Original Article

EVALUATION OF DYSLIPIDAEMIA IN TYPE 2 DIABETES MELLITUS

PATIENTS
Muhammad Anwar1, Syed Raza Jaffar2, Aamir Ijaz3, Najamuddin1, Fawad Sana2

1
Bolan Medical Complex Hospital Quetta, Pakistan
2
PNS Shifa Karachi, Pakistan
3
Armed Forces Institute of Pathology (National University of Medical Sciences), Rawalpindi, Pakistan

ABSTRACT
Objective: This study is aimed to evaluate the correlation of raised levels of Non-high-density lipoprotein
cholesterol (Non-HDL-C) in Type 2 Diabetic patients.
Study design: Cross sectional study
Place and duration of study: Department of Chemical Pathology and Endocrinology, PNS SHIFA hospital
Karachi, from 20.5.2014 to 20.11.2014.
Materials and Methods: Diabetic patients between 30-70 years age, of either gender and having diabetes for
more than five years were included in the study. Patients with co-existing Hypothyroidism, Chronic renal failure,
Nephrotic syndrome, Familial hypercholesterolaemic syndromes, already on lipid lowering drugs, anti-hypertensive
drugs, using beta blockers or thiazide diuretics, obese patients with BMI greater than 30 and those using alcohol
were excluded. Blood samples after overnight 10 hours fasting were taken for fasting plasma glucose, serum total
cholesterol and HDL-cholesterol.
Results: The average age of the patients was 48.75±11.02 years. Out of 232 patients, there were 124(53.45%)
males and 108(46.55%) females. Raised levels of non-high-density lipoprotein cholesterol (>3.33 mmol/L) in type 2
diabetic patients was observed in 80.6% (187/232) cases.
Conclusion: Raised level of non-high-density lipoprotein cholesterol in diabetes mellitus patients is reasonably
high. Appropriate therapeutic interventions should be carried out on basis of simple test such as non-HDL-C in type
2 diabetics to avoid risk of cardiovascular, cerebrovascular and renal disease complications, thereby reducing
mortality and morbidity in these patients.
Key words: Non-high-density lipoprotein cholesterol, Type 2 diabetes mellitus, Dyslipidaemias

This article can be cited as: Anwar M, Jaffar SR, Ijaz A, Najamuddin, Sana F. Evaluation of dyslipidaemia in type 2
diabetes mellitus patients. Pak J Pathol. 2017: 28(3): 135-140.

INTRODUCTION triglycerides (TG) levels, while LDL-C level may only

Dyslipidaemia can be defined as total be marginally elevated in this setting [3].
cholesterol, LDL-cholesterol, triglyceride, apo-B or CVD is the primary cause of morbidity and
lipoprotein (a) [Lp(a)] concentrations above the mortality in patients with diabetes and accounts for
ninetieth percentile or HDL-cholesterol or apo A-1 approximately 65% of overall death with diabetic
concentrations below the tenth percentile for the complications. Adults with diabetes have
general population [1]. Patients with diabetic approximately two to four times higher CVD rate than
dyslipidaemia have lipid particles that are more adults without diabetes [4]. This current dilemma may
atherogenic than in general population and even are be simplified by using the non- HDL-cholesterol (Non
at a slightly increased risk of cardiovascular morbidity HDL-C) and Total Cholesterol versus High Density
and mortality [2]. Hallmark of atherogenic Cholesterol (TC : HDL-C) ratio because these
dyslipidaemia is low levels of high-density lipoprotein parameters have shown to be better predictors of
cholesterol (HDL-C) as well as an elevated atherogenic dyslipidaemia and CVD [5]. Type 2
diabetes mellitus encompasses individuals who have
Correspondence: Dr Muhammad Anwar, Professor of
Pathology, Head Department of Chemical Pathology, Bolan insulin resistance and who usually have relative
Medical Complex Hospital, Quetta, Pakistan
(rather than absolute) insulin deficiency and
Email: mohammadanwar20000@gmail.com
decreased β-cell function [6]. Moreover, it is
Received: 10 May 2017; Revised: 21 Jul 2017; Accepted: 15 Aug 2017

Pakistan Journal of Pathology 2017; Vol. 28 (3): 135-140. 135

Evaluation of dyslipidaemia in type 2 diabetes mellitus patients
estimated that patients with diabetes have a two to
four-fold higher risk of ischaemic disease.
Dyslipidemia is a major risk factor for
macrovascular complications in Type 2 diabetes
mellitus patients [7]. In patients with diabetes,
alteration in the distribution of lipids increases the risk
of atherosclerosis [8]. The main characteristics of
dyslipidemia include high total cholesterol (TC), high
triglycerides (TG), elevated low-density lipoprotein
(LDL), and decreased high-density lipoprotein(HDL)
[9]. Among various dyslipidemias in diabetics the
most common is hypertriglyceridaemia followed by
decreased levels of serum HDL-cholesterol, raised
serum LDL-cholesterol and lastly increased serum
cholesterol levels [10]. Pakistan with a population of
approximately 150 million has a high prevalence of
diabetes as 12% in people above 25 years of age,
10% having impaired glucose tolerance [11].
MATERIALS AND METHODS
This cross-sectional study was conducted in
the Department of Chemical Pathology and
Endocrinology, PNS SHIFA hospital Karachi from
20.5.2014 to 20.11.2014. Two hundred and thirty-two
subjects were included in the study, calculated by
WHO sample size calculator, 5% margin of error and
95% confidence interval taking prevalence of DM as
11 % [16,17]. The study was conducted after
approval by the Ethical Review Board Committee.
Subjects of either gender between 18-70 years of
age with history of Type II DM of more than 5 years
duration who came for random plasma glucose and
Non-HDL-C (TC and HDL-C) in the Pathology
Department PNS SHIFA Hospital were prospectively
enrolled in this study. Type 1 DM Known Patients,
those on treatment for hyperlipidaemia,
hypertension and cardiovascular disease (CVD),
Hospitalized patients, patients with febrile illness
and pregnant women were excluded.
Pakistan Journal of Pathology 2017; Vol. 28 (3): 135-140.
Medical histories, physical examination
particularly name, age, gender, Body Mass Index
(BMI), were entered carefully in a specially designed
Proforma. All subjects fulfilling the inclusion criteria
were elaborately apprised about the study to obtain
their informed consent. Confounding variables were
removed by strictly following the exclusion criteria.
5ml of venous blood samples of all subjects for
random plasma glucose, TC and HDL-C analyses
were drawn from ante cubital vein, out of which 2 ml
were kept in sodium fluoride tubes for random blood
glucose estimation and 3 ml in plain gel containing
tubes for Non-HDL-C (TC and HDL-C) estimation.
The tests were performed on fully automated
chemistry analyser, Modular P 800 Roche/Hitachi,
using Roche calibrators, reagent kits and controls.
Random plasma glucose was estimated by
enzymatic end point glucose oxidase method (GOD).
TC was estimated by enzymatic end point cholesterol
oxidase method. HDL-C was analysed by direct
homogenous method.
Non-HDL-C was simply the difference
between the TC concentration and HDL-C
concentration. Value >3.33 mmol/L of Non-HDL-C
were to be considered as high [18].
Data was analyzed using statistical package
for social sciences version 20 (SPSS 20). Descriptive
statistics for qualitative variables like gender were
calculated in percentages. Mean and SD were
calculated for all quantitative variables like age,
random plasma glucose, total cholesterol, HDL-C and
BMI. Chi-square test was applied, p value ≤0.05 was
taken as significant.
RESULTS
Age distribution of the patients is presented
in figure-1. The average age of the patients was
48.75±11.02 years. Out of 232 cases, 124 (53.45%)
were male and 108 (46.55%) female as shown in
figure-2. Frequency of raised levels of non-high-
136
Evaluation of dyslipidaemia in type 2 diabetes mellitus patients

density lipoprotein cholesterol (>3.33 mmol/L) in type groups as shown in table-2. Similar effects on gender
II diabetic patients was observed in 80.6% (187/232) were observed and chi square test was applied on
cases (Figure-3). raised levels of non-high-density lipoprotein
The average of demographic characteristics, cholesterol of different gender groups but insignificant
lipids as well as random glucose level is presented in finding were observed as shown in table-3.
table-1. Raised levels of non-high-density lipoprotein
cholesterol was not significant among different age

Table-1: Showing descriptive statistics of study patients, n=232.

Variables Interquartile
95% Confidence Interval for Mean
Mean SD Median Range
Lower Bound Upper Bound
Age (Years) 48.75 11.02 47.33 50.18 50 15

Duration of type 2 DM (Years) 10.06 5.83 9.31 10.81 8 6

BMI (kg/m2) 25.91 2.17 25.63 26.19 26 3.4

PGR (mmol/L) 17.63 4.98 16.99 18.27 16.6 6.7

TC (mmol/L) 5.36 0.85 5.25 5.47 5.2 1.2

HDL-C (mmol/L) 1.00 0.28 0.96 1.03 0.87 0.22

Non-HDL-C (mmol/L) 4.38 1.03 4.24 4.51 4.22 1.48

Table-2: Showing frequency of raised levels of non-high-density lipoprotein cholesterol in type II diabetic
patients with respect to age groups.
Age Groups (Years) Non-high-density lipoprotein cholesterol Total
Normal, n=45 Raised, n=187
≤ 30 Years 2(14.3%) 12(85.7%) 14

31 to 40 Years 8(19.5%) 33(80.5%) 41

41 to 50 Years 17(19.1%) 72(80.9%) 89

51 to 60 Years 14(24.1%) 44(75.9%) 58

61 to 70 Years 4(13.3%) 26(86.7%) 30

Chi-Square=1.77; p=0.77

Table-3: Showing frequency of raised levels of non-high-density lipoprotein cholesterol in type II diabetic
patients with respect to gender
Non-High-Density Lipoprotein Cholesterol
Gender Total
Normal, n=45 Raised, n=187
Male 23(18.5%) 101(81.5%) 124

Female 22(20.4%) 86(79.6%) 108

Chi-Square=0.123; p=0.72

Pakistan Journal of Pathology 2017; Vol. 28 (3): 135-140. 137

Evaluation of dyslipidaemia in type 2 diabetes mellitus patients
Figure-1: Age distribution of the patients, n=232.
Figure-2: Gender distribution, n=232.
Figure-3: Frequency of raised levels of non-high-
density lipoprotein cholesterol in type II diabetic
patients, n=232.
Pakistan Journal of Pathology 2017; Vol. 28 (3): 135-140.
DISCUSSION
Non-HDL-C is the primary lipid agent for
coronary disease risk stratification and most lipid
lowering treatment strategies are targeted to reduce
raised Non-HDL-C levels. Therefore, to establish
personal CAD risk for initiation of dietary adjustments
drug intervention and monitoring, Non-HDL-C should
be estimated accurately [19,20].
Elnasri et al compared the frequency of Non
HDL-C in diabetics with age, sex matched healthy
controls in Sudan and found an increased incidence
of Non HDL-C in diabetics as compared to controls
with particularly statistically significant increase in
triglyceride levels and a decrease in HDL-cholesterol
levels [21].The results supported our findings. Adult
treatment panel III of national cholesterol education
programme (NECP) emphasized the need for
optimization of LDL cholesterol levels, but it has been
recently recommended that non- HDL cholesterol
may be a better predictor of CVD in diabetes [22].
There are several advantages to the non-HDL
cholesterol measurements. First, it makes no
assumption about the relationship between VLDL
cholesterol and triglyceride in patients with
lipoproteins considered to be atherogenic, i.e. VLDL,
IDL, LDL, and lipoprotein (a). Non- HDL cholesterol
has many practical advantages in a clinical setting
including the ability to be assessed in patients with
triglyceride levels greater than 400 mg/dl and in
patients who are not fasting [23].
Kannel WB also assessed the utility of non-
HDL cholesterol in DM [24] and found raised level
which supported our results. Our data was in
agreement with few other studies as well which
showed that in both hypertensive men and women
with diabetes, non- HDL-C was elevated [25].
Mathura et al found increased serum triglyceride
levels around 73.3% as the most common lipid
abnormality in DM followed by decreased serum
HDL-cholesterol and increased serum LDL-
138
Evaluation of dyslipidaemia in type 2 diabetes mellitus patients
cholesterol seen in 66.7% patients. A raised serum
total cholesterol level is seen in 46.7% patients [26].
This frequency is comparable to that seen in our
study as well. This study of Mathura et al showed a
comparison between Non-high-density lipoprotein
and low-density lipoprotein cholesterol. Measuring
Non-high-density lipoprotein cholesterol in Type 2
DM patients was simple, cost-effective and
convenient and did not require 12-hour fasting which
may be a risk for hypoglycaemia in these patients.
Clinicians may choose Non-high-density lipoprotein
as a routine measure in everyday practice [27].
Studies done in local population although
have shown increased incidence of dyslipidaemias
but there are conflicting results regarding the relative
frequency of various dyslipidaemias [28]. Our study
was done to determine the frequency of Non-HDL-C
in diabetes type 2 patients visiting PNS SHIFA
Karachi. The results of high frequency of Non-HDL-C
(81.5%) were in line with other studies done
internationally [29] and locally [30,31]. The high
frequency of Non-HDL-C in our study is related
probably to poor glycaemic control in our patients as
Non-HDL-C level is affected by the glycaemic control
as was shown by few international studies [32].
Moreover, glycaemic index was not
determined in our study population to correlate the
association of glycaemic control with dyslipidaemias.
However, despite its shortcomings, the strength of
the study is that there was significant proportion of
diabetic patients who had raised non-high-density
lipoprotein cholesterol being the commonest
dyslipidaemia. Therefore, timely diagnosis and early
start of treatment with the help of Non-HDL-C is
possible in managing type 2 diabetic patients and
subsequently preventing development
atherosclerosis leading to CAD.
Pakistan Journal of Pathology 2017; Vol. 28 (3): 135-140.
CONCLUSIONS
Frequency of raised level of non-high-density
lipoprotein cholesterol in diabetics is reasonably high.
Appropriate therapeutic interventions should be
carried out on basis of simple test such as non-HDL-
C in type 2 diabetics to avoid risk of cardiovascular
complications thereby reducing mortality and
morbidity in these patients.
AUTHORS CONTRIBUTION
Muhammad Anwar: All work done
Syed Raza Jaffar: Overall supervision and checked
research work.
Aamir Ijaz: Concept of research work, & supervision
in sample collection.
Najamuddin: Helped in Literature review, help in
sample collection.
Fawad Sana: Planning of research, arrangement of
reagent kits, sample analysis.
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