Complications of type 2 diabetes mellitus in Ramallah and al-Bireh: The Palestinian Diabetes Complications and Control Study (PDCCS)

Highlights

• Persons with type 2 diabetes in 11 primary health care clinics were sampled.

• Over three-quarters of the participants had at least one complication.

• 67% had at least one microvascular and 29% had at least 1 macrovascular complication.

• Around one fifth of the participants had good glycemic control (HbA1c < 7.0%).

• 89% had high blood pressure or were on anti-hypertensive medications.

Abstract

Background

Type 2 diabetes mellitus (T2DM) is a growing pandemic that will lead, if not managed and controlled, to frequent complications, poor quality of life, and high rates of disability and death. Little is known about T2DM complications in Palestine. The aim of this study is to estimate the prevalence of T2DM complications in Ramallah and al-Bireh governorate of Palestine.

Methods

The study was conducted in eleven primary healthcare clinics offering services for persons with T2DM. Macrovascular complications were assessed using the Diabetes complication index. Microvascular complications were measured by physical examinations and laboratory tests. Questionnaires, laboratory tests, and physical examinations were used to assess socio-demographic characteristics, co-morbidities and other risk factors.

Results

517 adult men and nonpregnant women participated in the study (166 men, 351 women). The response rate was 84%. Mean age and mean duration of diabetes were 58.1 and 9.4 years respectively. Prevalence of diagnosed microvascular and macrovascular complications was 67.2% and 28.6% respectively. 78.2% of the participants had poor glycemic control (HbA1c ≥ 7.0%).

Conclusion

Significant proportions of persons with T2DM had macro- and microvascular complications and poor metabolic control. These findings are important for policy development and the planning of health services.

Introduction

In 2014, 422 million people aged 18 years and above were living with diabetes worldwide. This accounts for 8.5% of the world’s population. Prevalence was highest in the Eastern Mediterranean region (EMR) increasing from 5.9% (6 million) in 1980 to 13.7% (43 million) in 2014. Of diabetes-related deaths, 43% occurred before the age of 70, with the highest proportion occurring in low- and middle-income countries (LMIC) [1].

Diabetes is a chronic disease; if not detected, managed and controlled it may lead to disability, poor quality of life and a high mortality burden [2], [3]. Diabetes is considered the 7th leading cause of disability worldwide and accounts for more than 2 million deaths annually [4]. Age-standardized mortality rates reach up to 140 per 100,000 population in the EMR region [1]. Diabetes complications can be microvascular including neuropathy, nephropathy, and retinopathy, or macrovascular including coronary artery disease (CAD), cerebrovascular disease (CVA) and peripheral vascular disease (PVD) [5], [6]. Type 2 diabetes mellitus (T2DM) is the leading cause of retinopathy, lower limb amputation and end-stage renal diseases (ESRD), and almost half of persons with T2DM die from cardiovascular complications [6]. Furthermore, diabetes and its complications exert a large economic burden on health systems, persons with diabetes, and their families. This cost can be direct medical expenditures, or indirect through disability and premature death [1], [4]. A recent systematic review estimated the global economic burden of diabetes and its complications to be US$ 825 billion, more than 60% of these costs bared in LMIC [4].

The majority of T2DM complications studies come from high-income countries and results vary greatly between countries [1]. In Palestine, previous studies have shown a high burden of T2DM. Diabetes prevalence in the West Bank was 10% in 2000 and 15% in 2010 and projected to reach 20.8% in 2020 and 23.4% in 2030 [7]. In 2015, diabetes was the fifth leading cause of death [8]. Despite this high burden in Palestine, little is known about diabetes mellitus complications and its determinants. A review published in The Lancet in 2009 indicated the scarcity of data on complications of diabetes in Palestine [9]. In a recent study conducted in the southern part of the West Bank, relatively high levels of T2DM complications were reported (39% for microvascular complications and 16% for microvascular complications) [10].

It is important to identify the burden of T2DM complications and understand their associated factors to contribute to the policy and decision-making process regarding the prevention, management, and control. The aim of this study is to identify the burden and patterns of diabetes complications among persons with T2DM in Ramallah and al-Bireh governorate of Palestine.