ABSTRACT
Diabetes mellitus and thyroid disorders are the two most
common endocrine disorders in clinical practice. Presence of thyroid
dysfunction in diabetic patients makes management of the disease more
difficult. The objective of this hospital based cross sectional study at the
Diabetic Clinic of Effia Nkwanta Regional Hospital, Sekondi, was to investigate
the prevalence of thyroid dysfunction and thyroid autoimmunity in clinically
euthyroid type 1 and type 2 diabetes mellitus patients and also to correlate
the glycated haemoglobin levels with thyroid function markers. One hundred and
thirty-two (132) clinically euthyroid type 1 and type 2 diabetes mellitus
patients and 132 age-matched and sex- matched non-diabetic control subjects
were included in the study. Data on sociodemography of patients and controls
such as age, sex, duration of diabetes, mode of glycaemic control were obtained
using a pre-tested questionnaire. The serum levels of thyroid biomarkers (TSH,
FT3, FT4, anti-TPO anti-TG) were evaluated using standard methods. The mean
serum FT3 (p = 0.2044) and TSH (p = 0.1869) in diabetic subjects were not
significantly different when compared to their control peers but the levels of
FT4 was significantly higher in the diabetic mellitus subjects compared to the
levels recorded among the control group (p < 0.0001). The prevalence of
thyroid dysfunction among the diabetic group was 11.36% (6.82% subclinical
hypothyroidism and 4.54 % subclinical hyperthyroidism) with 117 (88.64 %)
euthyroid. The prevalence of thyroid autoimmunity among the diabetic subjects
was5.30% and 3.79 % respectively for anti-thyroid peroxidase autoantibody
(anti-TPO) and anti- thyroglobulin autoantibody (anti-TG). Though not
statistically different, the auto-antibody reactivity was observed to be higher
among the diabetic group compared to the controls. Among the thyroid biomarkers
assayed, increasing FT4 levels was significantly associated with increasing
additive levels of fasting blood glucose and glycated haemoglobin after
Bivariate Pearson correlations analysis.
In conclusion, this study has shown that, the prevalence of
thyroid dysfunction among the diabetic population seen at Effia Nkwanta
Regional Hospital in Sekondi, Ghana was 11.36 % and the prevalence of thyroid
autoantibody reactivity (3.79-5.30 %) in the diabetes mellitus subjects was not
significantly different from non-diabetic subjects.
CHAPTER ONE
INTRODUCTION
1.1 Background
Diabetes mellitus is a condition
with multiple aetiologies arising from disturbances in glucose metabolism due
to a defect either in insulin production and release, action or a combination
of these leading to a high glucose level associated with other biochemical
derangements (World Health Organization, 2002). Diabetes mellitus results from
different metabolic disorders rather than a distinct pathological abnormality.
Some known clinical manifestations are drowsiness associated with
hyperglycaemia, excessive urination and thirst, weight loss, impaired vision
and vulnerability to some infections. The severest form of increased glucose
levels could lead to hyperosmolar syndrome and insulin deficiency as well as
life-threatening ketoacidosis. Defects in carbohydrate metabolism coupled with
the physiological system to undo the imbalance places a burden on other
endocrine systems. Continuous breakdown in endocrine control worsens the
metabolic imbalance and subsequently leads to hyperglycaemia (Bailey, 2000).
Worldwide, diabetes mellitus a well
known endocrine metabolic abnormality is a main cause of mortality. It was
projected that by the year 2000, 171 million people in the world would suffer
from diabetes and at this rate the number is expected to increase to about 366
million in 2030 (Wild et al., 2004). Presently, in every population in the
world, there are people who live with diabetes mellitus and other subtle forms
of glucose metabolic disorders. It is feared that without proper intervention
and preventive control measures, the burden of the disease and the other lesser
forms of glucose metabolic disorders are likely to increase globally (Zimmet et
al., 2001; Alberti., 2007). There is scanty information on the overall
prevalence of diabetes among Ghanaians, however;
the rate has been estimated to be about 6.3% among some inhabitants in the
capital, Accra (Amoah et al., 2002).
Thyroid diseases generally show as
either over production of thyroid hormones or under production of the thyroid
hormones. It can also result from swelling due to a neoplastic process or due
to the pressure effects on the thyroid gland from close anatomical structures (Jayakumar,
2011). Thyroid disease is a pathological condition that interferes with the
management and control of diabetes mellitus. According to Der et al., (2013),
the prevalence of thyroid disorders varies according to some factors. For
example dietary iodine intake of the population is known to affect the
prevalence of thyroid disorders seen in that population. In clinical practice,
thyroid diseases and diabetes mellitus are the two most common endocrine
disorders seen. The state of glycaemic dysregulation and thyroid dysfunction
have been observed to equally affect each other and the relationship between
the two conditions have been established previously(Feely and Isles, 1979).
Thyroid hormones contribute to the regulation of carbohydrate metabolism and
pancreatic function, while diabetes mellitus affects thyroid function tests. Rohdenburg
(1920) used the term 'thyroid diabetes' to explain the effect of thyroid
hormone excess on the effective control of glucose metabolism. Thyroid hormones
oppose the action of insulin and both insulin and thyroid hormones take part in
metabolism of various cells. Functional abnormalities can occur as a result of
overproduction or under production of either insulin or thyroid hormones (Satish
and Mohan, 2003). The prevalence of thyroid disease in patients with diabetes
has been shown to be significantly higher compared to the general population
which suggests a possible relationship between thyroid status and insulin
resistance (Goswami and Mallika, 2010). For example, Papazafiropoulou (2010)
showed that 12.3 % of Greek diabetic patients had thyroid dysfunction and Akbar et al.,
(2006) also showed that the thyroid dysfunction was prevalent in 16 % of type 2
diabetes mellitus subjects from Saudi Arabia.
1.2 Objectives
of the study
* To compare thyroid hormone levels
and prevalence rates of thyroid dysfunction in diabetes mellitus subjects with
age-matched and sex- matched nondiabetic control group.
* To compare the prevalence of
thyroid autoimmunity by estimating anti- thyroid peroxidase and
anti-thyroglobulin levels in types 1 and 2 diabetes mellitus and their control
subjects.
* To determine the type of thyroid
disorders associated with the diabetic subjects.
* To determine the relationship
between glycaemic control and thyroid dysfunction.
1.3 Justification
of the objectives
The prevalence and pattern of
various diseases including thyroid dysfunction vary from country to country and
also shows temporal changes over centuries. This difference is mainly because
of the fact that the causes of most of the diseases are multi factorial that is
to say they depend on race, genetic makeup, dietary habits, lifestyle of
individual as well as environmental factors which keep changing from place to
place and time to time. Since the symptoms of hypothyroidism and
hyperthyroidism are very similar to many other conditions and even in states of
normal health (Abalovich et al., 2007), it is therefore important that thyroid
function is tested biochemically alongside a careful clinical assessment of all
diabetes mellitus patients. It is known that unidentified thyroid dysfunction
could make management of diabetes and its complications more difficult.
Therefore, management of thyroid dysfunction in patients with diabetes may
prove useful.
For example, American Diabetes
Association (ADA) has proposed that people with diabetes to be checked for
thyroid disorders (Thakkar and Jain, 2011). A study among type 2 diabetes
mellitus subjects at Korle- Bu Teaching Hospital in Accra, Ghana showed that
10.1 % type 2 diabetes mellitus population studied had thyroid dysfunction. However,
data is not available on thyroid dysfunction and thyroid autoimmunity among the
diabetes mellitus patients seen at Effia Nkwanta Regional Hospital, Sekondi,
Ghana. This study aims to determine the frequency and types of thyroid
dysfunction and thyroid autoimmunity among diabetic subjects at Effia Nkwanta
Regional Hospital.
1.4 Expected
benefits of the study
Determination of frequency and
types of thyroid dysfunction and thyroid autoimmunity among diabetic patients
in Ghana will help inform clinicians whether it will be worthwhile screening
all diabetic patients for thyroid dysfunction. Epidemiological data would also
be available on thyroid dysfunction and thyroid autoimmunity among diabetes
mellitus patients seen at Effia Nkwanta Regional Hospital in Sekondi, which
will serve as foundation for further studies.
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