CONCORDANCE OF TYPE 2 DIABETES IN COUPLES SEEN AT THE OUTPATIENT CLINIC OF THE UNIVERSITY OF BENIN TEACHING HOSPITAL (UBTH), BENIN CITY, EDO STATE.

SUMMARY

INTRODUCTION: Type 2 Diabetes mellitus is a major cause of mortality and morbidity worldwide. There have been cases of its late diagnosis in spouses of diabetics managed at the author’s center. Furthermore, reports of a few studies done outside the author’s locality on the concordance of diabetes in spouses of diabetics indicate that these spouses are at a greater risk of the disease when compared to spouses of non diabetics. This study was undertaken to investigate the concordance of diabetes in couples seen at the author’s practice center.

AIM AND OBJECTIVES: The aim was to determine the concordance of Type 2 Diabetes in couples seen in the General Out Patient Clinic (GOPC), University of Benin Teaching Hospital (UBTH), with a view to identifying its risk factors and designing intervention.

The objectives were to determine the percentage of the spouses of diabetics seen at the GOPC of UBTH who also have Type 2 diabetes, to identify the factors which contribute to this percentage, to establish the relationship (if any) between being diabetic and marriage to a diabetic, to estimate the risk of diabetes in a spouse of a diabetic compared to a spouse of a non-diabetic and to estimate the concordance of established risk factors in concordant couples.

MATERIALS AND METHODS: This was a cross sectional comparative hospital based study. Two hundred and twenty six (226) consecutively recruited diabetics, sourced from the GOPC of UBTH as well as 226 age and sex-matched consecutively recruited non-diabetics and their respective spouses took part in the study. Fasting blood glucose was done to ascertain the glycemic status of the participants and this was analyzed using a statistical package.

RESULTS: 6.2% of the spouses of non-diabetics had diabetes. 16.4% of the spouses of diabetics also had diabetes i.e. the concordance of diabetes in couples seen at the GOPC of the UBTH was 16.4% . The results show that the percentage of diabetes in spouses of diabetics who participated in the study was 2.6 times the percentage in the spouses of nondiabetics. The higher percentage in spouses of diabetics was statistically significant (p =

0.001.)Thus, being the spouse of a diabetic appears to make the risk of being diabetic about 2.6 times more. However, after  adjusting for Body Mass Index and waist/hip ratio, the risk of diabetes in the spouse of a patient with diabetes was 2.27 (adjusted OR=2.267;95% C.I

0.214–0.911;p=0.027)  as compared with the spouse of a subject with normal blood glucose. The mean age, mean duration of marriage and mean duration of diabetes in partners were also significantly higher in concordant spouses than in discordant spouses.

Among the concordant spouses, concordance for diabetes was significantly higher in female spouses, the very elderly i.e. spouses within the 80 -89years age group, spouses who had been married for 50 – 59years, spouses whose partners had had diabetes for the longest duration of diabetes in the research (over 26years), those who had a high waist/hip ratio, lived a sedentary lifestyle, had never screened for diabetes, took the same diet with their diabetic partners and never took alcohol. Concordance was also highest among traders, in those with no formal education and in the Binis. Concordance for established risk factors was as follows: sedentary lifestyle - 91.9%, high waist/hip ratio - 67.5%, obesity - 29.7%, family history - 0.0%.

Apart from having a higher prevalence of diabetes, spouses of diabetics also had a significantly higher prevalence of hypertension, obesity and high waist/hip ratio than the spouses of non-diabetics.

CONCLUSION: The findings of this research suggest that spouses of diabetics are a high risk group for the disease and are more likely to be diabetic when compared to spouses of non-diabetics. It is recommended that spouses of diabetics be regarded as a target for screening, preventive measures and risk factor reduction.

TABLE OF CONTENTS                                                                                     Page

Title Page                                                                                                                    i

Declaration                                                                                                                 ii

Acknowledgement         iii Dedication          iv

Certification                                                                                                                v

Table of Content                                                                                                         vi

List of Tables                                                                                                              vii

List of Figures                                                                                                             ix

 

Summary                                                                                                                     1

Introduction                                                                                                                3

Literature Review                                                                                                       9

Materials and Method                                                                                                 26

Results                                                                                                                        37

Discussion                                                                                                                   70

Conclusion                                                                                                                  82

Limitations of Study                                                                                                   83

Recommendation                                                                                                        84

References                                                                                                                  85

      

CHAPTER ONE

INTRODUCTION

                    1.1       BACKGROUND

Type 2 Diabetes mellitus, formerly known as Non-insulin dependent diabetes mellitus (NIDDM) or Adult-onset diabetes is a metabolic disorder that is characterized by hyperglycemia in the context of insulin resistance and relative insulin deficiency.¹

Diabetes is a chronic, usually incurable, costly, but largely preventable non-communicable disease which is responsible for millions of deaths, debilitating complications, and incalculable human misery. It is one of the four priority non-communicable diseases (NCDs) identified by the World Health Organization (WHO), along with cardiovascular diseases (CVD), cancer and chronic respiratory diseases. Once a disease of affluence, it is now increasingly common among the poor.¹

The disease is one of the most challenging health problems in the twenty-first century.² It kills and disables, impoverishes families and overwhelms health systems. It affects rich and poor, young and old. Every eight seconds, somewhere in the world, someone dies from diabetes.²More than 80% of these deaths occur in low and middle income countries. Diabetes is the fourth or fifth leading cause of death in most high income countries, ² and it is also a major global cause of premature mortality³, sometimes in association with other chronic

illnesses.⁴

In 2011, diabetes accounted for about 4.6 million deaths worldwide². A large proportion of the 4 million people who die yearly from diabetes are in their most productive years (40-60 years), resulting in high economic costs to the human society. Almost half of diabetes deaths occur in people under the age of 70 years and 55% of diabetes deaths are in women. About 6.1% of all deaths in the African region is attributed to diabetes and 72.8% of these deaths occur in people under 60 years of age with women suffering twice as many of these deaths compared to men. Almost 80% of diabetes deaths occur in low- and middle-income countries where there is limited access to affordable treatment.²

The morbidity associated with the disease is enormous. It is the leading cause of renal failure in many populations in both developed and developing countries. Lower limb amputations are at least 10 times more common in people with diabetes than in non-diabetic individuals in developed countries and more than half of all non-traumatic lower limb amputations are due to diabetes. The condition is also one of the commonest causes of visual impairment and blindness in developed countries.1% of global blindness is attributable to diabetes. Diabetes increases the risk of heart disease and stroke. At least 50% of people with diabetes die of cardiovascular diseases. Diabetes is also a major disease of the opulent⁵.

In 2011, 14.7 million adults in the African region were estimated to have diabetes with a regional prevalence of 3.8%. This prevalence is expected to almost double by 2030. The African region also has the highest proportion of undiagnosed diabetes, at least 78%.  The highest prevalence of diabetes in the African region is in the Island of Reunion (16.3%), followed by Seychelles (12.4%), Botswana (11.1%) and Gabon (10.6%). However, Nigeria has the largest number of diabetics in Africa (about 3 million), followed by South Africa (1.9 million), Ethiopia (1.4 million) and Kenya (769,000). By the year 2010, the prevalence of diabetes in Nigeria was 3.9%.²

The focus of this research is on Concordance (which is defined as the presence of any given condition in both members of a pair or couple) ⁶. It is a modest attempt to contribute to the body of knowledge concerning Diabetes from the angle of spousal concordance. This kind of study is timely and apt because an important determinant of chronic illness is social context, and new studies are being designed to examine how a person’s social environment shapes well-being. Evidence on the effect of neighborhood is growing but an equally important, if not more important factor, is the social context of marriage.⁷

Spousal concordance studies is a relatively new line of research which examines the similarity of health conditions between spouses.⁷ The basis of this is the theory that by sharing a living environment, resources, life events and habits, individuals ultimately share health risks that may translate into having a disease which they might otherwise not have had in an alternative social context.⁷ It is important that Nigerian researchers key into this. Furthermore, despite the substantial evidence that marriage is beneficial to health, evidence on whether the health status of one spouse is similar or concordant with the other spouse is limited. Even more unfortunate is the fact that most of the researches on marriage and health have focused on white couples ⁷ with black nations suffering a great imbalance in this regard. Another negative tilt is that the main focus of many health care providers is on the individual instead of being on families.

Some authors have stated that marriage provides the primary source of social support and economic stability for married individuals and that this support and stability have been shown to be associated with physical health and reduced morbidity. They have opined that interventions targeted at couples may be more effective than those targeted at individuals and that since couples share important factors in disease etiology such as dietary habits and physical activity, married couples should always be treated as a unit if a disease is to be reasonably controlled.^8-11 Even the whole household is suggested as the unit to be addressed.^10-12The biopsychosocial model of healthcare which is fundamental to the practice of family medicine has a very useful application in this regard as it goes beyond just managing a disease in an individual into the management of systems such as families and the social environment. Since a family oriented approach is based on this model, it is the most effective and efficient way to prevent disease and promote health.¹⁰

Although there have been a rapid growth of literature on the subject of diabetes from the year 1986 upwards,⁸ studies on concordance of diabetes among couples are relatively few and insufficient. This may be why a definite scientific statement connecting diabetes and marriage has not been made. If there is indeed a connection, the exact factors that establish this link have to be identified so that they can serve as points to be addressed in the prevention or management of diabetes from the spousal angle. This is another reason why a study on this topic, which to the best of the researcher’s knowledge has never been reported in Nigeria, is expedient.

This research was centered on spouse pairs who have lived together for a considerable period of time with the aim of determining whether there is a significant degree of concordance of diabetes among them. It is also aimed at revealing the environmental and lifestyle factors which contribute to this concordance (if there are). The findings of this research may thus serve as the basis for screening spouses of diabetics for the condition and also present a stronger framework for environmental and lifestyle modification within the spousal context.

                    1.2       STATEMENT OF THE PROBLEM

Diabetes is a global health challenge and the family (more specifically, the spousal) approach to its management has not been sufficiently utilized, especially from the point of view of diagnosis. The researcher has observed that spouses of diabetics are hardly screened or even brought into the management scheme for these diabetics. This is despite the fact that some researchers have noted that these spouses have an increased risk of developing or having the disease. It has also been discovered by the researcher that there have been cases of missed or late diagnosis in spouses of diabetics. Examples of missed diagnosis include cases of spouses of diabetics who were brought to the hospital in diabetic coma and died shortly thereafter, without knowing that they were diabetic before they died. Cases of late diagnosis include those diagnosed of diabetic retinopathy, neuropathy or nephropathy within a short period of diagnosing Type 2 Diabetes. By the ideal structure recommended for the practice of Family Medicine, these cases of late or missed diagnoses in spouses of diabetics should be intolerable. Ideally,diseases should either be prevented or detected very early, especially among spouses and close family members of our patients.

A study which establishes a significantly increased risk of diabetes in spouses of known diabetics will strengthen the basis and seriousness with which the Family Physician explores the opportunities offered by the family structure in his or her bid to prevent or manage diabetes from a time that is appreciably close to its onset. This will go a long way in preventing or limiting its complications.

It is hoped that the practice in which spouses are sometimes excluded from the treatment plan while diabetes is being managed will be eliminated by this study. The present gap between how a family physician should fully manage diabetes (especially with spousal involvement) and what presently exists is too wide and should become non-existent in the near future.

RESEARCH HYPOTHESIS-The Null Hypothesis for this research was that there was no significant difference between the prevalence of diabetes in the spouses of diabetic patients seen at GPC of UBTH when compared to spouses of the non-diabetic patients seen in the same clinic.

                    1.3       AIM

To determine the concordance of Type 2 Diabetes in couples seen in the General Out-patient Clinic, University of Benin Teaching Hospital (UBTH), with a view to identifying its risk factors and designing intervention.

                    1.4       OBJECTIVES

1. To determine the percentage of the spouses of Type 2 diabetics who also have the condition i.e. the concordance of Type 2 Diabetes among couples seen at the GOPC of UBTH.
2. To assess the risk of diabetes in spouses of diabetics when compared to that of the nondiabetic subjects
3. To determine the relationship between having a diabetic spouse and being diabetic.
4. To identify the risk factors that contribute to the concordance of Type 2 Diabetes among couples managed at the GOPC, UBTH.
5. To estimate the concordance of risk factors for diabetes among couples who are concordant for diabetes at the GOPC of UBTH.

CONCORDANCE OF TYPE 2 DIABETES IN COUPLES SEEN AT THE OUTPATIENT CLINIC OF THE UNIVERSITY OF BENIN TEACHING HOSPITAL (UBTH), BENIN CITY, EDO STATE.

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