Khalil Naemat MD
Department of Internal
Medicine, King Hussein medical center
Dr. Khalil Naemat. P.O. Box 1834 Amman
know the incidence of hypertriglyceridaemia,
its age and sex distribution and prevalence
in NIDDM and IDDM and also to know
the relationship between the glycaemic
control and degree of hypertriglyceridaemia
and incidence of complications of
hypertriglyceridaemia in diabetes
Patients and Methods: one hundred
and twenty patients of well-established
diabetes mellitus were included in
the study. All patients underwent
the following investigations:
1. Base line investigations like blood
CP with ESR, Blood urea, urine RE,
ECG and x-ray chest.
2. Planned investigations: These included
fasting and 2 hours post prandial
blood glucose estimation, serum electrolytes,
serum creatinine, serum amylase, uric
acid, LFT's, TFT's, ETT and abdominal
ultrasound to look for liver texture
and for any evidence of fatty change;
morphology, texture of kidney and
pancreas and other abdominal viscera.
3. Total lipid profile which included:
Total fasting lipids, Total fasting
triglycerides, Total fasting cholesterol,
HDL cholesterol and LDL cholesterol.
Results: The commonest finding
was hypertriglyceridaemia both in
insulin- and non-insulin dependent
diabetic patients. It was more so
in non-insulin dependent diabetes
mellitus (70%) as compared to insulin-dependent
is the most common lipid abnormality
in diabetes mellitus, which is more
common in NIDDM than IDDM.
Early diagnosis, good glycaemic control
and dietary modification are usually
enough for prevention and treating
hypertriglyceridaemia in diabetes
Key words: lipid
profile, diabetes mellitus, hypertriglyceridaemia
Diabetes is a common endocrine
disease and its complications are major
stimuli for the enhancement of efforts towards
its control. There are currently 119.2 million
people with type 2 diabetes worldwide, and
the number is expected to increase to 212.9
million, in the year 2011 (1).
Type 2 diabetes is the most
prevalent form of diabetes and is due to
the combination of insulin resistance and
defective secretion of insulin by pancreatic
Diabetes mellitus is a major risk factor
for morbidity and mortality due to coronary
heart disease (CHD), cerebrovascular disease,
and peripheral vascular disease. Metabolic
control and duration of type 2 diabetes
are important predictors of coronary heart
disease (ischaemic heart disease) in elderly
subjects, particularly in women (3).
Hyperglycaemia affects biochemical parameters
and influences the progression of coronary
heart disease and mortality rates in diabetic
patients. Aggressive treatment to control
hyperglycaemia is much more effective in
reducing the number of complications than
standard treatment (4, 5).
The term hyperlipidaemia refers
to an increase in concentration of one or
more plasma or serum lipids, usually cholesterol
and triglycerides and the term dyslipidaemia
is used for either an increase or decrease
in concentration of one or more plasma or
serum lipids. Type 2 diabetic patients have
markedly increased risk of coronary heart
disease than similarly dyslipidaemic non-diabetic
Most recently, results of the Strong Heart
Study indicate that LDL cholesterol is an
independent predictor of cardiovascular
disease in patients with diabetes, along
with age, albuminuria, fibrinogen, HDL cholesterol
(inverse predictor), and percent body fat
(inverse predictor) (4). Atherogenic dyslipidaemia
(diabetic dyslipidaemia) is characterized
by 3 lipoprotein abnormalities: elevated
very-low-density lipoproteins (VLDL), small
LDL particles, and low high-density lipoprotein
(HDL) cholesterol (the lipid triad) (5,
6). Despite the high and widespread prevalence
of dyslipidaemia among people with and without
diabetes, only 2.2 % (7) of adults without
diabetes and 32 % (8) of diabetic patients
were receiving treatment with diet, exercise,
or drugs to reduce lipid levels and less
than one third of patients with established
cardiovascular disease received such treatment.
(7). Furthermore, among those who were being
treated, only 1 % reached the American Diabetes
Association (ADA) goal of LDL < 2.6 mmol/L
(100 mg/dl) (8).
The aims of the present study
- To know the incidence of
hypertriglyceridaemia, its age and sex
distribution and prevalence in NIDDM and
- To know the relationship
between the glycaemic control and degree
of hypertriglyceridaemia and incidence
of complications of hypertriglyceridaemia
in diabetes mellitus.
The sample of this prospective
study was conducted in the department of
medicine in King Hussein medical center
over a period of two years.
After institutional ethical
committee clearance and written informed
consent was taken, one hundred and twenty
patients of well-established diabetes mellitus
were included in the study.
Patients were selected for
study from among patients attending the
Outpatient Diabetes Clinic.
The selection criteria were:
patient of these one hundred and twenty
cases had established diabetes mellitus.
- Systemic diseases like
CRF, nephrotic syndrome, myxoedema, SLE
were excluded from the study on the basis
of history, clinical examination and relevant
- Diabetic patients taking
drugs like beta-blockers, oral contraceptive
pills, thiazide diuretics, corticosteroids,
or cimetidine for any reason, were also
- Smokers and alcoholics
were also excluded.
Those patients who agreed
to participate in the study were informed
of the program and schedule of the study.
The patient's personal data,
medical, family, dietary history and daily
activities were recorded. Height and weight
for BMI calculation were also measured and
recorded using a data collection form.
After 12 hours of fasting
(overnight) a sample of blood was collected
into appropriate tubes and taken to Chemical
Pathology Laboratory for analysis.
underwent the following investigations:
- Base line investigations
like blood CP with ESR, Blood urea, urine
RE, ECG and x-ray chest.
- Planned investigations:
These included fasting and 2 hours post
prandial blood glucose estimation, serum
electrolytes, serum creatinine, serum
amylase, uric acid, LFT's, TFT's, ETT
and abdominal ultrasound to look for liver
texture and for any evidence of fatty
change; morphology, texture of kidney
and pancreas and other abdominal viscera.
- Total lipid profile
which included: Total fasting lipids,
Total fasting triglycerides, Total fasting
cholesterol, HDL cholesterol and LDL cholesterol.
The total number of
patients included in the study was 120.
All of them were known diabetics. The female
to male ratio was 2:1.
Regarding the age group,
the majority of our patients were in the
age group ranging from 31-60 years. Only
14% were above the age of 60 years.
Regarding the type of
diabetes, we found that 15% had IDDM and
85% NIDDM. Regarding the duration of diabetes
mellitus 78% of the cases had diabetes mellitus
for the last 7-17 years.
The dietary intake in
45% of patients was complex carbohydrates
and high fibre diet. 25% had a liking for
a fat enriched diet of which females were
the majority. 15% were following no dietary
Regarding physical activity,
60% of patients had a strict sedentary life
pattern, with the vast majority of female
patients, restricted to their house keeping.
Very few patients were participating in sports.
Body mass index was
evaluated by the following formula in all
patients. BMI = weight in kilogram / height
in meters(9). 40% had normal body mass index,
15% below normal, while 45% had a body mass
index above the normal range.
The triglyceride levels
were raised only in 58% patients. 29% patients
had only raised serum triglyceride without
any clinical evidence of hyperlipidaemia.
Regarding the fasting
blood glucose it was found more to be more
than 140 mg/dl in 85% of cases. The majority
of patients had poor to uncontrolled glycaemic
Renal function tests
i.e. blood urea, serum creatinine and electrolytes
were carried out to rule out any renal pathology,
but they were found within the normal limits.
Liver function tests, thyroid functions
tests were normal.
In general 44% of the
patients had normal total serum lipids,
while 56% showed raised levels. Out of 56%,
46% had serum lipid levels in the range
of 1000-1500 mg/dl, while the remaining
10% of patients had a level in the range
of 1500-2500 mg/dl.
Total fasting serum
cholesterol was found normal in 80% patients.
20% had raised serum cholesterol in the
range of 251-300 mg/dl. All of these 20%
of cases also had triglyceride levels more
than 200 mg/dl, so fulfilling the hyperlipidaemic
criteria of National cholesterol education
programme of the USA.
LDL - cholesterol was
found to be normal in 80% of cases while
20% showed a raised level. HDL - cholesterol
in 15% of cases was less than 40 mg/dl,
who were at a higher risk of IHD, while
it was found above 40 mg/dl in the remaining
Hypertriglyceridaemia was found both in
IDDM and NIDDM patients. It was more in
NIDDM (70%) than IDDM (30%) patients.
In IDDM the majority
of patients had mild to moderate hypertriglyceridaemia.
The same was the case in NIDDM patients.
In our study, we found
that 24% had ischaemic heart disease as
evidenced by serial ECGs
Patients with diabetes can
have many lipid abnormalities, including
elevated levels of very low-density lipoprotein
cholesterol (VLDL-C), low-density lipoprotein
cholesterol (LDL-C), and triglycerides;
and low levels of high-density lipoprotein
cholesterol (HDL-C) (10). These patients
have a preponderance of abnormalities in
the composition of LDL-C (smaller, denser
particles), which increase atherogenicity
even if the absolute concentration of LDL-C
is not significantly increased. The combination
of elevated levels of small, dense LDL-C
particles and high triglyceride levels represents
a lethal cholesterol abnormality known as
About 20% of patients with
type 2 diabetes have hypertriglyceridaemia
or low HDL-C levels (11). These abnormalities,
as well as high VLDL-C levels and high total
and VLDL-related triglyceride levels, are
powerful risk indicators for CAD in patients
with type 2 diabetes. In addition, the combination
of elevated total cholesterol level, hypertension,
and uncontrolled hyperglycaemia is implicated
in the development of nephropathy.
In a study done in Russia,
dyslipadaemia was detected in 84% diabetic
patients(12). In one European study 40%
were hyperlipidaemic according to the criteria
of National cholesterol education programme,
(cholesterol and triglyceride greater than
200 mg/dl). An additional 23% showed hypertriglyceridaemia(13).
In another study hiperlipidaemia was found
in 28% of diabetic patients(14).
In our study total fasting
lipids of greater than 1000 mg/dl were found
in 56% and fasting hypercholesterolaemia
and increased LDL cholesterol in 20% of
the patients. The values of cholesterol
and LDL cholesterol declined from younger
to older ages; so these results are in conformity
with the previous study(15).
found to be the commonest dyslipidaemia
in this study i.e. 58%; greater than the
previous studies. The majority of patients
in our study were type II diabetics (70%)
as compared to type I (30%). Winocour et
al, has shown 40% hyperlipidaemia in IDDM
patients. Hypertriglyceridaemia was found
predominantly in all the cases while a few
had combined hyperlipidaemia, pure hypercholesterolaemia
however was not observed in a single case(16).
is comparatively more common in NIDDM than
IDDM(17) is probably due to increased production
and reduced clearance of rich lipoproteins-VLDL(18)
. Amongst the NIDDM patients hypertriglyceridaemia
is depending upon the variation in the apo
E gene, because significantly higher level
of VLDL - triglycerides have been found
in patients with epsilon 2 heterozygote
than in those without the epsilon 2 allele(19).
It is further interesting to note that even
the 1st degree relatives of NIDDM cases
have dyslipidaemia in general and hypertriglyceridaemia
in particular(20) . In the number of European
studies dislipidaemia is more common in
males, beyond 35 years of age(21). But in
our study it is more common in females.
One factor responsible for this is that
they are confined to their housekeeping
without any active physical activity.
Exercise has potential benefits
for these patients. It not only has a lipid
lowering effect but it also potentiates
the effect of diet or drug therapy on glucose
metabolism in NIDDM patients(22). In our
study only 24% were in the habit of taking
The poorer the glycaemic control,
the higher the degree of hypertriglyceridaemia.
This relationship can be explained by the
glucoregulatory and lipolytic actions of
insulin, and defect in this can lead to
dyslipidaemia more so in NIDDM patients(23).
If good glycaemic control is achieved then
not only the size of VLDL particle is reduced
but also increases in the concentration
of apo - B protein fraction of VLDL takes
place. These changes in turn lead to increased
clearance of VLDL particles and ultimately
dislipedaemia reverts(24).In one study 28%
of diabetic patients had hyperlipidaemia
with a poor glycaemic control as defined
by a glycated hemoglobin value of more than
10%(14). In our study 58% of the total patients
had poor glycaemic control as assessed by
serial 2 hours post prandial glucose estimation
according to WHO criteria(25). All of these
showed mild to severe dislipidaemia.
In WHO criteria, levels less
than 150 mg/ dl were taken as good, between
150-200 mg/ dl as permissible and above
200 mg/dl as poor glycaemic control.
Apart from the blood glucose
estimation glycaemic control can be monitored
by estimation of glycated HbAIC, glycated
fructosamine and glycated serum albumin.
Glycated HbAIC comprises 4-6% of the total
haemoglobin. Levels less than 10% reflect
a good glycaemic control over the preceding
8- 12 weeks(26). However, glycated serum
albumin can be a more reliable marker of
short term glycaemic control in IDDM than
Diabetic patients with hyperlipidaemia
frequently develop atherosclerosis. Superoxide,
which is present in diabetic patients with
hypertrigly ceridaemia, is suspected to
play an important role in the initiation
of this atheroselerosis. (28) Other atherogenic
factors specific to diabetes mellitus, however
are concomitantly present which potentiate
the process of atherosclerosis. Both low
HDL and high triglyceride levels are frequently
associated with other coronary risk factors.
Correction of both, may reduce coronary
artery disease risk without fear of adverse
side effects. (29)
In various studies the
plasma triglyceride level exceeding 3 m.mole/L
(270 mg/dl) is universally accepted as hypertriglyceridaemia
in diabetes mellitus(14) and the greater
levels are positively correlated with the
increased risk of coronery artery disease(30,31).
It is noteworthy that triglyceride levels
greater than 2 mmol/L are the angiographically
proven marker of coronary artery disease(32).
In long term follow
up, for more than 10 years, patients with
impaired glucose tolerance tests and or
frank diabetes mellitus, it was observed
that the mortality rate with respect to
IHD was remarkably high in those having
moderately severe hyperlipidaemia than those
with border line(33). Silent myocardial
infarction which is seen in 15-24% of patients
with diabetes mellitus(34) becomes even
more common in the presence of long standing
moderate to sever hyperlipidaemia. In our
study 24% had ischaemic heart disease. Their
lipid profile showed mild to moderate hypertriglyceridaemia
(200- 400 mg/dl, while total cholesterol,
LDL cholesterol and HDL cholesterol were
Hypertiglyceridaemia is the
most common lipid abnormality in diabetes
mellitus, which is more common in NIDDM
Early diagnosis, good glycaemic
control and dietary modification are usually
enough for prevention and treating hypertriglyceridaemia
in diabetes mellitus.
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