Olufemi Fasanmade

An Assessment of the Disease Burden of Foot Ulcers in Patients With Diabetes Mellitus Attending a Teaching Hospital in Lagos, Nigeria

The major part of the burden of people with diabetes mellitus (DM) is their impaired quantity and quality of life. This is due to acute and chronic complications of which diabetic foot ulceration (DFU) takes the greatest toll. Most studies on the disease burden of DFU were carried out in developed countries, and to date, no indigenous study has addressed the burden of foot ulceration in Nigerians with DM. This study attempted to determine the disease burden of this important DM complication. The study was carried out at the Lagos University Teaching Hospital (LUTH), Lagos, Nigeria. The working definition of disease burden encompassed prevalence, morbidity, mortality, and the direct economic costs of diabetes mellitus foot syndrome (DMFS). For determination of the estimates of prevalence, the “capture-recapture” and intensive case-counting methods were used, mortality and morbidity were determined from records of admissions, and associated deaths over a 3-year period (1998-2000). The direct economic costs of foot ulceration were derived from the costs incurred from in-patient days, tests, drugs/medications, surgery, and other miscellaneous units of services. The total number of people with DM seen in LUTH from 1998 to 2000 was 1500, the hospital prevalence of DFU using the capture-recapture method being 9.5%. A total of 7253 medical admissions were made in this 3-year period, and of this number 827 (11.4%) were DM related. DFU-related admissions were 97 in number, and this made up 1.3% and 11.7% of the total medical and diabetes admissions, respectively. During this period, a total of 61 lower limb amputations were carried out and 26 (42.6%) of these were DM related. The proportion of medical deaths due to DMFS deaths was greater than the proportion of medical admissions due to DFU (P = .007). The case fatality of individuals with DFU was ∼53%. A total number of 20 patients with DM foot ulcers were hospitalized during a 1-year period of the study (2003-2004). The majority had type 2 DM. A large majority (65%) of these patients had some form of surgery in addition to medical management of their condition. Mean costs for successfully treating a patient with DMFS was Nigerian Naira (NGN) 180 581.60. The total costs incurred ranged from NGN 20 400.00 to NGN 278 029.00. Drugs or medications accounted for the majority of the total costs incurred by the patients (46.9%).

Profile of Nigerians with diabetes mellitus - Diabcare Nigeria study group (2008): Results of a multicenter study

Background: Diabetes Mellitus is the commonest endocrine-metabolic disorder in Nigeria similar to the experience in other parts of the world. The aim was to assess the clinical and laboratory profile, and evaluate the quality of care of Nigerian diabetics with a view to planning improved diabetes care. Materials and Methods: In a multicenter study across seven tertiary health centers in Nigeria, the clinical and laboratory parameters of diabetic out-patients were evaluated. Clinical parameters studied include type of diabetes, anthropometry, and blood pressure (BP) status, chronic complications of diabetes, and treatment types. Laboratory data assessed included fasting plasma glucose (FPG), 2-h post-prandial (2-HrPP) glucose, glycated hemoglobin (HbA1c), urinalysis, serum lipids, electrolytes, urea, and creatinine. Results: A total of 531 patients, 209 (39.4%) males and 322 (60.6%) females enrolled. The mean age of the patients was 57.1 ± 12.3 years with the mean duration of diabetes of 8.8 ± 6.6 years. Majority (95.4%) had type 2 diabetes mellitus (DM) compared to type 1 DM (4.6%), with P < 0.001. The mean FPG, 2-HrPP glucose, and HbA1c were 8.1 ± 3.9 mmol/L, 10.6 ± 4.6 mmol/L, and 8.3 ± 2.2%, respectively. Only 170 (32.4%) and 100 (20.4%) patients achieved the ADA and IDF glycemic targets, respectively. Most patients (72.8%) did not practice self-monitoring of blood glucose. Hypertension was found in 322 (60.9%), with mean systolic BP 142.0 ± 23.7 mmHg, and mean diastolic BP 80.7 ± 12.7 mmHg. Diabetic complications found were peripheral neuropathy (59.2%), retinopathy (35.5%), cataracts (25.2%), cerebrovascular disease (4.7%), diabetic foot ulcers (16.0%), and nephropathy (3.2%). Conclusion: Most Nigerian diabetics have suboptimal glycemic control, are hypertensives, and have chronic complications of DM. Improved quality of care and treatment to target is recommended to reduce diabetes-related morbidity and mortality.

Characterization of lipid parameters in diabetes mellitus – a Nigerian report

Background Diabetes mellitus (DM) is a disorder that is often associated with cardiovascular events and underlying lipid abnormalities. Cardiovascular complications are common causes of DM deaths in Nigeria yet dyslipidaemia is one aspect of DM that is underdiagnosed and undertreated in our patients. This report seeks to determine the prevalence and pattern of lipid abnormalities in Nigerians with types I and 2 DM. Methods A total of 600 patients with DM aged between 22 – 79 years were evaluated for lipid abnormalities. The anthropometric indices, glycosylated haemoglobin, pattern of DM treatment and co-morbidities were noted. Total cholesterol (TCHOL), triglyceride (TG), high density lipoproteins (HDL-C), low density lipoproteins cholesterol (LDL-C) levels and the atherogenic indices levels were documented. Test statistic used included students t test and χ2. Results Well over half (89%) of the study subjects had lipid abnormalities and there was no statistically significant difference in the proportions of subjects with type 1 and 2 DM with lipid abnormalities. Elevated LDL-C, TCHOL, TG and reduced HDL-C were noted in 74%, 42%, 13%, and 53% respectively of the study subjects. The commonly noted combined lipid abnormalities were elevated TG and reduced HDL-C. Hypertension, significant histories of smoking and alcohol ingestion were found to be potential determinants of the occurrence of dyslipidaemia. Age, sex, type of DM and anthropometric indices were found to be determinants of the the pattern of dyslipidaemia. Only a small proportion – (8%)-of the subjects with dyslipidaemia were on treatment for it. Conclusion Having defined the scope of dyslipidaemia in our patients and also highlighting its gross undertreatment, we hope that our data will help sensitize health care practitioners on screening for and treating dyslipidaemia. Elevated LDL-C and reduced HDL-C should be the primary targets of treatment in our patients with dyslipidaemia.

Clinical features, predictive factors and outcome of hyperglycaemic emergencies in a developing country

BackgroundHyperglycaemic emergencies are common acute complications of diabetes mellitus (DM) but unfortunately, there is a dearth of published data on this entity from Nigeria. This study attempts to describe the clinical and laboratory scenario associated with this complication of DM.MethodsThis study was carried out in DM patients who presented to an urban hospital in Nigeria with hyperglycaemic emergencies (HEs). The information extracted included biodata, laboratory data and hospitalization outcome. Outcome measures included mortality rates, case fatality rates and predictive factors for HEs mortality. Statistical tests used are χ2, Students t test and logistic regression.ResultsA total of 111 subjects with HEs were recruited for the study. Diabetes ketoacidosis (DKA) and hyperosomolar hyperglycaemic state (HHS) accounted for 94 (85%) and 17 (15%) respectively of the HEs. The mean age (SD) of the subjects was 53.9 (14.4) years and their ages ranged from 22 to 86 years. DKA occurred in all subjects with type 1 DM and 73 (81%) of subjects with type 2 DM. The presence of HSS was noted in 17 (19%) of the subjects with type 2 DM.Hypokalaemia (HK) was documented in 41 (37%) of the study subjects. Elevated urea levels and hyponatraemia were noted more in subjects with DKA than in those subjects with HHS (57.5%,19% vs 53%,18%). The mortality rate for HEs in this report is 20% and the case fatality rates for DKA and HHS are 18% and 35% respectively.The predictive factors for HEs mortality include, sepsis, foot ulceration, previously undetected DM, hypokalaemia and being elderly.ConclusionHHS carry a higher case fatality rate than DKA and the predictive factors for hyperglycaemic emergencies mortality in the Nigerian with DM include foot ulcers, hypokalaemia and being elderly.

Prevalence of dysglycemia in Calabar: a cross-sectional observational study among residents of Calabar, Nigeria

Objective Population data on dysglycemia are scarce in West Africa. This study aimed to determine the pattern of dysglycemia in Calabar city in South East Nigeria. Design This was a cross-sectional observational study. Methods 1134 adults in Calabar were recruited. A multistage sampling method randomly selected 4 out of 22 wards, and 50 households from each ward. All adults within each household were recruited and an oral glucose tolerance test was performed. Dysglycemia was defined as any form of glucose intolerance, including: impaired fasting glucose (blood glucose level 110–125u2005mg/dL), impaired glucose tolerance (blood glucose level ≥140u2005mg/dL 2u2005h after consuming 75u2005g of glucose), or diabetes mellitus (DM), as defined by fasting glucose level ≥126u2005mg/dL, or a blood glucose level ≥200u2005mg/dL, 2u2005h after a 75u2005g glucose load. Results Mean values of fasting plasma glucose were 95u2005mg/dL (95% CI 92.1 to 97.5) for men and 96u2005mg/dL (95% CI 93.2 to 98.6) for women. The overall prevalence of dysglycemia was 24%. The prevalence of impaired fasting glucose was 9%, the prevalence of impaired glucose tolerance 20%, and the prevalence of undiagnosed DM 7%. All values were a few percentage points higher for men than women. Conclusions The prevalence of undiagnosed DM among residents of Calabar is similar to studies elsewhere in Nigeria but much higher than the previous national prevalence survey, with close to a quarter of the adults having dysglycemia and 7% having undiagnosed DM. This is a serious public health problem requiring a programme of mass education and case identification and management in all health facilities. Trial registration number CRS/MH/CR-HREC/020/Vol.8/43

Prevalence of a marker of active helicobacter pylori infection among patients with type 2 diabetes mellitus in Lagos, Nigeria

BackgroundThere appears to exist a potentially important interplay between diabetes mellitus (DM) and Helicobacter pylori (H. pylori) infection. Findings from previous studies have been conflicting. Only a few studies have examined the topic in a sub-Saharan African population. This study sought to determine the prevalence of H. pylori infection among Type 2 diabetes mellitus (T2DM) patients in Lagos, Nigeria.FindingsH. pylori infection was detected in 18% of T2DM patients and 13% of controls but there was no statistical significance in this difference (pu2009=u20090.52). The prevalence of H. pylori was neither associated with the known duration of T2DM nor was it associated with age, gender, body mass index (BMI), smoking status. T2DM was not shown to be a risk factor independently associated with risk for H. pylori infection (ORu2009=u20090.87, 95% CIu2009=u20090.58-1.31, pu2009=u20090.57).ConclusionsThe lack of a statistical significant difference between the H. pylori infection rates in T2DM patients and controls suggests that the infection is not increased in T2DM. Larger studies need to be conducted to confirm the study findings.

Diabetes foot ulceration in a Nigerian hospital: in-hospital mortality in relation to the presenting demographic, clinical and laboratory features.

This prospective study assessed in‐hospital mortality from diabetic foot ulcer in relation to the demographic, clinical and laboratory features at presentation. Forty‐two patients admitted with diabetic foot ulcer were followed up from admission till discharge from hospital. Those who survived or died were compared for any differences in demographic, clinical and laboratory parameters at presentation. The mean age and duration of diabetes for the 42 patients were 56.1 ± 1.9 years and 8.3 ± 1.1 years, respectively. The in‐hospital mortality rate amongst the 42 subjects was 40.5%. Ulcer grade 4, leucocytosis and anaemia were more prevalent in those who demised in comparison with survivors.

Type 2 diabetes mellitus and its risk factors among the rural Fulanis of northern Nigeria

BACKGROUNDnInformation about diabetes mellitus (DM) from the rural populations in Nigeria, particularly among the rural Fulanis is limited.nnnMATERIALS AND METHODSnThis was a cross-sectional study conducted in two rural districts of Sokoto State in Northern Nigeria. Using a modification of the WHO STEP wise approach to surveillance (STEPS) instrument, information on sociodemographic and anthropometric data was obtained. Either a casual or fasting plasma glucose (FPG) level was obtained in all subjects while oral glucose tolerance test was performed in a randomly selected group of 50 of the study participants.nnnRESULTSnThree hundred and ninety-three subjects participated in the study. The prevalence rates of DM, impaired fasting glycemia (IFG), and impaired glucose tolerance (IGT) were 0.8, 6.9, and 8%, respectively. The mean (SD) FPG was higher in males (5.1 ± 0.6 mmol/L) than in females (4.9 ± 0.6 mmol/l), but not statistically significantly (P = 0.20). The major risk factors for DM among the rural Fulani were obesity and increasing age.nnnCONCLUSIONnThe prevalence rates of DM and its principal risk factor obesity are low among the rural Nigerian Fulani. However, the prevalence of prediabetes is relatively high, a factor that may predispose to the future development of DM.

Effect of Vitamin D supplementation on glycemic control in Type 2 diabetes subjects in Lagos, Nigeria

Introduction: Improvement of glycemic control reduces the risk of diabetic complications. Reports suggest that Vitamin D supplementation improves glycemia. However, there are no data on the influence of Vitamin D on diabetes mellitus (DM) in Nigeria. Objective: To determine the effect of Vitamin D supplementation on glycemic control in Type 2 DM (T2DM) participants with Vitamin D deficiency. Design: This was a single-blind, prospective randomized placebo-controlled trial, involving T2DM participants attending the Diabetes Clinic of the Lagos University Teaching Hospital. Forty-two T2DM participants with poor glycemic control and Vitamin D deficiency were selected following a prior cross-sectional study on 114 T2DM participants for the determination of Vitamin D status and glycemia. These participants were randomized into two equal groups of treatment and placebo arms. Intervention: Three thousand IU of Vitamin D3 were given to the participants in the treatment arm. Glycemic status was determined at baseline and after 12 weeks. Statistical analysis was performed using Statistical Package for Social Sciences version 20. P < 0.05 was considered statistically significant. Results: Vitamin D3 supplementation resulted in a significant improvement in serum Vitamin D level and fasting plasma glucose in the treatment arm compared to placebo. There was a nonsignificant reduction in the mean HbA1c level in the treatment group after 12 weeks of Vitamin D3 supplementation (Z = −1.139; P = 0.127) compared to the placebo group, which had a further increase in the mean HbA1c level (Z = −1.424; P = 0.08). The proportion of participants with poor glycemic control (HbA1c > 6.5%) who converted to good control after Vitamin D supplementation was significantly higher in the treatment arm compared to placebo (P < 0.05). Conclusion: Vitamin D3 supplementation in persons with T2DM and Vitamin D deficiency results in a significant improvement in glycemic control.

Latent Autoimmune Diabetes Mellitus in Adults (LADA) and it’s characteristics in a subset of Nigerians initially managed for type 2 diabetes

Introduction Latent autoimmune diabetes in adults (LADA) is an entity characterized by the presence of GAD autoantibodies. LADA is largely understudied and underreported amongst Nigerians with Diabetes Mellitus (DM). We undertook to document the Prevalence, clinical and biochemical characteristics of LADA in a subset of Nigerians who hitherto had been treated for type 2 DM. Methods This is a cross-sectional study conducted on 235 patients being managed for type 2 DM. The diagnosis of LADA was made in the presence of Glutamic Acid Decarboxylase autoantibody (GADA) positivity in the study subjects. Thereafter persons with LADA were compared with those without LADA. Clinical parameters such as demographic data, history of diabetes mellitus (DM) and its complications were obtained, biochemical parameters including Fasting blood glucose (FBG), C-peptide, glycated haemoglobin (HbA1c) and lipid parameters were compared in both groups of Study subject. Test statistics used were Student t- test and χ 2. SPSS was used for data analysis. Results Thirty three out of 235 of the Study subjects were GADA positive, giving a prevalence of 14%. The mean age (SD) of the subjects with LADA is 53.24(7.22) with an age range of 30–63u2009years. Majority (48%) of LADA subjects were in the 50–59 age category. There was no significant difference in the proportion of males and females with LADA (p = 0.3). 37% of patients with LADA were on insulin for glycaemic control. Three (3) LADA subjects had history/clinical evidence of autoimmune thyroid disease. 66% of LADA were in the overweight/obese category. LADA subjects had significant poor long term glycaemic control compared with anti-GAD negative subjects (p = 0.026). About half of LADA subjects were insulinopaenic. LADA subjects had lower levels of total cholesterol than GADA-ve subjects (p = 0.03). A higher proportion of LADA had evidence of microvascular complications of DM compared with antiGAD negative individuals. Conclusion The diagnosis of LADA should be entertained in overweight/obese persons from the fourth decade of life presenting with DM. Pharmacotherapy with insulin is a potential means of managing hyperglycaemia in this group of patients especially since a significant proportion are insulinopaenic. The Prevalence of LADA in our patients is comparable to what obtains in Ghanaian and Caucasian populations.