|Year : 2017 | Volume
| Issue : 3 | Page : 800-805
Undiagnosed diabetes among adult attendants of a rural primary healthcare center in Menoufia Governorate
Ahmed M Zahran1, Aml A Salama2, Asma S Beddah MSc 3
1 Department of Internal Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Family Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Family Medicine, Horeen Family Health Unit, Menoufia, Egypt
|Date of Submission||16-Sep-2016|
|Date of Acceptance||11-Dec-2016|
|Date of Web Publication||15-Nov-2017|
Asma S Beddah
Horeen, Bereket Elsabea, Menoufia 32917
Source of Support: None, Conflict of Interest: None
The present study aimed to estimate the prevalence of undiagnosed diabetes in adult attendants of a primary healthcare center in a rural area.
The prevalence of diabetes is rapidly increasing worldwide. T2DM may remain undetected for many years, leading to severe complications and healthcare costs.
Patients and methods
We carried out a cross-sectional study on 1255 cases, with a mean age of 38.9±11.16 years. All participants were subjected to history taking, complete medical examination, and laboratory investigations (measurement of fasting blood glucose level and 2-h postprandial blood glucose level). We then compared our findings between the diabetic group and the normal group.
The prevalence of undiagnosed diabetes in adults was 4.2%. Undiagnosed diabetes was significantly associated with age (P < 0.05), sex (P < 0.05), hypertension (P < 0.001), hyperlipidemia (P < 0.001), and smoking status (P < 0.05).
The prevalence of undiagnosed diabetes in adult attendants of the rural primary healthcare center was 4.2%.
Keywords: fasting blood glucose level, 2-h postprandial blood glucose level, prevalence, undiagnosed diabetes
|How to cite this article:|
Zahran AM, Salama AA, Beddah AS. Undiagnosed diabetes among adult attendants of a rural primary healthcare center in Menoufia Governorate. Menoufia Med J 2017;30:800-5
|How to cite this URL:|
Zahran AM, Salama AA, Beddah AS. Undiagnosed diabetes among adult attendants of a rural primary healthcare center in Menoufia Governorate. Menoufia Med J [serial online] 2017 [cited 2020 Jun 6];30:800-5. Available from: http://www.mmj.eg.net/text.asp?2017/30/3/800/218288
| Introduction|| |
Type 2 diabetes mellitus (T2DM) is a public health concern worldwide and an important cause of morbidity and mortality. Through lifelong vascular complications, diabetes mellitus (DM) leads to excessive rates of myocardial infarction, stroke, renal failure, blindness, and amputations. The projections of its future impact are alarming. According to the WHO , DM affects more than 170 million people worldwide, and this number will increase to 370 million by 2030.
T2DM results from dysfunction in insulin action and insulin secretion, either of which may be the predominant feature, and are usually present when the disease becomes clinically manifest .
By definition, specific causes are not known, and autoimmune destruction of the pancreas does not occur. T2DM is preceded by insulin resistance and impaired glucose tolerance (IGT). Once insulin resistance is pronounced, the likelihood of T2DM development depends on the ability of the β cells to compensate adequately by increasing insulin secretion. Thus, the disease is of insidious onset and may remain asymptomatic for many years. The true duration of the disease is often not known .
Some studies have reported that diabetes may be present for as long as 9–12 years before a clinical diagnosis. However, these estimates represent mean values only, and the asymptomatic period may vary widely. Studies on patients with newly diagnosed T2DM provide evidence of early diabetes-related tissue damage during the preclinical phase. In the United Kingdom Prospective Diabetes Study, 50% of newly diagnosed diabetes cases had evidence of diabetes-related complications . Patients with impaired glucose homeostasis are generally asymptomatic. Characteristics of related risk factors for cardiovascular disease may be present, even with a mild degree of hyperglycemia. They include a history of hypertension (HTN), obesity, dyslipidemia, and macrovascular disease, such as stroke, coronary disease, or peripheral vascular disease . Progression of prediabetes to diabetes may take many years, but may also be rapid. The incidence is the highest in individuals with combined impaired fasting glucose (IFG) and IGT and similar in those with isolated IFG or IGT. Family physicians have an opportunity to identify patients at high risk for developing diabetes and institute primary prevention strategies . It is because of these factors that DM is identified as a chronic illness that requires continuing medical care and ongoing patient self-management education and support to prevent acute complications and reduce the risk of long-term complications .
| Patients and Methods|| |
The present study was conducted during the period between the beginning of July 2015 and the end of June 2016 in a family health unit in a randomly selected rural area (Horeen) of Birkat Alsaba District, Menoufia Governorate. The present study was approved by the research Ethics committee of Menoufia University, and written informed consent was signed by each study participant. Adult attendants of the family heath unit in Horeen village during regular visits were the target population for this study. Randomization was performed by selecting every third case at the beginning of the working day (3 days in each unit). The study sample size was calculated on the basis of the lowest prevalence of undiagnosed diabetes from the literature, which was 2.5% according to Herman et al. , and the highest prevalence, which was 15% according to Al Osaimi and Al-Gelban . Sample size was calculated using Epi Info program (Epi Info, Atlanta, Georgia, USA) with 95% confidence interval (CI), depending on the total number of adult population in the selected rural area (Horeen Village of Birkat Alsaba District, Menoufia Governorate). Therefore, the calculated sample size was 1200 participants. However, considering dropouts or refusal to participate in the study, a total sample size of 1255 male and female individuals from the village, aged 20 years or older, was taken as the study sample.
Well-established diabetic patient, even controlled.
Each person of the study group was subjected to the following:
Personal and social history including age, sex, socioeconomic standard, educational level, occupation, income, number of individuals per room, type of housing, material possessions, etc., according to the study by El-Gillany et al.  were obtained.
Clinical history included history of HTN, hyperlipidemia, and smoking status.
Height (cm), weight (kg), and BMI were obtained according to American Diabetic Association.
Patients were classified as having normal body weight if their BMI ranged from 18.5 to less than 25, overweight if they had a BMI of 25–29.9, and obese if their BMI was more than or equal to 30.
Blood pressure (BP) measurement: HTN was identified according to the following criteria:
Participants were classified as normotensive if their systolic BP was less than 120 mmHg and diastolic BP was less than 80 mmHg; were classified as prehypertensive if their systolic BP was more than or equal to 120 and less than 140 mmHg and/or their diastolic BP was more than or equal to 80 and less than 90 mmHg; and as hypertensive if their BP was more than or equal to 140/90 mmHg .
- Fasting blood sugar levels
- 2-h postprandial glucose level.
Fasting blood glucose levels were calculated according to American Diabetic Association .
Patients with fasting blood glucose levels less than 100 mg/dl were classified as nondiabetic; patients with fasting blood glucose levels ranging from 100 to less than 126 mg/dl were classified as prediabetics (IFG); and patients with fasting blood glucose levels more than or equal to 126 mg/dl were classified as diabetic.
2-h postprandial glucose level values were calculated according to American Diabetic Association .
Patients with postprandial glucose levels less than 140 mg/dl were classified as nondiabetic; patients with postprandial glucose levels ranging from 140 to less than 200 mg/dl were classified as prediabetics (IGT); and patients with postprandial glucose levels more than or equal to 200 mg/dl were classified as diabetics.
Then the normal participants (which have normal glycemic level) compare to diabetic participants with exception of participants (which have IFG or IGT) regarding their clinical characters (age, sex, history of HTN, hyperlipidemia, smoking and BMI and measuring of BP).
Data were collected regarding patient history, basic clinical examination, and laboratory investigations, and outcome measures were coded. Coded data were entered into a computer using a database developed for data entry on Microsoft Office Excel program for Windows, 2007. Data entry took place on a daily basis at the end of each working day. Data were analyzed with the Statistical Package for the Social Sciences (SPSS) v.21 for Windows (IBM Inc., Chicago, IL). Simple frequencies were used for data checking. Quantitative data of normally distributed variables were expressed as mean ± SD.
Qualitative data were expressed as numbers and percentages and analyzed using the c2-test by determining the least significant difference between two groups. Level of significance was set at P value less than 0.05.
| Results|| |
This study included 1255 persons (581 male and 674 female). Patient characteristics are shown in [Table 1]. The mean age of the studied participants was 38.9 ± 11.16 years. The percentage of females in the studied group was 53.7%; 37.4% of the participants were university graduates; 53.9% of the participants were involved in trades/free business; 82.1% of the studied group were married; and 38.7% were from middle socioeconomic status. [Table 2] shows the distribution of the studied group according to their blood glucose levels. The prevalence of normal fasting blood glucose was 80.6% in the studied group; the total prevalence of undiagnosed diabetes was 4.2%; the prevalence of isolated IFG was 7.9% in the studied group; the prevalence of isolated IGT was 4.4%; and combined IFG and IGT was 2.9% [Figure 1] and [Figure 2].
|Table 2: Distribution of the studied groups according to their blood glucose levels|
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|Figure 1: Distribution of cases according to their blood glucose level. FBG, fasting blood glucose; PP, postprandial.|
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|Figure 2: Distribution of diabetic cases according to their blood pressure.|
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The total prevalence of undiagnosed diabetes was 4.2%, distributed as follows:
- 2.8% had diabetic fasting blood glucose levels (≥126 mg/dl) and diabetic 2-h postprandial blood glucose levels (≥200 mg/dl)
- 0.6% had normal fasting blood glucose levels (<100 mg/dl) and diabetic 2-h postprandial glucose levels (≥200 mg/dl)
- 0.3% had diabetic fasting blood glucose levels (≥126 mg/dl) and normal 2-h postprandial blood glucose level (<140 mg/dl)
- 0.5% had IFG levels (100–125 mg/dl) and diabetic 2-h postprandial glucose levels (≥200 mg/dl).
[Table 3] shows the comparison between normal and diabetic groups regarding their clinical characteristics.
|Table 3: Comparison of normal and diabetic groups regarding their clinical characters|
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Association between sex and diabetes
Regarding sex distribution, undiagnosed DM was found in 6.7% (n = 32/481) of males and 3.6% (n = 21/584) of females. There was a statistically significant relationship [P = 0.02; odds ratio (OR)= 0.523; 95% CI: 0.298–0.92] between sex distribution and diabetes.
Association between age and diabetes
In the age group older than 45 years, out of 426 study participants, 32 (7.5%) had undiagnosed diabetes. Among the less than 30 years age group, nine (2.8%) patients had diabetes. A total of 12 persons in the age group 30–45 years were found to be diabetic (3.8%). As age increased, the prevalence of undiagnosed diabetes increased. The association between age and undiagnosed diabetes was statistically significant (P = 0.007).
Association between history of hypertension and diabetes
Among 1065 participants, 108 patients were known hypertensives. Among these 108 patients, 19 (17.6%) patients were found to have undiagnosed diabetes. There was a statistically significant (P < 0.001; OR = 5.795; 95% CI: 3.174–8.582) association between known hypertensives and undiagnosed diabetes.
Association between blood pressure level and diabetes
Among 1065 participants, 70 patients were prehypertensive and 74 were hypertensive. Among the 70 prehypertensive patients, 10 (14.3%) were found to have undiagnosed diabetes, and among the 74 hypertensive patients 16 (21.6%) were found to have undiagnosed diabetes. There was a statistically significant (P < 0.001) association between BP level and undiagnosed diabetes.
Association between history of hyperlipidemia and diabetes
Among the 63 patients known to be hyperlipidemic, 15 (23.8%) patients were found to have undiagnosed diabetes. There was a statistically significant (P < 0.001; OR = 7.9; 95% CI: 3.174–8.582) association between known hyperlipidemia history and undiagnosed diabetes.
Association between smoking and diabetes
Among 256 smokers, 21 (8.2%) were found to have undiagnosed diabetes. There was a statistically significant (P = 0.006; OR = 0.461; 95% CI: 0.261–0.814) association between known smoking and undiagnosed diabetes.
Association between BMI and diabetes
Out of 486 obese patients, 31 (6.4%) were found to have undiagnosed diabetes; out of 444 overweight patients 18 (4%) were found to have undiagnosed diabetes; and out of 135 normal BMI patients only four (3%) were found to have undiagnosed diabetes. There was no statistically significant relationship (P = 0.262) between BMI and diabetes.
| Discussion|| |
This study was performed at the Family Health Unit in Horeen Village to study the prevalence of undiagnosed diabetes in adult attendants in this unit.
The total prevalence of undiagnosed diabetes was 4.2%. This result agreed with Weili et al. , who showed that the prevalence of undiagnosed diabetes was 4.2%. Dasappa et al.  showed that the prevalence of undiagnosed diabetes was 2.33%. Al Osaimi and Al-Gelban  showed that 15% of the diabetics was undiagnosed. Subramani et al.  showed that the prevalence of undiagnosed diabetes was 11.1%. Another study by Herman et al.  in a rural area in Greater Cairo provided prevalence figures of 2.5%.
The present study showed that the prevalence of isolated IFG was 7.9% of the studied group, the prevalence of isolated IGT was 4.4% of the studied group, and the prevalence of combined IFG and IGT was 2.9%.
The study by Hadaegh et al.  showed that the prevalences of isolated IFG, isolated IGT, and combined IFG/IGT were 8.7, 5.4, and 4.0% in men and 6.3, 7.6, and 4.5% in women, respectively. Another study by Karve and Hayward  showed that 19.4% had IFG only, 5.4% had IGT only, and 9.8% had both IFG and IGT.
In the present study, diabetes was slightly higher in males than in females with statistically significant differences with regard to sex and diabetes. Sinnott et al.  showed that undiagnosed diabetes was associated with sex, and the prevalence rate was higher in males (2.9%) than in females (1%). American Diabetes Association  showed that undiagnosed T2DM was higher in women than in men. Simmons et al.  showed that the age-standardized prevalence of undiagnosed diabetes was higher among men than women (6.5 vs. 4.2%).
This study revealed that diabetes statistically significantly increased with age of patients. It was more frequent in patients aged older than 45 years. This result is in agreement with Akter et al. , who showed that there was a positive association between older age and risk of diabetes. The risk was significantly higher in individuals aged 45–49 years and in those aged 55 years or older than in younger individuals aged 35–39 years. This may be attributed to senescent changes such as increased visceral adiposity, decreased lean mass, and reduced physical activity, all having a direct influence on insulin resistance development .
In the present study, clinical history showed that HTN represented 10.1% of the total study sample; however, when clinical examinations were carried out, fewer patients had abnormal BP, may be due to controlling with medications.
The present study showed statistically significant differences regarding history of HTN between groups. This constituted 35.8% of the diabetic group. This result is in agreement with Chiwanga et al. , who showed that HTN is significantly associated with diabetes.
The present study detected that there was a statistically significant difference between groups with regard to history of hyperlipidemia (P = 0.05), which was reported in 28.3% of the diabetic group. This result agreed with the study by Hadaegh et al. , who showed that undiagnosed diabetes is associated with hyperlipidemia [hypertriglyceridemia (P < 0.001) and low high-density lipoprotein cholesterol levels (P < 0.01)]. Bener et al.  showed that hyperlipidemia was significantly higher in diabetic adult Qatari population [triglyceride (P < 0.001), high-density lipoprotein (P = 0.003)].
The present study showed statistically significant differences between groups with regard to smoking, which was reported to be 39.6% of the diabetic group. This result agrees with a study conducted in Indonesia by Pramono et al. , who showed that smoking was significantly associated with undiagnosed DM (P < 0.5). Bener et al.  showed that smoking in adult Qatari population was the major contributor for diabetes disease. This result disagrees with Al Osaimi and Al-Gelban , who showed that only 10.9% of diabetics were smokers and there was no relationship between diabetes and smoking.
The present study used anthropometric measurements – that is, BMI – as indicators of obesity and found that obesity at a level of 30 kg/m2 or more was a risk factor for diabetes. Ministry of Health and Population and El-Zanaty and Associates  showed that the prevalence of obesity (BMI ≥30 kg/m2) was 48% among rural women and 25.1% among rural men. In addition, the prevalence of overweight (BMI ≥25 and <30 kg/m2) was 26.8% among rural women and 34.2% among rural men. However, the present study provides information about the increasing levels of obesity among rural populations, with a total prevalence of 45.6% and overweight of 41.7%. Bad eating habits and sedentary lifestyle may be major contributing factors for obesity. Javid et al.  showed that the prevalence of obesity (BMI >25 kg/m2) was 36.82% and was significantly associated with the presence of DM (P < 0.001).
| Conclusion|| |
The prevalence of diabetes is increasing in our region as well as in our country and the world. The prevalence of undiagnosed diabetes in adult attendants of a primary healthcare center in a rural area (Horeen Village of Birkat Alsaba District, Menoufia Governorate) was 4.2%. Newly diagnosed diabetic patients who are unaware of their status are at high risk. To control DM and associated risk factors, effective public health education, a well-balanced diet, and increased physical activity are needed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Haring HU. Pathogenesis of type II diabetes: are there common causes for insulin resistance and secretion failure? Exp Clin Endocrinol Diabetes 1999; 107
Harris M, Klein R, Welborn T, Knuiman M. Onset of NIDDM occurs at least 4–7 years before clinical diagnosis. Diabetes Care 1992; 15
Echouffo-Tcheugui JB, Ali MK, Griffin SJ, Narayan KV. Screening for type 2 diabetes and dysglycemia. Epidemiol Rev 2011; 33
Aroda VR, Ratner R. Approach to the patient with prediabetes. J Clin Endocrinol Metab 2008; 93
Capes S, Anand S. What is type 2 diabetes? In: Gerstein HC, Haynes RB, editors Evidence based diabetes care
. Hamilton, ON: Decker Publishing; 2001:151–163.
Abou El-Ella SS, Tawfik MA, Hewait SA. Early detection of diabetes mellitus in high-risk children. Menoufia Med J 2014; 27
Herman WH, Aubert RE, Ali MA, Sous ES, Badran A. Diabetes mellitus in Egypt: risk factors, prevalence and future burden. East Mediterr Health J 1997; 3
Al Osaimi SM, Al-Gelban KS. Diabetes mellitus – Prevalence and associated cardiovascular risk factors in a Saudi suburban community. Biomed Res 2007; 18
El-Gillany A, El-Wehady A, El-Wasify M. Updating and validation of the socioeconomic status scale for health research in Egypt. East Mediterr Health J 2012; 18
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, et al.
The Seventh Report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. JAMA 2003; 289:2560–2572.
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2014; 37
Xu W, Xu Z, Jia J, Xie Y, Wang HX, Qi X. Detection of prediabetes and undiagnosed type 2 diabetes: a large population-based study. Can J Diabetes 2012; 36
Dasappa H, Fathima FN, Prabhakar R, Sar S. Prevalence of diabetes and pre-diabetes and assessments of their risk factors in urban slums of Bangalore. J Family Med Prim Care 2015; 4
Subramani R, Devi U, Shankar U, Rama, Rajalakshmi, Seshadhri G and Karthick. Prevalence of undiagnosed type 2 diabetes and its associated risk factors in rural population of Tamil Nadu. World J Med Sci 2014; 11:222–227.
Hadaegh F, Bozorgmanesh MR, Ghasemi A, Harati H, Saadat N, Azizi F. High prevalence of undiagnosed diabetes and abnormal glucose tolerance in the Iranian urban population: Tehran Lipid and Glucose Study. BMC Public Health 2008; 8
Karve A, Hayward RA. Prevalence, diagnosis, and treatment of impaired fasting glucose and impaired glucose tolerance in nondiabetic U.S. adults. Diabetes Care 2010; 33
Sinnott M, Kinsley BT, Jackson AD, Walsh C, O'Grady T, Nolan JJ, et al.
Fasting plasma glucose as initial screening for diabetes and prediabetes in Irish Adults: the Diabetes Mellitus and Vascular Health Initiative (DMVHI). PLoS One 2015; 10
Simmons D, Rush E, Crook N. Prevalence of undiagnosed diabetes, impaired glucose tolerance, and impaired fasting glucose among Māori in Te Wai o Rona: Diabetes Prevention Strategy David Simmons. N
Z Med J 2009; 122
Akter S, Rahman MM, Abe SK, Sultana P. Prevalence of diabetes and prediabetes and their risk factors among Bangladeshi adults: a nationwide survey. Bull World Health Organ 2014; 92:204–213A.
Atkins JL, Whincup PH, Morris RW, Wannamethee SG. Low muscle mass in older men: the role of lifestyle, diet and cardiovascular risk factors. J Nutr Health Aging 2014; 18
Chiwanga FS, Njelekela MA, Diamond MB, Bajunirwe F, Guwatudde D, Nankya-Mutyoba J, et al.
Urban and rural prevalence of diabetes and pre-diabetes and risk factors associated with diabetes in Tanzania and Uganda. Glob Health Action 2016; 9
Bener A, Zirie M, Janahi IM, Al-Hamaq AO, Musallam M, Wareham NJ. Prevalence of diagnosed and undiagnosed diabetes mellitus and its risk factors in a population-based study of Qatar. Diabetes Res Clin Pract 2009; 84
Pramono LA, Setiati S, Soewondo P, Subekti I, Adisasmita A, Kodim N, et al.
Prevalence and predictors of undiagnosed diabetes mellitus in Indonesia. Acta Med Indones 2010; 42
El-Zanaty and Associates. The DHS Program ICF International. Rockville, Maryland, USA. Cairo, Egypt: Egypt Health Issues Survey (EHIS); Ministry of Health and Population, Egypt, 2015.
Javid A, Masoodi MA, Ashraf A, Rashid R, Ahmad R, Ahmad A, et al.
Prevalence of diabetes mellitus and its associated risk factors in age group of 20 years and above in Kashmir, India. Al Ameen J Med Sci 2011; 4
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]