Prevalence of Diabetes Mellitus and its Association with Diabetic Peripheral Neuropathy, Peripheral Vascular Disorder among Security Personnel in United Arab Emirates

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Prevalence of Diabetes Mellitus and its Association with Diabetic Peripheral Neuropathy, Peripheral Vascular Disorder among Security Personnel in United Arab Emirates

https://doi.org/10.21203/rs.3.rs-4944110/v1

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Aim: The purpose of this study was to investigate the prevalence of Diabetes Mellitus (DM) and associated complications such as Diabetic Peripheral Neuropathy (DPN), and Peripheral Vascular Disease (PVD) among security personnel in the United Arab Emirates.

Methods: Data was gathered from a sample of 166 security professionals, aged 25–65, with a minimum of 8 hours of daily work hours, and at least 2 years of experience, using an observational, cross-sectional study design. The 10 g Semmes Weinstein monofilament testing, The Michigan Neuropathy Screening Instrument, and Vibration Pressure Threshold were used for DPN screening followed by the DN4 questionnaire, and the Ankle Brachial Index (ABI) was used for PVD assessment. An ethical clearance has been received from the Institutional Research Board (IRB) and informed consent was obtained from all subjects.

Results: The study found a prevalence of 9.6% of DM among security personnel in the UAE. It also found a statistically significant and strong association between DM and DPN (r=0.83, p < 0.001). On the other hand, a moderate correlation was found with PVD (r= 0.56). SPSS version 29 was used for data analysis and the statistical significance was set at p-value ≤0.05).

Conclusion: The prevalence of DM among securities in UAE is 9.6%, which is significant as the total DM prevalence in UAE according to the 2021 report is 12.3%. There is a strong correlation between DM and DPN suggesting that security personnel could be at higher risk of developing “Diabetic Foot Syndrome” due to the nature and demand of the job. In addition, neuropathy and peripheral vascular disease could increase the risk and cause associated foot complications.

Health sciences/Endocrinology

Health sciences/Health care

Health sciences/Health occupations

Diabetes Mellitus

security personnel

Peripheral vascular disease

Diabetic peripheral neuropathy

Diabetes Mellitus (DM) is a metabolic disease, causing a rise in blood glucose levels [1]. According to WHO, DM ranked 9th in the top 10 causes of death in 2020, and it also ranked 8th in DALYS (disability-adjusted life years) in 2019 [2]. It consists of numerous categories based on pathogenesis such as Type1, Type2, and gestational along with those caused by other disorders (endocrinopathies and steroid use) [3]. Fasting plasma glucose level > 126 g/ml or HbA1C level of > 6.5% is considered as the criteria for diagnosis of DM [4]. DM type 2, being the most common is caused due to insulin resistance or insufficient production [5]. It is majorly seen in middle-aged and older adults, who have persistent hyperglycemia caused due to dietary choices and poor lifestyle [3].

The disease has long-term complications including both microvascular, such as Diabetic peripheral neuropathy (DPN), and macrovascular, such as Peripheral vascular diseases (PVD)[5]. Peripheral vascular disease is a progressive circulation disorder caused by blockage, spasm, or narrowing of blood vessels. It has been studied that DM also increases the risk of atherosclerosis, which in turn further raises the risk of PVD[6]. DPN causes damage to peripheral nerves due to poor or uncontrolled blood glucose levels, with symptoms such as loss of sensation, pain, numbness, and tingling along with muscle weakness [6].

Security personnel oversee upholding a safe and secure environment in various sectors such as health, commercial, residential, etc. The working conditions of securities could be unfavorable, which includes extended and irregular working hours, fixed postures, exposure to extreme weather conditions, and night and shift duties. One of the major concerns is that this job requires them to work in an upright posture for prolonged hours and this can be a potential risk for various health conditions [7]. The associated risk could be higher in the presence of DM.

According to the International Diabetic Federation in 2021, the prevalence of DM in the UAE was 12.3% [8]. DM is a major health concern regarded as one of the key areas of research interest in the UAE. As per our literature review, the prevalence of Type 2 DM (T2DM) has not been assessed in specific professions in the UAE. Thus, a knowledge gap was identified supported by a lack of research on security guards regarding the prevalence of DM and its associated complications. Another factor that adds to studying this population is that the profession necessitates sitting and standing for longer hours, which itself is a potential risk factor for developing asymptomatic arterial insufficiencies. As PVD and DPN usually do not show many symptoms and go unnoticed generally, the chances of foot complications are higher. In addition, neglected and unattended PVD and DPN cases can cause diabetic foot ulcers which can eventually lead to disability with amputation. Thus, screening is recommended before the symptoms act up for both prevention and management. Therefore, the study aims to screen DM cases among security personnel in UAE and identify its macro as well as microvascular complications such as PVD and DPN under the following objectives:

To find the prevalence of Diabetes Mellitus among the security personnel in UAE.

To find out the association of Diabetes Mellitus with Diabetic peripheral neuropathy and Peripheral vascular disease among security personnel in UAE.

Study Design and Settings: A cross-sectional study was conducted at the College of Health Sciences, Gulf Medical University, Ajman, UAE. Sample and data collection was multicentric from different emirates of UAE. The study was flexible in including every sector where the securities were available. Security agencies across the UAE like universities, schools, and security accommodations were contacted for their cooperation in providing participants (security personnel) in the study. Participants who were willing to participate signed an informed consent form before their inclusion in the study. The ethical review board of GMU approved the study protocol (IRB-COHS-STD-59-NOV-2023) following which recruitment and data collection was initiated. The study was conducted between November 2023 to June 2024.

Inclusion Criteria:

Age 25–65 years.
Male and female security personnel.
Working for a minimum of 8 hours per day
Minimum 2 years of work experience in the field

Exclusion Criteria:

Type 1 diabetes.
Diagnosed/ Reported cases of peripheral neuropathy due to conditions other than diabetes
Undiagnosed (absence of Lab report) and self-reported cases of diabetes mellitus

Sampling Method and Sample Size: The study used non-probability convenience sampling. As per the reported DM prevalence of 12.3% in UAE [8], the required sample size was calculated to be 166 with a margin of error or absolute precision of \(\:\pm\:\)5% at 95% confidence, using the Scalex SP calculator [9].

Study Protocol and Procedure: Security personnel were recruited and familiarized with the data collection procedure. They were provided with a written informed consent form and were asked to read it carefully, giving them a chance to enquire and ensuring their willingness to participate in the study. Demographic data was collected on their age, gender, years of experience in the security field, and diabetes duration. Participants who reported diabetes were asked to confirm by providing the latest laboratory report (FBS, PPBS, and HBA1C). A total of 228 security personnel were screened, out of which 166 met the inclusion criteria for further screening of DM, DPN, and PVD. Before measuring blood pressure, the participants were made to stay relaxed in a high sitting position for 5 minutes to ensure that they were at resting posture. Brachial systolic blood pressure along with ankle systolic blood pressure were both recorded using Omron 5450 blood pressure monitor bilaterally and the means of both sides were noted to ensure accurate readings and to avoid possible errors. The usage of this machine has been validated for accurate results [10]. The ABI was calculated as the ratio of ankle systolic pressure to brachial systolic pressure. Following this, the participants were then screened for peripheral neuropathy using 10g Semmes Weinstein monofilament in both feet. To accurately measure the sensory response, the 10 g monofilament was placed perpendicular to the sole, and an even pressure was applied to the great toe and other spots (as shown in Fig. 1). The participants were considered positive for peripheral neuropathy if they failed to feel the monofilament sensation in more than one spot, 7/10 correct response was considered as a delayed response [11, 12]. The Michigan Neuropathy Screening Instrument (score ≥ 7-part A, score > 2-part B and Vibration Pressure Threshold (score > 20 Volts on Biothesiometer) was also used to affirm the presence of peripheral neuropathy [12, 13]. Participants who tested positive for peripheral neuropathy were given the Douleur Neuropathique en 4 Questions (DN4) questionnaire to check for the presence, severity, and nature of the neuropathy pain if present.

This study used a systematic approach to check the prevalence of DM amongst security personnel. All the procedures used in this study were standardized which allowed for accurate findings and analysis, contributing to the reliability and validity of this research.

Statistical Analysis: SPSS version 29 was used to conduct the statistical analysis. Demographic data such as age, gender, location, presence of diabetes mellitus, and years of work were analyzed using descriptive statistics. Following the test of normality, the Pearson correlation test was used to determine the association of diabetes with DPN and PVD (Table 4). The level of significance was set at p < 0.05.

Sample characteristics: This study recruited 166 security personnel across different sectors such as health, commercial, residential, etc. The mean age of the participants was 34.95\(\:\pm\:\)8.15 years. The descriptive data and diabetic profile for the participants has been listed in Table 1. The gender proportion in our sample has been listed in Fig. 2.1. The locations for data collection are shown in Fig. 2.2. The status of diabetes mellitus within the security personnel is shown in Fig. 2.3.

Table 1

Descriptive statistics and diabetic profile of the participants.
VARIABLES	MEAN AND STANDARD DEVIATION
Age	34.95 ± 8.15 years
BMI	23.41 ± 4.97
PRB	79.18 ± 11.68 beats per minute
BPSB	131.31 ± 17.83 mmHg
PRA	79.59 ± 11.03 beats per minute
BPSA	169.67 ± 24.99 mmHg
ABI	1.29 ± 0.12
Years of work	6.51 ± 4.97 years
Years of DM	6.70 ± 2.73 years
FBS (Diabetes cases only)	123 ± 37.89 mg/dL
PPBS (Diabetes cases only)	243 ± 75.11 mg/dL
HbA1C (Diabetes cases only)	7.10 ± 2.03%
Abbreviations used: BMI- Body Mass Index, PRB- Pulse Rate Brachial, BPSB- Blood pressure systolic, brachial, PRA- Pulse Rate Ankle, BPSA- Blood pressure systolic, ankle, ABI- Ankle Brachial Index, DM- diabetes mellitus, FBS- Fasting Blood Sugar level, PPBS- Post- Prandial Blood Sugar level, HbA1C- Glycated Hemoglobin levels

The prevalence of diabetes among the security was found to be 9.6% (Table 2) while the presence of Diabetic Peripheral Neuropathy, measured using Semmes- Weinstein monofilament, MNSI and VPT is mentioned in Table 3. The monofilament test showed positive responses in 3 nondiabetic people and 10 diabetic people. The higher mean score for MNSI and Volts was suggestive of confirmed cases of DPN (7/16) of diabetic population (Table 3). Additionally, it was also found that security guards with DPN also had neuropathic pain with a mean DN4 scale score of 3.75\(\:\pm\:\)2.05 (Table 3). The mean Ankle Brachial Index value calculated from all the participants was 1.29\(\:\pm\:\)0.12.

Table 2

The prevalence of diabetes among our sample.
	Frequency	Percent
Yes	16 people	9.6%
No	150 people	90.4%

Table 3

Screening of diabetic peripheral neuropathy among the DM cases.
Monofilament finding
	Frequency	Percent
Positive	10 out of 16 DM cases	62.5%
Michigan Neuropathy Screening Instrument (MNSI)
PART A (Mean ± s.d)- 9 ± 3	7 out of 16 DM cases	43.75%
PART B (Mean ± s.d)- 3.5 ± 2	7 out of 16 DM cases	43.75%
Biothesiometer
Vibration Pressure Threshold in Volts (Mean ± s.d)-26.44 ± 7.38	9 out of 16 DM cases	56.25%
DN4 score (Mean ± s.d)
3.75 ± 2.05	3 out of 16 DM cases	18.75%

Table 4

Association of Diabetes Mellitus and its complications (DPN and PVD)
		ABI	DPN
Diabetics	Pearson correlation (r-value)	0.56	0.83
	P value	0.03	< 0.001
Non- Diabetics	Pearson correlation (r-value)	0.16	Not Applicable
	P value	0.62	Not Applicable

Table 4 illustrates the association between diabetic securities with ABI and DPN. There was a moderate correlation between people with diabetes and the Ankle Brachial Index (r = 0.56). This correlation was statistically significant (p = 0.03). On the other hand, it was observed that there was a strong correlation (r = 0.83, p < 0.001) between the presence of diabetes and the DPN.

The study aimed to find the prevalence of diabetes among security personnel and to associate it with complications like PVD and DPN in the United Arab Emirates. The findings from this study highlight a note-worthy association of DM with its complications among an important population group. Our sample comprised 166 predominantly male participants with a mean age of 34.95 ± 8.15 years. The mean BMI was calculated as 23.41 ± 4.97, which falls within the normal range, but a tendency toward overweight [14]. It was noted that the systolic blood pressure measured from the ankle, although high, fell within the normal range (110–170 mmHg) provided by Gong et al. (2015) [15], this could be due to decreased arterial compliance in the peripheral arteries. As the compliance of the arteries goes down, especially in the periphery, the pulse pressure increases, this causes an elevation in the readings of the ankle BP. This process is more marked in middle-aged and elderly because of the natural stiffening of the arteries. The diabetics in our sample had an average FBS level of 123 ± 37.89 mg/dL, PPBS level of 243 ± 75.11 mg/dL, and HbA1C levels of 7.1 ± 2.03 %. The igher value of standard deviation in the demographics of our sample indicates the larger spread of the participants' data.

As per our review of the literature, few retrospective and descriptive analyses indicated a certain value of prevalence of diabetes mellitus which differed according to their sample, ranging from 8.6% [16] to 25.1% [17]. International diabetes federation (IDF), in 2017, IDF reported a 17.3% [18] prevalence of T2DM in UAE adults aged from 20–79. In 2019, it estimated a rate of 16.3 % Click or tap here to enter text.for adult in UAE suffering from type 2 diabetes mellitus [19]. The recent report by the IDF in 2021 identified that the prevalence of DM in the UAE is 12.3% [8] .The prevalence of diabetes mellitus among our sample was 9.6 %. The participants with diabetes mellitus hadthe disease for an average of 6.70 ± 2.73 years and the levels of the FBS, PPBS are indicative of poor glycemic control among them. The study identified a prevalence of 62.5 % for the presence of diabetic peripheral neurpathy according to the monofilament test. However, the MNSI and VPT indicated DPN among 43.75 % and 56.25 % respectively, which further confrmed the reults. These screening tools have shown to have good reliability and accuracy [20, 21]. The mean DN4 results among the participants was 3.75 ± 2.05 indicating moderate pain levels in those with DPN.

The association of diabetes with DPN was statistically significant (r = 0.83, p < 0.01) which signifies a considerable link between DM and the development of neuropathy (Table 4). This result falls in line with a previous study done by Al Sabbah et al. (2019) which suggests that DPN is the 2nd most common complication of T2DM [22]. The measurement of the mean ABI recorded in our study was 1.29, this indicates that there was no significant oddity in the status of the peripheral vascular condition among the security personnel because it falls within the normal range (0.9–1.4) given by Farfan. et al. (2021) [23]. The study suggested that the ABI limit falling within this range proposes normal blood flow and negligible risk of PVD [23]. However, the moderate correlation between ABI and diabetes (r = 0.56) indicated that diabetic individuals may be at an increased risk for PAD. This aligns with the study done by Khan. et al. (2021) [11]which suggested that the risk of developing vascular complications is much higher in diabetic people. Petrie. et al. (2018) stated that people with diabetes are twice as likely to get hypertension in comparison to those without diabetes [5]. Both micro and macrovascular complications are closely associated with diabetes mainly due to the presence of chronic hyperglycemia and insulin resistance which have a major role in initiating the process of these complications. Various mechanisms can lead to these complications namely, oxidative stress, inflammation, and increased production of glycation end products (AGEs) and their activation (RAGE) [5].

Recent research shows that neuropathy is one of the leading complications of diabetes [13]. AGE-induced damage increased vascular permeability, oxidative stress, and polyol accumulation are among the downstream cellular effects of hyperglycemia that are common with prolonged diabetes [24]. An absolute treatment approach to prevent the occurrence of neuropathy mainly due to diabetes is still in the process of being discovered hence, decelerating the process of development, and preventing the occurrence of complications are extremely important to reduce the harshness of neuropathy [18].

Limitations and future recommendations: The study instruments used in this study are not the gold standard diagnostic tool for the provisional diagnosis of the condition but only serve as a screening tool for detecting the presence of DPN. Hence these results must be verified with appropriate diagnostic measures like NCV. However, they are the most widely used measures in a community-based study. The other limitations of this study include relying on data obtained only from the 3 emirates, namely, Ajman, Dubai, and Ras al Khaimah, therefore it is difficult to generalize this data in the entire United Arab Emirates. The study design of this research was cross-sectional, perhaps a longitudinal study would have given us more precise data along with normal variations. The blood pressure measurement during our study was taken from both the arms and ankles and a mean was obtained, however, the measurement was only taken at once and not a minimum of 3 readings due to time constraints and the duty of security guards not allowing them to spare much time. A Doppler test could be more reliable. Moreover, the major limitation of this study was not considering the presence of confounding factors such as medications, smoking status, dietary habits, genetic factors, sleep, caffeine intake, and stress levels which contribute majorly to the variations in blood pressure and status of DM.

This study adds to the understanding of the prevalence of diabetes and its associated complications amongst the security personnel in the UAE. It was found that the presence of DM among securities is high with a prevalence of 9.6%, as compared to 12.3% in the whole of UAE. The resultant observation concludes there was a statistically significant association between diabetic mellitus and its complications PVD and DPN, this underscores the necessity of implying occupational health measures along with preventive strategies for the targeted population.

Addressing these health conditions and acting on them will help enhance the overall well-being and productivity of security personnel resulting in better health outcomes and reduced cost of healthcare.

Ethics approval and consent to participate: An informed written informed consent was obtained from all participants. Ethical approval for the study was obtained from the Institutional Research Board, College of Health Sciences, Gulf Medical University. The data collection procedure followed the ethical guidelines from “ Declaration of Helsinki”.

Consent for publication: Not Applicable

Availability of data and materials: All data generated or analyzed during this study are included in the supplementary file.

Competing interests: Authors declare no competing interest in this research work.

Funding: No funding is available for this research.

Authors Contribution: All authors contributed significantly to the manuscript under specific roles described below:

MA- Mohamed Anas Mohamed:

Data curation, Formal analysis, Methodology, Writing – original draft, review, editing, approval

SM- Saheema Moila Kiriyath:

Data curation, Formal analysis, Methodology, Writing – original draft, review, editing, approval

HD- Huda Mohamed Saddik Sheikh: Data curation, Formal analysis, Methodology, Writing – original draft, review, editing, approval

AD- Anjela Davis Panattuparambil: Data curation, Formal analysis, Methodology, Writing – original draft, review, editing, approval

SF- Shahwar Fatima Ansari: Data curation, Formal analysis, Methodology, Writing – original draft, review, editing, approval

PK- Praveen Kumar Kandakurti: Conceptualization, Project administration, Supervision, Writing – original draft, review & editing

KG- Kumaraguruparan Gopal: Methodology, Writing – original draft, Writing – review & editing

AH- Animesh Hazari: Conceptualization, Supervision, Analysis, Writing – original draft, review & editing, approval of final draft

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No competing interests reported.

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Prevalence of Diabetes Mellitus and its Association with Diabetic Peripheral Neuropathy, Peripheral Vascular Disorder among Security Personnel in United Arab Emirates

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