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January 1999, Volume 49, Issue 1

Original Article

Prevalence of Macrovascular Complications in Diabetics of WAH, District Rawalpindi

Rizwan Hashim  ( Department of Pathology, CMH, Bahawalpur. )
Farooq Ahmed Khan  ( Armed Forces Institute of Pathology, Rawalpindi. )
Dilshad Ahmed Khan  ( Armed Forces Institute of Pathology, Rawalpindi. )
Asma Shaukat  ( QMC, Bahawalpur. )

Abstract

Objective: To determine the prevalence of macrovascular complications in diabetic subjects with relation to age duration of diabetes and metabolic control..
Setting: Primary care centres of WAH, District Rawalpindi cross sectional population based study.
Methods: A total of 805 known diabetics (380 males and 425 females) were studied. Relevant history, detailed physican examination and ECG were done to assess the presence of ischaemic heart disease, stroke and diabetic foot complications. Their diabetic control was assessed by estimation of their plasma glucose and glycosylated haemoglobin.
Results: The prevalence of macrovascular complications was as follows: Ischaemic heart disease 19.8% (female 4.7%, males 7.8%), cerebrovascular disease 6.2% (females 4.7%, males 221%) and diabetic foot complications 2.1%. The macrovascular complications increased with age, duration of diabetes and were more prevalent in uncontrolled diabetics having glycosylated haemoglobin >8.6%.
Conclusion: Prevalence of macrovascular complication in our population is higher as compared to the West probably due to better management and diabetic care in those countries (IPMA 49:8, 1999).

Introduction

Diabetes, one of the most common chronic disorders among adults in the Western world is associated with increased prevalence of macrovascular disease1. Atherosclerotic heart disease is accelerated in patients with diabetes whose motbidity from ischaemic heart(IHD), cerebrovascular disease (CVD) and peripheral vasculardisease (PVD) greatly exceeds those of the non-diabetic population2.
Several studies have been carried out in USA, Europe and South Asian countries to determine the prevalence of macrovascular complications in their diabetic patients3-7. Diabetics suffer 2 to 4 times the risk of developing cardiovascular disease than non-diabetics in Europe8 and epidemiological studies demonstrate that diabetes mellitus carries a 2 to 6 fold increased risk of stroke9. Diabetic patients have an overwhelming propensity to atheroma and gangrene of the lower extremity and the risk of amputation is six times greater than in non-diabetic subjects10-11 . The studies carried out to know the prevalence of these complications in Pakistan were clinical based and they did not provide any information regarding the effects of duration and metabolic control upon macrovascular complications of diabete12,13. Hence a populationbased study was designed for the purpose inknown diabetics of Wah, District Rawalpindi.

Subjects and Methods

This was across sectional, populationbased study to see the pattern of diabetic complications in known diabetics repoiting to primary care centers in a localized population of Wali. Out of thirteen hundred and thirty-eight known registered diabetics in Wah, a total of 805 (380 males and 425 females) participated aflerfull informed consent. The duration of diabetes was the time between the diagnosis and the time of examination. A complete history about the macrovascular complications was enquired and a complete general physical and systemic examination perfonned.
Ischaeinic Heart Disease (IHD) was considered to be present if there was a history of inyocardial infarction that was confinned by ECG (i.e., pathological Q waves) at the time of examination/review of previous hospital records when present, or history of angina elicited and confinned by the physician. CVD was recorded if there was documentary evidence of stroke (cerebral infarction, haemorrhage or thrombosis), transient ischaemic attack (TIA), hemiplegia or monoplegia. Diabetic foot disease was considered if there were trophic foot ulcers, gangrene oramputationof any part of the extremities. The peripheral pulses (femoral, popliteal, dorsalis pedis and posterior tibial, were palpated.
To assess the metabolic control, plasma glucose and glycosylated haeinoglobin estimation were carried out. Plasma glucose was estimated by enzymatic method (oxidase/peroxidase) of Sera-pak, Ames, England. Its between bach CV was 3.5%. Plasma glycosylated haemoglobin (GHb) was estimated by using Sigma Diagnostics glycohaemoglobin quantitative column tecimique kit Cat No.440 from whole blood collected in EDTA/Sodiuin Flouride. Its between batch CV was 6.1%.
Statistical Analysis
The data was analyzed by the computer programme Special Package for Social Sciences (SPSS). The mean, median and percentile values of the analytes were calculated. The level of significance was put at p<0.05.

Results

Out of 805 diabetics the overall prevalence of IHD was 19.8%. It was slightly more common in males (22.1%) than females (17.5%). The percentage distribution of IHD gradually increased with advancing age. The prevalence of CVD was 6.2%. The males (7.89%) were affected more than the females (4.7%). CVD was more prevalent in diabetics of more than 50years of age. The total prevalence of diabetic foot disease was 2.1%. It was three times more common in males (3.42%) than females (0.94%) (Table 1).


IHD was common in patients who had longer duration of diabetes compared to those having shorter duration of illness. The peak incidence was seen in subjects having a 13-16 years duration. The prevalence of CVD increased with long standing diabetes and was seen in diabetics who had the disease for more than one and a half decade. Diabetic foot disease was also more common in patients having prolonged duration of diabetes (Figure 1).


IHD was commonly recorded in uncontrolled diabetics, CVD and diabetic foot disease showed a linear relation with glycosylated haemoglobin (Table II).

Discussion

It is well known that macrovascular disease represents a major threat to the health and life of people with diabetes mellitus2. The overall prevalence of IHD in our study was 19.8%(Table I) comparable to the prevalence of 15-27%noted from SouthEast Asiancountries13,17. H-ID gradually increased with the age of diabetic patients(Table I). These findings support similar observations noted in European diabetics. Insulin resistance and obesity am responsible for much of the abnormal lipid metabolism. The plasma lipid abnormalities alongwith glycosylation of vessel lead to increased risk of atherosclerosis and are likely to be an important cause of increased macrovascular disease18
CVD occurs 1.5 -2 times more frequently in diabetics than non-diabetics19,20. The overall prevalence of CVD in this study was 6.2 1% (Table I) comparable to the prevalence of 4.4-7% noted in European diabetics21,23. The prevalence of CVD in these diabetics was lower than that recorded in South East Asian countries (8.2%)16,17. The prevalence of CVD increased with age (Table I). Similar findings were noted in diabetics of WHO multinational study24. The mechanism that possibly explains the increased stroke damage after hyperglycaemia is cellular acidosis. It is suggested that both pH and lactate levels could independently contribute to cellular damage25-28.
Diabetic foot disease was common in older diabetics and the total prevalence was 2.1% (Table 1). This was lower than noted in the West (5-7%)21,29,30, probably due to frequent washing of feet and better hygiene. There are three main factors that lead to tissue necrosis in the diabetic foot disease, namely neumpathy, infection and ischaemia The feet are the target of peripheral neuropathy leading chiefly to sensoly deficit, while ischaemia results from atherosclerosis of the long vessels. The atherosclerosis in diabetics is oftenbilatenil, multisegmental and distal; it usually involvçs vessels below the knee31.
IHD was more frequent in patients with longerduration of diabetes (Figure 1). Silimar conclusions were recorded in studies conducted in Pakistan and abmad12,16,32. CVD was noted to increase withiong standing diabetes (Figure 1). These findings were in agreement with similar observation by other authorss33,34. Diabetic foot disease was more prevalent in subjects with prolonged duration of disease (Figure 1). These findings support similar observation in the West5.
Macrovascular complications were coiiunon in diabetics with poor metabolic control. IHD had a direct correlation with GHb levels (Table II). These findings support the association between DID and elevated GHb recorded in other studies33,35,36. CVD and diabetic foot disease were frequent in uncontrolled diabetics (Table II) and these observations were in agreement with the findings in others33-35. Similar findings were noted in European diabetics14.
In this study majority of the patients had poor metabolic control. The reason for poor diabetic care in these centers could be that a doctor examined 50-70 patients daily from the surrounding population. The doctor’s time spent with each patient was short and the doctor’s advice also appeared relatively ineffective. A high portion of overweight and obese patients were prescribed oral hypoglycaemic agents (7.9%) and these patients could be presumed diet failures, while few were treated with insulin injection(14.5%) and some were managed with diet control and weight reduction (6.6%).
This data provides an important population based information to this poorly studied field and also gives an overview of the magnitude of macrovascular diabetic complications in patients treated primarily by general practitioners and the reasons of poor metabolic control that aggravate the diabetic complications. It is concluded that macrovascular complications due to diabetes are common in our setup. Regular clinical examination, ECG and estimation of plasma glucose, GHb and lipid profile are necessaiy for evaluation of these complications. Establishment of diabetic clinic with facilities of diabetologist, dietician and chirodopodist are essential so as the doctor could spend more time with each patient for detailed examination and imparting health education.

References

1. Jarrett RJ Epidemiology and public health aspects of non-insulin dependent diabetes mellitus. Epidemiol. Rev., 1989; 11:151-71.
2. Jarrett RJ., Keen H, Chakrabati R. Diabetes. Hyperglycaemia and arterial disease. In Keen H, Jarrett J (eds), Complications of diabetes. London, Edward Arnold, 1982, pp. 179-203.
3. Mazze RS, Sinnock P. Deeb L, et al. An epidemiological model for diabetes mellitus in the United States: five major complications. Diabetes Res.Clin.Pract., 1985;1:185-91.
4. Gall MA, Rossmg P, Skott P. et al. Prevalenceof micro and macroalbuminuria, arterial hypertension retinopathy and large vessel disease in European type 2 diabetics. Diabetologia, 1991 ;34:655-61.
5. Cohen DL, Neil HA, Thorogood M, et al. A population based study of the incidence of complications associated with type 2 diabetes in the elderly. Diabetic Med., 1991;8:928-33.
6. Merriman A, Ross I. Findings among 100 type 2 diabetics in a clinic in Penang, Malaysia 1983-84. Ann,Acad,Med. Singapore, 1985;14:277-85.
7. Lester FT. Long standing diabetes mellitus in Ethiopia: a survey of 105 patients. Diabetologia, 1983;25:222-25.
8. Janka HU. Epidemiology and risk factors of macrovascular disease in diabetes mellitus. Horm.Metab.Res.Suppl., 1990;22:8-11.
9. Kuller LH, Dorman JS, Wolf PA. Cerebrovascular disease and diabetes in America - diabetes data compiled 1984. Harris MI and Hamman RF, EDS. Bethesda MD. N. York, U.S. Dept. ofHealth and Human Service, 1985, pp. 1-18.
10. Zdanov VS, Vihert AM. Atherosclerosis and diabetes mellitus. Bull.WHO., 1976;53:547-53.
11. Bell El. Incidence ofgangreneoftheextremitiçs in non-diabetic and in diabetic persons. Arch.Pathol., 1950;49:469-75.
12. Haider Z, Din FU, Obaidullah S. Prevalence of coronary heart disease in Pakistani patients suffering from maturity onset diabetes mellitus. J.Trop.Med.Hyg.,1978;81 :98-102.
13. Rahman MA, Zafar G, Shera AS. Changes in glycosylated proteins in long-term complications ofdiabetes mellitus. Biomed. Pharmacother,, 1990;44:229-34.
14. Ahuja MM, Kumar V. Chand M, et al. Vascular disease in Indian diabetics. Congress of the International Diabetes Federation. New Delhii, International Diabetes Foundation, 1976, p. 110.
15. Ibrahim S, Hashmi JA, Syed SA. Prevalence ofcoronary heartdisease in patients suffering from diabetes mellitus. Pak.J.Med.Res., 1975; 14:45.
16. Bhuripanyo P, Graisopa S, Suwanwatana C, et al. Vascular complications in non-insulin dependent diabetes mellitus (NIDDM) in Sringarind Hospital, Khon Kaen. J.Med.Assoc. Thai., 1992;75:570-77.
17. Patel JC. Complication in 8793 cases of diabetes mellitus. 14 years study in Bombay Hospital, Bombay, India. J.Med.Sci., 1989;43:177-83.
18. Best EM, Pitzele A, Green A, et al. Mesenteric blood flow in patients with diabetic neuropathy. J. Vasc.Surg., 1991,13(1): 84-90.
19. Palumbo JP. Elveback-Whianant JP. Nerologic complications of diabetes mellitus transient ischaemic attack, atroke and peripheral neuropathy. In Schoenberg BS (ed): Advances in Neurology. NewYork, Raven Press, 1978, pp. 593-613.
20. Abbott RD, Donahue RP. MacMahon SW, et al. Diabetes and the risk of stroke: the Honolulu.Heart Program. JAMA., 1987;257:949-52.
21. Neil HA, Thompson AV, Thorogood M, et al. Diabetes in the elderly: the Oxford Community Diabetes Study. Diabetic Med., 1989;6:608- 13.
22. Neilson NV, Ditzel J. Prevalenceof macro and microvascular disease as related to glycosylated hemoglobin in type I and 2 diabetic subjects. An epidemiologic study in Denmark. Horm.Metab.Res.Suppl., 1985; 15:19-23.
23. Morrish NJ, Stevens LK, Fuller JH, et al. Incidence of macrovascular disease in diabetes mellitus: the London cohort of the WHO multinational study of vascular disease in diabetics. Diabetologia, 1991 ;34:584-9.
24. Diabetes drafting Group. Prevalence of small vessel and large vessel disease in diabetic patients from I 4.centres. The World Health Organization Multinational Study of Vascular Disease in Diabetics. Diabetologia, 1985;28:61 5-40.
25. Smith ML, von-Hanwehr R, Siesjo BK.Changes in extra and intracellular PH in the brain during and following ischaemia in hyperglycemic and in moderately hypoglycemicrates. J.Cereb. Blood Flow.Metab., 1981,1:297-311.
26. Collins RC, Dobkin Bh, Choi DW. Selectivevulnerability ofthe brain: new insights into the pathophysiology of stroke. Ann.Intem.Med., 1989; 110:992-1000.
27. Giffard RG, Monyer H, Choi DW. Selective vulnerability of cultured cortical glia to injury by extracellular acidosis. Brain Res, 1990;530: 138-41.
28. Varhoeven S, Van Ballegooie E, Caspane AF. The prevalence of late complications of type 2 diabetes mellitus published erratus appears in Ned Tijdschr Geneeeskd 1990 Mar 10;134(10):512. Ned Tijdschr Geneeskd 1990; 134(6):283-7.
29. Muhlhauser I, Sulzer M, Berger M. Quality assessment of diabetes care according to the recommendations of the St. Vincent Declaration: a population based study in a rural area ofAustralia. Diabetologia, 1992;35:429-35.
30. Logerfo FW, Coffman JD. Vascular and microvascular disease of the foot in diabets.N.Engl.J.Med., 1984;31 1:1615-19.
31. Eschwege E, Richard JL, Thibult N, et al.Coronary heart disease mortality in relation with diabetes, blood glucose and plasma insulin levels. The Paris Prospective Study; ten year later. Horm.Metab.Res., 1985; 1 5(Suppl):41 -46.
32. El-Mahdi EM, Kaballo AM, Mukhtar EA. Featuresof non-insulin dependent diabetes mellitus (NIDDM) in the Sudan. Diabetes Rea.Clin.Pract., 1991;1 1:59-63.
33. Wingard DL, Barrett-Connor EL, Scheidt-Nave C. Prevalence ofcardiovascular and renal complications in older adults with normal or impaired glucose tol&ance or NIDDM. Diabetes Care. 1993; 16:1022-25.
34. Singer DE, Nathan DM, Anderson KM. et al. Evans association of HbA I cwithprevalent cardiovasculardisease in the original cohort of the Framingham Heart Study. Diabetes, 1992;4 1:202-9.
35. Goldstein DE, Little RR, Wiedmeyer HM, et al. Is glycohaemoglobin testing useful in diabetes mellitus? Lessons from the diabete control and complication trial. Clin.Chem., 1994;40:1637-40.

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