Glycemic control, cardiovascular risk profile and therapeutic interventions in type 2 diabetes mellitus patients at the New Nyanza Provincial General hospital, Kisumu

Abstract

Background: The number of people with type 2 diabetes around the world is estimated to rise from 251 million in 2000 to 380 million by 20251 . This rise will disproportionately affect the least developed countries of the world. While the prevention of diabetes is imperative, strict glycemic control-(treatment to target}, is critical in reducing the onset and or progression of complications for those already afflicted by diabetes mellitus i": HBA1c, fasting and postprandial glucose levels are vital indicators of the adequacy of glycemic control. Arterial blood pressure, the fasting lipid profile and urinary albumin excretion are parameters that can be used to make decisions regarding interventions in these patients, especially for coronary artery disease risk reduction-the most important cause of morbidity and mortality. Study questions: How well is Type 2 diabetes mellitus controlled at a provincial (level 5) hospital, what coronary artery disease risk factors are prevalent and what pharmacotherapeutic interventions are being utilized? Objective of the study: The study was designed to determine the demographic characteristics, cardiovascular risk factors, level of glycemic control and the pharmaco-therapeutic strategies utilised for CAD risk reduction in Type 2 Diabetes Mellitus patients attending the Outpatient Diabetic clinic at New Nyanza Provincial Hospital in Nyanza Province, Kenya. Study design: The study was a cross-sectional hospital based observational study: Site: at the Diabetes Outpatient Clinic at the New Nyanza Provincial General Hospital in Nyanza Province. Subjects: The study looked at Type 2 diabetes mellitus patients on follow up for at least 6 months at the clinic. Materials and methods: 119 patients consecutively sampled over nine months provided the data sought by the study. The data was categorized as follows: Socia-demographic, Clinical, Laboratory or Therapeutic strategies data. Results: The study population was rural with 65.5% (78) of the patients living outside the municipal boundaries. The median age was 58.4 (SO 8.9) years. Seventy (58.8%) of the patients were female. Cigarette smoking and alcohol use were low, nineteen (16%) and eight (6.7%) respectively. The patients were generally overweight (68.9%), with a mean body mass index of 27.0 (505.6) kg/rn". Twenty three (19.3%) had excellent control with a fasting plasma glucose of less than 6mMoljL. Only 13 patients (10.9%) had a well controlled postprandial profile of less than 10mMoljL. One hundred and four (87.4%) of the patients had good glycemic with HBA1c of less than 7%. Ninety five (79.8%) had excellent control of less than 6%. All patients except two (1.7%); were on pharmacologic management for glycemic control. One hundred and nine (91.5%) of the patients were OHAs with or without insulin. Twenty six (21.8%) were on insulin only, while eight (6.7%)were on both insulin and OHAs. The mean SBP and OBP were 129.6(5020.0) mmHg and 77.7(5011.0) mmHg respectively. Ninety five (79.8%) were on antihypertensive medications. The RAAS blocking anti hypertensive agents (ACEI and ARBs) were the most frequently used agents, with sixty eight (57.1%) using them. Forty five (47.4%) of those on treatment were at target blood pressure of lessthan 130mmHg systolic and 80mmHg diastolic. With regard to lipids, seventy two (60.5 %) had elevated LOL cholesterol above 2.6mmol/L. The utilization of lipid lowering agents was low with only nine (7.6%) patients on them. Antiplatelet agents were used in eleven (9.2%) patients. The mean estimated glomerular filtration rate was 70.5 ml/min (SO 27.2). Ninety seven (81.5%) patients had deranged renal function; with an estimated GFR below 60mil/min. The median albumin-creatinine excretion ratio was 15.0 (lOR 10-50). Forty four (37%) patients had microalbuminuria, with no patient having macro-albuminuria. Twenty three (52.3%) of patients with microalbuminuria were on RAAS blocking agents. There was no statistically significant difference in the choice of agents for blood pressure control between the patients with microalbuminuria and those with norma-albuminuria. There was no statistically significant socia-demographic predictor of glycemic control in this study population. Fasting glucose was found to independently predict blood glucose control from our data. There was a trend towards significance with the waist hip ratio. Conclusion: The level of glycemic control in the study population was good. This is however negated by the high prevalence of elevated LOL cholesterol, poorly controlled blood pressure, obesity and low up take of interventions for cardiovascular risk factor reduction.