Subgroups of patients with young-onset type 2 diabetes in India reveal insulin deficiency as a major driver

Rashmi B Prasad,Meet Shah,Annemari Käräjämäki,Banshi Saboo,Malay Parekh,Dattatrey Bhat,Olof Asplund,Pooja Kunte,Leif Groop,Chittaranjan S Yajnik,Emma Ahlqvist,Rucha Wagh,Sharvari R Shukla,Sanjeeb Kakati,Tiinamaija Tuomi,Anupam Datta,Sanat Phatak

doi:10.1007/s00125-021-05543-y

Abstract

Aim/hypothesisFive subgroups were described in European diabetes patients using a data driven machine learning approach on commonly measured variables. We aimed to test the applicability of this phenotyping in Indian individuals with young-onset type 2 diabetes.MethodsWe applied the European-derived centroids to Indian individuals with type 2 diabetes diagnosed before 45 years of age from the WellGen cohort (n = 1612). We also applied de novo k-means clustering to the WellGen cohort to validate the subgroups. We then compared clinical and metabolic-endocrine characteristics and the complication rates between the subgroups. We also compared characteristics of the WellGen subgroups with those of two young European cohorts, ANDIS (n = 962) and DIREVA (n = 420). Subgroups were also assessed in two other Indian cohorts, Ahmedabad (n = 187) and PHENOEINDY-2 (n = 205).ResultsBoth Indian and European young-onset type 2 diabetes patients were predominantly classified into severe insulin-deficient (SIDD) and mild obesity-related (MOD) subgroups, while the severe insulin-resistant (SIRD) and mild age-related (MARD) subgroups were rare. In WellGen, SIDD (53%) was more common than MOD (38%), contrary to findings in Europeans (Swedish 26% vs 68%, Finnish 24% vs 71%, respectively). A higher proportion of SIDD compared with MOD was also seen in Ahmedabad (57% vs 33%) and in PHENOEINDY-2 (67% vs 23%). Both in Indians and Europeans, the SIDD subgroup was characterised by insulin deficiency and hyperglycaemia, MOD by obesity, SIRD by severe insulin resistance and MARD by mild metabolic-endocrine disturbances. In WellGen, nephropathy and retinopathy were more prevalent in SIDD compared with MOD while the latter had higher prevalence of neuropathy.Conclusions /interpretationOur data identified insulin deficiency as the major driver of type 2 diabetes in young Indians, unlike in young European individuals in whom obesity and insulin resistance predominate. Our results provide useful clues to pathophysiological mechanisms and susceptibility to complications in type 2 diabetes in the young Indian population and suggest a need to review management strategies.Graphical abstract

Highlights

Type 2 diabetes has been traditionally considered as one disease characterised by both insulin resistance and insulin deficiency
We first sought to investigate the subgroups of individuals with young-onset type 2 diabetes in the Indian WellGen study and compare them with Swedish subgroups from the ANDIS study
The Indian participants were younger at diagnosis, had lower BMI, higher fasting plasma glucose and lower fasting C-peptide, HOMA2-B and HOMA2-IR compared with the ANDIS sub-cohort (Table 1)

Summary

Introduction

Type 2 diabetes has been traditionally considered as one disease characterised by both insulin resistance and insulin deficiency. India is referred to as one of the diabetes capitals of the world, and Indian individuals with type 2 diabetes differ from Europeans in that they develop diabetes at a younger age and are thinner [6, 7]. Recent studies show that both the increase in the diabetes prevalence and the characteristics of the affected individuals vary in different parts of India [11, 12]. Lean type 2 diabetes is prevalent in India, especially in undernourished regions [13]. Recent studies have shown that subgroups of type 2 diabetes in Indians show partial concordance with those in Europeans [14, 15]

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