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    Risk Factors For Diabetec

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    Akshat Archit

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    © All Rights Reserved
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    ‘Malaysian Journal of Pubtte Health Medicine 2001, Vol 1: 16:21 ORIGINAL ARTICN RISK FACTORS FOR DIABETIC NEPHROPATHY AMONG NON INSULIN DEPENDENT PATIENTS WHO ATTENDED CITY HALL'S STAFF CLINIC IN KUALA LUMPUR Umi Ahmad, Ma. Tdrle Mohd Nor & Osman Alt ABSTRACT Diabeses melinus and tes main complication, nephtopattys affects the econoitc wellbeing and quality of ife of tho sufferers ad the population. A matched case voniro! study wias conducted tn September 1999 to investigate the factors involved with nephropathy such as diabetic corral, smoking, ypertension, family history of esabetes ‘and diqbetic duration, Respondants were classified based on: the presence of microalbuminuria or macroalbuninurta. Seventy-b%0 pairs of case and control were studied. Duration of diabetes (p = 0.005), pravence of lethargy and weaksiess prior to diabetes diagnosis (p * 0.019), duration of smoking (p ~ 0.914), duration of kyperiension (2 0.000), systolic hypertension (p= 0.025), imcvntrolled dlabetes with poor HoAc level (p% 0.026) and lack of diabetes kerowiedge (p = 8.032) wore factors which rebuted significanily to nephropathy by wnivartate énalyis, in multvertate analysts, stole hyperianston (2 » 0.0015), lack of diabrias huowledge (p = 0.0197), presence of lethargy symptom tw = 0.0027), prolonged cabedte duration ¢p = 0.0301) cand higher body mats indices (p » 0.0213) were predictors to diabetic nephropathy. Key words : Diabetes mellitus (NIDDM), nephropathy, risk factors. INTRODUCTION Diabetes mellitus (NIDDM) kes become a major cluonic iion-commnnicable ditease in the world focluding Malaysia, is’ complications of maccovasculsr nud microvascular might affect the quality of life of the patients and drole. dependents, Proviaua sty showed that the cumulstive inckéence ‘of the albuminusia excretions arpoaget NIDDM. was 17% after having the dlabets for five yo ecideate Wit THOTERRE Yo. 3795 aor 10 years ad ‘67% afer 15 years’. ‘the. presence . of smiotoafoumimusia ean become a predictor to mortality dus to cardiovascular complications”. It has been used to catimate the rate of kidney failure anvongst the NIDDM patiant but foc SDDM patient, ‘thas been used we a prognostic fietor to predict ihe Kidney file i bg next 1520 years’ Hyperglycemia was known te ageravats slbuminarla Amouiget NIDDM. I: was foond that the Incteased in the fevel of HbAte will infuenved the proteinaria’®, However, it was shown that smoking anxng: fe dixbeticn all also influence the salbunineia and it corcelated well with the umber of cigarettes’, It was belioved that smoking nedvates ‘he clinical proteinuria’ however, Gall al (1997) disagrees” that smoking influenoed nephropathy sncong dlabeve patients, Hypertension ov the other 1 Deparment. of Connuaity Health, Faculty of Meatobje, UKM; Jalan Yeacoh Lauiff. Bander Tun Razek, Cherar, Kuala lainpur, 16 hand, was foutd es a promoter to the nephropathy, Among the IDDM, i was found that the ‘eghtopathy occurs after 10 yants of diabetic’, The objective of this study was to determine ‘the risk frctors. Tor neplropathy among dinbetics (NIDDM) attending staff clinic of City Hall, Kuala Lamput. MATERIALS AND. METHODS °F paRCmRiaKeN ive contol swéy was conducted ammng st6ff clic of City Hall, Kusls Lwmpur io September 1998. A total of 72-palts of sues and were selected, matched by age and 36%, The, NIDDM patienss were randomly chosén from ihe attendance list and HbA te test was cated out, They Were’ Insirucied to collect thelr extly morning wine te dsternine the presence of albuminuria, (urine ~aalp,was used to determine the sisorosfbuminwia atd inferoalbumiw kit for the microslbuwinuia), Pailents with tole]: albumin levels exccading 40 yo! was selected es cave, whist the nore! aecrmed as a contol, Urine Zul exemination and ‘alcrocopic’ examlnation (UFEME) seat was. then camtied ont among cases to exclude albimicutia duc to. urintry infeciioa, Patlents havog -writary infestion, IDDM, hennaturia, congestive heart iseace, past history of glonierulonephults aod kidney cancer were exchided from the sudy. ‘The dota was obteince ftom interviews using Pletésed questionnaire xt om patient's medical record, ‘The blood’ pressire maswremeats were sucaeured by using spbygmmumoontetet, The dagres ‘Malaysian Journal of Publie Health Medicine 2001, Vat. 1: 16-21 of disbetic Zontrol was measured by using HbAtc levels, which was tested in private laboratory and patients who exceeded 8%, was considered having Imcontrolied diabetes (DCCT Research Group,, 1993). Body mass index (BMI) vas ealvulsied by using formala of weight (kg) height (ir). Females having BML of more than 26 ka? and mele of more than 27 kg/m? were classified as overweight. Smokers were defined ‘es, patients who smoked more than 10 packs/year and ex-smokers, were patients who smoke before but has quittd recently. ‘The knowledge on the dict was measured by using series of questions end those who scored 32 out of 40 marks were considered knowledgeable. Statistical analysis was carried out by using ‘the SPSS program. For, dichotomous variables, the ‘Me Nemar 32st were carried out, Paired t-test was used to analyze quantative variables. Logistic regression test was used to assess, mmiple risk factors ‘Resuurs Sectodemography Out of 72 pairs, 54 pairs (75%) were maids and 18 5%). wer ‘females, ‘Table “1 shows the characteristics of the cases and controle. Theve was no significant difference between cases and controls in term of racial distribution, educational level, rusital status and monthly income. Duration of Diabetes Mellitus C1ses, have Touger duration of diabetes illness as compared to contto) group. The mean duration aniong cases wes, 79.5 + 58.0 months as compared to 565 48.8 manths among controls (paired test = 2.868, p= 0,005). The odds ratio for developing noplrapathy among patients who have had disbotes ‘for 5 years or more was 3 (95% confidence interval 1.33-6:16). It, vas found also that the duration of diabetes was’ sigaificantly correlated with blood lucost levels (= 0.216, p~ 0.009) ‘Table 1: Characteristics of eases and controls Description ‘Cases (%) ‘controls (%) x at Len ne72__palred-ttest Rice Malays 51 (70.8%) Al (56.9%) MB.951 1 0413 ‘Non Malays 21 (29.2%) 343.1%) ‘Aae(min years) ATAGS03 46.7025,55 Paved t test. TL O02 S658 duéation evel pron ‘Not schooling’ 4 (5.6%) 1 (2.8%) P= 7.748 3. 0,560 ks 26 aa 4dd-4%6)— 84) Secondary school 35 (48.6%) 33, (45.8%) i Universiy rq 3 (4%) Income 927.28 +, 5, 1008.60 Paired t test Th 0365 647.88 607.01, = 0,904. Marital status ; : : Maried 67,(93,0%) 66 (91.7%) a17243— 20,008" Widow 2 (28%) 228%) Bachelor 3 42K), 3, (5.556) Sigiificaan wtp 2008 Diabetés symptoms, significant_ symptom associated with diabetic. nephropathy where 1’ sng ™ 5.26, p= 0.019 (Table Potyuria was the misin eymptom amongel the oases and controls but there was no sigificent difference between the two groups.. Symptom of lethargy before being diagnosed as disbetic was found 1 be & 2), There were no other significant differences in, dlabetie symptom for thé two groups. “1 Malaysian Jowrat of Public Heolth Medicine 2001, Vol. 1: 16:21 ‘Table 2: Diabetic symptoms amongst eases and controls ‘Symptoms ‘Cases (%) + » Control (%) ihe P 51792) ~~ 50(70a) ii 0.189 surany——47 (652) oss 038 19(26.4) 8 (113) 5.26 0.019" Loosing weight 15(20.8) 16 (22.5) ° 1.000 5 3 cana did wot eopoare - Smoking ‘There was a significant difterence in the duration of smoking among the cases es compared to tie controls of which the duration of smoking. among, ceases was longer thea the comttols. However, there ‘was oo significant difference between cases, and contol in the amber of cigarettes and packsis of cigarettca’year snioked(Table 3). ypertexsion ‘There were 32 cases (44.4%) aud 23 controls GL9%) giving history of hypertension, — The duration of hypertension among the cases was 148 37 months as compared te 69 56 months among ‘controls (paired teat ~ 5.430, p< 0.05). There wes 2 significant telationship| between systolic hypertension end diabetic nepbropathy whore 3? mie 431, p = 0.038, however no similar result wes found for diastolic hypertension (Table 4). Diabetic control axl obesity ‘There was a significant relationship between HDALS levels and neptvopathy where 7? r91 = 497, p= 0.026. However, the body mass index (BMI) did not seem to influence nephropathy (x? ws = 0.026, p= 0.871) (Table 5). ‘able 3: Distetbution dt amoker among eases and controls ci — Car Xan! Categories Crsesio-72) Contras?) park eet P “Smoker 162.2%) BGO) — en O84 0359, Exeter 15 (208%) 15 (20.8%) Peo 1.000 Mean duration + 246.00287.43 ~ 173.62389.63 Paired t=2.688 0.014" smmoking (mnontbs) faayereeteer dey asti8s YB1oH44 Paired ™-0523. - 0.607 Smoking <10 7 packe/year end non 49 (68.1) 5576.4) omgker ; Vom l136 0.286 Stioking? 10 23 (319) 1703.6) fackslyear <7 $Signiifzant at p <0.05 ‘Malaysian Journal of Public Health Medicine 2001, Vol. 1: 16-21 ‘Table 4: Distribution of hypertension and treatment among case and control Categories Cases Control ae P (a7) {a~72) alred test Hiyparisnsion 32(44.4%) 83 GON) ai=2.06 0.181 ‘Min duration of 148 moms 60 months Paired ¢=5.430 0.000 hypertension Diasiolic hypericusion _ 22 persona 18 persons ei=3.56 0.059 Systolic hypertension 23 persons 11 persons tag 4.320.025" ¥ Significant at p S005 Table S:Distribuition of HbAte and obesity ~~ Categories Case (0) n=72 control Ca) n=72_—_ hug FP WibAie level : Good 1703.6) "30 (41.7) 497 | 00297 Pos (289) 55 (164) 42 (583) [Nutritional status ‘Normal 30 (41.7) 3244.4) 0026 o87t obese 42 (583) 40 (55.6) ‘significant at p 0.05 Factors associated with diabetic contro! of knowledge compated to controis (25.0%) where 2 oi 4.36, p= 0.037, : ‘The factors that influenced the diabetic controlled Logistic regression analysis was conducted to. ‘were investigated by using HbAYe levels. When the” predict tho developmen of nephropathy. All factors diabetic. controlled is poor, the risk of developing - significantly associated with ‘nephropathy: in nepliropathy will be high. Some of factors associated —~ anivariate enalysis was’ included im the logistic arith poor disbetic control are poor compliance to made, tn this sady,eystolis hypereeson, lack of the diabetic treatment, pose compliance.to follow up '” dietary knowledge, feeling lethargy prior to diabotes and lack of knowledge in’ dietary control. In this dingnsis, high body mass index and long duration study, the knowledge on diet was found to rae diabetic contributed significantly to risk of diabetic significant factor assoojated with: ne 7 ney ithy (Table 6) nays Has abo tat 43.136 oF ca “icker : ‘Table 6: Logistic regression model to prediet dlabetic nephropathy Vanni Regression Standard ‘OR Cles%) a _eeftictent (8) error z Tonsinae “a9 Ta6is ODOT Sysiolic hypertension 1.3362 0.4204 0.0015" 3.80 1,678.67, Lack of dict é ing 1.0216 a4ieo oo1g7# 2.78. 118-655 Lethargy sysiptom 1.6665 95563 0.0027" | 5.29 - 1,78 15.75 Body mass index _ 0.0989 (0.0930 0.023 1.10, 1.01 1.20 . ‘Duiation oF dlabetes, 0.0084, (10039. 0.0308, 1.01 1.01 ~ 1,02 © Significant arp 0.05 “The model vas developed from the logistic regression analysis ‘Odd of diabetes nephropathy = EXP [-4.7978 +0.0084 chiration of diabetes + 0.0989 body manss index + 1.6666 lethargy’ symptorn + 1.3362 systolic hyperterision + 1.0216 poor dietary knowledge} 7 . Malaysian Journal of Public Health Medicine 2001, Vol. 1: 16-21 Attribiite risk percent (ARP) and population attributable risk percent (PARP) Anwibute rik is a tisk difference between the ‘exposed individual and non-exposed individual. This risk comparison dcpicted the tsk due to exposure to the risk factor whilst PARP is the proportion of neplicopatiy cases inthe target population related t0 the presence of risk factors, (Table 7) Table 7 shows thet afer adjusting for the ote fctos, about 73% of the diabetic nephopetiy complication was aituted fo systolic hypertension, 0.9% to diabetic dumtions, 819% to sherry symptom prior diabetes diagnoses, 64% to poor dietary knowledge and 9% to increase of body mass index ‘Tablo-7: Attributable risk percent and population attributable risk percent to dlabetle nephropathy Proportion of vA Riskfectors “expose population ARF) crs) PON tm ‘Systolig a hyper sa 29.2 Bs 67-81. 45.0 37-33 Durntion of ae Duration 333 09 2-24 02-05-10 Presence of ee 110 a1 326 250-403 Poor diet ve 250 40 30a, 232-383 Body mass Baty 560 94 55 17292 PISCUSSION ‘me not significant afer contofting for other factors Diabetic nephripathy is one of the eoripication of diabetes selitu. It occurs more often and in mich shorter period ia NIDDM as compared to IDDM, ‘The prevece of microalbuminuria is to earlier sigh _-of apheapalln, i-indicate-the-possibility-of the fallen’ to develop the cardiovancular complication Inore than the kidaey ftiure Therefor, the NIDDM patients have higher sak of heart atack in the presence of miccosfbuminurin' This is diffecence fiom the IDDM patient, which is more towards developing the kidacy fallore with a, presence of ricrealbuminasist : Tn this sind, it was found that patents with nepheopatty shave Tonger diabetic history compared io the controls. Patient with: a longer diabetic duration (25 years) bas 3 times the risk of developing ephropathy complication as compared to the patints with shorter history of disbetes. The ‘sitnilar finding was reported in other studies Duration of diabetes was positively correlated with blood ghicose leveln ‘of which the, blood. glue levels (Iniicating. diabetes contro) increased with the increased ip tho: duration of diabetes, ‘These roland ,the relationship between duration, of ‘iabets nd fae nephropathy. It was.also shown that duration of smoking” wes significantly” longer ‘mong the cases as compared.to the contrals , However, the ‘difference 20 using logistic regression test, A. almiar result ins reported by Gal et al. (1997), however, Klein otal (1995)? has found the reverse, bit in his stody the fotal pack/ years used was mich higher, "The risk of nephropathy amoug patients with systetic-hypertension was 3 times compared (0 patients without hypertension but relatiouship wes fot found forthe diastolic hypertension (p = 0.523), ‘The findings wero found inconsistent” in the Terai, gone studies produced the sae rents 35 this one 2!" but others like Powic et ah, (1994)" the finding was different, The different in characteristics of samples as woll as degree, of albuminuria could possibly “explained: the inconsistency. ‘This study found that HbALe level of » 8% that indicates poor diabetic control was’ higher among the gases compared tothe conttas, 2° =4.96, P= 00026. OR = 7.63. (Clay 1.12 = 6.16), iil results were found in ether stadies **. The diabetic’ contol is influenced by various factors, hewever fn this study only poor compliance towards diabetic treatment, less compliarce to diabetic follow-up and poor knowledge on diabetic diet were studied, [tas found by. using raultivariate analysis. that: poor knowledge on diet has'a significant association with nephropathy afer controlling the otier factors, Other than thai systolic hyperteasiog, feeling of letherey, obesity aad duration of diabetic were also found ® Malawi Lournal of Public Health Medicine 2001, Vol ts 16-21 signiflont predictors. for a nephropathy in the logit regression model. “The taportanee dentifying fhotoro associated withthe development of nephropathy was co be able to prevent tho complication froma seting in. 1 can seo be use to at priority for effective vilisation of resources, Front this study fladings indicated that the incervention by reducing systolic hypertension aad increasing patiemt’s knowiedgs on dict will give + emendous impact aroand AS% and 31% reapectively 10 | the “nephropathy in the population, Farthennore, the peseace of lethargy. prior 1 diabetic diagnoses ‘od be used asa warning sig for the development of disbedc nephropathy among NIDDM patient hence. steps can be taken to svoid pauisots: fom eveloping premature nephropathy or even. subsequent moray, CONCLUSION Syaiolic hypertension, lethargy prtor to disbetie lognoses aud lack of disbetic dietary knowledge are factors that can predict the developticut of digbetic nephropathy, Therefore, auy progrimms performed to reduce the magnitude of diabetic nephropathy shoild focused on hypertencion contrat _ and increabed the patient knowledge on diabetic dict, REWERENCES

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