RISK FACTORS ASSOCIATED WITH TYPE 2 DIABETES MELLITUS AT POS

PEMBINAAN TERPADU/INTEGRATED COACHING POST OF NCD

THROUGHOUT THE PROVINCE OF DKI JAKARTA
(Data Analysis Surveillance Risk Factors of NCD Based of Posbindu-
PTM/NCD Health Office of DKI Jakarta Province 2017)

ABSTRACT

DKI Jakarta Province includes the top ten national DM. Posbindu PTM/NCD as one of the government
programs in early detection and monitoring of NCD risk factors that is implemented in an
integrated, routine, and periodic. This study aims to determine the risk factors associated with type
2 DM in Posbindu PTM/NCD throughout the Province of DKI Jakarta. This study used cross-sectional
design from data of NCD Risk Factor Surveillance, Health Office of DKI Jakarta Province 2017. The
analyzed sample was 12,775 respondents. Multivariate data analysis used multiple logistic regression
tests to determine predictive models, dominant factors and potential impacts. The result of this
study showed that the proportion of diabetes mellitus was 15,87%. Multivariate was found to be ≥45
years old (POR = 6.32), 35-44 years (POR = 1.82), 25-34 years (POR = 0.98), sex (POR = 0.63), family
history of DM (POR = 4.43) married (POR = 0.49), divorce (POR = 1.58), not working (POR = 1.93),
housewife (POR = 1.84), students (POR = 0.24), less active (POR = 1.20), hypertension (POR = 1.35),
and central obesity (POR = 1.29). The most dominant factor is age ≥45 years and there is a DM
family history. Potential impact if all physical activity and no obesity can reduce respectively 7.75%
and 14.39% of the total number of DM cases. This is necessary to improve the quality of Posbindu
PTM/NCD implementation from the government and the ≥15-year-old Jakarta citizens awareness
for monitoring of risk factors and early detection of NCD.

KEYWORDS: Diabetes mellitus, DKI Jakarta, Posbindu PTM/NCD, prediction model, surveillance
data, risk factor

INTRODUCTION

Diabetes Mellitus (DM) is one non-communicable disease or also called chronic disease in which
people with diabetes can not control the blood glucose levels. The function of the pancreas gland in
a healthy body, easily release the hormone insulin in charge of transporting sugar through the blood
to the muscles and other tissues for energy supplies. [1] According to Delice (2003) in Nainggolan
(2013), based on the WHO diabetes prevalence map in 2003, Indonesia was ranked 4th highest in the
world after India, China and USA for DM cases. [2] The result of Riskesdas 2013, the prevalence of DM
diagnosed by doctors or symptoms of age ≥15 years of 6.9% which is the highest 10 prevalence in
Jakarta Capital City by 3.0%. From the results, it is estimated that only about 26.3% have been
diagnosed DM. This means that there are still many people who have not been netted in the
diagnosis and if not done early detection soon, patients who have not been diagnosed slowly will
occur serious complications, because that DM is called as one silent killer. [3]
Modern lifestyle is often found in urban areas. The condition of the DM picture in urban areas can
reflect the situation in DKI Jakarta as a metropolitan city with all modern lifestyles that can be one
of the risk factors causing the increase in DM. [4] In addition to lifestyle as a factor that can be
modified there are many other factors that play a role in disrupting the metabolism of the hormone
insulin in the blood. According to the Ministry of Health (2014), factors that also play a role affect
the body's metabolism, thus increasing the risk of DM that is not modifiable factors such as age,
gender and family history of DM. [3] In addition, socio-demographic factors such as marriage and work
also play a role in increasing the risk of DM disease.[5]
Long-term’s study (2015) that age more than 50 years had a 1.70 times greater risk of developing
DM disease compared to age less than 50 years. [6] Scott’s study (2014) that people with a family
history of DM had a 2.72 times greater risk of developing DM disease than those without a history of
DM.[7] Shan’s study (2018) that poor diet including less consumption of vegetables and fruits will
increase the risk of 1.64 times to experience the incidence of DM compared with the pattern then
the good.[8]
Feller’s study (2010) that people with obesity will increase the risk 3.62 times to experience DM
disease in men and 2.74 times to experience DM disease in women compared with people who are
not obese.[9] Cho’s study (2015) that people with hypertension increased the risk of 1.60 times more
likely to experience DM disease compared with non-hypertensive. [10] Carlsson's study (2007) that
people who did not exercise (less physical activity) would increase the risk of 2.03 times more likely
to develop diabetes than those who exercised.[11]
Papier’s study (2016) that smoking and alcohol consumption can increase the risk of 1.7 times
greater to experience the incidence of DM compared with not smoking and not consume alcohol. [12]
Long’s study (2015) that married people can prevent the risk of 0.65 times to experience the
incidence of DM disease, which means that for unmarried have a risk of 1.54 times to experience
the incidence of DM compared with the married. [6] Rautio's study (2017) that unemployed males
have a 2.58 times greater risk of developing DM events compared with unemployed ones, while
unemployed women have a 1.80 times greater risk of developing DM incidence compared with that
works.[13] Kalyani study (2014) mentions that in women have a chance 2.01 times to experience the
incidence of DM disease compared with men.[14]
In the effort of controlling NCD risk factors, empowerment and enhancement of the participation of
all elements of the community is needed to build a joint commitment through integrated post,
routine, and periodic. NCD number of Posbindu PTM/NCD active in DKI Jakarta Province during 2017
as much as 645 Posbindu PTM/NCD with division of Posbindu PTM/NCD per region that is Central
Jakarta Administration City 117 Posbindu PTM/NCD, North Jakarta Administration City as many as 79
Posbindu PTM/NCD, West Jakarta Administration City as many as 133 Posbindu PTM/NCD, City
Administration Jakarta South as much 123 Posbindu PTM/NCD, East Jakarta Administration City as
many as 185 Posbindu PTM/NCD, and Kepulauan Seribu District as many as 8 Posbindu PTM/NCD. [15]
Based on the above description it is necessary to determine risk factor research related to DM type
2 in Posbindu PTM/NCD in DKI Jakarta Province.

METHODS

This research is a quantitative analytic observation research with cross-sectional design. This study
uses secondary data of Risk Factors Surveilance of NCD DKI Jakarta Provincial Health Office 2017
based on data recording and reporting of Posbindu PTM/NCD. The study was conducted in May-June
2018. Population and sample of research can be seen in Figure 1.
Data source in this research is data of Risk Factor Surveillance of NCD DKI Jakarta Provincial Health
Office 2017 collected from recording and reporting per identity of Posbindu PTM/NCD participants
in DKI Jakarta Province in 2017. Visits from participants of Posbindu PTM/NCD for willingness of
participants to conduct examination in Posbindu PTM/NCD so it does not require the existence of
Informed Consent. Data analysis in this research is done through three stages, namely univariate
analysis, bivariate analysis and multivariate analysis.

RESULTS

Univariate Analysis

The univariate analysis showed the frequency of the variables related to the variable of the
research variables namely diabetes mellitus, age, gender, family DM history, marital status, job
status, lack of vegetable and fruit consumption, lack of physical activity, smokers, alcohol
consumption, central obesity, and hypertension. Here's the frequency distribution of each variables.
The result of univariate analysis on the outcome and predictor variables in table 1, from 12,775
respondents studied, showed that 15,87% suffer from diabetes mellitus. Most respondents were ≥45
years old (53.78%), women (65.83%), housewives (44.26%), and central obese (60.82%). Based on
bivariate analysis, it was found that there was a correlation between risk factors of age, gender,
family history of DM, marital status, occupational status, smokers, less of physical activity, alcohol
consumption, and central obesity with the incidence of type 2 diabetes mellitus.

Multivariate Analysis

Multivariate analysis was conducted to determine the predictor variables that affect the incidence
of diabetes mellitus. In multivariate analysis, statistical test of multiple logistic regression analysis
was used. The variables tested using multivariate model are variables which in bivariate analysis
have significance p value <0,25. [16,17,18] Candidate of predictor variables to be included in bivariate
selection and multivariate modeling stages obtained age, gender, family history, marital status,
working status, smokers, less of physical activity, alcohol consumption, hypertension, central oesity
and less consumption of vegetables and fruits which is the consumption of vegetables and fruits
although not statistically significant but still included because it is substantially related to diabetes
mellitus. After multivariate analysis, the final model prediction of age, gender, family DM, marital
status, working status, less of physical activity, hypertension, and central obesity were found. The
final model results can be seen in table 2.
Based on table 2 it is found that age ≥ 45 years and age 35-44 years have chances of 6.32 times each
(POR = 6.32, 95% CI 3.71-10.75) and 1.82 times (POR = 1.82; 95% CI 1.06-3.14) to have diabetes
mellitus compared to age 15-24 years, whereas the age of 25-34 years had a chance of 0.98 times
(POR = 0.98; 95% CI 0, 55-1,73) prevented the risk of developing diabetes mellitus versus the age of
15-24 years (protective effect), but based on 25-34 years old statistics were less significant for the
incidence of diabetes mellitus. Women have a probability of 0.63 times (POR = 0.63; 95% CI 0.53-
0.74) preventing the risk of developing diabetes mellitus compared to men.
People with a family history of DM have an odds of 4.43 times (POR = 4.43, 95% CI 3.95-4.98) more
at risk for developing diabetes mellitus than people without a family history of DM. An unmarried
person has a probability of 0.49 (POR = 0.49, 95% CI 0.31-0.76) preventing the risk of diabetes
mellitus compared with married persons, while divorced persons have a probability of 1.58 times
(POR = 1.58; 95% CI 1.27-1.96) are more at risk for developing diabetes mellitus compared to
married people. The unemployed and the housewife each had a probability of 1.93 and 1.84 times
(POR = 1.93; 95% CI 1.58-2.35; 1.84; 95% CI 1.57-2.5) are more at risk for developing diabetes
mellitus than those who work, while students have a 0.24 chance (POR = 0.24; 95% CI 0.09-0.66)
preventing the risk of diabetes mellitus compared with people working.
People who have less of physical activity have a chance of 1.20 times (POR = 1.20; 95% CI 1.08 to
1.33) are at higher risk of developing diabetes mellitus compared to people doing physical activity.
People who suffer from hypertension have a chance of 1.35 times (POR = 1.35, 95% CI 1.22-1.51) are
at increased risk of developing diabetes mellitus compared to people without hypertension. People
with central obesity have a chance of 1.29 times (POR = 1.29; 95% CI 1.13 to 1.46) are at risk for
developing diabetes mellitus compared with non-obese central ones. For the prediction model we
can see the probability score in figure 2.

Potential Impact

In addition to calculating the POR, it can be calculated the impact size. The impact size describes
the number of cases occurring as a result of exposure or can be prevented by exposure to the
original population.
Based on table 3 the magnitude of the impact seen from modifiable risk factors such as less of
physical activity and central obesity. EF% for less physical activity of 7.75%, meaning 7.75% of all
actual cases occur is always less physical activity or if all respondents do physical activity there will
be a reduction of 7.75% in total cases of diabetes mellitus. EF% for central obesity amounted to
14.39%, meaning 14.39% of all actual cases occurred were due to central obesity or if all
respondents had no central obesity there would be a 14.39% reduction in the total number of cases
of diabetes mellitus. Of the risk factors that have the greatest potential impact is central obesity.

DISCUSSION

The results of age study in line with the study of age and incidence of DM by Zahtamal, et al (2007)
found that age more than equal to 45 years had 6.45 times greater risk for DM disease compared
with age less than 45 years. [19] In addition, research on the age and incidence of DM by Long (2015)
found that age more than 50 years had a risk of 1.70 times greater for DM disease compared with
age less than 50 years.[6] At the age of 25-34 years obtained POR of 0.98 (95% CI, 0.55-1.73) which
means there is no significant relationship (close to the value of POR 1 and over the range CI 1) or
between both groups have an opportunity the same to increase or prevent risks. Increased
prevalence of DM is closely related to increasing age. Older adults are at high risk for type 2
diabetes mellitus because the combined effect of increased insulin resistance and impaired
pancreas allows aging. Age-related insulin resistance appears to be primarily associated with
adiposity, sarcopenia, and physical activity.[20]
In women, a shorter reproductive period is a marker to decrease endogenous estrogen exposure
over time. Estrogen helps keep insulin secretion and glucose homeostasis for the long term. Low
estrogen negatively affects the distribution of body fat and fat accumulation, an important
contributor to type 2 diabetes.[21]
The results of this study are inversely proportional to the research conducted by Allorerung, et al
(2016) which that in women have a 2.78 times greater chance to experience DM disease compared
with men.[22] Kalyani’s study (2014) that in women have a 2.01 times greater chance to experience
DM disease compared with men.[14] But this study is in line with research conducted by Nur (2016)
which states that men have 2.48 times more chance of having diabetes mellitus compared to
women.[23] Naveed Sattar, MD, PhD, in The Diabetes Council (2018) that men older than 40 years are
at a higher risk of developing diabetes because they store fat in their organs than women who store
fat mostly on the surface layer. Research shows that women have more fat found under the skin
than men.[24]
Family history plays a very important role in blessing the incidence of diabetes mellitus type 2, but
this is also influenced by environmental factors one of life style. Life style can affect the
development of type 2 DM. If someone with a family history of type 2 diabetes may be a little
difficult to identify whether it is caused by lifestyle factors followed by offspring or genetics.
Possible factors both play a role. Studies show that a person with a family history of type 2 diabetes
can be prevented by a healthy lifestyle. [25]
The results of this study are in line with the study by Zahtamal, et al (2007) on family history found
that people who have a family history of DM have a 3.75 times greater risk to experience DM disease
compared with people who do not have a family history of DM. [19] A study of family history and the
incidence of DM by Scott (2014) found that people with a family history of DM had a 2.72 times
greater risk of developing DM disease than people without a family history of DM. [7]
Marital status has the possibility of influence on one's style and eating patterns. [5] Some findings
suggest that single, divorced and widowed status is a potentially disastrous health effect. Marriage
can provide an atmosphere of affection for couples that release stress and thus reduce the
activation of the neuroendocrine system, which can lead to decreased development of
atherosclerosis and other pathological processes including DM risk.[26]
The results of this study are inversely proportional to the research of Li S, et al (2015) states that
unmarried and unmarried people have a 4.72 times chance of developing DM disease compared to
married people.[27] Long study (2015) states that married people can prevent the risk of 0.65 times
to experience DM disease, which means that for unmarried have a chance of 1.54 times to
experience the incidence of DM compared with married people. [6]
This is related to the age of respondents. Of the 10,414 married respondents, 60.92% were ≥45 years
old and most had diabetes mellitus. In addition, the proportion of married and divorced women by
66.76% and 85.84%, respectively, was compared with those who had not been married. This study is
in line with research Nuryanti (2014) mentioned that married women have a 3.24 times chance and
divorced people 5.34 times more likely to have diabetes mellitus compared with unmarried people.
[28]
Irawan's research (2010) states that married people have 1.72 times more chance of having
diabetes mellitus compared with unmarried people. [5] According to Nuryanti (2014), married and
divorced women have a greater chance of developing diabetes mellitus compared to unmarried
women. It is associated with age, psychological condition, lifestyle changes, and hormonal changes
in women with pregnancy, breastfeeding, and menopausal conditions. [28]
Physical inactivity accompanied by other lifestyle causes insulin resistance which will lead to
diabetes in those who have only a small capacity to increase insulin secretion. [29]
This result is in line with the Wandansari (2013) study mentioning people who are not exercising
(less physical activity) will increase the risk 3.28 times more likely to develop diabetes than those
who do physical activity.[30] Carlsson's study (2007) suggests that people with less physical activity
will increase their risk by 2.03 times more likely to develop diabetes than those who do physical
activity.[11]
This type of work is closely related to the physical activity that one performs. [31] A person's work
may affect his or her physical activity. Unemployed groups tend to be less physically active, so that
limbs do not move, this can increase the risk of DM disease This study is in line with the Palimbunga
TM’s study, et al (2016) mentioned that unemployed people have a 2.72 times greater risk of
developing DM than those who work.[32] Rautio’s study (2017) found that unemployed men had a 2.58
times greater risk of DM, whereas unemployed women had a 1.80 times greater risk of developing
DM than those who worked.[13] While students or students have a greater opportunity to prevent
diabetes mellitus, this is because the respondents of students or students who have diabetes
compared with no diabetes proportion is very small compared with the proportion of working with
diabetes than those who did not have diabetes that is equal to 0.45%.
According to Marewa (2015) high blood pressure (hypertension) is one factor that can cause damage
to beta cells and the occurrence of insulin resistance. [33] The results of this study are in line with the
research of Cho (2015) mentioned that people with hypertension increase the risk of 1.60 times
greater to experience DM disease.[10] Study of Zou Disha et al (2017) mentions that people with
hypertension will increase the risk of 1.61 more to experience DM disease. [34] Obesity can affect
insulin secretion in which excessive fat mass can cause metabolic disorders that can lead to type 2
diabetes.[29] The results of this study are in line with the study conducted by Trisnawati S, et al
(2013) found that people with central obesity will increase the risk of 5.19 times to experience DM
disease compared with people who are not obese central. [35] In addition, a study conducted by Feller
(2010) stomach found that people with central obesity will increase the risk 3.62 times to
experience DM disease in men and 2.74 times to experience DM disease. [9]

Prediction Model of Type 2 Diabetes Mellitus in Posbindu PTM/NCD throughout DKI Jakarta
Province

Based on the multivariate analysis, there were 2 types of diabetes mellitus predictors at Posbindu
PTM in DKI Jakarta Province. It is possible to predict a person's probability of developing type 2
diabetes mellitus, making it easier for health workers to screen people at risk of developing
diabetes without the need for complicated and expensive invasive examinations. After ROC analysis,
the value of AUC 78,6% with sensitivity level and specificity about 70%, which means moderate
accuracy so that this prediction model is good enough to predict diabetes mellitus with cut off point
to know the indicator of diabetes mellitus by 18%. The following application using scoring model of
this prediction can be seen in the following example in figure 2:
Mrs. N is a 38-year-old housewife, has a family history of DM, less of physical activity, is married and
has central obesity, so the probability Mrs. N to have diabetes mellitus are:

Total score = 0 + 1 + 1,2 + 3 + 3,5 + 7,1 + 10 = 25,8 = 26, probability of about 0.27 or 27%.

Through the calculation of scores, then the probability of a housewife to experience diabetes
mellitus is 27%. Based on cut off point, then Mrs. N has a high probability of having type 2 diabetes
mellitus and is advised to perform more accurate examination through blood glucose testing.

Potential Impact

Based on the magnitude of the impact of type 2 diabetes mellitus in Posbindu PTM/NCD in DKI
Jakarta Province after a multivariate analysis, it is known that modifiable risk factors that have the
greatest impact are central obesity. In central obesity, 14.39% of all cases that actually occur are
due to central obesity or if all respondents have no central obesity there will be a reduction of
14.39% in the total number of cases of diabetes mellitus. Nationally, the proportion of central
obesity is 26.6%.[36] While the proportion of central obesity in the Province of DKI Jakarta amounted
to 36.5%.[37] Obesity is considered the most important factor in the development of disease
metabolism.[38] Central obesity is fat like a barrel, belly bulge forward. Obesity is likely to arise
coronary heart disease, diabetes and stroke. Measurement of obesity is based on the size of waist
circumference. The increase in waist size, the greater the risk of causing insulin resistance resulting
in diabetes mellitus.[39]
The risk of obesity can be lowered if doing a healthy lifestyle, which is to diet regularly and
continuously to lose weight so as to achieve ideal weight. An easy diet is balanced, low-fiber and
fiber-rich foods, avoid drinking alcohol and regular exercise, which is related to physical activity. A
minimum of 30 minutes of walking each day will burn 150 calories and can lose 6-7 kilograms per
year.[39]

CONCLUSION

There is a relationship between age, gender, working status, marital status, family history of DM,
less of physical activity, central obesity, and hypertension with the incidence of type 2 diabetes
mellitus in Posbindu PTM/NCD in DKI Jakarta Province. The prediction model of incidence of type 2
diabetes mellitus in Posbindu PTM/NCD in DKI Jakarta Province with a minimum probability of 18%
to predict type 2 diabetes mellitus. The results of this study can provide input to the Provincial
Health Office of DKI Jakarta, especially NCD program implementers to improve the quality of the
implementation of Posbindu PTM/NCD participants, especially participants of Posbindu PTM/NCD
aged 15 years and over who have risk factors associated with diabetes mellitus, especially those
who are obese central can make healthy healthy diet with balanced meals and regular exercise and
visit Posbindu PTM/NCD nearest to obtain risk factor checking service.
AKNOWLEDGEMENT

We would like to thank Prof. DR. dr. Ratna Djuwita, MPH for her help on this study, Staffs of
Provincial DKI Jakarta Health Office for their help give me data of Risk Factor Surveillance of NCD in
Posbindu PTM/NCD.

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Table 1. Characteristics of Respondent Posbindu PTM/NCD DKI Jakarta Province in 2017

Variable Frequency
n=12.775 %
Outcome
Type 2 Diabetes Mellitus
Diabetes Mellitus 2,027 15.87
Non Diabetes Mellitus 10,748 84.13
Predictors
Ages
≥45 years old 6,870 53.78
35-44 years old 2,511 19.66
25-34 years old 1,707 13.36
15-24 years old 1,687 13.20
Gender
Woman 8,410 65.83
Man 4,365 34.17
History Family of T2DM
Yes 2.503 19.59
No 10.272 80.41
Marital Status
Not marriage 1.895 14.83
Divorce 466 3.65
Marriage 10.414 81.52
Working Status
Not Working 705 5.52
Housewife 5.654 44.26
Students 1.109 8.68
Working 5.307 41.54
Smoker
Yes 2.171 16.99
No 10.604 83.01
Less of Physical Activity
Yes 5.455 42.70
No 7.320 57.30
Less of vegetables and
fruits consumption
Yes 4.578 35.84
No 8.197 64.16
Alcohol Consumption
Yes 294 2,30
No 12.481 97,70
Hypertension
Yes 4.159 32,56
No 8.616 67,44
Central Obesity
Yes 7.770 60,82
No 5.005 39,18
Tabel 2. Multivariate Analysis Results Variable Predictors of Diabetes Mellitus Type 2 in
Posbindu PTM/NCD throughout DKI Jakarta Province 2017

P 95% CI for POR

Variables valu POR Lower Upper
e
Ages
≥45 years 0,000 6,32 3,71 10,75
35-44 years 0,031 1,82 1,06 3,14
25-34 years 0,941 0,98 0,55 1,73
15-24 years 1
Gender
Women 0,000 0,63 0,53 0,74
Men 1
History Family of T2 DM
Yes 0,000 4,43 3,95 4,98
No 1
Marital Status
Not marriage 0,002 0,49 0,31 0,76
Divorce 0,000 1,58 1,27 1,96
Marriage 1
Working Status
Not Working 0,000 1,93 1,58 2,35
Housewife 0,000 1,84 1,57 2,15
Students 0,006 0,24 0,09 0,66
Working 1
Less of Physical Activity
Yes 0,001 1,20 1,08 1,33
No 1
Hypertension
Yes 0,000 1,35 1,22 1,51
No 1
Central Obesity
Yes 0,000 1,29 1,13 1,46
No 1

Table 3. Result of Calculation of Diabetes Mellitus Type 2 Size at Posbindu PTM/NCD in DKI
Jakarta Province 2017

Variables POR p’ EF%

Less of Physical Activity 1,20 0,42 7,75
Central Obesity 1,29 0,58 14,39
 Target Population
(n=85,351)

Not checking blood sugar

(n=69,770)
Aged <15 years (n=154)
More than one visits (n=2,792)

Based Population
(n=12,789)

Exclusion
Pregnant (n=14)

Eligible Population
(n=12,775)

Figure 1 Flow of Sample Selection

Figure 2 Case of Probability of Type 2 Diabetes Mellitus in Posbindu PTM/NCD in DKI Jakarta
Province 2017 Using Probability Scoring
 

 
 
Resume of Review :
1. The subject of research on the title does not exist, patients (DM patients) or visitors in
general? Factor 2 DM Risko type is determined by the age. The older the risk is getting
higher. It is worth to describe how many visitors per group of diseases suffered. Special
analysis that suffers from type 2 DM.
2. Early detection or prevention programs, it is worth all visitors of the age > 40 years
3. Key risk factors: Age, DM's history in diversity, obesity, hypertension, physical activity,
while gender, marital status, work status in theory not as a risk factor
4. The narrative of all subtitles, such as background etc focus in DM type 2 only, write
complete with type 2 DM.
5. Catagory age groups and job statuses need to be simplified (3 categories) and bias into 2
categories adjusted to the analysis stage, considering this secondary Data needs expertise
in statistical analysis techniques.