Opportunistic screening for type 2 diabetes mellitus in the out-patient clinic .

Experience from Basrah, Southern Iraq.

 

*Abbas Ali Mansour-MD,Assistant Professor of Medicine, Department of Medicine, Basrah College of Medicine, Basrah, Iraq

Abstract

Background: Opportunistic screening is more efficient than population screening for diabetes mellitus. The aim is to describe the prevalence of unrecognized diabetes mellitus (DM) among patients attending out-patients clinic in a major hospital in Basrah, Southern Iraq.
Methods: A cross-sectional observational study. The study conducted for the period between January 2006 to end of July 2007. Patients, who attended the out-patient clinic in Al-Faiha hospital in Basrah, were enrolled in this study if they were neither known diabetics nor had florid features of DM, and their age is 18 and above. New DM diagnosis was based on fasting plasma glucose (FPG) equal to or more than 126 mg/dl (7.0 mmol/l) on two occasions.
Results: The total study sample was 15505, of whom 7983(51.5%) were men and 7522(48.5%) were women .Age range was 44.83 15.83 ±.New DM was seen in 1036(6.7%). Mean age was higher among those with new diabetes 52.51 ± 12.12 vs 44.29 ± 15.92(p value <0.001). No clear difference was seen between both sexes regarding incidence of DM (0.007). All anthropometric indices value was clearly higher among those with diabetes. At age of 45 and above there was a clear difference between the diabetic group and non-diabetics (p value <0.001) with prevalence of DM more among those at age of 45 and above in both sexes.
Conclusion: Using opportunistic screening for DM in major hospital in Basrah, Southern Iraq, we detected 6.7% new patients with diabetes in the screened population.

Key words: Diabetes, Screening, Iraq

 

There are 2 potential strategies for diabetes mellitus (DM) screening: community- or population-based screening, and opportunistic screening.1 Opportunistic screening strategies take advantage of the presentation of the patient to the doctor or medical center (scheduled visit, emergency room visit, inpatient stay) to deliver a public health screening intervention.Opportunistic screening is more efficient than population screening.2


In 1997, the American Diabetes Association (ADA) Expert Committee on the Diagnosis and Classification of DM recommended that all non-diabetic individuals ≥45 years of age be screened for diabetes at 3-year intervals as a part of their routine medical care (opportunistic screening).3 They recommended office-based screening of patients with a variety of risk factors,other than age, including central obesity, physical inactivity, family history of diabetes, or a personal history of gestational diabetes.4 The screening can be performed with either fasting plasma glucose (FPG) levels or oral glucose tolerance tests (OGTTs).3


Analyses of mass screening programs in Germany found that people diagnosed with DM as a result of screening had better outcomes than those presenting spontaneously with DM. 5


Early diagnosis and treatment through opportunistic screening of type 2DM may reduce the lifetime incidence of major microvascular complications ,are cost effective ,and result in gains in both life-years and quality-adjusted life-year.6
The aim is to describe the prevalence of unrecognized DM among out-patients clinic in a major hospital in Basrah, Southern Iraq.

METHODS


A cross-sectional observational study conducted for the period between January 2006 to end of July 2007. Patients who attended the out-patient clinic in Al-Faiha hospital in Basrah, Southern Iraq, which is one of the main four hospitals in Basrah, were enrolled in this study if they were neither known diabetics nor had florid features of DM and their age is 18 and above. Written informed consent was taken from all subjects prior to enrollment. Patients were without previously diagnosed DM. Exclusion criteria were age less than 18 years, pregnancy, and a history of recent surgery, trauma, or illness. Each individual was screened only once.

Three blood pressure measurements were obtained by physicians. The measurements were made with the participant in a sitting position after 5 minutes of rest. Hypertension was defined as self-reported use of antihypertensive medication within the past 2 weeks or an average systolic blood pressure ≥140 mmHg, an average diastolic blood pressure ≥ 90 mmHg, or both.


Diabetes Screening Protocol
Those with random plasma glucose levels equal to or more than 130 mg/dl were considered as abnormal.7 The next morning FPG was measured. FPG was measured by a glucose oxidase method (Diagnostic Chemicals reagent kit). Fasting is defined as no caloric intake for at least 8 hours. New DM diagnosis was based on FPG equal or more than 126 mg/dl (7.0 mmol/l) on two occasions. 8

Anthropometric measurement
Waist circumference (WC) was measured at the umbilical level from the horizontal plane in centimeters (cm), using a plastic anthropometric tape with the subjects standing and breathing normally ,by the same physician during the physical examination with the participant standing erect.Standing height and weight measurements were completed with the subjects wearing lightweight clothing and no shoes. Height was measured to the nearest cm and weight was measured to the nearest half kilogram (kg). Body mass index (BMI) was calculated as body weight in kilograms divided by the squared value of body height in meters (kg/m2). Waist to hip ratio (WHpR) and waist to height ration (WHtR) were measured accordingly as ratios.

Statistical Analysis
All data were analyzed in 2007 by SPSS (Version 9.0, SPSS Inc., Chicago, Ill., USA). Student’s t test was used to compare differences between means and the x2 test was used to compare differences in proportions. A p value of < 0.05 was considered statistically significant.

Result


The total study sample (Table -1) was 15505,of whom 7983(51.5%) were men and 7522(48.5%) were women .Age range was 44.83± 15.83.New DM was seen in 1036(6.7%). Mean age was higher among those with new diabetes 52.51 ± 12.12 vs 44.29 ± 15.92(p value <0.001).There was no clear difference between both sexes regarding incidence of DM (0.007).


BMI, WC, WHpR and WHtR were 28.79± 5.40, 100.94 ± 11.96, and 0.95± 0.071 and 0.60 ± 0.07 respectively among the diabetic group,while that of non-diabetics was 26.03 ± 5.90, 90.47 ± 14.63, 0.89 ± 0.08 and 0.54 ± 0.09 for BMI, WC, WHpR and WHtR respectively (p value <0.001).All these anthropometric indices values were clearly higher among those with diabetes.


Hypertension was seen in 2113(13.6%).Patients with new DM have a higher incidence of hypertension (28.0% vs. 12.6%) with p value <0.001.


Distribution of new DM by age group and sex is in table-2. At age of 45 and above there was a clear difference between the diabetic group and non-diabetics (p value <0.001) with prevalence of DM more among those at age of 45 and above in both sexes.

 

Table -1-Major characteristics of the study sample (Figures in parentheses are percentages).

 

Diabetes   

Non- diabetes

P value

Total

Sex

Men

575(55.5)

7408(51.2)

0.007

7983(51.5%)

Women

461(44.5)

7061(48.8)

7522(48.5%)  

Age, years (mean ±  SD)

52.51 ± 12.12

44.29 ± 15.92

<0.001

44.83 ± 15.83

BMI, kg/m2 (mean ±  SD)

28.79± 5.40

26.03 ± 5.90

<0.001

26.21± 5.90

WC, cm (mean ±  SD)

100.94 ± 11.96

90.47 ± 14.63

<0.001

91.17±  14.70

WHpR(mean±SD)

0.95± 0.071

0.89 ± 0.08

<0.001

  0.89± 0.08

WHtR(mean±SD)

0.60 ± 0.07

0.54 ± 0.09

<0.001

 0.54 ± 0.09

Hypertension  

291(28.0 )

1822(12.6 )

<0.001

2113

Total

1036(6.7)

1446(93.3)

 

15505

 

Table -2- Prevalence of new diabetes by age and sex (Figures in parentheses are percentages).

Age (years) specific groups

Diabetes  

Non- diabetes

P value

Men

     

<25

4( 0.69)

698 (9.4 )

<0.001

25-34

39 (6.8 )

1936 (26.1 )

35-44

147 (25.5 )

1728 (23.3 )

45-54

175 (30.4 )

1265 (17.0)

55-64

126 (21.9 )

817 (11.0)

≥65

84 (14.6 )

964 (13.0)

Total

575(100)

7408(100)

Women

   

<0.001

<25

5 (1.0 )

694 (9.8 )

25-34

15 ( 3.2)

1376 (19.4)

35-44

68 (14.7)

1632 (21.7 )

45-54

180 (39.0)

1632 (23.1 )

55-64

99 (21.4 )

889 (12.5 )

≥65

94 (20.3 )

932 (13.1 )

Total

461(100 )

7061(100 )

Both men and women

     

<25

 9(0.9 )

1392 (9.6)

 <0.001

25-34

54 (5.2)

3312 (22.8)

35-44

215 (20.7)

3266 (22.5)

45-54

355 (34.2)

2897 (20.0)

55-64

225 (21.7)

1706 (11.7)

≥65

178(17.1)

1896 (13.1)

Total

1036(6.7)

1446(93.3)

Discussion


New DM was seen in 1036 (6.7%) in this study. The prevalence of unrecognized DM was 4.5% in a cross-sectional observational study at the Durham Veterans Affairs Medical Center 9 and in-patients presenting in the a fasted state for endoscopy or colonoscopy at a metropolitan teaching hospital in Australia ,was 7%.10


Almost all individuals in this study were screened using FPG, because it is easily applicable .Among 8,286 non-diabetic patients equal or more to 45 years of age in University of Michigan Health System,random plasma glucose was the most common screening method (95%), 3% were screened by FPG, 2% by HbA1c, 1% by random whole blood glucose, and less than 1% by OGTT 11with 4% were having abnormal results.


The anthropometric indices, BMI, WC, WHpR and WHtR were higher among those with DM in this study, which was similar to findings in an Iraqi study in Basrah.12
New type 2 DM started to rise at age of 35 and peaks at age of 45 in this study which is consistent with ADA criteria for screening.8


Conclusion: Using opportunistic screening for DM in a major hospital in Basrah Southern Iraq, we detected 6.7% new diabetics in the screened population.

Study limitation: Despite all our precautions, we cannot guarantee that some of the patients may not have had a few symptoms because it is well known that some patients with type 2 DM tend to deny onset of DM.13

 

Acknowledgements


The author wish to thank dr Hameed Laftah Wanoose , Department of Medicine, Al-Faiha Hospital, Basrah, Iraq for his help in collecting data and Lesley Pocock Publisher and Managing Director medi+WORLD International World CME for reviewing of the manuscript.

References


1- Engelgau MM, Narayan KM, Herman WH. Screening for type 2 diabetes. Diabetes Care. 2000 ;23(10):1563-1580. [PubMed: 11023153]

2- Johnson SL, Tabaei BP, Herman WH. The efficacy and cost of alternative strategies for systematic screening for type 2 diabetes in the U.S. population 45-74 years of age.Diabetes Care. 2005 ;28(2):307-311. [PubMed: 15677784]

3-Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.Diabetes Care. 1997 ;20(7):1183-1197. [PubMed: 9203460]
4-American Diabetes Association Clinical Practice Recommendations 2001. Screening for diabetes. Diabetes Care. 2001 ;24 Suppl 1:S1-133 [PubMed: 11403001]
5-Schneider H, Ehrlich M, Lischinski M,Schneider F: Bewirkte das flachendeckende Glukosurie-Screening der 60er und 70er Jahre im Osten Deutschlands tatachlich den erhofften Prognosevorteil fur die fruhzeitig entdeckten Diabetiker? Diabetes und Stoffwechsel. 1996; 5:33–38.

6- The cost-effectiveness of screening for type 2 diabetes. CDC Diabetes Cost-Effectiveness Study Group, Centers for Disease Control and Prevention.JAMA. 1998;280(20):1757-1763. [PubMed: 9842951]

7- Tabaei BP, Herman WH. A multivariate logistic regression equation to screen for diabetes: development and validation.Diabetes Care. 2002;25(11):1999-2003. [PubMed: 12401746]

8- Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Follow-up Report on the Diagnosis of Diabetes Mellitus. Diabetes Care 2003;26(11):3160–3167. [PubMed: 14578255]

9- Edelman D, Edwards LJ, Olsen MK, Dudley TK, Harris AC, Blackwell DK, Oddone EZ. Screening for diabetes in an outpatient clinic population. J Gen Intern Med. 2002 ;17(1):23-28. [PubMed: 11903772]

10- Zimmermann AT, Stranks SN, Gall SL, Hebbard GS . Opportunistic screening for type 2 diabetes mellitus in public hospitals. Med J Aust. 2002 ;177(9):524-525. [PubMed: 12405900]

11- Ealovega MW, Tabaei BP, Brandle M, Burke R, Herman WH.. Opportunistic screening for diabetes in routine clinical practice .Diabetes Care. 2004 ;27(1):9-12. [PubMed: 14693958]

12-Mansour AA, Al-Jazairi MI .Predictors of Incident Diabetes Mellitus in Basrah,Iraq. Annals of Nutrition and Metabolism .2007; 51( 4): 277-280. [PubMed: 17622787]

13-Steven B. Leichter. Borderline Personality Disorder and Diabetes:A Potentially Ominous Mix. Clinical Diabetes . 2005; 23( 3):101-102.

 

First Published February 2008


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