ABSTRACT
Diabetes and hypertension are among the commonest diseases in developed countries and the frequency of both conditions are the most common cause of the morbidity and mortality from non- communicable diseases in Africa. This study was designed to determine factors associated with nutritional status and prevalence of hypertension and type 2 diabetes among diabetic patients. A comparative, retrospective, survey study was carried out on 240 adult Nigerians suffering type 2 diabetes, who were screened for hypertension, and 140 of them who had hypertension and met the inclusion criteria were compared with 100 non hypertensive diabetic group. Demographic and some factors associated with hypertension were obtained using a pretested, structured and interviewer-administered questionnaire. Out of 240 diabetic patients screened, one hundred and forty (58.3 percent) of them had hypertension. A systematic sampling technique was used to select the subjects from the study population and data obtained were summarized and analyzed using descriptive and logistic regression statistics respectively. Physical inactivity (P < 0.05), obesity measured by BMI (P < 0.05), Age (P < 0.05), diabetes duration (P < 0.05), family history of hypertension (P < 0.05), and family history of both hypertension and type 2 diabetes (P < 0.05) were significantly associated with hypertension. The most significant associated factor of hypertension in diabetic patients was family history of hypertension (OR=3.1(1.774-5.636), P < 0.05), followed by family history of both health condition (OR=2.5 (1.309-4.724), P < 0.05). Subjects with family history of hypertension were 3.1times more likely to have both disease conditions compared to individual with no family history of hypertension. Subjects with both family history of hypertension and type 2 diabetes were 2.5 times more likely to have both disease condition compared to subjects with no family history of both hypertension and type 2 diabetes. Physical inactivity, obesity measured by BMI, age, family history of hypertension and family history of both hypertension and type 2 diabetes were proximate independent factors associated to comorbidity of hypertension and type 2 diabetes in this group of people. The presence of these factors should therefore provide guide for screening adult Nigerians suffering type 2 diabetes for hypertension in primary care. More of intervention to prevent hypertension among diabetic patients should be a compelling health priority in primary care settings particularly in resource-constrained environment.
CHAPTER ONE
INTRODUCTION
• BACKGROUND TO THE STUDY
Diabetes mellitus (DM) also known simply as diabetes, is a group of metabolic disorder in which there are high blood sugar levels over a prolonged period (American Diabetes Association, 2004). Diabetes is a chronic condition that arises when the pancreas does not produce enough insulin, or when the body cannot effectively use the insulin produced. In another definition, diabetes has been characterized as a chronic metabolic disorder of multiple etiologies characterized by chronic hyperglycemia with disturbances of carbohydrate, fat, and protein metabolism resulting from defects in insulin secretion, insulin action or both (Alebiosu, 2003; Kasiam, et al. 2009).
Diabetes mellitus is a growing public health problem affecting people worldwide both in developing and developed countries, and poses a major socio-economic challenge (Dahiru, Jibo, Hassan & Mande, 2008; Mbanya, Motala, Sobngwi, Assah & Enora, 2010). It is assuming epidemic proportions worldwide (Ogbera, Dada, Adeleye & Jewo, 2010). Each year, over three million deaths worldwide are attributable to diabetes-related causes (American Diabetes Association, 2013). In 2012 and 2013 alone, diabetes resulted in 1.5 to 5.1 million deaths per year, making it the eight leading cause of death worldwide and diabetes overall at least, doubles the risk of death (Vos, et al. 2012). The prevalence of diabetes for all groups worldwide was estimated to be 2.8 percent in 2000 and 4.4 percent in 2030 (Sarah, Gojka, Anders, Hilary & Richard, 2004). The number of people with diabetes is expected to rise to 592 million by 2035(Vos, et al. 2012). Globally, as of 2013, an estimated 382 million people have diabetes worldwide, with type 2 diabetes making up about 90 percent of the cases (Shi & Hu, 2014). According to Shi and Hu, this is equal to 8.3 percent of the adult’s population with equal rates in both women and men. Diabetic population in India, USA, Russian Federation, Brazil, Bangladesh, Egypt and Indonesia are as follows: 61.3, 23.7, 12.6, 12.4, 10.3, 8.4, 7.3 and 7.2 million (International Diabetes Federation, 2011). The most important demographic change to diabetes prevalence across the world appears to be the increase in population of people greater than 65years of age (Sarah, et al. 2004).
Before 1990s, diabetes was considered a rare medical condition in Africa.
Epidemiological studies carried out in that decade, however, provided evidence of a trend toward increased incidence and prevalence of type 2 diabetes in African populations (Sobngwi, Mauvais-Jarvis, Vexiau, Mbanya & Gautier, 2001). In Africa and in Nigeria, there are sparse and inadequate information on the prevalence of diabetes mellitus, however, available data suggest that the disease is emerging as a major and most challenging health problem in this region (Mbanya, Boniface & Nagan, 1996).
According to World Health Organization (WHO), there are 1.71 million people living with diabetes in Nigeria and this figure is projected to reach 4.84 million by the year 2030. Prevalence rate estimates of diabetes in Nigeria have been tagged at 2.5 percent compared to its 2.2 percent rate in 2003 (Nwankwo, Nandy & Nwankwo, 2010).
Hypertension (HTN) or high blood pressure, sometimes called arterial hypertension, is a chronic medical condition in which the blood pressure in the arteries is elevated on repeated measurement (Carretero & Oparil, 2000). Blood pressure is summarised by two measurements, systolic and diastolic, which depend on whether the heart muscle is contracting (systole) or relaxed between beats (diastole). This equals the maximum and minimum pressure, respectively. There are different definitions of the normal range of blood pressure. Normal blood pressure at rest is within the range of 100–140 mmHg systolic (top reading) and 60–90 mmHg diastolic (bottom reading). High blood pressure is said to be present if it is often at or above 140/90 mmHg on repeated measurement.
Diabetes and hypertension are major risk factors for cardiovascular disease, a leading cause of death in humans (Grossman & Messerli, 1996). Hypertension is an extremely common co-morbidity of diabetes, affecting 20–60 percent of individuals with diabetes (Mathew, et al. 2010). Many patients with diabetes have hypertension at the time of diagnosis, while others develop hypertension as the duration of the disease lengthens. Conversely a number of patients with systemic hypertension develop diabetes in the course of their disease. The nutritional status and prevalence of hypertension in the diabetic population is 1.5 to 3 times higher than that of non-diabetic age-matched groups (Wingard & Barrett- Conner, 1995). About 60 percent of patients with diabetes are diagnosed with hypertension, carrying up to 300 time’s higher risk than people without diabetes (Mathew, et al. 2010). According to Ostergren, Poulter & Sever (2008), approximately 15 percent of hypertensive patients are diabetic and approximately 75 percent of type 2 diabetic patients are hypertensive. In a prospective cohort study that included 12, 550 adults, the development of type 2 diabetes was almost 2.5 times more likely in persons with hypertension than in their normotensive counterparts (Gress, Nieto, Shahar, Wofford & Brancati, 2000). Insulin resistance and hyperglycemia combine to make hypertension more prevalent in the type 2 diabetic patient (Bell, 2009). Sowers and Epstein, (1995) suggests that these two common chronic diseases frequently coexist. The risk of vascular complications in diabetes, microvascular (retinopathy, nephropathy and neuropathy), and macrovascular (coronary artery disease, cerebrovascular disease, and peripheral artery disease) is greatly increased by hypertension (United Kingdom Prospective Diabetic Study Group, 1998). It is of public health importance to effectively control co-morbidity of diabetes and hypertension by changing of lifestyle and eating a healthy diet, which will sustain control of multiple risk factors in patients with hypertension or diabetes. Effective control of the co – morbidity will reduce human suffering and disability.
• Statement Of The Problem
Many patients with diabetes develop hypertension as the duration of the disease lengthens. Conversely a number of patients with systemic hypertension develop diabetes in the course of the disease. More than 80 percent of patients suffering either hypertension or diabetes are unaware of having both conditions (Siriwat & Wichai 2012). People with coexisting diabetes and hypertension are at increased risk of atherosclerosis, retinopathy, renal failure, nontraumatic amputations, and cardiovascular diseases and this is costly in terms of human suffering and national healthcare costs. These conditions not only result in high burden to the patients and family, but also impose a high national health care cost worldwide. Thus, the economic impact of hypertension and diabetes is an enormous burden on society. The main relevance of diabetic complications in a public health perspective is the relationship to human suffering and disability such as reducing human work productivity, reducing quality of life, increased risk of infertility, increase in death rate and the huge socio-economic costs through premature morbidity and mortality (American Diabetes Association, 1998).
Although there is an increasing body of data on diabetes and hypertension but data on coexistence of diabetes and hypertension, and the characteristics of individuals with the coexistence of both conditions have not been clearly identified, therefore making the information of prevalence of both conditions limited. Hypertension and diabetes carry an enormous public health burden, making the identification of risk factors and focus on preventive and control measures of these disorders an important strategy. Moreover, knowing risk factors associated with the conditions should be useful for health service and public health action in term of management and prevention. The data on co- morbidity of hypertension and type 2 diabetes is scanty. To the best of my knowledge, there are hardly any studies providing knowledge on risk factors of co-morbidity of hypertension and type 2 diabetes in diabetic patients in Ogun State. It is therefore necessary for one to carry out this study to reduce the prevalence.
• Objectives Of The Study
• General Objective
The main objective of this study was to determine the nutritional status and prevalence of hypertension and type 2 diabetes among patients attending Federal Medical Center in Abeokuta, Ogun State.
• Specific Objectives
Specifically, the objectives of the research were to determine the relationship between:
• Nutritional status and prevalence of hypertension and type 2 diabetes among diabetes sufferers.
• Individual physical inactivity and prevalence of hypertension and type 2 diabetes among diabetes sufferers.
• Obesity as measured by BMI and prevalence of hypertension and type 2 diabetes among diabetes sufferers.
• Family history of hypertension and type 2 diabetes and its prevalence among diabetes sufferers.
• Research Questions
• What is the relationship between high intake of salty food and prevalence of hypertension and type 2 diabetes among diabetes sufferers?
• What is the relationship between individual physical inactivity and prevalence of hypertension and type 2 diabetes among diabetes sufferers?
• What is the relationship between obesity as measured by BMI and prevalence of hypertension and type 2 diabetes among diabetes sufferers?
• What is the relationship between family history of hypertension and type 2 diabetes and its prevalence among diabetes sufferers.
• Research Hypotheses
H1: Occurrence of diabetes-hypertension co-morbidity is associated with increasing intake of salty diet.
H2: Occurrence of diabetes-hypertension co-morbidity is associated with increasing inactivity days.
H3: Occurrence of diabetes-hypertension co-morbidity is associated with obesity as measured by BMI.
• Significance Of The Study
Every research work seeks to improve knowledge about an existing problem and solution. With the current trend of transition from communicable to non-communicable diseases, it is projected that the later will equal or even exceed the former in developing nations thus culminating in double burden. Findings of this study will be of immense benefit in providing the useful information on how primary health care services should be strengthened with a concerted and multipronged effort to provide promotive, preventive, curative, and rehabilitative measures on persons with comorbidity of type 2 diabetes and hypertension, and persons with only hypertension or diabetes. This will provide a dedicated approach that will emphasizes on primary and secondary preventive practices and sustained control of multiple risk factors in patients with hypertension or diabetes. This study will also help to diagnose people living with diabetes or hypertension or co- occurrence of both illnesses and possible risk factors that can result to co-morbidity of these conditions. Also, the findings of the study will help to control complications of diabetes which has implications on cost reduction by adjusting modifiable risk factors identified to be associated to prevalence hypertension and diabetes; and newer fundamental findings of the study will add importantly to our overall knowledge of the cardiovascular complications of diabetes mellitus. For researchers, it will serve as base for further studies.
• Scope Of The Study
This study is strictly delimited to nutrition, physical activity, obesity as measured by BMI, and family history as the factors associated to occurrence of co- morbidity hypertension and type 2 diabetes. This study was carried out in Abeokuta, Ogun State. All information’s about the patients were obtained from subjects within the age group of 20years and above. Both male and female patients were considered for both subjects with hypertension-type 2 diabetes comorbidity and those with only type 2 diabetes. The study is limited to find the factors associated to occurrence of co-morbidity of hypertension and type 2 diabetes in diabetic patients.
• Definition Of Terms
This involves the variables used in this study. The dependent variable; diabetes- hypertension co-morbidity nominally defined as simultaneous or co-existence of diabetes and hypertension in an individual. Operationally, type 2 diabetes or hypertension may give rise to its co-morbidity in an individual. It is defined as rise in blood glucose level due to failure of cell to respond to insulin properly or elevated blood pressure on repeated measurement which resulted to prevalence of both conditions in an individual.
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