CHAPTER ONE
1.1 INTRODUCTION
Obesity and type 2 diabetes (diabetes) are important non-communicable health challenges whose magnitude is increasing worldwide. Non–communicable disease (NCD) is a medical condition or disease that is non-transmissible among people
. When compared with the year 2000, it is projected that there will be about 157% increase in prevalence of diabetes by the year 2030 in developing countries, namely: Middle Eastern crescent, sub-Saharan Africa and India
. The number of people with diabetes is increasing in every country
. The highest numbers of undiagnosed cases of diabetics are found in Africans, about 80%. Some of the reasons fuelling this crisis include: most are asymptomatic or with mild symptoms, poverty and poor health insurance coverage which is mainly for government workers
. Type 2 diabetes is associated with many preventable risks and causative factors, such as obesity, hypertension 4, 5, 6 , dyslipidaemia, poor diet, physical inactivity 4,7,8,9 or irregular exercise
, increasing age
and family history of diabetes
. Risk factors are factors whose presence is associated with an increased probability that the disease will develop later. Some are amenable to change (modifiable), while others are immutable (non-modifiable)
. Globally, diabetes was the cause of 1.5 million deaths in 2012
.
1.2 DEFINITION OF TERMS
1. Diabetes: Subjects were diagnosed based on random blood glucose (RBG) of 200mg/dl(11.1mmol/L) or more who had symptoms of diabetes. Diagnosis was also based on being a known diabetic and/or current use of anti-diabetic medication(s).
Subjects were grouped into normoglycaemia, impaired glucose and diabetes based on result of RBG. Normoglycaemia - < 140mg/dl (7.7mmol/l) Impaired - 140-199mg/dl (7.7-11.0mmol/l) Diabetes - ≥ 200mg/dl (≥11.1mmol/l) 2. Hypertension: Hypertension was defined as blood pressure ≥ 140mmHg systolic (SBP) and/or ≥ 90mmHg diastolic (DBP). It was also defined as history of a known hypertensive and/or current use of antihypertensive medication(s). The blood pressure was classified using Joint National Committee on Prevention, Detection, Evaluation and Treatment of high blood pressure JNC 7 report guideline
. For easy analysis, subjects were grouped into normotensive, SBP < 140mmHg and DBP < 90mmHg; and hypertensive, SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg or history of being a known hypertensive, and/or a current use of antihypertensive medication(s). 3. Known diabetes: Known diabetes was referred to as having a previous diagnosis of diabetes before the study. This implies that the subject has been previously informed by a medical professional of his or her diabetic status. 4. Obesity: Based on body mass index (BMI): BMI ≥ 30.0 kg/m
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. It was further categorized into Class I (mild) = 30.0- 34.9kg / m
Class II (moderate) = 35.0 – 39.9kg / m
Class III (Severe) = ≥ 40.0kg / m
5. Abdominal obesity: Normal abdominal waist circumference (WC) for women. WC < 80cm, while abnormal WC (abdominal obesity) for women WC ≥ 80cm. Normal WC for men was WC < 94cm, while abnormal WC for men WC ≥ 94cm
.
6. The family history of risk factor of diabetes was captured as Yes or No for presence or absence of type 2 diabetes in the subject’s family and was assessed in terms of degree of relationship. First degree: Affecting subject’s siblings Second degree: Affecting subject’s parents, uncles and aunties Third degree: Affecting subject’s grandparents and cousins. 7. Alcohol consumption: Was assessed on whether subject had ever consumed alcohol or not. Those who had ever consumed alcohol were further graded as moderate or heavy drinkers based on units of alcohol consumed in a week. One unit of alcohol equals 10mls or 8g of pure alcohol. This is about the amount of alcohol the average adult can process in one hour
. Units of alcohol consumed were calculated by multiplying the alcohol by volume (ABV), also known as percentage of alcohol of the brand (Appendix I) consumed by the volume in milliliter (ml) of the amount of alcohol consumed and divided by one thousand. Units of alcohol = ABV × Volume (ml)
Moderate intake < 21 units/week for men < 15 units/week for women Heavy intake ≥ 21 units/week for men ≥ 15 units/week for women 8. Tobacco use: It was assessed based on whether subjects had ever smoked cigarette or not. Cigarette smoking was assessed using smoking index = number of sticks smoked/day x number of years smoked. Where by >300 was significant.
9. Physical activity: It was assessed and coded based on the subject’s type of occupation and involvement in sporting or recreational activity regularly
. Physically active: Manual labourer, artisans, farmers, and apprentice. Moderate active: Traders, house workers or nanny, students, corpers, seamstress/tailor. Physically inactive: Office workers, unemployed, drivers and retirees. Physically inactive + recreational activity or exercise regularly = moderately active Moderately active + recreational activity or exercise regularly = physically active. For analysis, subjects were grouped into physically active and physically inactive (this include moderately active and physically inactive).
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1.3 STATEMENT OF PROBLEM `
There has been tremendous increase in the number of people who are obese suffering from such obesity-related morbidity as diabetes worldwide
. The situation in Abakaliki, Ebonyi State seems not to be different as the number seen in General out-Patient Clinic (GOPC) of Federal Teaching Hospital Abakaliki (FETHA), seems to be on the increase. This may be due to adoption of western lifestyle such as eating more of high energy rich foods, saturated fats following the proliferation of fast food shops and sedentary lifestyle. Obesity increases the risks of developing a number of health conditions, whose consequences occur with greater magnitude among obese subjects. The most important of these health conditions include type 2 diabetes, hypertension and dyslipidaemia
. Surprisingly due to lack of education, most of these obese subjects do not understand their condition and the risk they are exposed to. Unfortunately, most of these obese groups seem to indulge in lifestyle and behaviours that endanger their lives
. These include sedentary
lifestyle, eating more high energy foods and saturated fats, smoking and heavy alcohol consumption. There are many complications associated with diabetes that are difficult to manage and sometimes result in significant number of deaths and impairment of quality of life, both for the patient and the care giver
.
1.4 JUSTIFICATION OF THE STUDY
Obesity is associated with increased risk of cardiometabolic diseases such as diabetes. When obesity and diabetes co-exist, the risk of cardiovascular disease is increased
. Most of the studies on this subject were community based study. Hospital based studies were scarce to the best knowledge of the author. Since type 2 diabetes plays a major role in the development of cardiovascular morbidity and mortality in obese subjects, it is essential that this group should be screened for diabetes and other co-morbidities such as hypertension. Lifestyle modification should be instituted, so as to prolong or prevent development of diabetes for those who are at impaired glucose tolerance stage and complications in those who are diabetic 15, 16, 17,18,19,20 . This study established the prevalence of diabetes in Abakaliki, the prevalence of known type 2 diabetes and association of risk factors of diabetes with diabetes, among the study population, hence has provided information on the burden of obesity related diabetes. It highlighted the importance of family physicians using every encounter with the obese patients as an opportunity to counsel, screen and control diabetes among them. This study bridges the gap of studies and data on this subject within Abakaliki and Ebonyi State by providing needed information.
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The information provided by this study, will help family physicians, health professionals and healthcare managers in the formulation and implementation of strategies for health preventive and health promotive care.
1.5 RESEARCH QUESTION: 1) Is there significant difference between the magnitude of type 2 diabetes in the obese and the non-obese? 2) Is there significant association between diabetes and its associated risk factors in the study population?
1.6 AIM AND OBJECTIVES
1.6.1 AIM: To determine the magnitude of type 2 diabetes and its associated risk factors among obese adult patients attending GOPC, FETH Abakaliki, Ebonyi State, with a view to reducing the burden of the disease through advocating for lifestyle modification and screening of the obese.
1.6.2 OBJECTIVES
1. To determine the prevalence of type 2 diabetes among the obese and the non- obese subjects. 2. To determine the prevalence of known type 2 diabetics among the obese and the non-obese groups. 3. To assess the modifiable (waist circumference, cigarette smoking, alcohol consumption, physical activity) and non-modifiable (age, sex, and family history of diabetes) risk factors among the study population. 4. To correlate the body mass index, waist circumference, age, units of alcohol consumed and smoking index with random blood glucose.
1.7 RESEARCH HYPOTHESIS:
The null: There is no significant difference between magnitude of type 2 diabetes and its associated risk factors in the obese and in the non-obese. The alternative: There is significant difference between magnitude of type 2 diabetes and its associated risk factors in the obese and in the non-obese. Test statistics such as Fisher’s exact test, Chi-square test and t-test will be used to test for significance. P-value less than 0.05 will result in rejecting the null hypotheses.
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