Investigating metabolic control and complications in type 2 diabetic patients with low income in northwest of Iran, 2023

doi:10.21203/rs.3.rs-4924836/v1

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Investigating metabolic control and complications in type 2 diabetic patients with low income in northwest of Iran, 2023

https://doi.org/10.21203/rs.3.rs-4924836/v1

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Background and aim: Socioeconomic factors are very important in non-communicable diseases (NCD) and their complications as a risk factor or as a barrier to receive

effective health care. This study aimed to determine the prevalence of diabetes complications and factors related to glycemic control in type 2 diabetic patients with low income in Kurdistan Province, Iran.

Method: This cross-sectional study was conducted on 608 diabetic patients supported by the Imam Khomeini Relief Foundation in 2023 in the province of Kurdistan, northwest of Iran. In addition to collecting demographic data, major complications of diabetes were specified by clinical examination by specialist physicians and paraclinical data. Data analysis was performed in Stata version 16 using descriptive statistics and logistic regression modeling.

Results: A total of 608, 76.6% female, with mean age 62.7 years were investigated. Prevalence of retinopathy, nephropathy, neuropathy, and diabetic foot ulcers were 42.9%, 6.9%, 3.3% and 4.3%, respectively. HbA1C levels were favorable (≤7.5) in only 231 (38.0%) patients. Longer duration of diabetes was associated with worse glycemic control, whereas comorbidity of DM and hypertension was significantly associated with good glycemic control.

Conclusion: Based on the results obtained, the health care and glycemic control status of low-income diabetic patients is not favorable. Considering the vulnerability of this group due to their low-risk perception and low income, it is recommended to teach self-care behaviors and plan routine care to prevent disease complications and, if necessary, fully cover the cost of care for these patients by the national health system.

Diabetes

Complication

Retinopathy

Neuropathy

Diabetic foot ulcer

Nephropathy

Low-income

Diabetes is a chronic metabolic disease characterized by elevated blood glucose levels, which over time, if not controlled, can lead to serious which, if not treated, leads to serious complications such as cardiovascular disorders, retinopathy, nephropathy and neuropathy.[1]

The population of diabetics is increasing all over the world, most of whom live in low- and middle-income countries. [2]About 1.5 million deaths per year worldwide are directly related to diabetes. [3]The global increase in type 2 diabetes prevalence, particularly in middle- and low-income countries, is well documented. [4] In 2021, 537 million adult diabetics live in the world, which is estimated to increase by 46% to 783 million people by 2045 and the prevalence of diabetes from 10.5–12%. Over 90% of people with diabetes have type 2 diabetes, which is driven by socio-economic, demographic, environmental, and genetic factors[5]

Worldwide, the number of people with diabetes has quadrupled in the last three decades, and diabetes is the ninth leading cause of death. Currently, 1 in 11 adults worldwide has diabetes, and 90% of them have type 2 diabetes. [6] Chronic complications of diabetes are classified as microvascular (such as diabetic kidney disease, diabetic retinopathy and neuropathy) or macrovascular (cardiovascular disease) and lead to mortality and reduced quality of life. Hyperglycemia plays an important role in the pathogenesis of microvascular complications such as diabetic retinopathy, primary nephropathy and neuropathy, while atherosclerosis plays a role in the pathogenesis of macrovascular complications. [7, 8] Diabetes mellitus and hypertension often coexist. These two diseases are considered to be among the most prevalent in human societies. Among the many microvascular complications of diabetes, hypertension plays an important role in the development of diabetic nephropathy through glomerular hyperfiltration. Hypertension also causes atherosclerosis in diabetes. Thus, hypertension is a risk factor for chronic microvascular and macrovascular complications of diabetes. [9]

In recent decades, a large increase in the prevalence of diabetes has been observed in almost all regions of the world, particularly in disadvantaged areas. [5] For example, a study in Middlesbrough and East Cleveland, United Kingdom, showed that the prevalence of diabetes has increased in deprived areas. [10] In patients with diabetes, attention should be paid not only to treatment processes, because the social level and awareness of the patient play a role in the accurate control of blood glucose, which is the main cause of chronic complications. Also, the economic level of the patient is very important in terms of receiving health services and regular visits to follow up the treatment process. All these factors are very effective in preventing and delaying chronic complications and improving the quality of life of patients. People with low-income level and covered by support institutions are among the vulnerable groups in the field of health care and treatment due to their lack of economic power. The aim of this study was to determine the prevalence of diabetes complications and factors related to glycemic control in low-income people covered by governmental support institution in Kurdistan Province, Iran.

Study design, setting and study participants

The current study is a cross-sectional study (descriptive-analytical) conducted on 608 diabetic patients covered by the Imam Khomeini Institute, which supports the poor in society, in Kurdistan province, in 2023. The participants in this study had a low socioeconomic level and lived in the outskirts of the city or in remote areas

Patients were selected by census from the list of people covered by welfare institutions and from two densely populated cities of Kurdistan province (Sanandaj and Saqez).

Data collection and measurements

For all patients, demographic characteristics including age, sex, smoking, hypertension and hyperlipidemia, duration of diabetes, and family history of diabetes were recorded on a researcher-developed checklist. In addition, the exact value of the patients' body mass index (BMI) was calculated by measuring their height and weight and entered into the checklist. The status of care for these patients, including data on referrals to comprehensive health centers, annual visits to general practitioners, nutritionists, ophthalmologists, and internists, was also collected through patient interviews and entered into the checklist. All patients were then referred to ophthalmology, internal medicine, and cardiology specialists for a complete evaluation of diabetes complications. In addition, FBS and HbA1c tests were performed in a single laboratory using the same kits to check the patients' glycemic control status.

Ethical considerations

The proposal for this study was evaluated and approved by the Ethics Committee in Kurdistan University of Medical Sciences, Iran (Ethics Code: IR.MUK.REC.1401.329). Written informed consent was obtained from the participants before the data collection. Several methods were used to protect the confidentiality, anonymity and privacy of the participants. No personal information were written on the reports, and their data were collected using an assigned number rather than their name.

Statistical analyses

Data analysis was done using Stata software version 16. First, the data were summarized using descriptive indices such as mean, standard deviation, frequency, relative frequency and related graphs. Logistic regression modeling was used to evaluate the association between study variables and parameters of glycemic control, including fasting blood glucose (FBS) and hemoglobin A1c (HbA1c). The significance level of the tests used is considered to be 0.05.

A total of 608 patients with diabetes including 142 (23.4%) men and 466 (76.6%) women were investigated were investigated and followed to determine the complications of diabetes the situation of disease control among them.

The mean and standard deviation age of the patients were 62.7 ± 9.7 (min 14 and max 102) years. The mean and standard deviation of BMI and diabetes duration were 27.4 ± 3.5(min 16.4 and max 48.0) and 10.4 ± 5.7 (min 1 and max 32) years, respectively. Among the study patients, 445(73.2%) and 83 (13.7%) individuals were overweight and obese. The frequency of demographic and clinical factors is detailed in Table 1.

Table 1

Baseline demographic and clinical characteristics of the study subjects
Variable		N (%)
Sex
	Female	466 (76.6)
	Male	142 (23.4)
Hyperlipidemia
	No	214 (35.2)
	Yes	394 (64.8)
Hypertension
	No	212 (34.9)
	Yes	396 (65.1)
Familial history of diabetes
	No	270 (44.4)
	Yes	338 (55.6)
Current smoker
	No	601 (98.8)
	Yes	7 (1.2)
History of smoking
	No	586 (96.4)
	Yes	22 (3.6)
BMI
	< 25	80 (13.2)
	≥ 25	528 (86.8)
Age, mean ± SD		62.7 ± 9.7
Diabetes duration, mean ± SD		10.4 ± 5.7
BMI, mean ± SD		27.4 ± 3.5

When examining the complications of diabetes, the results showed that 261 (42.9%) patients had some degree of diabetic retinopathy. Neuropathy and nephropathy were reported in 20 (3.3%) and 42 (6.9%) patients, respectively. 184 (30.3%) patients had cardiac complications and 26 (4.3%) patients had diabetic foot ulcers. (Fig. 1).

Other variables that investigated in the present study were to check the level of regular visits to the 1st level of providing primary health care services (health care providers, general practitioners and nutritionists) and the 2nd level of providing specialized services (internal specialists and ophthalmologists). Based on the obtained results, the annual regular care of patients by internist and ophthalmologist is 7.1% and 20.2%, respectively. Only 39.6% of patients had regular visits to health centers once every three months, and less than 20% of cases were visited by a general practitioner once every three months. In addition, only 25.5% of the patients had regular nutrition counseling once every 6 months. (Fig. 2)

When examining the fasting glucose levels and HbA1C of the patients to compare their glycemic control with the standard glycemic targets[11–13], the results showed that fasting glucose levels were higher than 130 in 456 (75%) patients. Also, HbA1C values were favorable (≤ 7.5) in only 231 (38.0%) patients. Tables 2 and 3 show the modeling of the relationship between the variables studied and the control of diabetes in patients based on two indicators: fasting blood glucose and HbA1C.

Table 2

Logistic regression modeling of association between study variables and diabetes control (FBS < 130)
Variables	OR (95%CI)	P value
Sex (male vs. female)	1.13 (0.71–1.80)	0.613
Age	1.01 (0.98–1.02)	0.849
Diabetes duration	0.94 (0.91–0.98)	0.002
BMI	1.01 (0.95–1.06)	0.984
Hypertension	2.12 (1.35–3.33)	0.001
Hyperlipidemia	1.03 (0.67–1.57)	0.895
Familial history of DM	0.63 (0.42–0.94)	0.024
Smoking history	1.33 (0.51–3.48)	0.558
OR: odds ratio; CI: confidence interval

As shown in Table 2, diabetes duration, hypertension, and family history of diabetes are three significant factors associated with glycemic control based on FBS values. Longer duration of diabetes was associated with poorer glycemic control (OR = 0.94;95%CI:0.91–0.98). The odds of diabetes control (FBS ≤ 126mg/dl) among patients with hypertension were significantly 2.12 times (95%CI:1.35–3.33) higher than those without hypertension. Family history of DM is another significant factor associated with poorer glycemic control (OR = 0.63;95%CI:0.42–0.94).

Table 3

Logistic regression modeling of association between study variables and diabetes control (HbA1C < 6.5)
Variables	OR (95%CI)	P value
Sex (male vs. female)	1.06 (0.66–1.55)	0.946
Age	1.015 (0.99–1.03)	0.123
Diabetes duration	0.95 (0.90–0.96)	< 0.001
BMI	1.01 (0.95–1.06)	0.895
Hypertension	2.05 (1.36–3.10)	0.001
Hyperlipidemia	1.02 (0.68–1.51)	0.934
Familial history of DM	0.87 (0.60–1.27)	0.467
Smoking history	1.32 (0.53–3.28)	0.554
OR: odds ratio; CI: confidence interval

As shown in Table 3, the results of logistic regression modeling showed that diabetes duration and hypertension were two significant factors associated with glycemic control based on HbA1C levels. Longer duration of diabetes was significantly associated with poorer glycemic control/higher HbA1c (OR = 0.95;95%CI:0.90–0.96). The odds of diabetes control (HbA1C ≤ 7.5) in patients with hypertension were significantly 2.05 times (95%CI:1.36–3.10) higher than in those without hypertension.

This study was conducted to investigate the status of glycemic control and prevalence of diabetes complications in patients with low socioeconomic status in Kurdistan Province, western Iran. The results showed that more than 42% of the patients had some degree of diabetic retinopathy. Nearly 7% of the patients had nephropathy and 4.3% of them had diabetic foot ulcers. Although all reported cardiac complications may not be due to diabetes, based on our findings, cardiac complications were reported in about 30% of the patients. In addition to these cases, the patients' glycemic control status was not adequate, such that about 75% of the patients had fasting glucose levels above 130 mg/dL. HbA1c levels were also unfavorable (> 7.5) in approximately 62% of patients.

According to our results, the prevalence of retinopathy as a major microvascular complication was high (42%). In a systematic review conducted in 2022, the median prevalence (interquartile range) of retinopathy was reported to be 12% (6%-15%). [14] Leon Litwak et al, in a large study of 66726 DM patients in 28 countries across four continents (Asia, Africa, Europe and South America), showed that 53.5% of patients had microvascular complications [15]. The results of a systematic review in North Africa indicated 8.1–41.5% for the prevalence of retinopathy, which is consistent with our findings. [16]

Data modeling in this study showed that duration of diabetes and hypertension were two independent variables related to patients' blood glucose control. People who had diabetes for a longer period of time had poorer blood glucose control. In a study conducted by Mohammed Badedi et al. in Saudi Arabia, they showed that the duration of diabetes over 7 years had a direct relationship with blood glucose control[17], which is not consistent with the results of the present study. According to our data, people with high blood pressure were more likely to have good blood glucose control. It seems that having diabetes and hypertension at the same time may have increased patients' adherence to treatment and their attention to disease control. Another significant variable related to glycemic control was family history of diabetes, such that people with a family history of diabetes were significantly less likely to have fasting glucose levels below 126 mg/dL.

The results showed that patients' care, especially their self-care and regular visits to primary and secondary health care to control blood glucose and prevent related complications, is poor. For example, when discussing self-care, patients did not pay much attention to their weight control, such that 528 (86.8%) of the patients were overweight or obese (BMI > 25). In addition, the percentage of visits and regular care for patients in any of the planned care for patients, including regular visits to general practitioners, internists, ophthalmologists and nutritionists, was no more than 40%.

In general, although the prevalence of diabetes is increasing in most countries of the world, data on the prevalence of complications of the disease in different populations, especially low-income populations, are limited. According to a 2002 study, the prevalence of diabetes is higher in developed countries than in developing countries, although the complications of the disease are more severe in developing countries. [18] There are few studies in the world on the complications of diabetes in low-income people.

The present study has strengths and limitations. The most important strength of this study is the large sample size, accurate and direct examination of diabetes control indicators, and diagnosis of disease complications by relevant specialists. In addition, this research is the first study in Iran that specifically examines the prevalence of diabetes complications and the control status of this disease in one of the vulnerable groups of society, namely people with low income. Another strength of the study is that in addition to examining complications, it also evaluated the care status of these patients at the first and second levels of the health care system. The lack of a control group of people with a high-income level and the comparison of the studied indicators with these people is the main weakness of the present study. Another drawback of this study was the way the prevalence of nephropathy was determined. Because the detection of nephropathy was based on proteinuria and not microalbuminuria, the prevalence of nephropathy is underestimated.

At the time of questionnaire completion and referral, it was noted that a number of patients were being screened for the first time for retinopathy, cardiac complications, nephropathy, and neuropathy. In addition, almost none of the patients were being regularly monitored for glycemic control using the HbA1C index twice a year. Perhaps the most important reason for their non-referral, apart from the lower risk perception of these patients with regard to complications of the disease, is the economic status of the family. It is clear that in such vulnerable groups, in addition to informing patients and teaching self-care behaviors, it is necessary to plan the necessary care by the health system on a regular basis.

The data of this study showed that the condition of blood glucose control in diabetes patients with low-income level is not favorable. In addition, the level of health care and self-care of these patients is not in accordance with the standards of diabetes care. The referral of patients to receive nutritional counseling, regular blood glucose monitoring, and control of possible microvascular complications in these patients is very poor.

Given that lower risk perception and low income may play a role in the implementation of diabetes control care in this vulnerable group, planning for teaching self-care behaviors, regular referral and follow-up of patients, and, where appropriate, funding of their care by a national health system is recommended.

Competing Interests

The authors have no conflict of interests to declare.

Funding

This study was financially supported by the Kurdistan University of Medical Sciences and not role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Authors' contributions

SY, KR and BN designed the study. KR and PM collected the data. KR analyzed the data, and drafted the manuscript in collaboration with SY and BN. All the authors reviewed the data, read and approved of the manuscript.

Acknowledgements

This study was part of an approved MD thesis in Kurdistan University of Medical Sciences. We would like to thank the Health Deputy and Treatment Deputy of Kurdistan University of Medical Sciences for collaboration in this work. We also thank all the study participants.

Ethics approval and consent to participate

The proposal of the study was evaluated and approved by the Ethics Committee in Kurdistan University of Medical Sciences, Iran (Ethics Code: IR.MUK.REC.1401.329). All procedures were performed in accordance with the Declaration of Helsinki and informed consents were obtained from all subjects.

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No competing interests reported.

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You are reading this latest preprint version

Investigating metabolic control and complications in type 2 diabetic patients with low income in northwest of Iran, 2023

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Abstract

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Introduction

Materials and methods

Study design, setting and study participants

Data collection and measurements

Ethical considerations

Statistical analyses

Results

Discussion

Conclusion

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References

Additional Declarations

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