The study found that overall glycemic control among the study subjects was far below the internationally recommended standards and guidelines. Only fasting blood sugar was used to monitor glycemic control in this hospital similar to previous study done in Addis Ababa, Ethiopia [38]. This was due to unavailability of the service and high cost of the glycated hemoglobin (HbA1c) determination in the governmental hospitals of Ethiopia. In developed countries glycemic management is primarily assessed with the A1C test that reflects average glycaemia over approximately 3 months [39].
Glycemic control knowledge is very crucial to control blood sugar level. Majority of the patients didn’t have sufficient knowledge of target blood glucose level for diabetes management. This indicates that patients depend on their health care provider’s support to control and treat their diabetes. It is great problem for patients to take appropriate interventions without knowing target level of diabetes management. Unless patients understand the chronic progressive nature of the disease and actively involved in their management process, it would be difficult to achieve adequate glycemic level.
The majority, 148(64.9%), of patients had poor blood glucose control. Proportion of poor glycemic control was comparably similar with the studies conducted in Amman Jordan[11], Shanan Gibe hospital southwest Ethiopia[33], Dessie referral hospital northeast Ethiopia [34], Jimma university teaching hospital southwest Ethiopia [35] and university of Gondar referral hospital [40] where the rate of poor glycemic control was 65.1% 59.2%, 70.8%, 70.9 % and 64.7%, respectively. But our finding was lower when compared to previous studies conducted at Jimma university specialized hospital [41] and in MGM medical college, Navi Mumbai [36] where 81.9% and 91.8% of patients hadn’t achieved adequate level of glycemic control, respectively. The study also revealed that poor glycemic control was higher when compared with study conducted in Najran armed force hospital [42], Ambo hospital [43] and Ayder referral hospital [9] that 22%, 50% and 48.7% of the patients have poor glycemic control, respectively. Studies from western countries shown similar finding with respect to the quality of diabetes care and the glycemic outcome among the diabetic population [44–46], which highlights the progressive difficulty of maintaining optimal glycemic control in patients with type 2 diabetes as only few patients achieve the desired glycemic goals [44, 46]. The possible reason for this difference could be due to difference in knowledge of glycemic control, available health service, income, behavioral and clinical characteristics of the patients as well as lack of uniform guidelines. These finding highlights the need to work more on appropriate management of diabetes, as maintaining optimum glycemic control is main therapeutic goal for all patients.
In this study, the mean age of the type 2 DM patients was about 43±12.4 years, with the majority of them in the age group of 41–60 years. Patients in age range of 41–60 years constitute a higher proportion of patients with poor glycemic control when compared with those in the age group of <40 years and >60 years similar to previous study conducted in Dar es Salaam [16]. The presence of association between age and poor glycemic control in our study was consistent with previous study findings [9, 11, 16] which reported that younger age was associated with poor glycemic control. But study done in MGM medical college, India revealed that age was not statistically significantly associated with glycemic control [36]. The observed variation of association between age and poor glycemic control could be explained by the differences in population pyramids and distribution of age in different studies. Younger individuals are more likely to have more barriers to self-management behaviors such as healthy low-fat diet, glucose testing and compliant with their diet and medications.
The young age of patients in this study was striking. Previously, type 2 DM was predominantly a disease of middle-aged and older people. However recent reports indicated that type 2 DM is becoming an increasingly prevalent disorder among young’s around the world in all ethnicities driven by lifestyle factors [47–49]. This is linked to the global economic growth and changes in lifestyle and dietary habits. This rising is in parallel with the incidence of overweight and obesity, suggesting a possible causal relationship, particularly when the obesity is central and in relation to decreased physical activity [47–50]. Genetic and familial factors, low birth weight, fetal environmental factors, particularly maternal gestational diabetes and intrauterine growth retardation, and lack of physical activity during childhood and adolescence were the other contributing factors. All of these are associated with insulin resistance, although decreased insulin secretion is also required [47, 48, 51]. Despite the young age of onset and shorter duration of diabetes, this group tends to develop diabetes related complications such as nephropathy and CVD early in the disease process [52]. Type 2 DM in young’s can be controlled to a large extent through lifestyle modification measures. It is important that to screen this disease condition, and identify the at-risk cases [50]. Patient and family education for a young person with T2DM is very important and will focus on behavioral changes (diet and activity) [51]. Unfortunately we haven’t assessed the body mass index (BMI) of the patients to identify the nutritional status of the patients. Thus, in our study we haven’t identified the real cause of elevated proportion of young type 2 DM patients.
There was almost equal proportions of the patients among the two sexes (51.8% versus 48.2%). Compared to some previous studies the proportion of the women was low in our study finding. The step rise and associated complications of type 2 DM go along with mounting evidence of clinically important sex and gender differences. Large sex-ratio differences across countries are observed. Diversities in biology, culture, lifestyle, environment, and socioeconomic status impact differences between males and females in predisposition, development, and clinical presentation. Genetic effects and epigenetic mechanisms, nutritional factors and sedentary lifestyle affect risk and complications differently in both sexes [53]. In the first half of the last century the prevalence of type 2 DM was higher among women than among men, but this trend has shifted, so more men than women are now diagnosed with type 2 diabetes. This change in the gender distribution of type 2 diabetes is mainly caused by a more sedentary lifestyle particularly among men, resulting in increased obesity [54]. Men are more insulin resistant than women, which can be explained by their higher proportion of visceral and hepatic fat compartments [54, 55]. Even one meta-analysis demonstrated that, compared with the corresponding women, the men in eastern, middle and southern Africa had a significantly higher prevalence of impaired fasting glycaemia [56]. In our setup economic issue is a challenge for both sexes to follow the medical care. Thus the prevalence of diabetes mellitus was found to be lower or higher in women than in men when analyzed by African sub regions. Sex-based differences in the relationship between individual socioeconomic status and diabetes mellitus still need to be investigated in developing countries.
Being illiterate and having lower education was independently associated with poor glycemic control which complies with previous studies [19, 34, 35, 41]. This was unlike to study in Dares Salaam were education of patients was not associated with glycemic control [16]. Low education level is associated with poor health, low glycemic diabetes knowledge, low self-management behaviors, lower self-efficacy and lower continuity of care. Additionally, shortage of availability of health service may also negatively affect glucose control. Moreover, higher education level is correlated with better knowledge of diabetes complications and greater adherence to diet and medications.
Duration of first diagnosis of >10 years was significantly associated with poor glycemic control which was consistent with previous studies reported that the length of duration of diabetes associated with poor glycemic control [11, 36, 44, 57, 58]. Patients with shortest duration of disease may be relatively adherent to medication and recommended diets. From the pathophysiology of the disease, longer duration of diabetes is associated with progressive impairment of insulin secretion, increased insulin resistance and eventually decrease in insulin secretion. In earlier disease stages, the task of reaching glycemic goal is aided by residual ß-cell function, whereas in advanced stages, there is progressively less endogenous insulin secretion [11, 14, 16]. Therefore, as the disease progresses most patients require an increase in their medications to maintain glycemic control. However, as study done in Shanan Gibe Hospital Southwest Ethiopia, diabetes treatment for 5–10 years was one independent predictors of glycemic control among type 2 diabetes patients [33] due to poor medication adherence, poor lifestyle conditions and failure to adhere to regular follow up at diabetes clinic.
The storage and qualities of the drugs are critical issue in Africa including our setup. Due to pocket expense, there were situations where some patients couldn’t able to afford the cost and failed to purchase the drugs that leads to noncompliance. For example, most patients couldn’t able to store insulin below 80C due to lack of refrigerators and other storage facilities. Even the storage of oral medications didn’t comply with the recommended standard guidelines. While some of the participants’ anti-diabetic medications-related perceptions appeared to be similar to those expressed by western patients, there were perceptions that were different including the exaggerated concerns towards the medications could potentially lead to intentional non-adherence and affect health outcomes. Consensus was that some patients do not want to take medication long-term. Back home, medication was used on a short-term basis to ‘cure’ something and then it was stopped. Taking medication over a long period of time as a means to prevent damage from chronic disease may be unfamiliar and difficult to understand. There are several recurring reasons people did not want to take medication including a generalized fear of side effects. Even patients often stopped taking medications without informing their health care provider.
Regarding the feeding habits, patients in our country doesn’t flow the dietary recommendation as physicians ordered, because of economy of our patients to afford it. The typical diet the patients using were mostly ‘injera’ prepared from locally produced teff, sorghum and maize. There is no quality of water as most of rural patients were using from groundwater/well water, but urban patients were using tap water. Majority of the patients didn’t have devices (glucometer) to monitor glucose in blood. Some were illiterate, some patients failed to afford and others were inaccessible to the devices. This is even the current challenge in our country.
Although physical activity was shown to be protective among patients with type 2 DM [19], only a small proportion of patients with type 2 DM were participated in regular planned physical activity. There was statistically significant differences between patients who did not perform regular physical activity in terms of glycemic control and those who were participating in regular physical exercise. Study by Alramadan M etal in Saudi Arabia reported that low level of physical activity was one independent risk factors for inadequate glycemic control [59] and study in Ayder referral hospital, Mekelle town, Ethiopia showed that patients participated in regular exercise were less likely to be poorly controlled [9]. However, the lack of a relationship between exercise behavior/ physical activity and poor glycemic control was observed in other studies [14, 16, 19]. This difference possibly explained by difference in study population, culture, economy, environment and sample size. Most patients in rural walk in majority of their daily life for occupation related, but this was not associated with aerobic/ planned physical activity. Some patients were not voluntary to do planned aerobic physical activity as physician ordered (at least 150 minutes per week). This was due to most patients doesn’t have time, have no experience to do, fail to understand required procedures and lack of field area to practice it.
On the other hand, the odds of poor glycemic control was four times higher among smokers compared to nonsmokers. This complies with previous study that reported current smokers had an increased risk of poor glycemic control [60]. As well as Willi C et al reported that the risk of diabetes is shown to be higher by 45% in smokers than among nonsmokers [61]. Additionally study by Ohkuma T et al reported that HbA1c levels increased progressively with increases in both number of cigarettes per day and pack-years of cigarette smoking compared with never smokers. Smoking and its cessation showed dose- and time-dependent relationship with glycemic control and insulin resistance in patients with type 2 diabetes mellitus [62]. Smoking increases the risk of central obesity and insulin resistance as well as nicotine exposure has several other deleterious effects [63].
There different challenges in glycemic control in Africa including our country Ethiopia. Very few countries in sub-Saharan Africa can afford to screen and treat the complications of diabetes [64]. This resource-limited countries are unable to provide even minimum care in some instances [21]. Poorly skilled health care staff, delay in seeking medical attention and lack of access to affordable drugs contribute to the high rate of diabetes-related mortality [29, 65]. Even the newer classes of drugs are unaffordable for the majority of the population. One of the major challenges facing insulin-treated patients in sub-Saharan Africa is the lack of a constant supply of insulin at affordable cost [66]. This supply of insulin is erratic, even at large hospitals and the prospects for people with diabetes are poor [67, 68].
Achieving glycemic control in patients with diabetes is of paramount importance to their overall health and survival [47]. Poor glycemic control is a risk factor to both micro and macro vascular complications of diabetes and a major factor in the burden of the disease [23]. Self-management is a key element for the proper management, but strategies are currently lacking in developing countries context [22, 30]. Self-monitoring of blood glucose was rarely used, mainly because of the cost of testing supplies in 90% and the unavailability of testing supplies in 70 %of the countries in Africa [21]. Even though, patients with diabetes often struggle to achieve glycemic control targets, self-monitoring of blood glucose, physical activity and risk reduction behavior are insufficient [30, 47]. Even if treatment guidelines are available, they are hardly used and are not up to date [21]. Even in many European countries patients may find this degree of disease management difficulty, with a corresponding negative impact on adherence and glycemic control [44].
In general there are parcel of problems encountered in the management of diabetes in sub-Saharan Africa. This includes problems related to diagnosis, medical care, drug supply, monitoring, diabetes education, cost of medication, dietary advice and management infections associated with diabetes. Additionally, poor patient attendance, short consultation time, inadequate infrastructure, poor evaluation of complications of diabetes, poor record keeping, disproportionate distribution of health care facilities and lack of adequately trained health care professionals to care and treat diabetic patients are top challenges observed African countries including our country. In our setup patients are not supplied with medicaments, rather they purchase from the hospital by their own expense. If drugs are not available or in case of stock out from the governmental hospital pharmacy, patients purchase drugs from the private and community pharmacies. Rare patients that have written certificate for unable to purchase the medications, the government supply freely. Due to pocket expense, there are conditions where some patients couldn’t able to afford the cost and fail to purchase the drugs that leads to noncompliance. Adequate knowledge of the overall burden of diabetes in high-risk populations and countries is a prerequisite for effective diabetes health care delivery. This requires urgent targeted interventions to improve glycemic control in this population and prevent chronic complications.
Limitation of study
The study was cross-sectional study design, where causal relationship between the independent and dependent variables cannot be established. Medication adherences, dietary intake, blood glucose testing, smoking status and physical activities were obtained by self-report and may be limited by recall and social desirability bias. None of the patients had HbA1c determination; which is gold standard to determine patient’s 'glycemic level’. Absence of HbA1c determination directly compromise quality service given for the patients; since FBS reflect the glycemic status of the one spot. But measurement of glycated hemoglobin (HBA1c) would show the rate of glycemic control over 3 month’s period. Additionally BMI was not presented that would provide specific insight into uniqueness of this population especially regarding nutritional status of the patients.