Prevalence of cardiovascular risk factors in Libyan patients with type 2 diabetes mellitus, 2013-2022
Samia A. Elmiladi and Elham O. Elgdhafi
Abstract: Cardiovascular disease (CVD) remains the leading reason of death among the patients with diabetes mellitus (DM). Individuals with DM have two to five time's greater risk of developing CVD than non DM. Unfortunately, a little data exists on Libya's prevalence and characteristics of cardiovascular risk factors. This study was aimed to evaluate the cardiovascular risk factors and to assess their control among patients with type 2 DM (T2DM). All the patients with T2DM who attended the outpatient clinic at National Diabetes Hospital from September, 2013 to April, 2022 were interviewed and examined and included in this study. Demographical data age, smoking habit, body mass index measure, drug intake, history of previous cardiovascular events, blood pressure and fasting lipid profile were all recorded. 1049 patients have completed the study with a mean age of 54.06 ± 14.5 years old (females represented 68.0% of the studied sample size), there were different duration of diabetes between the studied sample, varying from newly diagnosed patients (n = 265, 25.2%) and above ten years of diabetes duration patients (n = 488, 46.5%). Active smoking in 129 patients (12.3%), the bodyweight of studied patients ranged from 44.0 Kg to 186 Kg (85.65 ± 1.73), 820 of the patients had uncontrolled body weight (78.85%). Uncontrolled blood pressure, even with treatment, was found in 304 patients (29.0%), uncontrolled dyslipidaemia in 45 patients (04.3%), and uncontrolled hyperglycaemia in 816 patients (77.9%). Established CVD was positive in 295 patients (28.2%), maximum age group was in 54 - 74 years (n = 516, 49.3%). The most typical age group with multiple (more than three) CVD risk factors was 54 - 74 years of age, were female patients with more than ten years of history of diabetes, uncontrolled hyperglycemia (HBA1c > 10%), uncontrolled body weight, uncontrolled blood pressure and dyslipidemia. Thus, present data clearly indicated that Libyan patients with diabetes mellitus have high CVD risk factors. Even in patients with previous events, these uncontrolled risk factors elevate the likelihood of repeated cardiovascular events. Patients with diabetes mellitus necessitate a more aggressive approach to control the modified risk factors such as hypertension, dyslipidemia, obesity and smoking.
Cardiovascular diseases (CVD) are ischemic heart disease, cerebrovascular disease, peripheral arterial disease, heart failure, cardiac arrhythmia and hypertensive heart disease. CVD remains the most important reason for death amongst patients with type 2 diabetes (T2DM), where they have 2 - 4 folds augmented risk for CVD [1, 2]. Also, it is responsible for 80.0% of the mortality in DM . DM as coronary artery disease (CAD) risk equivalent, showed that the risk of coronary artery disease CAD death for patients with DM without prior myocardial infarction (MI) was comparable with that of their non-diabetic counterparts who had a history of MI . A recent meta-analysis article with 13 cohort studies established that patients with DM have 43.0% lower risk for potential hard CAD events compared to those with previous MI suggesting that at least some subgroups in patients with Dm have much less risk than they believe before . Patients with DM have a reduction in life expectancy of about 4 - 8 years compared with an individual without diabetes , and cardiovascular risk factors are considered a clinical marker of macro- and micro-vascular DM complications . Although straight forward advances in cardiovascular therapy and prevention significantly reduce diabetes-related coronary mortality in developed countries , cardiovascular morbidity remains high in most patients with DM. Considering the increasing number of cardiovascular event survivors and the global epidemic of T2DM, the number of patients with T2DM at a higher cardiovascular risk is expected to rise, posing a tremendous challenge for healthcare systems worldwide. Therefore, the cost-effective urgent policies for reducing cardiovascular risk in this population are required . Due to all those mentioned above and the increased incidence of DM among Libyan citizens and to the best of our knowledge, no previous studies have been reported with ten years of duration data, therefore, we conducted this study to assess the cardiovascular risk factors in patients with type 2 diabetic mellitus in Libya.
Materials and methods
This is an observational study: all the patients who attended the outpatient clinic at National Diabetes Centre, Tripoli, Libya from September, 2013 to April, 2022 were included in this study. All the demographic data (including age, gender and smoking habit), the duration of diabetes, history of previous cardiovascular events such as previous coronary artery diseases, heart failure episode and cerebrovascular accident were taken. In addition, other parameters were: measurement of body weight and height for calculating body mass index (BMI), blood pressure measurement and testing for fasting lipid profile with an assessment of diabetes control by HBA1c measures. An ethical approval was obtained from Bioethics Committee at Biotechnology Research Center (BEC-BTRC-22-2022) to carry out this research.
Statistical analysis: continuous variables are expressed in mean ± standard deviation and they presented by means of descriptive statistics. A cross tabulation and Chi-square tests to calculate Pearson Chi-square. The level of p value of 95% confidence intervals (95% CI) with a p < 0.05 was considered significant. All the calculations were performed with STATA version 11 (StataCorp LLC, College Station, Texas, USA).
In Table 1, a total of 1297 diabetic patients were enrolled in this study and 1049 patients completed the study with a response rate of 80.9%. Their mean age was 54.06 ± 14.5 years and females represented 68.0% of the studied sample. 516 patients were in the age group between 54 - 74 years (49.2%). There is a wide difference in duration of diabetes among the studied sample, varying from newly discovered in 265 patients (25.2%), duration of two to five years in 142 patients (13.5%), duration of five to ten years in 154 patients (14.6%) and more than ten years of diabetes duration found in 488 patients (46.5%). 129 male patients with active smoking (38.4% of the total males, n = 336) and 12.29% of the total number of our patients were active smokers. The body weight of the studied patients ranged from 44 Kg to 186 Kg (85.65 ± 1.73). Body mass index (BMI) was calculated for each patient as following: the underweight range was present in 01.63 % of the patients, normal BMI in 19.5%, overweight was in 24.9%, obesity was in 25.3%, and morbid obesity was found in 27.9% of the sampled patients, thus, 820 of the patients have uncontrolled body weight (78.16%). Uncontrolled blood pressure, even with treatment found in 304 patients (29.0%), uncontrolled dyslipidaemia was present in 45 patients (04.3%), uncontrolled hyperglycaemia was present in 816 patients (77.8%). In Table 2, the established cardiovascular disease was positive in 295 patients (28.2%). The most typical age group with multiple CVD risk factors (more than three risk factors), i.e., female gender, more than ten years of a history of diabetes, uncontrolled hyperglycemia (HBA1c > 10%), uncontrolled bodyweight, uncontrolled blood pressure and dyslipidemia was 54 -74 years (Table 2).
Table 1: Distribution of cardiovascular risk factors in Libyan patients with diabetes mellitus
Table 2: Risk factors in patients with diabetes according to the presence of ccardiovascular disease
The principle that prevention is better than cure, it was necessary to conduct this study on Libyan patients with DM to reduce the complications. So, we evaluated the prevalence of CVS risk factors among T2DM in Tripoli between 2013 and 2022. The CVD risk factors can be modified or changed such as stress, systemic arterial hypertension, obesity, smoking, dyslipidemia and DM, or non-modified factors such as age, gender and genetic. Many studies demonstrated that the relative risk of incident coronary artery disease is more remarkable in diabetic females than in diabetic males [10, 11] and that was found in current study where female patients had more CV risk factors than male patients (uncontrolled hypertension, uncontrolled BMI, uncontrolled HbA1c and more than 10 years of duration of DM). However, it was opposite of what observed by Hussein and his colleagues , where 75.0% of the patients had more CV risk factors were male. Cigarette smoking is strongly associated with an increased risk of CAD among patients with T2DM , thus, it is found in our study that 12.3% of the patients are active smokers and this is because the majority of the patients are females and active smoking is socially unacceptable among the females in Libyan community. This is much lower than what was observed previously that 42.5% of their patients are smokers . Blood pressure is well-known to be a strong CVD risk factor, as mentioned in several studies like UKPDS trial, which showed that tight blood pressure control decreases 44.0% strokes risk, 37.0% lower in microvascular endpoints and 34.0% reduction in risk in the proportion of patients with deterioration of retinopathy . Systolic and diastolic blood pressure were significantly associated with myocardial infarction, stroke, coronary artery bypass, angioplasty and cardiovascular death . 29.0% of our patients were uncontrolled their hypertension even with treatment and this ratio is lower than that observed previously  where 53.0% did not meet the target values for systolic blood pressure, however, other study reported that 88.0% of the patients have uncontrolled blood pressure measurements .
Dyslipidemia is well known to increase CV morbidity and mortality and it is more frequent findings with DM . The risk of developing CVD increases two-fold when dyslipidemia , unexpectedly, it is found in our study that dyslipidemia is in 04.3% of the patients with an unknown explanation which could be of Mediterranean diet or to the regular strictness of the patients to lipid-lowering drugs. Indeed, more studies to explain this observational findings are needed. Our findings were much less compared with other studies where 60.8% of their patients had dyslipidemia , others found 28.0% of the patients , 55.0% of the patients , 44.5% of the patients  and 40.0% of the patients had dyslipidemia . However, some of our patients were under lipid lowering drugs and others are on anti-hypertensive drugs. For every one percent increase in HbA1c concentration, there was 38.0% higher risk of the macrovascular event, 40.0% higher risk of microvascular event and 38.0% higher risk of death . In the current study, 87.5% of the patients had HbA1c more than seven, which was higher than that of Afandi and others  where 59.0% of the patients, 77.0% of their patients  and 81.0% of other study  had HbA1c more than 7. Although excessive body weight is linked with morbidity and mortality in patients with T2DM, the control of this variable in diabetic populations has rarely been emphasized in most studies . Currently, 78.2% of the patients were uncontrolled body weight and 24.9% of the patients were overweight, 25.3% were obese and 27.9% were morbidly obese. This result is lower than that observed by Hussein et al.  who were 33.3% were obese and 31.8% of the patients were overweight. Bawadya et al.  found that 55.0% of the patients were obese and Alhazmi et al.  reported that 85.7% of the patients were obese. As a well-known fact, previous history of CVD carries a much higher risk of recurrent CVD events or death . Nearly, a third of our patients had an established CVS (28.2%). Our finding was lower than the finding by Hussein and others  where 55.8% of the patients had an established CVD.
Conclusion: A significant percentage of the Libyan patients with type 2 diabetes mellitus have profound CVD risk factors. Even in patients with previous events, the uncontrolled risk factors elevate the likelihood of repeated cardiovascular events. Patients with diabetes mellitus necessitate more aggressive approach to control modified risk factors such as hypertension, dyslipidemias, obesity and smoking.
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Elmiladi & Elgdhafi (2023) Prevalence of cardiovascular risk factors in Libyan patients with type 2 diabetes mellitus. Mediterr J Pharm Pharm Sci. 3 (2): 27-33. https://doi.org/10.5281/zenodo.7877416.