Diabetes Mellitus Among Hospitalized Patients in Mukalla City, Yemen: Prevalence, symptoms and complications

The purpose: The aim of this study is to determine the burden of DM among patients admitted to tertiary hospitals in Mukalla city at eastern Yemen. Patients and methods: It is a cross sectional study among patients admitted to in three main hospitals in Mukalla city. Results: the prevalence of DM among admitted patients to the three hospitals in Mukalla city is 16.6%. Age specic prevalence rate is higher among adults over 40 years (40.3%) than the younger patients (2.2%). In a logistic regression only, age is a determinate factor to DM. The main symptoms and signs of the hospitalized DM patients are: polyurea (72.6%), polydipsia (70.5%), blurring of vision (57.9%), marked loss of weight (54.7%) Paresthesia (51.2%) and polyphagia (34.7%). The main complications among hospitalized DM patients are diculty of vision (60.8%), Foot ulcer (53.6%) and loss of libido (49.2%). Conclusion: The prevalence of DM among hospitalized patients is high.


Introduction
At present, chronic diseases are re ected to be a growing public health issue worldwide. 1&2 Diabetes Mellitus (DM) is a group of metabolic disorders characterized by raised blood sugar levels or blood glucose levels, if not treated, might leads to serious impairment of the vision, blood vessels, heart, kidneys, and nerves over time. 3&4 Diabetes is a serious ailment that affects the quality of life, life expectancy, and health of an individual.
Thus, placing a substantial economic burden on the healthcare system. Diabetes mellitus is a global public health problem that affecting humans and threaten their life's. The global diabetes prevalence in adults (aged above 18) has increased from "4.7% in 1980 to 8.5% in 2014".
The predominance has been elevated swiftly in low and middle-income countries. 5 In the middle-east there are three countries' has been classi ed among the top ten countries with higher prevalence of diabetes are Saudi Arabia (23.9%), Kuwait (23.1%) and Qatar (22.9%). 6 Although there are common persecution among doctors in Yemen that DM is a common problem in Yemen; but studies about DM were scarce in the country. Recently published study in 2019 estimated the prevalence of DM among men in Yemen is 9.8%. 7 While one old study (published in 2004) reported that the overall prevalence of type II DM in Yemen was 4.6% (7.4% in males and 2% in females), 17 this study focusing on Type II Diabetes Mellitus and its relation with the impaired glucose tolerance and found that impaired Glucose Tolerance (IGT) and Impaired Fasting Glucose (IFG) were found in 2% and 2.2% of the study population. [17] . The prevalence of type II DM and its potential increase re ected by the high prevalence of obesity in normal Glucose Tolerance subjects in the Yemeni population constitutes a major public health problem. 8 Access to health services, cost of DM diagnosis and treatment as well as weak research capacity are challenges to understand the size of the DM problem in the country and speci cally at sub-national and remote governorates. Mukalla city is the capital of Hadhramout governorate at eastern Yemen, the city population is about 291,873 inhabitants. 9 In Mukalla city; health services are provided through three main tertiary hospitals and a network of health centers and district hospitals as well as the private sector. The three tertiary and referral hospitals are public hospitals; they are Ibn Sina hospital, University Hospital and the Maternity and childhood hospital. Up to our knowledge; no study addresses the DM as a common problem from the available data in the hospitals. So, the aim of the is study is determining the burden of DM among patients admitted to tertiary hospitals in Mukalla city in Yemen and to describe the clinical patterns of those Diabetic patients.

Patients And Methods
It is a cross sectional study carried out in Al-Mukalla city, the settings are the three tertiary public hospitals (Ibn Sina hospital, University Hospital and the Maternity and childhood hospital Ibn-Sina hospital, University Hospital and the Maternity and childhood hospital). The study targeted all patients admitted to the three mentioned hospitals during the period the period 7th of November 2019 to 7th of February 2020 and agree to participate; a detailed data then collected from DM Patients. A group of 5th year medical students of Hadharmout University were trained to collect data from the admitted patients though a pre-tested questionnaire. The questionnaire composed of four parts: part I and part II include personal data and patient diagnosis. part III and IV only for DM patients. (Part III: Type of DM and treatment. Part IV: Symptoms and complications of DM).
The data was checked for completeness, coded then entered into computer by using statistical package for social science (SPSS version 23). Then analyzed by using descriptive statistical tools (frequencies, percentage, mean and standard deviation), chi-square is be used to test associations between independent and dependent variables. The level of statistical signi cance is p<0.05.
Operational de nition used: Type 1 DM results from the body's failure to produce insulin, and presently requires the person to inject insulin. This usually develops in children or young adults but can occur at any age. (Also referred to as insulin-dependent diabetes mellitus (IDDM) or "juvenile" diabetes). 10 Type 2 DM (Formerly called adult onset) results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin de ciency. (Formerly referred to as noninsulin-dependent diabetes mellitus (NIDDM) or "adult-onset" diabetes). 10 Ethical consideration Approval of the study proposal was obtained from Hadhramout University College of Medicine, Department of Community Medicine in 2019. Objectives of the study were explained for participants and those who agree to participate were involved in study and those who refused to participate were excluding from study.

Results
The mean age of all patients admitted to the three hospitals in Mukalla city is 34.8 years (±23.7 ) and the median age of 31 years with a wide range of age from one year to 95 years.
During the study period; a total of 574 patients admitted to the studied three hospitals in Mukalla city during three months, out of them 95 patients are diabetic giving the prevalence of DM among admitted patients to 16.6%. Based on the type of health facility; Ibn-Sina hospital is used to provide care to adults only (Medical and surgical health services) the prevalence of DM among patients admitted to Ibn-Sina hospital is signi cantly higher among all the other hospitals (90/403, 22.3%) (P-value =0.000). while the prevalence of DM among patients admitted to the University hospital (provide care to children and mothers) is 5.8% (5/86) and no diabetic patients admitted to the Maternity and childhood hospital (n=85). The prevalence of DM among patients admitted to medical department is high (28.5%) followed by the prevalence of DM admitted to surgical department (15.4%) while it is very low in Gyn&Obs department (5.8%) and never among children admitted to pediatric departments. (Table1) Signi cant variations are reported regarding age group where adults over 40 Years have higher prevalence (40.3%) than younger 2.2% (P-value =0.000). While there is no signi cant variations regarding gender, the prevalence of DM among males admitted to hospitals is 18.7% while among admitted females is 14.2% (P-value =0.088). Table. 1 In logistic regression analysis only the age group is associated with DM (OR= 4, CI 95% 3.18 -4.82, P-value =0.000).  The American Diabetes Association (ADA) lists seven symptoms of diabetes; as follows: frequent urination, excessive thirst, extreme hunger, unusual weight loss, increased fatigue, irritability, and blurry vision it however, is not known how speci c these symptoms are common in Yemeni diabetic patients. 15 In this study in Mukalla; The most frequently symptoms reported by diabetic patients are: polyurea, polydipsia, blurring of vision, marked loss of weight, paresthesia and polyphagia, but there is no signi cant difference between type 1 and type 2 DM. The proportion of symptoms in this study is looking high, because about 25% of diabetic patients are subject to irregular treatment. Poor adherence of diabetic patients leads to complications. These complications occur in the majority of individuals with both type 1 and type 2 diabetes. Among the most prevalent micro-vascular complications are kidney disease, blindness, and amputations, with current therapies only slowing disease progression. Impaired kidney function, exhibited as a reduced glomerular ltration rate. 16  The study has certain limitations; rst the study is limited for three months that may not expose to the annual diabetic admission, the second it is a hospital-based study and may neglect disabled diabetic patients who receiving home care.

Conclusions
The prevalence of DM among hospitalized patients is high, and presenting with high proportion of symptoms and micro-vascular complications mainly retinopathy and food ulcer due to poor adherence to treatment.  Figure 1 percentage of DM patents under regular treatment by type of DM