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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 72-78

Gender difference in the risk of developing diabetes mellitus type 2 and oral glucose tolerance test in dental students


1 Department of Biochemistry, BJS Dental College, Hospital and Research Institute, Ludhiana, Punjab, India
2 IX Standard Student, BCM School, Ludhiana, Punjab, India

Date of Submission01-Apr-2019
Date of Acceptance29-May-2019
Date of Web Publication13-Nov-2019

Correspondence Address:
Ms. Khushboo Bhardwaj
Department of Biochemistry, BJS Dental College, Hospital and Research Institute, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_14_19

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  Abstract 


Introduction: Diabetes mellitus, one of the major noncommunicable diseases, has emerged as a global societal catastrophe and is the leading cause of illness, disability, and death. The risk factors for the development of diabetes mellitus type 2 such as age, gender, and family history are nonmodifiable factors while others such as smoking, diet, physical activity, and hypertension are modifiable factors. Indian Diabetes Risk Score (IDRS) provides a useful tool to identify the people at risk of developing the disease and to target those individuals for further screening and educating them for healthy lifestyle so that the occurrence of the disease can be delayed or prevented.
Materials and Methods: The present study was a cross-sectional study conducted on 102 BDS 1st year students (17 boys and 85 girls) of the age group 17–21 years. All the students were assessed for their risk to develop the disease using Indian Diabetes Risk Score (IDRS) and oral glucose tolerance test (GTT) using Glucometer (CareSens™II).
Results: The study revealed that out of 102 students, 35.3% and 64.7% students were in low- and moderate-risk groups, respectively. No student belonged to the high-risk group. Percentage of girls in moderate risk was significantly higher than boys. Mean blood sugar in girls was more. Two girls were suffering from impaired fasting glucose. Seven students (6.9%) including 2 boys (11.8%) and 5 girls (5.9%) depicted flat GTT curve with all values below 100 mg/dl.
Conclusion: Higher risk of disease in girls is largely due to their lack of exercise which is a modifiable factor and can thus be protected from the disease by adopting healthy lifestyle. History of the disease (nonmodifiable factor) is the risk factor in boys to be prone to the disease in their future and thus requires a regular screening and monitoring of blood sugar level.

Keywords: Dental students, diabetes mellitus type 2, IDRS, oral glucose tolerance test


How to cite this article:
Mahajan S, Bhardwaj K, Mahajan R. Gender difference in the risk of developing diabetes mellitus type 2 and oral glucose tolerance test in dental students. Int J Oral Health Sci 2019;9:72-8

How to cite this URL:
Mahajan S, Bhardwaj K, Mahajan R. Gender difference in the risk of developing diabetes mellitus type 2 and oral glucose tolerance test in dental students. Int J Oral Health Sci [serial online] 2019 [cited 2019 Dec 9];9:72-8. Available from: http://www.ijohsjournal.org/text.asp?2019/9/2/72/270874




  Introduction Top


Lifestyle related transition in the 21st century has led to noncommunicable diseases (NCDs) becoming a major public health problem on a growing magnitude. Diabetes mellitus, one of the major NCDs, has emerged as a global societal catastrophe and is the leading cause of illness, disability, and death. It is linked directly or indirectly to the behavior, nutritional, and environmental factors and is considered as the disease of urbanization.[1] According to the International Diabetes Federation, 415 million adults have diabetes, and it is estimated that it would rise to 642 million by 2040.[2] The WHO projects that diabetes will be the 7th leading cause of death by 2030.[3] According to the latest global figure on diabetes, India leads the world with 65 million diabetic people earning the dubious distinction of being labeled as the “Diabetic Capital” of the world.[4] Over the past three decades, the incidence of diabetes mellitus type 2 (T2DM) has increased markedly in children and adolescents, and about one-third of the new cases are being diagnosed in adolescents globally.[5],[6],[7] Pinhas et al.[8] were the first to highlight the rising trend of T2DM in children and adolescents. The search study group (an US multicenter observational study) found that the incidence of type 2 diabetes mellitus was highest among American Indian individuals aged 15–19 years followed by Asian Pacific Islanders and black individuals of the same age.[9] Contradictory reports are available regarding the differential distribution of NCD across gender. A multicentric cross-sectional survey in five Asian countries including India argued that male gender is a risk factor for NCD[10] while the survey conducted in Pacific island revealed increased prevalence of diabetes mellitus and other NCD among women.[11] Unfortunately, diabetes mellitus remains highly undiagnosed leading to increased risk of morbidity and mortality further adding the disease burden to the patients, their families, and the health-care system.[12] Among the youth of today, the students due to their busy academic schedule generally do not have much time for physical exercises and are also addicted to the unhealthy food habit resulting in obesity. There is enough evidence suggesting the beneficial effect of physical exercises but less data are available on the gender differences of these effects.[13] The onset of diabetes at an early age resulting in rapid progression to chronic vascular complications and end-organ damage[14] warrants early detection and prevention using simple and cost-effective screening tools. The use of risk scores to detect undiagnosed T2DM, namely the Finnish Diabetes Risk Score, the American Diabetes Association, and the Indian Diabetes Risk Score (IDRS) has been increasingly widespread in literature. Oral glucose tolerance test (OGTT) can help uncover glucose intolerance. Impaired fasting glucose (IFG) and impaired glucose tolerance, collectively called prediabetic states, have a high risk of conversion to diabetes and cardiovascular diseases[15],[16] and are the indicators of future diabetes prevalence. T2DM and insulin resistance syndrome are preventable to a large extent if intervened during prediabetes state.[17] The present study was an attempt to screen BDS 1st year students with undiagnosed type 2 diabetes mellitus and those at high risk to develop the disease in their future using IDRS and OGTT and to correlate the risk with various risk factors, i.e., gender, age, physical activity, waist circumference, family history of diabetes, and blood sugar level. The study was also aimed to reveal if IDRS alone or in combination with OGTT will help unmask the at-risk T2DM participants.


  Materials and Methods Top


The present study was a cross-sectional study. It was conducted in the Department of Biochemistry, Baba Jaswant Singh Dental College, Hospital and Research Institute, Ludhiana. The study was approved by the ethical committee of the institute. The BDS 1st year students were detailed about the importance of the study, and a written consent was obtained from the interested students. The students who were diabetic, taking hypoglycemic drugs or following diet restrictions were excluded from the study. A total of 102 students (17 boys and 85 girls) of the age group 17–21 years were screened for their risk for developing T2DM using Indian Diabetes Risk Score (IDRS). IDRS is a simple, fast, inexpensive, validated, and reliable screening tool and has proved as a successful method for the detection of undiagnosed diabetes in community.[18],[19] This tool, devised by Madras Diabetes Research Foundation, is based on multiple logistic regression models and takes into account age, physical activity, waist circumference, and family history of diabetes mellitus.[20] The score distribution according to IDRS is mentioned in [Table 1]. A score of zero (0) was allotted to all the students as they all belonged to age group <35 years. The waist circumference (indicative of central and general obesity) was measured using a measuring tape with an accuracy of 0.5 cm after normal expiration with the individual standing erect in a relaxed position. Abdominal/central obesity was considered to be present when the waist circumference was ≥80 in girls and ≥90 in boys. Besides parental history, the diabetic history of their grandparents and other relatives was also inquired. The students were also checked for acanthosis nigricans (a marker of insulin resistance) present as a velvety hyperpigmented thickening of the skin of the neck and the flexural areas. All the screened students, irrespective of their IDRS, were assessed for their OGTT after a glucose load of 75 g dissolved in 300 ml of distilled water unlike as recommended by Mohan et.al.[20] in person with IDRS >60. Only blood and urinary sugar during fasting and at different time interval after glucose load was checked using Glucometer (CareSens™II) and Benedict's test, respectively. The number of students and their percentage for each parameter and in each risk group was calculated and tabulated. The data thus obtained were analyzed statistically using t-test and Chi-square test. The significance of the results was established at P < 0.05.
Table 1: Indian Diabetes Risk Score (Mohan et al., 2005)

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  Results Top


Frequency distribution of the students as per their age and IDRS is given in [Figure 1]. About 11% of the students belonged to 17 years of age, 81% were from 18 to 19 years of age, 7% were from 20 years, while the age of only 1 student was 21 years. The mean age of the students was 18.5 ± 0.8 years. The mean age of boys and girls was 18.8 ± 0.8 years and 18.4 ± 0.8 years, respectively. The risk score of each student was calculated, and the students were divided into three risk group, i.e., low-risk group (IDRS < 30), moderate-risk group (IDRS = 30–50), and high-risk group (IDRS ≥ 60) as suggested by Mohan et al.[20] The study revealed that out of 102 students, 35.3% and 64.7% students were in low- and moderate-risk groups, respectively. No student belonged to the high-risk group. Ten boys (59%) and 26 girls (31%) accounted the low-risk group while the percentage of girls and boys in the moderate-risk group was 69% and 41%, respectively (P < 0.05) [Table 2] and [Figure 2]. Out of 48 students, 29% of boys and 51% of girls were not doing any physical exercise. Percentage of boys doing regular exercise and/or strenuous work was significantly more (71%) than girls (49%) (P < 0.05). The IDRS for the waist circumference was zero in 59% of both the sexes. It was 10 in 41.2% of boys and 29.4% of girls. IDRS 20 was found in 12% of girls. No boy was having IDRS 20 for abdominal obesity. Diabetic history was significantly higher in boys. Nearly 59% of the boys and only 7% of the girls were having a history of diabetes in one of their parents (P < 0.001). Fathers contributed more for the diabetic history than mother, and it was significantly higher (P < 0.001) for boys (35%) than girls (7%). No student was having their both parents suffering with the disease. Diabetic history in grandparents and relatives was also more in boys (70%) than in girls (57%). One boy was also having diabetes in his sister and his total IDRS was 50. No student was having the signs of acanthosis nigricans [Table 3], [Table 4] and [Figure 3]. Range and mean ± SD values in blood sugar during fasting and at different time intervals after glucose load in both the sexes are shown in [Table 5]. It increased after glucose load, attained the peak at 1 h, and decreased below fasting at 2 h. Mean sugar level was higher in girls than in boys, and the difference was significant during fasting (P < 0.05) and at 2 h (P < 0.01). Individually, blood sugar of all the students at all time intervals was within the normal reference range as prescribed by the WHO criteria of diagnosis of diabetes (i.e., fasting <110 mg/dl, 2 h <200 mg/dl) except two girls who showed IFG having blood sugar 114 mg/dl and 117 mg/dl during fasting and their IDRS was only 20 and 30, respectively. Of 102 students, seven students including two boys and five girls did not show change in blood sugar level following glucose load and exhibited flat curve with mean blood sugar level at fasting (95 ± 6.75 mg%), 1 h (97.14 ± 8.9 mg%), 1½ h (92.5 ± 10.1 mg%), and 2 h (90 ± 10.75 mg%) [Figure 4]. Students were divided into four subgroups as per the time at which their blood sugar attained peak value. Peak sugar level in 4 students was during fasting (101.75 ± 1.52 mg/dl) (subgroup 1), in 74 students at 1 h (127.21 ± 20.2 mg/dl) (subgroup 2), in 23 students at 1½ h (118.85 ± 10.7 mg/dl) (subgroup 3), and in 1 female, it was at 2 h (106 mg/dl) (subgroup 4) after glucose load [Figure 5]. Difference in the diabetic history and blood sugar in moderate-risk students and low-risk students was not found to be statistically significant [Table 6] and [Figure 6]. Sugar was not present in the urine of any student at any time interval.
Figure 1: Frequency distribution of students as per their age and IDRS

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Table 2: Number (n) and percentage (%) of students in different IDRS groups

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Figure 2: Percentage of students in low- and moderate-risk groups

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Table 3: - Number (n) and Percentage (%) of students in different risk parameters

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Table 4: Chi-square test for the risk factors for developing diabetes mellitus

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Figure 3: Risk factors for diabetes mellitus type 2 in boys and girls

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Table 5: Blood sugar (mg%) during fasting and at different time intervals after glucose load

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Figure 4: Glucose tolerance test curve

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Figure 5: Peak time for blood sugar in subgroup 1–4

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Table 6: History of diabetes in low and moderate risk students

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Figure 6: Blood sugar (mg%) during fasting and at different time intervals in low- and moderate-risk groups

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  Discussion Top


Diagnosis of NCD due to lack of clear etiological agent is highly dependent on identifying and tackling the risk factor. The risk factors for the development of T2DM such as age, gender, and family history are nonmodifiable factors while others such as smoking, diet, physical activity, and hypertension are modifiable factors.[21] IDRS provides a useful tool to identify the people at risk of developing the disease and to target those individuals for further screening and educating them for healthy lifestyle so that the occurrence of the disease can be delayed or prevented. It also helps to know the gender-based prevalence of the disease, its correlation with the associated factors, and the sex-related transmission of the disease to the future generation. The present study revealed girls to be more prone to the disease in their near future than boys as of 102 dental students, 58% of girls and 7% of boys were at moderate risk of developing the disease. The risk of developing the disease in girls is significantly associated with the lack of exercise (P<0.026) and more abdominal obesity as 51% of girls were not doing any physical activity and abdominal obesity of 12% girls was ≥90 (IDRS 20). In comparison to this, only 29% of boys were not doing physical exercise and waist circumference of no boy was above ≥100 (IDRS 20). It has been concluded that obesity increases insulin level but decreases insulin receptors on the target tissue causing clinical insulin resistance. On the other hand, exercise increases the number of insulin receptors and improves insulin sensitivity.[22] Positive family history of the disease could largely be responsible for the boys to be at risk of developing type 2 DM (P < 0.001). The present study also revealed that the percentage of father suffering from the disease was more than mothers in both the sexes and was more in boys thus indicating that fathers might be responsible for the transmission of disease more to their son. This hypothesis finds support from Gale and Gillespie[23] who revealed that fathers affected with type 1 diabetes mellitus were more likely to transmit the disease than the affected mothers. Acanthosis nigricans is not found in any student supporting the fact that this manifestation is a marker of the disease in children than in the adults.[24] A significant association of the risk of the disease with acanthosis nigricans (P = 0.004) was found in our previous study on school children aged 9–15 years.[25] Significantly higher blood sugar level in girls is attributable to their low basal metabolic rate in girls as compared to boys or less insulin receptor on the target organ due to obesity and physical inactivity.[22] Significantly low fasting blood sugar (P < 0.05) has been observed in females as compared to males of 17–25 years of age both of which undertook more than 3 h of supervised physical exercise daily for 1 year.[26] Vikram et al.[27] observed significantly higher fasting insulin and skinfold thickness in females than males of 14–17 years of age. These findings reveal that high risk of women to NCD is less biological, and more social and physical exertion could be protective for the females against the outcome of the diseases. IFG (>110 mg %) in two girls suggests these girls to be more prone to the disease in their future. Further, diagnosis of IFG in girls and flat curve in seven students with IDRS <60 suggest the importance of doing GTT in all the students rather than in person with IDRS >60 as suggested by Mohan et al.[20] which otherwise would have left undiagnosed with the problem other than diabetes mellitus such as Addison's disease (hypoadrenalism), Simmond's disease (hypopituitarism), hypothyroidism, and Steatorrhea due to impaired glucose absorption. Pickens et al.[28] observed flat curve with 110 mg/dl in 15% of the healthy children of age 1–13 years without the family history of diabetes. Different time for the peak blood sugar level in subgroups 1–4 suggested that normal curves pertaining to these subgroups might be considered pathological if referred to the statistical values of the whole groups. These results are in accordance with Knopf et al.[29] who found peak blood sugar at different time after glucose load in 100 normal nonobese children of 14–15 years of age with negative family history of diabetes. Among those, six exhibited flat curves also.


  Conclusion Top


Previously considered a disease of middle-aged and elderly people, diabetes mellitus, has now escalated in all age groups and is being detected in young adults at alarming rate all over the world. IDRS provided a useful tool for screening the at-risk students for developing T2DM in their future and help identifying the cause of the disease. Girls included in the present study are at more of risk of developing type 2 diabetes mellitus and/or other communicable diseases as evidenced by their high blood sugar, IFG, and flat GTT curve. Pronounced diabetic history in the family put the boys at risk of the T2DM. Fathers might be responsible for the transmission of T2DM more to their sons. Risk of developing the disease in girls would largely be because of their less physical activity and higher IDRS for abdominal obesity. GTT in all the students had unmask the students suffering from the diseases other than diabetes mellitus.

Pitfalls and future recommendations

This was a cross-sectional study with short sample size. The findings of the present study may not be similar in students from other regions of different socioeconomic, racial, and ethnic backgrounds. To our surprise, most of the students were not aware of the basics of the disease. T2DM can, therefore, be prevented to a large extent by creating health awareness in terms of healthy eating habits and exercises. Blood sugar should be estimated in the entire screened person irrespective of their IDRS.

Acknowledgment

We are thankful to the students and the staff of the Department of Biochemistry for their cooperation during the study. We are thankful to Dr Kusum Chopra for the statistical analysis of the data.

Financial support and sponsorship

All the expenses were borne by the institute.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Anand K, Shah B, Yadav K, Singh R, Mathur P, Paul E, et al. Are the urban poor vulnerable to non-communicable diseases? A survey of risk factors for non-communicable diseases in urban slums of Faridabad. Natl Med J India 2007;20:115-20.  Back to cited text no. 1
    
2.
International Diabetes Federation. IDF Diabetes Atlas. 7th ed. International Diabetes Federation; 2016.  Back to cited text no. 2
    
3.
Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047-53.  Back to cited text no. 3
    
4.
Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. Epidemiology of type 2 diabetes: Indian scenario. Indian J Med Res 2007;125:217-30.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
McGrath NM, Parker GN, Dawson P. Early presentation of type 2 diabetes mellitus in young New Zealand Maori. Diabetes Res Clin Pract 1999;43:205-9.  Back to cited text no. 5
    
6.
Ehtisham S, Hattersley AT, Dunger DB, Barrett TG; British Society for Paediatric Endocrinology and Diabetes Clinical Trials Group. First UK survey of paediatric type 2 diabetes and MODY. Arch Dis Child 2004;89:526-9.  Back to cited text no. 6
    
7.
Eppens MC, Craig ME, Jones TW, Silink M, Ong S, Ping YJ. Type 2 diabetes in youth from the Western Pacific region: Glycaemic control, diabetes care and complications. Curr Med Res Opin 2006;22:1013-20.  Back to cited text no. 7
    
8.
Type 2 diabetes in children and adolescents. American Diabetes Association. Pediatrics 2000;105:671-80.  Back to cited text no. 8
    
9.
Fagot-Campagna A, Pettitt DJ, Engelgau MM, Burrows NR, Geiss LS, Valdez R, et al. Type 2 diabetes among North American children and adolescents: An epidemiologic review and a public health perspective. J Pediatr 2000;136:664-72.  Back to cited text no. 9
    
10.
Ahmed SM, Hadi A, Razzaque A, Ashraf A, Juvekar S, Ng N, et al. Clustering of chronic non-communicable disease risk factors among selected Asian populations: levels and determinants. Global Health Action 2009,2:68-75.  Back to cited text no. 10
    
11.
Collins VR, Dowse GK, Toelupe PM, Imo TT, Aloaina FL, Spark RA, et al. Increasing prevalence of NIDDM in the Pacific Island population of Western Samoa over a 13-year period. Diabetes Care 1994;17:288-96.  Back to cited text no. 11
    
12.
Mohan D, Raj D, Shanthirani CS, Datta M, Unwin NC, Kapur A, et al. Awareness and knowledge of diabetes in Chennai – The Chennai urban rural epidemiology study [CURES-9]. J Assoc Physicians India 2005;53:283-7.  Back to cited text no. 12
    
13.
García-Ortiz L, Grandes G, Sánchez-Pérez A, Montoya I, Iglesias-Valiente JA, Recio-Rodríguez JI, et al. Effect on cardiovascular risk of an intervention by family physicians to promote physical exercise among sedentary individuals. Rev Esp Cardiol 2010;63:1244-52.  Back to cited text no. 13
    
14.
Subramani R, Devi U, Shankar V, Karthik S. Assessment of risk of type 2 diabetes mellitus among rural population in Tamil Nadu by using Indian diabetic risk score. Middle East J Sci Res 2014;21:223-5.  Back to cited text no. 14
    
15.
Nóvoa FJ, Boronat M, Saavedra P, Díaz-Cremades JM, Varillas VF, La Roche F, et al. Differences in cardiovascular risk factors, insulin resistance, and insulin secretion in individuals with normal glucose tolerance and in subjects with impaired glucose regulation: The Telde study. Diabetes Care 2005;28:2388-93.  Back to cited text no. 15
    
16.
Petersen JL, McGuire DK. Impaired glucose tolerance and impaired fasting glucose – A review of diagnosis, clinical implications and management. Diab Vasc Dis Res 2005;2:9-15.  Back to cited text no. 16
    
17.
American Diabetes Association. Standards of medical care in diabetes–2011. Diabetes Care 2011;34 Suppl 1:S11-61.  Back to cited text no. 17
    
18.
Mohan V, Deepa M, Deepa R, Shanthirani CS, Farooq S, Ganesan A, et al. Secular trends in the prevalence of diabetes and impaired glucose tolerance in urban South India – The Chennai urban rural epidemiology study (CURES-17). Diabetologia 2006;49:1175-8.  Back to cited text no. 18
    
19.
Nandeshwar S, Jamra V, Pal DK. Indian diabetes risk score for screening of undiagnosed diabetic subjects of Bhopal city. Natl J Community Med 2010;1:176-7.  Back to cited text no. 19
    
20.
Mohan V, Deepa R, Deepa M, Somannavar S, Datta M. A simplified Indian diabetes risk score for screening for undiagnosed diabetic subjects. J Assoc Physicians India 2005;53:759-63.  Back to cited text no. 20
    
21.
Vardhan A, Adhikari Prabha MR, Kotian Shanidhar M, Saxena N, Gupta S, Tripathy A. The value of Indian diabetic risk score as a tool for reducing the risk of diabetes in Indian medical students. J Clin Diagn Res 2011;5:718-20.  Back to cited text no. 21
    
22.
Vernillo AT. Diabetes mellitus: Relevance to dental treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:263-70.  Back to cited text no. 22
    
23.
American Diabetes Association. Classification and diagnosis of diabetes. Section 2. In Standards of medical care in diabetes. Diabetes Care 2017;40 Suppl 1:S11-24.  Back to cited text no. 23
    
24.
Gale EA, Gillespie KM. Diabetes and gender. Diabetologia 2001;44:3-15.  Back to cited text no. 24
    
25.
Mahajan S, Kaur P. Diabetes mellitus type II in school children: Risk evaluation and its genetic correlation. Int J Oral Health Sci 2017;7:4-9.  Back to cited text no. 25
  [Full text]  
26.
Anish TS, Shahulhameed S, Vijayakumar K, Joy TM, Sreelakshmi PR, Kuriakose A. Gender difference in blood pressure, blood sugar, and cholesterol in young adults with comparable routine physical exertion. J Family Med Prim Care 2013;2:200-3.  Back to cited text no. 26
[PUBMED]  [Full text]  
27.
Vikram NK, Misra A, Pandey RM, Luthra K, Bhatt SP. Distribution and cutoff points of fasting insulin in Asian Indian adolescents and their association with metabolic syndrome. J Assoc Physicians India 2008;56:949-54.  Back to cited text no. 27
    
28.
Pickens JM, Burkeholder JN, Womack WN. Oral glucose tolerance test in normal children. Diabetes 1967;16:11-4.  Back to cited text no. 28
    
29.
Knopf CF, Cresto JC, Dujovne IL, Ramos O, de Majo SF. Oral glucose tolerance test in 100 normal children. Acta Diabetol Lat 1977;14:95-103.  Back to cited text no. 29
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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