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Table of Content - Volume 8 Issue 1 - October 2017


 

Prevalence of complications of type 2 diabetes and its socioeconomic factors affecting it in Bushehr

 

Farkhondeh Amini1, Abbas Yazdanpanah2*, Abbas Ghavam3

 

1Department of Healthcare Management, Marvdasht Branch, Islamic Azad University, Marvdasht, IRAN.

2Assistant Professor, Department of Healthcare Management, Marvdasht Branch, Islamic Azad University, Marvdasht, IRAN.

3Assistant Professor, Department of Environmental Science, Institute of Sciences and High Technology and Environmental Sciences, Graduate University of Advanced Technology, Kerman, IRAN.

Email: abbas_yaz@miau.ac.ir

 

Abstract              Background: Type 2 diabetes is one of the most important health problems in the world. This study evaluates the prevalence of complications of type 2 diabetes and its socioeconomic factors in Bushehr province. Method: The present study was descriptive-correlation type. The subjects were 341 patients with type 2 diabetes who were referred to two-level diabetes clinics in Bushehr province. They were selected by simple random sampling. The data collection tool was a self-made questionnaire containing 60 questions and the reliability of this tool was analyzed by Cronbach's alpha test (0.72). Questions were about demographic information, socioeconomic status, treatment care status, and complications of the disease. The collected data were analyzed by SPSS version 20 and descriptive and inferential statistical tests. Results: 40.8% were male and 59.2% were female. 56% of patients had complications. The most complications included ocular complications (33.5%) and the least complications of diabetic foot disorder (4.5%). There was a significant relationship between the age of the affected people, the duration of complications, the nutritional status of people, lipid disorders, income level with complications.(p <0/05). The prevalence of neurological complications was 31%, ocular complications were 33.5%, cardiovascular complications were 19%, kidney complications were 5.9%, and diabetic foot was 4.5%. In people who were more than 9 years old with diabetes, complications were observed in 6.2% of those who were less than 6 years old. Conclusion: Based on the results of this study, attention to preventive measures (proper nutrition, self-care education for patients), and regular examinations for the early prevention and diagnosis of the disease and its complications, as well as special attention to the low income of the population, seems necessary.

Key Words: Type 2 diabetes, socioeconomic factors, complications.

 

INTRODUCTION

Diabetes is one of metabolic diseases and is a multifactor disorder that is specified with chronic increase of blood glucose and it is due to disorder in secretion or function of insulin or both of them. Considering the increasing trend and statistics of Diabetes all over the world, World Health Organization has declared it as a hidden epidemy and since 1993 has called all countries of the world for fighting with this epidemy. According to world health organization in 6 April 2016 9 (Genève), the number of people with diabetes has increased from 108 million people in 1980 to 422 million in 2014 9 (about four times) that most of them are living in developing countries. World prevalence of diabetes among above 18-years old adults has increased from 4.7% in 1980 to 8.5% in 2014. Diabetes prevalence in low and moderate income countries is rapidly increasing. Besides high prevalence, diabetes is along with various disorders such as disorder in glucose, protein and fat metabolism and chronic glucose increase causes destruction, function disorder and failure of various members especially eyes, kidneys, nerves, heart and vessels. Two important complication of diabetes type II include retinopathy and nephropathy which are respectively the main reason of blindness and kidney diseases in final stages. This disease in the adult population is the main reason of blindness, advanced kidney failure and mutilation in many countries. One of the most prevalent complications of diabetes is cardiovascular diseases which are one of the most prevalent reasons of death in many societies. A high percent of deaths are due to non-epidemic diseases so that from 56 million death cases in 2015, about 40 million cases have been due to non-epidemic diseases (70%) and 1.6 million death due to diabetes (4%). Diabetes is a costly disease due to creating complications. Besides financial costs, inappreciable costs such as pain, anxiety, disturbance and so mainly follow life quality reduction which is almost incomputable. Here, diabetes type II is the most prevalent type of diabetes and designates 90% of disease cases. Prevalence of diabetes type II is continually increasing. Health status of a population depends on complex and various factors that have both genetic and environmental aspect and in a wide range, they find a social aspect. Among effective risk factors in accession of diabetes type II are diabetes family record (heredity), obesity, age 45 years and more, race, pregnancy diabetes record or birth of child with the weight of 45 kg and higher, high blood pressure, high cholesterol level, disorder of glucose tolerance test, dietary, stress, smoking and so on. One of important effective factors is socioeconomic factors which have a considerable impact on health and its consequences such as life quality. Weak socioeconomic conditions during life impact health. People, who are in low social classes, suffer serious disease and early death twice as people who are in higher classes. Financial and mental social reasons such as family low capital, insecure job and living in inappropriate houses, low education contribute in creation of these differences that finally their impact leads to diseases or early death. In recent years, considerable increase is observed in evidences like socioeconomic status and diabetes type II. Most available socioeconomic inequalities among countries and various social groups in the countries are considered among underlying factors effective on health and definitive solution of such health problems especially in deprived classes won't be possible, unless the available inequalities in the society are considered by policy makers. Diabetes, in respect of disease prevalence and complications, mortality due to it and respective costs is considered one the most important healthcare and socioeconomic problems of the world. The relation of accession of this disease and complications due to it with socioeconomic factors have been confirmed in the world various studies. One of these studies is the study of Fonokashi et al that showed low socioeconomic status of diabetic patients is related to higher possibility of diabetes type II accession in younger adults. Considering the above mentioned cases and special attention to this disease and necessity of recognition of effective socio-economic factors in accession of complications sue to it, we decided to conduct a study with aim of determining prevalence of diabetes complications and socio-economic factors effective on it in diabetes clinics of Boushehr province.

 

MATERIAL AND METHODS

The present study has been of descriptive and cross sectional type which was conducted with the aim of determining prevalence of diabetes type II complications and effective socioeconomic factors in Bouchehr province in 2017. The studied population includes all patients with diabetes type II referring to diabetes clinics in Bouchehr province. Diabetic patients are referred to diabetic clinics for examination by specialists by healthcare centers. Research subjects were selected with simple random and multistage method as 400 persons. Data collecting tool was scholar made questionnaire which was used after determining reliability and validity. So that after preparing the primary version of the questionnaire, the validity of the questionnaire content was evaluated using specialists panel. Also, for investigating the reliability of the questionnaire, Cronbach's alpha method was used (a=0.72). This questionnaire has 4 sections including demographic information, information relating to socioeconomic status, information relating to healthcare status of the patient and information relating to disease complications that the information relating to three primary sections were completed according to the patient statements and information relating to complications from portable system of diabetes clinic. For performing this study, required coordination was performed with research vice-chancellor, university protection presidency and treatment vice-chancellor. Names of patients were extracted from diabetic clinic portable system. After work completion, the questionnaire data was analyzed using SPSS software and using statistical tests of qui-square (X2), independent t, logistic regression and Kolmogorov- Smirnov test.

Findings: In this study, 341 persons with diabetes type II that had agreed for preforming the survey with age range of 18 to 85 years and with age 56.7 years were studied. Among these people, 40.8% was men and 59.2%. 47.4% of people was family warden, 78.8% was living in cities, 82.7% of people was married, 62% of people had elementary education and less and in respect of gender, 93.5% was Persian. 49.9% was housewife and 26% was unemployed. 21.8% of people has income lower than 500,000 Toomans, 18.8% of people was smoking cigarette and hookah. 99.1% of people had treatment insurance and 64.9% had no complementary insurance. 14% lacked personal property and 58% didn’t exercise. 38.9% of people had abnormal HbA1c, 46.2% high blood pressure, 58.8% had blood fat disorders, 48.7% had obesity or extra weight. 56% of people had diabetic complications that among them 28.3% had one complication, 19.65 two complications, 6% three complications and 2.1% had four complications. Ocular and neural complications included the greatest complications. 23.5% had ocular complications and 30.9% neural complications and other complications included 19% of cardiac complications, 5.9% nephrogenic complications and 4.5% had diabetic leg.

 

Table 1: Frequency distribution of patients based on the research variables

Specifications

Number

Percent

Specifications

Number

Percent

Race

Persian

319

93.5

Marital status

Married

283

83.2

Turk

1

0.2

Single

14

4.1

Kord

1

0.2

Divorced

6

1.7

Lor

3

0.8

Widow

33

9.7

Arab

17

4.9

Living separated

5

1.4

Status occupation supervisor

Office (employee -military -retired )

145

42.8

Gender

woman

202

59.2%

Hand job

48

14.2

man

139

40.8%

Other jobs (self-employed - tradesman )

79

23.3

Obesity or extra weight

has

165

48.7%

housewife and unemployed

67

19.8

don’t have

174

51.3%

Patient employment status

 

85

24.9

HbA1c status

normal

193

61.1

hand job

18

5.3

abnormal

123

38.9

other jobs ((self-employed- tradesman )

41

12

blood pressure

above normal level

157

46.2

housewife and unemployed

197

57.8

natural

183

53.8

 

number of complications

no complication

148

44

type of insurance

 

 

treatment services

90

26.9

one complication

95

28.3

social security

131

39.1

2 complications

66

19.6

rural insurance

70

20.9

3 complications

20

6

armed forces

23

6.9

4 complications

7

2.1

relief committee

4

1.2

complementary insurance

yes

118

35.1

other insurances

14

4.2

no

218

64.9

no insurance

3

0.9

 


DISCUSSION AND CONCLUSION

In this study, the greatest prevalence of complications is related to ocular complications (33.5%) and neuropathy (31%) and the least prevalence was related to diabetic foot complication (4.5%). MeisamOlfatifar et al showed that in diabetic patients type II, neuropathy complication with prevalence of 57.34% and retinopathy complication with prevalence of 47.55% were respectively the greatest prevalence of chronic diabetes type II. Khamseh et al in their study showed that in patients' neuropathy was declared (57.7%) and after that respectively ocular complications (38%), renal (27.9%), cardiovascular (27.7%) and diabetic foot ulcer (7.9%). In the study of Heshmati et al it was specified that (65.8%) of patients suffered neuropathy, (26.8%) retinopathy, (14.5%) nephropathy, (38.8%) cardiovascular complication and (50.5%) other complications. Retinopathy was an important complication that in case of non-diagnose may lead to blindness. Determining the accurate time of this complication is not possible and occurs during time. So, regular reference to specialist physician and screening is very significant. Neuropathy is the early complication of diabetes type II and timely non-diagnose of diabetes and its complications may be the reason of relatively high prevalence of this complication in the present study. Diabetic foot complication is one of the most serious complications of diabetes which is preventable. Lack of sufficient care may lead to mutilation and dysfunction. Here, training patients and sensitivity of physicians to early diagnose of this complication seems necessary.

                                                  

Table 2: Complications prevalence in patients with diabetes type II

Complications

Frequency

Confidence Interval

Prevalence

neural (neuropathy)

(30.9%)04

26-36%

31%

ocular (retinopathy)

(33.5%)113

29-39%

33.5%

cardiovascular

(19%)64

15-23%

19%

renal (nephropathy)

(5.9%) 6

3-8%

5.9%

diabetic foot

(4.5%) 16

2-7%

4.5%

 

 

 

 

 

 

 

 

 

The results of the present study showed that families that have less income, have greater chance of suffering complications. In the study of Azar Tal et al, there is a significant statistical relation between income status and prevalence of complications of diabetes type II. Also, a significant relation was observed between house ownership status and prevalence of complications. And the chance of suffering complications in patients who lived in rented housed was higher. This variable was not investigated in similar studies. In the study of Askarshahi et al and Manaviat et al, no significant relation was observed between smoking and complications. In the study of Azartal et al, no statistically significant relation was found between diabetes consequences and physical activity. Regarding the impact of physical activity in reduction of resistance to insulin, it seems necessary that in the similar studies the physical activity rate is accurately calculated and this rate is not merely based on the patients statements.

Table 3: Relation between the study variables and complications in patients with diabetes type II

Variable

Frequency

No Complication

With Complication

P-Value

Number

Percent

Number

Percent

gender

woman

(59.2%)202

91

45

111

55

0.459

man

(40.8%)139

57

41

82

59

residence place

city

(78.7) 267

110

41.2

157

58.8

0.181

village

(21.2%)72

36

50

36

50

educations

diploma and higher

(19.9%) 68

38

47.1

36

52.9

0.566

less than diploma

(17.9%)61

56

36.1

39

63.9

elementary

(38.5%)122

22

45.9

66

54.1

illiterate

(26.1%)82

32

42.7

51

57.3

smoking

yes (regular and daily)

(8.5%)22

14

48.3

15

51.7

0.653

yes (sometimes)

(10.3%)35

13

37.1

22

62.9

no smoking

(81.1%) 275

119

43.8

153

56.2

exercise

do exercise

(42%)143

60

42

83

58

0.648

don’t exercise

(58%)198

88

44.4

110

55.6

income

less than 250 toomans

(13.2%) 43

12

27.9

31

72.1

0.023

between 250-500 thousand tooman

(8.3)27

9

33.3

18

66.7

between 500000-1million toomans

(22.3%)7

43

56.6

33

43.4

between 1-2 million toomans

(43.3%) 101

60

42.6

81

57.4

more than 2 million tooman

(11.6%) 68

19

50

19

50

fat disorders

no

(58.8%)200

66

33

134

67

0.000

yes

(41.1%) 42

82

58.6

58

41.4

house ownership status

personal property

293(9/85%)

134

45/7

159

54/3

047/0

rented property

(10%)34

7

6.20

27

4.79

organizational property

(1.2%)4

3

75

1

25

relatives property (others)

(2.3%)8

3

5.37

5

5.62

others

(0.6%)2

1

50

1

50

 


In this study, no significant relation was observed between the variable of the patient educations and job with complications. But there was a significant relation between the family warden job and complications. And the chance of suffering complications in people whose warden job was hand job or other occupations was more than people who were unemployed or housewife. It seems that occupational busyness and as a result less free time in caring patients have been effective in following the illness and treatment. In the study of Khani Jeihooni et al, the relation between educations and occupation with complications was significant. The results showed that the percent of diabetic complications in residents of urban regions is more than rural regions but the observed difference was not significant. In the study of Heshmati et al no significant relation was observed between the patients' resident place and prevalence of diabetic complications. It seems that urban and rural referees to diabetic clinic receive similar services and there is no difference in patients' access to diabetic clinic services

 

Table 4: The relation between social variables and complications in patients with diabetes type II

Variable

Significance level

Chance ratio

social factors

employment status of the patient

0.130

0.820

education level

0.90

0.849

education level of the patient father

0.208

1.257

education level of the mother

0.483

0.863

family warden job

0.202

 

handy job

0.863

1.071

office job

0.120

2.240

other occupations

0.027

2.395

residence place

0.347

1.308

number of family members

0.191

92

 The results of the study showed that the percent of prevalence of diabetic complications in men is more than women, but the observed difference was not statistically significant. In the study of Manaviat et al (retinopathy) and in the study of Nezakati et al (nephropathy) and in study of Marvasti et al (neuropathy) and Kouhian et al and Khani Jehooni et al and Askarshahi et al (retinopathy) no significant relation was observed between gender and complications. But in the study of Sheghagi et al this relation was significant and complications relating to diabetes in men were higher than women and in the study of Marvasti et al this relation became significant. But the complications in women were estimated more than men. It seems that attention of men and women to treatment cares is not the same. And men refer the physician when they suffer complications. But women are more sensitive to treatment and refer physician timelier but in the present study no significant difference was observed. The present study results showed that prevalence of diabetes complications has no significant relation with marital status and rave. In Marvasti et al study a significant relation was observed between neuropathy prevalence and race (Persian).


 

Table 5: The table of relation between demographic factors variable and complications in patients with diabetes type II

Variable

Significance Level

Chance Ratio

Demographic

factors

age

0.007

1.031

gender

0.680

0.904

marital status

0.680

0.953

race

0.761

10.39

 


The results of the study showed that the average age of patients with complication is more among patients who have no complication, that is, with age increase, diabetic complications are increased. Heshmati et al in their study showed that by increase of age, prevalence of neuropathy, retinopathy and cardiovascular disease significantly increased. In the study of Azartal et al, it was specified that there is a statistically significant relation between the number of diabetic consequences and age group. Bonakdaran et al (nephropathy), Nezakati et al, Kouhian et al (retinopathy) showed that there is a significant relation between age and complications. In the study of Godberg et al, a significant relation was found between age above 50 years old and complications. Regarding the role of time in accession of diabetic complications, regular follow up, continuous examinations and training patients in the field of self-care could be effective in reducing complications.


 

Table 6: The relation between variables of age and complications in patients with diabetes type II

age

Complications

Number

Mean

Standard Deviation

T

Significance Level

without complication

145

54.910

10.536

2.809

0.005

with complication

188

58.090

10.011


 

The results of the present study showed that the relation between the variable of blood fat disorders and diabetes complications was significant. This issue shows the significance of controlling blood fat in diabetic patients. Abdi et al showed that there is a significant relation between neuropathy and cardiovascular failure with blood fat. Godberg et al also showed that micro-scholar complications are related to high blood pressure and high triglyceride. In this study, no significant relation was observed between the variable of blood pressure status and complications. In the study of Manaviat et al and Khani et al (retinopathy complication), Nezakati et al (nephropathy) and Askarshahi et al, no significant relation was observed between blood pressure and complications accession. Also, no significant relation was observed between the number of references to physician and performing blood test and obesity with complications. In the study of Manaviat et al no significant relation was observed between obesity and complications (retinopathy). The results of the present study showed that there is no significant relation between HbA1c and complications. In the study of Marvasti et al this relation was significant. In this study, the duration of suffering diabetes with complications showed a significant relation. In the study of Bonakdaran et al (nephropathy), Nezakati et al, Kouhian et al (retinopathy) and Marvasti et al (neuropathy) showed that there is a significant relation between duration of suffering the disease and the complication.


 

Table 7: Table of relation between variables of treatment and complications in patients with diabetic type II

 

Variable

Significance Level

Chance Ratio

treatment status

times of referring to physician

0.64

1.149

time of performing blood glucose test

0.27

0.761

statusHbA1C

0.92

1.024

blood pressure status

0.27

1.329

extra weight or obesity

0.41

1.232

fat blood disorders

0.000

2.782

illness duration

0.013

1.044

 


Also, it was specified that people without complication enjoy more appropriate nutrition. In the study of Azartal et al, it was specified that there is a statistically significant relation between the number of diabetic consequences and nutrition status. Study of Hamingsen et al showed that there is no evidence that nutrition alone impacts the risk of diabetic complications. In fact, the poorer social classes of the society have more appropriate nutrition status and less selection power for using healthcare services, so enjoy lower health level.


 

Table 8:

Variable

Significance Level

Chance Ratio

term of diabetes suffering

duration less than 6 year

0.000

 

duration less than 6-9 years

0.004

2.54

duration above 9 years

0.000

2.61

 

People whose diabetes duration was 6 to 9 years, 2.5 times equal to (p=0.004) and people who were involved in diabetes more than 9 years, 2.6 times (p<0.0001), in people who suffered less than 6 years complications was observed.

 

Table 8: The relation between nutrition status and complications

Name Of Variable

Number

Rank Average

Sum of Ranks

P-Value

nutrition status

no complication

148

243.01

35966

0.000

with complication

255

178.02

45440

 


In this study, the most important factors which have a great impact on diabetes complications were age, income, nutrition status and patients' blood fat. Attention to these factors seems required for promoting health level and preventing diabetes complications and as a result increasing the patient's life quality. In fact life conditions and individual social category may influence style and method of people living and way of fighting the disease complications and also their access rate to required services, that affirmation of this subject needs studies with greater sample content. Since diabetes complications are in the first degree predictable and in case of creating complication are controllable and treatable, it is required that diabetic patients receive required trainings about significance of continuous regular examinations, observing dietary and so on.

 

ACKNOWLEDGMENT

Authors of this article appreciate helps of vice-chancellor for research, health and treatment vice-chancellor of medical sciences university and all experts of diabetic clinics under the coverage of Boushehr province medical sciences university and dear colleagues in cities centers who aided us in performing this study.

 

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