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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 4  |  Page : 206-210

Pattern of diabetes mellitus-related complications and mortality rate: Implications for diabetes care in a low-resource setting


1 Department of Public and Community Health, Novena University, Ogume, Delta State, Nigeria
2 Department of Optometry, University of Benin, Benin City, Edo State, Nigeria
3 Department of Health and Social Care Management, London School of Management Education, Ilford, England, United Kingdom
4 Department of Community Medicine, Edo University, Iyamho, Edo State, Nigeria

Date of Submission24-Dec-2019
Date of Decision21-Jan-2020
Date of Acceptance04-Mar-2020
Date of Web Publication23-Feb-2021

Correspondence Address:
Dr. Otovwe Agofure
Department of Public and Community Health, Novena University, Ogume, Delta State
Nigeria
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DOI: 10.4103/smj.smj_64_19

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  Abstract 


Background: Diabetes mellitus (DM)-related morbidity and mortality is gradually assuming an endemic proportion in Africa. In Nigeria, DM-related complications are responsible for 3%–15% medical admissions in most facilities. Despite this growing trend, there is a paucity of studies highlighting the morbidity and mortality due to DM in Nigeria. Objective: This retrospective study documented the pattern of DM-related complications and mortality rates in Warri Central Hospital, Warri, Delta State, Nigeria. Materials and Methods: This was a retrospective, descriptive, hospital-based study covering a 7-year period (2012–2018). Data on age, sex, fasting blood sugar (FBS), random blood sugar (RBS), comorbid conditions, and the number of deaths were extracted from the case files of DM patients in the records department of the hospital. The extracted data were analyzed using the IBM IBM SPSS software version 20.0 (IBM Corp., Chicago, USA). Results: A total of 78 patients were studied. The age range of cases was between 20 and 79 years, with a mean age of 54.9 ± 13.9 years. The overall prevalence of DM was 18.3%; overall mean FBS and RBS were 186.0 ± 49.1 mg/dl and 272.9 ± 59.2 mg/dl, respectively. The overall mortality rate was 28.2%. Major complications observed were hyperglycemic emergencies (20%), hypertension (18%), stroke (17%), and nephropathy (14%). Conclusion: The study highlighted that DM is associated with morbidity and mortality among the patients. Therefore, efforts must be intensified on promoting DM management practices by individuals, families, communities, health-care system, government, and its international partners to reverse this ugly trend.

Keywords: Complications, diabetes mellitus, mortality, pattern, prevalence


How to cite this article:
Agofure O, Odjimogho S, Okandeji-Barry OR, Efegbere HA, Nathan HT. Pattern of diabetes mellitus-related complications and mortality rate: Implications for diabetes care in a low-resource setting. Sahel Med J 2020;23:206-10

How to cite this URL:
Agofure O, Odjimogho S, Okandeji-Barry OR, Efegbere HA, Nathan HT. Pattern of diabetes mellitus-related complications and mortality rate: Implications for diabetes care in a low-resource setting. Sahel Med J [serial online] 2020 [cited 2021 Mar 6];23:206-10. Available from: https://www.smjonline.org/text.asp?2020/23/4/206/310028




  Introduction Top


Diabetes mellitus (DM) is a chronic disease primarily defined by the high levels of blood glucose (hyperglycemia) that is associated with severe morbidity due to both microvascular and macrovascular complications.[1] DM has become one of the biggest global health emergencies of the post-millennium era. This is because no country is immune from diabetes epidemic as it is a common threat that does not respect the borders or social class. It leads to morbidity and mortality among the patients. According to the International Diabetes Federation,[2] globally, an estimated 4 million people aged between 20 and 79 years are estimated to die from diabetes in 2017. In Africa, an estimated 0.23 million people died due to DM before the age of 60 years representing 77.0% of all death before 60 years.[2] Nigeria, the most populous country in Africa, has an estimated 1.7 million people living with the disease.[2] DM alone accounted for 2% of all mortality of all ages in Nigeria, with an estimated 27,500 number of deaths both males and females attributable to high blood glucose among the age group of 30–69 years.[3]

Most of the mortality attributable to DM is as a result of poor management practices leading to persistently high glucose levels, which often results in acute and chronic microvascular and macrovascular complications. The common complications associated with DM include cardiovascular disease (CVD), blindness, kidney failure, and lower-limb amputation. In Nigeria, the general management of DM both at the individual, facility, community, and governmental levels has been reported to be suboptimal.[4],[5],[6],[7] Nigeria has no known countrywide survey data on DM comprising the morbidity and mortality rate attributable to DM.[8] However, few available studies have reported the morbidity and mortality rates attributable to DM in Nigeria. A review study in Nigeria reported the pooled mortality rate to be 30.2 (95% confidence interval [CI] 14.6–45.8)/100,000 population, with a case fatality rate of 22.0% (95% CI 8.0%–36.0%). In addition, common complications reported were Hyperglycemic emergencies, diabetic foot, and CVDs.[8] A hospital-based study in Makurdi, North Central Nigeria, reported mortality for males is 47%, while that of female is 53%, with common causes of death attributable to hyperglycemic crises (38%), septicemia (18%), diabetic ulcers (15%), and a variety of other causes (29%).[9] Due to the relatively limited epidemiological evidence on the burden of DM in Nigeria and as recommended by the World Health Organization, the need for more research on the burden of diabetes, including country-specific response to diabetes treatment and management and anthropological and cultural perspectives of diabetes in Africa.[1],[8] This hospital-based study was designed to document the pattern of DM-related complications and mortality rate in a tertiary hospital in Warri, Delta State Nigeria, as this would contribute to the few already existing studies estimating the burden of DM-related complications and mortality in Nigeria. This would help in developing diabetes register across facilities and implementing a national response to DM in Nigeria.


  Materials and Methods Top


Study design

This was a retrospective, descriptive, hospital-based study over a 7-year period (2012–2018) in Central Hospital Warri, Delta State, Nigeria. Data were collected from March to June 2019.

Study setting

The study setting was Central Hospital Warri, in Warri South Local Government Area, Delta State. The hospital which was established over 100 years ago runs both inpatient and outpatient services. In addition, the hospital also operated a diabetes clinic on Tuesdays and Wednesdays every week, and an average of 40 DM patients attends each clinic day.

Study population

The study population consists of all patients diagnosed with DM in the hospital from January 2012 to December 2018. Seventy-eight DM patients were diagnosed within this period. Only patients who attended the hospital and were screened and diagnosed for DM during the period under review were included in the study. A total of 427 patients were screened for DM in the period under review, of which, 78 patients were diagnosed with DM.

Data collection

A pro forma was used to collect the data. This comprised sections on year, age, sex, type of DM diagnosed, fasting blood sugar (FBS), random blood sugar (RBS) records, type of complications, and deaths recorded. Diabetic patients diagnosed in the hospital were identified by sorting of hospital record files and register by going through their files to see their age, diabetes complications, mortality records, and FBS or RBS figures among patients. Diabetes was diagnosed with fasting blood glucose (FBG) >126 mg/dl or a random blood glucose (RBG) >200 mg/dl classification.[1] The FBG or RBG used for the study was those at diagnosis in the hospital.

Ethical consideration

Ethical approval was obtained before the study from the Ethics Committee of the Central Hospital Warri Delta State with protocol number CHW/ECC VOL 1/180 on March 21, 2019. In addition, permission to handle the patient records was also obtained from the Head of the Records Department Central Hospital, Warri.


  Results Top


As shown in [Table 1], more of the patients were 50–59 years in 2012 (3; 30%), in 2015 (6; 40.0%), in 2016 (3; 30.0%), in 2017 (3; 33.3%), and in 2018 (3; 25.0%). In addition, more of the patients were males in 2012 (5; 50%), in 2015 (10; 66.70%), and in 2016 (6; 60%).
Table 1: Demographic characteristics of the respondents

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According to [Table 2], the highest mean FBS was recorded in 2012 (282.6 ± 107.6 mg/dl) and the lowest was recorded in 2018 (161.8 ± 19.7 mg/dl). Furthermore, the highest mean RBS was recorded in 2012 (305.0 ± 130.3 mg/dl), and the lowest was recorded in 2017 (232.50 ± 30.4 mg/dl). Similarly, the highest prevalence of DM was recorded in 2012 (47.6%), and the lowest prevalence of DM was recorded in 2018 (9.0%). Furthermore, the highest mortality rate was recorded in 2015 (40%), and the lowest was recorded in 2016 (10%).
Table 2: Clinical information of the patients in 2012-2018

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[Figure 1] shows the overall prevalence of DM was 18.3%, whereas the overall mortality rate was 28.2%.
Figure 1: The overall prevalence of diabetes mellitus and mortality rate in 2012–2018

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According to [Figure 2], the highest prevalent complication was nephropathy (20%), and the lowest was sepsis (8%).
Figure 2: Prevalence of complications among the patients

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  Discussion Top


Rising prevalence of DM has been reported in Nigeria. For instance, the prevalence was reported in South west Nigeria in 1998,[10] South South Nigeria in 2001 and 2010,[11],[12] and North West Nigeria in 2013.[13]

The overall prevalence rate of DM was 18.3% or 183/1000 patients. The highest prevalence rate of 47.6% was recorded in 2012, followed by 2014 with a prevalence rate of 34.3% or 343/1000 patients, year 2013 with a prevalence rate of 276/1000 patients or 27.6%, year 2015 with a prevalence rate of 24.6% or 246/1000 patients, and the least was in year 2018 with 9.1% or 91/1000 patients. The reported prevalence of DM in the study was higher than the raw DM prevalence in North America and Caribbean (13.0%), Middle East and North Africa (9.60%), South-east Asia (8.50%), and Africa (3.30%).[2] Even in Nigeria, the observed prevalence of DM from the study was higher than the pooled prevalence of DM in North-west Nigeria (3.0%), in North-east (5.9%), in North-Central Nigeria (3.8%), in South-west (5.5%), and in South-East and South-South Nigeria (9.8%), respectively.[14] The prevalence of DM in the study was, however, lower than that of a study in Agbor metropolis with a prevalence of 59%,[15] but was, however, higher than another study in Ndokwa-West local government area which reported 5.4%.[16] The findings of the study show the increasing prevalence rate of DM in Nigeria.

The overall mean FBS of 186.02 ± 49.14 mg/dl and overall mean RBS of 272.92 ± 59.02 mg/dl were higher than the World Health Organization cutoff diagnosis criteria of >126 mg/dl for FBS and >200 mg/dl for RBS.[1] Persistent high blood glucose levels are the major cause of diabetes-related complications among DM patients. According to the findings of the study, the most common complications were hyperglycemic emergencies, hypertension, stroke, nephropathy, and hypoglycemia. This is a combination of both acute and chronic complications. This finding was slightly different from a study in Nigeria where the reported complications were hyperglycemia, septicemia, and diabetic foot syndrome.[8] The findings were similar to other studies which reported hyperglycemic crisis as the major complications of DM.[17],[18],[19] The findings were also similar to other studies which reported diabetic foot ulcers as one of the complications among the patients.[19],[20]

According to the findings of the study, the overall mortality rate was 28.21% or 282/1000 patients. The highest mortality of 40% or 400/1000 patients was recorded in 2015, whereas the least of 10% was recorded in 2016. This reported mortality rate was higher than the mortality rate of admitted patients from previous studies in Nigeria.[8],[19],[20],[21] The reported mortality rate of the study was, however, similar to that of a previous study in Nigeria which reported a mortality rate of 28.70%.[22] The prevalence of DM-related complications in the study could not be overlooked in the rate of mortality recorded as previously prevalence of DM-related complications has been reported to result in frequent hospitalizations and early mortality among DM patients.[19] This was corroborated by previous studies where DM-related complications were significantly associated with mortality among patients.[23],[24]

Implications for diabetes mellitus care

The results of the study highlighted the morbidity and mortality associated with DM. This calls for adequate monitoring and care of patients by the clinicians and other diabetic team members. For patients with poor glycemic control, clinicians should look out for common complications which could be treated to prevent the situation from deteriorating to further macrovascular complications. In addition, patients should be encouraged to attend the hospitals for checkup regularly as this would ensure proper monitoring of their glucose level by health-care practitioners. A patient-centered approach to care which includes a comprehensive plan to reduce DM complications should be adopted by the clinicians during patient care. For each clinic day or whenever the patients reports to the hospital, the glucose level of the patients should be measured and recorded to provide adequate follow-up of patients and reduce the risk of developing complications. For high-risk patients, both the glycated hemoglobin tests and lipid profile tests could be recommended to provide better management strategies for adoption.

Limitation of the study

The study was limited as only available records were sorted, and therefore, were included in the study. In addition, it was a hospital-based study so might not provide the true reflection of the magnitude of diabetes-related morbidity and mortality in the immediate community. The use of RBS also provides a limitation for the study as blood sugar level at the diagnosis was used for the study.


  Conclusion Top


The study illustrated a high-pattern prevalence of DM and mortality across the years reviewed. For instance while the prevalence of DM was the highest in 2012, it was the lowest in 2018. However, the mortality rate showed that the highest mortality was recorded in 2015 and the lowest was recorded in 2016. DM-related complications recorded include nephropathy, hypertension, stroke, and hyperglycemic emergencies. Consequently, morbidity and mortality among DM patients remain a challenge for the health-care system, and all efforts to improve DM care should be put in place to ensure that diagnosed DM patients experience better quality of life. This could be achieved by integrating primary, secondary, and tertiary prevention strategies in DM care in the study location and Nigeria.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycemia: Report of a WHO/IDF Consultation. Geneva, Switzerland: World Health OrganiZation; 2006.  Back to cited text no. 1
    
2.
International Diabetes Federation. IDF Diabetes Atlas. 8th ed. International Diabetes Federation; 2017.  Back to cited text no. 2
    
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World Health Organization. Diabetes Country Profiles. Geneva Switzerland: World Health Organization; 2016.  Back to cited text no. 3
    
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Oguejiofor O, Odenigbo C, Onwukwe C. Diabetes in Nigeria: Impact, challenges, future directions. Endocrinol Metab Synd 2014;3:130.  Back to cited text no. 5
    
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Ogbera AO, Ekpebegh C. Diabetes mellitus in Nigeria: The past, present and future. World J Diabetes 2014;5:905-11.  Back to cited text no. 6
    
7.
Agofure O, Oyewole OE, Igumbor EO, Nwose EU. Diabetes care in delta state of Nigeria: An expository review. Diabetes Update 2018;1:1-8.  Back to cited text no. 7
    
8.
Adeloye D, Ige JO, Aderemi AV, Adeleye N, Amoo EO, Auta A, et al. Estimating the prevalence, hospitalisation and mortality from type 2 diabetes mellitus in Nigeria: A systematic review and meta-analysis. BMJ Open 2017;7:e015424.  Back to cited text no. 8
    
9.
Ojobi JE, Odoh G, Aniekwensi E, Dunga J. Mortality among type 2 diabetic in patients in a Nigerian tertiary hospital. Afr J Diab Med 2016;24:17-20.  Back to cited text no. 9
    
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World Health Organization. Global Report on Diabetes. World Health Organization; 2016. Available from: http://who.int/diabetes/global-report/en/. [Last accessed on 2016 Apr 07].  Back to cited text no. 10
    
11.
Olatunbosun ST, Ojo PO, Fineberg NS, Bella AF. Prevalence of diabetes mellitus and impaired glucose tolerance in a group of urban adults in Nigeria. J Natl Med Assoc 1998;90:293-301.  Back to cited text no. 11
    
12.
Nwafor A, Owhoji A. Prevalence of diabetes mellitus among Nigerians in Port Harcourt correlates with socioeconomic status. J Appl Sci Environ Manage 2001;5:75-7.  Back to cited text no. 12
    
13.
Ekpenyong CE, Akpan UP, Ibu JO, Nyebuk DE. Gender and age specific prevalence and associated risk factors of type 2 diabetes mellitus in Uyo metropolis South Eastern Nigeria. Diabetol Croat 2012;41:17-28.  Back to cited text no. 13
    
14.
Sabir A, Ohwovoriole A, Isezuo S, Fasanmade O, Abubakar S, Iwuala S. Type 2 diabetes mellitus and its risk factors among the rural Fulanis of Northern Nigeria. Ann Afr Med 2013;12:217-22.  Back to cited text no. 14
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Uloko AE, Musa BM, Ramalan MA, Gezawa ID, Puepet FH, Uloko AT, et al. Prevalence and risk factors for diabetes mellitus in Nigeria: A systematic review and meta-analysis. Diabetes Ther 2018;9:1307-16.  Back to cited text no. 15
    
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Oshilonya HU, Ijioma SN, Ibeh IN. Prevalence of type-2 diabetes mellitus amongst suspected subjects in Agbor, Delta State, Nigeria and its relationship with age and gender. Arch Appl Sci Res 2015;7:18-20.  Back to cited text no. 16
    
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Nwose EU, Oguoma VM, Bwititi PT, Richards RS. Metabolic syndrome and prediabetes in ndokwa community of Nigeria: Preliminary study. N Am J Med Sci 2015;7:53-8.  Back to cited text no. 17
    
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Aguocha BU, Ukpabi JO, Onyeonoro UU, Njoku P, Ukegbu AU. Pattern of diabetic mortality in a tertiary health facility in South-Eastern Nigeria. Afr J Diab Med 2013;21:14-6.  Back to cited text no. 18
    
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Chijioke A, Adamu AN, Makusidi AM. Mortality patterns among type 2 diabetes mellitus patients in Ilorin, Nigeria. J Endocrinol Metab Diabetes S Afr 2010;15:79-82.  Back to cited text no. 19
    
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Unadike BC, Essien I, Akpan NA, Peters EJ, Assien OE. Profile and outcome of diabetic admissions at the university of Uyo teaching hospital, Uyo. Int J Med Med Sci 2013;5:286-9.  Back to cited text no. 20
    
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Ogbera AO, Chinenye S, Onyekwere A, Fasanmade O. Prognostic indices of diabetes mortality. Ethn Dis 2007;17:721-5.  Back to cited text no. 21
    
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Ogbera AO, Ohwovoriole AE, Soyebi O. Case fatality among diabetic in-patients. J Clin Sci 2002;2:18-21.  Back to cited text no. 22
    
23.
Cusick M, Meleth AD, Agrón E, Fisher MR, Reed GF, Knatterud GL, et al. Associations of mortality and diabetes complications in patients with type 1 and type 2 diabetes: Early treatment diabetic retinopathy study report no. 27. Diabetes Care 2005;28:617-25.  Back to cited text no. 23
    
24.
Bertoni AG, Krop JS, Anderson GF, Brancati FL. Diabetes-related morbidity and mortality in a national sample of U.S. elders. Diabetes Care 2002;25:471-5.  Back to cited text no. 24
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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