|Year : 2016 | Volume
| Issue : 4 | Page : 190-195
Determinants of glycemic control among persons with type 2 diabetes mellitus in Niger Delta
Chukwuani Ufuoma1, Yovwin D Godwin2, A Digban Kester3, J Chukwuebuni Ngozi4
1 Department of Family Medicine, Delta State University Teaching Hospital, Oghara, Nigeria
2 Department of Medical Laboratory Science, College of Health Sciences, Igbinedion University, Okada, Nigeria
3 Department of Medical Laboratory Science, Chevron Hospital, Warri, Nigeria
4 Department of Internal Medicine, Central Hospital (HMB), Warri, Nigeria
|Date of Web Publication||21-Dec-2016|
Department of Medical Laboratory, Chevron Hospital, PMB 1244, Warri, Delta State
Background: The rising burden of type 2 diabetes mellitus (T2DM) with its attendant's complication can be successively steamed in the face of appropriate self-care management. The latter is positively imparted by the level of knowledge of the disease itself, its impact on quality of life and available basic technique of its control. Aims: The study is, therefore, aimed to assess the level of glycemic control and its determinants among type 2 subjects attending a secondary hospital in Niger Delta. Subjects and Methods: Two hundred consenting adult type 2 diabetes patients of age more than 40 years and attended diabetes outpatient clinics at the Central Hospital Warri between March and August 2014 were used for this cross-sectional study. Two different questionnaires were administered to all the participants to collect the necessary information on diabetes knowledge as well as factors that might affect their glycemic control. Blood samples were collected for fasting blood glucose (FBG) and glycosylated hemoglobin (HbA1c) for all the respondents. Weight and height were also measured to the nearest 0.5 kilogram and centimeter using standardized equipment. Body mass index was then calculated as the ratio of weight in kilogram and height in meters square (kg/m 2 ). Statistical Analysis Used: Statistical Package for Social Science Version 16 was used to compute the data generated. Results: The mean age and diabetic duration of all participants were 54.8 ± 11.9 years and 8.5 ± 3.2 years, respectively. The overall mean knowledge score of the subjects was 6.90 ± 1.8 (69.0 ± 18.2%) The mean FBG level and HbA1c of respondents were 7.89 ± 3.6 mmol/L (range 4-20 mmol/L) and 8.2%, respectively, with 55% of the population having poor glycemic control and 45% good glycemic control. The diabetic knowledge scoring of those with poor glycemic control was significantly lower than those with good glycemic control. In addition, diabetics' with poor glycemic control HbA1c >7.0 had longer diabetic duration (1-19 years; 8.06 ± 4.30) when compared with those with good glycemic control, HbA1c < 7.0 (1-15 years; 6.44 ± 4.02). Conclusions: The proportion of poor glycemic control among patients with T2DM in Central Hospital Warri is relatively high with diabetic duration and inadequate diabetic knowledge identified as significant determinants.
Keywords: Diabetes knowledge, glycemic control, glycosylated hemoglobin, Warri
|How to cite this article:|
Ufuoma C, Godwin YD, Kester A D, Ngozi J C. Determinants of glycemic control among persons with type 2 diabetes mellitus in Niger Delta. Sahel Med J 2016;19:190-5
|How to cite this URL:|
Ufuoma C, Godwin YD, Kester A D, Ngozi J C. Determinants of glycemic control among persons with type 2 diabetes mellitus in Niger Delta. Sahel Med J [serial online] 2016 [cited 2019 Oct 13];19:190-5. Available from: http://www.smjonline.org/text.asp?2016/19/4/190/196361
| Introduction|| |
The prevalence of type 2 diabetes mellitus (T2DM) is rapidly increasing all over the world.  Global estimates of diabetes prevalence were predicted as 6.4%, affecting 285 million adults as at 2010 and will increase to 7.7% and 439 million adults by 2030.  This is due to population growth, aging, urbanization, as well as increase in the prevalence of obesity and physical inactivity.  In Nigeria, the prevalence of T2DM in adult populations varies from 0.65 in rural Mangu village (Plateau) to 11% in urban Lagos.  Nigeria as a developing country already overburdened with a growing population in the face of low resources and increasing life expectancy is likely to produce sub-optimal treatment of its increasing chronic non communicable disease.  Poor glycemic control is likely to be an outcome of such sub-optimal treatment. Glycemic control has been defined as type 2 diabetes achieving a target of fasting plasma glucose level of between 80 and 110 mg/dl, or glycosylated hemoglobin (HbA1C) of <7.0%. HbA1c is a test that measures the average amount of diabetic control over a period of about 3 months (the average red blood cell lifetime) and used as a significant indicator and marker of glycemic control. Diabetics who manage to keep their HbA1c below 7.0% are considered to have good glycemic control while those above 7.0% are considered to have a poor glycemic control.  Achieving the above targets is considered the basis in the management and prevention of diabetic complications. This has been demonstrated by the UK prospective diabetes study (UKPDS) which showed that proper control of blood glucose could reduce the complications of diabetes.  This target is, however, difficult to maintain thus resulting in suboptimal diabetic control. The latter is the resultant effect of the variable outcome of quality of life which has been negatively imparted in Nigeria. , Therefore, to achieve proper glucose control, patients need to adhere to medications, undertake lifestyle modifications, and frequent blood glucose monitoring. If people living with diabetes are to follow such physicians' recommendations, it is imperative for the physicians and other caregivers to understand their knowledge of diabetes. Such information gleaned may help in designing an effective intervention program for those living with diabetes. Several studies have demonstrated that knowledge of diabetes is a key factor that imparts on appropriate self-care management thus resulting in poor glycemic control. ,,, Furthermore, there has been demonstrated variation of how these factors (diabetes knowledge and coexisting factors) affects glycemic control in different care settings. ,, It is noteworthy also that some of the studies that has been carried out on glycemic control did not use HbA1c as index of control;  hence, this study was conducted in a secondary health center using HbA1c as an index of assessing glycemic control.
| Subjects and methods|| |
Study design and patients
The study is a cross-sectional design and conducted among T2DM patients aged 40 years, (although, there are documented evidence of a few persons below 40 years with type-like features) and above, who attended diabetes outpatient clinics at the Central Hospital Warri between March and August 2014. A random sample size of 200 consenting patients calculated using formula for calculating sample size for cross-sectional study by Daniel et al. in 1999  were recruited for the study. Patients were excluded from the study if they refused consent were below 40 years and those with severe speech or obvious mental impairment. The study was approved by the Ethical Committee of Central Hospital Warri.
Upon recruitment, a two-part questionnaire with Part A accessing social demographic factors and Part B assessing patient self-care behavior as well as an instrument from the University of Michigan (2006) of 14 items were administered to all the participants. (Michigan questionnaire and the abridged one in Appendix 1). The first questionnaire sought information about sociodemographic and relevant characteristics including age, gender, onset and duration of T2DM as well as information related to patient's self-care behaviors. Diabetes knowledge test (DKT) questionnaire  consisted 10 items directly from the University of Michigan DKT (2006) of 14 items but with modification, substituting the food items on the original DKT with the locally available food consumed in the study population was the second questionnaire used. The instruments were in-depth interview guide and questionnaire, which was either self-administered or interview administered, depending on the literacy level of the respondent. For the illiterate respondents, the questionnaire was transcribed in pidgin English, which is a local language understood and spoken by all the indigene of the city. The respondents were scored based on total correct responses out of 10 items and were classified as either having low or high diabetes knowledge. Each correct answer was awarded 1 point with a maximum score obtainable in the DKT as 10 points. Higher scores (>7 points) indicate higher knowledge based on the DKT.
Laboratory and anthropometric measurements
After an overnight fast, 3 ml each of venous blood sample was collected from all the participants into fluoride and ethylenediaminetetraacetic acid (EDTA) bottles then send to the laboratory where fasting plasma glucose was analyzed by glucose oxidase method  on a BM/Hitachi 902 auto analyzer. (Roche Diagnostics GmbH, D-68298 Mannheim, Germany) auto analyzer. (Roche Diagnostics GmbH, D-68298 Mannheim, Germany) and HbA1c was measured immunochemically on DCA 2000 HbA1c auto analyzer using kits supplied by Boehringer Mannheim (Mannheim, Germany)  auto analyzer. (Boehringer diagnostics, Mannheim) and HbA1c was measured by suitable tubes (EDTA tubes) immunochemically on DCA 2000 HbA1c auto analyzer using kits supplied by Boehringer Mannheim (Mannheim, Germany)  commercially prepared standards and control samples were used to ensure accuracy of test results. Glycemic status was categorized as good glycemic control if HbA1c <7% and poor glycemic control if HbA1c ≥7%.  Weight and height were measured with light clothes and taking the shoes off, respectively. Weight was taken to the nearest 0.5 kg and height was taken to the nearest centimeter. Weight was measured without shoes or heavy clothing with a SECCA® scale. It was recorded to the nearest 0.5 kg. Height was determined to the nearest 0.5 cm with a rigid measure against a vertical wall. Body mass index (BMI) was then calculated as the ratio of weight in kilograms to the square of height in meters.  Statistical Package for Social Science Version 16 (Released 2007. SPSS for Windows, Chicago) was used to compute the data generated.
| Results|| |
The total number of 200 patients that participated in the study had mean age and duration of diabetes, 54.8 ± 11.9 years and 8.5 ± 3.2 years, respectively. Majority were male 52% and 53% had more than secondary education. Other demographics are shown in [Table 1].
The overall mean knowledge score of the subjects was 6.90 ± 1.8 (69.0 ± 18.2%) with the percentage distribution of responses on DKT shown in [Table 2]. The mean fasting blood glucose level and HbA1c of respondents were 7.89 ± 3.6 mmol/L (range 4-20 mmol/L) and 8.2%, respectively, with 55% of the population having poor glycemic control and 45% good glycemic control. There was no statistically significant difference in the age gender and BMI of those with poor glycemic control when compared to those with good control; however, there was statistical significance difference in diabetic duration and higher scores in diabetic knowledge between the two groups [Table 3].
|Table 2: Percentage distribution of responses on diabetes knowledge test |
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| Discussion|| |
More than half (55%) of the participants in our study group had poor glycemic control. This finding is similar to reports from other countries with prevalence of poor glycemic control ranging from 50% to 60% (Ethiopia, US, Saudi), ,, but lower than those reported in Bahrain,  UK,  and Jordan  with values between 65% and 79%.
The differences in variation may be explained by the differences in study designs, characteristics of the study populations, and the types of treatment facilities. Furthermore, differences in race and ethnicity of the studied populations,  dosage for oral medication, compliance with regimens, self-monitoring of blood glucose, and socioeconomic status may differ by race/ethnic group leading to greater improvements in control in some groups but not in others. Socioeconomic status may influence diabetes management and control since it is often associated with access to health care, healthcare utilization, use of medication, and access to good nutrition.
In Nigeria, however lower rates 34-45% has been reported in Enugu  and Ibadan.  Although a comparative higher value of 65.7% has been reported in a different study in a secondary care setting in Ibadan, South-West Nigeria by Adisa et al. 2011.  This difference seen in these variation could probably be explained by the nature of cases seen in the tertiary setting where most often poorly controlled and complicated cases are managed as it is a reference center. Even though in most teaching hospital, proper counseling and teaching of diabetic patients in the clinic either in the form of the regular group counseling with the presence of family physicians or with nurses, pharmacist, and dietitian. The impact of these measures did not seem to reflect in the study population by Adisa et al. This approach had been shown to enhance the patient-doctor relationship and to have a positive effect on the compliance of the patient.
The current study showed that patients with duration of diabetes of more than 10 years were more likely to have poor glycemic control compared to those with duration of 10 years or less. This finding is consistent with that reported in previous studies where longer duration of diagnosed diabetes was associated with increased HbA1c values. ,,
This might be explained by the fact that the amount of carbohydrate attached to the HbA1c increases with increasing duration of the disease.  The UKPDS  and the Belfast Diet Study  showed that beta cell function begins to decline 5-10 years after diagnosis of diabetes which lead to decreases in insulin, consequently poor glucose utilization thus poor control.
Almost all the respondents (80%) know what a diabetic free food is. Furthermore, the DKT question that was most frequently answered correctly (83%) by our respondents was the one that asked about which food was highest in carbohydrate. This we think may be as a result of the type of education or prevailing cultural thinking about diabetes which suggests that diabetes patients are to avoid any sugar containing food. Expectedly, our respondents also performed poorly with regard to the question about HbA1c test. Majority of them (75%) did not know that HbA1c test measures average blood glucose level 6-10 weeks prior to the test. This is no surprise because as at the time of this study no such test was routinely available in the hospital. Several studies have recorded similar findings of patients having poor knowledge of HbA1c test. ,,,
Consequently, there was statistically significant difference in the mean knowledge scores of respondent with poor glycemic control when compared to those with good control P = 0.001 showing that diabetic knowledge have significant relationships with glycemic control. This is consistent with other studies ,,, that reported that diabetes knowledge and other factors such as attitude and adherence to health regimens were associated with glycemic control. This corroborates the fact that knowledge is necessary to produce the behavioral changes required for effective self-management and eventual metabolic control.  Arseneau et al. have found that illness-specific knowledge is one component of effective self-management. 
This, however, differs from other authors who found that there was no correlation between knowledge  with glycemic control. The implication of the finding is that diabetes knowledge is an important factor on how patients will follow their management plan but should not be seen as an end in it.
Lack of relationships among age and gender and poor glycemic control in our study is consistent with Shani et al., , who found neither age nor gender was related to the achievement of good glycemic control. However, Wahba and Chang  found that older patients had better improvements in HbA1c. The BMI of those with poor control were not statistically different from those with good glycemic control. This may be as a result of the fact that most of the participants in the study were obese with a mean BMI of 31.00.
Limitation of the study
Some of the respondents had nonresponse (missing value) in most of the questions, this was a limitation as the remaining cases after listwise deletion might not be the true representative of the responses if there was no missing value.
In addition, the responses to all the questions were all self-reported. There could be the problem of recall from the respondents, which might make the reliability of the responses difficult to validate.
| Conclusions|| |
Inadequate knowledge of diabetes, as well as the duration of the disease, was significantly associated with poor glycemic control. The proportion of the poor glycemic control among patients with T2DM in Central Hospital Warri is relatively high. A misconception in the knowledge of blood glucose motoring with HbA1c test was seen as a major drawback in the DKT even though their overall knowledge was slightly adequate. Health care facilities focused on easily comprehensible educational programs that emphasize lifestyle modification and blood glucose monitoring are therefore recommended.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]