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THE PREVALENCE AND RISK FACTORS FOR DIABETIC RETINOPATHY AMONG ADULT DIABETICS ATTENDING GENERAL OUT- PATIENT CLINICS OF THE FEDERAL MEDICAL CENTRE OWERRI
SUMMARY
Background:
Blindness from diabetic retinopathy is a preventable complication of diabetes mellitus if the retinopathy is detected early. Among other approaches, awareness of the prevalence and risk factors for diabetic retinopathy by health care professionals and diabetic patients could help in early detection, management and prevention of this complication. This study sets out to determine the prevalence and risk factors for diabetic retinopathy among diabetic patients attending the outpatient clinics of the Federal Medical Centre Owerri, Imo State. The hospital has a well established ophthalmology department where most diabetic patients are usually referred to when they experience marked reduction in vision. In the case of diabetic retinopathy, it becomes unfortunately late for any meaningful intervention to be made to save vision. Although primary care physicians working in the general outpatient clinics where most of these patients are first seen and treated are aware of the possibility of eye complications from diabetes, they tend to underscore the contributions of various risk factors to the development of these complications. It is therefore imperative to carry out this study in order to establish the prevalence of diabetic retinopathy and its associated risk factors so as to aid compliance with risk control measures and help drive the practice of continued retinopathy screening.
Methodology:
This was a cross- sectional analytical study of 200 diabetics using researcher administered questionnaire. Systematic random sampling method was adopted for
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selection of subjects. The study which spanned a period of 6 months lasted between 15th March and 15th September, 2010. The bio-data, weight, height, blood pressure, serum lipid profile, glycated haemoglobin values, fasting blood glucose levels and visual acuity were obtained directly from the subjects using the questionnaires. Body mass index, waist to hip ratio and conicity index values were derived from the measured values. The results were analyzed using statistical package for social sciences (S.P.S.S) version 15.0 and presented as tables showing means, frequencies and odds ratio with corresponding 95% confidence intervals. P-values less than 0.05 were considered to be statistically
significant.
Results:
The prevalence of diabetic retinopathy in the study population was 43%. Positive correlation was found with higher educational level, married status, family history of hypertension, visual impairment, increasing LDL-C levels, increasing duration of disease, smoking and blood pressure of respondents. However, further analysis of the results using multiple regression , identified high body mass index, increasing glycated haemoglobin levels, high LDL-C levels, increasing age, and visual impairment as risk factors for diabetic retinopathy.
Conclusion:
Diabetic retinopathy is prevalent among diabetics in this part of the country. In view of the identified risk factors, it is recommended that risk control measures be adopted in the management of all diabetic patients seen by Family Physicians at the general outpatient clinics of the Federal Medical Centre Owerri.
TABLE OF CONTENTS
Title Page i
Certification by the Supervisors ii
Certification by the Head of Department iii
List of Acronyms ix-x
Summary 1-2
Chapter 1 3-11
Chapter 2 12-32
Chapter 3 33-45
Chapter 4 46-56
Chapter 5 57-68
References 69-84
Appendices 85-88
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CHAPTER ONE
INTRODUCTION
1.0 Background:
Diabetes mellitus is recognized as a group of heterogeneous disorders with the common elements of hyperglycaemia and glucose intolerance, due to insulin deficiency, impaired effectiveness of insulin action or both.1,2,3 It is a common endocrine metabolic disorder and a leading cause of death worldwide.1,3 There are more than 154 million diabetics
globally and its prevalence is on the increase especially in the developing nations. 1,2,3 Majority of those that suffer the disease are reported to be of African and Asian origin. 1,3
This may be the result of genetic predisposition and lifestyle of people in these areas. 1,3 Nigeria being the most populous African country may harbor a substantial number of people with this condition.2,3, The rapid increase in the number of persons with diabetes mellitus is expected to lead to an increase in the number of persons with complications from it.1,2,3 One of such complications of diabetes mellitus is retinopathy which is a highly specific vascular complication that affects the retina of the eyes.1,2 The complications of diabetes mellitus are termed either small vessel (microvascular) or large vessel (macrovascular) disease.1,2,3 Small vessel disease includes retinopathy, nephropathy and neuropathy.2,3 Well conducted clinical trials have shown that good control of diabetes and hypertension significantly reduces the risk for retinopathy in diabetics. 2,3 This assertion is further supported by the results of the Diabetes Control and
Complications Trial (DCCT) which demonstrated that tight glucose control will delay the development of small vessel disease.2,3.
These small vessel diseases usually affect the eyes and the kidneys. In contrast to these, large vessel disease results in diabetic cardiovascular events and diabetic foot ulcers.2,3 These complications are usually slow, requiring many years to progress to clinically detectable levels. In the case of diabetic retinopathy, there is no exact interval between the time of diagnosis and development of the disease.2,3 Visual loss is usually noticed in diabetic subjects through complaints made by the affected individuals and further confirmed by visual acuity tests.
Not all diabetics are equally at risk of retinopathy.3 It is known that vision threatening retinopathy virtually never appears in type 1 diabetic patients in the first 3-5 years of diabetes or before puberty while up to 20% of patients with type 2 diabetes have retinopathy even at the time of diagnosis.3 After 15 years of diagnosis of diabetes, about 2% of persons become blind while about 10% develop severe visual loss.1,2,3 After 20 years of the disease, more than 75% of the patients will have some form of retinopathy or the other.1,3 With the surging prevalence of diabetes worldwide, the number of people bearing these complications is expected to rise astronomically.1,3,4 For instance, the prevalence of diagnosed diabetes in the United States rose from 6.5% between 1999 and 2002 to 7.8% between 2003 to 2006 as shown by an American study.4
Developing nations currently witnessing rapid urbanization, industrialization as well as increasing economic capabilities like Nigeria have higher propensity to develop diabetes due to changes in lifestyle.2,3,4 It is expected that this rise in prevalence of diabetes mellitus brought by urbanization and industrialization will also trigger an increase in the number of new cases of diabetic retinopathy.1,2,4
In addition to the rising number of diabetics, there is also an increase in the occurrence of some factors known to potentiate the development of retinopathy in diabetics. These are
termed risk factors.2,3,4
Principal among these risk factors are hypertension, poor glycaemic control, increasing level of blood lipids, increasing body mass index, smoking, higher educational status, and alcohol consumption.1,2 They are modifiable risks since they can, to a large extent be controlled. Age, sex, and race are non modifiable risks to which the individual can hardly influence. The modifiable risk factors are mainly the concern of this study. The non modifiable risk factors though included in the study since they constitute important demographic parameters, are not really the concern of this study.
Hypertension for example, has a frequency of 20-40% among diabetics in Nigeria.5 Its prevalence in the general population is only 10-15%. 6 This shows that the occurrence of hypertension is more than twice enhanced in the presence of diabetes.3,5,6 Fortunately, hypertension is controllable by the use of antihypertensive drugs, regular exercises, avoiding high salt intake, reducing psychosocial stress and avoiding use of excess alcohol, hence its contribution to retinopathy in diabetics can be put to check by
observing these steps.3,5,6
It has been reported that avoiding tobacco use and the correction of associated hypertension are important therapeutic measures in the management of diabetic retinopathy3. It is expected from this report that tobacco smoking may play a role in the progression of retinopathy in diabetics who smoke.
In addition to good glycaemic control and reduction of blood pressure as a means of checking the development of retinopathy in diabetics, proper patient education, aimed at achieving high level of health literacy is also important. In a study to examine the association between health literacy and diabetes outcomes among patients with type 2 diabetes, inadequate health literacy was found to be independently associated with worse glycaemic control and higher rates of retinopathy.7
Diabetic retinopathy is among the target diseases of vision 2020 which is a global initiative of the WHO for the elimination of avoidable blindness.1 It is the Right to Sight initiative with the objective of assisting member states in eliminating avoidable blindness by the year 2020.1 The global target is to ultimately reduce blindness prevalence to less than 0.5% in all countries or to less than 1% in any community.1 For this goal to be achieved in Nigeria and in Imo State there has to be the will on the part of the health care professionals to make systematic observations and then ask research questions that will help to proffer solutions to this growing health concern. This study was designed to show the prevalence of diabetic retinopathy among adult diabetics that presented to the General Outpatient Clinics of the Federal Medical Centre Owerri.
It is hoped that a good understanding of these risk factors and how they affect diabetics in this area will contribute to the development of the discipline of Family Medicine in Nigeria. This is because reports from this study will make the Family Physician to begin to devote time to properly examine the eyes of diabetic patients presenting to him during each encounter and then begin to aim at risk reduction in the patient. This way, he will be accomplishing his role as one who manages his patients in a holistic manner. The assimilation and adoption of these findings will prepare the family physician to target particular diabetics out of a whole lot that present to him daily for closer eye examination, follow up, as well as prompt and appropriate referral to ophthalmologists.
2.0 Rationale for the Study
The rise in the prevalence of diabetes mellitus has assumed epidemic proportions globally, with the disease affecting both the poor and the affluent, especially in Africa where diet and lifestyle have changed as a result of an increase in income.2,8 The myriad of complications of which diabetic retinopathy is prominent is also expected to increase proportionately. This is because an increase in the number of new cases will lead to a rise
in the number of those who develop complications.4,5,6
Retinopathy is a common complication of diabetes mellitus, resulting in new cases of blindness for over 40,000 people with diabetes per year.9 Diabetes is becoming an increasing health problem in the developing countries of the world with the World Health Organization projecting a 170% increase in the number of people with diabetes in developing countries by the year 2025.10 This is likely to strain the health budgets of resource poor countries.2,9,10 For example, a recent estimate in Tanzania showed that treatment of diabetic complications alone represented 31% of the total outpatient costs in the main Hospital in Dar es Salaam, with a yearly cost of $138 per person.2
Currently, about 4.8% of the over 37 million cases of blindness due to eye diseases throughout the world are due to diabetic retinopathy.1,10 The number of people with visual impairment worldwide in 2002 was in excess of 161 million, out of whom about 37 million were blind.1,10 Blindness is an important health care issue that exerts both economic and social costs.10,11 Data on the prevalence and causes of blindness at a national level are essential for developing national policies and strategies for optimal utilization of available resources and prioritization of regions and areas for the elimination of avoidable blindness.10,11
In Imo State, the prevalence of ocular disease had risen so much that it became a source of worry to the government and other non governmental bodies in the State who spend huge sums of money in organizing free eye examinations and surgeries for the affected indigenes of the area who are unable to afford surgery.8 This has become a major public health issue as State funds are directed to a health problem that is largely preventable.8,11 It had been observed that more people are gradually losing their sight as a result of eye disease even at a very young age.8,11 However, preliminary investigations often reveal one form of chronic illness or the other at the background, commonly diabetes mellitus.
In most cases, the affected individuals are not even aware of the disease they have (diabetes mellitus) not to talk of its complications. It becomes imperative therefore, to continue to carry out screening for diabetes by Family Physicians using every encounter with the patient as an opportunity. However, for already identified diabetics, there should be adequate information provided about all the complications of the disease including retinopathy which for now is lacking in most of our health institutions.10
Expectedly, not all diabetics progress to retinopathy.3 It is hence logical to think that there may be other risk factors predisposing diabetics to retinopathy.3,10,11 It is this observation that actually prompted this research which in the course of time shall proffer solution to the problem as it tries to achieve its aim and objectives.
The preponderance of ocular manifestations of diabetes mellitus is a pointer to poor diabetic control in the long term since such manifestations are late sequalae of the disease process. This study is therefore necessary as it describes the prevalence of retinopathy among diabetics and also identifies those factors increasing the chances of developing retinal damage in diabetics.
Retinopathy is a recognized complication of diabetes mellitus and therefore should be the concern of the Family Physician in any case of uncontrolled diabetes as it reduces the quality of life of the affected individual in the event of partial or total visual loss. The family, society and the available health facility are hence brought under pressure.
It is important that this study was carried out in Owerri at this time to actually identify the individuals with diabetes who are at risk of developing ocular complications and as such appreciate the burden of diabetes and its attendant complications. It should also provide a framework for appropriate planning and designing of treatment and disease control modalities.
In this regard, primary diabetic care givers (Family Physicians) should be trained and encouraged to provide first hand screening to the patients, preferably in a well planned retinopathy screening programme which for now is obviously lacking in most hospitals in Imo State. Although primary diabetic care givers are usually aware of the possibility of eye complications from diabetes, they tend to wait until patients make visual complaints before screening them or inviting eye care specialists to join in their management. Diabetic retinopathy screening protocols are in most cases either not available or not strictly followed.
Finally, the results generated from this study will provide compelling evidence that developing strategies for diabetes prevention, glycaemic control and early/regular eye examination, would reduce the impact of diabetes on vision. It will also add to baseline information for other researches to be carried out in the area subsequently and shall also add to what is already known about the disease in this country.
3.0 Aim:
The aim of this study is to determine the prevalence and risk factors for retinopathy in
diabetic patients attending outpatient clinics at the Federal Medical Centre Owerri.
4.0 Objectives:
- To determine the prevalence of diabetic retinopathy among adult diabetics
attending the General Out-patient Clinics of the Federal Medical Centre
Owerri.
- To determine the risk factors for the development of diabetic retinopathy in adult diabetic patients such as age, sex, duration of diabetes, body mass index, hypertension, level of glycaemic control and cholesterol levels.
- To determine the relationship between diabetic retinopathy and lifestyle such as alcohol intake and smoking.
- To determine the relationship between diabetic retinopathy and family type, marital status, level of educational attainment and type of occupation.
THE PREVALENCE AND RISK FACTORS FOR DIABETIC RETINOPATHY AMONG ADULT DIABETICS ATTENDING GENERAL OUT- PATIENT CLINICS OF THE FEDERAL MEDICAL CENTRE OWERRI
