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ORIGINAL ARTICLE
Year : 2009  |  Volume : 10  |  Issue : 2  |  Page : 56-62 Table of Contents     

Hypertension in Yemeni patients with type II diabetes and its association with vascular complications


Al-Thawra Teaching Hospital, Sana'a University, Sana'a, Yemen

Date of Web Publication17-Jun-2010

Correspondence Address:
Abdul-Karim M Al-Khawlani
Assistant Professor, Department of Internal Medicine, Faculty of Medicine, Sana’a University
Yemen
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Background: Diabetes Mellitus (DM) and its complications are a common problem among Yemeni population. Hypertension is commonly associated with type II DM. Both are risk factors for vascular complications. This study was designed to assess the prevalence of hypertension in Yemeni patients with Type II DM, and its association with macrovascular and microvascular complications.
Objective: The aim of this study is to determine the prevalence of hypertension among Yemeni patients with diabetic Type II, and its association with vascular complications of DM.
Subjects and methods: A Cross Sectional Study was carried out in Al-Thawra Hospital, between June to December 2007. A total of one hundred eighty-nine adult patients with Type II DM were included in the study. The diagnosis of Diabetes was based on the WHO criteria, while the diagnosis of hypertension was based on the criteria of the fifth Joint National Committee (JNC-5). The patients were divided into two groups: with and without hypertension, and their clinico-laboratory parameters were studied and analyzed.
Results: The mean age was 55.6 ± 10.2 years, and mean BMI was 22.61 ± 3.6 kg/m 2 . The mean time duration of DM was 8.9 ± 6.3 years. The prevalence of hypertension in Type II diabetic patients was 55% (N = 104 patients). No significant differences were observed in the duration, sex and BMI of both groups. Hypertension was significant in the elderly, low HDL cholesterol, and poor glycemic control group. The hypertensive diabetic groups were observed to have more ischemic heart disease (IHD), diabetic nephropathy, diabetic retinopathy and peripheral neuropathy than the normotensive diabetics.
Conclusion: Hypertension is common among Yemeni patients with Type II DM. It's associated with increased prevalence of both micro-and macro-vascular complications.

Keywords: diabetes mellitus, hypertension, diabetic complication, yemen


How to cite this article:
Al-Khawlani AKM, Raja Y, Al-Ansi AQ. Hypertension in Yemeni patients with type II diabetes and its association with vascular complications. Heart Views 2009;10:56-62

How to cite this URL:
Al-Khawlani AKM, Raja Y, Al-Ansi AQ. Hypertension in Yemeni patients with type II diabetes and its association with vascular complications. Heart Views [serial online] 2009 [cited 2021 Oct 19];10:56-62. Available from: https://www.heartviews.org/text.asp?2009/10/2/56/63745


   Introduction Top


Diabetes mellitus is a disease with a high prevalence worldwide. In the last few years its prevalence has become more widespread in the developing countries. This is especially the case in the eastern Mediterranean countries, which have experienced an upward surge in the prevalence of DM over the last 20 years. This is likely a result of economical development and changes in lifestyle, especially in nutritional habits. Hypertension frequently co-exists with diabetes [1] . There is an increased prevalence of hypertension among diabetic patients. When hypertension and DM occur together, the two disease entities appear to aggravate one another, worsening both diabetes and cardiovascular end points [2] . The prevalence of hypertension in type II diabetic patients is estimated to be 50% [3] and as high as 74% in another estimation [4] .

A high prevalence of hypertension in diabetes means that these two diseases may be etiologically related. Central adiposity and insulin resistance can exert effect on blood pressure [5] . Along with hyperglycemia, hypertension are major contributors to the development and progression of macrovascular and microvascular complications in people with diabetes [6] . Compared to the general population, people with diabetes face a two to four-fold increased risk of cardiovascular disease (CVD) [1],[7] . Concomitant hypertension significantly accelerates the progression of diabetes nephropathy, retinopathy and neuropathy [8],[9] .

There is evidence that intensive reduction in blood pressure will reduce microvascular and macrovascular complications in patients with diabetes [10] . The Seventh Report of the Joint National Committee on Prevention, Detection Evaluation and Treatment of High Blood Pressure (JNC-7) [11] and American Diabetes Association (ADA) [12] have recommended that blood pressure should be decreased to less than 130/80 mm Hg in these patients.

In the Republic of Yemen, the population is ethnically homogenous and up to the present time, there is no information to show the prevalence of hypertension among Diabetic Type II in the adult population. The prevalence of diabetes mellitus Type II among Yemeni population has been found to be 4.6% in Sana'a city (7.4% in male and 2% in female) [13] .

In this study, we sought to determine the prevalence of hypertension among Yemeni patients with diabetic Type II, and its association with vascular complications of DM.


   Subjects and Methods Top


A total of one hundred eighty-nine adult Yemeni patients (93 male and 96 female) aged between 30-85 years, with diabetes mellitus Type II, were enrolled in this cross-sectional study. Patients included those who attended the out-patient clinic in Al-Thawra General Teaching hospital in Sana'a city from June to December 2007. Diagnosis of DM Type II was based on clinical features and confirmed biochemically according to WHO criteria [14] . The study was approved by the Ethical Committee of the Faculty of Medicine & Health Sciences, Sana'a University. Patients consented to participate in the study.

The inclusion criteria for this study were patients with DM Type II, normotensive or hypertensive patients with no evidence of any other causes of secondary hypertension. Patients with Type I or signs suggestive of Type I, such as ketonuria were excluded from the study. The following data was collected: patients' age, sex, body mass index (BMI) and duration of the disease. Symptoms related to diabetes, its complications, and the types of the treatment were recorded. All patients were subjected to clinical assessment which included detailed clinical examination. Assessment and grading of retinopathy was carried out by a qualified ophthalmologist. Body weight (kg) and height (cm) were measured with indoor clothes and without shoes. Overweight was defined as BMI between 25-29.9kg/m 2 and obese 30kg/m 2 according to WHO criteria [15] .

Blood pressure was calculated as the mean of two measurements performed in a sitting position after 5 minutes rest with 5 minutes interval using a random-zero mercury sphygmomanometer. Individuals were considered hypertensive if systolic blood pressure was 140 mmHg and diastolic blood pressure was 90 mmHg, in two sittings or were taking anti-hypertensive drugs. These cut-offs were considered according to the criteria of the Joint National Committee (JNC-5) [16] .

Capillary whole blood sample, after 8-12h fasting, were obtained, plasma glucose concentrations and two hours postprandial glucose were assessed by means of a glucose hexakinase method (Roche Diagnostic, Mannheim, Germany). HbA1C was determined and any patient with HbA1C above 7% was considered to be uncontrolled. Serum total cholesterol, HDL cholesterol, and triglyceride were measured by means of enzymatic techniques (Boehringer-Germany, Mannhein). The Friedword Formula was used to calculate LDL cholesterol. Hypercholesterolemia was considered high with cholesterol level over 200mg/dl. Hypertriglyceridemia was defined as triglyceride level greater than 150mg/dl, following the criteria as per summary of the third report of the National Cholesterol Education Program (NCEP 2001) [17] .

Diabetic nephropathy was diagnosed by the presence of positive persistent proteinuria by urinary dipstick, or creatinin of more than 1.6mg/dl, or end stage renal disease. Microalbuminuria was not done because of limited resources.

All patients underwent a standard 12 lead electrocardiogram (ECG) which, if abnormal, or if there was any history of chest pain, the patient underwent echocardiography. Patients were considered as having IHD if they had one of the following: Hospitalization for acute myocardial infarction, or an episode of angina pectoris, 12-lead ECG for previous acute MI, or angina, history of coronary artery bypass graft, and percutaneous transluminal coronary angioplasty.

Neuropathy was assessed using a Semmes-Weinstein 109 filament over the feet, reflexes, and vibrations sense, over the great toe or ankle, and history of neuropathic symptoms (tingling, numbness, and burring pain). Cerebro-vascular disease was supported by clinical, or radio diagnostic evidence (CT scan) of cerebrovascular accident, or history of stroke. The physicians ascertained the presence of peripheral vascular disease on physical examination when one or more foot pulses were absent, or if amputation and/or gangrene were present, and the presence of vascular symptoms of cramps and/or claudication.


   Statistical Analysis Top


The study sample was divided into 2 groups according to the presence of hypertension, normotensive and hypertensive groups. Data were analyzed using statistical package for the social sciences (SPSS/PC + version 15). Chi-Square test was used to test the difference between proportions and a T-test was used for continuous variables. A p-value less than 0.05 were considered to represent statistical significance.


   Results Top


A total of 189 diabetic patients were included in this study (93 patients were male and 96 were female). Mean age was 55.6 ± 10.8 years and mean body mass index BMI was 22.6 ± 10.2kg/m 2 . Only 13% (24 patients) were overweight (BMI 22-29.9kg/m 2 ) and 5.8% (11 patients) were obese (BMI 30kg/m 2 ) while the majority of patients 69.3% (131 patients) were within normal weight limits (BMI < 25kg/m 2 ).

Fifty five percent, [104 patients (51 male and 53 female)] had co-existing hypertension. 96 patients had systolic hypertension, with a mean 163.2 ± 18.1mmHg, and 43 patients had diastolic hypertension, with a mean 105.3 ± 8.6 mmHg, the remaining 85 patients, 45% (42 male and 43 female) were normotensive, with no evidence of previous or current treatment for hypertension.

The characteristics of the patients with both hypertensive and normotensive groups were comparable in sex, BMI and duration of diabetes. The hypertensive diabetic groups had a mean age of 57.9 ± 9.8 years, while the normotensive groups had a mean age of 52.8±10. The difference between the two groups were significant (p = 0.001) [Table 1].

[Table 2] shows the parameters of the biochemical variables in the two comparative groups. The percentage of hypertension among non-controlled blood glucose patients was 60.8% (93 out of 153), while it was 41.7% (15 out of 36) among the controlled blood glucose patients. The difference between the two groups was statistically significant (P = 0.049) [Figure 1].

There was no difference in laboratory parameters such as cholesterol, triglyceride and LDL, but HDL was lower in hypertensive groups, the difference between the two groups was significant (P = 0.015) [Table 3].

The prevalence rate of microvascular and macrovascular complications of diabetes in both normotensive and hypertensive groups are shown in [Table 4].

The problems of neuropathy (P = 0.005), retinopathy (background (P = 0.033) and proliferate (P = 0.036), nephropathy (P = 0.002), and ischemic heart disease (P = 0.006) were higher in the hypertensive groups, and the difference in both groups was statistically significant. While the difference in the prevalence of stroke (P = 0.355), and peripheral vascular disease (P = 0.331), were not statistically significant.


   Discussion Top


Our findings showed that the prevalence of hypertension in type II diabetic Yemeni patients is 55%. This rate is much higher than the previously reported rate by Gunaid et al in 1997 which was 24.2% [18] . This finding could be attributed to the changing criteria in the diagnosis of hypertension and changes in lifestyle. Moreover, the previous study by Gunaid et al reflected the prevalence of hypertension in both type I, and type II diabetes, while our rates indicate hypertension in type II DM only. Our results demonstrate a comparable rate of hypertension in type II diabetic patients, with that reported from most of the countries in the region [Figure 2]: Saudi Arabia 52% [19] ; United Arab Emirates 40.4% [20] ; Bahrain 38% [21] ; Kuwait 46.5% [22] . In Sudan, the prevalence in Sudan was 40% [23] . However, a comparison of our data with these reports is difficult because of the different criteria used between our study and the others including different age groups, and the different methodologies.

In developed countries, the rates were as high as 75% in United States [24] and 63% in France [25] . The rate is higher in Europe and the US because hypertension and diabetes mellitus are on the rise in industrialized nations where populations are aging and both diseases increase with age. The mean age of our patients was 55.6 ± 10.8 years, while in US was 65.9 ± 8.3 [23] and in France was 63.4 ± 0.3 [26] .

Our data showed that hypertensive diabetic patients are older, more obese, and with prolonged duration of diabetes. Although the differences were statistically significant only in older age, this finding is consistent with the findings of other studies [27] . The association between obesity and hypertension in type II diabetes mellitus is epidemiologically established [28] . Factors that increase the likelihood of hypertension include increasing age and duration of diabetes [29],[30] . The lower prevalence of obesity in our study could be attributed to the nature of the local diet, pattern of lifestyle, and environmental factors, in addition to the sample size of the study.

We found that hypertension is higher in those with poor blood glucose control compared to those with good control. This is consistent with the literature [31],[32] . This is also supported by the findings of trials on the role of tight glycemic control in prevention, or delaying long term diabetic complications including hypertension [33] . High density lipo-protein cholesterol (HDL) was lower in hypertensive groups, while the prevalence rate of total cholesterol, triglyceride, and low density lipo-protein (LDL) were comparable in both groups. These findings are in line with published literatures [34],[35],[36] . Apart from triglyceride, which was not high, the low prevalence of obesity in our sample, may suggest that the metabolic syndrome "syndrome X" [37] does not play a role in the pathogenesis of hypertension in our patients, and the hypertension could be related to genetic, or environmental factors such as khat chewing [38] .

Regarding patients with macrovascular complications of diabetes, we found that the prevalence of ischemic heart disease is higher in hypertensive diabetic patients than normotensive diabetic patients while the difference in patients with peripheral vascular disease and stroke were not. This may be due to the limited number of patients with stroke and peripheral vascular disease. This association would be better clarified if a case control design with higher sample size was adopted.

In patients with microvascular complication, we found that the prevalence of the nephropathy, retinopathy (background and proliferate retinopathy), and diabetic neuropathy were higher in the hypertensive groups than in the normotensive groups. Along with hyperglycemia, hypertension is a major contributor to the development and progression of macrovascular and microvascular complications in people with diabetes [39] . The high prevalence of hypertension in diabetic patients is associated with increased stiffness of large arteries which often precedes macrovascular events [40] . Similarly, hypertension significantly accelerates the progression of diabetic nephropathy, retinopathy, and neuropathy [7],[41] .


   Conclusion Top


We conclude that hypertension is a common problem among our diabetic patients. The occurrence of hypertension is significantly associated with older age, poor glycemic control, low HDL cholesterol, and increase in the incidence of ischemic heart disease. Vascular complications such as retinopathy, neuropathy, and nephropathy are more frequent when both diseases co-exist. Therefore, early detection and rigorous control of both blood glucose and blood pressure would reduce the vascular complications. A large sample size study in this patient population is needed.

 
   References Top

1.Sowers JR; Epstein M; Frolich ED. Diabetes, hypertension, and cardiovascular disease: An update: Hypertension. 2001;371035-1059.   Back to cited text no. 1      
2.Stamler J; Vaccaro O; Neaton JD; Wentworth D. Diabetes, other risk factors, and 12- year cardiovascular mortality for men screen in the Multiple Risk factor Intervention Trial. Diabetes Care 1993:16:434-444.   Back to cited text no. 2      
3.Basit A; Hydrie MZI; Hakeem R; Ahmedani MY; Masood Q; Frequency of chronic complication of diabetes. J CoII P S P 2004;14:79-83.   Back to cited text no. 3      
4.Cowie CC, Harris MI. Physical and metabolic characteristics of persons with diabetes. In: Harris MI; Cowie CC; Reiber G; et al. eds. Diabetes in Americ, 2nd ed. Washington, D C: US Government printing office; 1995:117.   Back to cited text no. 4      
5.Niaura R, Banks SM, Ward KD, et al. Hostility and metabolic syndrome in older males. The normative aging study. Psych Som Med 2000; 62:7-16.   Back to cited text no. 5      
6.Beckman JA, Crenger MA, Libby P. Diabetes and atherosclerosis epidemiology, pathophysiology and management: JAMA.2002; 287: 2570-2581.   Back to cited text no. 6      
7.Nakagani T; Qiao O; Tuomilehto J; Balkau B; Tajima N; Hu G; Johsen B. Screen-detected hypertension and hypercholesterdemia as predictors of cardiovascular mortality in five populations of Asian origin: the DECODA study. Eur J Cardiovasc Prev Rehabil. 2006; 13: 555-561.   Back to cited text no. 7      
8.Fong DS; Aiello LP; Ferris FL 3rd; Klein R. Diabetic retinopathy. Diabetes Care.2004; 27: 2540-2553.   Back to cited text no. 8      
9.UK Prospective Diabetes Study Groups: Tight blood pressure control and risk of macrovascular and microvascular complication in Type II diabetes: UK PDS 38. BMJ. 1998;317:703-713.   Back to cited text no. 9      
10.Zanella MT; Kohlmann O; Ribeiro AB. Treatment of obesity, hypertension and diabetes syndrome. Hypertension. 2001;38([part2]):705-708.   Back to cited text no. 10      
11.Chobanian AV; Bakris GL; Black HR; Cushman WC; Green LA; Izzo JL Jr; Jones DW; Materson BJ; Oparil S; Wright JT Jr; Roccella EJ: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report. JAMA. 2003;289:2560-2572.   Back to cited text no. 11      
12.American Diabetes Association: Treatment of hypertension in adults with diabetes (Position Statement). Diabetes Care 2003; 26 (Suppl. 1):S80-S82.   Back to cited text no. 12      
13.Al-Habori M; Al-Mammari M; Al-Meeri A. Type2 diabetes mellitus and impaired glucose tolerance in Yemen: Prevalence, associated metabolic changes and risk factors. Diabetes Research and Clinical Practice. 2004; 65:275-281.   Back to cited text no. 13      
14.World Health Organization. Definition, diagnosis and classification of diabetes mellitus and complications. Part 1: Diagnosis and classification of diabetes mellitus. Geneva: World Health Organization 1999.   Back to cited text no. 14      
15.World Health Organization. Obesity: preventing and managing the global epidemic. World Health Organization, Geneva 1998.   Back to cited text no. 15      
16.The Joint National Committee: The Fifth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. Arch Intern Med 1993; 153:154- 183.   Back to cited text no. 16      
17.Executive Summary of the Third Report of the National Cholesterol Education Progress (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adult (Adult Treatment Panel III). JAMA.2001; 285(19):2486-2487.   Back to cited text no. 17      
18.Gunaid AA; El-khally FMY; Hassan NAGM, Mukhtar E. Demographic and clinical features of diabetes mellitus in 1095 Yemeni patients. Ann Saudi Med.1997; 17(4):402- 409.   Back to cited text no. 18      
19.Akbar DH; Ahmed MM; .Algamdi AA. Cardiovascular risk factors in Saudi Arabian and Non-Saudi Arabian diabetic patients in Saudi Arabia. East Mediterr Health J, 2003; 9/5: (5-6):884-889.   Back to cited text no. 19      
20.Malik M; Bakir A; Abi Saab B; Roglic G; .Riny H. Glucose intolerance and associated factors in the multi-ethnic population of United Arab Emirates: result of the national survey. Diabetes Research and Clinical Practice.2005; 60:188-195.   Back to cited text no. 20      
21.Al-Mhroos F; Al-Roomi K ; McKeigme PM. Relation of high blood pressure to glucose intolerance, plasma lipids and educational status in an Arabian Gulf population. International Journal of Epidemiology. 2000; 29: 71-76.   Back to cited text no. 21      
22.Al-Sultan FA, Al-Zanki N. Clinical epidemiology of Type II diabetes mellitus in Kuwait. Kuwait Medical Journal. 2005; 37(2):98-104.   Back to cited text no. 22      
23.Khair M M, Ahmed A M, Elbalaa A: Hypertension in Type II diabetic patients. Saudi Medical Journal.2003; Vol 24 (6): 690-691.   Back to cited text no. 23      
24.Berlowitz DR; Ash AS; Hickey EC; Glickman M; Friedman R; Kader B: Hypertension management in patients with diabetes: the need for more aggressive therapy. Diabetes Care. 2003; 26:355-359.   Back to cited text no. 24      
25.Charpentier G; Gens N; Vaur L; Clerson P; Amer J; Guaret P; Combori TP. Arterial hypertension management in patients with type2 diabetes. Arch Mal Coeur Varss. 2002; Jul-Aug 95 (7-8):661-665.   Back to cited text no. 25      
26.Le Loch JP; Thervet F; Desriac J; Boyer JF; Simon D. Management of diabetic patients by general practitioners in France: an epidemiological study. Diabetes Metab. 1997;Feb: 26 (1): 43-49.   Back to cited text no. 26      
27.Davis TM; Stratton IM; Fox CJ; Holman RR .Tuner RC .UK prospective diabetes study 22. Effect of age at diagnosis on diabetic tissue damage during the 6 years of N1DM. Diabetes Care. 1997; 40:1435-1441.   Back to cited text no. 27      
28.Hu FB; Monson JE; Stompfer MJ; Colditz G; Liu S; Solomon CG, et al. Diet, Lifestyle and the risk of Type II diabetes mellitus in women. N Engl J Med. 2001; 345: 790- 797.   Back to cited text no. 28      
29.Stamler J; Vaccari O; Neaton TD; Wentworth D. Diabetes, other risk factors and 12-year cardiovascular mortality for men. Screen in the multiple risk factor intervention trial. Diabetes Care 1993; 10:434-444.   Back to cited text no. 29      
30.CDC Diabetes Cost - Effectiveness Group: Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for type2 diabetes. JAMA.2002; 287:2542-2555.   Back to cited text no. 30      
31.Vijan S; Hayward RA .Treatment of hypertension in Type2 Diabetes Mellitus: Blood Pressure Goals, Choice of Agents, and Setting Priorities in Diabetes Care. Ann Int Med, 2003; 138 (7):593-602.   Back to cited text no. 31      
32.Saydah SH; Fradkin J; Cowic CC. Poor control of risk factors for vascular disease among adult with previously diagnosed diabetes. JAMA.2004; 291:335-343.   Back to cited text no. 32      
33.UKPDS Group. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type II diabetes (UKPDS 33). Lancet.1988; 352:837-855.   Back to cited text no. 33      
34.Laakso M, Sarlund H, Mykkanen L. Insulin resistance is associated with lipid and Lipoprotein abnormalities in subjects with varying degrees of glucose tolerance. Arteriosclerosis.1990; 10:223-231.   Back to cited text no. 34      
35.Biermon El. Atherogenesis in diabetes. Arteriosclerosis Thromb Vasc Biol.1992:12:647- 656.   Back to cited text no. 35      
36.Howard BV. Lipoprotein metabolism in diabetes mellitus. J Lipid Res.1987; 613-628.   Back to cited text no. 36      
37.Liese AD, Ayer M, Davis EJ, Heffner GM. Development of multiple metabolic syndrome. An Epidemiological Perspective. 1998; 20: 157-172.   Back to cited text no. 37      
38.Hassan NAGM; Gunaid AA; El Khally FMY; Al-Noami MY; Murray-Lyon IM. Qat chewing and Arterial Blood pressure. A Randomised Controlled Clinical Trial of selective alpha-1 and beta-1 Adrenoceptor Blockades. Saudi Med J 2005; 26: 537 - 5 541.   Back to cited text no. 38      
39.Wannomethee SG; Shaper Ag; Durrington PN; Perry IJ. Hypertension, serum insulin, obesity and metabolic syndrome. J Harr Hyperten.1998; 12:735-741.   Back to cited text no. 39      
40.Lehmonn ED, Gosling RG, S?nksen PH. Arterial compliance in diabetes. Diabetic Med.1992; 9:114-119.   Back to cited text no. 40      
41.Tesfaye S, Chatarvedi N, Eaton SE, Ward JD, Manese, et al. Vascular risk factors and diabetic neuropathy. N Engl J Med.2005; 352:341-350.  Back to cited text no. 41      


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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