported from West that upper body adiposity, measured as the
waist to hip ratio (WHR) was associated with greater risk of
NIDDM. Diabetic subjects had higher Waist-Hip ratio (WHR) as
compared to the non diabetic subjects. There are strong association
of oral pills used subjects with BMI and central adiposity,
as found in men and women. The studies of Ramachandran et al.
(9) showed that BMI increase in men and women may contribute
towards the increased prevalence of diabetes. Besides, impaired
glucose tolerance (IGT) is another factor for the diabetes.
This condition of IGT can be related to BMI, WHR, age etc.
The present study also showed that BMI, WHR were higher in diabetic
The present study shows a reduction in FEV1/FVC%
among Group I patients and Group II compared to normals (Table
2). The decrease in FEV1/FVC% in Group I and Group
II subjects may be related with the poor mechanical properties
of the lung viz. lung compliance and elastic recoil of lungs.
The elastic behaviour of lung can be considered as a mechanical
system with two parallel elements. An elastic component is
responsible for pressure generated at a low lung volume, whereas
less elastic component with high tensile strength causes large
changes in pressure with changes in volumes and prevents over
extension of the first element. Elastin and Collagen have been
designated as morphologic equivalents of these two elements.
Total lung capacity (TLC) was lower in diabetic groups. This
implies that alteration in the collagen and elastin is the main
factor in the diabetic patients (10). Schuyler et al. (11)
reported a decrease in total lung capacity, loss of elastic
recoil and low lung volumes and abnormal pressure volume relationship
in IDDM patients. This may be due to the respiratory muscle
weakness. This finding showed that loss of lung elastic recoil
in IDDM patients is due to the alterations of both collagen
and elastin. Studies conducted by Asanuma et al. (12) reported
that forced vital capacity, vital capacity, diffusing capacity
were decreased in diabetic patients. This is due to the abnormal
peripheral airways, which increases with age and gas transfer
was also affected by microangiopathy. Loss of elastic recoil
leads to dynamic collapse of small airways during expiration.
In addition, myopathic or neuropathic changes affecting the
respiratory muscles further impairs the endurance, efficiency
of ventilatory pump (6).
Significant reduction in lung volume ratio among Group I and
Group II patients were observed in the patients. This denotes
lower mechanical properties of lungs and hence restrictive lung
disease cannot be ruled out. The lung volume ratios may be
helpful in differentiating obstructive and restrictive diseases.
The reduced lung capacity might result from abnormal collagen
formation as well as decreased rates of connective tissue break
down in diabetes patients which shows resistance to oxygen uptake
across the alveolar capillary membrane. Significant reduction
in FEV25-75%, among group I subjects (Table III)
were compared to normal controls shows a lower airway calibre
and higher airway resistance and hence obstructive disease cannot
be ruled out. Ashapherwani et al. (13) showed that the initial
part of' expiratory FVC curve FEV25-75% depends on
non-bronchopulmonary factors like neuromuscular factors and
mechanical equipment factors of inertial distortion of' lungs.
The thickening of alveolar wall due to the increased amounts
of collagen, elastin basal lamina results in the microangiopathy
(14). The study conducted by Singh et al. (15) showed
a restrictive pattern of lung disease in DM patients.
There is a decreased trend in expiratory flow rates among both
Group I and Group II patients as compared to control which denotes
the reduced force generating capacity of expiratory muscle and
higher airway resistance. Obese nature of' insulin administered
groups and oral pills used subjects may add more problems in
performing forced expiratory manoeuvre. The ventilatory functions
depend upon the compliance of the thorax-lung system, airway
resistance and muscle strength rather than anatomical lung volume.
Deterioration in the lung function with advancing age is mainly
caused by the change in these functions.
Increase in FMFT in Group II subjects (Table III) showed the
increase in duration to conduct the FVC test. This increased
duration may be due to lower efficiency of airways and lesser
force generating capacity of respiratory muscles and greater
airway resistance. Side effects such as breathing difficulty
in DM patients taking oral medication may be a factor for increased
duration of FMFT and reduced FEV25-75%.
Selvarn A. Gross hyperglycemia, domiciliary management in
a rural set up, Manual of Advanced Postgraduate Course in
Diabetology 1998; 18:170-175.
Udawat, Sanjeev Mahashwari, Goyal RK. Clinical profile of diabetes
mellitus in central part of Rajasthan. The Antiseptic
2001; 98: 58-61.
C, Ramirez MD, Anthony Dal Nogare MD, Connie Hsia MD, Carlos
Arauz MD, lrfan Butt MS, Suzanne M Strowig MSW, Laura Schnurr-Breen
BSN, Philip Raskin MD, Relationship between diabetes control
and pulmonary function in Insulin- dependent diabetes mellitus.
Am J Med 1991; 91: 371-376.
A, Snehalatha C. NIDDM in India and Indians, is it increasing? IDF
Bulletin 1999; 40:27-39.
Kaira. Diabetes management through diet, Health 2001;
V, Darvin G, Mcbrayer Luis C, Ramirez Philip Raskin, Connie
CW Hsia, Dallas Texas.
Glycemic control and cardiopulmonary function in patients with
insulin-dependent diabetes mellitus. Am J Med 1997; 103:
M, Snehalatha C, Vijay V, Vidyavathi P, Indu J, Ramachandran
A. Reduction in body weight helps to delay the onset of diabetes
even in non-obese with strong family history of disease. Diab
Res Clin Pract 1997; 35: 107-112.
A. Epidemology of non-insulin dependent diabetes in India
and the developing world. Practical Diabetes International
1995; 12: 68-70.
A, Snehalatha C, Latha E, Vijay V, Viswasanathan M. Rising prevalence
of NIDDM in urban population in India. Diabetologia 1997;
R, Schuyier Dennis E, Niewoehner, Scott R, Inkley, Robert Kohn.
Abnormal lung elasticity in Juvenile Diabetes Mellitus. Am
Rev Resp Dis 1976; 116:118.
MR, Niewoehner DE, Inkley SR, Kohn R. Abnormal lung elasticity
in juvenile diabetes mellitus. Am Rev Resp Dis 1976;
Y, Fujiya S, Ide II, Agishi J. Characteristics of pulmonary
function in patients with diabetes mellitus. Diab Res Clin
Pract 1983; 1(2): 95-101.
Desai AG, Solepure AB.
A study of pulmonary functions of competitive swimmers. Indian
J Physiol Pharmacol 1989; 4: 228-232.
Sandier. Is the lung a 'Target Organ' in diabetes mellitus.
Arch Intern Med 1990;150: 1385 - 1388.
S, Sircar SS, Singh KP. Are ventilatory impairments related
to early onset and long history of Diabetes ? J Indian Med
Assoc 1995; 93(12): 458-459.