Thai Journal of Physiological Sciences Vol. 21 No. 2 Oct. 2008-Mar.

2009

Original Article

A Correlative Study of BMI and IOP in Diabetic and Nondiabetic South Indian Population Sheila Pai1, Shobha Pai2, Ashwin Pai3, Ramasamy C1, Rekha D Kini1

ABSTRACT

Diabetes is a risk factor for POAG (primary open angle glaucoma), a second leading cause for legal

blindness. Elevated intraocular pressure, a main risk factor for glaucoma, is a concern in diabetics. IOP (Intraocular pressure) has been associated with various systemic, familial, anthropometric and demographic factors by several studies. There has been no study relating these factors in diabetes in particular. This study was undertaken to find out the effect of BMI on intraocular pressure in subjects with diabetes. 101 subjects, 65 diabetics and 36 nondiabetics, aged 40-70 yrs attending diabetes check facility at KMC (Kasturba Medical College) hospital were included. Hypertensives, known diabetics undergoing treatment, glaucoma, or receiving IOP-lowering treatment, ocular diseases were excluded. Participants underwent standardized examinations including applanation tonometry and anthropometric indices. Intraocular pressure (IOP) was assessed in both eyes using Goldmann applanation tonometer and recorded as the average of three measurements. Subjects height, weight in kilograms was measured. BMI was calculated as weight in kilogram / (height in m)2. Statistical analysis was done by Students t-test. The mean IOP (19.71.64 mmHg) in diabetics was higher than the nondiabetics (p<0.0001). The mean BMI (23.133.05) in diabetics was higher than nondiabetics (p<0.003). A significant trend in increase in IOP to increase in BMI was observed when different grades of BMI were compared. A significant correlation was found between BMI and IOP (p<0.0001). The diabetics have higher IOP and higher BMI. The BMI is associated with increased IOP in subjects with diabetes. Key words: Diabetes, Body Mass Index, Intraocular Pressure, glaucoma

INTRODUCTION
Diabetes is one of the worlds greatest health challenges and its prevalence appears to be increasing. India is already a world leader, with over 35 million people

1 2

Dept.of Physiology, Kasturba Medical college, Mangalore Dept. of Ophthalmology, KMC, Mangalore. 3 Dept. of Ophthalmology, KMC, Mangalore. Address for Correspondence Dr. Sheila R Pai Department of Physiology, Center for Basic Sciences Kasturba Medical college, Bejai, Mangalore- 575004, Karnataka, India. Email: drsheilapai@yahoo.co.in Phone number:91 9448109840 Fax: 91 824 2428 183

with diabetes - a number that is predicted to increase to around 80 million by 2030. Diabetes mellitus is an important ocular risk factor. People with diabetes are 25 times more likely to become legally blind than those without diabetes. Diabetes as a pre-existing condition also increases the risk of glaucoma, the second leading cause of visual impairment and blindness. Many studies have suggested an increase in the relative risk of people with diabetes mellitus to present ocular hypertension during the clinical course of the disease favoring the emergence of open angle glaucoma1,2, Evidence of an association between primary open-angle glaucoma and diabetes is conflicting. The potential association between diabetes and pri-

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Sheila Pai, et al.

mary open angle glaucoma (POAG) has been studied by many groups3, with most studies supporting a weak association between the two diseases4,5. Some have failed to confirm an association between diabetes mellitus and primary open angle glaucoma and ocular hypertension.4 Elevated IOP is a major significant risk factor for the development of POAG.5 Although the link between diabetes and POAG is not clearly understood, data show that diabetes may increase the risk of POAG by elevating IOP. Elevated IOP is a concern in people with diabetes as it is one of the main risk factors for glaucoma. IOP is the only modifiable risk factor. It needs to be assessed concurrently with other risk factors. Several studies have reported factors including 5-8 age , sex4, African ancestry4, blood pressure11, BMI10, alcohol, smoking, myopia and family history of glaucoma to be positively associated with elevated IOP in general population. Till date there are no evidences correlating the effect of these parameters with elevated IOP in diabetes. Hence this study was undertaken to evaluate the effects of body mass index on elevated intraocular pressure (IOP) in diabetes, in South Indian population who are, ethnically, prone to develop diabetes.

assessed in both eyes using Goldmann applanation tonometer and recorded as the average of three measurements. Subjects height, weight in kilograms, blood pressure and pulse rate were measured. BMI was calculated as weight in kilogram / (height in m)2.

Statistical analysis
All data are expressed as means standard deviations. Statistical analysis was done by Students t-test and Pearson correlation coefficients. The p-values less than 0.05 were considered statistically significant

RESULTS
Selected characteristics of the study are shown in Table 1. When IOP was compared between subjects with diabetes and those without diabetes, it was found the diabetics exhibited a statistically significant higher IOP compared to their counter parts (p<0.0001). Comparison of BMI between diabetics and nondiabetics showed a significant higher BMI in the diabetics to the nondiabetics (p<0.003). To evaluate the relation between BMI and IOP, The subjects were categorized into 3 groups (group I with BMI<20, group II with BMI 20-25 and group III with BMI>25). In diabetics, IOP showed a statistically significant increase with BMI (Table 2). There was significant increase in IOP (p<0.01) when group II was compared with group I. Similarly, IOP was also significantly high (p<0.01) when group III was compared with group I. A significant high IOP (p<0.05) was also observed when compared between group II and group III. When the IOP in diabetic males and females were compared no statistically significant difference was found in all the 3 groups. Among the diabetic male subjects a statistically significant difference in IOP was seen only between group III and group II (p<0.05) and group III and group I (p<0.05). Among the diabetic female sub-

MATERIAL AND METHODS

101 subjects, aged between 40-70 years out of which 65 were diabetics and 36 nondiabetics (control group) who underwent comprehensive medical checkup in a diabetes check facility at KMC hospital, Mangalore were included in our study after obtaining their consent. Exclusion criteria included hypertensive, known diabetics undergoing treatment, glaucoma or receiving IOPlowering treatment, ocular diseases. Participants underwent standardized examinations including applanation tonometry, measurement of blood pressure, and anthropometric indices, Ocular examinations including visual acuity and funduscopy. Intraocular pressure (IOP) was

Table 1. Comparison of variables between Diabetics and Nondiabetics Variables Diabetics (n=65) mean SD 19.7 1.64 23.13 3.05 Non Diabetics (n=36) mean SD 18.0 1.68 21.31 2.37

p value

IOP (mmHg) BMI

p<0.0001 p<0.003

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Table 2. Correlation between BMI and IOP in diabetics BMI Male Group I BMI <20 Group II BMI 20-25 Group III BMI >25
**p<0.01, Gr II & Gr III versus Gr I

IOP (mmHg) mean SD Female (n=3) 16.672.31 (n=24) 19.581.44 (n=8) 20.251.28 Total (n=5) 17.62.19 (n=45) 19.61. ** (n=15) 20.531.41**,

(n=2) 180 (n=21) 19.431.57 (n=7) 20.861.57*

P< 0.05, Gr III versus Gr II

*P<0.05, Gr III versus Gr II

P<0.05, Gr III versus Gr I P< 0.01, Gr II versus Gr I P<0.01, Gr III versus Gr I

Table 3. Correlation between BMI and IOP in diabetics and nondiabetics IOP (mmHg) mean SD Diabetics Group I BMI <20 Group II BMI 20-25 Group III BMI >25
**p<0.01, D.Gr II versus ND.Gr II ***p<0.001, D.Gr III versus ND.Gr III

BMI

tion was more significant in diabetic females (p<0.001) than in males (p<0.01). Contrary to this, in nondiabetics the correlation was not significant.

Nondiabetics (n=10) 17.051.80 NS (n=20) 18.551.54** (n=6) 17.51.0***

DISCUSSION
Diabetes mellitus (DM) is a risk factor for openangle glaucoma, although the mechanistic interrelationship of the two is debatable. Newly diagnosed diabetes mellitus and high levels of blood glucose are associated with elevated IOP and high-tension glaucoma. The development of glaucomatous optic nerve damage, based on visual field loss and/or optic disc findings, is more likely to be associated with high intraocular pressure (IOP).3 Diabetics seem to have higher intraocular pressures and may have a higher rate of glaucoma than those without diabetes4. The mean intraocular pressure in maturity onset diabetes was 19.26 mm of Hg which was higher than the normal mean intraocular pressure reported in the general population by Becker was 16.1 mm of Hg18. Klein et al8 and others1,3,4,8,17,20 have observed a slightly higher mean IOP among the diabetic participants than the no diabetic comparison group. The finding in the present study clearly indicates a higher mean IOP (19.7 1.64 mmHg) in diabetics as compared to the nondiabetic population (18.0 1.64 mmHg) and is consistent with these studies. However it is not in agreement with the reports of

(n=5) 17.62.19 (n=45) 19.61. 0 (n=15) 20.531.41

NS= Not significant, D.Gr I versus ND.Gr I

jects, a significant increase in IOP was observed when group II was compared with group I (p<0.01). There was a significant increase in IOP when group III was compared with group I (p<0.01). When IOP was related to BMI and compared between subjects with diabetes and without diabetes (Table 3), in group I there was no significance observed. The IOP in group II and group III showed a significant increase (p<0.01 and p<0.001) respectively in diabetics compared to nondiabetics. Correlative analysis showed a very statistically significant association between BMI and IOP in diabetic subjects (p<0.0001). The correla-

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Sheila Pai, et al.

Palomar16, Armaly and Baloglour17 who observed low IOP in diabetics as compared to nondiabetics. A few early studies found no evidence of increased pressure in diabetes13-15 and one study found evidence of lower pressures16. Although etiologic links between IOP and diabetes remain unclear, several hypotheses have been advanced. Genetic factors are likely to play a role. There is also evidence that diabetes-related autonomic dysfunction is likely to increase IOP. A cellular basis for the higher IOP in diabetes was related to accumulation of fibronectin in trabecular meshwork tissue22. When BMI was evaluated, it was found that the mean BMI in diabetics was 23.13 3.05 and the mean BMI was 21.31 2.37 in nondiabetics. The BMI was significantly higher in diabetics than those without diabetes (p<0.003). A trend of increasing IOP with increasing BMI was observed in diabetics which was statistically significant. BMI was positively correlated with increasing IOP (p<0.0001 ) in diabetic subjects. A significant association was also observed in both sexes. In non diabetics there was no significance found between BMI and IOP. Obesity is an established determinant of diabetes which is associated with elevated IOP. The relationship between an increased BMI and IOP has been well established. The Barbados Eye Study found larger body size, as measured by BMI, was associated with increasing IOP3. Although obesity is related to diabetes, the association between BMI and IOP was an independent factor (Barbados Eye Study). A relation between obesity and IOP was also found in studies by Shiose et al.6,7, Klein et al.8 and Bulpitt et al.19 in their Japanese, American and British populations respectively. An association between obesity and IOP was also found in the Japanese population by Keiko Mori4. Moreover, some epidemiological studies examined the relationship between obesity and IOP cross-sectionally and have found that obesity was an independent risk factor for increase in IOP, even when considered with age, systolic blood pressure (SBP) and diastolic blood pressure (DBP).3,5,8,11 The results in this study are in agreement with the above studies, suggesting a strong positive association between BMI and IOP in diabetics. In the nondiabetics the correlation was not so significant. This suggests that BMI has an additive effect on the raised IOP along with hyperglycemia in diabetic subjects.

The basis for the elevated IOP among persons with high BMI in diabetics is less certain. Several mechanisms could underlie an effect of overweight on IOP. Mechanically, it has been suggested that intraorbital pressure due to excess fat may cause an increase in episcleral venous pressure and a consequent decrease in outflow facility10. Both increased insulin secretion and insulin resistance result from obesity. Sang Woo Oh et al20 suggest that insulin resistance might contribute to the association between IOP and obesity. High glucose levels in the aqueous humor of diabetics may trigger excess fibronectin synthesis, leading to excessive accumulation of this in the trabecular meshwork and contribute to development of higher IOP in diabetics by increasing outflow resistance21,22. Obesity increases blood viscosity through increasing red cell count, hemoglobin and hematocrit and consequently increased outflow resistance of episcleral veins results. Further, obesity is also a risk factor for hypertension. Elevated BP increases IOP by increasing ciliary artery pressure and ultrafiltration of aqueous humor. Because corticosteroid secretion is increased in obese persons, this may also explain this relationship10. So, by various combined effects, obesity increases resistance in outflow facility, which, in turn, may contribute to the development of increased IOP in the diabetics. The study showed a significantly higher IOP in diabetics than the nondiabetics. The data showed an increase in IOP with increasing BMI and there was a positive correlation between this variable and IOP in diabetics. It indicates that the increase in BMI appears to be a positive additive determinant of raised IOP in diabetics. Because BMI correlates with raised IOP in diabetics and it also predicts the future increase in IOP independently from the baseline IOP, excess weight is undoubtedly is one of the most important risk factors for elevated IOP in diabetics. Weight control is the most natural primary intervention method in the inter-relation of obesity, diabetes and elevated IOP and in the prevention of subsequent development of POAG in diabetics.

REFERENCES 1. Mitchell P, Smith W, Chey T, et al. Open-angle glaucoma and diabetes: the Blue Mountains eye study, Australia. Ophthalmology 1997; 104(4):712-8.

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2. Klein BEK, Klein R, Moss SE. Intraocular pressure in diabetic persons. Ophthalmology 1984; 91:1356-60. 3. M Cristina Leske, Suh-Yuh Wu, Anselm Hennis, et al. Risk Factors for Incident Open-angle Glaucoma The Barbados Eye Studies. Ophthalmology 2007; 13:1762-3. 4. Tielsch JM, Katz J, Quigley HA, et al. Diabetes, intra-ocular pressure, and primary open-angle glaucoma in the Baltimore eye survey. Ophthalmology 1995; 102:48-53. 5. L. M. Weih, B. N. Mukesh, C. A. McCarty, et al. Taylor. Association of Demographic, Familial, Medical, and Ocular Factors With Intraocular Pressure Arch Ophthalmol 2001; 119(6):875-80. 6. Shiose Y. The aging effect on intraocular pressure in an apparently normal population. Arch Ophthalmol 1984; 102:883-7. 7. Shiose Y, Kawase Y. A new approach to stratified normal intraocular pressure in a general population. Am J Ophthalmol 1986; 101:714-21. 8. Klein BEK, Klein R, Linton KL. Intraocular pressure in an American community: The Beaver Dam Eye Study. Invest Ophthalmol Vis Sci 1992; 33:2224-8. 9. Wu SY, Leske MC. Associations with intraocular pressure in the Barbados Eye Study. Arch Ophthalmol 1997; 115:1572-6. 10. K. Mori, F. Ando, H. Nomura, et al. Shimokata.Relationship between intraocular pressure and obesity in Japan. Int J Epidemiol 2000; 29(4):661-6. 11. Lee JS, Lee SH, Oum BS, et al. Relationship between intraocular pressure and systemic health parameters in a Korean population. Clin Experiment Ophthalmol 2002; 30:237-41. 12. Armstrong JR, Daily RK, Dobson HL, et al. The incidence of glaucoma in diabetes mellitus. A comparison with the incidence of glaucoma in the general population. Am J Ophthalmol 1960; 50:55-63. 13. Bouzas AG, Gragoudas ES, Balodimos MC, et al. Intraocular

14. 15.

16. 17.

18.

19.

20.

pressure in diabetes. Relationship to retinopathy and blood glucose level. Arch Ophthalmol 1971; 85:423-7. Bankes JLK. Ocular tension and diabetes mellitus. Br J Ophthalmol 1967; 51:557-61. Waite JH, Beetham WP. Visual mechanisms in diabetes mellitus; a comparative study of 2002 diabetics, and 457 non diabetics for control. N Engl J Med 1935; 212:367-429. Palomar-Palomar A. Manifestaciones oftalmologicas de la diabetes mellitus. Arch Soc Oftalmol Hispano-Am 1956; 16:827-1067. Armaly MF, Baloglou JP. Diabetes mellitus and the eye. II Intraocular pressure and aqueous outflow facility. Arch Ophthalmol 1967; 77:493-502. Becker B. Diabetes mellitus and primary angle glaucoma. The XXVII Edward Jackson Memorial Lecture. Am J ophthalmol 1971; 71:1-16. Bulpitt CJ, Hodes C, Everitt MG. Intraocular pressure and systemic blood pressure in the elderly. Br J Ophthalmol 1975; 59:717-20. Sang Woo Oh, Sangyeoup Lee, Cheolyoung Park, et al. Elevated intraocular pressure is associated with insulin resistance and metabolic syndrome. Diabetes/Metabolism Research and Reviews

2005; 21(5):434-40. 21. Dielemans I, de Jong PT, Stolk R, et al. Primary open-angle glaucoma, intraocular pressure, and diabetes mellitus in the general elderly population. The Rotterdam Study. Ophthalmology 1996; 103(8):1271-5. 22. An-Fei Li, Nobuhiro Tane, Sayon Roy, Fibronectin overexpression inhibits trabecular meshwork cell monolayer permeability. Molecular Vision 2004; 10:750-7. 22. Toshiyuki, Naoya Fujimoto, Katsuhiro H, et al. Effect of chronic hyperglycemia on intraocular pressure in patients with diabetes. Am J Ophthamol 2007; 144(2):339.

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