Introduction: Diabetes mellitus (DM), is the universally occurring non-communicable disease as well as exemplary health problem affecting peo-ple worldwide.1 The number of cases of DM are rising at an enormous pace irrespective of any age, gender, economic status or ethnicity around the globe.Objective: To evaluate the macro-vascular complications and its correlation with different risk factors among type-2 diabetic patients.Methodology: This cross-sectional study was conducted at Red Crescent General Hospital Latifabad Hyderabad from October 2018 to October 2020. Type 2 diabetics of either gender, between age 20 and 70 years, on diabetic medication visited during the study duration were included in the study. Data related to socio-demographic details and clinical features was collect-ed from the participants using a written questionnaire. Collected data was analyzed using SPSS ver. 22.Results: Significant association (p&lt;0.05) was demonstrated between Coro-nary artery diseases and the risk factors like; age of patient, the duration of diabetes mellitus, diastolic as well as systolic blood pressures, body mass index and serum triglycerides levels. While the statistically significant asso-ciation (p&lt;0.05) of peripheral vascular diseases with the duration of diabe-tes mellitus, systolic blood pressure and serum triglyceride levels. Whereas, cerebrovascular disease was associated (p&lt;0.05) with age, systolic and diastolic BP.Conclusion: The coronary artery disease seems to be most frequent macro-vascular complication among the type 2 diabetic patients. Whereas the risk factors including; advancing age, duration of diabetes mellitus, hyperten-sion, BMI as well as serum triglycerides levels are the most significant fac-tors for these complications.Key Words: Coronary artery disease, Cerebrovascular Disease, Diabetes Mellitus Type 2, Peripheral vascular diseas

Allah Bachayo Rajar

Ghulam Hussain Baloch

Munazza Shaikh

Partab Puri

Sadiq Ali Khowaja

Tariq Feroz Memon

English

Journal of Muhammad Medical College, Mirpurkhas

  J Muhammad Med Coll  Vol 11 (2) Nov 2020-April 2021 Abstract:  Introduction: Diabetes mellitus (DM), is the universally occurring non-communicable disease as well as exemplary health problem affecting peo-ple worldwide.1 The number of cases of DM are rising at an enormous pace irrespective of any age, gender, economic status or ethnicity around the globe. Objective: To evaluate the macro-vascular complications and its correlation with different risk factors among type-2 diabetic patients. Methodology: This cross-sectional study was conducted at Red Crescent General Hospital Latifabad Hyderabad from October 2018 to October 2020. Type 2 diabetics of either gender, between age 20 and 70 years, on diabetic medication visited during the study duration were included in the study. Data related to socio-demographic details and clinical features was collect-ed from the participants using a  written questionnaire. Collected data was analyzed using SPSS ver. 22. Results: Significant association (p<0.05) was demonstrated between Coro-nary artery diseases and the risk factors like; age of patient, the duration of diabetes mellitus, diastolic as well as systolic blood pressures, body mass index and serum triglycerides levels. While the statistically significant asso-ciation (p<0.05) of peripheral vascular diseases with the duration of diabe-tes mellitus, systolic blood pressure and serum triglyceride levels. Whereas,        cerebrovascular disease was associated (p<0.05) with age, systolic and    diastolic BP.  Conclusion: The coronary artery disease seems to be most frequent macro-vascular complication among the type 2 diabetic patients. Whereas the risk factors including; advancing age, duration of diabetes mellitus, hyperten-sion, BMI as well as serum triglycerides levels are the most significant fac-tors for these complications. Key Words: Coronary artery disease, Cerebrovascular Disease, Diabetes Mellitus Type 2, Peripheral vascular diseases. Introduction: Diabetes mellitus (DM), is the universally occurring non-communicable disease as well as exemplary health problem affecting people worldwide.1 The num-ber of cases of DM are rising at an enormous pace irre-spective of any age, gender, economic status or ethnic-ity around the globe.2This rise in number of cases of DM and its related degenerative effects as well as complications poses an enormous social and economic burden to population.2According to the international          Journal of Muhammad Medical College Website: jmmc.mmc.edu.pk Original Article   1: Registrar Medicine, Department of Medicine, Liaquat University Hospital, Hyderabad    2: Senior Lecturer, Department of Community Medicine, Muhammad Medical College, Mirpurkhas    3: Associate Professor, Depart-ment of Community Medicine Muhammad Medical College, Mirpurkhas.   4: Assistant Professor, Department of Community Medicine Isra University, Hyderabad.    5: Assistant Professor, Department of Community Medicine Muhammad Medical College, Mirpurkhas.  6: Assistant Professor, Department of Community Medicine LUMHS, Jamshoro   *=corresponding author  ghulamhussain95@gmail.com  Macrovascular Complications and their risk factors in Type 2 Diabetic Patients in Hyderabad, Pakistan. Munazza Shaikh 1, *, Sadiq Ali Khowaja 2, Allah Bachayo Rajar3, Ghulam Hussain Baloch 4, Partab Puri 5, Tariq Feroz Memon 6.  53  J Muhammad Med Coll  Vol 11 (2) Nov 2020-April 2021 diabetes federation (IDF), approximately 463 million people between age 20 and 79 years are living with DM while this toll is expected to rise up to 700 million by 2045. Over two third of DM cases are residing in low- and middle-income countries.3 Type 2 diabetes mellitus (DMT2) is the most common type of DM that accounts for around 90% of DM cases throughout the globe. The number of DMT2 cases are increasing in most of the countries.4Approximately, 374 million people are already at risk of developing type 2 diabetes worldwide.1 Various micro and macro-vascular complications are associated with DMT2 that may have which correspondingly have severe individual and social consequences.5Long term macro-vascular complications of DM like peripheral vascular disease (PVD), coronary artery diseases (CAD) and cerebrovascular diseases like stroke are rapidly growing and strongly associated with the DMT2 and 2-4 folds more common in DMT2patient-comparison with those without diabetes.6According to the world health organization (WHO), the prevalence of CAD only in Eastern Mediterranean region (EMRO) is  54% while these deaths may vary from 13% to 49% depends on the country that also accounts for consider-able number of deaths in the region.7 Pakistan is amongst the low-middle income country where the overall 70% of global burden of diabetics is present.8During 2019, IDF reported 6.8% prevalence of DM among 20–79 years’ age adults in Pakistan. This surge in diabetes cases is attributed to distorted life-style and rapid urbanization in the country.9 Despite this rise in prevalence, very limited studies have report-ed the burden of DM complications and the risk factors linked with the complications of disease in the coun-try.8The studies conducted in past highlighted the high incidence of the co-morbidities among diabetics in Paki-stan which stresses on the strict presentational measures and early detection of disease.10 Prevalence studies on the complications of DMT2 give noticeable and significant information that play a pivot-al role in the policy and practice. But still the scantiness of information related to the risk factors for the co-morbidities in DMT2 patients in Pakistan specially in Sindh and its cities demand a need for attention, screening and interventional program to estimate the prevalence and correlation of risk factors of different co-morbidities of DM in Sindh. For this reason, the pre-sent study was designed with an aim to evaluate the macro vascular complications and its relationship with different risk factors among type-2 diabetic patients in at tertiary care hospital of Hyderabad, Sindh, Pakistan. Methodology:  A cross-sectional study was conducted at Red Crescent General Hospital Latifabad Hyderabad from October 2018 to October 2020. All patients visited the outpa-tient department or admitted in the hospital with posi-tive history of DMT2, taking any medication (insulin or oral hypoglycemic drugs or both), between age of 20 and 70, either gender, socioeconomic status or religion, given consent of participation were included in the study. Patients with type I DM, not willing to partici-pate, mentally compromised or unconscious were ex-cluded from the study. Informed consent was obtained from all the partici-pants individually prior to the commencement of the interviews. Sample size of 435 was calculated using Rao-soft 11online sampling calculator while non-random consecutive sampling technique was applied for selection of participants. A pre-designed and pre-tested written questionnaire was used to collect infor-mation of all the study participants. The questionnaire comprises of questions regarding socio-demographic variables like; age, sex, economic status, education status, information of Body Mass Index (BMI), duration of disease, medication history, family history of diabe-tes and smoking history and the details of laboratory diagnosis as well as any comorbidities on examination.  The Body weight was calculated wearing least amount of clothing and height was measured without wearing the shoes. BMI measured using formula; BMI = kg/m2 where kg is a person’s weight in kilograms and m2 is their height in meters square. BMI between 18.5 and 24.9 was labelled as healthy while BMI <18.5 (Underweight), 25.0-29.9 (overweight) and ≥30.0 was considered as obese11. Serum glucose (Random and Fasting) levels, Glycated hemoglobin (HbA1c), total lipid profile including; se-rum cholesterol, serum High density lipoprotein (HDL), serum low density lipoprotein (LDL) and serum very low-density lipoprotein (VLDL) were measured.  the hyper-tension (HTN) status of the patients using the WHO standard definition for HTN. Statistical analysis was per-formed using SPSS ver. 22. Demographic variables and co-morbidities were demonstrated by descriptive statis-tics. Mean and standard deviation (SD) were deter-54  J Muhammad Med Coll  Vol 11 (2) Nov 2020-April 2021 mined for quantitative data. Student t-test was per-formed for determining the association amongst macro-vascular complications and its risk factors. Level of sig-nificance was set at P < 0.05. Results: Out to total 435 participants, most of the participants were female. Most (70.87%) participants were 40 years of age or above, while 29.13% were younger than 40 years of age. The age ranges between 27 and 71 years, with a mean age of 48.7 ±10.8 years. was 24.21±4.08 kg/m2.    * ppbg: Post prandial blood glucose     * HTN: Hypertension   The mean duration of DM was 8.7±4.6 years (range 3-31 years). The mean BMI among the study participant was 24.21±4.08 kg/m2. Table I shows the gender wise distribution of socio-demographic details, along with laboratory and clinical findings of study participants. Table II is demonstrating the relationship between different macro vascular complications among study participants with different risk factors .Table II is demonstrating the relationship between different macro vascular complications among study partici-pants with different risk factors.   SOCIO-DEMOGRAPHIC  &CLINICAL FEATURES Male Female Total 210(48.27) 225(51.71) 435 n % n % n % Family history of DM             Positive Negative 112 98 53.33 46.66 95 130 42.22 57.77 207 228 47.58 52.41 Duration of DMT2             Up to 5 years Over 5 years 53 157 25.23 74.76 87 138 38.66 61.33 140 295 32.18 67.81 Hypertension (mmHg)             Systolic HTN Diastolic HTN 71 47 33.80 22.38 79 50 35.11 22.22 157 97 36.09 22.29 BMI (kg/m2)             Normal Overweight Obese 140 53 17 66.66 25.23 8.09 108 95 22 48.00 42.22 9.77 248 148 39 57.02 34.02 8.96 Smoker             Yes No 143 67 68.09 15.40 28 197 12.44 87.55 166 269 38.16 61.83 LABORATORY FINDINGS Mean ±SD Mean ±SD Mean ±SD Glycemic status             FBS (mg/dL) 2 hours ppbg* (mg/dL) HbA1c (%) 203.5 301.7 8.81 81.3 100.3 2.4 206.4 309.6 9.4 92.1 115.2 2.7 210.1 309.4 9.6 87.5 112.9 2.5 Lipid profile (mg/dL)             Serum total cholesterol level Serum HDL level Serum LDL level Serum Triglyceride 186.2 43.5 140.3 231.1 47.7 26.7 42.6 126.9 188.8 42.6 143.5 213.1 47.9 25.4 45.3 103.4 188.2 42.1 141.2 221.5 48.1 28.7 43.7 115.4 Table I: Gender wise distribution of demographic, clinical and laboratory findings (n=435)  55  J Muhammad Med Coll  Vol 11 (2) Nov 2020-April 2021 Table II: Macro-vascular complications and their relation with different risk factors (n=435) PERIPHERAL VASCULAR DISEASE   Yes 23 (5.29) No 412 (94.71) p value Mean ±S.D Mean ±S.D  54.6 8.4 53.9 9.6 0.731  10.9 7.7 6.1 5.8 0.002* Systolic BP (mmHg) 144.5 22.7 134.4 21.1 0.02*  88.5 13.7 84.9 11.5 0.14  8.6 2.1 9.3 2.7 0.22 BMI (kg/m2) 22.7 3.4 23.8 3.9 0.18  182.6 56.3 188.4 43.3 0.53  41.5 27.8 43.3 26.5 0.75  285.5 113.7 237.3 112.6 0.04*  135.8 47.2 144.6 41.7 0.32 CORONARY ARTERY DISEASE   Yes 73 (16.78) No 362 (83.22) P-value Mean ±S.D Mean ±S.D  58.4 10.4 51.7 10.7 0.00*  10.7 6.7 6.3 5.9 0.01* Systolic BP (mmHg) 148.3 27.8 135.3 26.5 0.00*  89.3 15.8 83.5 13.8 0.00*  9.4 2.3 9.2 2.1 0.46 BMI (kg/m2) 24.4 3.6 22.3 4.1    0.01*  185.4 51.3 189.3 47.4 0.52  45.7 42.4 40.1 19.3 0.07  240.2 151.5 211.3 100.8 0.04*  140.9 44.8 141.2 43.6 0.95 CEREBROVASCULAR DISEASE   Yes 28 (6.43) No 407 (93.56) P-value Mean ±S.D Mean ±S.D  59.6 11.2 50.6 11.3 <0.001*  9.4 5.2 7.4 5.4 0.058 Systolic BP (mmHg) 150.3 26.8 135.7 25.4 0.003*  90.5 13.3 82.6 12.3 0.001*  9.2 2.4 9.6 2.7 0.44 BMI (kg/m2) 23.8 5.1 24.1 3.9 0.72  191.6 49.0 186.9 49.7 0.62  43.2 18.5 41.7 23.2 0.73  253.5 167.0 219.6 112.8 0.13  138.6 44.1 140.2 42.4 0.84 56  J Muhammad Med Coll  Vol 11 (2) Nov 2020-April 2021 Discussion: DM is the growing metabolic disorder and a serious medical problem providing the patients and health care system with great deal of burden in the form of comorbidities12 while complications related to DM fur-ther imposing economic burden on the families and the country. The findings of this study provided a po-tential insight for prevalence of complications and their risk factors in the DMT2 patients of Sindh. Our study findings strongly suggest that there is an associa-tion between DMT2 and chronic macro-vascular com-plications.  The prevalence of macro-vascular compli-cations amongst our study population with type 2 DM was 28.5%. The rising trends in the prevalence of the complications was observed as compared to the previ-ous studies. A study conducted in Punjab, Pakistan by Gillani et al.13 reported the prevalence of macro vascu-lar complication in their study was 21.7%. While a study by Al-Khawlani et al14 reported that 25.4% of their participants with DMT2 were having macro vas-cular complication. A study from Saudi Arabia reported 12.1% of total macro vascular diseases among their diabetic participants that is quite lower than our study.15 In the present study, among the patients with macro vascular complications of DMT2, 16.78% had CADs, 6.43% had CVD and 5.29% had PVD. Several studies also reported similar trend of macro vascular complications as demonstrated in this study. Alaboud et al. reported the consistent findings of macro vascu-lar complications in their study participants.15 Another study by Gedebjerg et al16 also reported higher preva-lence (15%) of CADs in their patients followed by 5% CVDs and 2% PVDs in their study. Moreover, Uddin et al17 reported prevalence of 8.5% CADs, 2.0% CVD and 2.2% PVD in their newly diagnosed DMT2 patients.  The risk factors analysis in the present study demon-strated that duration of DMT2 was the main risk factor for CAD and PVD while systolic hypertension was the common risk factor in CAD, PVD and CVD. Al-Khawlani et al14 also reported the findings consistent with cur-rent study. Moreover, age and diastolic blood pressure were significantly associated with CAD and CVD. A study from Pakistan 13 reported the strong association between age and CAD that is consistent with the find-ings of present study.  Serum triglycerides was a com-mon significantly associated factor of CAD and PVD in this study, a finding consistent with published studies. 18,19 This may be due to fact that high serum triglycer-ides may lead to increase chances of thrombus for-mation within the vessels and lead to blockage of blood circulation in the vessels. With strengths, there are many limitations in the study. Foremost, limited duration and resources only one center was included in the study. Furthermore, only macro vascular compli-cations were studied in the present study while many risk factors like economic status, treatment etc. are not included for the study.  Conclusion:  The coronary artery disease seems to be most fre-quent macro-vascular complication among the type 2 diabetic patients. Whereas the risk factors including; advancing age, duration of diabetes mellitus, hyper-tension, BMI as well as serum triglycerides levels are the most significant factors for these complications.  References: 1. World Health Organization (WHO) 2020. Diabetes, available at https://www.who.int/health-topics/diabetes#tab=tab_1 (Last accessed Nov. 2020) 2. Bommer C, Sagalova V, Heesemann E, Manne-Goehler J, Atun R, Bärnighausen T, Davies J, Vollmer S. Global economic burden of diabetes in adults: projections from 2015 to 2030. Diabetes care. 2018 May 1;41(5):963-70. 3. Saeedi P, Salpea P, Karuranga S, Petersohn I, Malanda B, Gregg EW, et. al. Mortality attributa-ble to diabetes in 20–79 years old adults, 2019 estimates: Results from the International Diabetes Federation Diabetes Atlas. Diabetes research and clinical practice. 2020 Feb 15:108086. 4. Meo SA, Zia I, Bukhari IA, Arain SA. Type 2 diabe-tes mellitus in Pakistan: Current prevalence and future forecast. JPMA. The Journal of the Pakistan Medical Association. 2016Dec;66(12):1637.  5. Bekele BB. The prevalence of macro and micro-vascular complications of DM among patients in Ethiopia 1990–2017: Systematic review. Diabetes & Metabolic Syndrome: Clinical Research & Re-views. 2019 Jan 1;13(1):672-7. 6. Khanam PA, Hoque S, Begum T, Habib SH, Latif ZA. Microvascular complications and their associated risk factors in type 2 diabetes mellitus. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2017 Dec 1;11: S577-81. 7. Narres M, Claessen H, Droste S, Kvitkina T, Koch M, Kuss O. et al. The Incidence of End- Stage Renal Disease in the Diabetic (Compared to the 57  J Muhammad Med Coll  Vol 11 (2) Nov 2020-April 2021 Non-Diabetic) Population: A Systematic Review. PLoS ONE.2016;11(1): e0147329. 8. Lee R, Wong TY, Sabanayagam C. Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss. Eye and Vision.2015;2(1):17. 9. Man RE, Sabanayagam C, Chiang PP, Li LJ, Noonan JE, Wang JJ, et al. Differential Associa-tion of Generalized and Abdominal Obesity with Diabetic Retinopathy in Asian Patients with Type 2 Diabetes. JAMA ophthalmology. 2016;134(3):251-7 10. Dobrica E, Gaman MA, Cozma MA, Gaman AM, Diaconu CC. Macro vascular and microvascular complications in type 2 diabetes mellitus: did hypertension change the setting? Journal of Hy-pertension. 2019 Jul 1;37: e140-1. 11. World Health Organization. Cardiovascular dis-eases. WHO. 2018. Available at;http://www.emro.who.int/health-topics/cardiovascular-diseases/index.html (Last ac-cessed Nov. 2020) 12. Basit A, Fawwad A, Baqa K. Pakistan and diabe-tes—A country on the edge. Diabetes research and clinical practice. 2019 Jan 1; 147:166-8. 13. Gillani AH, Bashir S, Ahmed AB, Usman M, Mus-tafa A, Iqbal T, Batool N. 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BMJ open. 2018 Aug 1;8(8): e020961.  

Macrovascular Complications and their risk factors in Type 2 Diabetic Patients in Hyderabad, Pakistan.

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Macrovascular Complications and their risk factors in Type 2 Diabetic Patients in Hyderabad, Pakistan.

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