DOI: https://doi.org/10.21203/rs.2.13197/v1
Objective To assess the magnitude of diabetic complication and associated factors among diabetes mellitus patients attending in Gurage zone hospitals.Results According to this study the magnitude of diabetic complication among diabetic patients were 61% and the marital status; divorced [AOR: 0.252(0.11, 0.59); p=0.002], poor glycemic control [AOR: 1.88(1.04, 3.39); p=0.036], Body Mass Index >25 [AOR: 4.42(1.32, 14.86); p=0.016] and duration of illness > 6years [AOR:1.79 (1.02, 3.17) ; p=0.044] and 10years [AOR: 4.68(2.07, 10.61); p=<0.001] were significantly associated with diabetic complication.
Key terms Diabetic complications, magnitude, associated factor
Diabetes is a chronic disease marked by high level of blood glucose that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin that was produced. It is one of the chronic non communicable diseases which have emerged as a leading global health problem (1). In Africa it was estimated that 15.5 million adults aged 20–79 years were living with diabetes as according to International Diabetic Federation report (IDF) (2). Out of the estimated cases 69.2% of adults were living with DM but they are unaware of their condition. Ethiopia is one of the 32 countries of the IDF African region report. There were 2,567,900 cases of diabetes in adults in Ethiopia in 2015.(3). According to studies done in Jimma University specialized hospital report the number of people with diabetes has risen from 108 million in 1980 to 422 million in 2014 (4)
The seriousness of the disease is due to its complication. Complication of DM account for increased morbidity, disability and mortality and threats for the economies of all countries especially in the middle and low economic countries (5). In 2016, an estimated 1.6 million deaths were directly caused by diabetes. Another 2.2 million deaths were attribute to high blood glucose in 2012 (1).
Based on the time required to develop complication diabetes has been classified in acute and chronic ones. Acute complication consists diabetic ketoacidosis which is the most common acute complication and it mostly occur in type 1 diabetes mellitus (DM). Hyperglycemic hyperosmolar non ketosis syndrome mostly occurs in type 2 DM and hypoglycemia (6, 7). The chronic complications are broadly classified in to macro vascular, micro vascular and other complication of DM. Macro vascular complication of DM are primarily disease of coronary artery, cerebrovascular, and peripheral vascular. Microvascular complication of DM is those that affect small blood vessels typically include retinopathy, neuropathy and nephropathy. Other complication of DM is bacterial and fungal infection which occurs due to direct effects of hyperglycemia on cellular immunity (8). DM can result in an increased risk of sever sight impairment, end stage kidney disease, cardiovascular disease and in some cases early death. In type 2 diabetes 75% of people will die of heart disease and 15% of stroke. The mortality rate from cardiovascular disease is up to five times higher in people with diabetes than in people without diabetes. The risk of death from diabetes related cause increased by 21% (9). Since there is limited study in the study area, this study finding addresses to determine the magnitude of DM complication with its associated factor in the study area.
To assess magnitude and associated factors of diabetic complication among diabetic patients attending Gurage Zone Hospitals, Gurage, South West Ethiopia, from April 1—may, 30, 2019.
This study was conducted at Gurage zone hospitals which is located in Southern Nations Nationalities and Peoples’ Region state (SNNPRs) of Ethiopia. The “Gurage” zone has three primary and one general hospital and 72 health centers. All hospitals have chronic follow up clinic especially for diabetes mellitus and hypertension. Those four hospitals were “Attat” (private hospital), “Gunchire”, and “Bui” are primary hospitals and Butajira is the only General hospital in the zone. The study was conducted from April 1- April 30, 2019 G. C.
Institutional based cross sectional study was conducted.
All diabetic patients who were on follow up at Gurage Zone Hospitals.
All sampled diabetic patients attending “Butajira” general hospital, “Attat” and “Gunchire” primary hospitals follow up clinics during the study period.
All diabetic patients who had follow up in Gurage zone sampled hospitals and were on follow up during the study period were included in the study.
Patients who were newly diagnosed for diabetes mellitus and on treatments for less than three months durations were excluded.
Patients who were unconscious and had mental illness during data collections were excluded.
Sample size was determined by using population formula.
n=(〖Z(a/2)〗^2 P(1-P))/D^2
n—Minimum sample
P—Estimate % of diabetic complications among diabetic patients.
D—Margin of error (0.05)
Z(a/2)– Standard normal
n=((〖1.96)〗^2 x0.525(1-0.525))/((〖0.05)〗^2 )=384
Since the source of populations were 1540 which were below 10,000, the finite population correction is needed:
nf=n/(1+n/N)=384/(1+384/1540)=305
Where N = total population
The result after the correction became 307 and adding non response rate of 10% (307x10% = 30.7) of the total sample size; 30.7+307 = 338.
Stratified sampling method was used to select the study sample from selected hospitals. First one general hospital was purposively selected and two primary hospitals were selected by random sampling method from three primary hospitals. Then stratified sampling and proportional allocation was done. See figure 1 below.
Diabetic complication
The data were collected using structured questionnaire and by reviewing patients cards for laboratory results and other medical findings. The questionnaire had three parts. These includes socio-demographic data, medical related factors and management parts
Three diploma nurses were selected for data collection for each hospital with two BSc nurses for supervisors. Training were given for both data collectors and supervisors for two days before the actual data collections about the study procedure and data collection techniques
Diabetic control:
Good < = 130 or RBS< = 200 and
Poor >130 of FBS/RBS>200
Diabetic complication:
No: if the diabetic patients have neither acute nor chronic complication.
Yes: if the patients has one complication either acute(hypoglycemia, DKA and HHNS) or chronic complication(Macro vascular, micro vascular, neuropathy, nephropathy or diabetic foot ulcer) that rule out by laboratory investigation and physical examination during follow up.
To assure the quality of data, properly designed data collection tool (structured questionnaire) was prepared in English and translated to Amharic language and then back to English to check the consistency by fluent English speaker (English language teacher) and finally the data were collected by English language. The questionnaire was pre tested on 5 %( 17) diabetic patients at in “Buiprimary” hospital follow up clinic to check the accuracy and validity of the questionnaire. Training was given for both data collectors and supervisors. Then data were checked and entered into EPI data version 3.1
After data collection each questionnaires’ was checked visually for completeness. The responses were entered into EPI data Version 3.1 and exported to SPSS version 23 for clearing, coding and analysis. Both descriptive and analytic analysis was performed. Those explanatory variable with p- value <0.2 at 95% CI in bivariate were eligible for multivariate and those variables with p value≤0.05 were significant in multivariate at 95% CI.
Before data collection, Ethical clearance letter was obtained from Wolkite University College of medicine and health science department of nursing and dispatch to each selected hospitals and Gurage zonal health office. The respondents were informed and their oral consent was obtained. The respondents had the right to refuse or with draw from participating in the interview at any time were respected and the information provided by each respondents were kept confidentially, each questionnaire were coded and information were not shared to the third party.
The result of the study was dissiminated to Wolkite University College of medicine and health science, department of nursing, Butajira general hospital, Attat primary hospital and Gunchire primary hospitals.
From a total of 338 diabetic patients included in the study, the response rate was 100%. Among the total respondents, 192(56.8%) were male.
Among the total participants 155(45.9%) used oral hypoglycemic agent, 160(47.3%) used insulin only and 23(6.8%) were used both oral hypoglycemic agent and insulin. Those who adhered to physical activity were 222(65.7%) and 245(72.5%) ate recommended dietary practice. From the participants 59.2% had taken their daily dose properly and 39(11.5%) had smoke cigarette in addition to anti diabetic drugs. Besides, 160(47.3%) were type1 diabetes mellitus and 178(52.7%) were type2 diabetes mellitus, 150(44.4%). Moreover; 27(8%) were under weight, and 34(10%) were overweight. Regarding their blood glucose level; 274(81.1%) had RBS > = 200mg/dl, 303(89.6%) had FBS > = 130mg/dl. From the participants; 168(49.7%) had low density lipoprotein (LDL)> = 130mg/dl, whereas, 82(24.3%) had high level lipoprotein (HDL) > = 60 mg/dL.
Regarding acute complication of diabetes mellitus; 48(14.2%) had DKA, 21(6.2%) had HHNS and 22(6.5%) had hypoglycemia. But from chronic complication 50(14.8%) had Neuropathy, 49(14.5%) had visual impairment (retinopathy) and 57(16.9%) had diabetic foot ulcer, 69(20.4%). From the total of DM patients who had complication; 91(26.9%) had acute complication whereas 205(60.7%) had chronic complication
This study showed that the magnitude of DM complication among diabetic patients in Gurage zone hospitals was 61% and it was relatively similar with study done in Northeast Ethiopia (59.7%) and Bahirdar (53.5%) in Ethiopia [10,11].So, designing strategy for early diagnose and management of DM should be crucial.
In this study finding; DM patients who live with DM between 6–10 years and above 10 years were 1.79 and 4.68 times more likely to develop diabetes complication respectively when compared with patients who had live with DM less than 5 years duration.This study was similar with study conducted in Felegehiwot referral hospital, Bahirdar, Arbaminchand Jimma[10,12, 13]. So, patients should be clinical managed properly by intiating early diagnose and treatment.
Regarding Body mass index in our study; those diabetes mellitus patients who had higher BMI (>25kg/cm2) had 4 times [AOR: 4.42, 95% CI: (1.32, 14.86)] more likely to develop diabetic complication when compared with patients who had BMI <18 kg/cm2. It was similar with study done in China[(14)] and Pacific Islands [(15)].This will imply that having recommended dietary practice and exercising physical activity regularly will be strengthened.
In this study; those patients who were widowed marital status were 75% [AOR: 0.252; 95% CI: (0.11, 0.59)] less likely to develop diabetic complication when compared with patients who had married marital status and it was similar with study done in Iran ((0.74; 0.56–0.97))[(16)].
This study finding suggest that those patients who had poor glycemic control were 2 times [AOR: 1.88, 95% CI: (1.04, 3.39)] more likely to develop diabetic complication when compared with patients who had good glycemic control.This study finding was similar with study done in Arbaminch and Gonder[12,(17)]. So, continous follow up and checking patients FBS should be taken thoroughly.
The magnitude of diabetic complications among the Gurage zone hospitals was 61%. Being widowed, Long duration of illness, having BMI greater than 25 kg/cm2 and having poor glycemic control were found to be significantly associated with DM complication.
Based on the findings of this study; provision of health education, self-care practice and early diagnose and proper management of patient condition should be strengthened.
The study design was cross sectional nature of the study so it is snap shot and could not confirm cause and effect relationship.
The study was conducted after approval of the proposal by Ethical Review Committee of wolikite university ethical review board. Written informed consent was obtained from each study participant by assuring privacy and confidentiality throughout the data collection period in the hospitals. There was no risk or hazardous procedures putting the participants at harm. .
The consent to publish was reached with authors.
The data supporting the finding had attached to editorial office if necessarily competing interests
There is no competing interest.
No funding is required
The authors contribute for this study is conducting and preparing the manuscript
First of all we would like to acknowledge Wolikite University for permission of this study to be conducted..
DM -Diabetes mellitus
FBS- fasting blood sugar
RBS- Random blood sugar
WHO- world health organization
JUSH- Jimma University Specialized Hospital
IDF- International Diabetes Federation
1.World health organization. Diabetes.http://www.who.int. 30 Oct 2018
2.International Diabetes Federation, “Africa region 2017” H or. International Diabetes Federation, Africa region. 2017.
3.Federation international daibetes. International Diabetes Federation, Ethiopia. Ethiopia; 2015.
4.Muktar Beshir Ahmed EY and GT. Diabetic Complications among Follow-up Patients: A Cross-sectional Study at Jimma University Specialized Hospital Diabetic Clinic. Journal of Clinical and Molecular Endocrinology. 2018;3(1:45):1–7.
5.Abdulfeta B. Olokoba LBO and OAO. type 2 diabetes mellitus: a review current trends”, 2012 Jul; 27(4): 269-273,. 27(4):269–73.
6. Joslin diabetes center. Diagnosing impaired glucose tolerance”, https://www.tsin.org,2019.7
7.Adam Felman, “what to know about type 1 diabetes”, Nov 19, 2018.
8.Type 2 Train Education https://WWW. . trainceu. co. Acute complication of type 2 Diabetes mellitus| Diabetes.
9.F.Brutsaert E. complications of diabetes mellitus. https://www.msdmanuals.com.
10.Khardor R. type 2 diabetes mellitus. htttps://emedicine.medscape.com.
11.Dr. Colin Tidy, “Diabetes mellitus”, 19 May 2016,https://patient.info.
12.Lebeta KR, Argaw Z, Birhane BW. Prevalence of Diabetic Complications and Its Associated Factors Among Diabetes Mellitus Patients Attending Diabetes Mellitus Clinics ; Institution Based Cross Sectional Study. 2017;5(2):38–43.
13.Abejew AA, Belay AZ, Kerie MW. Diabetic Complications among Adult Diabetic Patients of a Tertiary Hospital in Diabetic Complications among Adult Diabetic Patients of a Tertiary Hospital in Northeast Ethiopia. 2015;(February)
14.Chisha Y, Terefe W, Assefa H, Lakew S. Prevalence and factors associated with diabetic retinopathy among diabetic patients at Arbaminch General Hospital , Ethiopia : Cross sectional study. 2017;1–9.
15.Dawit Worku (MD)1, Leja Hamza (MD)2 KW (MD)3 A. Patterns of Diabetic Complications at Jimma University Specialized Hospital, Southwest Ethiopia. Ethiopia journal of health science. 2010;20(1).
16.Cui J, Ren J, Chen D, Xin Z, Yuan M, Xu J. Prevalence and associated factors of diabetic retinopathy in Beijing , China : a cross-sectional study. 2017;1–6.
17.Thu S, Tin W, Kenilorea G, Gadabu E, Tasserei J, Colagiuri R. The prevalence of diabetes complications and associated risk factors in Pacific Islands countries. Diabetes Research and Clinical Practice [Internet]. 2013;103(1):114–8. Available from: http://dx.doi.org/10.1016/j.diabres.2013.09.017.
18.Ramezankhani A, Azizi F, Id FH. Associations of marital status with diabetes , hypertension , cardiovascular disease and all- cause mortality : A long term follow-up study. 2019;1–15.
19.Fasil A, Biadgo B, Abebe M. glycemic control and diabetes complications among diabetes mellitus patients attending at University of gondar hospital, northwest ethiopia. Dove press journal. 2019;12:75–83.
Table 1: Factors associated with diabetes complications among diabetes mellitus at Gurage Zone Hospitals, southwest, Ethiopia, 2019 (n=338).
Variables |
DM Complication |
COR (95%) CI |
AOR(95%)CI |
P- value |
||
|
No |
Yes |
|
|
|
|
Age |
15-34years |
44(33.1%) |
42(20.5%) |
1.00 |
|
|
35-44years |
25(18.8%) |
33(16.1%) |
1.38(0.71, 2.7) |
|
|
|
45-54years |
40(30.1%) |
76(37.1%) |
1.99(1.13, 3.52) |
|
|
|
>55years |
24(18.0%) |
54(26.3%) |
2.35(1.24, 4.47) |
|
|
|
Marital status |
Married |
81(60.9%) |
150(73.2%) |
1:00 |
1:00 |
1:00 |
Single |
33(17.3%) |
19(9.3%) |
0.45(0.29, 0.87) |
0.93(.43, 2.02) |
0.931 |
|
Divorced |
13(9.8%) |
21(10.2%) |
0.87(0.42, 1.83) |
0.523(0.23. 1.18) |
0.120 |
|
Widowed |
16(12.0%) |
15(7.3%) |
0.51(0.24, 1.17) |
0.252(0.11, 0.59) |
0.002* |
|
Educational status |
Illiterate |
32(24.1%) |
68(33.2%) |
1:00 |
|
|
Read and write |
12(9.0%) |
19(9.3%) |
0.745(0.32, 1.72) |
|
|
|
Primary |
28(21.1%) |
36(17.6%) |
0.605(0.32, 1.16) |
|
|
|
Secondary |
34(25.6%) |
34(16.6%) |
0.471(0.25, 0.88) |
|
|
|
College & above |
27(20.3%) |
48(23.4%) |
0.837(0.45, 1.57) |
|
|
|
Pattern of drug use |
Never missed |
99(74.4%) |
101(49.3%) |
1:00 |
|
|
Some times |
28(21.1%) |
86(42.0%) |
3.01(1.81, 5.01) |
|
|
|
Frequently |
6(4.5%) |
18(8.8%) |
2.94(1.12, 7.72) |
|
|
|
Glycemic control |
Good |
102(76.7%) |
113(55.1%) |
1:00 |
1:00 |
1:00 |
Poor |
31(23.3%) |
92(44.9%) |
2.68(1.65, 4.36) |
1.88(1.04, 3.39) |
0.036* |
|
BMI |
<18.5 |
17(12.8%) |
10(4.9%) |
1:00 |
1:00 |
1:00 |
18.5-24.9 |
108(81.2%) |
169(82.4%) |
2.66(1.174, 6.03) |
2.26(0.91, 5.65) |
0.08 |
|
>=25 |
8(6.0%) |
26(12.7%) |
5.53(1.82, 16.8) |
4.42(1.32, 14.86) |
0.016* |
|
Duration of illness |
<5years |
79(59.4%) |
71(34.6%) |
1:000 |
1:00 |
1:00 |
6-10years |
42(31.6%) |
73(35.6%) |
1.93(1.18, 3.18) |
1.79(1.02,3.17) |
0.044* |
|
>10years |
12(9%) |
61(29.8%) |
5.65(2.82, 11.34) |
4.68(2.07, 10.61) |
<0.001* |
|
Hypertension |
No |
93(69.9.7%) |
106(51.7%) |
1:00 |
|
|
Yes |
40(31.1%) |
99(48.3%) |
2.17(1.37,3.44) |
|
|
|
LDL(mg/dL) |
<130 |
76(57.1%) |
94(45.9%) |
1:00 |
|
|
>=130 |
57(42.9%) |
111(54.1%) |
1.57(1.01, 2.44) |
|
|