As incidence of diabetes is continuously increasing in india and diabetic dyslipidemia is a leading cause of atherosclerotic disease process like coronary artery disease. If we diagnosed and treat dyslipidemia in early stage, we can decrese the risk of atherosclerotic diseases. But current guidelines recommend measurement of fasting lipid profile and majority of the patients present in the hospital are in nonfasting state so their lipid profile is deferred due to their nonfasting status which impedes their treatment. However, recent studies suggest nonfasting lipid profile may better or similarly predict cardiovascular disease events than fasting levels. So, if validate for treatment of diabetic dyslipidemia then measurement of nonfasting lipid profile may have many practical advantage for clinical practice. So a prospective study was carried out in 100 diabetic patients in 25-65 years age group including both sexes irrespective of community or background which were present in inpatient department of medicine, Mata Chanan Devi hospital, New Delhi, during the time period of 2012-2014. It is a 210 bedded, tertiary care hospital in west Delhi, where the patients travel from all north India. The patients with Coronary event (myocardial infarction, unstable angina) and procedures (coronary artery bypass, coronary angioplasty) in previous 4 weeks, ischemic stroke in prior 3 months, chronic alcoholic patients, patients having pancreatitis, hypothyroidism, pregnancy and patients on lipid lowering drugs in previous 3 months, were not included in the study. After taking written informed consent lipid profile was done from each subject at the time of admission and next day morning (after 8-12 hr fasting). Self reported time since last meal was also noted at the time of admission. LDL was measured by direct method. Non HDL cholesterol was calculated by total cholesterol – HDL cholesterol. SPSS (statistical package for social sciences) software version 16.0 was used for statistical analysis. Wilcoxon Signed Ranks test done to compare the total mean fasting and nonfasting lipid profile. We divided the study subjects according to self reported time since last meal. Like 0-1 hour include patient taking meal before < 1 hour and 1-2 hour include <2 hour post meal and so on other groups. Comparison of fasting and non fasting lipid profile was done by Wilcoxon Signed Ranks Test in all groups. All P values were 2-tailed. P value <0.05 is statistical significant.

Salient findings Out of 100 patients, there were 44 females and 56 males subjects. Minimum age is 32 years and maximum age is 65 years. Mean age in males is 56.12 ± 8.05 and in females 57.91 ± 7.13. Incidence of diabetes was higher in >50 years of age group and among males. 15 out of 100 diabetic subjects were on insulin therapy and rest 85 were on Oral hypoglycemic drugs only. Out of 100 diabetic patients 45 were hypertensive, 7 CAD, 9 CKD and 10 had history of CVA. Mean fasting blood sugar was 112.26mg/dl and mean post prandial blood sugar was 192.65mg/dl as patients were on treatment for diabetes. Mean HbA1c among females was 7.54 ± 1.39 and in males was 7.79 ± 1.48. The mean total cholesterol level in the 100 diabetic patients included in the study in the fasting state was 166.48± 45.30mg/dl, and in the non-fasting state it was 167.06 ± 46.03mg/dl, the p value was more than >0.05 thus making it statistically insignificant. The mean HDL level in the fasting state was38.93±13.72mg/dl, and in the non-fasting state it 38.67±13.30mg/dl, the p value is > 0.05, making it statistically insignificant. The mean direct LDL level in the fasting state was 86.41±34.90mg/dl and in the non-fasting state it was 86.35±38.38mg/dl, the p value again > 0.05, making it statistically insignificant. The mean triglyceride level in the fasting state was 184.82± 29.26 mg/dl and in the non-fasting state it was 205.87± 31.83 mg/dl, it is higher in the nonfasting group and the p value is <0.05, which is statistically significant. The mean non HDL level in the fasting state was 127.55±43.06 mg/dl and in the non-fasting state it was 128.38±43.21 mg/dl, the p value >0.05, making it statistically insignificant Comparison of nonfasting and fasting lipid profile according to time since last meal Post meal values of total cholesterol, HDL cholesterol, direct LDL cholesterol, non HDL cholesterol and triglycerides correlate with their fasting values. There was no significant difference in fasting and nonfasting total cholesterol, HDL c, direct LDL c and non HDLc as a function of time since last meal. Triglycerides is significantly increased up to 6-7 hour after meal as p value is <0.05. Although it is higher in nonfasting even after 6-7 hours but statistically insignificant. The highest increased in levels of triglycerides were noted 3 to 5 hour after meal.

Conclusion- Difference between nonfasting and fasting values of total cholesterol, HDL cholesterol, direct LDL cholesterol and non HDL cholesterol were statistically insignificant. Triglycerides values were significantly high in non-fasting state. Post meal level of all lipids and lipoproteins correlate with their fasting values in the different groups of time since last meal. Triglycerides were increase after meal and maximum increased from fasting was seen 3 to 5 hours after meal. Total cholesterol, HDL cholesterol, direct LDL cholesterol and non HDL cholesterol differ insignificantly from their fasting values as a function of time since last meal. In our study level of lipids differed minimally in nonfasting. We measured direct LDL which differed insignificantly from fasting direct LDL. Calculated LDL can underestimate after meal as elevated triglycerides in Friedewald formula (LDLc = TC – HDLc – TG/5). In our study higher nonfasting than fasting triglycerides were likely attributable directly to fat intake. And recent studies suggest nonfasting or postprandial hypertriglyceridemia is a significant risk factor for atherosclerosis. From above findings we conclude that nonfasting blood draws may be highly effective and practical for lipid profile testing in diabetic patients. Recommendations- Lipid profile can be done in nonfasting state in diabetics and it is more practical and more feasible as we spend our maximum time in nonfasting state. LDL should be done by direct method as in nonfasting state increased triglycerides can underestimate the calculated LDL by Friedewald formula. Non HDL cholesterol can be measured in nonfasting state. More recently this is studied for better predictor of cardiovascular risk than LDL because it includes all Apo-B containing atherogenic lipoproteins. Future research should focus on studies reducing the levels of nonfasting triglycerides and thus remnant lipoprotein cholesterol in an attempt to reduce the risk of cardiovascular disease and death further than that currently obtained by reducing mainly LDL cholesterol levels. Furthermore the results also highlight the need for randomized double blind trials of new and established drugs to reduce nonfasting triglycerides and remnant lipoprotein cholesterol, with the ultimate aim of reducing risk of cardiovascular disease and early death.

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Lokesh Gupta

Department of medicine, Mata Chanan Devi Hospital, Janakpuri, New Delhi