European Journal of Cardiovascular Medicine

Type 2 diabetes, often known as T2DM or T2D, is a clinical condition marked by decreased insulin production and increased insulin resistance.[1] One of the most prevalent chronic diseases in the world, diabetes mellitus is on the rise. It is one of the top five causes of death. In India as well, it is a serious public health issue. In India, there were an estimated 62.4 million diabetic patients in 2011, and that figure is expected to increase to 101.2 million by 2030.[2,3,4] Beyond glycemic control, there are numerous factors that need to be addressed in diabetes care.[5] Although the primary clinical goal in managing diabetes is still glycemic control, long-term care focuses on preventing microvascular and macrovascular consequences. Cardiovascular disease is the main cause of death in diabetic people in about 80% of cases (CVD). Comparatively speaking, Asians are more likely than Whites to get coronary heart disease (CHD).[6] In particular, if  glycaemic management is inadequate, which is a significant risk factor for atherosclerosis and coronary heart disease, hyperlipidaemia is a frequent consequence of diabetes mellitus.[7,8] Different forms of dyslipidaemia that are recognised in the general population can be included in diabetes mellitus. However, one phenotype that is primarily associated with insulin resistance and insulin deficit is more prevalent in diabetes mellitus patients. Low levels of high density lipoprotein cholesterol (HDL-C), a rise in low density lipoprotein cholesterol (LDL-C), and high levels of plasma triglycerides are characteristics of this phenotype (TG).[9] The logarithm of the ratio of plasma TG to HDL-C (log10 TG/HDL-C) is known as the atherogenic index of plasma (AIP). It closely relates to the risk of CVD. It can serve as a standalone index for calculating cardiac risk.[10] Any change in a lipid profile parameter's level raises a person's chance of developing atherosclerotic problems.[11] To estimate atherogenic risk, the atherogenic index can be employed as a supplement to the lipid profile. Compared to standard lipid measures, AIP is more helpful.[12,13] Even if the other parameters seem to be normal, it can be used as a signal.[14] The purpose of this study was to evaluation of dyslipidemia with HbA1c levels in diabetes mellitus..[15,16]

Hundred & ten (110) patients who were known to have type 2 diabetes mellitus and attended a tertiary care facility in Western UP, India, between January 2019 and June  2019 but were not taking any lipid-lowering medications participated in this cross-sectional study. The study covered patients who were older than 40 years. Critically sick patients and those with other secondary dyslipidaemia-related conditions were eliminated. All of the patients were interviewed using a pre-designed pro forma after receiving informed consent. Following tests, investigation reports were examined by the biochemistry department. A number of variables were examined, including glycated haemoglobin (HbA1c), total cholesterol (TC), triglycerides (TG), low density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C). The autoanalyzer Cobas C311 was used to determine fasting plasma glucose and lipid profile, including TC, LDL-C, HDL-C, VLDL-C, and TG. The atherogenic index of plasma (AIP) was computed using the log10 TG/HDL-C calculation. Nephelometry was used to measure the amount of glycated haemoglobin. Guidelines from the ATPIII (Adult Treatment Panel III) and NCEP (National Cholesterol Education Program) were used to diagnose dyslipidemia, which is indicated by one or more of the following criteria: LDL-C >100 mg/dl, TG >150 mg/dl, and HDL-C <40 mg/dl. Glycemic control was poor in patients with HbA1c ≥7% and in those with HbA1c<7%, glycemic control was considered good. Patients with dyslipidaemia were divided into three groups: mixed dyslipidaemia (all three parameters TG, LDL-C and HDL-C were abnormal), combined two parameter dyslipidaemia (any two parameters abnormal), and isolated single parameter dyslipidaemia (any one parameter abnormal). Patients with good diabetes control (HbA1c < 7%) and those with poor glycaemic control (HbA1c ≥7%) had their lipid profile values compared.[5] AIP was used to group patients into three risk categories: low risk (-0.3 to 0.1), medium risk (0.1 to 0.24), and high risk (greater than 0.24).[17] SPSS version 20 was used to analyse the data. Descriptive data were used to determine the number of patients with dyslipidaemia in each category (males and females, patients with good glycemic control and patients with poor glycemic control). Descriptive data were also used to determine the number of patients in each category with low, moderate, and high CVD risk. Using an independent samples T test, the means of various parameters, including Fasting plasma glucose and HbA1c between patients with and without dyslipidemia, as well as TC, HDL-C, LDL-C, TG, and AIP, were compared between males and females. Graphs and tables were created with Microsoft Word.

Among 110 type 2 diabetic patients who were included in the study, 56 were males and 54 were females. 85.5% of total patients were found to have dyslipidaemia [Figure 1]. Among males, 82.1% patients had dyslipidaemia. Whereas in females, the proportion of patients with dyslipidaemia was 88.9% [Figure 2]. The proportion of patients with mixed (combined three parameter) dyslipidaemia, combined two parameter dyslipidaemia and isolated single parameter dyslipidaemia were 7.3%, 29.1% and 49.1% respectively. Among the male diabetic patients, the proportions of mixed (combined three parameter) dyslipidaemia, combined two parameter dyslipidaemia and isolated single parameter dyslipidaemia were found to be 7.1%, 25% and 50% respectively. Among females, 7.4%, 33.3% and 48.2% of patients had mixed (combined three parameter) dyslipidaemia, combined two parameter dyslipidaemia and isolated single parameter dyslipidaemia respectively [Table 1]. The most common pattern of dyslipidaemia was isolated single parameter dyslipidaemia. Isolated dyslipidaemia with low HDL-C was found to be most common in both males (39.3%) and females (38.9%). Second most common pattern was combined two parameter dyslipidaemia with high triglycerides and low HDL-C in both males (23.2%) and females (31.5%).None of the patients had isolated single parameter dyslipidaemia with high triglycerides and combined two parameter dyslipidaemia with high LDL-C and triglycerides.  No statistically significant difference was found in parameters such as age, fasting plasma glucose (FPG), glycated haemoglobin (HbA1c), total cholesterol (TC), HDL cholesterol (HDL-C), LDL cholesterol (LDL-C), triglycerides (TG) between males and females. Also, there was no statistically significant difference in variables like age, FPG and HbA1c between patients with dyslipidaemia and those without dyslipidaemia. Out of the 110 patients enrolled in the study, 71(64.5%) patients had poor glycaemic control (HbA1c≥7). Statistically significant elevation of total cholesterol and LDL cholesterol was found in patients with poor glycaemic control as compared to those with good glycaemic control (HbA1c<7) [Table 2]. The patients with dyslipidaemia in patients with good glycaemic control and patients with poor glycaemic control were 84.8% and 86.0% respectively [Table 3]. Among the total subjects, 91 (82.7%) were found to be at high risk for CVD (AIP >0.24), 12 patients (10.9%) were at moderate risk (AIP 0.1 to 0.24) and 7 (6.3%) had low risk for CVD (AIP -0.3 to 0.1) [Table 4].

Table 1:  Prevalence of different types of dyslipidaemia in males and females.

Table 2:  Comparison of lipid parameters in patients having poor glycemic control with patients with good glycemic control.

Table 3:  Comparison of the prevalence of various kinds of dyslipidaemia in patients with and without good glycemic control.

Table 4:  According to AIP, the number of patients with low, moderate, and high CVD risk in persons with both good and poor glycemic control.

It is widely known that people with type-2 diabetes mellitus have a significantly increased risk of macrovascular problems due to dyslipidaemia (T2DM). Diabetes dyslipidaemia frequently shows up as increased triglyceride levels (TG), decreased HDL cholesterol, or increased levels of low-density lipoprotein cholesterol (LDL-C). Guidelines from the Adult Treatment Panel III (ATPIII) and National Cholesterol Education Programme (NCEP) defined dyslipidaemia as having one or more of the following abnormalities in the blood: triglycerides >150 mg/dl, HDL cholesterol <40 mg/dl, or LDL cholesterol >100 mg/dl.[18] In our study, 85.5% of total diabetic patients were found to have  dyslipidaemia which was similar to different studies done in the past in different parts of India.[18,19,20,21,22] The prevalence was also similar to a study done in Nepal.[23] No statistically significant difference in lipid parameters were found in males and females. In our study, 64.5% patients were in the category of those having poor glycaemic control (HbA1c≥7). Patients with poor glycaemic control had statistically higher total and LDL cholesterol levels than did patients with adequate glycaemic control. A study conducted in Nepal found that isolated single parameter dyslipidaemia with low HDL-C was the most prevalent pattern.[23] In contrast, a study conducted in Bhopal, Madhya Pradesh, India, found that mixed dyslipidaemia—a condition in which TG and LDL-C were elevated while HDL-C was decreased—was the most prevalent pattern.[21) AIP revealed that 82.7% of the total individuals had a high risk of developing CVD (AIP > 0.24). Moderate risk (AIP 0.1 to 0.24) and low risk (AIP -0.3 to 0.1), respectively, were 10.9% and 6.3%. Patients were found to be at high risk for CVD in 85.3% of cases of poor glycaemic control and 80% of cases of good glycaemic control. Diabetic patients' dyslipidaemia is brought on by insulin resistance or insufficiency, which encourages visceral adipocyte lipolysis and raises plasma and liver free fatty acid levels. Additionally, the endothelium enzyme lipoprotein lipase's activity declines. AIP revealed that 82.7% of the total individuals had a high risk of developing CVD (AIP > 0.24). AIP 0.1 to 0.24) and low risk, respectively, were 9.9% and 6.3%. (AIP -0.3 to 0.1).  Patients were found to be at high risk for CVD in 85.3% of cases of poor glycaemic control and 80% of cases of good glycaemic control. In diabetic patients dyslipidaemia is brought on by insulin resistance or insufficiency, which encourages visceral adipocyte lipolysis and raises plasma and liver free fatty acid levels. Additionally, the endothelium enzyme lipoprotein lipase activity declines. All of these result in hepatic steatosis, increased plasma levels of bigger, TG-rich very low density lipoprotein 1 (VLDL1) particles, increased hepatic apolipoprotein B (ApoB) secretion, poor chylomicron clearance, and reduced receptor-mediated endocytosis in the liver.[24,25] The decrease in HDL-C may be caused by increased hepatic lipase activity, which catalyses HDL cholesterol.[26]

Dyslipidemia is a common and significant complication of diabetes mellitus, contributing to increased cardiovascular morbidity and mortality. HbA1c not only reflects glycemic control but also correlates strongly with lipid abnormalities. In the Indian scenario, where diabetes prevalence is high and resources may be limited, HbA1c can serve as a useful dual marker for both glycemic status and dyslipidemia risk. Early detection, regular monitoring, and a comprehensive management approach are essential to reduce long-term complications. In conclusion, Patients with type 2 diabetes mellitus were reported to have a high frequency of dyslipidaemia. Isolated single parameter dyslipidaemia with low HDL cholesterol was the most prevalent kind of dyslipidaemia. Most diabetic patients have a high risk of developing cardiovascular disease.

1.      Davidson MB, Peters AL, Schriger DL. An alternative approach to the diagnosis of diabetes with a review of the literature. Diabetes Care. 1995;18(7):1065-71. doi: 10.2337/diacare.18. 7.1065.

2.      Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. Epidemiology of type 2 diabetes: Indian scenario. Indian J Med Res. 2007;125(3):217-30.

3.      Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010;87(1):4-14. doi: 10.1016/j.diabres.2009.10.007.

4.      AnjanaRM, Pradeepa R, Deepa M, Datta M, Sudha V, Unnikrishnan R, et al. Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: phase I results of the Indian Council of Medical Research-India DIABetes (ICMR-INDIAB) study. Diabetologia. 2011;54(12):3022-7. doi: 10.1007/s00125-011-2291-5.

5.      American Diabetes Association. Standards of medical care in diabetes--2007. Diabetes Care. 2007;30 Suppl1:S4-S41. doi: 10.2337/dc07-S004.

6.      O'Keefe JH Jr, Miles JM, Harris WH, Moe RM, McCallister BD. Improving the adverse cardiovascular prognosis of type 2 diabetes. Mayo Clin Proc. 1999;74(2):171-80. doi: 10.4065/74.2.171.

7.      NaheedT, Khan A, Masood G. Dyslipidaemias in Type 2 Diabetes Mellitus Patients in a Teaching Hospital of Lahore, Pakistan. Pak J Med Sci. 2003;19(4):283-6.

8.      Nathan DM, Buse JB, Davidson MB, Ferrannini E, Holman RR, Sherwin R, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2009;32(1):193-203. doi: 10.2337/dc08-9025.

9.      MooradianAD. Dyslipidemia in type 2 diabetes mellitus. Nat Clin Pract Endocrinol Metab. 2009;5(3):150-9.

10.   NiroumandS, Khajedaluee M, Khadem-Rezaiyan M, Abrishami M, Juya M, Khodaee G, et al. Atherogenic Index of Plasma (AIP): A marker of cardiovascular disease. Med J Islam Repub Iran. 2015;29:240.

11.   Barua L, Faruque M, Banik PC, Ali L. Atherogenic index of plasma and its association with cardiovascular disease risk factors among postmenopausal rural women of Bangladesh. Indian Heart J. 2019;71(2):155-160. doi: 10.1016/j.ihj.2019.04.012.

12.   DobiásováM, Urbanová Z, Samánek M. Relations between particle size of HDL and LDL lipoproteins and cholesterol esterification rate. Physiol Res. 2005;54(2):159-65.

13.   Tan MH, Johns D, Glazer NB. Pioglitazone reduces atherogenic index of plasma in patients with type 2 diabetes. Clin Chem. 2004;50(7):1184-8. doi: 10.1373/clinchem.2004 .031757.

14.   NwaghaUI, Ikekpeazu EJ, Ejezie FE, Neboh EE, Maduka IC. Atherogenic index of plasma as useful predictor of cardiovascular risk among postmenopausal women in Enugu, Nigeria. Afr Health Sci. 2010;10(3):248-52.

15.   NwaghaUI, Ikekpeazu EJ, Ejezie FE, Neboh EE, Maduka IC. Atherogenic index of plasma as useful predictor of cardiovascular risk among postmenopausal women in Enugu, Nigeria. Afr Health Sci. 2010;10(3):248-52.

16.   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(19):2486-97. doi: 10.1001/jama.285.19.2486.

17.   DobiásováM. AIP--atherogenic index of plasma as a significant predictor of cardiovascular risk: from research to practice. Vitr Lek. 2006;52(1):64-71.

18.   Pandya H, Lakhani JD, Dadhaniya J, Trivedi A. The prevalence and pattern of dyslipidemia among type 2 diabetic patients at rural based hospital in Gujarat, India. Indian J Clin Pract. 2012;22(12):36-44.

19.   Dixit AK, Dey R, Suresh A, Chaudhuri S, Panda AK, Mitra A, et al. The prevalence of dyslipidemia in patients with diabetes mellitus of ayurveda Hospital. J Diabetes MetabDisord. 2014;13:58. doi: 10.1186/2251-6581-13-58.

20.   Agrawal Y, Goyal V, Chugh K, Shankar V, Singh AA. Types of dyslipidemia in type 2 diabetic patients of Haryana region. Sch J App Med Sci. 2014;2(4):1385-92.

21.   Borle AL, Chhari N, Gupta G, Bathma V. Study of prevalence and pattern of dyslipidaemia in type 2 diabetes mellitus patients attending rural health training centre of medical college in Bhopal, Madhya Pradesh, India. Int J Community Med Public Health. 2016;3:140-4.

22.   Sarfraz M, Sajid S, Ashraf MA. Prevalence and pattern of dyslipidemia in hyperglycemic patients and its associated factors among Pakistani population. Saudi J Biol Sci. 2016;23(6):761-766. doi: 10.1016/j.sjbs.2016.03.001.

23.   Shrestha HK, Khanal L. Prevalence and pattern of dyslipidemia among type 2 diabetes mellitus patients in a  tertiary center hospital of Nepal. Endocrinol Metab Int J. 2017;4(3):54-6.

24.   Garvey WT, Kwon S, Zheng D, Shaughnessy S, Wallace P, Hutto A, et al. Effects of insulin resistance and type 2 diabetes on lipoprotein subclass particle size and concentration determined by nuclear magnetic resonance. Diabetes. 2003;52(2):453-62. doi: 10.2337 /diabetes.52.2.453.

25.   ReavenGM, Chen YD, Jeppesen J, Maheux P, Krauss RM. Insulin resistance and hyperinsulinemia in individuals with small, dense low density lipoprotein particles. J Clin Invest. 1993;92(1):141-6. doi: 10.1172/JCI116541.

26.   AnnemaW, Tietge UJ. Role of hepatic lipase and endothelial lipase in high-density lipoprotein-mediated reverse cholesterol transport. CurrAtheroscler Rep. 2011;13(3):257-65. doi: 10.1007/s11883-011-0175-2.