Profiles and Drivers of Complications from Diabetesamongst Diabetes Patients in Cameroon: CrossSectional Study

Background: Diabetes prevalence is increasing throughout the whole world. Urbanisation is associated with change in diet patterns, increase physical inactivity and sedentary behaviour and increasing prevalence of obesity and Type 2 Diabetes. The prevalence of undiagnosed diabetes in Africa is >60% and prevalence of diabetes will increase to 35 million in the next 20 years. Late diagnosis and under-resourced health systems will lead to increase in complications. Methods: Data was collected from patient hospital records and structured questionnaires administered to 723 consented diabetes patients on routine consultation. Descriptive statistics were used to give the frequencies of profiles of complications. The outcome variable was the existence of complication(s) from diabetes (retinopathy, nephropathy, neuropathy, diabetic foot and cardiovascular accident) as recorded in patient records ascertained from laboratory diagnosis. Multivariable logistic regression model was used to identify statistically significant (p<0.05) drivers of complications from diabetes. Results: More than two thirds (72.1%) of the patients had a diabetes complication. The majority of patients aged ≥ 40 years (93.8%), on medication (79.1%), had unstable glycemia (68.3%), living with diabetes for ≥ 21 years (48.4%), and overweight (37.4%), obese (34%), hypertensive (43.6%), advised to stop smoking (47.6%), recommended following a low fat and weight loss diet (64.5%) and to control blood sugar (97.3%) had complications. Having diabetes for6–10 years (AOR:0.47, CI:0.20-0.69, p=0.013) & for ≥ 21 years (AOR:2.98, CI:1.89-4.69, p<0.001), obese (AOR:1.81, CI:1.12-2.92, p=0.037), hypertensive (AOR:1.49, CI:1.02-2.19, p=0.040), “sometimes” had a hard time doing what health provider suggested (AOR:2.05, CI:1.26-3.36, p=0.004), “sometimes” and “most of the time” in the past 4 weeks was able to do what the doctor said (AOR:2.66, CI:1.39-5.06, p=0.003; & AOR:2.71, CI:1.70-5.29, p=0.003 respectively), and “Yes” recommended to follow a low fat and weight loss diet (AOR:2.16, CI:1.41-3.31, p<0.001) were drivers of complications from diabetes after controlling for gender and age. Conclusion: The majority of diabetes patients had atleastone complication. Obesity, hypertension, living with diabetes ≥ 21 years, difficulty adhering to medical advice was drivers of complications from diabetes. This research is critical to understand where interventions may be most effective for diabetes prevention and management.


Background
Diabetes is an important public health problem worldwide.It is a burden to health and economic systems all over the world particularly in Low and Middle Income Countries (LMIC).Diabetes is responsible for major contemporary causes of morbidity and mortality.Diabetes patients are at risk of disabling and life-threatening health problems including infections.Apart from cardiovascular disease (CVD), nephropathy, neuropathy and amputation diabetes also causes other complications like visual impairment such as diabetic retinopathy [1].The increase in the prevalence of diabetes and better management coupled with increase life expectancies implies future increases in the rates of complications.More so, diabetes is preceded by a symptomless phase [2,3] and diagnosis more often than not intervenes at the latter stages of the disease when complications have set in.About 50% to 75% of adults with diabetes are unaware of their conditions and undiagnosed in LMIC and already have complications [1][2][3].Diabetes complications affect many parts of the body and are major cause of disability, productivity loss, reduced quality of life, mortality and greater use of health services.Common long term complications from diabetes include damage to large blood vessels of the heart, brain and legs (macrovascular complications) and damage to small blood vessels leading to eye, kidney, feet and nerves problems (microvascular complications).The digestive system, skin, sexual organs, teeth and gums and the immune systems are also affected by diabetes [1][2][3].In Cameroon, prevalence of diabetic retinopathy was 42% in a reference centre in Yaoundé [4].The incidence of diabetes complications is linked to poor management of blood glucose, duration of disease and existence of cardiovascular risk factors [5][6][7][8].Many patients ISSN 2380-548X Open Access 2 remain unscreened for complications due to low referrals, socioeconomic factors and lack of awareness [9].Type 2 diabetes patients more often are affected by other diseases rendering management of the condition, patient education ineffective and deleterious.Increase in other ailments is associated to increase knowledge of disease and greater uptake of health services [10,11].Diabetic patients also have other pathologies [12,13].Complications from diabetes continue to rise though they can be avoided or delayed by effective management entailing control of risk factors of the complications and implementation of screening strategies [1].Though complications due to diabetes are not rare, no guidelines and standards have been set to diagnose and assess complications.Estimates of complications from diabetes are hardly compiled due to scarcity of data [3].The focus of this article is to determine the profiles of diabetic patients and determine drivers of the complications from diabetes among outpatients.

Setting and study population
Data was collected by 11 researchers from 12 June to 10 September 2012 during the evaluation phase of the project "Prevention and treatment of diabetic retinopathy in Cameroon" in the towns of Yaoundé and Bamenda.Consented diabetes patients coming for routine consultation in the diabetes clinics and those referred to project sites (Yaoundé Central Hospital and Bamenda Regional Hospital) for further investigation on the diabetes retinopathy were contacted.Non-diabetes patients were excluded from the study.Patients living with diabetes for the last 12 months and being followed up in a diabetes clinic were included in the study.

Procedures
Participants were randomly selected from patients attending routine check-up and consultation for diabetes and complications at diabetes clinics.The study was explained to the each patient by a researcher.Patients who agreed to partake in the study provided consent by signing or thumb-printing a consent form.Data on patient health such as medical tests, diagnosis and medication being taken as prescribed by the doctor were collected from patients' medical records.A structured questionnaire explored socio-demographic parameters, knowledge about the project, causes of diabetes, complications and associated pathologies, management of diabetes (diet, physical exercise, medication, insulin, eye examination, angiography and laser photocoagulation and costs), adherence to medical advice, medical recommendations, medical history, attendance of health education talks, familiarity with posters, handouts, flyers and the messages on diabetes and knowledge, practices, attitudes and beliefs on diabetes.Questions pertaining to adherence to medical advice were; One response was chosen from: "none of the time", "sometimes" or "most of the time".

5.
Advised to stop smoking 6. Recommended to follow a low fat and weight loss diet 7. Recommended to control blood sugar with response being either "Yes" or "No"

Data management and analysis
Data was entered in Epi Info platform and analysed with STATA 13 SE (StataCorp.2012,College Station, TX: Stata Corp LP).Mean and standard deviations were computed.Pearson χ² were calculated at statistical significance of p<0.05.The outcome variable was the existence of complication(s) from diabetes (retinopathy, nephropathy, neuropathy, diabetic foot and CVD) as ascertained from hospital records.The exposure variable were socio-demographic and health variables and adherence to medical advice.Univariate analysis identified variables at p<0.05 which were fitted in a multivariable logistic regression model to determine statistically significant independent variables of complications from diabetes.A sample size of 700 was sufficient to detect an effect size (Cohen f2) of 0.02 corresponding to a R2 as low as 0.0196 for a multivariable model which could further be stratified by sex.

Ethical issues
Ethical clearance was obtained from the National Ethics Committee of Cameroon and the Cameroon Baptist Convention (CBC) Health Board Institutional Review Board (IRB).All participants who accepted to take part in the survey gave written informed consent.Data obtained was codified, kept confidential and analysed anonymously.

Role of the funding partner
The sponsor played no role in the study design, data collection, analysis and interpretation or in writing this article.

Profile of diabetes patients with complications
More than two thirds (72.1%) of the participants had a diabetes complication.Prevalence of complications was: diabetic foot (24.6%), diabetic retinopathy (21.2%), neuropathy (7.2%), nephropathy 3.9%, and cardiovascular accident 1.5%.Diabetes patients of the age group 40-59 years were most often (50.8%)affected by the complications followed by those of the age group ≥ 60 years (43.0%).Also complications affected the following most: 66.7% married participants,22.6%divorced ones, 79.1% of patients on medication (52.8% on oral anti-diabetes medication, 18% on insulin and 8.3% on oral antidiabetics +Insulin), 68.3% of diabetes patients with unstable glycaemia, 48.4% of those living with diabetes for ≥ 21 years, 36.1% of patients diagnosed between 1-5 years, 54.5% of the participants advised to stop smoking, 37.4% overweight and 34% obese patients, 43.6% diabetic patients with hypertension, 97.3% of those recommended to control blood sugar, 64.5% of those advised to follow a low fat and weight loss diet and 96.5% of participants with other pathologies.
Gender differences in the prevalence of the following characteristics with complications were observed; marital status, educational level, current diabetes treatment, number of years living with diabetes, nephropathy, number of complications, having other pathologies and BMI.

Drivers of complications from diabetes
Diabetes complications were positively associated with living with diabetes for ≥ 21years, hypertension, obesity, "Sometimes" had a hard time doing what the health provider suggested and "Sometimes" and "Most of Open Access

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the times" in response to 'how often in the past 4 weeks the patient was able to do what the doctor said' , "Yes" recommended to follow a low fat and weight loss diet, to control blood sugar and advised to stop smoking and protective forl iving with diabetes for 6-10 years, in univariate analysis.

Discussion
Though there is a dearth of data on complications from diabetes in Africa there is no doubt this cannot be neglected.Complications from diabetes are responsible for frequent and prolonged hospitalisations of diabetic patients and significantly associated to morbidity and mortality.Complications from diabetes hardly occur singly.This study described the profile of outpatients with complications from diabetes, ability to adhere to medical advice and drivers of complications from diabetes amongst outpatients attending routine check-up in diabetes clinics.
The prevalence of diabetic foot was the highest (24.6%) complication though previous studies put it at 42%.Studies indicated foot complications in Africa are due to neuropathic foot infection and not peripheral vascular diseases.Whilst the prevalence of diabetic retinopathy in our study was 21.2% previous studies indicated variation from 37.3% to 42.2% in Cameroon [4,14] though Ghana and Nigeria have recorded a prevalence of 17.9% and 18% respectively [15][16][17][18].Prevalence of retinopathy ranged from 8.1% in Tunisia [19] to 41.5% in Egypt [20].Diabetic neuropathy prevalence was 7.2% compared to 26% to 68% in Africa from 1990 to 2003 and 28% to 55% in Europe and North America [21], 21.9% in Egypt [20] and 36.7% in Sudan [22].Diabetic nephropathy is main cause of end-stage renal disease in the world [23] and probably in Africa though published data in Africa populations are rare.We observed a 3.9% prevalence of diabetic nephropathy.Kidney disease is common in people with diabetes than those without it [3].African American diabetic patients have higher risks of kidney failure and higher prevalence nephropathy than Caucasians [24].In Africa, nephropathy may be increasingly responsible for chronic kidney failure [25].Renal failure is main cause of mortality in T2D patients in South Africa [26].Nephropathy prevalence attained 6.7% in Egypt [20].Though the prevalence of cardiovascular complications was lowest in our study other studies showed high prevalence of cardiovascular risk factors in participants with clinical diabetic nephropathy and patients with diabetic nephropathy are at greater risk of excess cardiovascular morbidity [27,28].Cardiovascular complications of diabetes include angina, myocardial infarction or heart attack, stroke, peripheral artery disease and congestive heart failure.CVD accounted for 70% deaths in people with T2D [29].Diabetic patients have a four-fold risk of suffering from CVD than non-diabetics [30,31].Prognoses into cardiovascular complications of diabetes in Sub-Saharan Africa are limited by diagnostics facilities and well trained medical personnel to probe into coronary heart disease and ischaemic heart disease regularly which are no more uncommon and seen in the few equipped urban health facilities where about 30% of patients in CVD intensive care units are diabetic [32].

Open Access
Variations in prevalence of complications are probably due to low referrals for follow up in few specialised centre's, differences in health seeking attitudes of patients and barriers to uptake of services [9], prohibitive out of pocket pay for tests complications or absence of competent services to carry out the prognosis, ethnicity [33] and differences in criteria for case definition and methodology, selection bias [34] and lack of published data.The prevalence of these complications was probably higher in the population than the observed prevalence in our study because we computed only prevalence from outpatients who could afford and have done the requisite tests that allows for diagnosis and follow up in health facilities.Also, 51.6% of patients with complications reported that the cost of angiography and photocoagulation at subsidized rates of USD 10 and USD 20 respectively were expensive and only 66.6% could afford anannualsubsidized angiography and 34% prescribed photocoagulation.
Living with diabetes for many years (≥ 21 years), hypertension and obesity, advised to stop smoking (univariate), "Yes" recommended to follow low fat & weight loss diet and to control blood sugar (univariate) were drivers of complications from diabetes as observed in other studies [1,35,36], "sometimes" having a hard time following health providers' suggestions and "sometimes" and "most of the time" as response to 'How often in the past 4 weeks I did what the doctor said' were drivers of complications from diabetes.Diabetes patients who "sometimes" hardly follow the health providers' advice had about two-fold risk of complications.Though not statistically significant, respondents who reported "most of the time" followed the doctors' suggestion exactly and affirmed that "sometimes" and "most of the time" it was easy doing what the health provider suggested were protected from complications from diabetes in univariate analysis.
Losing weight lowers blood pressure, blood glucose and cholesterol levels.This can be done through a combination of healthy eating (high fibre and low fat foods, reduce salt intake) and being active.Smoking alone is the greatest lifestyle risk factor for diabetes complications and is the second leading cause of death after wars in the 20th century [37].Smoking can undo benefits accrued through weight loss, healthy eating, good blood pressure and good blood sugar control.Smoking affects circulation.It renders small blood vessels narrower increasing heart rate and blood pressure and makes blood cells and blood vessels walls sticky and facilitating build-up of dangerous fatty material resulting in heart attack, stroke and other blood vessel diseases.Diabetics who smoke have less control over their diabetes and higher blood pressure than abstainers with diabetes.Keeping blood glucose and blood pressure within the recommended range by regular checks reduces risk from long-term diabetes complications.
Age, gender, education, marital status, "Followed my doctor's suggestion exactly" and "It was easy doing what my health provider suggested" were not drivers of complications from diabetes though male gender and poor education were risk factors elsewhere [38].
Participants' SBP (138mmHg; CI: 135.9-140.7)and DBP (83.7 mmHg; CI: 8 2.3-85.1)were higher than in general Cameroon populations of SBP (127.3 mmHg) in 2010 [39].Higher SBP is a surrogate for hypertension.This indicates susceptibility to complications of diabetes patients.Complications from diabetes can be delayed or avoided.Control of drivers of complications such as obesity and blood pressure within recommended range is advised.A healthy weight, healthy eating habits, and avoiding smoking reduce risk of complications.Access to medication and equipment and education of patients and health personnel and a good health system responding to periodic eye, foot examination and blood tests are needed.Screening for diabetes related complications is advised as interventional strategies exist that can reverse or delay progression of complications.One of the challenges of diabetes in Sub-Saharan Africa is paucity in documentation of risk factors [40].Our results provide evidenced-informed data from outpatients and should guide health initiatives, research on epidemiological changes and enhance knowledge on the drivers of complications from diabetes critical in understanding where interventions may be most effective for diabetes prevention and management.

Conclusion
Complications of diabetes affect many parts of the body especially the nerves, feet, kidneys, eyes and heart.Lack of effective strategies to support better management of diabetes will lead to increase complications resulting in more disability, loss in productivity especially for the age group of 40-59 years and increase morbidity and mortality from diabetes-related complications.Obesity, hypertension, living with diabetes for ≥ 21 years and difficulty adherence to medical advice were drivers of complications from diabetes.

Limitations and strengths of the study
The study is a cross-sectional study limited in causal inferences.Interviews required finding respondent at a health facility.It is likely that under representation of sick diabetes patients in hospitals, poor ones who could not afford to come for routine check-up and working patients occurred particularly for those working overtime or in shifts.Interviewer administered questionnaires on adherence to medical advice was selfreported and susceptible to reporting (recall) bias.The study was done in urban areas and results may not be generalizable to rural populations.Categorisation of variables (age into age groups, etc) might have led to loss of information.Instant translation of questions into a local language in some few cases by researcher or use of an interpreter may lead to poor understanding of the questions and responses may not be factual.Assessment of complications and clinical parameters were carried out by different health providers in different settings and inter/intra observer variability was not done.
Despite the limitations the study provides valuable information on where interventions may be more effective for chronic disease conditions, complications and drivers which provides critical knowledge in the care and management.The study had a high response rate (>90%) and quantitative focussing on diabetes patients on routine consultation.Population based analysis of drivers of complications rather than exploring the drivers of each complication separately epidemiologically explained who is at risk of any complications from diabetes because the risks factors overlap for each complication.Trained researchers administered structured questionnaires respecting standard guidelines in definition of diabetes, hypertension, BMI classes and patient books were used to ascertain the complications following laboratory diagnoses and management of condition by health provider.

1 . 2 . 3 . 4 .
Had a hard time doing what the health provider suggested Followed my doctor's suggestions exactly It was easy doing what my health provider suggested How often in the past 4 weeks were you able to do what the doctor said?