INTRODUCTION
The health impact of
Diabetes Mellitus is a cause for concern in the world and in Nigeria. The
prevalence worldwide in 2021 was one of ten people.1 According to WHO, more than 95% of people
with Diabetes have type 2 Diabetes Mellitus (DM)2. The estimated
prevalence in Nigeria is 4.3% and that in Port Harcourt is 6.8%. 3
Prevalence is increasing more in low and medium countries (including Nigeria)
than in high income countries. 2 Up to 75% of adults with diabetes
are found in low and middle income countries. 1
As far back as
2018, it was estimated that one out of seventeen adults in Nigeria were living
with diabetes Mellitus. 4 This a staggering figure.
Statement of problem
Negative outcomes in
terms of morbidity and mortality have been associated with poor glycaemic
control which can be further complicated by dyslipidaemia. 5, 6, 7.
Both are independent risk factors for cardiovascular and cerebrovascular
accidents. 5, 8
Up to 85
percentage of patients with type 2 DM have dyslipidaemia. (range
is 70- 85%) Cardiovascular events are a major cause of mortality in patients
with diabetes. (at least 50%) 6,7
Cardiovascular events associated with Type 2 DM include Ischaemic heart disease,
stroke, coronary artery disease and peripheral artery disease.6
Patients with
type 2 DM and dyslipidaemia are up to four times more at risk for
cardiovascular accidents than the general population.
Poor glycaemic
control is a contributory factor to cardiovascular risk.5 Good
glycaemic control alone does not eliminate cardiovascular risk in the presence
of dyslipidaemia because dyslipidaemia is an independent risk factor for
cardiovascular events in patients with diabetes. Therefore, there is a negative
multiplier effect which if not properly managed would affect outcome
Dyslipidaemia
usually exists several years before diabetes is diagnosed. This means that at
the time of diagnosis and presentation the patient is already at risk for
cardiovascular events. A Canadian study also discovered that over half of the
population of persons who had diabetes for two years had dyslipidaemia. 9
It is
mandatory for persons with type 2 DM be screened for dyslipidaemia regardless
of other risk factors. The presence of dyslipidaemia should be determined at
diagnosis and yearly afterwards. 10
It is of
utmost importance to establish the current presentation pattern of newly
diagnosed diabetic patients in our own environment
The aim of
this study was to assess the pattern of glycaemic control and dyslipidaemia in
newly diagnosed persons with Type 2 Diabetes Mellitus attending the medical
clinic of RSUTH over a four month period in 2023.
METHOD
Study Design: This was a retrospective cross-sectional study. Carried out over a
period of 4 months using patients records in the
diabetic clinic of a tertiary hospital in Rivers State.
Study Area: This is one of the two tertiary
hospitals in Rivers State. A state in southern Nigeria.
Sample population was new patients attending the diabetic arm of the medicine clinic.
Inclusion
criteria was any first time patient attending the medicine clinic with
diabetes. Exclusion criteria was any patient attending the medicine clinic that
did not have diabetes.
Sample size was 63. 63 patients’ data were recalled, and analysed with MS Excel and
SPSS. All the new patients within the four months period were 63. Purposive
sampling technique was used.
The results of
the following laboratory investigations were obtained from the records. Fasting
plasma glucose, Glycated haemoglobin, Triglycerides, Total cholesterol and HDL.
LDL was calculated.
Data analysis: Data was entered into an excel
sheet and exported to SPSS version 23 for analysis.
Result. Most respondents were females 66.2%, majority were above 50 years
(70.6%) and the three most common presenting complaints were excessive
urination (22.2%), poor vision (13.9%) and numbness of feet (11.1%). 80% had
poor glycaemic control (ADA level 1 hyperglycaemia) and 84% had various forms
of dyslipidaemia (raised total cholesterol 26.3%, raised (LDL 73.7%) and
reduced HDL 44.7%). Mean HbA1c was 12%. The most common dyslipidaemia was
elevated LDL. However no significant statistical correlation between
hyperglycaemia and dyslipidaemia was found.
DISCUSSION
Most of our patients
were females and this is not unexpected as females are more prone to diabetes.11
A fifth of the
patients presented with untreated and uncontrolled diabetes as evidenced by
features of target organ damage. The most frequent presentations being frequent
urination, poor vision and numbness of the feet. Diabetes is uncontrolled when
the glucose level is above 11mmol/l in a random specimen. These patients were
not previously on treatment as this was their first time in the clinic and
their presenting complaints were features of organ damage.
Untreated
diabetes is when a diabetic patient has not been on treatment before and
uncontrolled diabetes is when a patient is on treatment and the blood glucose
is not properly controlled. 12
Poor vision
and numbness of feet are microvascular complications of diabetes. 13
Diabetes retinopathy is the commonest cause of preventable blindness. 14
It is possible to slow the progress of diabetic retinopathy if it is detected
in the early or moderate stages. However, loss of vision is irreversible. 14
Most patients with diabetes retinopathy have no symptoms especially in the
early stages. 11, 14 Usually annual eye
check is recommended for patients with diabetes. Some patients have some symptoms and they
include, blurred vision, distorted vision, impaired colours, presence of
floaters and loss of vision.14
A study done
in Nnewi had a higher percentage of people presenting with visual disturbances.
Of the first-time patients in their clinic, 44% (as opposed to our 13.2%)
presented with either bilateral or unilateral blindness. 15
Majority of
the patients had various forms of dyslipidaemia. (84%). This is expected as
there is a strong interplay between hyperglycaemia and hyperinsulinemia and the
evolution of dyslipidaemia. 16 The typical picture found in these
patients has been termed diabetic dyslipidaemia.17
Hyperglycaemia
increases oxidative stress and enhances leucocyte endothelial interactions and
leads to glycosylation of proteins in the body leading eventually to the
formation of Advanced Glycosylation End Products (AGE) 18 which will
in the long run affect endothelia cell as well as vascular wall function and
promote atherothrombosis. Hyperglycaemia also induces
hyper acetylation of a histone molecule in the genes coding for diabetes and
cardiovascular disease,19 in addition it
induces DNA methylation of genes coding for glucose metabolism. The effect of
these in, in-vitro studies has been found up to six days after one
hyperglycaemic episode.
Diabetic
dyslipidaemia tends to present with an increased level of small dense LDL (sdLDL). 17 Postprandial lipaemia
also presents as the clearance of lipoprotein remnants from the blood stream
tends to be modulated by the presence of diabetes. In diabetic patients the
rate of production of VLDL is increased and in uncontrolled cases the LDL
receptors can be decreased, these eventually lead to macrovascular
disease.
The
dyslipidaemia and hyperglycaemia need to be treated as a matter of urgency to
reduce the cardiovascular risk and improve patient outcomes. 6
Primary prevention here involves preventing and delaying new onset of
cardiovascular disease in Type 2DM patients by detecting risk factors and
managing them. Those with dyslipidaemia can now be stratified into high risk
and very high risk based on the presence of ASCVD and end organ damage to
determine the depth of treatment. 10
Several
treatment algorithms exist by various groups for Patients with Type 2 diabetes
and dyslipidaemia and include, intense life style modification and
pharmacological treatment. (including use of statins
and newer lipid lowering drugs) to be re-evaluated every 8 to 16 weeks till the
patient stabilizes. 7 9 10 Treatment is individualized.
Healthy life
style practises remain a fundamental part of CVD prevention strategies and
management of diabetes. It is vital in minimizing the incidence of CVD. The
goal is to maintain the LDL -C below 2mmol/L or to achieve a reduction of 50%
from the baseline value.9 Lifestyle intervention includes, weight
management, exercise, well balanced, moderate energy meals, elimination,
reduction in or moderate intake of alcohol as well elimination all tobacco
products. 10
The World
Health Organization has strongly recommended that the quality of care of
persons with diabetes be intensified and more initiative and preventive than
reactionary. 20 The WHO took this a step further and established a
five point target for people with diabetes and number four involves have a
minimum of 60% of affected people 40 years and above receiving statin therapy. 21
The goal is to
lower the lipid level. The lower the better, the earlier the better. 22
To achieve
this, after selecting the pathway for the patient, the expected target should
be clearly communicated with them. Then these patients can have their lipid
profile reassessed every 8 to 12 weeks, to monitor the effect of the instituted
treatment.
Glycaemic
control goals when accessed using glycated haemoglobin is a target of less than
7%. 5
CONCLUSION
Majority of the new
patients attending the diabetes clinic at presentation had dyslipidaemias and
need immediate effective intervention to improve mortality and morbidity.
Conflict of interest:
Authors have declared
that there was no conflict of interest
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