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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 12  |  Issue : 4  |  Page : 492-502

Clinical profile and types of youth-onset diabetes in Chennai: The indian council of medical research registry of youth-onset diabetes in india – chennai centres


1 Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India
2 Institute of Child Health and Hospital for Children, Chennai, Tamil Nadu, India
3 Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
4 Government Kilpauk Medical College, Chennai, Tamil Nadu, India
5 Tamil Nadu Government Multi Super Speciality Hospital, Chennai, Tamil Nadu, India
6 Stanley Medical College and Hospital, Chennai, Tamil Nadu, India
7 Dr V Seshiah Diabetes Care and Research Institute, Chennai, Tamil Nadu, India
8 Prof. M. Viswanathan Diabetes Research Centre, Chennai, Tamil Nadu, India
9 Dr. A. Ramachandran’s Diabetes Hospitals, Chennai, Tamil Nadu, India
10 Dr. Mohan’s Diabetes Specialties Centre, Chennai, Tamil Nadu, India
11 Diabetes Medicare Centre, Chennai, Tamil Nadu, India
12 Aruna Diabetes Centre, Chennai, Tamil Nadu, India
13 Sree Clinic Diabetes Centre, Chennai, Tamil Nadu, India
14 Swamy Diabetes Centre, Chennai, Tamil Nadu, India
15 Kanchi Kamakoti Child Trust Hospital, Chennai, Tamil Nadu, India
16 Moses Diabetes and Medical Centre, Chennai, Tamil Nadu, India
17 Southern Railway Hospital, Chennai, Tamil Nadu, India

Date of Submission08-Jun-2021
Date of Acceptance16-Jun-2021
Date of Web Publication12-Jan-2022

Correspondence Address:
Dr. Viswanathan Mohan
Madras Diabetes Research Foundation, ICMR Centre for Advanced Research on Diabetes, Dr. Mohan’s Diabetes Specialities Centre, IDF Centre of Excellence in Diabetes Care, 4, Conran Smith Rd, Gopalapuram, Chennai 600086, Tamil Nadu.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jod.jod_76_21

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  Abstract 

Background: The first national-level multicentric clinic-based registry of youth-onset diabetes from India was started in the year 2006 by the Indian Council of Medical Research (ICMR). Objective: In this study, we present the data collected from one of the Regional Collaborating Centre, Chennai (RCC03) of the ICMR Young Diabetes Registry (YDR). Materials and Methods: YDR recruited young diabetes participants reporting on/after January 1, 2000, with age onset ≤25 years at the time of diagnosis of diabetes, and residing within the Chennai Metropolitan Area. The reporting centers (RCs) that were willing to participate in the registry were included, and their staff was trained to fill-in the baseline and follow-up proforma. Results: Overall, 29 RCs participated, which includes six government hospitals, and remaining are private speciality hospitals or single-physician clinics. So far, RCC03 had contributed 4194 young diabetes participants to ICMR-YDR from the Chennai region. Among the registered 48.1% (n = 2020) were type 1 diabetes mellitus (T1DM), 43.4% (n = 1821) were type 2 diabetes mellitus (T2DM), 6.4% (n = 269) were gestational diabetes mellitus, and remaining 2.0% (n = 84) had secondary diabetes. Among T1DM, 58% of them had age onset of <15 years, whereas in T2DM, 95% of them had age onset <15 years. Differences in their clinical profiles were seen among these participants. All T1DMs were on insulin treatment at the time of registration or they had been prescribed insulin at their first visit to the RCs, and 12% of the T2DMs were on insulin. Conclusions: The observations from RCC03 of the registry reveal that 48.1% were T1DM and 43.4% were T2DM. These results suggest that there is equal contribution of T1DM and T2DM cases in the Chennai region, which needs to be studied in detail.

Keywords: Chennai, ICMR, registry, type 1 diabetes, type 2 diabetes, young diabetes


How to cite this article:
Amutha A, Dhakshayani RV, Dharmarajan P, Suresh E, Periyandavar I, Shanmugam A, Seshiah V, Viswanathan V, Ramachandran A, Anjana R M, Vijayakumar G, Paneerselvam A, Srivatsa A, Nallaperumal S, Vasanthi T, Moses A, Roy S, Mohan V. Clinical profile and types of youth-onset diabetes in Chennai: The indian council of medical research registry of youth-onset diabetes in india – chennai centres. J Diabetol 2021;12:492-502

How to cite this URL:
Amutha A, Dhakshayani RV, Dharmarajan P, Suresh E, Periyandavar I, Shanmugam A, Seshiah V, Viswanathan V, Ramachandran A, Anjana R M, Vijayakumar G, Paneerselvam A, Srivatsa A, Nallaperumal S, Vasanthi T, Moses A, Roy S, Mohan V. Clinical profile and types of youth-onset diabetes in Chennai: The indian council of medical research registry of youth-onset diabetes in india – chennai centres. J Diabetol [serial online] 2021 [cited 2022 Jan 27];12:492-502. Available from: https://www.journalofdiabetology.org/text.asp?2021/12/4/492/335598




  Introduction Top


Disease registries are a collection of secondary data related to patients, about their specific condition and diagnosis, and they play an essential role in surveillance studies. India has a history of successful registries like the Indian Council of Medical Research (ICMR) Cancer Registry, the ICMR Young Diabetes Registry (YDR), the Chronic Kidney Disease Registry, and the Hemophilia Registry. These registries help us to understand the demographic and socioeconomic details, clinical characteristics, biochemical profile, associated complications, and treatment in the abovesaid conditions. The registries also help clinicians and policymakers to make targeted decisions during the management of disease conditions in an Indian setup.

The first national-level multicentric clinic-based registry of youth-onset diabetes from India was started in the year 2006 by ICMR. The YDR objectives and the organizational structure have been detailed in an earlier publication.[1] Currently, ICMR-YDR has 11 regional collaborating centers (RCCs; including phases I and II) coordinating with data collection from its own geographically based reporting centers (RCs), which in turn transfer data to the Technical Coordinating Unit. A recent publication also provides the results from phase I baseline data collected so far in the whole registry.[2]

In this article, we present the data collected from one of the Regional Collaborating Centre, Chennai (RCC03). The paper aims to present the variations in young-onset diabetes data collected at the Chennai RCs.


  Materials and Methods Top


A detailed methodology of the YDR registry is published elsewhere.[1] A uniform registry protocol, training manuals, and proformas were developed and adopted across all RCs. The YDR registry recruited all individuals with diabetes reporting on/after January 1, 2000, with age ≤25 years at the time of diagnosis of diabetes (defined as fasting plasma glucose ≥126 mg/dL or 2-h post-load plasma glucose ≥200 mg/dL) and residing within the assigned geographical area. The classification into various diabetes categories was done based on the assessment of the principal investigator of the study/physician/diabetologist/pediatrician at the RC using symptom-based clinical criteria agreed on by the registry expert group before initiation of data collection in 2006.[1] The definition of different forms of diabetes used in the registry is given as [Table S1]. Phase I of the YDR was a pilot study to evolve, validate, and standardize the data collection at two to three centers, and phase II formed the main registry at extended centers.
Table S1: Criteria for Classification of Diabetes Used in YDR

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We contacted all the clinics in the government and private hospitals and clinics in Chennai for their willingness to join the ICMR-YDR. The criteria to join the registry is that they should see young diabetes participants in their clinic as per the ICMR criteria. Once they agreed, the RCs have to give a consent letter to participate and share their data with ICMR. We trained the staff from RCs (who have agreed to join the registry) to fill the proforma.

At the Chennai site, the registry started in 2006, gradually with three to five private diabetes centers from Chennai. Over the years, the number of RCs have grown, and we have now 29 centers currently participating in the registry. From the year 2010, major government hospitals and their affiliated peripheral hospitals started registering young diabetes participants into the registry.

Data collection

Information from participants was obtained using a baseline proforma at the time of registration in the RCs.[1] Data from the period 2000 to 2006 were collected retrospectively in a structured format from medical records, and prospective data were collected from the year 2007 to date. We captured the follow-up data of individuals registered in YDR annually using an annual follow-up proforma.[1]

The staff in each RC manually filled the proforma from their electronic records or medical records. One of our team members will go to each RC and collect the filled proforma after checking the provided information. Data verification was done and entered into the ICMR software. Baseline data entries were completed in August 2019 and follow-up data entries in December 2019. Data were downloaded from the software for the study analysis (January 2020). Storage of hard copies of all proformas was done at RCC03. Duplication of data was prevented by using exact and adequate patient identifier characteristics (a combination of full name, age, gender, and postal code). The ethics committee approvals were obtained from all RCCs but not mandatory for the RCs, and it has been detailed elsewhere.[1] Informed consent was obtained from all the participants.

Statistical analysis

Descriptive statistics are given as mean with standard deviation and frequencies as percentages. One-way analysis of variance was used to compare continuous variables, while the chi-square test was used to compare proportions between the groups. We used paired t-tests to compare the means and chi-square or Fisher’s exact tests to assess differences in proportions as appropriate. Data have been combined in groups as type 1 diabetes mellitus (T1DM) and Latent Autoimmune Diabetes in Adults (LADA) as one group, type 2 diabetes mellitus (T2DM) and clinical Maturity Onset Diabetes in Young (MODY), gestational diabetes mellitus (GDM), and other diabetes types like drug-induced diabetes, fibrocalculous pancreatic diabetes, and other genetic syndromes were put together to form a category named “Secondary diabetes.”


  Results Top


From the Chennai metropolitan area, we contacted 53 possible RCs, and 29 responded to participate in the registry. Currently, these 29 RCs are giving baseline data to ICMR. [Figure 1] shows the geographic regions in Chennai for the registry. Each center had been provided with a separate code (RC code number). There are six government hospitals, and the remaining are private speciality hospitals and single-physician clinics from Chennai.
Figure 1: Distribution of reporting centers at Regional Collaborating Centre, Chennai

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[Table 1] lists the name of the principal investigators, name of the RCs, area of the center, and the number of participants provided by each center in phases I and II of the YDR registry. Overall, from phases I and II, RCC03 has contributed 4194 young diabetes participants to the ICMR-YDR. Out of 4194 participants, 586 (14%) participants were provided by the government hospitals, the primary source was from the Institute of Child Health and Hospital for Children. Among the private hospitals, the Dr. Mohan’s Diabetes Specialities Centre contributed the highest number, with 2306 (55%) participants followed by other private diabetes hospitals.
Table 1: Number of participants recruited from the Regional Collaborating Centre, Chennai in phases I and II (2006–2019)

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[Table 2] shows the distribution of diabetes classification of young diabetes at RCC03. Among the participants registered (n = 2020), 48.1% were T1DM or LADA, (n = 1821) 43.4% were T2DM or clinical MODY, (n = 269) 6.4% were GDM, and the remaining (n = 84) 2.0% belong to secondary diabetes. Gender distribution shows that (n = 2295) 54.7% of young diabetes participants at RCC03 were females [Table 3].
Table 2: Young diabetes participants according to classification at the Regional Collaborating Centre, Chennai

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Table 3: Gender distribution of the participants at the Regional Collaborating Centre, Chennai

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[Table 4] shows the anthropometry and biochemical profile of different types of young diabetes at RCC03. The anthropometric and biochemical profile given above clearly shows the differentiation of T1DM, T2DM, and other young diabetes participants in the registry.
Table 4: Anthropometry and biochemical profile of different types of diabetes at the Regional Collaborating Centre, Chennai

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[Figure 2] shows the stratification according to age at diagnosis at RCC03. Among T1DM, 58% of them fall under the age-onset category of less than 15 years, whereas in T2DM, 95% of them had age onset above 15 years of age. [Table 5] shows the treatment pattern of young diabetes participants. Among T1DM, 83% were on insulin treatment, and only 12% of T2DM were on insulin.
Figure 2: Stratification according to age at diagnosis. DM = diabetes mellitus, GDM = gestational diabetes mellitus

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Table 5: Treatment pattern of young diabetes participants at the Regional Collaborating Centre, Chennai at the time of registration visit

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Data on religion, education, socioeconomic status, parental history of diabetes, mode of presentation, previous hospitalization, complications, and comorbidities are given in [Table S2][Table S3][Table S4][Table S5].
Table S2: Demographic profile of youth onset diabetes at RCC03

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Table S3: Mode of presentation of youth onset diabetes at RCC03

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Table S4: History of hospitalization of youth onset diabetes at RCC03

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Table S5: Complications and comorbidities of youth onset diabetes at RCC03

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  Discussion Top


This article brings out the data collected from Chennai RCC03 from different diabetes clinics in the government and private sectors, and the data received cover most of the Chennai city. There are variations in the data collected like government hospitals gave mostly of T1DM, whereas private hospitals consist of T2DM and GDM participants. All RCs have contributed participants to RCC03, and it adds strength to the nationwide data pool.

The ICMR registry, which has been started in 2006 with five RCCs, has been now extended to 11 centers. Currently, phases I and II of the registry have been extended to phase III (cohort based) successfully, which will bring more precise and detailed information on the young diabetes individuals. Some of the clinics were able to give consent in phase I but were able to provide participants only in phase II. Few centers that were able to provide participants in phase I could not provide participants in phase II, which may be due to unforeseen management decisions like the change of directors/dean/doctors of the hospital. We have registered RCs even if they have given details of one patient. Overall, we have collected baseline details of 1784 individuals in phase I and 2410 with young-onset diabetes in phase II.

It is interesting to note that the overall percentage of T1DM (48%) and T2DM (43%) differs considerably from the nationwide paper, where 63.9% had T1DM and 25.3 had T2DM.[2] The increasing trend for T2DM to develop in young people is of particular concern. In children and adolescents in some parts of the Asia-Pacific region, T2DM now outnumbers T1DM by a ratio of 4:1 in less than 18 years.[3]

Similarly, the female predominance of young diabetes is seen in RCC03, whereas it was males in the national data. Recently, the Pediatric Diabetes Consortium (PDC) registries reported that in their study, children and adolescents with T2DM were more likely to be female.[4] The above data show that data differ in the southern region, i.e., in Chennai. If more collaborating center-wise data get published, we will be able to see the differences or characteristics of each region’s data.

The age at onset of diabetes peaks for T2DM and other forms of diabetes after the age of 15 years, whereas for T1DM, the majority of them fall below 15 years. The mean reported age and age at diagnosis of diabetes in children and adolescents varies in different regions[5],[6],[7],[8],[9] either by reporting less than 14 years of age or their upper age limit as 18 years. Therefore, these studies tend to miss data on children and adolescents in the left out age groups leading to underestimations in some of the studies. If researchers would adopt a standard age breakdown and limit the age of adolescents studied up to 20 years of age, it would be helpful to collate the data worldwide.[10]

The majority of the T1DMs (62.6%) visit the RC for the first time within one year of onset of diabetes, whereas in the case of T2DM, it differs: 45% get registered within a year and 40% report to the center only after three years. This shows that even though they have been diagnosed as T2DM, it takes a longer time to reach proper treatment facilities. Already, these T2DMs may have remained undiagnosed, and this situation leads to high prevalence of complications at the time of clinical diagnosis of diabetes.[11],[12]

As reported by the PDC registries,[4] T1DM had higher mean glycated hemoglobin levels at the time of diagnosis, and in our study also, T1DM had higher levels when compared to other categories of diabetes at the time of registration visit to the RCs. In The SEARCH for Diabetes in Youth (SEARCH) study,[13] 11.2% of the youth-onset T2DMs were on insulin only. Similar results have been observed in these data also.

Recent studies reported around 80% of young T2DMs have a parental history of diabetes, and it increases risk of not only glucose intolerance but also other cardiometabolic risk factors like overweight, low high-density lipoprotein cholesterol, and high blood pressure in Asian Indian adolescents.[14],[15],[16],[17] The present study had similar findings with strong parental history of diabetes. In our study, 24% of T1DMs were presented with osmotic symptoms at the time of presentation, whereas in The European Diabetes (EURODIAB) Prospective Complications Study on T1DM, polyuria was the most common presenting symptom (96%).[18] In T2DM, they had other clinical forms of presentations like giddiness, breathlessness, body pain, shoulder pain, etc.

In this study, both T1DM and T2DM reported a history of hospitalization at the time of registration visit to the RCs, either due to diabetic ketoacidosis in T1DM or uncontrolled hyperglycaemia in T2DM. This calls for early treatment in these youths to prevent diabetes complications. Higher prevalence of microvascular complications was found in T2DM than in T1DM. Also, the presence of cardiometabolic risk factors such as dyslipidemia and hypertension in T2DM subjects leads to increased risk of developing cardiovascular disease in the future. This underscores the need for prevention and aggressive control of T2DM at younger age in order to prevent chronic complications in the future.[19]

The strengths of the registry include longitudinal data of large sample sizes. At present, YDR gives both retrospectively and prospectively from the year 2000 with over 20,000 data to date, i.e., around 20 years. It helps in tracking down the natural history of disease over time and provides generalizable evidence and effectiveness of diabetes treatment in the world.

The study has few limitations. The whole geographic region, i.e., Chennai, could not be covered due to various reasons (funding constraints, insufficient staff, the unwillingness of RCs, etc.). This is a collection of data on young diabetes from the clinics who were willing to participate. There could be ascertainment bias since there may be missed proportion of the young diabetes from the target population. However, these data give a snapshot of the clinical profile of young diabetes attending urban diabetes centers. As there is no systematic registry protocol or a central electronic medical record system in our country, these data give very valuable information on the pattern of young diabetes. Only limited variables were used for the main analysis, and the remaining are given as [Tables S1]–[S5].

The ICMR-YDR is contributing to the nationwide data of both youth-onset T1DM and T2DM. Large diabetes registries especially for the children and adolescents are in need of the hour worldwide in every region due to the increasing incidence of T1DM and T2DM and its impact on health care. A recent systematic review of national diabetes registries worldwide renders 12 registries across four continents, giving new insights on prevalence, treatment, complications, and mortality among diabetic patients.[20] These registries help a lot in health care planning, making policies, and to construct management guidelines.

Acknowledgements

We wish to thank the MDRF staffs Mrs. P. Latha, Mrs. V. Shanthalakshmi and Ms. K. Divya for their tremendous work done for this project. We wish to thank the ICMR, particularly Dr. Tanvir Kaur, Deputy Director General, and Dr. R. S. Dhaliwal, Scientist and Head, all the expert committee group members, and the Department of Non Communicable Diseases and its staff who supported this project. We also thank Dr. Nikhil Tandon, Dr. P. A. Praveen from the Technical Coordinating Unit for successfully making the phase II data entry completion. Special thanks to Dr. A. K. Das for his constant support and encouragement for this project. We wish to thank the Health Secretary, Government of Tamil Nadu, for granting permission to the government hospitals to give their data to this ICMR registry. We would like to thank the principal investigators and the research staff of all the RCs for contributing participants to the Chennai Collaborating Centre and to ICMR. We have given authorship to those who have given more than 10 baseline proformas to the ICMR registry. The remaining investigators are acknowledged for their contributions below:

1. Dr. V. Parthasarathy

2. Dr. Jaishree Gopal

3. Dr. S. Lakshmi Narayan

4. Dr. K. Baraneedharan

5. Dr. Jalaja Ramesh

6. Dr. Uma Ram

7. Dr. V. A. Gunasekaran

8. Dr. R. Madhavan

9. Dr. K. P. Hemchand

Financial support and sponsorship

This project was funded by the Indian Council of Medical Research.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Praveen PA, Madhu SV, Mohan V, Das S, Kakati S, Shah N, et al. Registry of youth onset diabetes in India (YDR): Rationale, recruitment, and current status. J Diabetes Sci Technol 2016;10:1034-41.  Back to cited text no. 1
    
2.
Praveen PA, Madhu SV, Viswanathan M, Das S, Kakati S, Shah N, et al. Demographic and clinical profile of youth onset diabetes patients in India—Results from the baseline data of a clinic based registry of people with diabetes in India with young age at onset-[YDR-02]. Pediatr Diabetes2021;22:15-21.  Back to cited text no. 2
    
3.
Cockram CS. The epidemiology of diabetes mellitus in the Asia-Pacific region. Hong Kong Med J 2000;6:43-52.  Back to cited text no. 3
    
4.
Van Name MA, Cheng P, Gal RL, Kollman C, Lynch J, Nelson B, et al; Pediatric Diabetes Consortium. Children and adolescents with type 1 and type 2 diabetes mellitus in the pediatric diabetes consortium registries: Comparing clinical characteristics and glycaemic control. Diabet Med 2020;37:863-7.  Back to cited text no. 4
    
5.
Lee WRW, Yap KPF, Loke KY, Hamidah K, Chia YY, Ang S. Characteristics of childhood onset type 2 diabetic patients in Asia and Singapore (Abstract). Pediatr Endocrinol Metab 2000; 13:1209.  Back to cited text no. 5
    
6.
Punnose J, Agarwal MM, El Khadir A, Devadas K, Mugamer IT. Childhood and adolescent diabetes mellitus in Arabs residing in the United Arab Emirates. Diabetes Res Clin Pract 2002;55:29-33.  Back to cited text no. 6
    
7.
Moore KR, Harwell TS, McDowall JM, Helgerson SD, Gohdes D. Three-year prevalence and incidence of diabetes among American Indian youth in Montana and Wyoming, 1999 to 2001. J Pediatr 2003;143:368-71.  Back to cited text no. 7
    
8.
Oeltmann JE, Liese AD, Heinze HJ, Addy CL, Mayer-Davis EJ. Prevalence of diagnosed diabetes among African-American and non-Hispanic White youth, 1999. Diabetes Care 2003;26:2531-5.  Back to cited text no. 8
    
9.
Grinstein G, Muzumdar R, Aponte L, Vuguin P, Saenger P, DiMartino-Nardi J. Presentation and 5-year follow-up of type 2 diabetes mellitus in African-American and Caribbean-Hispanic adolescents. Horm Res 2003;60:121-6.  Back to cited text no. 9
    
10.
Pinhas-Hamiel O, Zeitler P. The global spread of type 2 diabetes mellitus in children and adolescents. J Pediatr 2005;146:693-700.  Back to cited text no. 10
    
11.
Bloomgarden ZT. Type 2 diabetes in the young: The evolving epidemic. Diabetes Care 2004;27:998-1010.  Back to cited text no. 11
    
12.
Song SH, Hardisty CA. Early onset type 2 diabetes mellitus: A harbinger for complications in later years–clinical observation from a secondary care cohort. Qjm 2009;102:799-806.  Back to cited text no. 12
    
13.
Badaru A, Klingensmith GJ, Dabelea D, Mayer-Davis EJ, Dolan L, Lawrence JM, et al. Correlates of treatment patterns among youth with type 2 diabetes. Diabetes Care 2014;37:64-72.  Back to cited text no. 13
    
14.
Reinehr T. Clinical presentation of type 2 diabetes mellitus in children and adolescents. Int J Obes (Lond) 2005;29(Suppl 2):S105-10.  Back to cited text no. 14
    
15.
Amutha A, Datta M, Unnikrishnan IR, Anjana RM, Rema M, Narayan KM, et al. Clinical profile of diabetes in the young seen between 1992 and 2009 at a specialist diabetes centre in South India. Prim Care Diabetes 2011;5:223-9.  Back to cited text no. 15
    
16.
Amutha A, Datta M, Unnikrishnan R, Anjana RM, Mohan V. Clinical profile and complications of childhood- and adolescent-onset type 2 diabetes seen at a diabetes center in South India. Diabetes Technol Ther 2012;14:497-504.  Back to cited text no. 16
    
17.
Anjana RM, Lakshminarayanan S, Deepa M, Farooq S, Pradeepa R, Mohan V. Parental history of type 2 diabetes mellitus, metabolic syndrome, and cardiometabolic risk factors in Asian Indian adolescents. Metabolism 2009;58:344-50.  Back to cited text no. 17
    
18.
Soltesz G, Patterson CC, Dahlquist G; EURODIAB Study Group. Worldwide childhood type 1 diabetes incidence–what can we learn from epidemiology? Pediatr Diabetes 2007;8(Suppl 6):6-14.  Back to cited text no. 18
    
19.
Nanayakkara N, Curtis AJ, Heritier S, Gadowski AM, Pavkov ME, Kenealy T, et al. Impact of age at type 2 diabetes mellitus diagnosis on mortality and vascular complications: Systematic review and meta-analyses. Diabetologia 2021;64:275-87.  Back to cited text no. 19
    
20.
Bak JCG, Serné EH, Kramer MHH, Nieuwdorp M, Verheugt CL. National diabetes registries: Do they make a difference? Acta Diabetol 2021;58:267-78.  Back to cited text no. 20
    


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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]



 

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