European Journal of Cardiovascular Medicine

Coronary risk factors in type 2 diabetes patients vary significantly between urban and rural populations due to differences in lifestyle, socioeconomic status, and healthcare access¹. Urban patients face higher risks from sedentary behavior and unhealthy diets, while rural patients struggle with limited healthcare resources. Studies have shown that the prevalence of T2DM is much higher in urban areas (8.1%) compared to rural areas (2.3%), despite similar BMI levels. Urban residents often have elevated blood glucose and LDL cholesterol levels², with 47% of urban diabetics having high LDL versus 20% in rural settings. Central obesity is also more common among urban diabetics. These findings underscore the need for targeted interventions to address urban lifestyle risk factors for diabetes prevention.

These findings emphasize that unhealthy diets and physical inactivity—common in urban lifestyles—significantly contribute to cardiovascular risk factors such as obesity and high LDL cholesterol. Urban diabetics show higher rates of smoking (27%), high total cholesterol (57%), and low HDL cholesterol (17%), indicating a clustering of lipid-related risks. In contrast, rural diabetics have a higher prevalence of hypertension (40%) and elevated triglycerides (34%), reflecting different metabolic stressors³. Despite these contrasts, obesity remains a shared burden, with central obesity affecting 54% of urban and 57% of rural diabetics. These differences reveal distinct risk factor patterns shaped by environment and lifestyle. Addressing both urban and rural needs with tailored interventions is essential to reduce the overall cardiovascular burden.

Coronary risk factors in diabetes show distinct patterns across urban and rural settings, necessitating tailored interventions. Urban populations are more prone to sedentary lifestyles, poor dietary habits, and higher rates of smoking and dyslipidemia, leading to an increased burden of diabetes and cardiovascular risk. In contrast, rural populations, while less sedentary, face challenges such as limited healthcare access, poor disease awareness, and low treatment compliance⁴. Studies report that 52.2% of rural individuals have three or more metabolic syndrome risk factors, compared to 39.7% in urban populations. Despite these differences, both groups suffer from poor diabetes control due to unique contextual barriers. Urban patients may neglect treatment adherence, while 70% of rural patients lack basic diabetes awareness^5,6. These findings highlight the urgency of location-specific strategies—focusing on lifestyle modification in urban areas and improving healthcare access and education in rural communities—to reduce the growing burden of coronary risk factors.Although urban populations typically show higher diabetes prevalence and related coronary risk factors, rural populations are increasingly affected by these issues. The higher prevalence of hypertension and metabolic syndrome risk factors among rural residents highlights a growing concern. Bridging these disparities requires targeted interventions that promote lifestyle changes and enhance healthcare access in both urban and rural areas to mitigate risk and improve outcomes.

AIM

To study the occurrence of coronary risk factors in urban and rural patients with type 2 diabetes mellitus in a tertiary care hospital.

The study was initiated after obtaining approval from the Institute’s Scientific Research Committee and the Institute’s Ethical Committee. It was conducted in the Department of General Medicine at Mahatma Gandhi Medical College & Hospital, Jaipur. This was a prospective, observational, hospital-based study carried out over a period of 18 months. Prior to participation, written informed consent was obtained from each patient enrolled in the study. Inclusion criteria consisted of individuals aged over 18 years who were willing to participate and were diagnosed with type 2 diabetes mellitus, based on the American Diabetes Association diagnostic criteria. Both urban (cities, towns, and suburbs) and rural (villages) patients were included. Patients suffering from chronic illnesses such as heart failure, chronic liver disease, chronic kidney disease, and pregnant females were excluded from the study.

Table 1: Table showing demographic features of rural and urban Type 2 DM patients

Most rural patients had a lower BMI (21.39 ± 3.3) compared to urban patients (22.56 ± 4.8, p=0.05) and were less involved in sedentary work (78% vs 88%, p=0.019). Age, gender distribution, smoking, and alcohol use did not differ significantly between the two groups.

Figure 1,2: Graph showing occurrence of chronic diseases and BP and glucose levels of rural and urban Type 2 DM patients

In this study, hypertension and cerebrovascular accidents were significantly more common in urban patients (p=0.024 and p=0.03, respectively), while diabetes, its duration, and coronary heart disease showed no significant rural–urban difference.

In this study, rural patients had significantly lower fasting blood sugar (124.4 ± 27.7 mg/dL vs 176.4 ± 44.6 mg/dL, p=0.001) but higher postprandial sugar (288.8 ± 70.2 mg/dL vs 254 ± 59.2 mg/dL, p=0.028), while systolic and diastolic pressures and HbA1c showed no significant differences between rural and urban groups.

Table 2: Table showing lipid profile of rural and urban Type 2 DM patients

Urban patients had significantly higher HDL levels (43.57 ± 6.7 mg/dL) compared to rural patients (38.46 ± 4.5 mg/dL, p=0.001), while triglycerides were also slightly higher in urban populations (p=0.048). Total cholesterol and LDL levels showed no significant differences between the groups.

Table 3: Table showing incidence of albuminuria in rural and urban Type 2 DM patients

Gross albuminuria was significantly more common in urban patients (17) than rural patients (8) (p=0.043), indicating a higher burden of advanced kidney involvement. Microalbuminuria and total proteinuria did not differ significantly between the groups.

Table 4: Correlation table for lifestyle factors as risk factors for CHD

In this study (N=100), smoking and alcohol consumption showed a significant positive correlation with coronary heart disease (CHD) (p=0.000), while sedentary lifestyle had a weaker but notable association (p=0.061). These findings suggest lifestyle factors play a critical role in CHD risk among diabetic patients.

Table 5: Correlation of BP and glucose levels with occurrence of CHD

In this study of 100 patients, systolic and diastolic pressures showed significant positive correlations with coronary heart disease (r=0.607 and r=0.433, *p*<0.001), while fasting blood sugar had a weaker, nonsignificant association (r=–0.004, *p*=0.903).

Table 6: Correlation of lipid profile with the occurrence of CHD

In this study (N=100), LDL cholesterol levels showed a statistically significant positive correlation with coronary heart disease (r=0.263, p=0.008).

Table 7: Correlation of albuminuria with occurrence of CHD

In this study, gross, micro, and total albuminuria showed significant positive correlations with coronary heart disease (gross albuminuria r=0.473, microalbuminuria r=0.348, total albuminuria r=0.567; all p<0.001).

In this study, males were more commonly affected by CHD, though both genders showed increased risk in their early fifties, emphasizing age as a key factor in CHD among T2DM patients. Consistent with the Rancho Bernardo study, diabetes was found to eliminate the natural cardiovascular protection typically seen in premenopausal females. As a result, diabetic women face risks equal to or greater than men, driven by hormonal and metabolic disruptions. This highlights the need for gender-specific strategies in the early detection and management of CHD risk in diabetic patients⁷.

This study showed a significantly higher incidence of CHD among those with sedentary lifestyles, highlighting the impact of physical inactivity on cardiovascular risk. Male diabetics reported higher smoking and alcohol use, behaviors that compounded their CHD risk, consistent with other Indian studies linking adverse habits and family history to heart disease. The mean diabetes duration was about eight years, with females having slightly longer durations, while males with CHD showed a statistically significant longer disease history, suggesting duration of diabetes as a crucial risk factor⁸. The overall mean BMI was 21.8 ± 4.32, with 14.4% of participants classified as overweight or pre-obese (BMI >25). Urban participants had higher mean BMIs than rural ones, reflecting lifestyle differences. Since overweight and obesity are well-established risk factors for T2DM, these findings reinforce the urgent need for effective weight management strategies. This is critical to curb the growing diabetes burden and its cardiovascular complications.

Body Mass Index (BMI), though widely used, may not adequately capture cardiovascular risk, especially in Indian diabetic populations where central obesity—better measured by waist-hip ratio (WHR)—is more predictive. Studies have shown that WHR is highly prevalent among diabetic individuals of Indian origin, often acting as an independent risk factor for coronary artery disease (CAD)⁹, even in the absence of other metabolic abnormalities. This underscores the unique risk profile of Indian diabetics, who tend to develop central adiposity more readily. In the present study, hypertension was seen in 42% of diabetic patients and was significantly more common in those with nephropathy and CHD. Patients with CHD had markedly higher mean systolic and diastolic blood pressures, reflecting the strong association between hypertension and cardiovascular complications. These findings are consistent with those of Venugopal et al.¹⁰, who reported a 25.6% hypertension prevalence in T2DM patients. Hyperinsulinemia-induced salt retention and sympathetic activation may underlie this trend, intensifying cardiovascular risks. Together, these observations call for comprehensive screening and control of both central obesity and hypertension to improve outcomes in diabetic populations.

Lipid abnormalities were highly prevalent in this study, with LDL derangement affecting nearly half (49.5%) of participants, and triglyceride levels significantly higher in urban diabetics. These findings reflect a typical atherogenic profile seen in Asian T2DM populations, marked by elevated triglycerides, high LDL, and low HDL, contributing substantially to cardiovascular risk. Similar patterns have been reported in studies from China and other Asian regions, linking dyslipidemia to metabolic syndrome and coronary artery disease. This underscores the urgent need for early detection and aggressive management of lipid disorders in diabetic patients to prevent macrovascular complications¹¹.

This study revealed notably higher lipid abnormalities in urban diabetic patients compared to rural counterparts, with elevated total cholesterol, LDL, and triglycerides contributing to increased cardiovascular risk. These findings align with the Strong Heart Study, which showed a 1.54-fold higher hazard of CHD in diabetics with high triglycerides and low HDL.  Similarly, Gazzaruso et al.'s¹² study showed a significant correlation (p < 0.05) between silent CAD and lower mean serum HDL cholesterol levels. These findings underline the importance of dyslipidemia, notably high triglycerides and cholesterol, as well as low HDL levels, in the development of silent CAD among diabetic patients . This highlights the need for early lipid monitoring and targeted interventions to manage these risk factors, potentially reducing the incidence of unrecognized cardiovascular complications.

In this study, microalbuminuria was present in 26% of diabetic patients, aligning with previous reports ranging from 25% to 35%. It was significantly associated with BMI, ischemic heart disease (*p*=0.00005), and hypertension (*p*=0.001), emphasizing its role as an early indicator of both renal and cardiovascular complications. Obesity, particularly central obesity, exacerbates insulin resistance and systemic inflammation, contributing to microvascular damage and glomerular stress¹³. A strong association was also observed between microalbuminuria and diabetic retinopathy, reflecting shared microvascular pathology. Notably, 56.3% of CHD patients had microalbuminuria, reinforcing its predictive value for cardiovascular disease. These findings highlight the urgent need for early screening and targeted metabolic interventions in diabetic patients¹⁴.

This study highlights the critical need for targeted interventions focusing on modifiable risk factors, lipid abnormalities, and kidney health to mitigate CHD risk in patients with T2DM. A high prevalence of both CHD and its associated risk factors was observed among T2DM patients in urban and rural populations. Modifiable factors such as smoking (34.4% rural, 15% urban) and sedentary lifestyles (88% urban, 58% rural) were common, while obesity remained relatively uncommon. Dyslipidemia was prevalent, with LDL derangement being the most frequent lipid abnormality (49.5%), and urban patients showing significantly higher triglyceride levels. Microalbuminuria was detected in 26% of patients, reflecting a significant burden of early kidney involvement. Several factors showed strong associations with CHD, including serum cholesterol, LDL cholesterol, HbA1c, microalbuminuria, and hypertension. After adjusting for confounding variables, microalbuminuria emerged as the strongest independent predictor of CHD. These findings emphasize the importance of comprehensive, multifaceted risk assessment and early intervention strategies to reduce cardiovascular complications in T2DM.

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