ASSOCIATION OF CLINICAL AND BIOCHEMICAL FACTORS WITH SERUM TESTOSTERONE LEVELS IN TYPE 2 DIABETIC MALES Ravi Kumar Meena, Debasish Chaudhury, Amita Yadav Dept. of Medicine, Lady Hardinge Medical College, New Delhi

INTRODUCTION Low Serum Testosterone (LST) in diabetics is associated with: Reduced insulin sensitivity Visceral obesity Dyslipidaemia Cardiovascular burden There is absence of study on Indian population.

AIMS & OBJECTIVES To determine the association of serum testosterone level in type 2 male diabetics & healthy controls. To find out influence of various factors like Glycaemic status, Microvascular Complications, Obesity, waist circumference, and BMI on testosterone level.

MATERIALS AND METHODS STUDY DESIGN: Cross sectional observational study. STUDY PERIOD: November 2014 to March 2016. STUDY POPULATION: Patients of type 2 diabetes mellitus presenting to medical OPD of LHMC and Associated Hospitals & apparently healthy non diabetics. SAMPLE SIZE: 80 diabetic patients (cases) & 80 non diabetic apparently healthy age matched volunteers (controls) recruited for study. SAMPLING METHOD: Every alternate diabetic patient was screened for selection criteria and then recruited for study. Study was conducted after EC approval and informed written consent was obtained.

CRITERIA FOR SELECTION INCLUSION CRITERIA: Type 2 Diabetes with duration of diabetes ≥5 years Age ≥ 35 and ≤ 65 years   EXCLUSION CRITERIA: Patients with other risk factors known to cause gonadal insufficiency Patient suffering from acute or chronic systemic illness. Patient diagnosed to be having internal malignancy.

METHODOLOGY Anthropometric data, smoking, Duration of DM, alcohol consumption, medications & history suggestive of micro and macro-vascular complications. Symptoms of hypogonadism (ADAM Questionnaire). BMI ( kg∕m2){< 18.4 – underweight,18.5-22.9- normal, 23-24.9- overweight >25 –obese}. Waist circumference : (cut off upper limit 90cm (males) . Hip circumference: measurement taken at the level of greater trochanters Waist-to-hip Ratio : will be measured as a ratio WC/ HC Assessment of Microvascular complications

BIOCHEMICAL INVESTIGATIONS & BIOCHEMICAL DATA INTERPRETION FBG, lipid profile, LFT, KFT, serum electrolytes, HbA1c Urine sample: urine-R/M, UACR. Serum testosterone:electrochemiluminescence immunoassay “ECLIA” Normal values: Age group 20-49 years(249-836ng/dl) Age group> 50 years (193-740ng/dl) by using calibrator COBAS 411 by Roche. In this study, Low serum testosterone was defined as 20-49 years - <249 ng/dl, >50 years - <193ng/dl

LH and FSH Level-by “ECLIA”(LH: 1.7-8.6 IU/L, FSH: 1.5-12.4 IU/L) FBG: by Glucose oxidase- peroxidase (upper limit taken as 126mg/dl) . BLOOD UREA: by UREASE method (upper limit 50mg/dl). SERUM CREATININE: by JAFFES ALKALINE PICRATE method (upper limit 1.4mg/dl in males,) TOTAL CHOLESTEROL (TC): by CHOLESTEROL OXIDASE(upper limit 200mg/dl. TRIGLYCERIDE (TG): Done by GPO–PAP–ESPAS method (upper limit 150mg/dl). HDL- PEG-PAP method (lower limit 40mg/dl (males). LDL-(cut off upper limit is 100 mg/dl) HbA1c- LATEX AGGLUTINATION INHIBITION method (cut off upper limit 6.5%) Urinary micro-albuminuria : by IMMUNOTURBIDIOMETRY. Urinary albumin :creatinine ratio more than 30 mg/g labelled as micro-albuminuria.

STATISTICAL ANALYSIS Quantitative variables were compared using Unpaired t-test between the two groups. Qualitative variables were correlated using Chi-Square test. Univariate and multivariate logistic regression was used to assess the association of low testostrone with various parameters. Pearson correlation coefficient was used to find out association of various parameters with testosterone. A p value of <0.05 was considered statistically significant Data was entered in MS EXCEL spreadsheet and analysed using Statistical Package for Social Sciences (SPSS) version 21.0.

OBSERVATIONS & RESULTS Age and various other anthropometric measurements [Mean± SD] Variables DM Healthy P value Age(years) 50.54±5.93 48.96±9.17 0.199 BMI(kg/m2) 24.69±4.39 22.60±3.30 0.001 WAIST(cm) 87.10±9.45 82.31±6.71 <0.0001 Testosterone(ng/dl) 341.11±177.63 435.97±149.69 <0.001

Testosterone level association with Various Anthropometric measurements in DM (mean ± SD) Parameter Group Mean (±SD) p-value Duration of diabetes 5-10 375.85 ±180.28 0.007 >10 260.20 ±144.37 Age 35-45 387.50 ±141.59 0.416   46-55 330.90 ±192.43 56-65 316.72 ±174.82 BMI Normal 376.10 ±147.28 0.010 Overweight 330.66 ±198.66 Obese 311.26 ±189.23 Waist <=90 341.40 ±169.4 0.987 >90 340.76 ±192.71 ADAM Absent 393.66 ±165.53 <0.0005 Present 183.62 ±105.93

Testosterone level association with Microvascular complications in DM (mean ± SD) Parameter Group Mean (±SD) p-value Retinopathy (N=35) Absent 400.27 ±165.75 0.001 Present 265.14 ±164.79 Neuropathy (N=45) 432.64 ±167.76 <0.0005 269.99 ±151.81 Nephropathy (27) 352.14 ±159.48 0.483 319.57 ±210.32

Testosterone levels in different groups classified according to biochemical parameters in DM(mean ± SD) Parameter Group Mean (±SD) p-value FBG <=110(N=6) 284.40 ± 153.1 0.419 >110(N=74) 345.75 ± 179.56 HbA1C <=7(34) 284.40 ±162.86 0.008 >7(46) 345.75 ±176.54 Dyslipidemia Absent 371.42 ±188.43 0.03 Present 287.92 ±144.85

Relationship between serum testosterone level and symptoms of androgen deficiency in diabetic group by using ADAM questionnaire. ADAM questionnaire Normal SERUM TESTOSTERONE Low SERUM TESTOSTERONE Total p-value   No 51(85.00%) 9(15.00%) 60(100%) <0.0005 Yes 5(25.00%) 15(75.00%) 20(100%) 56(70.00%) 24(30.00%) 80(100%)

CONCLUSION Serum Testosterone Levels (ng/dl) are significantly lower in DM >5 years duration compared to healthy population Study shows an significant association of low serum testosterone level with following factors in DM: HIGH BMI LONGER DURATION OF DM M ICROVASCULAR COMPLICATION(RETINOPATHY,NEUROPATHY) INCREASING HbA1C ADAM QUESTIONNAIRE DYSLIPIDAEMIA

Strengths: one of the few studies that have assessed the association of testosterone with control of and development of complications of diabetes. possible necessity to measure the serum testosterone levels in type 2 diabetics. Limitations It was a carried out in a tertiary care centre, cross sectional study Determination of SHBG and free serum testosterone levels were not carried out

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