Assessment of Diabetes Control Level and Associated Cardiovascular Risk Factors ()
1. Introduction
According to WHO, 24 million adults live with diabetes in Africa and this figure is expected to rise by 129% to 55 million by 2045. The age-standardized mortality rate for diabetes is 48 per 100.000 inhabitants. This is more than double the global rate of 23 per 100.000. The first cause of death of the diabetic subject is represented cardiovascular diseases [1] .
Our work aimed to assess the level of control of diabetes and associated cardiovascular risk factors.
2. Patients and Method
This was an observational cross-sectional study, conducted from April 13th, 2021 to July 07th, 2021 at the Diabetes and Cardio-Metabolic Diseases Management Centre (DIABCARMET). The patients are managed by specialist doctors, diabetologists and cardiologists.
2.1. Inclusion Criteria
Included in this study were T2D patients:
· 18 years of age or older;
· seen in external consultation;
· followed for at least 03 months at the DIABCARMET centre;
· having a patient record containing parameters to control cardiovascular risk factors.
2.2. Exclusion Criteria
Not included in this study were patients:
· type 1 diabetics;
· hospitalized type 2 diabetics;
· type 2 diabetics followed for less than three months at the DIABCARMET centre;
· whose files were incomplete;
· not having agreed to take part in this study.
2.3. Data Collection
The purpose and approach of our study was clearly explained to patients in order to obtain their consent. A standardized survey sheet in the form of a 6-page questionnaire was designed to collect the various data from our study. This questionnaire examined the following parameters:
v Socio-demographic data
· civil status: surname, first name, age, sex;
· the level of education in French: primary, secondary or university;
· the sector of activity according to the classification of the National Agency of Statistics and Demography of Senegal in sectors of primary, secondary and tertiary activity [2] ;
· Monthly income level: based on World Bank criteria of July 1st, 2020 [3] ;
· the type of health cover: mutual health insurance, health insurance or if he pays at his own expense or with the help of a third party;
v Personal history
· the duration of the T2D;
· ongoing treatment and adherence;
· the duration of evolution of the other risk factors and their treatment;
v lifestyle, namely, active smoking, alcohol consumption and physical inactivity. Physical inactivity was selected for absence of daily physical activity or moderate intensity physical activity < 150 minutes or < 75 minutes for high intensity activity per week [4] ;
v Anthropomorphic data: weight, height, body mass index (BMI) by Quetelet index (weight/height2 in kg/m2), abdominal perimeter. Obesity was selected for BMI ≥ 30 kg/m2; Abdominal obesity from a waist circumference ≥ 102 cm in men and 88 cm in women [5] ;
v the measurement of blood pressure in mm Hg at the office by an automatic blood pressure monitor OMRON Intellisense M6 Comfort. The normal value was a PAS < 140 and/or PAD < 90 mm Hg according to WHO [6] ;
v Comprehensive clinical review of all devices and systems;
v The biological paraclinical exploration included:
· Glycated hemoglobin with a normal rate < 6.5% [7] ;
· Total cholesterol, HDL cholesterol, LDL cholesterol and triglycerides (g/l); the standards selected are those of ESC and EASD 2019 [7] .
The objectives for controlling diabetes and cardiovascular risk factors were:
· a cessation of smoking;
· the absence of a physical inactivity;
· the absence of obesity with a BMI < 30 kg/m2 and a waist circumference <102 cm in men and <88 cm in women;
· Glycated hemoglobin < 7% according to IDF [8] ;
· systolic blood pressure < 130 mm Hg and diastolic blood pressure < 80 mm Hg, according to French National Authority for Health [7] ;
· cholesterolemia as recommended by ESC and EASD in 2019 [7] :
- Total cholesterol < 2 g/l;
- HDL-c > 0.4 g/l;
- A triglyceride level < 1.5 g/l;
- LDL-c < 1 g/l; in patients with moderate CV risk; less than 0.7 g/l in patients with high CV risk and less than 0.55 g/l in patients with very high CV risk.
Patients with type 2 diabetes who had been at high cardiovascular risk for more than 10 years and/or with target organ involvement or cardiovascular disease or kidney failure were considered to be at very high risk.
2.4. Data Analysis
The data analysis was performed with the Excel 2010 software of the Microsoft office suite. The varied uni analysis made it possible to determine the distribution of each variable to be studied.
Quantitative data were expressed as a standard mean ± deviation.
The statistical test used was Xi2 (Khi-two). It was considered significant for a p value < 0.05.
2.5. Ethical Considerations
The subjects investigated all gave their informed consent. The collection of their data was carried out in the respect of anonymity with confidentiality of the information provided.
3. Results
Of a total of 404 patients surveyed, 326 met the inclusion criteria of our study. The number of patients not included was 78 (19.3%). The reasons for exclusion were represented by incomplete patient records (93.59%), a follow-up time of less than three months (5.13%), type 1 diabetes (1.28%). No patient refused to participate in the investigation.
3.1. Sociodemographic Data
The average age of patients was 58 ± 11 years (extremes of 23 and 90 years). The age group [56 - 65] was the most represented with 111 patients (34.05%), followed by those over 65 with 82 patients (25.15%) (Figure 1). 240 female (74%) and 86 male (26%) diabetics; a gender ratio of 0.35.
The proportion of subjects enrolled in the French language was 61% (n = 200 patients), 41% at an elementary level, 37% at a secondary level and 22% at the university level.
One hundred and eighty-two patients (55.8%) were unemployed or retired. Among those who had a profession, the tertiary sector was most represented with 119 patients (36.5%) of the population. Middle-income patients were most represented with 49% in the lower middle and 44% in the upper middle.
The majority of patients (75%) did not have health coverage and paid for their care and medication. The others were either affiliated with a health insurance company or were covered by the Institute of Health Insurance or insurance as shown in Figure 2.
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Ans: years; Fréquence: frequency; Tranche d’âge: age group.
Figure 1. Age distribution of patients.
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PASF (PAE): Paid at own expense; Mutuelle de santé: Mutual health insurance; IPM (HII): Health Insurance Institute; Assurance: insurance; Type de prise en charge: Type of medical care.
Figure 2. Distribution of patients by type of medical care assistance.
3.2. Lifestyle
Seventy-nine patients remained sedentary (24.23%) including 64 women and 15 men (p = 0.10). A notion of smoking was found in 4 patients (1.23%), 2 of whom had stopped smoking for less than 3 years. Alcohol consumption was found in 19 patients (5.83%); including 7 women and 12 men (p = 0.001).
3.3. Duration of Development of Diabetes
Patients with a duration of diabetes of more than 10 years were the most represented (n = 128; 39.26%), followed by those with 1 to 5 years of diabetes with (n = 115; 35.28%).
3.4. Anti-Diabetic Treatment
The most prescribed therapeutic protocols for patients were the combination biguanides-sulfamides hypoglycemic to 96 patients (29.45%) followed by the combination Biganide-Insulin and Biguanide alone prescribed to 51 patients each (15.64%) (Table 1).
3.5. Adherence to Anti-Diabetic Treatment
In our study, 184 patients (56.44%) had minimal adherence problems, 99 patients (30.37%) had good adherence, and 43 patients (13.19%) had poor adherence (Figure 3). Adherence was significantly related to the monthly income level (p = 0.05) but was not related to the education level (p = 0.50) and the professional sector of the patients (p = 0.50).
3.6. Diabetes Control
Two hundred and thirteen patients (65.33%) had glycated hemoglobin less than 7%. The mean value of glycated hemoglobin was 6.78% ± 2.22% with extremes of 4% and 19%.
3.7. Control of Other Risk Factors Associated with T2D
One hundred and twenty-eight patients (39.26%) had a normal BMI, 4 were
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Table 1. Distribution of patients by diabetes treatment.
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Mauvaise observance: poor compliance; Minime problème d’observance: minimal compliance problem; Bonne observance: good compliance; Observance: compliance; Fréquence en %: frequency in %.
Figure 3. Adherence to diabetes treatment.
underweight, 117 were overweight. Sixty-seven patients were still moderately obese and 2 were morbidly obese. Obesity was found in 25% of women and 10.4% of men (p = 0.01). Abdominal obesity was observed in 151 patients, a prevalence of 47.48% of which 139 were female and 12 male (p = 0.001) (Table 2). The average body mass index of our patients was 26.66 ± 4.76 kg/m2, with extremes of 14.98 and 45.2 kg/m2.
Hypertension was associated with T2D in 168 patients, a prevalence of 51.53%. These diabetic-hypertensive patients were divided into 124 female and 44 male (p = 0.90). All hypertensive patients were on antihypertensive treatment. Fourteen of the hypertensive patients had a controlled BP (< 130/80 mm Hg) or a control rate of 8.33%.
Dyslipidemia was observed in 183 patients (56.13%), of which 136 were women (74%) and 47 were men (26%) (p = 0.50). Pure hypercholesterolemia was the most represented type with 173 patients, or 95%. (Table 3). Of these patients, 169 received statin-based lipid-lowering therapy, and one patient was treated with fibrate. One hundred and nine patients (33.44%) met the recommended LDL-c targets.
The general characteristic of the patients is reported in Table 4.
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Table 2. Distribution of patients by BMI.
BMI: body mass index.
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Table 3. Distribution of patients by type of dyslipidemia.
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Table 4. General characteristics of patients by risk factors associated with T2D.
4. Discussion
The average age of patients in our work was 58 ± 11 years. This age of diabetic patients is close to that found by Yameogo et al. in Dakar which was 58.2 ± 9.2 years [9] . Diop et al. and Ndour et al. in African studies found slightly younger patients with an average age of 53.2 ± 9.2 years and 52.2 ± 12.4 years respectively [10] [11] . In contrast, Mcfarlane et al. in the United States found an average age of 64.5 ± 0.33 years [12] and Charpentier et al. in France 62 ± 11 years [13] . Diabetic patients were younger in African studies than in Western studies. This difference could be explained by the higher life expectancy in the West.
In our work, we noted a female predominance with a sex-ratio of 0.35 as found by Yameogo et al. with a sex-ratio of 0.3 [9] and Belhadj in Algeria [11] . On the other hand, a meta-analysis of European studies found a male predominance [14] . This female predominance in our study could be explained by the fact that women are the majority of patients attending hospital structures in our context. This hypothesis had already been defended by Yameogo et al. in a similar study [9] .
The prevalence of obesity in our study was 21.16%. Yameogo et al. found a lower prevalence of 9.11% of obese patients while Charpentier et al. in France found a higher prevalence of 39% [9] [13] .
The prevalence of abdominal obesity was 47.48% with a very significant female predominance (p = 0.001) in our work. This state of affairs could find its explanation at the socio-cultural level, given that African black societies seem to generally encourage overweight among women, being seen as an aesthetic criterion or sign of social comfort. Abdominal obesity is associated with increased metabolic and cardiovascular morbidity and mortality; it leads to a greater sensitivity of perivisceral fat to the lipolytic action of catecholamines, sympathetic nervous system and cortisol, causing an increase in the release of free fatty acids leading to insulin resistance and therefore predisposition to diabetes.
Just under a quarter of patients in our work remained sedentary (24.23%); without any significant difference between the two sexes. In his series, Yameogo et al. found that four out of five patients were sedentary [9] . Mbaye et al. also found a prevalence of 79.7% of physical inactivity among diabetics in their series [11] .
The relatively low sedentary level in our study contrasts with levels obtained in other studies across the country. This could be explained by the fact that our study, being carried out in a center dedicated to cardio-metabolic diseases, the management of patients is much more specialized.
However, the still high rate of inactivity could be explained by the advanced age of the patients, the prevalence of obesity and overweight as well as the female predominance. Indeed, these conditions are often factors limiting the practice of physical activity.
Regular physical activity was identified in the INTERHEART study as one of three factors that reduce the risk of myocardial infarction (the other two being: regular fruit and vegetable consumption and moderate alcohol consumption) [15] . The cardiovascular benefit of regular physical activity, especially in type 2 diabetics, would come from a significant decrease in peripheral insulin resistance, resulting in a decrease in fasting blood sugar. It also remains beneficial in lowering blood pressure by lowering peripheral vascular resistance.
In our series, tobacco consumption was found in 2 patients (0.6%). This rate was lower than that of 6% found by Yameogo [9] . Charpentier and Belhadj reported prevalence close to 11% and 10% of smokers in their populations, respectively [13] [16] . In McFarlane et al., 17% of men and 7% of women were smokers [12] . The INTERHEART study found that smoking was the second risk factor for myocardial infarction after dyslipidemia [15] . Therefore, its management suggests special attention and patients will have to be accompanied as necessary by supportive psychotherapy for the termination.
A duration of evolution of more than 10 years is found in more than one third of our patients of our work (39.26%) as by several other authors [9] [13] reflecting the chronic nature of this condition.
One-third of our study population (30.37%) had good adherence and just over half had minimal adherence problems (56.44%). Only 13.19% had poor adherence. The reasons for this poor adherence were dominated by poor understanding of treatment followed by fear of addiction or addiction. Low monthly income was a significant cause of poor adherence. The compliance level of our study population was higher than that found by Yameogo et al. [9] . Tieno and Abobo et al. had found optimal adherence in Burkina in 46.8% and 45% of patients respectively [17] [18] .
In the light of these data on anti-diabetic treatment, it is clear that therapeutic education efforts remain to be made to improve patient compliance.
If we consider a glycated hemoglobin target < 7%, 213 patients (65.34%) were controlled. This control rate was higher than the 28.8% found by Yaméogo et al. [9] and the 26.7% found by McFarlane [12] . Belhadj et al. in Algeria found control rates even lower at 18.7% [16] . The relatively low sedentary rate of our population may have contributed to this. Moreover, the rate of prescription of insulin therapy (42.6%) in line with the duration of diabetes in our series contrasts with the therapeutic inertia often observed in studies of sub-countries developed in relation to the low availability and accessibility of insulin associated with a fear of hypoglycemia [1] .
The prevalence of hypertension was 51.53% in T2D in our study with a control rate of 8.33%. A control rate of hypertension slightly higher than that of 5.4% found by Yaméogo et al. and lower than the rates of 22% found by Sayad et al. [19] 26.5% found by McFarlane in the USA [12] . It appears that blood pressure control is still very insufficient in hypertensive diabetic patients. In diabetics, dual therapy or triple therapy is recommended.
With respect to cholesterol control, 109 patients (33.44%) had achieved LDL-c targets. This rate was close to 35.5% found by Mcfarlane et al. [12] and was higher than the 4% reported by Yameogo et al. [9] .
5. Conclusion
Type 2 diabetes was frequently associated with other cardiovascular risk factors. Control of diabetes and these factors was insufficient. Therapeutic education of type 2 diabetics patients adapted to our socio-cultural realities needed to be improved. It would also be relevant to carry out longitudinal follow-up of these patients.