Journal of Diabetes and Its Complications 18 (2004) 264–270
Prevalence of diabetic complications in fibrocalculous pancreatic
diabetic patients and type 2 diabetic patients
A cross-sectional comparative study
Karuna Kanta Barman, Mahesh Padmanabhan, Gopal Premalatha, Raj Deepa,Mohan Rema, Viswanathan Mohan*
Madras Diabetes Research Foundation, No. 4, Conran Smith Road, Gopalapuram, Chennai 600 086, India
Received 17 January 2003; received in revised form 20 May 2003; accepted 17 June 2003
Abstract
Objective: To determine the prevalence of diabetes-related complications in subjects with fibrocalculous pancreatic diabetes (FCPD) and
compare them with subjects with type 2 diabetes mellitus matched for age, sex, and duration of diabetes. Methods: The study group
comprised of 277 FCPD patients and 277 age, sex, and duration of diabetes-matched type 2 diabetic patients. All the study subjects
underwent a detailed clinical examination, and fasting blood samples were obtained for biochemical studies. Peripheral Doppler was used for
diagnosis of peripheral vascular disease (PVD). Vibratory perception threshold (VPT) was determined using biothesiometry for diagnosis of
neuropathy. Diagnosis of coronary artery disease (CAD) was based on medical history and 12-lead resting ECG. Retinal photographs were
used for diagnosis of retinopathy using a modified version of Early Treatment Diabetic Retinopathy Study (ETDRS) grading system.
Results: FCPD patients had lower body mass index (BMI) (P < .001), systolic blood pressure (P< .0001), diastolic blood pressure
(P < .001), serum cholesterol (P< .001), serum triglyceride (P< .001), and serum creatinine (P < .01) but higher glycosylated hemoglobin
(P < .001) levels compared to patients with type 2 diabetes. Prevalence of CAD was significantly higher among type 2 diabetic patients
(11.9%) compared to FCPD patients (5.1%), P < .003. There was no significant difference in the prevalence of other diabetic complications
between the two study groups (type 2 diabetes vs. FCPD: retinopathy—37.2% vs. 30.1%, PVD—4.3% vs. 4.7%, Neuropathy—25.3% vs.
20.9%, Nephropathy—15.0% vs. 10.1%). Multiple logistic regression analysis revealed the following risk factors for diabetes complications
among type 2 diabetic subjects—retinopathy: BMI (P= .028), duration of diabetes (P< .001), and glycosylated hemoglobin (P= .026);
nephropathy: diastolic blood pressure (P= .016) and glycosylated hemoglobin (P= .040); neuropathy: age (P < .001), duration of diabetes
(P= .003), and glycosylated hemoglobin (P= .001). Among subjects with FCPD, systolic blood pressure (P= .013), glycosylated
hemoglobin (P= .021), and duration of diabetes (P< .001) were associated with retinopathy; BMI (P= .057), glycosylated hemoglobin
(P= .010), and duration of diabetes (P= .024) with nephropathy and age (P= .011) and BMI (P= .010) with neuropathy. Conclusion: The
prevalence of retinopathy, nephropathy, neuropathy, and PVD was similar among FCPD patients and type 2 diabetic patients, but the
prevalence of CAD was lower among FCPD patients.
D 2004 Elsevier Inc. All rights reserved.
Keywords: Fibrocalculous pancreatic diabetes; Type 2 diabetes; Diabetic retinopathy; Coronary artery disease; Peripheral vascular disease; Diabetic
nephropathy
1. Introduction
Fibrocalculous pancreatic diabetes (FCPD) earlier called
‘‘tropical pancreatic diabetes’’ is a unique form of diabetes
1056-8727/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S1056-8727(03)00074-6
* Corresponding author. Tel.: +91-44-2835-9048; fax: +91-44-2835-
0935.
E-mail address: [email protected] (V. Mohan).
URL: http://www.mvdsc.org.
secondary to tropical chronic pancreatitis (TCP) (Balak-
rishnan, 1987; Mohan & Premalatha, 1997). TCP is a
nonalcoholic form of chronic pancreatitis predominantly
affecting young undernourished individuals in developing
countries (Geevarghese 1968; Mohan et al., 1985). Until the
1980s, it was believed that long-term diabetes-related com-
plications were uncommon in all secondary form of diabetes
including FCPD (Bank, Marks, & Vinik, 1975; Maekawa,
Ohneda, Kai, Saito, & Koseki, 1978; Sevel, Bristow, Bank,
K. Kanta Barman et al. / Journal of Diabetes and Its Complications 18 (2004) 264–270 265
Marks, & Jackson, 1971) The basis for this belief was that
in most secondary forms of diabetes, the patients succumb
to the primary illness and do not live long enough to
develop the specific diabetes-related complications, which
typically set in after 10–15 years duration of diabetes.
In earlier studies, we showed that retinopathy, includ-
ing the sight-threatening forms, occurs among FCPD
patients (Rema et al., 1985). Neuropathy (Ramachandran
et al., 1986), left ventricular dysfunction (Ramachandran
et al., 1987), autonomic neuropathy (Mohan, Premalatha,
Padma, Chari, & Pitchumoni, 1996; Mohan, Sastry, &
Premalatha, 1996), and macrovascular disease (Mohan,
Ramachandran, & Viswanathan, 1989) were also observed
in these patients. However, the above studies were either
case reports or were based on small number of patients as
they were published 15–20 years ago (Mohan, Premalatha,
et al., 1996; Mohan et al., 1989; Mohan, Sastry, et al., 1996;
Ramachandran et al., 1986, 1987; Rema et al., 1985). FCPD
is an uncommon form of diabetes and constitutes only about
0.5–1% of all diabetic patients even at our centre, which is a
referral centre for diabetes in general and FCPD in particular
(Mohan & Alberti, 1991).
Furthermore, there is no data on the prevalence of
ischemic heart disease, peripheral vascular disease (PVD),
or nephropathy in FCPD and virtually none comparing the
various complications in matched subjects with type 2
diabetes. In this paper, we report on a study of long-term
complications of diabetes in a large group of FCPD patients
and compare them with age-, sex-, and duration-matched
type 2 diabetic patients. To our knowledge, this is the first
comprehensive study of diabetes-related complications in
FCPD patients.
2. Methods and materials
The study group comprised of 277 consecutive FCPD
patients who were followed for a minimum period of 5
years at the M.V. Diabetes Specialities Centre, at Chennai
(formerly Madras) in southern India. An equal number of
type 2 diabetic patients matched for age, sex, and duration
of diabetes registered at our centre were included for
the study.
Diagnosis of FCPD was made based on the criteria
described earlier (Mohan & Alberti, 1991; Mohan & Pre-
malatha, 1997). Basically, patients classified as FCPD had
diabetes as defined by the World Health Organization
(WHO) consulting group criteria (WHO, 1999) and un-
equivocal evidence of chronic pancreatitis, including history
of recurrent abdominal pain, pancreatic calculi on plain
abdominal X-ray, ultrasound evidence of dilated pancreatic
ducts, and low fecal chymotrypsin levels (<5.8 units/g)
(Mohan, Ramachandran, et al., 1989; Mohan, Snehalatha,
et al., 1989).
Type 2 diabetes was diagnosed according to the WHO
consultation group criteria (WHO, 1999). Patients with type
2 diabetes (who constitute over 90% of all patients at our
centre) were selected from the diabetes electronic medical
record system at our centre to match the FCPD patients for
age, sex, and duration of diabetes. Selection and matching
were done by a nonmedical person to eliminate bias in
patient selection.
A detailed clinical history was taken in all patients
including age at onset, previous history of angina/infarc-
tion, and hospitalization. All patients underwent a thorough
clinical examination, which included recording of height
and weight, blood pressure measurement, and elicitation of
ankle and knee jerks. Height was measured with a tape to
the nearest centimeter. Subjects were requested to stand
upright without shoes with back against the wall, heels
together, and eyes directed forward. Weight was measured
with an electronic balance (ATCO, Chennai, India), which
was kept on a firm horizontal surface. The scale was
checked every day and calibration was done with
‘‘known’’ weights. Weight was recorded to the nearest
0.1 kg. Body mass index (BMI) was calculated using the
formula weight (kg)/height (m2). Blood pressure was
recorded in the sitting position in the right arm to the
nearest 2 mm Hg with a mercury sphygmomanometer
(Diamond, Pune, India).
Biochemical parameters included fasting plasma glucose
estimations, glycosylated hemoglobin, a complete lipid pro-
file, and serum creatinine. All biochemical studies were done
using Ciba Corning Express Plus autoanalyzer (Medfield,
USA). Plasma glucose (glucose oxidase method), serum
cholesterol (CHOD-PAP method), serum triglycerides
(GPO-PAP method), and serum creatinine (modified kinetic
method by Jaffe) were estimated using kits supplied by
Boehringer Mannheim (Germany). Glycosylated hemoglo-
bin (HbA1c) was estimated by the high-pressure liquid
chromatography (HPLC) method using the Variant machine
(BIORAD, California). Urine samples were collected after an
overnight fast. Spot urine protein was estimated using sulfo-
salicylic acid method, and protein/creatinine ratio was calcu-
lated as described earlier (Varley, Gowenlock, & Bell, 1980).
Microalbuminuria was estimated using commercially avail-
able immunoturbidometric assay kits from Randox (Randox,
UK) on Hitachi 912 Auto Analyser (Hitachi, Germany). The
urine sample was added to a buffer containing antibody
specific for human serum albumin. The absorbance of the
resulting turbid solution is proportional to the concentration
of albumin in the sample solution. By constructing a standard
curve from the absorbances of the standards, the albumin
concentration in the sample can be determined. The mean
inter- and intra-assay coefficients of variation were 3.4% and
2.4%, respectively. If microalbuminuria or proteinuria were
present, they were confirmed by another urine sample
obtained at least a month later. Only those with persistent
microalbuminuria or proteinuria on at least on two occasions
were considered to have this condition.
Peripheral Doppler studies were done using Vas Lab
Doppler machine (Kody Labs, Madras). The dorsalis pedis
Table 1
Clinical and biochemical characteristics of the study population
Variable
Type 2 diabetes
(n= 277)
FCPD
(n= 277)
Males n (%) 197 (71%) 197 (71%)
K. Kanta Barman et al. / Journal of Diabetes and Its Complications 18 (2004) 264–270266
(DP) and posterior tibial (PT) pressures were measured by
inflating the BP cuff just above the ankle on both lower
limbs. The average of DP and PT was taken as ankle
pressure, and similarly brachial pressure was measured in
both upper limbs. The ankle/brachial index (ABI) was
calculated from ankle and brachial pressures. A resting
12-lead Electrocardiogram was done in all patients.
Biothesiometry studies were performed by a single
observer in a standardized fashion using a Biothesiometer
(Biomedical Instrument, Newbury, OH, USA), by measur-
ing vibratory perception threshold (VPT) on the great toes.
Subjects were requested to remove their shoes and socks
and lie supine on a couch for at least 5 min before the
measurements were made. The foot was kept warm during
the measurement and as the room was air conditioned, the
temperature of the room was around 25 jC. The biothesi-
ometer tactor, which vibrates at 100 Hz with an amplitude
proportional to the square of the applied voltage, was
applied perpendicular to the test site with a constant and
firm pressure. Subjects were initially familiarized with the
sensation by holding the tactor against the distal palmar
surface. VPT was then measured at the distal plantar surface
of the right great toe. The voltage was slowly increased at
the rate of 1 V/s, and the VPT was defined as the moment
when the subject indicated they first felt the vibration. The
voltage at which this occurred was recorded. Three further
cycles of readings at each site were performed, recorded,
and the mean calculated.
A detailed retinal examination was done by a retinal
specialist after complete dilatation of eyes using both
phenylephrine (10%) and tropicamide (1%). Retinal exam-
ination included indirect and direct ophthalmoscopy. In
all study subjects, retinal photography was done as de-
scribed earlier (Rema, Ponnaiya, & Mohan, 1996). Using
a Topcon VT-50 camera of three fields in both eyes, 45jphotographs were taken. The three photographic fields
selected were (1) one stereo pair of the posterior pole
centered on the fovea to show the macula and optic disc,
(2) one temporal field whose nasal edge touched the
macula, and (3) the third field was centered as far as
possible nasally to the optic disc with the disc on the
edge of the field. The photographs were graded by MR
using a modified version of the Early Treatment Diabetic
Retinopathy Study (ETDRS) grading system (ETDRS
Group, 1991). The study was approved by the institutional
ethics committee.
Age (years) 48F 10 47F 11Duration of diabetes (years) 11F 7 11F10
BMI (kg/m2) 24.8F 3.7 19.0F 3.3*
Systolic BP (mm Hg) 135F 15 124F 17*
Diastolic BP (mm Hg) 83F 7 80F 8*
Fasting plasma glucose (mg/dl) 202F 97 211F 82
Glycosylated hemoglobin (%) 9.6F 2.2 10.7F 2.5*
Serum cholesterol (mg/dl) 209F 50 174F 44*
Serum triglycerides (mg/dl) 202F 140 123F 78*
HDL cholesterol (mg/dl) 42F 10 42F 12
Serum creatinine (mg/dl) 0.98F 0.7 0.8F 0.3*
* P < .001 compared to type 2 diabetes.
3. Definitions
Nephropathy was defined as proteinuria z500 mg/day in
the absence of nondiabetic proteinuria. Nondiabetic protein-
uria was defined as proteinuria in the presence due to
urinary tract infection or in the absence of retinopathy
particularly in those with short duration of diabetes. Micro-
albuminuria was diagnosed if the albumin levels estimated
by the albumin creatinine ratio (ACR) method exceeded
30 mg/g of creatinine.
Coronary Artery Disease (CAD) was diagnosed if the
subject had either myocardial infarction or ischemia. Myo-
cardial infarction was diagnosed if the subject had any
previous hospital records documenting treatment for myo-
cardial infarction and presence of pathological Q waves on
ECG suggestive of recent or past myocardial infarction.
Myocardial ischemia was diagnosed if there was unequiv-
ocal ST/T changes in resting ECG suggestive of ischemia in
the presence of exertional angina.
PVD was diagnosed if the ABI was less than 0.9 (Pre-
malatha, Shanthirani, Deepa, Markowitz, & Mohan, 2000).
Neuropathy was diagnosed if ankle jerks were absent
and/or the vibration perception threshold (VPT) at the bony
prominence of the right big toe was greater than 25 (Young,
Breddy, Veves, & Boulton, 1994).
Retinopathy: The retinal photographs were assessed in
comparison to the ETDRS standard photographs for severity
of retinopathy as described earlier (ETDRS Group, 1991).
Briefly, level 10 represents no retinopathy, level 20 through
50 nonproliferative diabetic retinopathy, and level 60 pro-
liferative retinopathy.
3.1. Statistical analysis
Statistical analysis was done using the SPSS program
(version 4.0.1) on an IBM PC compatible computer. Stu-
dent’s t test was used to compare means between groups.
Chi-square test was used to compare proportions. P < .05
was considered to be statistically significant. Multiple
logistic regression analysis was carried out using diabetic
complications as the dependant variable, and age, systolic
BP, diastolic BP, BMI, duration of diabetes, glycosylated
hemoglobin, serum cholesterol, and serum triglycerides
were taken as the independent variables. Multiple logistic
regression analysis was not performed for PVD and
Table 2
Prevalence of diabetes complications among the study groups
Complication
Type 2
diabetes
(n= 277)
FCPD
(n= 277)
P
value
CAD
Infarction n (%) 15 (5.4%) 6 (2.2%) .08
Ischemia 18 (6.5%) 7 (2.5%) .04
Overall 33 (11.9%) 13 (5.1%) .003
PVD n (%) 12 (4.3%) 13 (4.7%) ns
Retinopathy n (%)
Nonproliferative diabetic retinopathy 87 (31.4%) 90 (32.9%) ns
Proliferative diabetic retinopathy 16 (5.8%) 10 (3.6%)
Overall 103 (37.2%) 100 (36.1%)
Neuropathy n (%) 70 (25.3%) 58 (20.9%) ns
Nephropathy n (%) 42 (15.0%) 30 (10.1%) ns
Microalbuminuria n (%) 65 (23.5%) 73 (26.4%) ns
K. Kanta Barman et al. / Journal of Diabetes and Its Complications 18 (2004) 264–270 267
CAD owing to small numbers of study subjects with
these complications.
4. Results
4.1. Clinical features of the study population
Table 1 shows the clinical and biochemical character-
istics of study population. Seventy-one percent of the study
population were males. The FCPD patients had lower BMI
(P < .001), systolic blood pressure (P < .001), diastolic
blood pressure (P < .001), serum cholesterol (P < .001),
serum triglyceride levels (P < .001), and serum creatinine
(P < .01) but higher glycosylated hemoglobin (P < .001)
levels compared to patients with type 2 diabetes. There
was no significant difference in fasting plasma glucose and
HDL cholesterol levels among the study groups.
Table 3
Prevalence of complications among subjects with DM secondary to chronic panc
References n Country Age
Duration of
diabetes HbA1c
Okuno et al.,
1990
649 DM=296 Japan – < 10 years
in 80% of
patients
–
Levitt et al.,
1995
30 South
Africa
48F 1.9 8 (1–33) 10.4%
(6.2–23.
Gullo et al.,
1990
40 Italy 49.2 + 7.9 7.9F 5.5 8.8F 1
Larsen et al.,
1978
25 Denmark 39F 11 10F 6 7.4 + 1.
Briani et al.,
1988
86 Italy 52F 9.9 12.4 + 6.8 7.3F 1
Present
study
277 India 47F 11 11F10 10.7F 2
CAD—Coronary artery disease, PVD—peripheral vascular disease, CAP—chro
chronic pancreatitis, CP—chronic pancreatitis, FCPD—fibrocalculous pancreatic
4.2. Prevalence of macrovascular complications
The overall prevalence of CAD was significantly higher
among type 2 diabetic subjects compared to FCPD
patients (P < .003). The prevalence of PVD was low in
both type 2 diabetic subjects (4.3%) and FCPD (4.7%)
and there was no statistical difference between the two
groups (Table 2).
4.3. Prevalence of microvascular complications
There was no significant difference in the prevalence of
retinopathy (both nonproliferative and proliferative), neu-
ropathy, nephropathy, or microalbuminuria between the
FCPD and type 2 diabetic patients (Table 2).
Multiple logistic regression analysis revealed glycosy-
lated hemoglobin [odds ratio (OR) = 1.19, P= .026], dura-
tion of diabetes (OR = 1.20, P < .001), and BMI (OR = 0.90,
P= .028) to be associated with retinopathy in type 2 diabetic
patients. Among subjects with FCPD, in addition to dura-
tion of diabetes (OR = 1.21, P < .001) and glycosylated
hemoglobin (OR = 1.21, P= .021), systolic blood pressure
(OR = 1.04, P= .013) also showed a strong association.
The risk factors for nephropathy among type 2 diabetic
subjects were glycosylated hemoglobin (OR = 1.25,
P= .040) and diastolic blood pressure (OR = 1.07, P=
.016). In subjects with FCPD, glycosylated hemoglobin
(OR = 1.31, P= .010) and duration of diabetes (OR = 1.10,
P= .024) were the risk factors for nephropathy.
Age showed a strong association with neuropathy in both
FCPD (OR= 1.05, P= .011) and type 2 diabetic (OR = 1.08,
P < .001) subjects. In addition to age in type 2 diabetes,
duration of diabetes (OR= 1.10, P= .003) and glycosylated
hemoglobin (OR = 1.36, P= .001) were associated with
neuropathy. BMI (OR = 0.86, P= .010) showed a negative
association with neuropathy in FCPD patients.
reatitis
Retinopathy
(%)
Nephropathy
(%)
Neuropathy
(%)
CAD
(%)
PVD
(%)
Type of
diabetes
33 21.0 36.3 – – CAP,
CCP,
OCP
4)
33.3 23 – – – CAP
.9 47.5 – – – – CP
2 20 – 18.5 – – Insulin
requiring
CP
.2 37 23.8 – – – CP
.5 36.1 10.1 20.9 5.8 4.7 FCPD
nic alcoholic pancreatitis, CCP—chronic calcific pancreatitis, OCP—other
diabetes.
K. Kanta Barman et al. / Journal of Diabetes and Its Complications 18 (2004) 264–270268
Table 3 compares the prevalence of micro- and macro-
angiopathy among subjects with chronic pancreatitis in
different studies. The results reveal that the prevalence
of retinopathy is similar in all the studies, while the pre-
valence of nephropathy is lower in our patients compared
to other studies.
5. Discussion
This study reports on micro- and macrovascular compli-
cations in FCPD, a unique form of diabetes secondary to
TCP. There are few reports in the world literature, which
have looked at the diabetic complications in patients sec-
ondary to chronic pancreatitis (Briani et al., 1988; Gullo,
Parenti, Monti, Pezzilli, & Barbara, 1990; Larsen et al.,
1978; Levitt et al., 1995; Okuno, Oki, Kawakami, Doi, &
Baba, 1990) and none that have reported on all the compli-
cations in FCPD patients. TCP differs from temperate zone
pancreatitis in several aspects: The onset of the disease is at
younger age, alcoholism is absent by definition, and the
disease follows a more accelerated course to reach the end
points, namely, calculi formation, diabetes, and steatorrhoea
(Mohan & Alberti, 1991). In addition, higher prevalence of
pancreatic cancer in FCPD patients has been reported (Chari
et al., 1994).
Type 2 diabetic subjects are known to have 2–4 times
higher risk for CAD compared to nondiabetic subjects
(Haffner, 2000). It has been well documented that Asian
Indians have very high rates of premature CAD (McKeigue,
1992) and diabetes (King, Aubert, & Herman, 1998).
Recently in a population-based study, we reported the
prevalence of CAD among type 2 diabetic patients to be
21.4% (Mohan, Deepa, Rani, & Premalatha, 2001; Mohan,
Shanthirani et al., 2001). In the present study, the preva-
lence of CAD among type 2 diabetic patients (11.9%) was
significantly higher than FCPD patients (5.8%). The lower
prevalence of CAD among FCPD patients could be attrib-
uted to several factors: lower BMI, blood pressure, serum
cholesterol, and triglyceride levels (Sevel et al., 1971).
Moreover, type 2 diabetes is a component of the insulin
resistance syndrome that predisposes an individual to CAD
(Reaven, 1993), while FCPD being a secondary form of
diabetes has only hyperglycemia (Mohan & Alberti, 1991),
and other components of the insulin resistance syndrome
are absent.
We have earlier shown that in contrast to CAD, PVD is
less common among Indians (Premalatha et al., 2000). In
this study, the prevalence of PVD is low among both FCPD
and type 2 diabetic patients without any significant differ-
ence between the two groups. The reason for this so-called
‘‘Indian paradox’’ of having low rates of PVD despite high
rates of CAD (Mohan, Deepa, et al., 2001; Mohan, Pre-
malatha, & Sastry, 1995a, 1995b; Mohan, Shanthirani, et al.,
2001; Premalatha et al., 2000) is unclear but may be
explained by the difference in the risk factors predisposing
to CAD and PVD. It could also possibly be due to lower
smoking rates in our population (Mohan, Deepa, et al.,
2001; Mohan, Shanthirani, et al., 2001). It has been
reported that earlier Lp(a) levels are higher in Indians (Enas,
2001). This could also explain, at least partly, the higher
susceptibility to CAD in our type 2 diabetic patients
(Mohan et al., 1998).
Retinopathy is considered the most specific vascular
complication of diabetes. The prevalence of retinopathy in
FCPD patients (36.1%) was similar to that observed among
type 2 diabetic patients (37.2%). The results are in agree-
ment with earlier studies on type 2 diabetic subjects from
South India (Rema et al., 1996) and also studies on
pancreatic diabetes from Japan (Okuno et al., 1990), South
Africa (Levitt et al., 1995), and Italy (Briani et al., 1988;
Gullo et al., 1990). The risk factors for retinopathy in this
study population were the duration of diabetes and glyco-
sylated hemoglobin.
This study reports on the prevalence of nephropathy
among FCPD patients for the first time. The prevalence
was lower compared to type 2 diabetic patients (10.1% vs.
15.0%), but the difference did not reach statistical signifi-
cance. Occurrence of diabetic nephropathy has been
reported in earlier studies of secondary diabetes (Doyle,
Balcerzak, & Jeffrey, 1964; Duncan, MacFarlane, & Rob-
son, 1958; Ireland, Patnaik, & Duncan, 1967; Shapiro &
Smith, 1966) and in diabetes secondary to other forms of
chronic pancreatitis (Gullo et al., 1990; Levitt et al., 1995;
Okuno et al., 1990). An earlier study had reported diabetic
nephropathy to be one of the causes of death in FCPD
patients (Mohan, Premalatha, et al., 1996; Mohan, Sastry,
et al., 1996).
The prevalence of neuropathy varies based on the
criteria used for diagnosis and specifically on the method-
ology used to detect the neuropathy. The prevalence of
neuropathy varies from 10% to 90% in different studies,
with the highest prevalence rates being reported where
nerve conduction velocity is measured (Lehtinen, Uusi-
topa, Siitonen, & Pyorala, 1989; Maser et al., 1989;
Mohan, Premalatha, et al., 1996; Mohan, Sastry, et al.,
1996; Neil, Thompson, John, McCarthy, & Mann, 1989;
Young, Boulton, MacLeod, Williams, & Sonksen, 1993).
Biothesiometry is often used for screening of neuropathy
particularly in epidemiological studies because of its sim-
plicity, low cost, and its high specificity (Boulton, Knight,
Drury, & Ward, 1985). However, it only measures large
fiber neuropathy and has a low sensitivity. Using biothe-
siometry and ankle jerks, the prevalence of neuropathy in
FCPD patients was found to be 20.9% compared to 25.3%
among type 2 diabetic patients. In an earlier study, we
have reported that 22.5% of FCPD patients have autonom-
ic neuropathy compared to 35.7% of patients with type 2
diabetes (Mohan, Premalatha, et al., 1996; Mohan, Sastry,
et al., 1996). Another study on South Indian FCPD
patients reported that 21.7% had cardiac autonomic neu-
ropathy (Govindan & Das, 1996).
K. Kanta Barman et al. / Journal of Diabetes and Its Complications 18 (2004) 264–270 269
It is difficult to compare the prevalence of various
complications among patients with different forms of chron-
ic pancreatitis because of the following: (i) differences in
sample sizes, (ii) varying definitions of chronic pancreatitis,
(iii) different definition of complications, and (iv) varying
durations of diabetes and severity of hyperglycemia in
different studies. Despite these differences, it is striking that
the overall prevalence of microvascular complications,
namely, retinopathy and nephropathy, seems to be similar
in most studies of diabetes secondary to chronic pancreatitis
of different etiologies, confirming that these two complica-
tions appear to be a consequence of hyperglycemia.
There are not many studies on the prevalence of macro-
angiopathy among diabetes secondary to chronic pancreati-
tis. The only study that showed a high prevalence of PVD
(25.3%) among chronic pancreatic diabetic subjects had
used segmental blood pressure assessment, which is prob-
ably more sensitive than ankle brachial index (ABI) (Ziegler
et al., 1994). We have also recently shown that the sensi-
tivity of the ABI is much lower than duplex Doppler
screening, which picks up silent plaques in the peripheral
arteries even in those with normal ABI (Premalatha, Rav-
ikumar, Sanjay, Deepa, & Mohan, 2002).
This study has several limitations. Firstly, it is clinic
based, and hence referral bias could have affected the
results. Secondly, it is a cross-sectional study, which has
its own limitations. Thirdly, the duration of diabetes is based
on the known duration. Both FCPD and type 2 diabetes
have an insidious onset, and hence patients in both groups
could have had a variable period of undiagnosed diabetes.
However, the careful matching for age, sex, and duration of
diabetes would have eliminated some of these differences.
In summary, diabetes-related complications do occur in
FCPD, and this underscores the need to screen for com-
plications right from the time of diagnosis of diabetes and
also to aim for good control of hyperglycemia in this group
of patients.
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