Journal of Diabetes & Metabolism

To determine the percentage of inadequate glycemic control and its correlates among type 2 diabetes patients attending a private diabetes and endocrine center at Dallah Hospital - Riyadh (KSA). And to compare our results with other previous similar studies which reported the unsatisfactory glycemic control in type 2 diabetes could be related not only to treatment modality and adherence to life style changes, but also to other factors like gender, duration of diabetes, body mass index, and dyslipidemia [1].

Diabetes mellitus is the most prevalent non-communicable metabolic disorder, presenting a significant public health burden in all aspects [2]. WHO estimated the affected numbers with diabetes in the year 2000 to reach as much as 170 million, the figure may jump to 366 millions in year 2030 [3,4]. The disease considered to be more frequent in Arab Gulf states compared to Europe and North America [5]. Numbers of clinical studies conducted in Kingdom of Saudi Arabia, demonstrated the high prevalence of the disease almost (34.1%) in Saudi males and (27.6%) in females [6,7] which represent a major public health, in addition to the social and economic burden. Results from mega trails in the recent years had established the central role of tight and sustained glycemic control among type-1 and type-2 diabetic patients, as a result it has been proposed to manage and maintain HA1c to value less than 7% [8]. DCCT and UKPDS clearly demonstrates the link between glycemic control and diabetes complications and UKPDS proved that, as much as 1% reduction in HbA1c led to 21% reduction of death related to diabetes,14% in myocardial infarction and 37% in microvascular complications [9]. This results motivated health care providers and patients to achieve the recommended HbA1c goal [10,11]. Some previous studies have reported the unsatisfactory glycemic control in type 2 diabetes could be related not only to treatment modality and life style changes, but also to other factors like gender, duration of diabetes, body mass index, and dyslipidemia [1], but our study shows some different results.

This analytical study designed to estimate the percentage rates of uncontrolled diabetic patients and its correlates among adult population of type 2 diabetes receiving health care at a private diabetes and endocrine center, which is a part of Dallah hospital (350 beds capacity) and have 4 consultants endocrinologist, 2 senior registrar, 2 specialist, one dietitian and 3 health educators, the center receives Saudi and non Saudi patients from all over Riyadh city. 85% of our patients have medical insurance while 15% are self paying patients. The policy at the center recommend that each diabetic patient should receive complete diet counseling and health education settings by a certified clinical nutritionist and health care educator along with foot care counseling when applicable, and a routine laboratory tests following a fixed protocol used in the center according to the ADA recommendations [10] including HbA1c, Lipid profile, kidney function tests and microalbuminuria.

A special standard data collection (Microsoft Excel) program used in the study which contain, information about patients gender, age, nationality, type and duration of diabetes, level of patient education, type of anti diabetic medication and doses (including Insulin, Metformin, Sulfonylurea, Acarbose, Thiazolidinediones and DPP-4 inhibitors) as well as compliance to medications, the blood pressure measurement (taken 5 min after rest in setting position with a Riester brand sphygmomanometer), Body mass index was calculated by dividing the body weight (in kilograms) by the height (in meters) squared (BMI=weight/height2), data about smoking habits, patients adherence to diet , exercise, and self blood glucose monitoring at home were noted. Other associated diseases and co-morbidities as well as diabetes complications like erectile dysfunction in men, peripheral neuropathy in both sex, detection of background diabetic retinopathy were assessed by using a non mydriatic retinal camera (TRC-NW300); history of coronary heart diseases and cerebrovascular accident disease were documented as well, after revision of cardiologist or neurologist notes in patients files, by the clinical findings or by brain scan imaging in case of cerebrovascular accident.

Also all medications prescribed to patients for hypertension, hyperlipidemia and the use of Aspirin (primary or secondary prevention) were documented. The data entered in the excel sheet program by the treating physicians themselves at the end of each patient visit.

A total of 594 patients of age more than 18 years who had type- 2 diabetes were drawn for the study, in the diabetes and endocrine center at Dallah Hospital in Riyadh- Kingdom Saudi Arabia, during the period of February to April 2011. The patients’ inclusion criteria include those who have been followed up in the center for at least one year or more, with regular follow up visits (at least 4 visits/year) and who had complete data information in their hospital file. Patients excluded from study include patient with type-1 diabetes, patient under age of 18 year or type -2 DM with incomplete data in their file or those who have less than 3 visits/year, pregnant ladies with diabetes or gestational diabetes and patients on hemodialysis were excluded in addition to patients with anemia to avoid any factors that may have negative impact in HbA1c value.

Techniques used for testing HhA1c and microalbuminuria are the latex immunoagglutination inhibition assay (DCA systems) [12], and the dry chemistry technique (Vitros) were utilized for lipids testing, study was approved by the hospital ethical committee.

The demographic characteristics in 594 patients showed the different level of education, where 39.2% of patients have got college or university degree, 25% completed secondary schools while 9.5% stopped their education at elementary schools and 26.3% were without formal education. More over the sample showed that 74% of the patients were Saudi and 26.3% were non Saudi, out of them 283 (48%) females and 310 (52%) were male with mean age of both sex of 55.5 years. 7% of the patients were under 40-years of age while more than one third of the studied sample were above 60-years.The mean duration of diabetes in both sex was about 10.6 years with mean body mass index (BMI) of 32.0 (Table 1).

Table 1: Demographic characteristics of type 2 diabetic patients (n=594).

The mean average of HbA1c in this study was 7.81% (Table 2), and patients reach adequate glycemic control of less than 7% Hba1c were (35%) 208 of the patients, while patients with fair control HbA1c between 7.1 - 8% were (30.5%) 181 of the patients. The remaining 205 (34.5%) patients had inadequate glycemic control with HbA1c of more than 8%. The average HbA1c in females and males was found almost same as 7.84% and 7.78% respectively. The majority of patients 518 (87%) taking one to three drugs for diabetes, 5.6% taking 4 drugs or more and only 6.7% of the patients were controlled on diet alone. The percentage of patients taking insulin alone or with OHAs constitutes 27% of the patients. Surprisingly 40.7% of our patients were taking DPP-4 inhibitors which are a new class of OHAs introduced recently to gulf markets.

Table 2: HbA1c level and Anti-diabetic medications used for treatment of DM type 2 (patients n=594).

Patients on Aspirin as primary or secondary prevention were almost 57.2% of the patients (Table 2) and 436 (73.4%) of the patients from the studied sample were taking treatment for hyperlipidemia (statins or fibrates) out of them 333 (74%) patients reached LDL-C level of <2.6 mmol/l and only 296 (66%) reached target of less than 1.7 mmol/l for triglycerides. More over 71% of male patients have HDL more than 1 mmol/l, compared to 56% of females with HDL-c of more than 1.2 mmol/l.

Numbers of patients taking antihypertensive treatment were almost 336 (57%) out of them 284 (84.4%) patients got their systolic blood pressure <130 (mmHg) while 305 (90.8%) patients got diastolic blood pressure <80 (mmHg). Urine protein examination revealed that 25% of the patients demonstrated microalbuminuria (less than 300 mg) while 5% have frank proteinuria of more than 300 mg (Table 3).

Table 3: Results of lipids profile, protein in urine and BP measurements (patients n=594).

The study also showed that 18% of the male patients are regular smokers, 40.4% of patients perform regular physical activities of more than 30 minutes a day. 57.7% of the patients were adhering to diet plan as recommended by the dietitian, while 84.2% of patients performing the self blood glucose monitoring at home of more than 2 times/week, and 93% of the studied sample were adherent to their treatment (Table 4).

Table 4: Life style and measures of compliance (patients n=594).

Concerning the complication and associated pathology of type 2 diabetes, the adverse effect of hyperglycemia and metabolic disorder leading to serious complications were documented in the study as follow, 24.5% of male patients have got erectile dysfunction, 23% have painful peripheral neuropathy needed treatment,16.2% have retinopathy, 12.5% have ischemic heart disease, 3.3% have cerebrovascular accident, 3.2% got diabetic foot, and 30% have documented microalbuminuria or proteinuria and 14.5% have primary hypothyroidism as associated disorder (Table 5).

Table 5: Complication & associated pathology of diabetes type 2 (Total no. of patients 594).

This analytical study was conducted to estimate the percentage rates of controlled and uncontrolled diabetic patients and its correlates among type 2 diabetes population receiving satisfactory health care according to international standard at a private diabetes and endocrine center.

In this study, 35% of the patients got an adequate glycemic control of HbA1c less than 7% (according to ADA recommendation) and 30.5% had HbA1c between 7.1-8% which is not so far from the expected goal. These findings are better than similar studies, done in our region or outside the region [13-18]. The adequacy of glycemic control widely varies due to availability of medications, patient’s income, type of diabetes, patient’s education, culture and life style of populations surveyed, as well as methods used to collect data. For example the percentages of type 2 diabetes patients achieving the target of HbA1c less than 7% in some other centers were about 24% in UK [13], 31% in UAE [14], 17.6% in Kuwait [15], 25% in Finland [16] , 29% in Singapore [17], 27% in Brazil [18], 29.7% in Thailand [19], 32% in Canada [20], 27.5% in Jordan [1].

Certainly it is difficult to reach a desired glycemic control goal despite the availability of all facilities as new classes of drug in form of oral or injectable medication (GLP-1 DPP-4 inhibitors, insulin and insulin analogs) in addition to modern insulin devices. In our study (27%) of type 2 diabetes patients received insulin, and 93% of our patients adhered to their prescribed medication. Yet 2/3 of the patients did not reach the desired HbA1c target of less than 7%, this may be partially due to lack of adherence to recommended life style intervention.

The study showed no relation between gender, BMI and reaching a good glycemic control, as the HbA1c was almost the same in both sex and in normal, overweight or in obese patients, ranging between 7.78%-7.85% (Tables 6 and 7) with insignificant p-value.

Table 6: HbA1c level according to BMI (patients n=594).

Table 7: HbA1c level according to gender (patients n=594).

More over study showed that glycemic control was significantly correlated with the duration of diabetes, as when the duration of the diabetes is less than 5 years the HbA1c average is 7.31% and if the duration is more than 10 years the HbA1c average is 8.22% (Table 8) this may be due to progressive nature of Beta cells destruction in diabetic patient. A correlation was noticed for other variables like, patient’s age and level of lipid profile. Young age group or patients who have lower LDL or Triglycerides has better glycemic control % (Tables 9 and 10). These findings are not consistent with the findings of a number of studies which reported, that younger age groups patients were associated with poor glycemic control [21].

Table 8: HbA1c level according to duration of diabetes (patients n=594).

Table 9: HbA1c level according to age group (patients n=594).

Table 10: Relation between dyslipidemia and HbA1c (patients n=594).

Our study conclude a positive correlation between duration of diabetes, age of patients, dyslipidemia and the glycemic control, but no correlation between gender or body mass index in order to reach a good glycemic control.

Despite the great efforts done by the health care providers to reach the desired glycemic control goal, it’s difficult to achieve an HbA1c level of less than 7%.

The authors wish to thank Mr. Salah Saadeh, Statiscian at Dallah Hospital for his support in analysis the data.