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ORIGINAL ARTICLE
Year : 2021 | Volume
: 13
| Issue : 3 | Page : 142-147
Profiles of diabetes care, control and complications in Benghazi, Libya 2020: A cross sectional study
Omar Alfalah1, Imhemed Eljazwi1, Najat Buzaid2
1 Department of Internal Medicine, Faculty of Medicine, University of Benghazi and Benghazi Medical Center, Benghazi, Libya
2 Department of Internal Medicine, Faculty of Medicine, University of Benghazi and 7th October Hospital, Benghazi, Libya
Correspondence Address:
Dr. Omar Alfalah
Department of Internal Medicine, Faculty of Medicine, University of Benghazi and Benghazi Medical Center, Benghazi
Libya
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijmbs.ijmbs_45_21
Background: Diabetes mellitus is one of the growing health problems worldwide. Comprehensive medical evaluation, screening for complications, and proper diabetes care are crucial to improve outcome. Objectives: We aimed to study the profile of diabetes in Benghazi city and assess the changes since the last study of 2002. Patients and Methods: This study is a descriptive cross-sectional study of 504 persons with diabetes who were following at Benghazi diabetes center during June and July in 2020. Results: The age was, mean ± standard deviation; 57.8 ±12.3 years. with equal sex split. A quarter (24.8%) of participants graduated from a university/college. About half of the patients were obese (48.4%) Hypertension and dyslipidemia were found in 35.1% and 42.1%. respectively. The mean glycated hemoglobin A1c (HbA1c) was 8.3% ±1.7%. Self-monitoring of blood glucose (SMBG) was practiced by 20.2% of all patients, Less than two thirds (63.5%) of all patients had diabetes eye screening within the previous year. However, none of the participants had ever had a comprehensive feet examination. Ramadan fasting was observed by most of participants (95.4%). Conclusions: There is an improvement regarding annual eye examination, taking the medications regularly, SMBG, assessment of lipid profile, and regular follow-up with HbA1c in comparison with the practice in 2002. On the other hand, there is a decline in having comprehensive feet examination, practicing regular exercise, and diet control. The uncovered gaps in diabetes care need urgent attention.
Keywords: Benghazi, diabetes complications, diabetes management, diabetes, profile
Diabetes mellitus (DM) is one of the fastest-growing healthcare challenges globally in the twenty-first century. The number of patients affected by DM reached 463 million in 2019 and is expected to reach 578 million in 2030, and perhaps 700 million in 2045.[1] North Africa and the Middle East had the highest prevalence of DM in the adult population aged 20–79 years in 2019 (12.2%) and is expected to be the highest in 2030 and 2045 (13.3% and 13.9%, respectively).[1] The Libyan national noncommunicable diseases survey in 2009 reported a prevalence of diabetes of 16.4%.[2] Also, the prevalence of DM in Benghazi in 2001 was reported at 14.1%.[3] According to the international diabetes federation (IDF), the prevalence of DM in Libya was estimated at around 9.7% in 2019.[1] This is probabaly an underestimation as there were new data since 2010.[2]
Benghazi is the second-largest city in Libya, with estimated population of around one Million in 2021. Benghazi diabetes center (BDC) is the main place where most of diabetic patients attend for diabetes care.[4]
Management of diabetes is a multidisciplinary approach. It includes glucose-lowering approaches by lifestyle management and pharmacological treatment. Treatments are directed not only to control diabetes but also to prevent vascular complications. Screening and management of retinopathy, nephropathy, diabetic foot risk screening, detection and management of dyslipidemia and hypertension, antiplatelet therapy when appropriate, and smoking cessation are essential in comprehensive diabetes care. Diabetes education, self-management approaches, and medical nutrition therapy are integral parts of diabetes management.
The profile of diabetes health care at Benghazi Diabetes Centre was described in 2002 by interviewing 805 person with diabetes at BDC.
The present study was conducted to examine the demographic and clinical profile of people with diabetes in Benghazi city looking for changes since 2002.
Patients and MethodsSettings
This study is a descriptive cross-sectional study conducted at BDC from 1st of June to the end of July in 2020. A total of 504 participants (252 males and 252 females) following at BDC were included. The total number of consultations at the BDC from January to July 2020 was 33,745.
Assessments
The questionnaire aimed from Roaeid and Kablan study.[4] The data were collected after verbal consent was obtained. The study questionnaire was administered through face-to-face interviews, and the results were recorded anonymously.
Statistical analysis
Five hundred and four persons with diabetes agreed to participate in the study, and only ten patients declined consent to participate. Data on all the patients who attended during the study period and agreed to participate were entered in the questionnaire forms. Data were analyzed using SPSS (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.). All variables are expressed as numbers, percentages, mean, and standard deviation (SD) as appropriate. Differences between the variables were explored using the Chi-square test and t-test, P < 0.05 was considered statistically significant.
ResultsCharacteristics of the study population
The total number of participants was 504. The mean ± SD age was 57.8 ± 12.3 years, ranging between 16 and 85 years. The duration of diabetes was 12.8 ± 10.8 years. The body mass index (BMI) was 30.9 ± 12.4 kg/m2, measured at the interview with higher results among females 32.2 ± 5.7 kg/m2 than males 29.7 ± 16.5 kg/m2. Obesity with a BMI ≥ 30 kg/m2 was found in 243 (48.2%) of the participants. More than 70% of participants were educated; university/college education was the most achieved by 125 (24.8%) of participants [Table 1].
Clinical care profiles
Nearly two thirds ie 320 (63.5%) participants had their eyes examined by comprehensive dilated eye examination within the previous year; among them, 176 (55%) were female. None of the participants recalled having had undergone a comprehensive feet examination. Hypertension was found among 177 (35.1%). Two hundred and twelve (42.1%) of all patients had dyslipidemia, high low-density lipoprotei-c, low high-density lipoprotei and high triglycerides more common in females, and 12 (2.4%) reported never having an assessment of their lipid profile [Table 2].
Antidiabetic therapies
There were 489 patients with T2DM (97%) and only 15 patients with T1DM (3%). T2DM was treated with different modalities, including diet control, insulin, and oral antidiabetic drugs drugs. Insulin was used by 310 (61.5%) of participants, of all participants among them; 160 (51.6%) were using a premixed formulation of regular insulin and NPH insulin; while 104 (33.5%) of them were using both regular insulin and NPH insulin as separate formulation. Among patients with T2DM, 22 (4.5%) used a combination of sulfonylureas and insulin (nine premixed Mixtard; five patients were using NPH/regular insulin combination; four patients Novomix). There were 152 (30.2%) participants over 65 years of age; among them, 105 (69.1%) were treated with insulin, 39 (25.7%) were using sulfonylureas, and six patients were using a combination of insulin and sulfonylureas; among those six patients, three patients were using Mixtard insulin, one patient was using Novomix, one patient was using aspart, and one patient was using glargine.
Self-monitoring of blood glucose
One fifth of patients ie 102 (20.2%) were practicing slef-monitoring of blood glucose (SMBG) using a glucose meter. Among Type 1 DM (T1DM) 11 (73.3%), and T2DM, 91 (18.6%) were using a glucose meter for SMBG. Among these ninety-one participants with T2DM; sixty patients were on insulin, and the other thirty-one were on oral antidiabetic drugs ADD drugs. Among the sixty patients who were on insulin; 25 (41.6%) were on premixed (30/70) insulin, 22 (36.7%) were on NPH/regular insulin, separate injections 5 (8.3%) were on glargine/aspart, 4 (6.7%) were on Novomix, 3 (5%) were on Novomix/glargine, 1 (1.7%) were on aspart.
Glycemic control
The mean hemoglobin A1C (HbA1c) was 8.3% ± 1.7%, HBA1c was slightly higher among females, and the mean fasting plasma glucose was 170 ± 63 mg/dl [Table 2]. The target HbA1c <7% was reached only by 93 (18.4%) of all participants; 56 (60.2%) were male and 37 (39.8%) were females (P = 0.029). Regarding patients aged ≥65 years, 33 (21.7%) out of 152 males had HbA1c of <7%. The mean duration of DM for all participants who reached the target was 12.8 ± 12 years. Among all patients who reached the target HbA1c, metformin was used by 82 (88.2%), followed by insulin which was used by 39 (41.9%), then sulfonylureas which were used in 27 (29%). Metformin as monotherapy was used by 28 (30.1%), and insulin as monotherapy was used by 10 (10.8%), and their combination was used by 28 (30.1). Furthermore, the metformin and sulfonylureas combination were used by 25 (26.9%). While HbA1c of <10% was reached by 409 (81.1%) of all participants; 211 (51.6%) were males and 198 (48.4%) were females. Regarding patients ≥65 years old, 129 (84.9%) out of 152 had a HbA1c of <10%. Metformin was used by 359 (87.8%) of patients who had a HbA1c of <10%, while insulin was used by 235 (57.5%), and sulfonylureas were used by 116 (28.4%).
During the last Ramadan before the study, fasting was observed by most of the participants, 481 (95.4%). The reasons for not fasting were hypoglycemia or severe hyperglycemia (2.4% and 2.2%, respectively).
Acute complications
Seventy-two patients (14.3%) repotyed having been admitted to hospital within 1 year. The main reason for admission were blood glucose control and cataract surgery 13 (18.1%) for each. These were followed by acute coronary syndrome (ACS), in 12 (16.7%) Other reasons for admission included road traffic accidents, fracture, and cholecystectomy. Diabetic ketoacidosis (DKA) was the cause of admission to the hospital for 5 (6.9%) patients; all of whom had T1DM.
DiscussionThis study aimed to explore the profile of diabetic patients in the BDC. The mean age of participants was a little higher than Roaeid and Kablan's study, about 5.5 year. The mean duration of DM was similar to the mean duration of diabetes in the 2002 study.[4]
In the present study, the mean BMI (30.9 kg/m2) is higher than previously reported results from the same center (29.5 kg/m2).[5] The mean BMI is also marginally higher than results from Tunisia.[6] In contrast, the mean BMI is lower than BMI reported in Saudi Arabia.[7] Obesity reflected in BMI ≥30 kg/m2 was found in 48.2% in the present study, less frequent than that described in another institution in the same city (68% in Benghazi Medical Center by Buzaid and Nagem[8] and in Bahrain (56.5%)[9] but higher than in Sudan (23.9%).[10]
The proportion of patients achieving higher education levels are similar. University/college was the most prevalent level of education among the participants Illertatcy rates in the current study was less than 25% which is a major improvement from 2002 when illertatcy wrate was almost three-quaers (74.2%) and graduates were less than 4%.[4] Different educational levels were reported from Libya and other neighboring countries within the context of diabetes cohorts. For example, in Tripoli, 19.4% of patients had a university level, and 16.7% were illiterates;[11] while in Tunisia, 4% only had a university level and 39% were illiterates,[6] and in Sudan, 18.9% had a university level, and 29.2% were illiterates.[10]
T2DM represents the majority in our study which was 97%; as compared to Roaeid and Kablan study, 87.2% were T2DM,[4] as well for Tunisia; T2DM represented 90%, while in Sudan 93.2% had T2DM, [10] there is recently diabetes speciality clinics and youth diabetic clinic at Benghazi medical center, where patients are followed by endocrinologests, so most of type one patients are following these clinics.
Most pharmacological therapy approaches were not following guidelines. the international guidelines, like the ADA guidelines. Diet control alone as management only was applied by 0.2%, and 88.1% of patients with T2DM were using oral non insulin antidiabetic drugs, mainly metformin, while 61.5% of all participants were using insulin; as compared to Roaeid and Kablan study, 2.7%, 57.7%, and 47.3% were using diet control alone, OHG drugs, and insulin respectively.[4] Diet control with metformin alone was used by 12.5% of patients. Sulfonylureas alone were used by 0.8% of patients, while combination therapy of metformin with sulfonylureas was used by 26.6% of patients, and this was the second most common combination after insulin with metformin which represents 50.3%; as compared to Roaeid and Kablan study, 3.1%, 31.9%, and 22.6% of patients using metformin alone, sulfonylureas alone, and metformin with sulfonylureas respectively; while in Roaeid and Kablan study, insulin never combined with OHG dugs.[4]
Lack of updated locally agreed treatment guidelines and unavailability of some medications could have contributed to these results. There is a rematkable improvement regarding adherence to the medication by the patients, as in present study study, only 4.8% of participants were not taking their medication regularly; compared to Roaeid and Kablan study, who reported that 27.1% were not taking their medication regularly. Over one third (34.3% of patients had an attack of hypoglycemia at least once in their lives; compared to Roaeid and Kablan study, 53.5% reported the same.[4]
Smoking habits does not seen to have changed; 25% of all male patients were active smokers, 16.7% were ex-smokers, and none of the females were smokers; compared to Roaeid and Kablan study.[4] Also a study in Tripoli, reported that 26.4% were active smokers, and 40.3% were ex-smokers,[11] and the result was <27.3% in BMC by Buzaid and Nagem.[8] Also our results are less than rates observed in Tunisia (39.6%).[6]
Most of the patients in this study only 11.1% of all patients were regularly exercising which is noticeably lower that the reported rates in Benghazi in 2002 and in Sudan (41.5% and 27.7% respectively).[4],[10]
Less than two-thirds ie, 63.5% of all patients had diabetes eye screening within the previous years which is lower than the 2002 study (49.2%).[4] However, none of the participants in the present study had ever undergone a comprehensive feet examination; which is a remarkable deterioration from the 2002 study.[4] Hypertension prevalence increased to 35.1% of total participants in this study compared to the 2002 study reporting only 15.3% with hypertension. However, this may be attributed to the fact that 48.3% had never checked their blood pressure.[4] This result was nearer to what was observed in Tripoli (20.8%);[11] and lower than what was by Buzaid and Nagem,[8] and Zantour(6) et al.,[6] respectively. Dyslipidemia was found in 42.1%, and only a minority had never checked their lipid profile; this is aremarkable improvement form the 2002 study when 76% had never checked their lipid profile.[4] Also our results are better that the rate of 34.54% in Tunisia.[6]
SMBG was practiced by only 20.2% of participants. I was used by 73.3% of T1DM and only 18.6% of T2DM patients. This low rate might be due to the high expense of the glucose meters and strips. In the Roaeid and Kablan study, 8% of all patients were monitoring their glucose by using urine stick, while among patients with T1DM 2.4% were using a glucose meter.[4]
The most notable improvement compared to the 2002 study was HbA1c, as none of the participants had ever checked HbA1c in Roaeid and Kablan study, as HbA1c was available but in private labs only, [4] The mean HbA1c in this study was 8.3% ± 1.7%. This result is higher than what was reported by Allaghi et al.[12] 7.8% ± 1.6%, but less than what was reported by Al-Rubeaan et al; [7] 8.8 ± 1.7%.
During Ramadan, most of the patients observed fasting, and only a minority could not fast either due to hypoglycemia or severe hyperglycemia. These findings represent a higher fasting blood glucose levels than that was previously reported by Allaghi et al., just over a decade ago in the same city (70.4%), this was mainly attributed to a higher frequency of patients with severe hyperglycemia in our study (27%).[12]
Acute complications leading to admission to hospital within the previous year were reported by 14.3% of all patients. The main reason for admission was mainly due to two categories, including blood glucose control and cataract surgery followed by ACS, Roaeid and Kablan reported that 24% had been admitted within the previous year to the hospital. However, metabolic disorders (hypoglycemia, diabetic ketoacidosis, uncontrolled DM) were the main reason for admission representing 48.3% of cases. In contrast, cataract surgery represents 16.1%, and acute myocardial infarction represents 6.7%.[4]
ConclusionsThere is an improvement in diabetic patients regarding annual eye examination, taking the medication regularly by the patients, SMBG, checking lipid profile, and regular follow-up with HBA1C. On the other hand, there is a serious decline regarding comprehensive feet examination, practicing regular exercise, and diet control compared with the previous study.
Diabetes care strategies and implementation of comprehensive diabetes assessment, screening for complications, and diabetes care, also the implementation of diabetes education programs are urgently needed. Keeping a comprehensive records is of paramount importance, ideally using dedicated electronic data bases. Periodic re-assessment of the prevalence of diabetes and prediabetes and their managment and outcomes are warranted.
Authors' contributions
Omar Alfalah: acquisition of data, analysis, interpretation of data. Imhemed Eljazwi: concept and designing, revising it critically for intellectual content, final approval. Najat Buzaid: revising for intellectual content, final approval.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Compliance with ethical principles
The study was approved by the Research Ethics Board at the Benghazi medical center.
References
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