alexa Analytic Study of 594 Type 2 Diabetic Patients Attending a Private Diabetes and Endocrine Center at Dallah Hospital in Riyadh, KSA | Open Access Journals
ISSN: 2155-6156
Journal of Diabetes & Metabolism
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Analytic Study of 594 Type 2 Diabetic Patients Attending a Private Diabetes and Endocrine Center at Dallah Hospital in Riyadh, KSA

Saher Safarini*, Hilali H Hilali, Samia Elsheikh and Abdalla K Omer

Diabetes and Endocrine Center, Dallah Hospital, KSA

*Corresponding Author:
Saher Safarini
Diabetes and Endocrine Center- Dallah Hospital
P.O. Box 87833 Riyadh, 11652
Riyadh - Kingdom of Saudi Arabia
E-mail: [email protected]

Received date: September 06, 2012; Accepted date: November 26, 2012; Published date: November 30, 2012

Citation: Safarini S, Hilali HH, Elsheikh S, Omer AK (2012) Analytic Study of 594 Type 2 Diabetic Patients Attending a Private Diabetes and Endocrine Center at Dallah Hospital in Riyadh, KSA. J Diabetes Metab 3:234. doi: 10.4172/2155-6156.1000234

Copyright: © 2012 Safarini S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Objective: To assess the inadequate glycemic control and its correlates among type 2 diabetes patients attending a private diabetes and endocrine center at Dallah Hospital - Riyadh, (KSA) and to compare our results with other previous similar studies.

Material and method: An analytical study was carried out on a 594 patients with type 2 diabetes who were attending the diabetes and endocrine center at Dallah Hospital in Riyadh during the period from February to April 2011. Data were collected by the treating physicians themselves at the end of each patient visit and entered on a special standard form (Microsoft Excel) program.

Results: The mean average of HbA1c in this study was 7.81%. 35% of patients achieved adequate glycemic control of HbA1c less than 7% (according to ADA recommendation). There is correlation between duration of diabetes, patient’s age, dyslipideamia and the glycemic control, but this correlation does not exist with the gender of the patient or patient’s body mass index for those who reached a good glycemic control.

Conclusion: Our analysis study conclude a positive correlation between the duration of diabetes, patients’ age, dyslipidemia and the glycemic control, which is not shown with body mass index or gender of the patients. More efforts on health education should be spent to convince patients on the importance of life style modification and compliance with the treatment to achieve a satisfactory targeted level of HbA1c.

Keywords

Glycemic control; HbA1c; Diabetes mellitus; Dallah hospital - Saudi Arabia

Objective:

To determine the percentage of inadequate glycemic control and its correlates among type 2 diabetes patients attending a private diabetes and endocrine center at Dallah Hospital - Riyadh (KSA). And to compare our results with other previous similar studies which reported the unsatisfactory glycemic control in type 2 diabetes could be related not only to treatment modality and adherence to life style changes, but also to other factors like gender, duration of diabetes, body mass index, and dyslipidemia [1].

Introduction

Diabetes mellitus is the most prevalent non-communicable metabolic disorder, presenting a significant public health burden in all aspects [2]. WHO estimated the affected numbers with diabetes in the year 2000 to reach as much as 170 million, the figure may jump to 366 millions in year 2030 [3,4]. The disease considered to be more frequent in Arab Gulf states compared to Europe and North America [5]. Numbers of clinical studies conducted in Kingdom of Saudi Arabia, demonstrated the high prevalence of the disease almost (34.1%) in Saudi males and (27.6%) in females [6,7] which represent a major public health, in addition to the social and economic burden. Results from mega trails in the recent years had established the central role of tight and sustained glycemic control among type-1 and type-2 diabetic patients, as a result it has been proposed to manage and maintain HA1c to value less than 7% [8]. DCCT and UKPDS clearly demonstrates the link between glycemic control and diabetes complications and UKPDS proved that, as much as 1% reduction in HbA1c led to 21% reduction of death related to diabetes,14% in myocardial infarction and 37% in microvascular complications [9]. This results motivated health care providers and patients to achieve the recommended HbA1c goal [10,11]. Some previous studies have reported the unsatisfactory glycemic control in type 2 diabetes could be related not only to treatment modality and life style changes, but also to other factors like gender, duration of diabetes, body mass index, and dyslipidemia [1], but our study shows some different results.

Materials and Methods

This analytical study designed to estimate the percentage rates of uncontrolled diabetic patients and its correlates among adult population of type 2 diabetes receiving health care at a private diabetes and endocrine center, which is a part of Dallah hospital (350 beds capacity) and have 4 consultants endocrinologist, 2 senior registrar, 2 specialist, one dietitian and 3 health educators, the center receives Saudi and non Saudi patients from all over Riyadh city. 85% of our patients have medical insurance while 15% are self paying patients. The policy at the center recommend that each diabetic patient should receive complete diet counseling and health education settings by a certified clinical nutritionist and health care educator along with foot care counseling when applicable, and a routine laboratory tests following a fixed protocol used in the center according to the ADA recommendations [10] including HbA1c, Lipid profile, kidney function tests and microalbuminuria.

A special standard data collection (Microsoft Excel) program used in the study which contain, information about patients gender, age, nationality, type and duration of diabetes, level of patient education, type of anti diabetic medication and doses (including Insulin, Metformin, Sulfonylurea, Acarbose, Thiazolidinediones and DPP-4 inhibitors) as well as compliance to medications, the blood pressure measurement (taken 5 min after rest in setting position with a Riester brand sphygmomanometer), Body mass index was calculated by dividing the body weight (in kilograms) by the height (in meters) squared (BMI=weight/height2), data about smoking habits, patients adherence to diet , exercise, and self blood glucose monitoring at home were noted. Other associated diseases and co-morbidities as well as diabetes complications like erectile dysfunction in men, peripheral neuropathy in both sex, detection of background diabetic retinopathy were assessed by using a non mydriatic retinal camera (TRC-NW300); history of coronary heart diseases and cerebrovascular accident disease were documented as well, after revision of cardiologist or neurologist notes in patients files, by the clinical findings or by brain scan imaging in case of cerebrovascular accident.

Also all medications prescribed to patients for hypertension, hyperlipidemia and the use of Aspirin (primary or secondary prevention) were documented. The data entered in the excel sheet program by the treating physicians themselves at the end of each patient visit.

A total of 594 patients of age more than 18 years who had type- 2 diabetes were drawn for the study, in the diabetes and endocrine center at Dallah Hospital in Riyadh- Kingdom Saudi Arabia, during the period of February to April 2011. The patients’ inclusion criteria include those who have been followed up in the center for at least one year or more, with regular follow up visits (at least 4 visits/year) and who had complete data information in their hospital file. Patients excluded from study include patient with type-1 diabetes, patient under age of 18 year or type -2 DM with incomplete data in their file or those who have less than 3 visits/year, pregnant ladies with diabetes or gestational diabetes and patients on hemodialysis were excluded in addition to patients with anemia to avoid any factors that may have negative impact in HbA1c value.

Techniques used for testing HhA1c and microalbuminuria are the latex immunoagglutination inhibition assay (DCA systems) [12], and the dry chemistry technique (Vitros) were utilized for lipids testing, study was approved by the hospital ethical committee.

Results

The demographic characteristics in 594 patients showed the different level of education, where 39.2% of patients have got college or university degree, 25% completed secondary schools while 9.5% stopped their education at elementary schools and 26.3% were without formal education. More over the sample showed that 74% of the patients were Saudi and 26.3% were non Saudi, out of them 283 (48%) females and 310 (52%) were male with mean age of both sex of 55.5 years. 7% of the patients were under 40-years of age while more than one third of the studied sample were above 60-years.The mean duration of diabetes in both sex was about 10.6 years with mean body mass index (BMI) of 32.0 (Table 1).

  No. of patients %
Level of education    
College or university level 232 39.2%
Secondary school  level 150 25%
Elementary  school  level 56 9.5%
No formal education 156 26.3%
Nationality    
Saudi 437 74%
Non-Saudi 157 26%
Sex    
Male 310 52%
Female 284 48%
Age (year ) mean 55.6    
< 40 49 7%
40-59 347 59%
60-69 127 22%
>70 70 12%
Duration of  DM 2 (years) mean 10.6    
<5 156 26%
5-10 143 24%
10-15 126 21%
>15 169 28%
Body Mass Index (kg/m2)( mean 32)    
< 19.9 under weight 2 0.3%
20-25 normal weight 68 11%
25.1-30 over weight 181 31%
> 30.1 obese 343 58%
     

Table 1: Demographic characteristics of type 2 diabetic patients (n=594).

The mean average of HbA1c in this study was 7.81% (Table 2), and patients reach adequate glycemic control of less than 7% Hba1c were (35%) 208 of the patients, while patients with fair control HbA1c between 7.1 - 8% were (30.5%) 181 of the patients. The remaining 205 (34.5%) patients had inadequate glycemic control with HbA1c of more than 8%. The average HbA1c in females and males was found almost same as 7.84% and 7.78% respectively. The majority of patients 518 (87%) taking one to three drugs for diabetes, 5.6% taking 4 drugs or more and only 6.7% of the patients were controlled on diet alone. The percentage of patients taking insulin alone or with OHAs constitutes 27% of the patients. Surprisingly 40.7% of our patients were taking DPP-4 inhibitors which are a new class of OHAs introduced recently to gulf markets.

  No. of patients   %
Hb A1c (mean 7.81%) < 7%
7.1-8%
8.1-9%
More than 9%  
208
181
97
108
35.0%
30.5%
16.3%
18.2%
Hb A1c  (mean according to sex)
     Average Hb A1c  ( in females)
     Average Hb A1c  (In males)
284
310
7.84%
7.78%
Number of anti diabetic drugs  prescribed
Diet  only
One drug
2 drugs
3 drugs
4 drugs
5 drugs
40
151
204
163
33
3
6.7%
25.4%
34.3%
27.4%
5.6%
0.5%
Type of anti diabetic drugs  prescribed    
Insulin only 30 5.0%
Insulin & OHAs 133 22.0%
Metformin 510 85.9%
DPP 4 242 40.7%
Sulfonylureas 338 56.9%
TZDs 97 16.3%
Acarbose 8 1.3%
Medications for Hyperlipidemia, HTN and the use of Aspirin    
Aspirin 340 57.2%
ARBs 222 37.4%
ACE 79 13.3%
Statins and or fibrates 436 73.4%

Table 2: HbA1c level and Anti-diabetic medications used for treatment of DM type 2 (patients n=594).

Patients on Aspirin as primary or secondary prevention were almost 57.2% of the patients (Table 2) and 436 (73.4%) of the patients from the studied sample were taking treatment for hyperlipidemia (statins or fibrates) out of them 333 (74%) patients reached LDL-C level of <2.6 mmol/l and only 296 (66%) reached target of less than 1.7 mmol/l for triglycerides. More over 71% of male patients have HDL more than 1 mmol/l, compared to 56% of females with HDL-c of more than 1.2 mmol/l.

Numbers of patients taking antihypertensive treatment were almost 336 (57%) out of them 284 (84.4%) patients got their systolic blood pressure <130 (mmHg) while 305 (90.8%) patients got diastolic blood pressure<80 (mmHg). Urine protein examination revealed that 25% of the patients demonstrated microalbuminuria (less than 300 mg) while 5% have frank proteinuria of more than 300 mg (Table 3).

No of patients %
Patients with hyperlipidemia (n=451)
LDL(mmol/l) ( No. of patients 333 from 451 ) < 2.6
TG (mmol/l) (No. of patients 296 from 451) < 1.7
HDL (mmol/l) Male (No. of patients 163 from 230) ≥ 1.0
8 patients have missed data
Female ( No. of patients 120 from 213) ≥ 1.2
9 patients have missed data
333
296
171

120
74%
66%
71%

56%
Urine protein examination (mcg/mg creatinine). patients (n = 547) Normal < 30
Microalbuminuria 31- 299
Proteinuria > 300

387
135
25

71%
25%
5%
Patient taking anti hypertensive treatment (n=336)

Systolic blood pressure (mmHg) <130
Diastolic blood pressure(mmHg) < 80

284
305

84.40%
90.80%

Table 3: Results of lipids profile, protein in urine and BP measurements (patients n=594).

The study also showed that 18% of the male patients are regular smokers, 40.4% of patients perform regular physical activities of more than 30 minutes a day. 57.7% of the patients were adhering to diet plan as recommended by the dietitian, while 84.2% of patients performing the self blood glucose monitoring at home of more than 2 times/week, and 93% of the studied sample were adherent to their treatment (Table 4).

  No. of patients %
Smoker(males) 56 18.0%
Physical Activities (Participate in at least 30 min /day of physical exercise) 240 40.4%
Adherence to Diet (Following eating plan as recommended by dietitians) 343 57.7%
Adherence to Treatment 550 93.0%
Self Monitoring Blood Glucose at home 500 84.2%

Table 4: Life style and measures of compliance (patients n=594).

Concerning the complication and associated pathology of type 2 diabetes, the adverse effect of hyperglycemia and metabolic disorder leading to serious complications were documented in the study as follow, 24.5% of male patients have got erectile dysfunction, 23% have painful peripheral neuropathy needed treatment,16.2% have retinopathy, 12.5% have ischemic heart disease, 3.3% have cerebrovascular accident, 3.2% got diabetic foot, and 30% have documented microalbuminuria or proteinuria and 14.5% have primary hypothyroidism as associated disorder (Table 5).

Micro proteinuria( 31-299) mcg/mg creatinine 135 25%
Erectile dysfunction (males) 76/310* 24.5%
Peripheral neuro pathy 137 23.0%
Retinopathy 96 16.2%
Hypothyroidism 86 14.5%
Ischemic heart disease 74 12.5%
Proteinuria >300  mcg/mg creatinine 25 5.0%
Cerebro-vascular accident 20 3.3%
Diabetic foot 19 3.2%

Table 5: Complication & associated pathology of diabetes type 2 (Total no. of patients 594).

Discussion

This analytical study was conducted to estimate the percentage rates of controlled and uncontrolled diabetic patients and its correlates among type 2 diabetes population receiving satisfactory health care according to international standard at a private diabetes and endocrine center.

In this study, 35% of the patients got an adequate glycemic control of HbA1c less than 7% (according to ADA recommendation) and 30.5% had HbA1c between 7.1-8% which is not so far from the expected goal. These findings are better than similar studies, done in our region or outside the region [13-18]. The adequacy of glycemic control widely varies due to availability of medications, patient’s income, type of diabetes, patient’s education, culture and life style of populations surveyed, as well as methods used to collect data. For example the percentages of type 2 diabetes patients achieving the target of HbA1c less than 7% in some other centers were about 24% in UK [13], 31% in UAE [14], 17.6% in Kuwait [15], 25% in Finland [16] , 29% in Singapore [17], 27% in Brazil [18], 29.7% in Thailand [19], 32% in Canada [20], 27.5% in Jordan [1].

Certainly it is difficult to reach a desired glycemic control goal despite the availability of all facilities as new classes of drug in form of oral or injectable medication (GLP-1 DPP-4 inhibitors, insulin and insulin analogs) in addition to modern insulin devices. In our study (27%) of type 2 diabetes patients received insulin, and 93% of our patients adhered to their prescribed medication. Yet 2/3 of the patients did not reach the desired HbA1c target of less than 7%, this may be partially due to lack of adherence to recommended life style intervention.

The study showed no relation between gender, BMI and reaching a good glycemic control, as the HbA1c was almost the same in both sex and in normal, overweight or in obese patients, ranging between 7.78%-7.85% (Tables 6 and 7) with insignificant p-value.

Body Mass Index (kg/m2)( mean 32) No.of patients and % HbA1c mean%
20-25 normal weight 68 (11%) 7.83%
25-30 over weight 181 (31%) 7.85%
> 30 obese 343 (58%) 7.78%

Table 6: HbA1c level according to BMI (patients n=594).

Gender No HbA1c Average
Male patients 310 7.78%
Female patients 284 7.84%

Table 7: HbA1c level according to gender (patients n=594).

More over study showed that glycemic control was significantly correlated with the duration of diabetes, as when the duration of the diabetes is less than 5 years the HbA1c average is 7.31% and if the duration is more than 10 years the HbA1c average is 8.22% (Table 8) this may be due to progressive nature of Beta cells destruction in diabetic patient. A correlation was noticed for other variables like, patient’s age and level of lipid profile. Young age group or patients who have lower LDL or Triglycerides has better glycemic control % (Tables 9 and 10). These findings are not consistent with the findings of a number of studies which reported, that younger age groups patients were associated with poor glycemic control [21].

Duration of DM 2 (years) mean 10.6 No of patients and % HbA1c mean%
<5 156 (26%) 7.31%
5-10 143 (24%) 7.58%
10-15 126 (21%) 8.22%
>15 169 (28%) 8.15%

Table 8: HbA1c level according to duration of diabetes (patients n=594).

Age (year ) mean 55.6 No. of patients and % HbA1c mean%
< 40 49 (7%) 7.65%
40-59 347 (59%) 7.91%
60-69 127 (22%) 7.65%
>70 70 (12%) 7.72%
mean 148.25 7.73
Standard Deviation 136.54 0.123

Table 9: HbA1c level according to age group (patients n=594).

LDL and TG level No of patients HbA1c average P-value
LDL less than 2.6 mmol/l 424 7.92%  
LDL more than 2.6 mmol/l 170 7.52% 0.005
TG less than 1.7 mmol/l 338 7.90%  
TG more than 1.7 mmol/l 256 7.68% 0.005

Table 10: Relation between dyslipidemia and HbA1c (patients n=594).

Conclusion

Our study conclude a positive correlation between duration of diabetes, age of patients, dyslipidemia and the glycemic control, but no correlation between gender or body mass index in order to reach a good glycemic control.

Despite the great efforts done by the health care providers to reach the desired glycemic control goal, it’s difficult to achieve an HbA1c level of less than 7%.

Acknowledgements

The authors wish to thank Mr. Salah Saadeh, Statiscian at Dallah Hospital for his support in analysis the data.

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