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Prevalence and screening for risk factors of type 2 diabetes in Rize, Nourtheast Turkey: findings from a population-based study
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Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Original research
Prevalence and screening for risk factors of type 2 diabetes in Rize, Nourtheast Turkey: findings from a population-based study A. Bayındır C¸evik a,∗ , M. Metin Karaaslan b , S. Koc¸an b , H. Pekmezci b , S. Baydur S¸ahin c , A. Kırbas¸ d , T. Ayaz e a
˘ Recep Tayyip Erdogan University (RTEU) School of Health Department of Medical Nursing Turkey RTEÜ Health Care Services Vocational School Turkey c RTEU School of Medicine Department of Endocrinology and Metabolic Diseases Turkey d RTEÜ School of Medicine Department of Biochemistry Turkey e RTEÜ School of Medicine Department of Internal Medicine Turkey b
a r t i c l e
i n f o
a b s t r a c t
Article history:
Aims: We aimed to determine the prevalence of diagnosed and undiagnosed diabetes, risk
Received 2 February 2015
factors affecting the healthy population, and factors that increase diabetes risk in the adult
Received in revised form
northeast Turkish population.
3 April 2015
Methods: Using population proportional cluster sampling, 930 adults were selected. After
Accepted 1 June 2015
excluding people with diabetes, risk screening was conducted in the healthy population (n:
Available online xxx
825) using the Information Form and FINDRISK questionnaire. Fasting venous blood and biochemical parameters were measured.
Keywords:
Results: Prevalence of diabetes was 13.6% (new % 2.3), translating to approximately 44 thou-
Screening
sand adults. Among the healthy population, 37.5% had high risk. Prevalence of not exercising
Prevalence
(78.2%), obesity (36.1%), and hypertension (24.5%) were high. Predictors of risk of diabetes
Risk factors
were aging (OR 1.09), low education (OR 0.51), familial diabetes history (OR 15.27), not exer-
Diabetes
cising (OR 0.41), obesity (OR 5.17), high waist circumference (OR 1.05), heart disease (OR 4.81),
Turkey
and hypertension (OR 2.60). Conclusions: This study can stimulate early screening for cardiovascular diseases and hypertension and initiating aggressive treatments in people with high diabetes risk. In primary health services, number of doctors and nurses trained in diabetes should be increased and dieticians should be involved. People with high risk should receive lifestyle regulations training. © 2015 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
∗
Corresponding author. Tel.: +90 4642141059; fax: +90 4642141089. E-mail address: [email protected] (A. Bayındır C¸evik).
http://dx.doi.org/10.1016/j.pcd.2015.06.002 1751-9918/© 2015 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: A. Bayındır C¸evik, et al., Prevalence and screening for risk factors of type 2 diabetes in Rize, Nourtheast Turkey: findings from a population-based study, Prim. Care Diab. (2015), http://dx.doi.org/10.1016/j.pcd.2015.06.002
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1.
Introduction
The increase in type 2 diabetes presents a real and serious challenge for public health in Turkey, as well as other industrialized countries [1]. The International Diabetes Federation (IDF) estimates that there are 381.8 million people with diabetes in 2013 [2]. In the Turkey Diabetes Epidemiology study (TURDEP-II), it was determined that the prevalence of diabetes is 16.5% in the Turkish population, that 45.5% of people with diabetes were unidentified, and that the deterioration of glucose tolerance (IGT) increased by 106% in the last 12 years [1] as a result of a combination of a number of factors including: under-performing health systems, low awareness among the general public and health professionals [3–5]. Numerous studies showed that type 2 diabetes can be prevented at a rate of 58% by implementing early interventions aimed at altering lifestyle behaviors of high risk groups [6–10]. It is recommended to use two methods for determining high risk populations. The first method involves clinical and demographic characteristics, while the second method involves questionnaires that provide risk evaluation by examining the presence or absence or risk factors [11,12]. The correct population-wide strategy is initiating risk identification and then conducting glucose tests for high risk patients. In international population-based studies, venous blood glucose measurements are the gold standard for determining the prevalence of diagnosed and undiagnosed diabetes [13–15]. With this method, asymptomatic diabetes and abnormal glucose tolerance can be detected and also the 10-year risk of type 2 diabetes can be predicted with 85% accuracy [11,15]. The American Diabetes Association (ADA) recommends that people who have a BMI of 25 kg/m2 or above and who also have the following should be screened: physical inactivity, history of diabetes in first-degree relatives, being in a high risk race group, giving birth to a baby that weights >9 Ib, hypertension (≥140/90 mmHg or receiving antihypertensive treatment), women with PCOS, A1c ≥5.7%, IGT or IFG on previous testing, and obesity [16]. In addition to the ADA criteria, the Society of Endocrinology and Metabolism of Turkey (SEMT) determined dyslipidemia; coronary, peripheral, and cerebral vascular disease; habit of consuming saturated fats and lack of pulp intake; and antipsychotic medication use to be diabetes risk factors specific to the Turkish population [17]. There is currently no screening program for diabetes or impaired fasting glucose in Northeast Turkey. There is no known risk assessment questionnaire that is used in Northeast Turkey. In order for health authorities to implement preventive interventions, solid data on risk factors that affect the population and on the regional distribution of asymptomatic individuals who have high risk is needed.
2.
Methods
The aim of this study is to determine the prevalence of diagnosed and undiagnosed diabetes in the Turkish population aged 20–79 years living in the northeast, to screen the healthy population for diabetes risk factors, to determine factors that
affect high risk of diabetes, and to provide regional data for health authorities.
2.1.
Study design, settings, and procedures
This research was planned as a descriptive and cross-sectional study. The universe of the study consisted of the population aged older than 20 years living in Rize. By means of population proportional systematic cluster sampling, adults registered at 30 FHC’s were selected using a random numbers table. Among those who were invited to the study, 87% participated. In the study, the participants were screened for diabetes and phases of population based screening for diabetes were taken into account [18]. Venous blood samples were collected from the participants after 10 h of fasting. Analyses were conducted using an Architect C 1600 (Abbott, USA) at the RTEU Hospital Biochemistry Laboratory[19]. Among 930 people who were selected with random methods, 105 people who were known and confirmed by FPG [16] were separated. The healthy population (n: 825) was screened for diabetes risk. Systolic and diastolic blood pressures (sBP, dBP), weight, height, waist and hip circumferences were measured according to the standard protocols [18]. Body mass index (BMI) was calculated as weight (kilograms) divided by square of height (meters) [20]. Considering ethics, the group with diabetes took biochemical tests and received counseling services.
2.2.
Data Collection Instruments
Patient Information Form: Includes sociodemographic characteristics, questions for evaluating diabetes risk, biochemical analyses, and anthropometric measurement records. Type 2 Diabetes Risk Assessment (FINDRISK) Form: It was developed in 2001 as a DEHKO project by the National Public Health Institute [21,22]. This has been validated for use in a multi-ethnic population in the UK [15] and is widely used in the Turkish population. The Risk Test Form had eight questions, with the total test score providing a measure of the probability of developing type 2 diabetes over the following 10 years. Total scores of <7 correspond to low 10-year diabetes risk (1%), 7–11 points correspond to mild risk (4%), 12–14 points correspond to medium risk (16%), 15–19 points correspond to high risk (33%), and 20 points and above correspond to very high risk (50%) [21,22].
2.3.
Statistical analysis
For data analysis, the SPSS 20.0 software was used. Risk of diabetes was calculated according to the FINDRISK model. In the comparison of risk factors of high and low risk groups within the healthy population, Pearson chi square and the independent samples t test was used. Risk factors were determined considering the ADA (2013) and TEMD (2013) guidelines and demographic characteristics. For determining the factors that contribute to increased risk of diabetes, logistic regression analysis was used. In logistic regression analysis, diabetes risk (low/high) was the dependent variable while sex, age, education (≤8 years/>8 years), marital
Please cite this article in press as: A. Bayındır C¸evik, et al., Prevalence and screening for risk factors of type 2 diabetes in Rize, Nourtheast Turkey: findings from a population-based study, Prim. Care Diab. (2015), http://dx.doi.org/10.1016/j.pcd.2015.06.002
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status (married/single), number of children, sBP, dBP, APG, TC, TG, HDL-C, LDL-C, waist circumference, obesity (present/not present), exercise (does/does not), diabetes in first-degree relatives (present/not present), menopause (present/not present), HT (present/not present), CVD (present/not present), thyroid disease (present/not present), PAD (present/not present), PCOS (present/not present), antipsychotic medication use, and giving birth to a large baby (yes/no) were the independent variables.
2.4.
was accepted. Hypertension: sKB≥140; dKB≥90 and/or use of antihypertensive medicine were accepted [23]. The Presence of Metabolic Syndrome (MetS): Diagnostic criteria of the International Diabetes Federation (IDF) were taken into consideration. In addition to the criteria of waist circumference of ≥94 cm in men and ≥80 cm in women, a high fasting blood pressure (≥100 mg/dL) or type 2 diabetes, high tension (≥85/130 mm Hg) or hypertension, low HDL-C (<40 mg/dL in men; <50 mg/dL in women), and high triglyceride (≥150 mg/dL) were accepted as diagnosis criteria [24].
Research variables
BMI: Values of 18.5 and lower were classified as “underweight”, 18.5 to <25 as “normal weight”, >25 as “overweight”, >30 as “obese” [19]. Classification of blood glucose: Normal plasma glucose (Fasting plasma glucose (FPG)≤ 100 mg/dL), Deteriorated Fasting Glucose: (IGT) (FPG:100–125 mg/dl) and diabetes (FPG≥ 126 mg/dl) was considered [16]. Presence of Heart Disease: A diagnosis by a doctor and/or use of heart medicine
3.
Results
Among the study population (n: 930), the prevalence of diabetes was determined to be 13.6% (n: 124). In people with diabetes, 84.7% (n: 105) were diagnosed before and 15.3% (n: 19) were newly diagnosed. 11.4% of men (n: 39) and 11.2% of women (n: 66) were known to have diabetes, while 3.7%
Table 1 – Demographic characteristics and risk factors of the healthy population (n = 825). Men (n: 303) n (%) Residential area 101(33.3) Urban 202(66.7) Rural Educational level 165(54.5) ≤8 years 138(45.5) >8 years Smoking 93(30.7) Current smoker 210(69.3) Non-smoker Alcohol consumption 19(6.3) Yes 284(93.7) No Exercise (≥5 times per week; at least 30 min) Yes 77(25.4) 226(74.6) No 86(28.4) MetS 30(9.9) CVD 74(24.4) HT 19(6.3) Thyroid 20(6.6) PAD 1(0 .03) Stroke – PCOS 18(5.9) Antipsychotic drug use 99(32.7) Obesity 48.09 ± 12.91 Age 122.28 ± 19.30 sKB 77.65 ± 11.11 dKB 161.18 ± 88.32 TG 41.17 ± 9.01 HDL-C 88.03 ± 25.13 FPG 32(10.6) Hypoglycemia (<70 mg/dl) 233(77.4) FPG (70–100 mg/dl) 25(8.3) IPG (100–125 mg/dl) 11(3.7) Diyabet (≥126 mg/dl) 28.09 ± 4.11 BMI WC 99.38 ± 12.24
Women (n: 522) n (%)
Total or Mean (n: 825) n (%)
p
247(47.3) 275(52.7)
348(42.2) 477(57.8)
<0.001
373(71.5) 149(28.5)
538(65.2) 287(34.8)
<0.001
82(15.7) 440(84.3)
175(21.2) 650(78.8)
<0.001
1(0.02) 521(99.8)
20(2.4) 805(97.6)
<0.001
103(19.7) 419(80.3) 165(31.6) 38(7.3) 128(25.5) 103(19.7) 88(16.9) 2(0.04) 50(9.6) 105(20.1) 199(38.1) 44.81 ± 13.95 115. 87 ± 18.92 74.08 ± 11.20 135.55 ± 73.61 49.45 ± 10.89 86.77 ± 23.87 53(10.3) 411(79.7) 44(8.5) 8(1.6) 28.44 ± 5.94 93.35 ± 15.72
180(21.8) 645(78.2) 251(30.4) 68(8.2) 202(24.5) 122(14.8) 108(13.1) 3(0.04) 50(9.6) 123(14.9) 298(36.1) 3.34 4.63 4.41 4.45 −11.14 0.717 85(10.4) 644(78.8) 69(8.4) 19(2.3) −0.89 5.62
0.05 0.33 0.18 0.97 <0.001 <0.001 0.90 – <0.001 0.11 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.28
<0.001 <0.001
CVD: Cardiovascular disease, HT: Hypertension, PAD: Peripheral Arterial Disease, PCOS: Polycystic Ovarian Syndrome, sBP: Systolic Blood Pressure, dBP: Diastolic Blood Pressure, TG: Triglycerides, HDL: High density lipoprotein, LDL: Low density lipoprotein, FPG: Fasting Plasma Glucose, IPG: Impaired Plasma Glucose DM: Diabetes Mellitus, BMI: Body Mass Index WC: Waist circumference.
Please cite this article in press as: A. Bayındır C¸evik, et al., Prevalence and screening for risk factors of type 2 diabetes in Rize, Nourtheast Turkey: findings from a population-based study, Prim. Care Diab. (2015), http://dx.doi.org/10.1016/j.pcd.2015.06.002
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Table 2 – Diabetes risk of the northeastern Turkish population.
Diabetes risk score Mean 10-year risk (%)
Men (n: 303)
Women (n: 522)
Min-Max
t
p
11.99 ± 6.21 17.44 ± 17.25
12.67 ± 7.01 19.92 ± 18.47
0–30 1–50
−1.38 −1.904
0.16 0.05
of men (n: 11) and 1.6% of women (n: 8) were newly diagnosed with diabetes. In the healthy population, there was no significant difference between men and women in terms of diabetes prevalence (p: 0.934). When we excluded the patients with previously known diabetes, in total, 825 people (63.27% women, 36.73% men) participated in the study (urban: %42.2, rural: 57.8%). The mean age of men was 48.09 ± 12.91 years. The number of men who were educated for more than 8 years, who smoked and consumed alcohol, (p < 0.001), and who exercised (p: 0.057) was higher. The prevalence of thyroid and peripheral arterial disease (PAD) prevalence and antipsychotic medication use is more common in women (p < 0.001). Waist circumference, sBP, dBP, BMI, and biochemical parameters including TG, HDL, and FPG values are slightly higher in men (p < 0.001) (Table 1). Men have a mild (11.99 ± 6.21; 4%) and women have a medium diabetes risk (12.67 ± 7.01; 16%). There are no significant differences in diabetes risk scores and 10-year risk percentiles between men and women (p > 0.05) (Table 2). According to the diabetes risk scores of the FINDRISK model, 21.1% of the population is in the high risk group, while 16.4% is in the very high risk group (Table 3). In the healthy population, people with a risk score of ≤14 were grouped as low risk individuals, while those with a score of ≥15 were grouped as high risk individuals. Number of children and age were found to be higher in people with high diabetes risk. People who were married and were educated for ≤8 years exhibited more risk (p < 0.001). Not smoking (p < 0.005) and not exercising (p < 0.001) is more common in the risky population. In the high risk population, the prevalence of obesity, MetS, HT, CVD, PAH, (p < 0.001) and PCOS, thyroid diseases, and stroke (p < 0.005) are higher. Giving birth to a large baby (p < 0.005) and having a familial history of diabetes (p < 0.001) are more common in high risk individuals. Similarly, sBP, dBP, BMI, mean waist circumference, APG, TG, and LDL-C values were found to be higher (p < 0.001), while HDL-C values were found to be lower (Table 4). It was determined that increase in age (OR 1.09, 95% CI [1.06–1.126, p < 0.001), decrease in education (OR 0.51, 95% CI [0.27–0.93], p < 0.05), obesity (OR 5.17, 95% CI [2.85–9.39], p < 0.001), waist circumference (OR 1.05, 95% CI [1.02–1.07], p < 0.001), familial history of diabetes (OR 15.27, 95% CI [8.02–29.10], p < 0.001), and not exercising (OR 0.87, 95% CI
Table 3 – Distribution of the northeastern Turkish population according to diabetes risk groups. Total score <7 7–11 12–14 15–19 ≥20
Level of risk Very low Low Medium High Very high
10-year risk %1 %4 %16 %33 %50
% (n) 25.0(206) 21.0(173) 16.5(137) 21.1(174) 16.4(135)
[0.33–6.69], p < 0.001) contributed to high diabetes risk. Hypertension (OR 2.60, 95% CI [1.42–54.76], p < 0.005) and heart disease (OR 4.81, 95% CI [1.61–14.37], p < 0.005) were associated with high diabetes risk (Table 5). The model predicts the risk of diabetes for the entire population at 68% accuracy (−2 log likelihood: 379.28, Cox & Snell R Square: 0.50; Nagelkerke R Square: 0.68; p < 0.001).
4.
Discussion
The main finding of this study is that the prevalence of diabetes is 13.6% in the northeast of Turkey, that 37.5% of the healthy population is in the high risk group according to the FINDRISK model, and that the high risk population has more diabetes risk factors compared to the low risk population. Also, increased age, low level of education, familial history of diabetes, not exercising, high waist circumference, and obesity increased diabetes risk in the population. Being in the high risk group was associated with hypertension and heart disease.
4.1.
Prevalence and high risk groups
It was determined that the prevalence of diabetes is 15.1% in men and 12.8% in women and that the prevalence rate is slightly lower than the entire Turkish population (16.5%) [1]. Considering the population of Rize (323012) [25], it can be said that 2 of every 10 people (approximately 44,000 people) have diabetes. It was determined that the prevalence of diabetes in the study population is higher than the prevalence in eastern and middle Asia countries (9.1%) [9] and similar to the prevalence rates in south and middle America (11.35%). In the CREDIT study, which was conducted in the Turkish population, the prevalence of diabetes was found to be 12.7% [26]. As in other population-based studies, the present study also indicated that the prevalence of diabetes is higher in women [1,9,27]. According to a previous study which was conducted using the FINDRISK, 10.5% of the population was found to have high risk [28]. In the present study, 21.1% of the population had a high 10-year diabetes risk, while 16.4% had very high risk. It is expected that 310 people (37.5%) will develop diabetes in the next 10 years in the study population. It is evident that one third of the population (n: 103,260 people) has high risk. In the present study, it was determined that men were in the mild risk group and women were in the medium risk group. In one study, which evaluated diabetes risks using the FINDRISK model in 3 cohorts of a Dutch population, it was found that 16–28% of the population was in the medium and high risk groups [29]. Considering these findings, it is observed that diabetes risk in the north eastern population of Turkey is much higher compared to the Dutch population.
Please cite this article in press as: A. Bayındır C¸evik, et al., Prevalence and screening for risk factors of type 2 diabetes in Rize, Nourtheast Turkey: findings from a population-based study, Prim. Care Diab. (2015), http://dx.doi.org/10.1016/j.pcd.2015.06.002
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Table 4 – Factors associated with high diabetes risk (n: 825). 10-year diabetes risk
Low risk (n: 516)
High risk (n: 309)
Total or mean (n: 825)
p
Gender Men Women
199(38.8) 316(61.2)
103(33.3) 206(66.7)
302(36.7) 520(63.3)
0.11
Educational level ≤8 years >8 years
276(53.8) 237(46.2)
260(84.1) 49(15.9)
536 (65.2) 286(34.8)
<0.001
Marital status Married Single
424(82.7) 89(17.3)
294(95.1) 15(14.4)
718(87.3) 104(12.7)
<0.001
Smoker Current smoker Non-smoker
126(24.4) 390(75.6)
49(15.9) 260(84.1)
175(21.3) 647(78.7)
<0.005
Alcohol consumption Yes No
18(3.5) 498(96.5)
2(0.6) 307(99.4)
20(2.4) 802(97.6)
<0.005
Exercise Yes No
139(26.9) 377(73.1)
41(13.3) 268(86.7)
177(21.5) 645(78.5)
<0.001
History of family DM Yes No
158(30.6) 358(69.4)
175(56.6) 134(43.4)
175(56.6) 489(59.5)
<0.001
Obesity Yes No
101(19.6) 415(80.4)
197(63.8) 112(36.2)
298(36.3) 524(63.7)
<0.001
CVD Yes No
17(3.3) 496(96.7)
51(16.5) 258(83.5)
68(8.3) 754(91.7)
<0.001
MetS Yes No
102(19.8) 414(80.2)
149(48.2) 160(51.8)
251(30.5) 571(69.5)
<0.001
HT Yes No
53(10.3) 463(89.7)
149(48.2) 160(51.8)
202(24.6) 620(75.4)
<0.001
Thyroid disease Yes No
61(11.9) 452(88.1)
60(19.4) 249(80.6)
121(14.7) 701(85.3)
<0.005
PAD Yes No
49(9.5) 467(90.5)
59(19.1) 250(80.9)
108(13.1) 714(86.9)
<0.001
Presence of PCOS (n: 514) Yes No
21(6.7) 291(93.3)
29(14.4) 173(85.6)
50(9.7) 464(90.3)
<0.005
Antipsychotic drug use Yes No
60(11.7) 453(88.3)
62(20.1) 247(79.9)
122(14.8) 700(85.2)
<0.001
Stroke Yes No
0(0) 516(100)
3(1.0) 306(99.0)
3(0.04) 819(99.6)
<0.005
Giving birth to a large infant (n: 522) Yes No
29(9.2) 285(90.8)
33(16.0) 173(84.0)
62(10.2) 548(89.8)
<0.005
Fruit and vegetable consumption (n: 790) 344(71.5) Every day 137(28.5) Not every day
210(68.0) 99(32.0)
554(70.1) 236(29.9)
0.28
Please cite this article in press as: A. Bayındır C¸evik, et al., Prevalence and screening for risk factors of type 2 diabetes in Rize, Nourtheast Turkey: findings from a population-based study, Prim. Care Diab. (2015), http://dx.doi.org/10.1016/j.pcd.2015.06.002
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Table 4 (Continued ) 10-year diabetes risk
Low risk (n: 516)
High risk (n: 309)
Oral contraceptive use (n: 522) Yes No
19(6.0) 296(94.0)
Diabetes symptom complaints Yes No Age Number of children sKB dKB BMI WC FPG TC TG HDL-C LDL-C
4.2. risk
Total or mean (n: 825)
p
7(3.4) 200(96.6)
26(3.2) 796(96.8)
0.17
17(3.3) 492(96.7)
28(9.2) 277(90.8)
44(5.4) 769(94.6)
<0.001
41.0 ± 12.3 2.0 ± 1.6 113.5 ± 16.8 73.2 ± 10.8 26.6 ± 4.8 90.3 ± 14.4 83.5 ± 18.4 207.5 ± 45.2 135.9 ± 78.0 47.0 ± 11.1 132.6 ± 37.5
54.2 ± 11.7 3.3 ± 1.6 125.8 ± 20.6 79.0 ± 11.0 31.1 ± 4.9 104.0 ± 11.1 93.3 ± 30.9 220.9 ± 45.5 159.9 ± 81.7 45.3 ± 10.5 143.0 ± 40.7
<0.001 −10.5 −9.30 −7.36 −13.04 −14.15 −5.60 −4.07 −4.17 2.16 −5.6
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
Prevalence of risk factors and contribution of high
It is known that aging increases the risk of diabetes [1,30]. It was determined that people with high risk were older and that increased age increased the risk of diabetes by a factor of 1.10. In a study which examined the prevention of diabetes, it was found that aging increased diabetes development by a factor of 2.59 [31]. In the population, mean BMI was found to be higher in people with high risk compared to those with low risk. It is known that obesity increases the development of diabetes [32]. Due to obesity, women (38.1%) and men (36.1%) were found to be prone to diabetes. In one study which was conducted in a primary care setting in Cuba, it was reported that 80% of the population with diabetes was overweight and obese [28]. Also, in the present study, it was determined that the rate of obesity (63.8%) is higher in people with high risk. The body-mass index does not indicate the distribution of body fat, and waist circumference is also used as a measure of obesity and the associated insulin resistance and diabetes [13,33]. The waist circumference values of both men and women are higher than the values determined for the Turkish population [30]. Waist circumference of people with
high risk is higher than those with low risk. The increase in waist circumference contributes to high risk by a factor of 1.05. Lack of physical activity is an important factor in the development of type 2 diabetes [33]. It was found that not exercising was more common in the high risk group (%86.7) and increased diabetes risk by a factor of 0.41. In this study, not exercising posed a risk against women. Low educational level has a positive effect on disease development and acquisition of related risk factors [34,35]. People with high risk were found to have low levels of education. Low educational level increases diabetes risk in women (71.5%) This finding indicates that people with low educational levels do not conform to healthy lifestyle habits and therefore their diabetes risk increases. In a study conducted in Malaysia, it was found that women were mostly married and had low levels of educational and glycemic control [35]. It was found that people who were married and who had more children had higher risk of diabetes. In one study, women had low educational levels and obesity was more common among these women compared to their better educated counterparts [34]. Numerous studies provide evidence for the relationship between obesity and weight gain and high risk of diabetes [36,37]. In the present study, it was determined that obesity
Table 5 – Factors influencing high diabetes risk.
Age Educational level Exercise Waist circumference History of family Obesity Hypertension CVD Constant
B
SE
Wald
Sig
OR
95% CI
0.09 −0.67 −0.87 0.05 2.72 1.64 0.95 1.57 −11.74
0.01 0.31 0.33 0.01 0.32 0.30 0.30 0.55 1.381
45.55 4.69 6.69 18.49 68.75 29.16 9.64 7.92 72.34
<0.001 <0.05 <0.05 <0.001 <0.001 <0.001 <0.005 <0.005 <0.001
1.09 0.51 0.41 1.05 15.27 5.17 2.60 4.81 0.00
1.06–1.12 0.27–0.93 0.21–0.80 1.02–1.07 8.02–29.10 2.85–9.39 1.42–54.76 1.61–14.37
OR: Odds Ratio. 95% CI: Confidence interval.
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played a role against women (63.8%) and that obesity increased the population’s diabetes risk by a factor of 5.17. Previous studies showed that familial history of diabetes indicates proneness to diabetes [38,39]. In the ATTICA study, which was conducted with the Greek population, it was reported that familial history of diabetes is an important predictor of diabetes development (OR 2.8) [34]. In this study, familial history of diabetes (OR 15.27) was determined to be a far more important predictor than in the Greek population. Risk of cardiovascular disease and hypertension is known to begin in the preclinical period of diabetes [17,40]. In the nondiabetic population, the prevalence of heart disease (16.5%) was found to be high. Heart disease is 2-4 times more frequent in people with diabetes [41]. In a Korean study, it was found that cardiovascular mortality is more effective in the group with diabetes (OR 1.07) [42]. Cardiac morbidity related to diabetes risk was 4.81 times more common. In the northeast of Turkey, cardiac morbidity related to high diabetes risk is 4 times more common than the Korean population. The prevalence of hypertension is 2 times more common in people with diabetes compared to non-diabetics [43]. Consistently, in the present study, the presence of HT increases diabetes risk by a factor of 2.60 in the healthy population. The model acquired in this study predicts diabetes risk of the entire population at a high rate (68%). It can be said that the model has high reliability for health research [44]. There are various limitations of present the study. The study sample represents a specific population living in Rize, the northeast region of Turkey; therefore, the study findings cannot be generalized to the people who live in other geographic regions of Turkey. In this study, OGTT could not be used for determining the prevalence of diabetes due to its cost. Therefore, IFG was evaluated and IGT could not be assessed. Nevertheless, the findings of the present study provided information that can guide primary health service providers in preventing diabetes.
5.
Conclusion
This epidemiological study provides important data that has not been obtained from the region before for health authorities. Aging, low educational level, familial history of diabetes, not exercising, obesity, high waist circumference, heart disease, and hypertension were determined to be predictors that increase the risk of diabetes. Familial history of diabetes was found to be a very important predictor of diabetes and low educational level played a prominent role in the acquisition of risks related to diabetes development. In the study, the contribution of risk factors to increased diabetes risk in the population was found to be higher compared to other studies conducted with different populations. Considering that one third of the population has high risk and that they will develop diabetes in the next 10 years, the number of doctors and nurses in family health centers who are trained in diabetes should be increased and dieticians should be involved. Since atherosclerosis develops in the early period, screening high risk groups for cardiovascular disease and hypertension and initiating aggressive treatments can be cautionary. Individuals with high risk should be thought as people diagnosed with
7
diabetes and they should receive intense training on lifestyle regulations.
Author’s note This risk screening study was carried out within the project titled “Evaluation and management of cardiometabolic risk factors in adults living in the city of Rize: a population-based study”
Funding ˘ This study was supported by the Recep Tayyip Erdogan University (RTEU) Scientific Research Project (SRP) unit as the research numbered 2012.110.01.1. All costs of the study were covered by the RTEU SRP unit.
Conflict of interest The authors state they have no conflict of interest.
Acknowledgments Authors offer their thanks to the Provincial Health Director Dr. Mustafa Tepe who provided permit and support on conducting the survey part of the study, to the laboratory supervisor Köksal Karaca for his assistance on conducting biochemical analyses, to the Family Health Center staff and to all participants of the study.
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Contents lists available at ScienceDirect
Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Original research
Prevalence and screening for risk factors of type 2 diabetes in Rize, Nourtheast Turkey: findings from a population-based study A. Bayındır C¸evik a,∗ , M. Metin Karaaslan b , S. Koc¸an b , H. Pekmezci b , S. Baydur S¸ahin c , A. Kırbas¸ d , T. Ayaz e a
˘ Recep Tayyip Erdogan University (RTEU) School of Health Department of Medical Nursing Turkey RTEÜ Health Care Services Vocational School Turkey c RTEU School of Medicine Department of Endocrinology and Metabolic Diseases Turkey d RTEÜ School of Medicine Department of Biochemistry Turkey e RTEÜ School of Medicine Department of Internal Medicine Turkey b
a r t i c l e
i n f o
a b s t r a c t
Article history:
Aims: We aimed to determine the prevalence of diagnosed and undiagnosed diabetes, risk
Received 2 February 2015
factors affecting the healthy population, and factors that increase diabetes risk in the adult
Received in revised form
northeast Turkish population.
3 April 2015
Methods: Using population proportional cluster sampling, 930 adults were selected. After
Accepted 1 June 2015
excluding people with diabetes, risk screening was conducted in the healthy population (n:
Available online xxx
825) using the Information Form and FINDRISK questionnaire. Fasting venous blood and biochemical parameters were measured.
Keywords:
Results: Prevalence of diabetes was 13.6% (new % 2.3), translating to approximately 44 thou-
Screening
sand adults. Among the healthy population, 37.5% had high risk. Prevalence of not exercising
Prevalence
(78.2%), obesity (36.1%), and hypertension (24.5%) were high. Predictors of risk of diabetes
Risk factors
were aging (OR 1.09), low education (OR 0.51), familial diabetes history (OR 15.27), not exer-
Diabetes
cising (OR 0.41), obesity (OR 5.17), high waist circumference (OR 1.05), heart disease (OR 4.81),
Turkey
and hypertension (OR 2.60). Conclusions: This study can stimulate early screening for cardiovascular diseases and hypertension and initiating aggressive treatments in people with high diabetes risk. In primary health services, number of doctors and nurses trained in diabetes should be increased and dieticians should be involved. People with high risk should receive lifestyle regulations training. © 2015 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
∗
Corresponding author. Tel.: +90 4642141059; fax: +90 4642141089. E-mail address: [email protected] (A. Bayındır C¸evik).
http://dx.doi.org/10.1016/j.pcd.2015.06.002 1751-9918/© 2015 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: A. Bayındır C¸evik, et al., Prevalence and screening for risk factors of type 2 diabetes in Rize, Nourtheast Turkey: findings from a population-based study, Prim. Care Diab. (2015), http://dx.doi.org/10.1016/j.pcd.2015.06.002
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1.
Introduction
The increase in type 2 diabetes presents a real and serious challenge for public health in Turkey, as well as other industrialized countries [1]. The International Diabetes Federation (IDF) estimates that there are 381.8 million people with diabetes in 2013 [2]. In the Turkey Diabetes Epidemiology study (TURDEP-II), it was determined that the prevalence of diabetes is 16.5% in the Turkish population, that 45.5% of people with diabetes were unidentified, and that the deterioration of glucose tolerance (IGT) increased by 106% in the last 12 years [1] as a result of a combination of a number of factors including: under-performing health systems, low awareness among the general public and health professionals [3–5]. Numerous studies showed that type 2 diabetes can be prevented at a rate of 58% by implementing early interventions aimed at altering lifestyle behaviors of high risk groups [6–10]. It is recommended to use two methods for determining high risk populations. The first method involves clinical and demographic characteristics, while the second method involves questionnaires that provide risk evaluation by examining the presence or absence or risk factors [11,12]. The correct population-wide strategy is initiating risk identification and then conducting glucose tests for high risk patients. In international population-based studies, venous blood glucose measurements are the gold standard for determining the prevalence of diagnosed and undiagnosed diabetes [13–15]. With this method, asymptomatic diabetes and abnormal glucose tolerance can be detected and also the 10-year risk of type 2 diabetes can be predicted with 85% accuracy [11,15]. The American Diabetes Association (ADA) recommends that people who have a BMI of 25 kg/m2 or above and who also have the following should be screened: physical inactivity, history of diabetes in first-degree relatives, being in a high risk race group, giving birth to a baby that weights >9 Ib, hypertension (≥140/90 mmHg or receiving antihypertensive treatment), women with PCOS, A1c ≥5.7%, IGT or IFG on previous testing, and obesity [16]. In addition to the ADA criteria, the Society of Endocrinology and Metabolism of Turkey (SEMT) determined dyslipidemia; coronary, peripheral, and cerebral vascular disease; habit of consuming saturated fats and lack of pulp intake; and antipsychotic medication use to be diabetes risk factors specific to the Turkish population [17]. There is currently no screening program for diabetes or impaired fasting glucose in Northeast Turkey. There is no known risk assessment questionnaire that is used in Northeast Turkey. In order for health authorities to implement preventive interventions, solid data on risk factors that affect the population and on the regional distribution of asymptomatic individuals who have high risk is needed.
2.
Methods
The aim of this study is to determine the prevalence of diagnosed and undiagnosed diabetes in the Turkish population aged 20–79 years living in the northeast, to screen the healthy population for diabetes risk factors, to determine factors that
affect high risk of diabetes, and to provide regional data for health authorities.
2.1.
Study design, settings, and procedures
This research was planned as a descriptive and cross-sectional study. The universe of the study consisted of the population aged older than 20 years living in Rize. By means of population proportional systematic cluster sampling, adults registered at 30 FHC’s were selected using a random numbers table. Among those who were invited to the study, 87% participated. In the study, the participants were screened for diabetes and phases of population based screening for diabetes were taken into account [18]. Venous blood samples were collected from the participants after 10 h of fasting. Analyses were conducted using an Architect C 1600 (Abbott, USA) at the RTEU Hospital Biochemistry Laboratory[19]. Among 930 people who were selected with random methods, 105 people who were known and confirmed by FPG [16] were separated. The healthy population (n: 825) was screened for diabetes risk. Systolic and diastolic blood pressures (sBP, dBP), weight, height, waist and hip circumferences were measured according to the standard protocols [18]. Body mass index (BMI) was calculated as weight (kilograms) divided by square of height (meters) [20]. Considering ethics, the group with diabetes took biochemical tests and received counseling services.
2.2.
Data Collection Instruments
Patient Information Form: Includes sociodemographic characteristics, questions for evaluating diabetes risk, biochemical analyses, and anthropometric measurement records. Type 2 Diabetes Risk Assessment (FINDRISK) Form: It was developed in 2001 as a DEHKO project by the National Public Health Institute [21,22]. This has been validated for use in a multi-ethnic population in the UK [15] and is widely used in the Turkish population. The Risk Test Form had eight questions, with the total test score providing a measure of the probability of developing type 2 diabetes over the following 10 years. Total scores of <7 correspond to low 10-year diabetes risk (1%), 7–11 points correspond to mild risk (4%), 12–14 points correspond to medium risk (16%), 15–19 points correspond to high risk (33%), and 20 points and above correspond to very high risk (50%) [21,22].
2.3.
Statistical analysis
For data analysis, the SPSS 20.0 software was used. Risk of diabetes was calculated according to the FINDRISK model. In the comparison of risk factors of high and low risk groups within the healthy population, Pearson chi square and the independent samples t test was used. Risk factors were determined considering the ADA (2013) and TEMD (2013) guidelines and demographic characteristics. For determining the factors that contribute to increased risk of diabetes, logistic regression analysis was used. In logistic regression analysis, diabetes risk (low/high) was the dependent variable while sex, age, education (≤8 years/>8 years), marital
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status (married/single), number of children, sBP, dBP, APG, TC, TG, HDL-C, LDL-C, waist circumference, obesity (present/not present), exercise (does/does not), diabetes in first-degree relatives (present/not present), menopause (present/not present), HT (present/not present), CVD (present/not present), thyroid disease (present/not present), PAD (present/not present), PCOS (present/not present), antipsychotic medication use, and giving birth to a large baby (yes/no) were the independent variables.
2.4.
was accepted. Hypertension: sKB≥140; dKB≥90 and/or use of antihypertensive medicine were accepted [23]. The Presence of Metabolic Syndrome (MetS): Diagnostic criteria of the International Diabetes Federation (IDF) were taken into consideration. In addition to the criteria of waist circumference of ≥94 cm in men and ≥80 cm in women, a high fasting blood pressure (≥100 mg/dL) or type 2 diabetes, high tension (≥85/130 mm Hg) or hypertension, low HDL-C (<40 mg/dL in men; <50 mg/dL in women), and high triglyceride (≥150 mg/dL) were accepted as diagnosis criteria [24].
Research variables
BMI: Values of 18.5 and lower were classified as “underweight”, 18.5 to <25 as “normal weight”, >25 as “overweight”, >30 as “obese” [19]. Classification of blood glucose: Normal plasma glucose (Fasting plasma glucose (FPG)≤ 100 mg/dL), Deteriorated Fasting Glucose: (IGT) (FPG:100–125 mg/dl) and diabetes (FPG≥ 126 mg/dl) was considered [16]. Presence of Heart Disease: A diagnosis by a doctor and/or use of heart medicine
3.
Results
Among the study population (n: 930), the prevalence of diabetes was determined to be 13.6% (n: 124). In people with diabetes, 84.7% (n: 105) were diagnosed before and 15.3% (n: 19) were newly diagnosed. 11.4% of men (n: 39) and 11.2% of women (n: 66) were known to have diabetes, while 3.7%
Table 1 – Demographic characteristics and risk factors of the healthy population (n = 825). Men (n: 303) n (%) Residential area 101(33.3) Urban 202(66.7) Rural Educational level 165(54.5) ≤8 years 138(45.5) >8 years Smoking 93(30.7) Current smoker 210(69.3) Non-smoker Alcohol consumption 19(6.3) Yes 284(93.7) No Exercise (≥5 times per week; at least 30 min) Yes 77(25.4) 226(74.6) No 86(28.4) MetS 30(9.9) CVD 74(24.4) HT 19(6.3) Thyroid 20(6.6) PAD 1(0 .03) Stroke – PCOS 18(5.9) Antipsychotic drug use 99(32.7) Obesity 48.09 ± 12.91 Age 122.28 ± 19.30 sKB 77.65 ± 11.11 dKB 161.18 ± 88.32 TG 41.17 ± 9.01 HDL-C 88.03 ± 25.13 FPG 32(10.6) Hypoglycemia (<70 mg/dl) 233(77.4) FPG (70–100 mg/dl) 25(8.3) IPG (100–125 mg/dl) 11(3.7) Diyabet (≥126 mg/dl) 28.09 ± 4.11 BMI WC 99.38 ± 12.24
Women (n: 522) n (%)
Total or Mean (n: 825) n (%)
p
247(47.3) 275(52.7)
348(42.2) 477(57.8)
<0.001
373(71.5) 149(28.5)
538(65.2) 287(34.8)
<0.001
82(15.7) 440(84.3)
175(21.2) 650(78.8)
<0.001
1(0.02) 521(99.8)
20(2.4) 805(97.6)
<0.001
103(19.7) 419(80.3) 165(31.6) 38(7.3) 128(25.5) 103(19.7) 88(16.9) 2(0.04) 50(9.6) 105(20.1) 199(38.1) 44.81 ± 13.95 115. 87 ± 18.92 74.08 ± 11.20 135.55 ± 73.61 49.45 ± 10.89 86.77 ± 23.87 53(10.3) 411(79.7) 44(8.5) 8(1.6) 28.44 ± 5.94 93.35 ± 15.72
180(21.8) 645(78.2) 251(30.4) 68(8.2) 202(24.5) 122(14.8) 108(13.1) 3(0.04) 50(9.6) 123(14.9) 298(36.1) 3.34 4.63 4.41 4.45 −11.14 0.717 85(10.4) 644(78.8) 69(8.4) 19(2.3) −0.89 5.62
0.05 0.33 0.18 0.97 <0.001 <0.001 0.90 – <0.001 0.11 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.28
<0.001 <0.001
CVD: Cardiovascular disease, HT: Hypertension, PAD: Peripheral Arterial Disease, PCOS: Polycystic Ovarian Syndrome, sBP: Systolic Blood Pressure, dBP: Diastolic Blood Pressure, TG: Triglycerides, HDL: High density lipoprotein, LDL: Low density lipoprotein, FPG: Fasting Plasma Glucose, IPG: Impaired Plasma Glucose DM: Diabetes Mellitus, BMI: Body Mass Index WC: Waist circumference.
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Table 2 – Diabetes risk of the northeastern Turkish population.
Diabetes risk score Mean 10-year risk (%)
Men (n: 303)
Women (n: 522)
Min-Max
t
p
11.99 ± 6.21 17.44 ± 17.25
12.67 ± 7.01 19.92 ± 18.47
0–30 1–50
−1.38 −1.904
0.16 0.05
of men (n: 11) and 1.6% of women (n: 8) were newly diagnosed with diabetes. In the healthy population, there was no significant difference between men and women in terms of diabetes prevalence (p: 0.934). When we excluded the patients with previously known diabetes, in total, 825 people (63.27% women, 36.73% men) participated in the study (urban: %42.2, rural: 57.8%). The mean age of men was 48.09 ± 12.91 years. The number of men who were educated for more than 8 years, who smoked and consumed alcohol, (p < 0.001), and who exercised (p: 0.057) was higher. The prevalence of thyroid and peripheral arterial disease (PAD) prevalence and antipsychotic medication use is more common in women (p < 0.001). Waist circumference, sBP, dBP, BMI, and biochemical parameters including TG, HDL, and FPG values are slightly higher in men (p < 0.001) (Table 1). Men have a mild (11.99 ± 6.21; 4%) and women have a medium diabetes risk (12.67 ± 7.01; 16%). There are no significant differences in diabetes risk scores and 10-year risk percentiles between men and women (p > 0.05) (Table 2). According to the diabetes risk scores of the FINDRISK model, 21.1% of the population is in the high risk group, while 16.4% is in the very high risk group (Table 3). In the healthy population, people with a risk score of ≤14 were grouped as low risk individuals, while those with a score of ≥15 were grouped as high risk individuals. Number of children and age were found to be higher in people with high diabetes risk. People who were married and were educated for ≤8 years exhibited more risk (p < 0.001). Not smoking (p < 0.005) and not exercising (p < 0.001) is more common in the risky population. In the high risk population, the prevalence of obesity, MetS, HT, CVD, PAH, (p < 0.001) and PCOS, thyroid diseases, and stroke (p < 0.005) are higher. Giving birth to a large baby (p < 0.005) and having a familial history of diabetes (p < 0.001) are more common in high risk individuals. Similarly, sBP, dBP, BMI, mean waist circumference, APG, TG, and LDL-C values were found to be higher (p < 0.001), while HDL-C values were found to be lower (Table 4). It was determined that increase in age (OR 1.09, 95% CI [1.06–1.126, p < 0.001), decrease in education (OR 0.51, 95% CI [0.27–0.93], p < 0.05), obesity (OR 5.17, 95% CI [2.85–9.39], p < 0.001), waist circumference (OR 1.05, 95% CI [1.02–1.07], p < 0.001), familial history of diabetes (OR 15.27, 95% CI [8.02–29.10], p < 0.001), and not exercising (OR 0.87, 95% CI
Table 3 – Distribution of the northeastern Turkish population according to diabetes risk groups. Total score <7 7–11 12–14 15–19 ≥20
Level of risk Very low Low Medium High Very high
10-year risk %1 %4 %16 %33 %50
% (n) 25.0(206) 21.0(173) 16.5(137) 21.1(174) 16.4(135)
[0.33–6.69], p < 0.001) contributed to high diabetes risk. Hypertension (OR 2.60, 95% CI [1.42–54.76], p < 0.005) and heart disease (OR 4.81, 95% CI [1.61–14.37], p < 0.005) were associated with high diabetes risk (Table 5). The model predicts the risk of diabetes for the entire population at 68% accuracy (−2 log likelihood: 379.28, Cox & Snell R Square: 0.50; Nagelkerke R Square: 0.68; p < 0.001).
4.
Discussion
The main finding of this study is that the prevalence of diabetes is 13.6% in the northeast of Turkey, that 37.5% of the healthy population is in the high risk group according to the FINDRISK model, and that the high risk population has more diabetes risk factors compared to the low risk population. Also, increased age, low level of education, familial history of diabetes, not exercising, high waist circumference, and obesity increased diabetes risk in the population. Being in the high risk group was associated with hypertension and heart disease.
4.1.
Prevalence and high risk groups
It was determined that the prevalence of diabetes is 15.1% in men and 12.8% in women and that the prevalence rate is slightly lower than the entire Turkish population (16.5%) [1]. Considering the population of Rize (323012) [25], it can be said that 2 of every 10 people (approximately 44,000 people) have diabetes. It was determined that the prevalence of diabetes in the study population is higher than the prevalence in eastern and middle Asia countries (9.1%) [9] and similar to the prevalence rates in south and middle America (11.35%). In the CREDIT study, which was conducted in the Turkish population, the prevalence of diabetes was found to be 12.7% [26]. As in other population-based studies, the present study also indicated that the prevalence of diabetes is higher in women [1,9,27]. According to a previous study which was conducted using the FINDRISK, 10.5% of the population was found to have high risk [28]. In the present study, 21.1% of the population had a high 10-year diabetes risk, while 16.4% had very high risk. It is expected that 310 people (37.5%) will develop diabetes in the next 10 years in the study population. It is evident that one third of the population (n: 103,260 people) has high risk. In the present study, it was determined that men were in the mild risk group and women were in the medium risk group. In one study, which evaluated diabetes risks using the FINDRISK model in 3 cohorts of a Dutch population, it was found that 16–28% of the population was in the medium and high risk groups [29]. Considering these findings, it is observed that diabetes risk in the north eastern population of Turkey is much higher compared to the Dutch population.
Please cite this article in press as: A. Bayındır C¸evik, et al., Prevalence and screening for risk factors of type 2 diabetes in Rize, Nourtheast Turkey: findings from a population-based study, Prim. Care Diab. (2015), http://dx.doi.org/10.1016/j.pcd.2015.06.002
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Table 4 – Factors associated with high diabetes risk (n: 825). 10-year diabetes risk
Low risk (n: 516)
High risk (n: 309)
Total or mean (n: 825)
p
Gender Men Women
199(38.8) 316(61.2)
103(33.3) 206(66.7)
302(36.7) 520(63.3)
0.11
Educational level ≤8 years >8 years
276(53.8) 237(46.2)
260(84.1) 49(15.9)
536 (65.2) 286(34.8)
<0.001
Marital status Married Single
424(82.7) 89(17.3)
294(95.1) 15(14.4)
718(87.3) 104(12.7)
<0.001
Smoker Current smoker Non-smoker
126(24.4) 390(75.6)
49(15.9) 260(84.1)
175(21.3) 647(78.7)
<0.005
Alcohol consumption Yes No
18(3.5) 498(96.5)
2(0.6) 307(99.4)
20(2.4) 802(97.6)
<0.005
Exercise Yes No
139(26.9) 377(73.1)
41(13.3) 268(86.7)
177(21.5) 645(78.5)
<0.001
History of family DM Yes No
158(30.6) 358(69.4)
175(56.6) 134(43.4)
175(56.6) 489(59.5)
<0.001
Obesity Yes No
101(19.6) 415(80.4)
197(63.8) 112(36.2)
298(36.3) 524(63.7)
<0.001
CVD Yes No
17(3.3) 496(96.7)
51(16.5) 258(83.5)
68(8.3) 754(91.7)
<0.001
MetS Yes No
102(19.8) 414(80.2)
149(48.2) 160(51.8)
251(30.5) 571(69.5)
<0.001
HT Yes No
53(10.3) 463(89.7)
149(48.2) 160(51.8)
202(24.6) 620(75.4)
<0.001
Thyroid disease Yes No
61(11.9) 452(88.1)
60(19.4) 249(80.6)
121(14.7) 701(85.3)
<0.005
PAD Yes No
49(9.5) 467(90.5)
59(19.1) 250(80.9)
108(13.1) 714(86.9)
<0.001
Presence of PCOS (n: 514) Yes No
21(6.7) 291(93.3)
29(14.4) 173(85.6)
50(9.7) 464(90.3)
<0.005
Antipsychotic drug use Yes No
60(11.7) 453(88.3)
62(20.1) 247(79.9)
122(14.8) 700(85.2)
<0.001
Stroke Yes No
0(0) 516(100)
3(1.0) 306(99.0)
3(0.04) 819(99.6)
<0.005
Giving birth to a large infant (n: 522) Yes No
29(9.2) 285(90.8)
33(16.0) 173(84.0)
62(10.2) 548(89.8)
<0.005
Fruit and vegetable consumption (n: 790) 344(71.5) Every day 137(28.5) Not every day
210(68.0) 99(32.0)
554(70.1) 236(29.9)
0.28
Please cite this article in press as: A. Bayındır C¸evik, et al., Prevalence and screening for risk factors of type 2 diabetes in Rize, Nourtheast Turkey: findings from a population-based study, Prim. Care Diab. (2015), http://dx.doi.org/10.1016/j.pcd.2015.06.002
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Table 4 (Continued ) 10-year diabetes risk
Low risk (n: 516)
High risk (n: 309)
Oral contraceptive use (n: 522) Yes No
19(6.0) 296(94.0)
Diabetes symptom complaints Yes No Age Number of children sKB dKB BMI WC FPG TC TG HDL-C LDL-C
4.2. risk
Total or mean (n: 825)
p
7(3.4) 200(96.6)
26(3.2) 796(96.8)
0.17
17(3.3) 492(96.7)
28(9.2) 277(90.8)
44(5.4) 769(94.6)
<0.001
41.0 ± 12.3 2.0 ± 1.6 113.5 ± 16.8 73.2 ± 10.8 26.6 ± 4.8 90.3 ± 14.4 83.5 ± 18.4 207.5 ± 45.2 135.9 ± 78.0 47.0 ± 11.1 132.6 ± 37.5
54.2 ± 11.7 3.3 ± 1.6 125.8 ± 20.6 79.0 ± 11.0 31.1 ± 4.9 104.0 ± 11.1 93.3 ± 30.9 220.9 ± 45.5 159.9 ± 81.7 45.3 ± 10.5 143.0 ± 40.7
<0.001 −10.5 −9.30 −7.36 −13.04 −14.15 −5.60 −4.07 −4.17 2.16 −5.6
<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
Prevalence of risk factors and contribution of high
It is known that aging increases the risk of diabetes [1,30]. It was determined that people with high risk were older and that increased age increased the risk of diabetes by a factor of 1.10. In a study which examined the prevention of diabetes, it was found that aging increased diabetes development by a factor of 2.59 [31]. In the population, mean BMI was found to be higher in people with high risk compared to those with low risk. It is known that obesity increases the development of diabetes [32]. Due to obesity, women (38.1%) and men (36.1%) were found to be prone to diabetes. In one study which was conducted in a primary care setting in Cuba, it was reported that 80% of the population with diabetes was overweight and obese [28]. Also, in the present study, it was determined that the rate of obesity (63.8%) is higher in people with high risk. The body-mass index does not indicate the distribution of body fat, and waist circumference is also used as a measure of obesity and the associated insulin resistance and diabetes [13,33]. The waist circumference values of both men and women are higher than the values determined for the Turkish population [30]. Waist circumference of people with
high risk is higher than those with low risk. The increase in waist circumference contributes to high risk by a factor of 1.05. Lack of physical activity is an important factor in the development of type 2 diabetes [33]. It was found that not exercising was more common in the high risk group (%86.7) and increased diabetes risk by a factor of 0.41. In this study, not exercising posed a risk against women. Low educational level has a positive effect on disease development and acquisition of related risk factors [34,35]. People with high risk were found to have low levels of education. Low educational level increases diabetes risk in women (71.5%) This finding indicates that people with low educational levels do not conform to healthy lifestyle habits and therefore their diabetes risk increases. In a study conducted in Malaysia, it was found that women were mostly married and had low levels of educational and glycemic control [35]. It was found that people who were married and who had more children had higher risk of diabetes. In one study, women had low educational levels and obesity was more common among these women compared to their better educated counterparts [34]. Numerous studies provide evidence for the relationship between obesity and weight gain and high risk of diabetes [36,37]. In the present study, it was determined that obesity
Table 5 – Factors influencing high diabetes risk.
Age Educational level Exercise Waist circumference History of family Obesity Hypertension CVD Constant
B
SE
Wald
Sig
OR
95% CI
0.09 −0.67 −0.87 0.05 2.72 1.64 0.95 1.57 −11.74
0.01 0.31 0.33 0.01 0.32 0.30 0.30 0.55 1.381
45.55 4.69 6.69 18.49 68.75 29.16 9.64 7.92 72.34
<0.001 <0.05 <0.05 <0.001 <0.001 <0.001 <0.005 <0.005 <0.001
1.09 0.51 0.41 1.05 15.27 5.17 2.60 4.81 0.00
1.06–1.12 0.27–0.93 0.21–0.80 1.02–1.07 8.02–29.10 2.85–9.39 1.42–54.76 1.61–14.37
OR: Odds Ratio. 95% CI: Confidence interval.
Please cite this article in press as: A. Bayındır C¸evik, et al., Prevalence and screening for risk factors of type 2 diabetes in Rize, Nourtheast Turkey: findings from a population-based study, Prim. Care Diab. (2015), http://dx.doi.org/10.1016/j.pcd.2015.06.002
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played a role against women (63.8%) and that obesity increased the population’s diabetes risk by a factor of 5.17. Previous studies showed that familial history of diabetes indicates proneness to diabetes [38,39]. In the ATTICA study, which was conducted with the Greek population, it was reported that familial history of diabetes is an important predictor of diabetes development (OR 2.8) [34]. In this study, familial history of diabetes (OR 15.27) was determined to be a far more important predictor than in the Greek population. Risk of cardiovascular disease and hypertension is known to begin in the preclinical period of diabetes [17,40]. In the nondiabetic population, the prevalence of heart disease (16.5%) was found to be high. Heart disease is 2-4 times more frequent in people with diabetes [41]. In a Korean study, it was found that cardiovascular mortality is more effective in the group with diabetes (OR 1.07) [42]. Cardiac morbidity related to diabetes risk was 4.81 times more common. In the northeast of Turkey, cardiac morbidity related to high diabetes risk is 4 times more common than the Korean population. The prevalence of hypertension is 2 times more common in people with diabetes compared to non-diabetics [43]. Consistently, in the present study, the presence of HT increases diabetes risk by a factor of 2.60 in the healthy population. The model acquired in this study predicts diabetes risk of the entire population at a high rate (68%). It can be said that the model has high reliability for health research [44]. There are various limitations of present the study. The study sample represents a specific population living in Rize, the northeast region of Turkey; therefore, the study findings cannot be generalized to the people who live in other geographic regions of Turkey. In this study, OGTT could not be used for determining the prevalence of diabetes due to its cost. Therefore, IFG was evaluated and IGT could not be assessed. Nevertheless, the findings of the present study provided information that can guide primary health service providers in preventing diabetes.
5.
Conclusion
This epidemiological study provides important data that has not been obtained from the region before for health authorities. Aging, low educational level, familial history of diabetes, not exercising, obesity, high waist circumference, heart disease, and hypertension were determined to be predictors that increase the risk of diabetes. Familial history of diabetes was found to be a very important predictor of diabetes and low educational level played a prominent role in the acquisition of risks related to diabetes development. In the study, the contribution of risk factors to increased diabetes risk in the population was found to be higher compared to other studies conducted with different populations. Considering that one third of the population has high risk and that they will develop diabetes in the next 10 years, the number of doctors and nurses in family health centers who are trained in diabetes should be increased and dieticians should be involved. Since atherosclerosis develops in the early period, screening high risk groups for cardiovascular disease and hypertension and initiating aggressive treatments can be cautionary. Individuals with high risk should be thought as people diagnosed with
7
diabetes and they should receive intense training on lifestyle regulations.
Author’s note This risk screening study was carried out within the project titled “Evaluation and management of cardiometabolic risk factors in adults living in the city of Rize: a population-based study”
Funding ˘ This study was supported by the Recep Tayyip Erdogan University (RTEU) Scientific Research Project (SRP) unit as the research numbered 2012.110.01.1. All costs of the study were covered by the RTEU SRP unit.
Conflict of interest The authors state they have no conflict of interest.
Acknowledgments Authors offer their thanks to the Provincial Health Director Dr. Mustafa Tepe who provided permit and support on conducting the survey part of the study, to the laboratory supervisor Köksal Karaca for his assistance on conducting biochemical analyses, to the Family Health Center staff and to all participants of the study.
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