Factors affecting FBS in diabetes

Int J Nutr Sci 2020;5(1):13-18

International Journal of Nutrition Sciences

Journal Home Page: ijns.sums.ac.ir

Original Article

Factors Affecting Fasting Blood Glucose in Patients with

Type 2 Diabetes Mellitus
Muhammad Ridwanto1*, Dono Indarto1,2,3, Diffah Hanim1
1. Department of Nutrition Sciences, Universitas Sebelas Maret, Surakarta, Central Java, Indonesia
2. Department of Physiology, Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Central Java, Indonesia
3. Biomedical Laboratory, Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Central Java, Indonesia

ARTICLE INFO A BSTRAC T

Keywords: Background: Type 2 diabetes mellitus (T2DM) is a metabolic disease
BMI which has high morbidity and mortality rates every year. Indonesia has
Psychological stress
Smoking
10.3 million people with diabetes mellitus (DM) in 2017 and becomes
Potasium the top country for DM worldwide. This study assessed factors affecting
Diabetes mellitus fasting blood glucose levels in patients with T2DM.
Methods: Totally, 210 patients with T2DM participated in a cross sectional
study. Inclusion criteria were patients suffering from T2DM aged 20-60
years old and lived in Purbalingga and Banjarnegara regencies. Nutritional
status was determined using body weight and height, psychological stress
by Perceived Stress Scale (PSS-10), smoking habit by a questionnaire and
intake of potassium using a 24 hour recall questionnaire. Blood glucose
*Corresponding author: levels were measured by hexokinase method
Muhammad Ridwanto,
Departmentof Nutrition Sciences, Results: A correlation between BMI (P=0.02), smoking habits (P=0.04)
Universitas Sebelas Maret, and potassium intake (P=0.02) with fasting blood glucose levels was
Surakarta, Central Java, Indonesia. noted in T2DM patients; whereas, psychological stress (P=0.85) was not
Tel: +62-852-59557051
Email: correlated with fasting blood glucose levels.
[email protected] Conclusion: These findings revealed that body mass index (BMI),
Received: July 16, 2019
Revised: December 23, 2019
smoking habits and potassium intake had positive correlation with fasting
Accepted: January 2, 2020 blood glucose levels in patients with T2DM.
Please cite this article as: Ridwanto M, Indarto D, Hanim D. Factors Affecting Fasting Blood Glucose in Patients with
Type 2 Diabetes Mellitus. Int J Nutr Sci. 2020;5(1):13-18.

Introduction while the prevalence of diabetes in Central Java

Type 2 diabetes mellitus (T2DM) is a metabolic Province was 1.6 % (2).
disease that becomes a global health problem However, the prevalence of T2DM has not
because of its high morbidity and mortality rates been established. Some studies have indicated that
every year. The global prevalence of T2DM is modification of internal and external factors plays
estimated to increase from 424 millions in 2017 an important role in reduction of diabetes prevalence
to 625 millions in 2045 (1). Indonesia has become (3, 4). Franz et al. (2015) reported that individuals
the sixth rank of countries with diabetes in the with obesity have twice higher risk to suffer from
world and it reached 10.3 million people in 2017. T2DM than individuals with normal weight. Fat
According to data of Basic Health Research in accumulation in such obese individuals resulted in
Indonesia, the prevalence of diabetes in Indonesia light or moderate chronic inflammation, by which
was 1.5% in 2013 and increased to 20% in 2018, it can reduce insulin sensitivity. Therefore, it will
Int J Nutr Sci March 2020;5(1)   13
 Ridwanto et al.

increase blood glucose level in blood circulation (5-7). Committee of Medical Research, Faculty of
Psychological stress and smoking habits are other Medicine, Universitas Sebelas Maret numberred
risk factors of diabetes, which have extensively 43/UN27.6/KEPK/2018 (sim-epk.keppkn.kemkes.
been studied in recent years (8-10). In physiological go.id). All selected participants filled and signed
conditions, stress responses are regulated by two the informed consent to follow this study. Research
different pathways including sympathetic nervous participants in this cross sectional study were
system for quick responses and neuroendocrine enrolled using an Open Epi Programe (http://www.
system for prolonged system. Briefly, stress stimulus openepi.com) with 95% confidence interval and
will activate hypothalamic nuclei through the correlus 80% power and were selected using a purposive
nucleus and stimulate the medula adrenal gland to sampling method.
release catecolamin hormones such as adrenalin, A total of 210 patients with T2DM aged 20-
noradrenalin and dopamine. If the stress is persistent, 60 years old and were members of diabetes
the hypothalamus-pituitary adrenal axis (HPA) organizations (Persadia and Prolanis) in Purbalingga
will be activated and the hypothalamus produces and Banjarnegara Regencies met the inclusion
corticotropin-releasing hormone to stimulate the criteria. Selected research partipants were excluded
anterior pituitary and the cortex adrenal, releasing from this study if having diabetes complications and
the cortisol hormone (8, 10, 11). comobidities (such as asthma, tuberculosis and HIV/
It was shown that light or moderate stress AIDS) and used insulin injections. Antropometric
will induce the release of growth hormones and data consisted of body weight (kg) and height (m),
endorphins. Furthermore, prolonged and severe which were measured using a weight scale (GEA,
stress led to a higher release of cortisol hormone, Indonesia) and microtoice scale (GEA, Indonesia).
which can increase blood glucose level through The Perceived Stress Scale (PSS-10) questionnaire
gluconeogenesis and inhibition of insulin action was used to measure psychological stress, while
(10, 12). Some evidences indicated that smoking can open questionnaire was used to collect data of
increase inflammation and oxidative stress, resulting smoking habits. Potasium intake was obtained from
in interferences in pancreatic β cells function (8). the 24-hour food recall and converted into mg daily
High nicotine levels in cigarettes may lead to insulin intake with a modified nutrisurvey software (www.
resistance by inhibition of insulin secretion (14). nutrisurvey.de). Adequate potassium intake was
Those nicotine compounds interact with the based on recommended dietary allowance (RDA)
nicotinic acetylcolinesterase (NAchR) receptor and in Indonesia for participants who aged 20-60 years
result in Mechanistic target of rapamycin (mTOR) old with T2DM (4,700 mg/day).
activation (13). As a result, excessive mTOR Research participants had adequate potassium
expression will up-regulate the insulin receptor intake, if consumed 90-119% from RDA, 70-79%
substrate-1 (IRS-1) Ser 636 insulin receptor so that moderate deficiency, <70% severe deficiency and
insulin does not recognize its receptors (14). In normal >120% excessive intake. All participants underwent
condition, potasium is required for electrolyte water 8 hour fasting in the night before taken their blood
balance and is located in intracellular compartments. venous in the following morning. Around 3 mL
In human body, potassium levels equal to 53.8 mmol/ blood sample was taken from lower arm vein of the
kg are tightly maintained in a narrow range of 3.5– participants, which was used to measure fasting
5.0 mmol/L, a balance between potassium intake blood glucose level with the hexokinase method at
and excretion through the kidney and the intestinal the clinical pathology laboratorium, of Dr. Goteng
tract (15). Taraoenadibrata Hospital, Purbalingga.
Serum insulin levels are also needed to transport Their fasting blood glucose levels were
potassium into cells, but the affinity is lower than the categorized into 3 groups of 70.0-105.0 mg/dL
affinity of glucose uptake (16). Progressively, higher as normal, <70.0 mg/dL as hypoglycemia and
blood glucose level is proportionally associated with >105 mg/dL as hyperglycemia. All collected data
higher potassium levels too. Insulin deficiency in were statistically analyzed using a SPSS software
diabetic patients causes translocation of intra-cellular (Statistical Package for Social Sciences, version 16,
potassium to the extra-cellular compartments due to Chicago, IL, USA, www.spssindonesia.com). All
hypertonicity (17). Therefore, the objective of this study numeric data were presented as mean±SD, whereas
was to investigate the association of factors affecting categorical data (age, smoking habit, duration of ilnes
fasting blood glucose levels in patients with T2DM. and Taking oral anti-diabetic drugs) were presented
as frequency and percentages.
Materials and Methods To analyze the relationship of BMI, psychological
The research protocol was approved by Ethical stress, duration of illness, age and potasium intake
  14 Int J Nutr Sci March 2020;5(1)
 Factors affecting FBS in diabetes

with fasting blood glucose levels, the Pearson Most participants had moderate stress and the
correlation test was used with the significan value majority of male participants were active smokers.
of p less than 0.05. For further investigation, some Around seventy percent of participants had <5
confounding factors such as age, duration of diabetes years duration of ilnes and had high fasting blood
illnes and oral diabetes drugs were analyzed using the glucose levels. In Table 2, the relationship between
regression linier test instead of BMI, psychological BMI, psychological stress, smoking habits and
stress, smoking habit and potasium intake. potassium intake with fasting blood glucose levels
were presented. The increased BMI (r=0.141, P=0.04),
Results smoking habits (r=0.113, P=0.03) and potassium intake
The basic characteristics of participants with T2DM (r=0.156, P=0.02) had a significant relationship with
were similar except for smoking habits and fasting fasting blood glucose level, whereas psychological
blood glucose levels (Table 1). The average age stress did not show any correlation with fasting blood
of T2DM participants was 52.67±5.2 years with glucose levels in T2DM patients. In Table 3 based on
49% males and 51% females and the majority of multivariate analysis and linear regression test results,
participants had a range of age betwen 46 and 55 BMI variables, smoking habits and potassium intake
years old. Antropometric data showed that 47.6% of showed a positive relationship with increased fasting
participants were overweight and 14.7% had obesity. blood glucose levels in T2DM patients.

Table 1: Basic characteristics of patients with type 2 diabetes mellitus

Variable Male Female Total Mean±SD
(n: 103) (n: 107) (n: 210)
% % %
Age (Years)
36-45 11 (5.8) 10 (4.2) 21 (10.0) 52.7±5.2
46-55 54 (25.7) 65 (31.0) 119 (56.7)
55-60 38 (18.1) 32 (15.2) 70 (33.3)
Duration of illness (years)
<5 75 (35.7) 72 (34.0) 147 (70.0) 4.3±3.0
5-10 23 (11.0) 33 (15.7) 56 (26.7)
>10 5 (2.3) 2 (1.0) 7 (3.3)
Taking oral anti-diabetic Drugs
1 52 (24.7) 55 (26.3 107 (51.0)
>1 49 (23.3) 54 (25.7) 103 (49.0
Body mass index (kg/(m)2)
Underweight 5 (2.3) 2 (1.0) 7 (3.3) 24.1±3.4
Normal 38 (18.1) 34 (16.2) 72 (34.3)
Overweight 45 (21.4) 55 (26.2) 100 (47.6)
Obese 1 13 (6.1) 15 (7.2) 28 (13.3)
Obese 2 2 (1.0) 1 (0.4) 3 (1.4)
Psychological Stress
(PSS 10) 12 (5.025) 12 (5.025) 22 (10.5) 19.6±4.2
Mild 90 (42.025) 98 (46.025) 188 (89.5)
Moderate
Smoking habits
Yes 70 (33.3) 0 (0) 70 (33.3)
No 33 (15.7) 107 (51.0) 140 (66.7)
Potasium intake (mg/d)
Severe deficiency 11 (5.4) 28 (13.3) 39 (18.6) 945.8±3.3
Moderate deficiency 14 (6.7) 15 (7.1) 29 (13.8)
Mild deficiency 21 (10.0) 28 (13.3) 49 (23.3)
Normal 8 (3.8) 16 (7.6) 24 (11.4)
Over intake 49 (23.3) 20 (9.6) 69 (32.9)
Fasting blood glucose (mg/dL)
Hypoglycemia 4 (1.5) 1 (0.4) 5 (1.9) 173.7±54.8
Normal 8 (3.9) 5 (9.0) 27 (12.9)
Hyperglycemia 91 (43.2) 101 (48.0) 179 (85.2)

Int J Nutr Sci March 2020;5(1)   15

 Ridwanto et al.

Table 2: Correlation of BMI, psychological stress, smoking habits and potasium intake, with fasting blood glucose
levels in T2DM
Variable r* P**
BMI 0.141 0.041
Psychological stress 0.006 0.929
Smoking habits 0.113 0.032
Potasium intake 0.156 0.023
*Correlation coefficient, **P value Pearson, BMI: Body mass index, T2DM: Type 2 diabetes mellitus

Table 3: Regression linear between BMI, psychological stress, smoking habits, potasium intake and confounding
variable with fasting blood glucose levels
Variable r* 95%CI P**
Age 0.078 0.014-2.812 0.252
BMI 1.590 4.748- 432 0.019
Psychological stress 0.174 1.959-1.611 0.848
Smoking habits 1.870 25.610- 5.870 0.042
Potassium intake 0.025 0.047-0.003 0.024
Duration of DM illness 0.078 1.011-3.834 0.252
Taking oral anti-diabetic drugs 1.321 5.835-23.917 0.232
*Regression coefficient, **P value regression linear, BMI: Body mass index, DM: Diabetes mellitus, CI: Confidence
interval

Discussion study conducted by Colditz and colleagues (1992).

In this study, we found that BMI, smoking habits They investigated women (n=84,360; 34-59 years)
and potassium intake were significantly correlated from the Nurse’s Health Study for six-years and
with fasting blood glucose levels in T2DM patients, found that high potassium intake may be associated
whereas psychological stress was not associated. with a decreased risk for developing T2DM in
These Findings were in line with previous studies. women with BMI less than 29, but in women with
Onyesom et al. (2013) reported a positive but weak BMI equal or more than 29 were inverse (28).
correlation between BMI and blood glucose levels Psychological stress and fasting blood glucose
among the male subjects (r=0.43); while female level did not illustrate any significant relationship
subjects showed a positive and strong correlation in patients with T2DM. The findings in this study
(r=0.53) (18). revealed that patients who experienced psychological
In addition, a person who has obesity, he may stress were more likely to be in the moderate
have a higher risk of unstable blood glucose level category. The results of this study are in line
compared to a person who has normal body weight with previous research which stated that chronic
(6, 7, 9). Theoretically, smoking habit is a risk factor psychological stress can affect the activation of
of T2DM. The results of our study indicated that the hypothalamic-pituitary-adrenal (HPA) axis by
smoking habit was also a risk factor of T2DM and increasing the hormone cortisol, activation of the
in line with previous studies (8, 18-20). Smoking autonomic nervous system and inflammation that
can cause damage of beta pancreatic cells (8, 19), causes insulin resistance (10, 29, 30). Psychological
leading to disruption of insulin production (8, 20). stress is due to a pressure factor and unpreparedness
Furthermore, nicotine in cigarettes inhibits insulin in the person’s soul to accept the situation (31, 32).
secretion by interacting with NAchR receptor and
stimulating mTOR action (13, 21-24). Conclusion
Increased mTOR activities induce IRS-1 Ser 636 The findings in this study had implications that
expression and result in insulin resistance in skeletal BMI, smoking habits and potassium intake, have
and fat cells in patients with T2DM (14, 21-24). In a positive correlation with fasting blood glucose
the physiological condition, potassium is required for levels in patients with T2DM.
cellular depolarization including pancreatic beta cells
(25-27). From our study, a significant relationship Acknowledgment
was observed between potassium intake and fasting We would like to thank the Head and staff of
blood glucose level in patients with T2DM. This District Health Office and Health Community
finding is in accordance with a prospective cohort Centers, Purbalingga and Banjarnegara Regencies
  16 Int J Nutr Sci March 2020;5(1)
 Factors affecting FBS in diabetes

for providing permission to do this research study. 11 Cassell P, Neverova M, Janmohamed S, et al. An
We also thank to the Director and Staff of General Uncoupling Protein 2 Gene Variant is Associated
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12 Benert A, Ozturk M, Yildirim E. Association
Conflict of Interest between Depression, Anxiety and Stress
None declared. Symptoms and Glycemic Control in Diabetes
Melitus Patients. Int J Clin Endocrinol. 2017;2.
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