Predictors of poor glycemic control in type 2 diabetic patients attending public hospitals in Dar es salaam, Tanzania.

Abstract

Background: Diabetes is a major health problem worldwide thus becoming pandemic. Due to its chronic nature and complications accompanying the disease progression, the cost of managing diabetes is significant. Tanzania has also experienced a significant rise in the burden of diabetes and is estimated that more than 400,000 people are living with diabetes. A major concern in the management of diabetes is the occurrence of diabetic complications which occur as a result of poor glycemic control. Various factors have been found to be associated with poor glycemic control. Identification of these factors is important in order to formulate appropriate interventions that will result in improved glycemic control and prevention of chronic complications. Objectives: The aim of this study was to determine the level of glycemic control and explore the factors associated with poor glycemic control among type 2 diabetes mellitus (T2DM) patients. Methodology A cross sectional study was carried out at diabetic clinics for T2DM patients at Muhimbili National Hospital (MNH), Temeke hospital, Amana hospital and mwananyamala hospital where by a systematic random sample of 469 T2DM patients were enrolled over a period of 8 weeks from 3rd March 2013 to 10th May 2013 to participate in the study. After obtaining informed consent from patients, a structured questionnaire and data collection form were used to collect information from the participants. The questionnaires sought information about socio-demographic, clinical characteristics, self-care management behaviours and medication adherence. Blood pressure, weight and height and were measured. All available last readings for fasting blood glucose (FBG) measurements and lipid were abstracted from patients' records. Poor glycemic control was defined as FBG ≥7.2mmol/L. Data entry, cleaning and analysis was conducted by use of Statistical package for Social Sciences (SPSS) software version 20. Data were described using mean for continuous variables and proportions for categorical variables. Significance testing of proportions was carried out by using Chi-square test, where a probability (P) of less than 0.05 was considered to be statistically significant. Any factor with p- value of less or equal to 0.2 was considered for Binary logistic regression which was used to study the independent factors predicting “poor” glycemic control. Results The mean age of patients was 54.93 years. Majority (63.5%) of patients were females and only 8 patients had records of lipid profile measurements. Out of 469 patients, 69.7% had FBG ≥ 7.2 mmol/L indicating poor glycemic control. Females aged between 40-59 years were found to have a significant poor glycemic control (76.1%) as compared to their male counterparts of the same age group. Thirty eight percent of T2DM patients had poor medication adherence, which was associated with poor glycemic control. The mean disease duration since diagnosis was 7.19 years and the proportion of poor glycemic control increased with age. Significantly high proportion of poor glycemic control was observed in patients who had longer disease duration of more than 20 years since diagnosis (p=0.027). In Multivariate analysis revealed five variables associated with poor glycemic control; patients who were not insured for health care, taking more than one oral hypoglycemic agent (OHA), having normal body mass index (BMI), being obese and not adhering to diabetic medications. Conclusion: Despite the importance of serum lipids monitoring and established association of serum lipids and diabetes and their effect on cardiovascular complications, the unexpected finding in our study was that records in lipid profile measurements were not available for almost all the patients studied in public hospitals. The findings from this study indicate that T2DM patients in Dar es Salaam have generally poor glycemic control and the independent variables associated with poor glycemic control were lack of insurance for health care, taking more than OHA, Normal BMI, obesity and low adherence to oral hypoglycemic agents. From these finding it is recommended that all diabetic patients should be screened for lipid profile since high cholesterol levels, triglycerides (TAG) and low density lipoproteins (LDL) are associated with increased risk of cardiovascular events and accumulation of cholesterol may contribute to ß-cell dysfunction. An education program should be developed to educate patients on the importance of medication adherence and weight management for better glycemic control.