1 Department of Internal Medicine, Academy of Medical Original Research Article

Sciences, Pariayaram, Kannur, Kerala, India;

2 Research Division, Gulf Medical University, Ajman, United
Arab Emirates

RISK FACTORS OF TYPE 2 DIABETES MELLITUS IN THE

RURAL POPULATION
OF NORTH KERALA, INDIA: A CASE CONTROL STUDY
Balakrishnan Valliyot1, Jayadevan Sreedharan2, Jayakumary Muttappallymyalil2,
Sudha Balakrishnan Valliyot1

Key words: diabetes mellitus, risk factors, rural
population, North Kerala, India
SUMMARY
The aim of the study was to assess the risk factors
associated with type 2 diabetes mellitus (T2DM) in
rural population of North Kerala, India. The study
included 100 T2DM cases randomly selected among
patients with diabetes admitted to medicine ward and
200 controls without DM recruited from visitors and
patient attendants at a tertiary care centre in the
northern part of Kerala, India. A questionnaire that
contained sociodemographic characteristics and risk
factors was used for data collection. ANOVA was
performed to find the significance of more than two
means. Simple binary logistic regression and multiple
binary logistic regression were performed to find the
crude and adjusted odds ratio (OR) and 95%
confidence interval (CI) was calculated to find the
significance of the observed OR. A p value <0.05 was
considered statistically significant. Study results
showed those above 50 years of age to have five times
more chance to get diabetes when compared with
Corresponding author: Dr. Jayadevan Sreedharan, Assistant Director &
Professor, Research Division, Gulf Medical University, Ajman, United Arab
Emirates
E-mail: drjayadevans@gmail.com
those in the 20-30 age group. Gender and religion did
not show any statistically significant association with
diabetes. Physical activity was observed as a
protective factor for the development of DM.
Hypertension, especially systolic hypertension,
emerged as a strong risk factor for T2DM in this study.
Subjects with systolic hypertension had 4.6-fold
chance to develop T2DM, making it mandatory to
screen all patients with hypertension above 25 years of
age for T2DM irrespective of the presence of other risk
factors. In conclusion, results of the present study will
be of use in planning primordial, primary and
secondary measures of prevention at the community
level.
INTRODUCTION
Type 2 diabetes mellitus (T2DM) is the commonest
form of diabetes affecting more than 90% of the
diabetic population worldwide. There is a rapid
upsurge in the number of diabetic patients and this
explosive growth is noted in both urban and rural
areas. Wild et al. estimated the number of T2DM
patients in the year 2000 at 174 million and predicted
it to increase to 366 million in 2030 (1).

Diabetologia Croatica 42-1, 2013 33

 B. Valliyot, J. Sreedharan, J. Muttappallymyalil, S. Balakrishnan Valliyot / RISK FACTORS OF TYPE 2 DIABETES
The majority of the patients with diabetes in
developed countries are above age 64. It is predicted
that by 2030, the number of people aged above 64 with
diabetes will be around 82 million, of which about 48
million in developing countries. India has the largest
diabetic population and it is expected to increase to
174 million in the year 2025 (2). In developing
countries, the majority of people with diabetes are in
the 45-64 age group (3).
Seventy percent of the Indian population live in rural
areas. It is a well-known fact that urban and rural
populations have different lifestyles, work patterns,
and environmental and sociocultural factors. The
presentation of T2DM is not uniform throughout the
world and there are geographical and ethnic variations
in the presentation of T2DM across the world. Most
studies from western countries (4-6) and urban studies
from India point to lifestyle changes (7), sedentary life
(5), diet and related epidemiological transition (8) as
the major factors in the development of DM. The risk
factors hitherto specified in the development of T2DM
in the western and urban population cannot fully apply
to a rural setting. So, when there is a rapid upsurge of
T2DM in both urban and rural areas, it is an imperative
to identify the factors predisposing to the development
of the disease, which affects one out of every five
Indians. There are only limited studies on the subject
from India; of them, the most acclaimed studies are
from Chennai and other metropolitan cities in India.
The majority of the studies from India are prevalence
studies on DM and only very few studies have focused
on the profile and risk factors of T2DM. The North
Malabar areas of Kerala state include Kannur,
Kasargod and Wayanad districts and most of the
population in this area have a traditional rural lifestyle.
Hence, this study was undertaken to determine the risk
factors of T2DM among rural population of North
Kerala, India.
MATERIALS AND METHODS
This study was conducted at the Academy of Medical
Sciences, Pariyaram, which is a Research Centre and
Postgraduate Institute situated in the Kannur District
of North Malabar area in Kerala, India.
34
One hundred cases with T2DM and 200 unmatched
controls without DM were recruited for the study.
Cases were randomly selected among patients with
diabetes admitted to the medicine ward and 200
controls among visitors and patient attendants. A case
control ratio of 1:2 was adopted in this study.
A pretested structured interviewer administered
questionnaire was used for data collection. The
questionnaire contained data pertaining to
sociodemographic characteristics and various risk
factors associated with the occurrence of DM.
Collected data were analyzed using SPSS 13 version
(IBM, Illinois, Chicago). Frequency, percentage, mean
and standard deviation were calculated and
associations between variables were assessed using
chi-square test. Also, t-test was used to find significant
differences of two means and ANOVA was employed
to find the significance of more than two means. In
addition to the above statistical tools, simple binary
logistic regression analysis and multiple binary
logistic regression were performed to find crude and
adjusted odds ratio (OR). The 95% confidence interval
(CI) was calculated to find the significance of
observed OR. In all cases, p value <0.05 was
considered statistically significant.
RESULTS
Gender wise distribution of subjects showed that
71.0% of cases and 59.0% of control subjects were
males. A statistically significant association was found
between cases and controls with regard to gender
(p<0.05). With regard to age, 83.0% of the case group
subjects and more than 56.0% of control group
subjects were above age 40. A highly significant
association was observed between cases and controls
with regard to age (p<0.001). The majority of study
subjects from both case and control groups belonged
to Hindu religious groups. There was no statistically
significant association between diabetes status and
religion. When the participants were compared
according to occupation, it was found that 29% of
control subjects and 25% of cases were homemakers,
whereas 8% of control subjects and 7% of cases were
manual laborers. Other occupational groups included
 B. Valliyot, J. Sreedharan, J. Muttappallymyalil, S. Balakrishnan Valliyot / RISK FACTORS OF TYPE 2 DIABETES
professionals, mechanics, etc. A highly significant
statistical association was observed between diabetes
status and occupation (p<0.001).
Dietary pattern showed that among controls 93%
were having mixed diet and 7% were vegetarians,
whereas among cases 89% were mixed diet consumers
and 11% were on vegetarian food. When further
analyzed with chi-square test, dietary pattern did not
show any significant association. It was observed that
38% of the cases and 18.5% of the controls were
tobacco users. When tested with chi-square test,
tobacco use showed a statistically significant
association (p<0.001).
Assessment of self-reported physical activity showed
that 42% of cases and 14.5% of control group subjects
were involved in heavy work. Among cases and
controls, 39% and 18% were involved in moderate
physical activity, respectively, whereas 19% of cases
and 67.5% of controls were involved in sedentary
activity. The association between physical activity
with regard to diabetes status was found to be
statistically significant (p<0.01).
With regard to family history of DM, 55.0% of cases
and 37.5% of controls had a family history of DM. The
association observed was high (p <0.001). A detailed
study of the family history of DM showed that in 24%
of cases and 11.5% of controls mothers were diabetic,
whereas fathers were diabetic in 10.5% of controls and
7% of cases.
When compared according to body mass index
(BMI) less than 18.5 kg/m2, both cases and controls
were equally distributed, whereas 67% of cases and
62% of controls had BMI in the range of 18.5-25
kg/m2 .Overweight was recorded in 25% of cases and
29% of control subjects. BMI greater than 30 kg/m2
was found in only 3% of cases and 4.5% of controls.
There was no statistically significant association
between BMI and diabetic status.
Systolic blood pressure of less than 140 mm Hg was
measured in 93.5% of control subjects and 61% of
cases. When this observation was tested with Pearson
chi-square test, systolic blood pressure was found to
be a significant factor associated with diabetes status
(p<0.001). With regard to diastolic blood pressure,
Diabetologia Croatica 42-1, 2013
88.5% of control group subjects and 82% of case
group subjects had a diastolic blood pressure of less
than 90 mm Hg. There was no statistically significant
association between diastolic blood pressure and
diabetic status. Details are given in Table 1.
Table 2 shows that the mean age was lower in the
case group than in the control group. The mean height
in both cases and controls was found to be equal.
Difference in the mean weight was not statistically
significant. Age, gender, occupation, physical activity,
family history, diet, tobacco use, and systolic blood
pressure showed statistically significant correlation
with diabetic status level. The above parameters that
revealed significance were included in the simple
binary logistic regression model and then in the
multiple logistic regression model. The OR and its
confidence interval are shown in Table 3.
Age was found to be a significant factor. In
comparison with the 20-29 age group, the 40-49 age
group had a 4.7-fold and 50-55 age group 5.5-fold
likelihood of developing DM. On adjustment for all
other factors, gender was not found to yield
statistically significance. Physical activity was
measured according to their type of work and was
divided into minimal, moderate and hard physical
activity. For those involved in doing hard activity, the
chance of getting diabetic was by 89% less when
compared to those doing minimal activity, which was
statistically significant. Family history was found to be
an important risk factor with a p value of 0.001.
Multiple logistic regression analysis showed an
adjusted OR of 3.09. Those with a family history of
DM had 3.09-fold greater chance of getting the disease
as compared to those without a family history of DM.
Tobacco use appeared as a significant risk factor for
the occurrence of DM. The adjusted OR was 2.49,
which was statistically significant. Systolic blood
pressure was another risk factor for the development
of DM. After adjusting for all other factors, the OR
observed was 4.69 with a CI of 2.13-10.40. So, age,
family history, physical activity, tobacco use and
systolic hypertension emerged as significant
independent risk factors for the occurrence of DM.
35
 B. Valliyot, J. Sreedharan, J. Muttappallymyalil, S. Balakrishnan Valliyot / RISK FACTORS OF TYPE 2 DIABETES

Table 1. Sociodemographic characteristics and other correlates between cases and controls

Cases Controls Total

Variable Group p value
n % n % n %
Male 71 71.0 118 59.0 189 63.0
Gender p<0.05
Female 29 29.0 82 41.0 111 37.0
20-29 4 4.0 28 14.0 32 10.7
30-39 13 13.0 59 29.5 72 24.0
Age group (yrs) p<0.001
40-49 41 41.0 73 36.5 114 38.0
50-59 42 42.0 40 20.0 82 27.3
Hindu 67 67.0 121 60.5 188 62.7
Religion Christian 17 17.0 42 21.0 59 19.7 p<0.05
Muslim 16 16.0 37 18.5 53 17.7
Home maker 25 25.0 58 29.0 83 27.7
Laborer 7 7.0 16 8.0 23 7.7
Occupation Farmer 29 29.0 13 6.5 42 14.0 p<0.001
Teacher 6 6.0 7 3.5 13 4.3
Others 33 33.0 106 53.0 139 46.3
Heavy 42 42.0 29 14.5 71 23.7
Physical activity Moderate 39 39.0 36 18.0 75 25.0 p<0.01
Minimal 19 19.0 135 67.5 154 51.3
Yes 55 55.0 75 37.5 130 43.3
Family history p<0.001
No 45 45.0 125 62.5 170 56.7
<18.5 5 5.0 9 4.5 14 4.7
18.6-25 67 67.0 124 62.0 191 63.7
Body mass index p<0.05
25.1-30 25 25.0 58 29.0 83 27.7
>30 3 3.0 9 4.5 12 4.0
Mixed 89 89.0 186 93.0 275 91.7
Pattern of diet p<0.05
Vegetarian 11 11.0 14 7.0 25 8.3
Yes 38 38.0 37 18.5 75 25.0
Tobacco use p<0.001
No 62 62.0 163 81.5 225 75.0
Normal 61 61.0 187 93.5 248
Systolic blood pressure p<0.001
Hypertension 39 39.0 13 6.5 52
Normal 82 82.0 177 88.5 259
Diastolic blood pressure p<0.05
Hypertension 18 18.0 23 11.5 41

Table 2. Distribution of cases and controls according to age, height, weight, body mass index (BMI) and blood
pressure (mean ± standard deviation, SD)

Cases Control
Factor p value
Mean SD Mean SD
Age (yrs) 41.07 9.03 45.63 7.88 p<0.001
Height (cm) 162.71 8.10 162.94 7.6 NS
Weight (kg) 63.56 10.94 62.03 9.28 NS
BMI (kg/m2) 23.98 3.31 23.39 3.09 NS
Systolic blood pressure 125.93 13.51 141.6 19.44 p<0.001
Diastolic blood pressure 81.44 8.94 85.44 10.53 NS

36
 B. Valliyot, J. Sreedharan, J. Muttappallymyalil, S. Balakrishnan Valliyot / RISK FACTORS OF TYPE 2 DIABETES

Table 3. Distribution of significant variables: binary logistic regression analysis

Variable Group Crude OR CI Adjusted OR CI

20-29 1 - 1 -
30-39 1.54 0.46-5.15 1.85 0.47-7.27
Age (yrs)
40-49 3.93 1.29-11.97 4.73 1.33-16.83
50-55 7.34 2.36-22.79 5.48 2.14-29.36
Male 1 - 1 -
Gender
Female 0.59 0.35-0.98 0.841 0.42-1.71
Minimal 1 - 1 -
Physical activity Moderate 0.75 0.39-1.44 0.82 0.38-1.77
Heavy 0.10 0.05-0.19 0.11 0.05-0.24
No 1 - 1 -
Family history
Yes 2.04 1.25-3.32 3.09 1.6-6.12
No 1 - 1 -
Tobacco use
Yes 2.70 1.58-4.63 2.49 1.22-5.15
No 1 - 1 -
Hypertension
Yes 9.20 4.61-18.35 4.69 2.12-10.40

DISCUSSION is not a factor, but leisure time activity is also as

Type 2 diabetes mellitus is one of the most important
public health problems in the developed and
developing countries. Age, gender, occupation,
physical activity, obesity, family history, diet, tobacco
use and hypertension were investigated in this study. It
was observed that those above 50 years of age had a
fivefold chance to get diabetes when compared to
those of the 20-30 age group. In a study of T2DM risk
factors in southeast Anatolia, Turkey, Acemoglu et al.
(9) found OR of 3.99 for 40-49 age group, 4.3 for 50-
59 age group and 6.16 for those above 60 years of age.
In our study, OR was 4.7 for those in the 40-49 age
group, which is consistent with the findings reported
by Acemoglu et al. (9). The findings of the present
study were in conformity with King et al. (10), the
NUDS (11) and CUPS (12) studies, and the
significance of this finding is that it will help greatly in
planning the screening and preventive measures in
diabetes. The screening should preferably be
undertaken before 35 years of age and early
intervention should start at an earlier age in this region.
In the present study, gender was not found to be a
statistically significant risk factor.
Our results showed that physical activity is a
protective factor for the development of DM.
Acemoglu et al. (9) report that physical activity alone
important in the development of T2DM. Kokiwar et
al. (13) found the prevalence of diabetes among hard
working group to be lower as compared with sedentary
workers. Gill and Cooper also support the fact that
physical activity has a protective role in the
development of T2DM (14). Karter et al. (15) report
that in the North California study conducted in 1999,
the majority of patients had a maternal history of DM.
Shashank and Rakesh (16) suggest that pedigree
analysis is an excellent tool to study the genetic factor
in diabetes. The finding of this study is very important
in planning preventive strategy and will help identify
the potential candidates who have a high chance to
develop diabetes (16). Earlier, Kawakami et al. (17)
have reported a 3.27 times higher risk for development
of T2DM in those smokers who use 16-26 cigarette
per day when compared to non-smokers. The present
finding is also similar to this finding. In various
studies conducted in the United States, where women
were followed up for 8 years, 2333 cases of T2DM
were confirmed, with a 1.42-fold risk reported (18,19).
Rimm et al. (20) showed that tobacco use may
increase the risk of developing diabetes and the
relative risk for men was 1.94-fold. The findings of the
present study were higher than those reported by
Rimm et al. (20).

Diabetologia Croatica 42-1, 2013 37

 B. Valliyot, J. Sreedharan, J. Muttappallymyalil, S. Balakrishnan Valliyot / RISK FACTORS OF TYPE 2 DIABETES
Hypertension, especially systolic hypertension,
emerged as a strong risk factor for T2DM in the
present study. Subjects with systolic hypertension had
a 4.6-fold chance to develop T2DM, making it
mandatory to screen for T2DM all patients with
hypertension above 25 years of age, irrespective of the
presence of other risk factors. Anderson and Mark
noticed in their study that 57.4% of diabetics had
hypertension (21). According to the Health Survey,
51% of diabetics had hypertension and a 2.5-fold risk
of diabetes in hypertension, less than that noticed in
the present study. According to a recent JNC VII
report, hypertension is twice as common among
diabetics (22). Acemoglu et al. (9), who studied the
risk factors of T2DM in a region of Turkey, found that
hypertension increased the risk of diabetes and
recorded a 2.05-fold risk. Subtle autonomic
dysfunction, decreased baroreceptor sensitivity,
associated nephropathy, endothelial dysfunction due to
hyperglycemia, and many other factors contribute to
the development of hypertension in diabetes. Age is
associated with a progressive rise in systolic blood
pressure and aging vessels become stiffer due to the
loss of elasticity, increased collagen cross-linking,
fibrosis of vessel wall, and reduced vascular
compliance (9). Isolated systolic hypertension occurs
earlier in people with diabetes when compared to
nondiabetics. The exact mechanism that leads to the
development of diabetes in hypertension is not known.
T2DM was associated with insulin resistance and long
standing T2DM leading to endothelial changes.
38
CONCLUSION
The risk factors of T2DM have regional and ethnic
variations. The results of the present study suggested a
positive relationship of age with the incidence of
diabetes, however, with no gender difference in the
development of DM. Manual laborers are less affected
compared to other occupations. Those engaged in hard
work have a less chance to develop diabetes than those
with sedentary habits. This also proves the protective
effect of physical activity in the prevention of T2DM.
Those with a family history of diabetes have three
times greater chance to get T2DM compared to those
without it. Dietary factors were not found to be a
statistically significant risk factor in the development
of T2DM. Hypertension is a significant risk factor in
the development of T2DM. Many factors like obesity,
diet, stress, occupation, which are considered more
important in the western and urban studies, were not
found to be significant in this rural area, whereas
strong genetic factors, tobacco use, less physical
activity and systolic hypertension emerged as strong
risk factors.
 B. Valliyot, J. Sreedharan, J. Muttappallymyalil, S. Balakrishnan Valliyot / RISK FACTORS OF TYPE 2 DIABETES
REFERENCES
1. Wild SH, Roglic G, Green A, Sicree R, King H.
Global prevalence of diabetes: estimate for year
2000 and projections for 2030. Diabetes Care
2004;27(5):1047-1052.
2. Diabetes atlas, Executive summary, World
Diabetes Foundation, second Edition, 2003.
3. Sicree R, Shaw JE, Zimmet PZ. Global burden of
diabetes. Diabetes atlas, 2nd edn. Brussels:
International Diabetes Federation, 2003:15-71.
4. Ziv E, Shaffir E. Psammomys obesus: nutritionally
induced NIDDM-like syndrome on thrifty gene
background. In: Shafrir E, ed. Lessons from
animal diabetes. London: Smith-Gordon,
1995;285-300.
5. Heimlich SP, Ragland DR, Lecins RQW. Physical
activity and reduced occurrence of non insulin
dependent diabetes. N Engl J Med 1991;325:147-
152.
6. Mooy JM, DeVries H, Grootenhuis PA, Bouter
LM, Hein Major RJ. Stressful life events in
relation to prevalence and undetected type 2
diabetes. Diabetes Care 2002;15(3):197-201.
7. Arunachalam S, Guneshekharan S. Diabetes
research in India and China today. From literature
based mapping to health care policy. Curr Sci
2002;82:1086-1097.
8. Ramachandran A, Snehalatha C, Latha F. Rising
prevalence of NIDDM in an urban population in
India. Diabetologia 1997;40:232-237.
9. Acemoglu H, Ceylan A, Saka G, Plalanci Y, Erten
M, Turgut S, et al. Risk factors for diabetes in
South Eastern Anatolia of Turkey. Int J Epidemiol
2001;3(1):1540-2614.
10. King H, Aubert RE, Herman WH. Global burden
of diabetes 1995-2025. Prevalence, numerical
estimate and projections. Diabetes Care
1998;21:1414-1431.
Diabetologia Croatica 42-1, 2013
11. Ramachandran C, Snehalatha, Kapur A, Vijay V,
Mohan V, Das AK, et al. High prevalence of
diabetes and impaired glucose tolerance in India:
National Urban Diabetes Survey (NUDS).
Diabetologia 2001;44(9):1094-1101.
12. Mohan V, Santhirani CS, Deepa R. Prevalence of
diabetes and IGT in selected south Indian
population with special reference to family history,
obesity and lifestyle factor – Chennai Urban
Population Study [CUPS-14]. J Assoc Physicians
India 2003;51:771-777.
13. Kokiwar PR, Gupta S, Durge PM. Prevalence of
diabetes in a rural area of central India. Int J
Diabetes Dev Countries 2007;27(1):8-10.
14. Gill JMR, Cooper AR. Physical activity and
prevention of type 2 diabetes mellitus. Curr Opin
Sports Med 2008;38(10):807-824.
15. Karter AJ, Rowell SE, Ackerson LM, Mitchell BD,
Ferrara A, Selby JV, et al. Excess maternal
transmission of type 2 diabetes. The Northern
California Kaisser Permanent Diabetes Registry.
Diabetes Care 1999;22:938-943.
16. Shashank RJ, Rakesh MP. Family history and
pedigree charting – a simple genetic tool for Indian
diabetes. JAPI 2006;54:437-439.
17. Kawakami N, Takatwuka N, Shimizu H,
Ishibarshi H. Effect of smoking on the incidence
of NIDDM. Replication and extension in a
Japanese cohort of male employee. Am J
Epidemiol 1997;145:103-109.
18. Vanderpump MP, Tunbridge WM, French JM,
Appleton D, Bates D, Rodgers H, et al. The
incidence of diabetes mellitus in an English
community – a 20-year follow up of the Wickham
survey. Diabetes Med 1996;13:741-747.
19. Giannini C, Dyck PJ. Basement membrane
reduplication and pericyte degeneration precede
development of diabetic polyneuropathy and are
associated with its severity. Ann Neurol
1995;37:498-504.
39
 B. Valliyot, J. Sreedharan, J. Muttappallymyalil, S. Balakrishnan Valliyot / RISK FACTORS OF TYPE 2 DIABETES

20. Rimm EB, Chan J, Stampfer MJ. Prospective 22. National High Blood Pressure Education
study of cigarette smoking, alcohol use and the risk programme working group report on HTN in
of diabetes in men. Br Med J 1995;310:555-559. Diabetes. Hypertension 1994;23:145-158.
21. Anderson EA, Mark AL. The vasodilator actions
of insulin. Implication for the insulin hypothesis of
hypertension revisited. Cardiovasc Risk Factors
1993;3:159-163.

40