wed that low level of adherence and abstaining from alcohol/tobacco correlated with poor glycemic control (Table 3).
Table 1. Patients’ characteristics and other variables.
P-values are for the sex differences.
Table 2. Level of glycemic control among the participants.
Table 3. Correlates of good/fair glycemic control in the patients.
*Use of alcohol and/or tobacco.
Figure 1. Age distribution of the patients.
Figure 2. Distribution of fasting Blood glucose in the study population.
The findings of this study reveal an overall poor glycemic control among medical out-patients in one of the major hospitals in Enugu metropolis. A total of 63 (52.9%) had poor control. Glycemic control was similar in males and females, in all age groups and all categories studied. It was slightly better among rural dwellers. Only the poor medication adherence and non-substance use correlated with poor control.
Individuals with FBG greater than 125 mg/dl are at greater risk of developing chronic complications of diabetes and other cardiovascular complications like strokes and myocardial infarction  . Therefore, poor glycemic control status in diabetic patients should be considered a target for public health authorities as well as health educationists.
The rate of poor glycemic control in the index study is within the range reported in Nigeria and the sub-continent  -     . Unlike in most of these studies, we used fasting blood glucose as an indicator of control instead of HbA1C. Although fasting blood glucose offers only a narrow window into the overall blood glucose level of the patient, it is often the most available method of checking glycemic control in our setting and often more likely to be available at home, health centers and most private hospitals. It therefore forms the basis for day to day management of patients and adjustment of medications.
Females and younger patients had non-statistical higher rates of poor control. This is similar to previous studies      . The reasons for relationship between age, gender and glycemic control may be multifaceted. Better glycemic control has been associated with the duration of diabetes  and by implication older individuals. Other factors such as multiple comorbidities in older individual, use of multiple medications and hence increased pill burden, dependency and poverty may all be contributory. The high proportion of females reported in this study may be attributed to fact that females were also younger who are known to be less adherent and have poor health seeking behaviour   . The index report is similar to a previous study from Iran  .
Rural dwellers also had a non-significant higher rate good glycemic control when compared to urban dwellers. Reasons for this may be attitudinal which may be linked to pressure from family members and relatives to try one cure after the other as well as prevalent poor knowledge and practice of diabetes   . The non-significant finding between urban and rural dwellers is similar to was reported from other studies   .
There was no significant difference between patients who were employed and those who were not at the time of the study. The relationship between employment status and affordability of health care may not always be straightforward. It is important to remember that most patients in the African context have very high rates of social support and may not be fully responsible for their medical bills  . Furthermore, being actively engaged during working hours may interfere with taking medications especially insulin.
Similar to other studies BMI did not correlate with glycemic control   . One suggested reason for the lack of correlation between BMI and glycemic control was the fact that patients with diabetes gain weight with age irrespective of glucose control  .
Glycemic control also did not differ significantly between patients with different levels of education. Several studies have reported that formal education significantly improves adherence    which may contribute to glycemic control. However, higher level of education does not necessarily enhance the understanding of the disease and its complications  .
An interesting finding is the negative correlation of substance use (alcohol and tobacco) with poor glycemic control. It is interesting to note that neither of these substances correlated with glycemic control alone but did so when combined. Reasons for this are not clear because of the limitations of the index study. It is an established fact that both tobacco and alcohol may worsen the cardiovascular complications of diabetes just as poor glycemic control. Hence one may be inclined to suggest that those who had poor control and/or who presented with complications were more likely to abstain. In Saudi Arabia, researchers also did not find any correlation between smoking and glycemic control  . The history of previous diabetic coma was recorded in few cases and did not correlate with the level of glycemic control. Diabetic Keto-acidosis has been reported to predict poor long term glycemic control in children   . Previous history of coma in the index study may not only reflect poor control but also severity at diagnosis due to high level of unawareness. Medical comorbidities were common among our patients because of their age distribution. Comorbidities increase pill load leading to drug fatigue and hence non-adherence to medications including anti diabetic drugs. However, there was no correlation between the number of associated comorbidities and level of control which is similar to some studies  .
Improving glycemic control remains a key factor in the management of diabetes and prevention of complications. In a region with high levels of infectious diseases and growing burden of metabolic disorders the measures towards improving glycemic control cannot be overemphasized. The apparent lack of significant correlates in this study suggests that the answer to this problem may lie elsewhere—patients education and lifestyle changes that are associated with it.
This study has some limitations. First, the time between the previous estimation of FPG and the current FPG was not the same for all patients. Secondly, as previously stated HbA1c is more useful in estimating long term control. Thirdly, our study did not include data on diet and lifestyle changes required in the management of such patients. Furthermore, we recruited patients from a teaching hospital set-up which may include many cases of difficult-to-manage cases as well as complicated cases of diabetes which in turn may limit the generalization of our findings.
The majority of the patients in the current study had poor glycemic control status. The level of medication adherence and substance use are correlated with poor control. The index study suggests that many factors may be related to glycemic control which may include patients’ education and drug selection. Further research should be conducted to evaluate patient and physician centered factors in glycemic control.
Conflicts of Interest
The authors declare no conflicts of interest regarding the publication of this paper.
Cite this paper
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