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THE PREVALENCE OF HYPERTENSION IN DIABETIC PATIENTS ATTENDING THE OUTPATIENT DEPARTMENT OF THE FEDERAL MEDICAL CENTRE, OWERRI, IMO STATE
SUMMARY
Background
Diabetic Mellitus (DM) is the commonest endocrine disorder in Nigeria and the 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; and hypertension, an association that results in increased morbidity and mortality. Both often co-exist. This study was designed to determine the prevalence of hypertension in diabetics attending the Outpatient Clinic of the Federal Medical Centre (FMC), Owerri, to relate certain risk factors to the occurrence of hypertension among the study subjects and recommend measures towards reducing morbidity and mortality in diabetic patients who are hypertensive.
Patients and Methodology
A cross-sectional study of 300 patients attending Outpatient Clinic of FMC, Owerri was conducted. Demographic data, anthropometric indices, family history of DM and hypertension, duration of DM or symptoms and hypertension, blood glucose, blood pressure (BP) and history of certain risk factors were documented.
Results
Mean ages for males (M) and females (F) were 57.15 ± 12.08 years and 55.12 ± 11.62 years respectively. M: F was 1:12. The mean durations of DM and hypertension for known diabetics and hypertensives were 5.42 ± 4.25 years and
2.92 ± 2.89 years respectively. The mean body mass indices (BMI) were 24.71 ± 3.87kg/m2 and 27.07± 5.96kg/m2 for males and females respectively with 18% of the study subjects having obesity (BMI ≥30.00kg/m2). Family history of DM and hypertension were present in 44% and 25.33% of the subjects respectively with 97% being first degree relations in both cases. Most of the known diabetics and hypertensives had poor glycaemic and blood pressure (84.67% and 78.70%
respectively) control.
Conclusion
The prevalence of hypertension in the study was 44%.
The study recommends early routine screening for DM, regular blood pressure check, BMI monitoring, and aggressive health promoting lifestyle modifications for all diabetics especially prehypertensive diabetics with the aim of maintaining blood pressure and BMI at optimal levels. A review of management protocol to integrate home based care, patient’s input and family participation with hospital based care is recommended. Further studies are needed to determine factors responsible for poor treatment outcome in diabetic and hypertensive patients with a view to stemming the tide.
TABLE OF CONTENTS
List of Tables xii
List of Figures xiii
List of Abbreviations and Acronyms xiv
Summary xv-xvi
| Title | i |
| Declaration | ii |
| Dedication | iii |
| Acknowledgement | iv |
| Certification | v |
| Table of Contents | vi |
CHAPTER ONE 1
1.0 Introduction 1
1.1. Rationale of Study 3
1.2. Aim 5
1.3. Objectives 5
CHAPTER TWO 6
2.0 Literature Review 6
2.1. History of Diabetes Mellitus 6
2.2. Definition of Diabetes Mellitus 8
2.3. Classification 8
2.4. Diagnosis of Diabetes Mellitus 10
2.5. Epidemiology 12
2.5.1. Global Prevalence 12
2.5.2. Prevalence in Africa 13
2.5.3. Prevalence in Nigeria 14
2.6. Risk Factors Associated with Diabetes Mellitus 15
2.6.1. Genetic Factors 15
▪ Type 1 DM 15
▪ Type 2 DM 16
2.6.2. Environmental Factors 16
- Obesity 17
- Physical Activity 18
- Diet/Urbanization 18
2.6.3. Age 19
2.6.4. Malnutrition in Utero 20
2.6.5. Alcohol 20
2.6.6. Vaccination 21
2.6.7. Cigarette Smoking 21
- Management of Diabetes Mellitus 21
- Recent Advances in Cure of Diabetes Mellitus 23
- Prevention of Diabetes Mellitus 25
- Complications of Diabetes Mellitus 26
-
Hypertension 28
- Definition and Classification of Hypertension 28
- Aetiology of Hypertension 30
-
Risk factors associated with Hypertension 30
- Genetics 30
- Environmental Factors 31
▪Salt Intake 31
▪Physical Activity 32
▪Obesity 33
- Age and Sex 33
- Alcohol 33
- Cigarette Smoking 34
2.12. Hypertension in Diabetes 34
- Aetiopathogenesis of Hypertension in Diabetes 35
- Prevalence of Hypertension in Diabetes 38
- Diagnosis of Hypertension in Diabetes 39
- Investigation of Hypertension in Diabetes 39
- Treatment of Hypertension in Diabetes 40
Non-Pharmacological Therapy 41
Pharmacological Therapy 41
.Antihypertensive drugs 41
.Other drugs 44
2.13. Prognosis 45
CHAPTER THREE 47
3.0 Methodology 47
3.1. Location 47
3.2. Study Area 47
3.3. Study Design 48
3.4. Study Population 48
3.5. Sampling 48
3.5.1. Sampling Method 49
3.6. Inclusion Criteria 50
3.7. Exclusion Criteria 50
3.8. Materials and Sample Collection 50
3.8.1 Data Collection 50
3.8.2 Data Collection Procedure 51
3.9 Criteria for Diagnosis 56
3.10 Statistical Analysis 56
CHAPTER FOUR 58
4.0 Results 58
4.1. Socio-Demographic and Clinical Characteristics of Study 58
4.1.1 Age and Sex distribution 58
4.1.2. Body Mass Index 59
4.1.3. Duration of Disease and Symptoms for Known and
New Diabetics respectively 60
4.1.4. Blood Pressure of Study Subjects 61
4.1.5. Prevalence of Hypertension 62
4.1.6. Systolic Blood Pressure of Study Subjects 62
4.1.7. Diastolic Blood Pressure of Study Subjects 63
4.1.8. Duration of disease for known hypertensives 64
4.2. Distribution of Comparative Variables 65
4.3. Risk Factors and Hypertension Among Study Subjects 66
4.3.1a. Obesity 66
4.3.2a. Family History of Diabetes Mellitus 66
4.3.3a. Family History of Hypertension 66
4.3.4a. Alcohol Intake 66
4.3.5a. Cigarette Smoking 66
4.3.1b. Obesity 67
4.3.2b. Family History of Diabetes Mellitus 68
4.3.3b. Family History of Hypertension 68
4.3.4b. Alcohol Intake 68
4.3.5b. Cigarette Smoking/Snuffing 68
4.3.6 Relationship of the Risk Factors to Hypertension 69
CHAPTER FIVE 70
5.0 Discussion 70
5.1 Age and Sex Distribution 71
5.2 Prevalence of Hypertension and Comparative Analysis of
Hypertensive and Normotensive Subgroups 72
5.3 Duration of Disease in Known Diabetics and Symptoms
in New Patients, and Treatment Outcome 75
5.4 Duration and Treatment Outcome for Hypertensives
Among the Study Subjects 76
5.5 Risk Factors and Hypertension 77
5.5.1 Obesity 77
5.5.2 Family History of Diabetes 78
5.5.3 Family History of Hypertension 79
5.5.4 Alcohol Consumption and Cigarette Smoking 80
5.6. Limitations of Study 81
5.7. Conclusion 82
5.8. Recommendations 82
References 85
CHAPTER ONE
1.0 Introduction
In the last decades, two disease conditions have received the greatest attention worldwide. They are Acquired Immunodeficiency Syndrome (AIDS) and NonCommunicable Diseases (NCDs) notably hypertension and diabetes mellitus (DM). These two conditions which in the early 80s were either non-existent in Nigeria or termed “Whiteman’s sickness” have grown so much in significance that within a span of just twenty years, health statistics in Nigeria have dramatically altered, so much that even far beyond the shores of Nigeria and Africa, these conditions are a main worry. AIDS and NCDs are global pandemics and major causes of morbidity and mortality in the world 1.
While 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 noncommunicable diseases. NCDs are implicated for rising morbidity and mortality in Africa, and carry great concern for the future. The number of people living with diabetes at present is put at over 7 million in Africa, and 240 million globally. 2,3 These populations are about a third, and a quarter of the corresponding number of hypertensives in Africa, and the world respectively. The global estimate of hypertension is put at over 1 billion with about 20% of people living in Africa 4,5. Left uncontrolled, diabetes can cause a lot of complications such as blindness, kidney failure, lower-limb amputation and cerebraovascular accident3. It is the fourth biggest cause of death worldwide with three (3) million deaths annually; every ten (10) seconds a new death from DM is reported 3. Simply put “diabetes is
one of the biggest health catastrophes the world has ever seen,”3 according to Dr. Martin Silink (President, International Diabetes Federation).
Diabetes is the commonest and most important endocrine disorder in Nigeria; surprisingly, no national register exists for the disease at present and projected number of people living with DM in the country is put at about four (4) million 6 . It constitutes 20% of in-patients in medical wards at the University of Nigeria Teaching Hospital (UNTH), Enugu 6.
The relationship between diabetes and hypertension has long been established. Many diabetics are also hypertensive, in fact, DM increases the risk of systolic hypertension by 2.5 times6. This co-existence worsens the patient’s cardiovascular outcome and overall prognosis.
The increase in the prevalence of DM and hypertension in African communities is attributable to the drastic lifestyle changes accompanying urbanization and modernization 7. There has been an increase in consumption of refined diet and saturated fat with decreased fibre 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. Only few studies (prevalence, pattern of disease, aetiopathogenesis and complications) have been done on DM and hypertension in Nigeria and Africa as a whole despite the fact that they are major health problems. Of note, majority of the studies were hospital based and not a true reflection of the impact of both diseases at the community where substantial populations remain undetected. 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 NCDs1.
Three main forces drive the emergence of NCDs as major health problems in subSaharan Africa as a whole over the next 20-30 years; these are increasing elderly populations as infant death rates and fertility fall, increasing urbanization and associated change in lifestyles and the population of tobacco and western diets by multinational companies 1.
In sub-Saharan Africa, it is estimated that deaths due to NCDs were 1/3 of deaths due to communicable diseases 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 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 programme for early detection and effective control 8.
The Committee submitted its final report in 1997. Their findings have formed a basis for prevention and treatment of NCDs, and further research on NCDs in Nigeria.
1.1 Rationale of Study
The burden of DM is enormous in terms of pressure on existing health resources- human and materials. It is financially crippling to the individual patient in terms of diet, drugs and management of complications. It is emotionally devastating (erectile dysfunction, poor sight, diet restriction, social stigmatization of diabetic ulcer patients and amputees) and distorts 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 6. The rising prevalence imposes a great burden on health systems in Nigeria. This study will practically be a guide to the design and implementation of appropriate strategies for early diagnosis and treatment, and population based primary prevention of DM and hypertension.
The reported prevalence of hypertension in diabetics is about twice in age-matched non-diabetics and hypertension greatly increases the cost of care 1.
In the last couple of years there has been an upsurge in the number of diabetic patients presenting at Federal Medical Centre (FMC) Owerri. Many of these patients are also hypertensive. Appreciation of the extent of the problem and assessment of results of efforts made at controlling the diseases will be derived from the study.
Both DM and hypertension 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 on family dynamics; in depth knowledge and appreciation of diabetes and hypertension 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 sub-specialties concerned with both diseases. The family physician is a member of this team, and thus, should 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 epidemic will 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 study will give a representative figure on the burden of co-existent DM and hypertension in Owerri, South-East Nigeria, relate certain risk factors to the occurrence of hypertension among the diabetics and interventions to change these established modifiable risk factors.
1.2 Aim
The study aimed at determining the prevalence of hypertension in diabetic patients attending the Outpatient Department of the Federal Medical Centre, Owerri.
1.3 Objectives
Specifically, the study set out to:
- Relate the occurrence of hypertension in the study subjects to risk factors such as obesity, cigarette smoking, alcohol consumption, family history of diabetes and hypertension.
- Recommend measures towards reducing morbidity and mortality in diabetic patients who are hypertensive.
