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Background: Diabetes mellitus (DM) is the commonest endocrine disorder in Nigeria and its prevalence has been rising at an alarming rate in the last two decades. This carries with it a concomitant rise in the prevalence of diabetic complications resulting in increased morbidity and mortality. It is worthy of note that people don`t just develop diabetes overnight, they go through an intermediate, often symptomless, stage known as pre-diabetes (PD) characterized by impaired fasting glucose(IFG) and/or impaired glucose tolerance (IGT). Diabetes/pre-diabetes often coexists with hypertension probably because they share similar lifestyle risk factors. This association doubles the overall cardiovascular risk.  

Aim: This study was designed to determine the pattern of pre-diabetes and its associated risk factors among hypertensive patients attending the General Out-patient Clinic (GOPC) of Federal Medical Centre, (FMC) Owerri, with a view to recommending measures for early detection, management and ultimate reduction in the burden of DM among the study population.

Materials and methods: This was a hospital based cross-sectional study involving 320 hypertensive patients that were consecutively recruited and age and sex matched 320 nonhypertensive, non-diabetic subjects consecutively recruited as control group. The study lasted for four months. Relevant data on demographic features, and risk factors of PD/DM were obtained using a pre-tested, self administered, questionnaires while the anthropometric indices, blood pressure and plasma glucose were done using standard clinical measurements. Data was analyzed using Statistical Package for Social sciences version 15.

Results: The prevalence of PD among the hypertensive patients was 33.1% while that in the control group was 16.2%. IFG, (29.4%, 14.3%) was the commoner pattern for pre-diabetes than IGT, (3.8%, 1.9%) among the study and control groups respectively. Majority of the subjects in the study group were females, belonged to 50-59 years, were traders, Ibos, Christians, married, of low socio-economic class and had primary level of education. Positive family history of DM (OR=52.19, 15.99-170.31), overweight (12.50, 2.37-66.67), obesity (8.33, 2.00-34.48), past cigarette smoking (15.05, 2.38-95.02), current cigarette smoking (7.11, 1.29-39.18) and inadequate physical activity (9.19, 3.07-27.48) were independent risk factors for PD.

Conclusion: This study demonstrated a high prevalence of PD among the study population with IFG being the commoner pattern in this environment. Overweight, obesity, cigarette smoking, inadequate physical activity, hypertension and family history of DM were independent risk factors for prediabetes. Routine blood glucose screening of the hypertensive patients for pre-diabetes and a comprehensive health education on healthy lifestyle practices such as adequate exercise and healthy diet is recommended.


Title Page                                                                                                                    i

Declaration                                                                                                                                          ii

Certification                                                                                                                                        iii

Dedication                                                                                                                                          iv

Acknowledgement                                                                                                                               v

Table of contents                                                                                                                                vi

Expanded table of contents                                                                                                               vii

List of abbreviations and acronyms                                                                                                    x

List of tables                                                                                                                                      xii

List of figures                                                                                                                                   xiii

List of appendices                                                                                                                             xiv


Summary                                                                                                                     1

Chapter one:     Introduction                                                                                       3

Chapter two:     Literature review                                                                               10

Chapter three:   Materials and methods                                                                      42

Chapter four:    Results                                                                                               59

Chapter five:     Discussion                                                                                         80

References                                                                                                                   90

Appendices                                                                                                                 107


CHAPTER ONE- INTRODUCTION                                                                                 3

1.1 Statement of the problem                                                                                                  6

1.2 Relevance of the study to Family Medicine                                                                     7

1.3 Aim and Objectives                                                                                                          9

CHAPTER TWO- LITERATURE REVIEW                                                                    10

2.1 Diabetes mellitus                                                                                                             10

2.1.1 Definition                                                                                                                       10

2.1.2 History                                                                                                                           10

2.1.3 Classification                                                                                                                 12

2.1.4 Diagnosis                                                                                                                       13

2.1.5 Prevalence                                                                                                                      14

2.1.6 Complications                                                                                                                17

2.1.7 Prevention                                                                                                                      18

2.2 Pre-diabetes                                                                                                                     20

2.2.1 Definition/diagnosis                                                                                                       20

2.2.2 Prevalence                                                                                                                      21

2.2.3 Risk factors of diabetes/pre-diabetes                                                                             23

2.2.4 Prevention and treatment of PD                                                                                     36

2.3 Hypertension                                                                                                                   36

2.3.1 Definition/classification                                                                                                 37

2.3.2 Aetiology                                                                                                                       38

2.4 Hypertension and diabetes co-existence                                                                       38

2.4.1 Aetiopathogenesis of hypertension in diabetics                                                            39

2.4.2 Prognosis of hypertension/DM co-existence                                                                 40

CHAPTER THREE- MATERIALS AND METHOD                                                      42

3.1 Study Area                                                                                                                        42

3.2 Study site/Health facility                                                                                                  43

3.3 Study population                                                                                                               44

3.4 Study duration                                                                                                                   44

3.5 Study design                                                                                                                      44

3.6 Sample size determination                                                                                                44

3.7 Sampling method                                                                                                              46

3.8 Selection criteria                                                                                                               46

3.8.1 Inclusion criteria                                                                                                            46

3.8.2 Exclusion criteria                                                                                                           46

3.9 Method of Data collection                                                                                                47

3.9.1 Pre-testing of the questionnaire                                                                                     47

3.9.2 Sample/Data collection                                                                                                  48

3.10 Definitions and Diagnostic criteria                                                                                 54

3.11 Data analysis                                                                                                                   57

3.12 Ethical issues                                                                                                                  57

3.13 Funding of the study                                                                                                       58

CHAPTER FOUR- RESULTS                                                                                            59

4.1 Socio-demographic characteristics of the study population   59
4.2 Prevalence of Prediabetes   66
4.3 Pattern of Prediabetes   67
4.4 Distribution of risk factors   68
4.5 Association between Prediabetes and the Non-modifiable risk factors   72
4.6 Association between Prediabetes and the modifiable risk factors     75
4.7 Multivariate analysis of Risk factors       78
CHAPTER FIVE-DISCUSSION                                                80
5.1 Socio-demographic characteristics of the study populations       80
5.2 Prevalence of Prediabetes       81
5.3 Pattern of Prediabetes       82
5.4 The risk factors of Prediabetes       83
5.4.1 The non-modifiable risk factors       83
5.4.2 The modifiable risk factors       85
5.5 Limitations of the study       88
5.6 Conclusion       89
5.7 Recommendation       89




Two non-communicable disease conditions have received the greatest global attention in the last two decades. These two conditions which in the early 80s either attracted minimal attention in sub-

Saharan Africa or were termed “Whiteman’s sickness” have grown so much in significance that within a span of just about twenty years, the health statistics in Nigeria and other parts of subSaharan Africa have been dramatically altered by them. As a result, besides Acquired Immune Deficiency Syndrome (AIDS), Non-Communicable Diseases (NCDs) notably hypertension (HBP) and diabetes mellitus (DM) have emerged global pandemics and major causes of morbidity and mortality in the world.1

Whereas a lot of studies, advocacy and funding with free screening and treatment are on-going on a wide scale for AIDS in Nigeria and Africa, little can be said for NCDs. Non-Communicable Diseases are implicated for rising morbidity and mortality in Africa, and carry great concern for the future. They are the second leading causes of death in Africa among people aged 15-59 years.2 The number of people living with diabetes currently is put at over 7 million in Africa, and 240 million globally.3,4 These populations are about a third and a quarter of the corresponding number of hypertensive patients in Africa, and the world respectively.

Hypertension is an increasingly important health issue, not just in the developed nations but also in the developing countries of the world including those of sub-Saharan Africa.5 It has been referred to as a “silent killer” because it often has no detectable symptoms while causing continuous and progressive damage to vital (target) organs in the body. HBP is an important risk factor for coronary heart disease (CHD), cerebrovascular disease, heart failure, peripheral vascular disease and renal failure in both men and women. It is the leading global risk for mortality, being responsible for about 7.5 million deaths (13%) annually, and the fifth leading contributor to the global burden of disease.6 The global estimate of HBP is put at over one billion with about 20%

of people affected living in Africa.7,8

A number of risk factors for HBP have been identified. These include age, increased body mass index (BMI) (overweight and obesity), excessive alcohol consumption, family history of hypertension, smoking and sedentary life style. Diabetes Mellitus is also a risk factor for HBP and

both conditions often co-exist.9,10

Diabetes mellitus (DM) is the fourth highest cause of death worldwide with three million deaths annually: every ten seconds, a new death from DM is reported.4 Simply put “diabetes is one of the biggest health catastrophies the world has ever seen”.4 This is according to Dr. Martin Silink (President, International Diabetes Federation). Diabetes Mellitus is the commonest and most important endocrine disorder in Nigeria with about 4 million people estimated to be affected”. It constitutes 20% of in-patients in the medical wards at the University of Nigeria Teaching Hospital (UNTH), Enugu.11

DM when left uncontrolled can cause a lot of complications affecting almost all parts of the body systems. Such complications include blindness, renal failure, lower limb amputations and cerebrovascular accident, heart and blood vessel diseases, erectile dysfunction in men etc.4 DM itself is a major cause of cardiovascular disease and is even considered a cardiovascular disease

equivalent currently.12-14

The increase in the prevalence of DM and HBP in African communities is attributable to the drastic lifestyle changes accompanying urbanization and modernization.15 There has been an increase in the consumption of refined diet and saturated fat with decreased fiber intake and reduced physical activity. Unfortunately prospective approaches to this burden and possible preventive strategies have been hindered by scarcity of data on NCDs in Africa. Studies on DM and HBP (prevalence, pattern of disease, aetiopathogenesis and complications) in Nigeria and Africa as a whole are limited despite the fact that they are major health problems. Indeed Africa is experiencing one of the most demographic and epidemiological transitions in the world history characterized by the tremendous rise in the burden of NCDs.1 The relationship between DM and HBP has long been established. Many diabetics are also hypertensive and DM is said to increase the risk of systolic hypertension by 2.5 times.11 DM is a risk factor for hypertension and both often co-exist9,10 possibly because they share similar lifestyle factors. This doubles the overall risk factor for cardiovascular disease.


Individuals do not just develop DM overnight, they go through a prolonged intermediate phase termed pre-diabetes (PD) which at present has been recognized as a phase in the natural history of DM.16 It is almost always present before a person develops the more serious type 2 DM. Prediabetes is a medical condition in which the blood glucose level is higher than the normal value but not high enough to meet the criteria for the diagnosis of DM. It is characterized by fasting plasma glucose of 100-125mg/dl (5.6-6.9mmol/L) and/or plasma glucose level 140-199mg/dl (7.811.0mmol/L) 2hrs after a 75g oral glucose load.17 These conditions are known as impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) respectively. The current use of PD solely relates to people with IFG and/or IGT and it is equivalent to potential DM.18

IFG increases the risk of DM and both undiagnosed DM and IFG are associated with DM complications and risk factors19,20. Hence a study of pre-diabetes and its risk factors may be akin to a study of DM and its risk factors since they share these similar features.

In sub-Saharan Africa, it is estimated that NCDs deaths were one-third of communicable disease deaths in 1990 and that by 2020 they will be roughly equal.1 Thus, even in the poorest African countries where communicable diseases predominate, NCDs are substantial causes of morbidity and mortality in adults especially in urban areas.

In view of this, the Federal Government of Nigeria in 1988 established an Expert Committee on NCDs led by Prof. O. O. Akinkugbe with the main objective of identifying risk factors involved in these disease conditions and formulating suitable programmes for early detection and effective control.21 The committee submitted her final report in 1997. Their findings have formed a basis for prevention and treatment of NCDs, and further research on NCDs in Nigeria.



The burden of DM is enormous in terms of pressure on existing health resources- human and material. It is financially crippling to the individual patient in terms of diet, drugs and management of the complications. It is emotionally devastating for such complications as erectile dysfunction, poor vision and social stigmatization of diabetic ulcer disease and the attendant amputation. It is more distressing to know that many of these diabetic patients present to the physicians when the irreversible complications of DM had already set in. These complications can involve all parts of the body systems and include diabetic foot ulcer gangrene, renal impairment which may necessitate repeated dialysis or renal transplant, erectile dysfunction, cerebrovascular disease, retinopathy, coronary artery disease and other micro and macro vascular complications. These complications significantly contribute to death and also impair the quality of life of the affected individuals, care givers, families, communities involved and the nation at large. Its management can be burdensome and can distort the family balance. To the various governments especially in Africa, the problem of DM is a nightmare. Little wonder the life expectancy of a type 1 diabetic child in the world`s poorest countries is 12 months in contrast to 50-60 years in the developed world.11 The rising prevalence imposes a great burden on health systems in Nigeria. This study will be a guide to the design and implementation of appropriate strategies for early diagnosis and a population based primary prevention of DM since the chances of its development have been shown to decrease by lifestyle changes and drug treatment.22,23A more aggressive and  proactive intervention measure is urgently needed to combat this growing burden of DM since all its associated complications have been demonstrated at its pre-diabetic stage.24-28 In view of this, screening for PD both in the general populace and specifically in the high risk groups such as hypertensive patients is recommended as people with PD are at increased risk for the development

of cardiovascular complications independent of progression to type 2 DM.24-28

Any action geared towards the prevention of DM is a worthwhile venture.

This type of study has not been carried out in Owerri, thus there is a knowledge gap regarding PD and its burden in the locality. It is hoped that the findings of this study would help to bridge this gap and also generate data for a better understanding of the concept of PD and its risk factors in the Nigerian population.


In the last couple of years, there has been an upsurge in the number of diabetic patients presenting at Federal Medical Centre, Owerri (FMCO). Many of these patients are also hypertensive. Both DM and HBP have strong familial background and require a lot of family support in form of finance and care. Coupled with the far reaching social and economic implications of their complications on family dynamics; in-depth knowledge and appreciation of DM and HBP and the interactions between them is very relevant in family medicine. Recent trends in the management of both diseases emphasize home care, patient`s input, family involvement/support and participation of experts in the various sub-specialties concerned with both disease conditions. The family physician more than any other member of the medical team fits as the leader of the team, and thus, must be at the fore of research and development of strategies for the management of these diseases.

The costs of caring for people with DM and conditions that result from having poorly managed DM are very high; the pandemic would overwhelm healthcare resources everywhere if urgent actions are not taken. The goal, therefore, should be to prevent DM and its complications from being a bigger problem in Nigeria. This can best be done at the primary level of prevention.

This study will help to determine the prevalence of pre-diabetes and its associated risk factors in the study population. Appreciation of the burden posed by this condition in hypertensive patients would help sensitize the family physician that sees every encounter with a patient as an opportunity to render both preventive and promotive health services to routinely assess and screen the high risk groups for pre-diabetes. The detection of DM at its earliest stage, pre-diabetes, and the implementation of the necessary intervention measures such as lifestyle modification (increased physical activity, reduced excessive caloric intake) and occasionally drug treatment would help prevent or at the least slow down the progression to overt DM and its potential complications and burden.




To determine the pattern of pre-diabetes and its associated risk factors among adult hypertensive patients attending the General Outpatient Clinic of Federal Medical Centre, Owerri, with a view to early detection, management and reduction in the burden of DM in the hypertensive patients.


  1. To describe the socio-demographic characteristics of the study population.
  2. To determine the prevalence of pre-diabetes among the study population.
  3. To describe the non-modifiable risk factors of age, sex and family history of DM among the study population.
  4. To describe the modifiable behavioral risk factors of alcohol use, cigarette use, physical activities and nutritional status using BMI anthropometry among the study population.


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