A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Medicine in the branch of Internal Medicine
Johannesburg, 2014 / Background
Diabetes is a global epidemic. The International Diabetes Federation estimates that there are at least 285 million diabetics worldwide and this is estimated to grow to over 440 million by 2030 1 . A study was conducted at the Helen Joseph Hospital Diabetic clinic in an attempt to identify predictors of glycaemic control and to compare the level of care to the 2012 Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) guidelines.
Methods
Patients were recruited from the Helen Joseph Hospital Diabetic clinic. To be included the patient had to be part of the coloured (mixed race) community, be willing to give informed consent, be older than 18 years, have an HBA1C taken within 6 months, have a diagnosis of Type 2 diabetes mellitus and be a clinic attendee for at least 1 year. Pregnant patients, Type 1 diabetic patients, patients with a psychotic disorder or aphasia were excluded. Data collection consisted of face-to-face interviews, review of treatment, medication knowledge evaluation, a short examination and collection of recent blood results. Statistical analysis was done by stratifying patients into two groups by using the mean HBA1C. Variables with a p < 0.1 from this analysis were used in a logistic regression model. In addition, the correlation between continuous variables were tested. A comparison was made between the level of care and the 2012 SEMDSA guidelines.
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Results
A total of 100 patients were recruited into the study. The mean age was 62.8 years with mean duration of diabetes of 15.8 and clinic attendance of 10.9 years. The group had very poor education level and the median income of R1200 per month was also low. The mean HBA1C was found to be 9.74%, well above the target recommended by SEMDSA. Knowledge of diabetes with respect to management and complications was very poor.
Age > 50 years (OR 0.372 CI 0.06-2.26), estimated glomerular filtration rate ≥ 60 ml/min/1.73m2 (OR 0.90 CI 0.25-3.27), experiencing a microvascular complication (OR 0.73 CI 0.11-5.07) or any other diabetic complication (OR 0.56 CI 0.07-4.38) and having experienced a hypoglycaemic episode (OR 0.31 CI 0.09-1.10) predicted better glycaemic control. Duration of diabetes < 10 years (OR 1.36 CI 0.37-5.02), diastolic blood pressure ≥ 70 mmHg (OR 2.80 CI 0.80-9.78), aspirin dosage ≥ 150 mg daily (OR 6.47 CI 1.60-26.05), simvastatin dosage = 40 mg daily (OR 2.35 CI 0.31-18.10) and body mass index > 25 kg/m2 (OR 1.09 CI 0.49-2.41) all predicted a poorer glycaemic result.
HBA1C was found to positively correlate with diastolic blood pressure (p = 0.0024, r = 0.31). Systolic blood pressure positively correlated with diastolic blood pressure (p < 0.0001, r = 0.56). Apart from correlating with systolic blood pressure and HBA1C, diastolic blood pressure also positively correlated with the triglyceride level (p = 0.0003, r = 0.36). Positive correlations between total cholesterol, triglycerides, HDL-C and LDL-C were found. As expected, body mass index and waist circumference correlated positively (p < 0.0001, r = 0.82).
Level of care was not at the level recommended by the 2012 SEMDSA guidelines. Only 6% of patients met the waist circumference goal. Only 15% of patients achieved blood
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pressure goal. Most of the patients (86%) who qualified for aspirin did not receive it. In the group of patients receiving aspirin 33% did not qualify. According to the SEMDSA guidelines, most of the patients not receiving a statin (90%) should have been on statin therapy. Only 23.5% of patients on statins were at lipid goal. The frequency of laboratory testing did not meet SEMDSA guidelines. There were 31 (31%) patients without a urea, creatinine and electrolyte test for the previous year and 37 (37%) patients without a lipogram for the previous year. Only 21 patients had a listed urine albumin/creatinine ratio and only 33% of these had been done in the previous year.
Conclusions
Various new variables were identified in the search for predictors of glycaemic control. It was surprising to find that education level, monthly income, smoking status and knowledge of diabetes did not have a statistical impact on glycaemic control. Increased age, duration of diabetes, glomerular filtration rate, hypoglycaemic frequency and diabetic complications experienced were associated with improved glycaemic control. Increased diastolic blood pressure, aspirin dosage, statin dosage and body mass index were associated with worse glycaemic control. The standard of care in the clinic was found on the whole to be inferior to the level of care recommended by SEMDSA.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:wits/oai:wiredspace.wits.ac.za:10539/17483 |
| Date | January 2014 |
| Creators | Roux, Daniel Jacobus |
| Source Sets | South African National ETD Portal |
| Language | English |
| Detected Language | English |
| Type | Thesis |
| Format | application/pdf, application/pdf |
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