https://imcjms.com Ibrahim Medical College Journal of Medical Science https://imcjms.com/registration/journal_full_text/391 Tue, 28 Sep 2021 11:00:24 +0000 Abstract Background and objectives: Diabetes mellitus (DM) is a major health problem in South Asian Region including Bangladesh. Increasing prevalence of DM is likely to cause higher morbidity and mortality. The objective of this study was to find out the prevalence and incidence of diabetic complications in a Bangladeshi diabetic cohort attending BIRDEM, a largest referral center in Bangladesh for endocrine and metabolic diseases. Methodology: The study was conducted in BIRDEM-OPD (outpatient department) from 1 January to 31 December of 1995 and analyzed the data of diabetic cases preserved in BIRDEM registry since 1956. Up to 31 December 1985, the REFERENCE NUMBER (Ref No) of last case was ‘49,510’. Therefore, this retrospective cohort comprised of all those patients having Ref No 49,510 or less and attending BIRDEM-OPD for follow-up. In the year 1995, the cohort had follow-up for at least ten years. The duration of follow-up was 39 years (1956 to 1995).  The study also retrieved follow-up data from the guidebook of each registered diabetic patient. All data regarding clinical, anthropometric and biochemical investigations preserved in BIRDEM registry and in the patient's guidebook were retrieved and analyzed. The cohort was categorized into three groups (Gr1, 2 and 3) based on follow-up duration: >15, 10-15 and <10years, respectively. Results: Micro-vascular complications (retinopathy and nephropathy) were the highest among both Gr1 with follow-up >15y and Gr2 with follow-up 10-15y. Compared with the Gr2, retinopathy (34.4 vs. 48.5 %: c2 =11.5, p <0.001) and nephropathy (24.0 vs. 39.2 %: c2 = 15.6, p<0.001) were significantly higher in the Gr1. In contrast, HTN, skin-lesion and periodontal diseases were significantly higher in the Gr2 than in Gr1. All types of complications were found increasing with the duration of follow-up. For Gr1, the increasing trend of cerebrovascular accident (CVD/ stroke) and CHD was significant (p<0.01 and p<0.001). Mean blood glucose of study population revealed moderate to severe hyperglycemia in successive follow-up visits. The comparison between patients with and without severe hyperglycemia (2hPG: <10.0 vs. ³10.0 mmol/l) showed very little difference of complications. The increasing age over 40 years showed significant risk for CHD and hypertension. Conclusion: CHD, stroke and PVD were less frequent compared to those with retinopathy and nephropathy. Compared to microvascular complications the macrovascular events resulted in either early death or complete disability to pursue long-term follow-up. The most important and consistent predictors were female gender and duration of diabetes.  IMC J Med Sci 2022; 16(1): 002. DOI: https://doi.org/10.55010/imcjms.16.002 *Correspondence: M. Abu Sayeed, Department of Community Medicine, Ibrahim Medical College, 1/A Ibrahim Sarani, Segunbagicha, Dhaka-1000. email: sayeed@imc.ac.bd; sayeed1950@gmail.com   Introduction It has been proved that maintenance of normal blood glucose unequivocally reduces mortality from acute events (or complications) in diabetic population [1,2]. It has also been unanimous among diabetologists that normoglycemia is always desirable for wellbeing of the diabetic subjects [1]. The most common chronic complications were the development of either micro- or macro-vascular complications. The microvascular lesions encompass retinopathy, nephropathy and neuropathy. The macrovascular complications are related to atherosclerosis and include mainly coronary artery disease (CAD), peripheral vascular disease (PVD) and cerebrovascular disease (CVD or stroke). Three most world famous prospective studies – Diabetes Complication Control Trial (DCCT) [2], United Kingdom Prospective Diabetes Study (UKPDS) [3] and Minnesota study [4] concluded that strict monitoring and maintenance of normal blood glucose certainly prevents microvascular complications. In contrast, both the studies could not confirm whether and not ‘strict control of blood glucose’ effectively prevents macrovascular complications and prevents atherosclerotic mortality [3,5]. However, there have been a very few cohort studies to assess the diabetes complications in the south-east Asian region. This cohort study addressed to determine the prevalence and incidence of micro- and macro-vascular complications in a diabetes population of Bangladesh.   Study design The study basically analyzed retrospective data of a cohort of diabetic patients who were registered in the past at Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM). BIRDEM is the largest national referral center for diabetes and endocrine diseases in Bangladesh. BIRDEM started registration and follow-up of diabetic patients since 28 February 1956. The diabetic patients from all areas of the country are usually referred to this center. The patients are registered after confirmation of diagnosis. Once registered, they get a unique ‘Reference Number’ (Ref No) printed on the guidebook for follow-up care throughout life. Baseline information of all registered patients is stored in the center. Follow- up care records are maintained in the BIRDEM registry and also written in the guidebook of the patient. The first registration was started on the 28 February 1956 with Ref No 00001. This study cohort included all registered diabetic patients from the first Ref No 00001 (28February 1956) to the last Ref No 49,510 registered on the 31 December 1985. A total of 49,510 diabetic subjects were registered during this period. The selection criteria of the cohort was, therefore, all diabetes patients registered at BIRDEM during this period and attending BIDEM-OPD with their guidebooks for regular follow-up visits. The data collection period was one year, starting from the first January to the 31December 1995. Prior to the study, the doctors and health staff of BIRDEM-OPD were discussed about the study protocol. It was decided that whoever attends with reference number £49,510 would be received in a special counter designed for this cohort study (Figure-1). The guide-books were photocopied for retrieval of data. The BIRDEM history-sheet and guide book were the sources of data.     Figure-1: Steps for collecting data from the patient’s guidebook and from the newly generated investigations’ reports. BP – blood pressure; ECG – electrocardiogram; CCR – creatinine clearance; GB – guidebook   The baseline information included socioeconomic status, smoking habits, and family history of diabetes, hypertension, coronary heart disease, peripheral vascular disease and foot ulcer. The clinical and anthropometric examination included age, height, weight and calculated body mass index. In addition, measurements of blood pressure (for hypertension), peripheral arterial pulse for peripheral arterial disease (PAD), peripheral sensation (for neuropathy), electrocardiogram (for CHD), ophthalmoscopy (for retinopathy) and urinary albumin (for nephropathy) were taken. Similarly, for the assessment of biochemical risk factors for micro- and macro-vascular organic lesion some biochemical investigations were also included. These were plasma glucose, blood lipids, urea, creatinine, electrolytes and total urinary protein. The duration of study cohort was 39 years ranged from 1956 to 1995. We categorized the cohort into three groups: Gr1 with >15 years follow-up, Gr2 with 10-15 years and Gr3 with <10 years. Gr3 was included in the study as the reference for comparative analysis between the recent and the older subjects with varying duration of follow-ups. The biophysical (BMI, BP, 2hPG) characteristics of the patients with shorter duration were compared with the longer duration. Statistical analyses: The prevalence of complications was shown in percentages. Comparison between groups (men vs. women, rural vs. urban, Gr1 vs. Gr2) were estimated by unpaired t-test. Chi-sq test was used to determine the associations between variables. Chi-sq trend test estimated the trend of complications with increasing duration. The level of significance was accepted p<0.05. SPSS Window 19.0 Version was used for all these analyses.   Results According BIRDEM registry 26,349 diabetic patients were registered up to 31 December 1980. This was Gr1 cohort. Of the total 26,349, only 171 (0.7%) were found attending BIRDEM-OPD for follow up. The baseline and follow up data (complications, hospitalization and other investigations) of these 171 patents were retrieved either from their guidebooks or from the BIRDEM registry. The Gr2 cohort comprised 23,161 patients registered from 1 January 1981 to 31 December 1985. Of them, 625 (2.7%) were found attending BIRDEM-OPD for follow up. The Gr3 consisted of only 110 diabetic patients, supposedly, with fewer complications. They were registered from January 1986 through December 1990. The socio-demographic characteristics of Gr1 and Gr2 are shown in Table-1 and 2. The tables also depicted the number of patents attended follow up in successive 5 years interval. Both the groups showed urban predominance than the rural plus suburban. The predominance of female was found in Gr2 but of male in Gr1.   Table-1: Area and sex distribution of the study population, registered up to December 1980 (Gr1), and according to successive 5-year follow-up (n = 171).     Table-2: Area and sex distribution of the study population, registered from Jan 1981 through December 1985 (Gr2), and according to successive 5-year follow-up (n = 625).     Table-3: Mean post-prandial plasma glucose level of study population observed at registration and in the successive 5-year follow-up for ³15-year follow-up study (male + female, n=171, Gr1).     Table-4: Comparison of mean post-prandial plasma glucose level of the study population observed between at registration and last 5-year follow-up period for male and female     Table-5: The prevalence of macrovascular complications among the diabetic patients (n=171) who had ³15 years follow-up.     Table-6: The prevalence of microvascular complications among the diabetic patients (n=171, older group) who had ³15 years follow-up at BIRDEM-OPD.     The trend of 2h post-prandial glucose (2hBG) level of Gr1 is shown at registration and in the subsequent 5 year follow-up period in Table-3. The values of 2hBG were increasing significantly in every 5 years. This indicated that glycemic control target (≤7.8mmol/l) could not be maintained over the years. The significant increasing trend was observed in both male and female cases (Table-4). 2026 Ibrahim Medical College. All rights reserved.