Journal of Diabetes & Metabolism

Chronic Diabetic Complications and Associated Factors among People with Type-2 Diabetes Mellitus in Debretabor Hospital, Northwest Ethiopia, 2018

Beselam Gizachew Astatkie, Wolde Melese Ayele^* and Yeshimebet Alli Dawed ^*Correspondence: Wolde Melese Ayele, Public Health, Wollo University, Ethiopia, Tel: +251921885231, Email:

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Introduction

Diabetes defined as “a metabolic disorder of multiple etiology characterized by chronic hyperglycemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in the insulin secretion, insulin action, or both” [1]. Complications attribute to diabetes are long term effects that a patient with diabetes develop through time including macro vascular complications (coronary artery disease (CAD), peripheral vascular disease, and stroke) and micro vascular complications (diabetic nephropathy (DN), diabetic retinopathy (DR), and peripheral neuropathy) [2].

Diabetes complications have significant direct social and economic impact on individuals, families, health systems & countries, and indirect productive losses. The productivity losses are due to patient disability resulting from complications and premature mortality, time spent by family members accompanying patients when seeking care [3].

Even though diabetic complications have been existed for too long and interventions have been done, they still are constantly increasing worldwide at an alarming rate [4]. In Ethiopia it has been estimated that the prevalence of DM is seven percent in adult population and from all deaths diabetes cause one percent [5]. There have been various factors proved to be associated with chronic diabetic complications. As a matter of fact, number of studies showed that diabetic complications are significantly associated with sociodemographic factors [4-7] behavioral factors [8,9] and clinical factors [4,10,11]. But there is limited evidence about chronic diabetic complications and associated factors in Ethiopia, especially in the study area. Therefore, this study was aimed to determine the magnitude of chronic diabetic complications and associated factors among Type 2 diabetes patients in Debretabor hospital, and the result assumed to have greater implication for evidence based practice.

Materials and Methods

Study design, setting, and sampling

Institutional based cross-sectional study was conducted from March 1 to April 5/2018 in Debretabor Hospital, South Gondar zone, Northwest Ethiopia. It is 99 kilo meters away from Bahir Dar, main city of the regional state and 667 kilo meters North of Addis Ababa, capital city of Ethiopia. Diabetic clinic is one the hospital’s different outpatient department clinics which gives service for total of 1091 diabetic patients.

A total of 424 sample size was determined using similar study done in Bahir Dar, Ethiopia [12], age, drug regimen and duration of diabetes considered as main associated factors. By using open EPI version 7 and considering 95% CI, 80% power, 10% non-response rate, the sample size was 424.

Systematic sampling technique was used to select study participants. The diabetic clinic provides these services for both types of diabetics only on Wednesday and Thursday every week. An average 120 and 950 patients with T2 diabetes mellitus are treated per day and per month respectively. Sampling interval was determined by dividing the expected number of type 2 diabetic patients per month (950) with the sample size (424) which gives approximately two, then every two patients were taken until the desired sample size was reached.

Prior to the study ethical approval from the ethical review board of Wollo University, and permission from the hospital was obtained. Each study participant requested a verbal consent to participate in the study. During and after the data collection process, patientrelated data were kept confidential and to ensure that interview was held on a private basis throughout the process. Above all the anonymity of each participant was kept by only using codes and also whatever information they provide was kept confidential and was not be shared with anyone else.

Operational definitions

Chronic diabetic complications: A patient with diabetes who have at least one confirmed macro vascular complications by a physician (diabetic related cardiovascular disease, peripheral vascular disease, and stroke) or micro vascular complications (including diabetic nephropathy (DN), diabetic retinopathy (DR), and peripheral neuropathy) after being diagnosed with diabetes.

Physical activity: Adults over 18 years of age should perform at least 150 min per week (3 days) of moderate-intensity or 75 min per week of vigorous-intensity aerobic physical activity.

Moderate activity: Means that while exercising, breathing is faster, heart rate is increased and one feels warmer including brisk walking, riding a bicycle, gardening and climbing the stairs for at least 10 minutes,3 days per week.

Vigorous activity: Means that while exercising, breathing will be much stronger and heart rate will increase rapidly including running, riding a bicycle uphill, strenuous sports such as tennis, basketball, football, etc. for at least 10 minutes every 3 days per week.

Smoker: An adult above 18-year-old who smoke tobacco at least one puffs per day.

Quit smoking: A person who has quit smoking one year ago.

Alcohol drinkers: Greater than one standard drinks (285ml of beer) per day or more than 5 drinks per week for women and more than 2 standard drinks per day or more than 10 drinks per week for male.

Low diet diversity: A diet that contain only 3 or less food group out of total of 9 food groups.

Medium diet diversity: A diet that contain 4-5 food groups out of the total.

High diet diversity: A diet that contains 6 or more food groups out of total.

Preventive care services: Diabetes patients should perform these services, daily self-monitoring blood glucose, dilated and comprehensive eye examination by ophthalmologist, urinary albumin test, assessed for neuropathy &comprehensive foot evaluation at least once a year then check up for HbA1c status at least twice per year.

High self-reported adherence: Patient who has total score of zero, based on Morisky measuring scale having eight item questions, answering yes or no for each of them.

Medium self-reported adherence: Patient who has total score of 1 or 2 from Morisky adherence questions.

Low self-reported adherence: Patients who has total score greater than 2 by answering ‘yes ’to at least two adherence questions. Body mass index (BMI): Calculated as weight (kg)/height (m²), Underweight=BMI, <18.5 kg/m², Normal weight=BMI, 18.5- 24.9 kg/m², Overweight=BMI, 25-29.9 kg/m², Obesity=BMI, >30 kg/m².

Data collection and quality

Data were collected using a structured questionnaire consisting of questions for socio-demographic factors, behavioral & clinical factors of people with T2 diabetes mellitus for presence of chronic diabetic complications. Primary data and patient’s medical chart review to determine clinical factors was employed by trained nurses. Anthropometric measures of Weight and height was measured according to standard procedures by data collectors. BMI& Blood Pressure (BP) measurements quality assured by training the data collectors, observation by the supervisor and repeated measurements being implemented. Measurements were done twice and the average was taken with the nearest 0.01 value of each.

Statistical analysis

Data were cleaned, coded and entered into EPI INFO version 7.1.2 and exported to SPSS version 20 for advanced analysis. Frequency tables, percentage, mean, and graphs was used to describe study results. Bivariable logistic regression was used to determine factors associated with chronic complications. Variables with p-value ≤ 0.2 in the bivariate logistic regression were fitted to the multivariable logistic regression model. Model fitness was checked through Hosmer and Lemeshow model fitness. Adjusted odds ratio with 95% confidence level was used to assess the strength of the association. Variables with p-value <0.05 were considered as statistically significant. The pretest data was not included in the final model.

Results

Socio-demographic characteristics of study participants A total of 424 people with type-2 diabetes mellitus were participated in the study. Among them, 255 (60.1%) were males with median age of 59 years, interquartile range of 17 years. One hundred thirteen (26.7%) were between 60-67years of age and 354 (83.5%) were Christian in religion. About two-third 276 (65.1%) of the participants were urban residents and 176 (41.5%) were unable to read and write (Table 1).

Table 1: Socio-demographic characteristics of people with type-2 diabetes mellitus at Debretabor Hospital, Ethiopia 2018 (N=424).

Behavioral and clinical characteristics of study participants Regarding to behavior of participants, only 9 (2.1%) were smokers, but 166 (39.25%) were alcohol drunker. Whereas, 355 (83.7%) were not doing physical activity.

Three hundred and ninety-three (92.7%) were on low diet diversity, but none were on high diet diversity. The dietary habit of the diabetic patients was 100% staple foods, 233 (55%) were green vegetable eaters, 96 (22.6%) were fish meat eaters.

Majority, 365 (86.1%) of the participants had no family history of diabetes. Relatively, small 176 (41.5%) had initial eye examination, 91 (21.5%) had self-monitoring blood glucose, 71 (16.7%) had test for urine albumin, 43 (10.1%) had neuropathy examination, while none of the participants had test for their HbA1C status. More than half, 296 (69.8%) of the participants were people with low treatment adherence (Table 2).

Table 2: Behavioral and clinical characteristics of study participants at Debretabor Hospital, Ethiopia 2018 (N=424).

Proportion of diabetic complications

The study revealed that, two hundred and twenty-two (52.4%, (95% CI: 48-57%)) of the study participants had at least one chronic diabetic complications. Micro vascular complications (43.9%) accounted higher proportion than that of macro vascular. Out of all chronic complications Retinopathy (26.4%), Nephropathy (9.2%) and Neuropathy (8.3%) were the highest (Figure 1).

Figure 1: Proportion of chronic Diabetic complications among T2 Diabetes mellitus patients Attending in Debretabor Hospital, 2018.

Factors associated with chronic diabetic complications In the bivariable analysis age of participants, sex, educational status, marital status, income, alcohol drinking status, diet diversity, physical activity, family history of diabetes, preventive care services, Body Mass Index (BMI), Blood Pressure (BP), Fasting Blood Glucose (FBG), drug regimen and duration of diabetes had p-value ≤0.2.

The results of multivariable analysis showed that presence of chronic diabetic complications was significantly associated with age of the participants, diabetes duration, preventive care services and drug regimen.

Participants aged 50-59 [ (AOR=3.47 (95%CI: 1.64-7.34)], 60-67 [AOR=4.14 (95%CI: 1.95-8.80)] and >67 [ (AOR=4.23 (95% CI: (1.80-9.89)] times more likely to have chronic diabetic complications compared to those who were less than 50 years of age.

Similarly study participants who had had at least one preventive care services were 60% [ (AOR=0.40 (95%CI: 0.24-0.69)] less likely to develop chronic diabetic complications than patients who had no service. Participants with 5-10 years of duration with diabetes [AOR=2.25 (95%CI: 1.28-3.97)], and more than 10-year duration [AOR=17.72 (95%CI: 8.25-38.07)] times more likely to have complications than patients with less than 5yrs of diabetes duration. Moreover, patients who were taking both oral medications and insulin injection were [(AOR=2.42 (95% CI: 1.18- 4.94)] times more likely to have complications than patients who took only oral anti diabetic drug regimens (Table 3).

Table 3: Factors associated with presence of Diabetic complications among type 2 diabetic people at Debretabor Hospital, Ethiopia 2018 (N=424).

Discussion

The overall prevalence of chronic diabetic complication was 52.4% which is almost similar with other studies in Jimma, Ethiopia (52.5%) and in Iran (52.6%) [13,14]. But it is lower than a study conducted in Nepal where its prevalence is 72.4% [15]. This difference might be due to the small sample size been used in the Nepal study and economic, cultural and lifestyle differences. In this study increasing age, preventive care measures, diabetes duration and type of drug regimen were significantly associated with presence of diabetic complications.

Patients whose age is >50 was more susceptible to develop chronic complications than patients who were less than 50 years of age. This result was congruent with the findings in different researches [12,16-18]. It is also supported by a study in Europe in which patients with type 2 diabetes, age is independently associated with the risk of macro vascular complications and death [19]. This might be due to older peoples are at high risk for developing type 2 diabetes and its complications due to combined effects of insulin resistance, impaired pancreatic islets function and impaired muscular and vascular functions with ageing [20].

Type 2 DM patients who were able to do at least one of the preventive measures were less likely to develop chronic complications. This result agreed with a study conducted in Brazil showing that taking multidisciplinary measures is protective of diabetic complications [11]. This might be due to screening patients before they start to complain about symptoms is a better way to elite many complications in their early stages and prevent getting them severe [21].

The present study found that as patients’ diabetic duration gets longer the more likely they develop at least one of the chronic complications than those patients whose duration of diabetes is less than 5 years. This result agreed with studies [16-18]. Diabetes duration is independently associated with the risk of micro vascular complications, and the effects of diabetes duration are greatest at younger rather than older ages [20].This might be due to development of diabetic complications is stepwise process appearing overtime [22].

Those study participants who took both oral anti diabetic medication and insulin injection were 2.38 times more likely to develop diabetic related complications. This finding is concordant to the studies [16,23], whereas studies in UK showed that early addition of insulin to oral anti diabetic medications can safely keep HbA1c close to 7% in first six years which in turn decrease risk of complications [24]. This difference might be due to many patients remain poorly controlled with oral anti diabetic medications and insulin initiation is often delayed [25].

The study had limitations of including of any laboratory findings concerning to complications such as eye examination, albuminuria laboratory result, neuropathy examination and others. And also the document review made difficult to find the full information about patients’ laboratory results. Since the study was an institution based, it is difficult to extrapolate the result to the general populations.

Conclusions

The chronic complications of diabetes were found to be more prevalent, with diabetic retinopathy being the most obvious complication which further predisposes the patient for blindness. The factors for higher proportion of chronic complications found to be increased age, low preventive care measures, longer duration of diabetes and taking both oral and insulin injections were observed in the study.

Conflict of Interest

All the authors declare that they have no competing interests.

Authors Contribution

The corresponding author originated, wrote the proposal, participated in data collection, analysis of data, and drafted the paper for publication. The other two were participated in proposal writing, approval, data analysis and reviewing the document. All the authors participated in manuscript writing to send for publication.

Availability of Data and Materials

All the required data has been included in the manuscript based on request we will give.

Consent for Publication

Not applicable.

Funding

This research study received no specific grant from funding agency in public commercial, or for profit sectors.

Acknowledgment

The authors would like to thank Wollo university and Debretabor Hospital for its’ consideration in making ethically securing of this research project. They are also acknowledged to the study participants for their time and data collectors for their commitment.

References

1. Intine RV, Sarras MP. Metabolic memory and chronic diabetes complications: potential role for epigenetic mechanisms. Curr Diabetes Rep. 2012;12:551-559.
2. Martínez-Pérez B, de la Torre-Díez MLCI. Mobile Health Applications for the Most Prevalent Conditions by the World Health Organization: Review and Analysis. J Med Internet Res. 2013;15.
3. Organization W. Definition, diagnosis and classification of diabetes mellitus and its complications: report of a WHO consultation. Part 1, Diagnosis and classification of diabetes mellitus. 1999.
4. Gebre MW. Review article Diabetes mellitus and associated diseases from Ethiopian perspective : Systematic review. Ethiop J Heal Dev. 2013;27:249-253.
5. Hall V, Thomsen RW, Henriksen O, Lohse N. Diabetes in Sub Saharan Africa 1999-2011 : Epidemiology and public health implications . A systematic review. BMC Public Health. 2011;11:564.
6. Papatheodorou K, Papanas N, Banach M, Papazoglou D, Edmonds M. Complications of diabetes 2016. J Diab Res. 2016.
7. Evaristo-Neto AD, Foss-Freitas MC FM. Prevalence of diabetes mellitus and impaired glucose tolerance in a rural community of Angola. Diabetol Metab Syndr. 2010;2:63.
8. Khan AR, Lateef ZNA, Fatima S, Abdullah S, Al A. Prevalence of Chronic Complication among Type 2 Diabetics Attending Primary Health Care Centers of Al Ahsa District of Saudi Arabia: A Cross Sectional Survey. Glob J Health Sci. 2014;6:245-253.
9. Muyodi MM. Prevalence and risk factors of diabetic complications and screening practices among newly diagnosed type 2 diabetes patients at kisii level 6 hospital, kisii county, kenya. 2016.
10. Liu X, Li Y, Li L, Zhang L, Ren Y, Zhou H. Prevalence, awareness, treatment, control of type 2 diabetes mellitus and risk factors in Chinese rural population : the RuralDiab study. Nat Publ Gr. 2016;1-9.
11. SilVa EFF, Ferreira CMM, de Pinho L. Risk factors and complications in type 2 diabetes outpatients. Rev Assoc Med Bras. 2017;63:621-627.
12. Abejew AA, Belay AZ, Kerie MW. Diabetic Complications among Adult Diabetic Patients of a Tertiary Hospital in Northeast Ethiopia. Hindawi. 2015.
13. Adhikari S, Shrestha S, Shakya RKN. Prevalance of Chronic Complications and Drug Utiliza-tion Pattern of Type II Diabetes Mellitus. 2017:006.
14. Lebeta KR, Birhane AZBW. Prevalence of Diabetic Complications and Its Associated Factors Among Diabetes Mellitus Patients Attending Diabetes Mellitus Clinics; Institution Based Cross Sectional Study. Am J Heal Res. 2017;5:38-43.
15. Barrot‐de la Puente J, Mata‐Cases M, Franch‐Nadal J, Mundet‐Tudurí X, Casellas A, Fernandez‐Real J, et al. Older type 2 diabetic patients are more likely to achieve glycaemic and cardiovascular risk factors targets than younger patients: analysis of a primary care database. Int J Clin Pract. 2015;69:1486-1495.
16. Worku D, Hamza KWL. Patterns of diabetic complications at Jimma University. Ethiop J Heal Sci. 2010;20:33-39.
17. Aynalem SB, Zeleke AJ. Prevalence of Diabetes Mellitus and Its Risk Factors among Individuals Aged 15 Years and Above in Mizan-Aman Town, Southwest Ethiopia, 2016 : A Cross Sectional Study. Int J Endocrinol. 2018.
18. Puente JB, Casellas A, Mauricio D. Older type 2 diabetic patients are more likely to achieve glycaemic and cardiovascular risk factors targets than younger patients : analysis of a primary care database. Int J Clin Pr. 2015;69:1486-1495.
19. Stanifer JW, Cleland CR, Makuka GJ, Egger R, Maro V, Maro H, et al. Prevalence, Risk Factors, and Complications of Diabetes in the Kilimanjaro Region : A Population-Based Study from Tanzania. PLoS One. 2016;11:1-13.
20. Litwak L, Goh S, Hussein Z, Malek R, Prusty V, Khamseh ME. Prevalence of diabetes complications in people with type 2 diabetes mellitus and its association with baseline characteristics in the multinational A 1 chieve study. Diabetol Metab Syndr. 2013;5:57.
21. Zoungas S, Woodward M, Li Q, Cooper ME, Hamet P, Harrap S, et al. Impact of age, age at diagnosis and duration of diabetes on the risk of macrovascular and microvascular complications and death in type 2 diabetes. Diabetologia. 2014;57:2465-2474.
22. Amati F, Dube JJ, Coen, Paul M MS-R, Toledo FGS, Goodpaster BH. Physical Inactivity and Obesity Underlie the Insulin Resistance of Aging. Diabetes Care. 2009;32:1547-1549.
23. Maghbooli Z, Pasalar P, Keshtkar A, Farzadfar F, Larijani B. Predictive factors of diabetic complications : a possible link between family history of diabetes and diabetic retinopathy. J Diabetes Metab. 2014;13:11-15.
24. Cho PNH. IDF Diabetes Atlas 6th ed. De Visu Digital Document Design 2013.
25. Nickerson HD, Dutta S. Diabetic Complications : Current Challenges and Opportunities Diabetic Complications : Current Challenges and Opportunities. J Cardiovasc. 2016;5:375-379.