Akhidue, K; Otokunefor, O (2024). Greener Journal of Medical Sciences, 14(2): 101-104.
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Greener Journal of Medical Sciences
Vol. 14(2), pp. 101-104, 2024
ISSN: 2276-7797
Copyright ©2024, the copyright of this article is retained by the author(s)
https://gjournals.org/GJMS
1 Consultant Endocrinologist, Rivers State University Teaching Hospital.
2 Senior Lecturer, University of Port Harcourt Teaching Hospital.
Type: Research
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Introduction: Diabetes Mellitus is a growing concern all over the world. The estimated prevalence in Nigeria is 4.3% and that in Port Harcourt is 6.8%. Negative outcomes (increased morbidity and mortality) have been associated with poor glycaemic control which can be further complicated by dyslipidaemia. Both are independent risk factors for cardiovascular and cerebrovascular accidents
The aim of this study was to assess the pattern of glycaemic control and dyslipidaemia in newly diagnosed persons with Type 2 Diabetes Mellitus attending the medical clinic of the Rivers State University Teaching Hospital.
Method: This was a retrospective cross-sectional study. It was carried out in Rivers State Nigeria, in the medical outpatient department. 63 patients’ data were recalled, and analysed with MS Excel and SPSS.
Result. Most respondents were females 66.2%, above 50 years (70.6%) and presented with excessive urination (22.2%), poor vision (13.9%) and numbness of feet (11.1%). Of the total, 80% had poor glycaemic control (fasting values above 7mmol/L) and 84% had various forms of dyslipidaemia [raised total cholesterol (26.3%), raised LDL (73.7%) and reduced HDL (44.7%)]. The most common dyslipidaemia was elevated LDL. However, no statistical correlation between hyperglycaemia and dyslipidaemia was found. Mean HbA1c was 12%.
Discussion: A fifth of these patients presented with complicated uncontrolled diabetes and features of target organ damage. This necessitates immediate intense intervention (behavioural changes and drug therapy) and very close bimonthly monitoring. Physician inertia if present needs to be overcome to reduce dyslipidaemias. These are high risk patients “The lower, the better, the earlier the better” is the goal. This will improve overall outcome.
Conclusion: Majority of the new patients attending the diabetes clinic at presentation had dyslipidaemias and need immediate effective intervention to improve mortality and morbidity.
Published: 18/08/2024
Otokunefor, O.
E-mail: mayslady@ hotmail.com
Phone: 08037056312
Keywords: dyslipidaemia, glycaemic control, Type 2DM patients.
The health impact of Diabetes Mellitus is a cause for concern in the world and in Nigeria. The prevalence worldwide in 2021 was one of ten people.1 According to WHO, more than 95% of people with Diabetes have type 2 Diabetes Mellitus (DM)2. The estimated prevalence in Nigeria is 4.3% and that in Port Harcourt is 6.8%. 3 Prevalence is increasing more in low and medium countries (including Nigeria) than in high income countries. 2 Up to 75% of adults with diabetes are found in low and middle income countries. 1
As far back as 2018, it was estimated that one out of seventeen adults in Nigeria were living with diabetes Mellitus. 4 This a staggering figure.
Statement of problem
Negative outcomes in terms of morbidity and mortality have been associated with poor glycaemic control which can be further complicated by dyslipidaemia. 5, 6, 7. Both are independent risk factors for cardiovascular and cerebrovascular accidents. 5, 8
Up to 85 percentage of patients with type 2 DM have dyslipidaemia. (range is 70- 85%) Cardiovascular events are a major cause of mortality in patients with diabetes. (at least 50%) 6,7 Cardiovascular events associated with Type 2 DM include Ischaemic heart disease, stroke, coronary artery disease and peripheral artery disease.6
Patients with type 2 DM and dyslipidaemia are up to four times more at risk for cardiovascular accidents than the general population.
Poor glycaemic control is a contributory factor to cardiovascular risk.5 Good glycaemic control alone does not eliminate cardiovascular risk in the presence of dyslipidaemia because dyslipidaemia is an independent risk factor for cardiovascular events in patients with diabetes. Therefore, there is a negative multiplier effect which if not properly managed would affect outcome
Dyslipidaemia usually exists several years before diabetes is diagnosed. This means that at the time of diagnosis and presentation the patient is already at risk for cardiovascular events. A Canadian study also discovered that over half of the population of persons who had diabetes for two years had dyslipidaemia. 9
It is mandatory for persons with type 2 DM be screened for dyslipidaemia regardless of other risk factors. The presence of dyslipidaemia should be determined at diagnosis and yearly afterwards. 10
It is of utmost importance to establish the current presentation pattern of newly diagnosed diabetic patients in our own environment
The aim of this study was to assess the pattern of glycaemic control and dyslipidaemia in newly diagnosed persons with Type 2 Diabetes Mellitus attending the medical clinic of RSUTH over a four month period in 2023.
Study Design: This was a retrospective cross-sectional study. Carried out over a period of 4 months using patients records in the diabetic clinic of a tertiary hospital in Rivers State.
Study Area: This is one of the two tertiary hospitals in Rivers State. A state in southern Nigeria.
Sample population was new patients attending the diabetic arm of the medicine clinic.
Inclusion criteria was any first time patient attending the medicine clinic with diabetes. Exclusion criteria was any patient attending the medicine clinic that did not have diabetes.
Sample size was 63. 63 patients’ data were recalled, and analysed with MS Excel and SPSS. All the new patients within the four months period were 63. Purposive sampling technique was used.
The results of the following laboratory investigations were obtained from the records. Fasting plasma glucose, Glycated haemoglobin, Triglycerides, Total cholesterol and HDL. LDL was calculated.
Data analysis: Data was entered into an excel sheet and exported to SPSS version 23 for analysis.
Result. Most respondents were females 66.2%, majority were above 50 years (70.6%) and the three most common presenting complaints were excessive urination (22.2%), poor vision (13.9%) and numbness of feet (11.1%). 80% had poor glycaemic control (ADA level 1 hyperglycaemia) and 84% had various forms of dyslipidaemia (raised total cholesterol 26.3%, raised (LDL 73.7%) and reduced HDL 44.7%). Mean HbA1c was 12%. The most common dyslipidaemia was elevated LDL. However no significant statistical correlation between hyperglycaemia and dyslipidaemia was found.
Most of our patients were females and this is not unexpected as females are more prone to diabetes.11
A fifth of the patients presented with untreated and uncontrolled diabetes as evidenced by features of target organ damage. The most frequent presentations being frequent urination, poor vision and numbness of the feet. Diabetes is uncontrolled when the glucose level is above 11mmol/l in a random specimen. These patients were not previously on treatment as this was their first time in the clinic and their presenting complaints were features of organ damage.
Untreated diabetes is when a diabetic patient has not been on treatment before and uncontrolled diabetes is when a patient is on treatment and the blood glucose is not properly controlled. 12
Poor vision and numbness of feet are microvascular complications of diabetes. 13 Diabetes retinopathy is the commonest cause of preventable blindness. 14 It is possible to slow the progress of diabetic retinopathy if it is detected in the early or moderate stages. However, loss of vision is irreversible. 14 Most patients with diabetes retinopathy have no symptoms especially in the early stages. 11, 14 Usually annual eye check is recommended for patients with diabetes. Some patients have some symptoms and they include, blurred vision, distorted vision, impaired colours, presence of floaters and loss of vision.14
A study done in Nnewi had a higher percentage of people presenting with visual disturbances. Of the first-time patients in their clinic, 44% (as opposed to our 13.2%) presented with either bilateral or unilateral blindness. 15
Majority of the patients had various forms of dyslipidaemia. (84%). This is expected as there is a strong interplay between hyperglycaemia and hyperinsulinemia and the evolution of dyslipidaemia. 16 The typical picture found in these patients has been termed diabetic dyslipidaemia.17
Hyperglycaemia increases oxidative stress and enhances leucocyte endothelial interactions and leads to glycosylation of proteins in the body leading eventually to the formation of Advanced Glycosylation End Products (AGE) 18 which will in the long run affect endothelia cell as well as vascular wall function and promote atherothrombosis. Hyperglycaemia also induces hyper acetylation of a histone molecule in the genes coding for diabetes and cardiovascular disease,19 in addition it induces DNA methylation of genes coding for glucose metabolism. The effect of these in, in-vitro studies has been found up to six days after one hyperglycaemic episode.
Diabetic dyslipidaemia tends to present with an increased level of small dense LDL (sdLDL). 17 Postprandial lipaemia also presents as the clearance of lipoprotein remnants from the blood stream tends to be modulated by the presence of diabetes. In diabetic patients the rate of production of VLDL is increased and in uncontrolled cases the LDL receptors can be decreased, these eventually lead to macrovascular disease.
The dyslipidaemia and hyperglycaemia need to be treated as a matter of urgency to reduce the cardiovascular risk and improve patient outcomes. 6 Primary prevention here involves preventing and delaying new onset of cardiovascular disease in Type 2DM patients by detecting risk factors and managing them. Those with dyslipidaemia can now be stratified into high risk and very high risk based on the presence of ASCVD and end organ damage to determine the depth of treatment. 10
Several treatment algorithms exist by various groups for Patients with Type 2 diabetes and dyslipidaemia and include, intense life style modification and pharmacological treatment. (including use of statins and newer lipid lowering drugs) to be re-evaluated every 8 to 16 weeks till the patient stabilizes. 7 9 10 Treatment is individualized.
Healthy life style practises remain a fundamental part of CVD prevention strategies and management of diabetes. It is vital in minimizing the incidence of CVD. The goal is to maintain the LDL -C below 2mmol/L or to achieve a reduction of 50% from the baseline value.9 Lifestyle intervention includes, weight management, exercise, well balanced, moderate energy meals, elimination, reduction in or moderate intake of alcohol as well elimination all tobacco products. 10
The World Health Organization has strongly recommended that the quality of care of persons with diabetes be intensified and more initiative and preventive than reactionary. 20 The WHO took this a step further and established a five point target for people with diabetes and number four involves have a minimum of 60% of affected people 40 years and above receiving statin therapy. 21
The goal is to lower the lipid level. The lower the better, the earlier the better. 22
To achieve this, after selecting the pathway for the patient, the expected target should be clearly communicated with them. Then these patients can have their lipid profile reassessed every 8 to 12 weeks, to monitor the effect of the instituted treatment.
Glycaemic control goals when accessed using glycated haemoglobin is a target of less than 7%. 5
Majority of the new patients attending the diabetes clinic at presentation had dyslipidaemias and need immediate effective intervention to improve mortality and morbidity.
Authors have declared that there was no conflict of interest
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