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Anemia among adults with diabetes attending a general hospital in eastern Ethiopia: a cross-sectional study
Teshome Tujuba, 1 Behailu Hawulte Ayele, 2 Sagni Girma Fage, 3 Fitsum Weldegebreal41, Medical Laboratory, Guelmsau General Hospital, Guelmsau City, Ethiopia 2 School of Public Health, Faculty of Health and Medicine, Haramaya University, Harala State, Ethiopia; 3 School of Nursing and Midwifery, Faculty of Health and Medicine, Haramaya University, Ethiopia; 4 Faculty of Health and Medicine, Haramaya University, Harar City, Ethiopia News Agency: Sagni Girma Fage, Faculty of Health and Medical Sciences, Haral University, Ethiopia, Harar, Ethiopia POBox 235 Email giruu06@gmail.com Background: Although anemia is a common disease among diabetic patients, there is very little evidence of anemia in this part of the population in Ethiopia, especially in the research environment. Therefore, the purpose of this study was to evaluate the degree of anemia and related factors in adult diabetic patients treated in a general hospital in eastern Ethiopia. Methods: A cross-sectional study of health basics was conducted on 325 randomly selected adult diabetic patients. Follow-up clinic at the Gramsoe General Hospital in eastern Ethiopia. Use pre-tested structured questionnaires to collect data through interviews and then perform physical and laboratory measurements. Then enter the data into EpiData version 3.1, and use STATA version 16.0 for analysis. Fit a binary logistic regression model to identify factors related to anemia. When p-value<0.05, all statistical tests are declared significant. Results: The degree of anemia in adult diabetic patients was 30.2% (95% confidence interval (CI): 25.4%-35.4%). Men (36%) have higher anemia than women (20.5%). Male (adjusted odds ratio (AOR) = 2.1, 95% CI: 1.2, 3.8), DM ≥ 5 years (AOR = 1.9, 95% CI: 1.0, 3.7), comorbidities (AOR = 1.9, 95) %CI : 1.0, 3.7) and suffering from diabetic complications (AOR = 2.3, 95% CI: 1.3, 4.2) were significantly associated with anemia. Conclusion: Anemia is a moderate to moderate public health problem among adult DM patients in the study subjects. Male gender, the duration of DM, the presence of DM complications, and DM comorbidities are factors related to anemia. Therefore, routine screening and appropriate management should be designed for men, DM patients with long DM duration, and anemia patients with complications and comorbidities, so as to improve the quality of life of patients. Early diagnosis and regular monitoring of diabetes may also help minimize complications. Keywords: Anemia, Diabetes, General Hospital, Eastern Ethiopia
Anemia refers to the decrease in the number of circulating red blood cells (RBC) and/or the reduction in oxygen-carrying capacity as a result, which is insufficient to meet the physiological needs of the human body. 1,2 It affects developing and developed countries, for human health, social and economic development. 3 There are approximately 1.62 billion people with anemia in the world, accounting for 24.8% of the global population. 4
Diabetes mellitus (DM) is a metabolic disease, roughly divided into type I_juvenile or insulin-dependent diabetes and type II_non-insulin-dependent diabetes. 5 In diabetic patients, anemia is mainly due to inflammation, drugs, nutritional deficiencies, kidney disease, accompanying autoimmune diseases, 6,7 relative reduction in erythropoietin production, absolute or functional iron deficiency, and red blood cell survival shorten. 8,9 Therefore, anemia is common in diabetic patients. 10,11 In adults, the prevalence of anemia is 24% among women of childbearing age (15-49 years) and 15% among men aged 15-49. 12
In patients with DM, especially those with obvious kidney disease or renal insufficiency, the prevalence of anemia is about 2 to 3 times higher than that of patients without DM. 13,14 Anemia and diabetes, such as nephropathy, retinopathy, neuropathy, poor wound healing, and macrovascular disease [15,16], have a negative impact on the quality of life of patients. 17-19 Despite these facts, research reports indicate that as many as 25% of diabetic patients still cannot recognize anemia.20,21
Early recognition and treatment of anemia in DM patients can help reduce morbidity and mortality, and improve their quality of life. 22 However, overall, the evaluation of anemia in diabetic patients in Ethiopia is very low, and so far, there is no relevant research. This is especially true in the study area. Therefore, this study aims to estimate the degree of anemia in diabetic patients at the Gramsoe General Hospital in eastern Ethiopia and determine the factors related to it.
The study was conducted at the Glymso General Hospital (GGH) located in Glymso Town, Habro District, Oromiya State, Eastern Ethiopia. The hospital is located about 390 kilometers east of Addis Ababa, the capital of Ethiopia. 23 According to a report by the Habro Woreda Health Office, GGH is a referral center for an estimated 1.4 million people in the surrounding catchment area. It provides healthcare services to more than 90,000 patients in its different departments and clinics every year. The Diabetes Clinic is one of the professional units providing services to approximately 660 diabetic patients. Habro District is located at an altitude of 1800-2000 meters.
A hospital-based cross-sectional study was conducted from June 9, 2020 to August 10, 2020. Eligible participants are adult (≥18 years) diabetic patients who are followed up at GGH. Adult diabetic patients who have received blood transfusions in the past 3 months, patients who are pregnant or recently given birth or suffer from mental illness, patients who have undergone surgery or bleeding for any reason, and patients who have received intestinal parasite treatment are not included. Learn.
The sample size was determined by using a single population ratio formula and based on the following assumptions: 95% confidence interval, 5% error rate, and anemia prevalence of diabetic patients from Dessie Referral Hospital in Northeast Ethiopia (p = 26.7) %). 24 After adding 10% to the non-responders, the final sample size is 331.
660 diabetic patients were actively followed up in a diabetes clinic in GGH. Divide the total number of diabetic patients (660) by the final sample size (331) to get two sampling intervals. By using the register of diabetic patients receiving diabetes follow-up services in the hospital as a sampling frame, we applied a systematic random sampling technique to include all other patients in the study. Provide each study participant with a unique identification number to avoid duplication, in case the same patient reappears during the study for another follow-up.
Collect data on sociodemographic variables, alcohol consumption, smoking, and diet characteristics by using a structured questionnaire adapted from the step-by-step approach of the WHO chronic disease risk factor monitoring manual. 25 Tea and coffee consumption, waterpipe use, Carter’s chewing questionnaire, contraceptive use, and menstrual history were obtained by reviewing different literature. The 26-30 questionnaire was written in English and translated into the local language (Afaan Oromoo), and then translated back to English by different language experts to check consistency. Obtain clinical data such as the duration of diabetes, type of diabetes, complications of diabetes, and fasting blood glucose levels from the patient’s medical records. The data was collected by two professional nurses and a laboratory technician, and supervised by a master of public health graduate.
Measure blood pressure (BP) using a digital blood pressure meter (Heuer) that is regularly verified. Before measuring blood pressure, the subject had not drunk any hot beverages, such as tea, coffee or smoked tobacco, chewed Caterpillar, or performed vigorous exercise in the last 30 minutes. After the subject rested for at least five minutes and recorded the average BP reading, three independent measurements were taken on the left arm. The second and third measurements were taken five and ten minutes after the first and second measurements, respectively. Hypertension is defined as patients with elevated BP (SBP≥140 or DBP≥90mmHg) or those who have been previously diagnosed as taking antihypertensive drugs. 31,32
To determine the nutritional status through body mass index (BMI), we measured the height and weight of the patient. When each participant stood upright on the wall, their heels touched the wall together, did not wear shoes, kept their heads upright, and measured their height with a ruler and recorded the nearest 0.1 cm. Use a digital scale marked 0-130 kg to measure your weight. Before each measurement, calibrate the scale to zero level. Measure the weight of the participant while wearing light clothes and no shoes, and record the closest 0.1 kg. 33,34 Body mass index (BMI) is calculated by dividing body weight (kg) by height (m). Then the nutritional status is defined as: if BMI <18.5, underweight; if BMI = 18.5–24.9, underweight; if BMI = 25–29.9, overweight; if BMI ≥30.35,36, obesity
Near the midpoint between the bottom edge of the palpable ribs and the top of the end, use a non-elastic tape measure to measure the waist circumference and record to the nearest 0.1 cm. Central obesity is defined as the waist circumference threshold for men ≥ 94 cm, and the waist circumference threshold for women ≥ 80 cm. 30,36 During the training period, 10 adult diabetic patients were subjected to relative technical measurement error (%TEM) to minimize random anthropometric measurement errors. The recognized relative technical measurement errors within and between observers are less than 1.5% and less than 2%, respectively.
Laboratory technicians collected approximately two milliliters (2 mL) of blood samples from all participants and placed them in a test tube containing tripotassium ethylenediaminetetraacetic acid (EDTA K3) anticoagulant for the determination of hemoglobin. Properly mix the collected whole blood and use the Sysmex XN-550 hematology analyzer for analysis. The measurement of hemoglobin was adjusted by reducing the height of all participants by subtracting 0.8 g/dl and smoking status by subtracting 0.03 g/dl. Then define anemia as a female hemoglobin level <12g/dl and a male <13g/dl. The severity of anemia is divided into: the hemoglobin levels of men and women are 11–12.9 g/dl and 11–11.9 g/dl, respectively, which are mild anemia, while the hemoglobin levels of moderate and severe anemia are 8–10.9 g/dl, respectively dl and <8 mg/dl. Male and female
Collect five milliliters (5 mL) of venous blood in a test tube without anticoagulant to determine creatinine and urea. The whole blood without anticoagulant is clotted for 20-30 minutes and centrifuged at 3000 rpm for 5 minutes to separate the serum. Then, the Mindray BS-200E (China Mindray Biomedical Electronics Co., Ltd.) clinical chemistry analyzer was used to determine the serum creatinine and urea content by acid picrine and enzymatic methods. 37 Use creatinine clearance rate to estimate glomerular filtration rate. Use the Chronic Kidney Disease (CKD) Ratio (GFR), expressed as the CKD-EPI Cockroft-Gault formula expressed per 1.73 square meters.
Fasting blood glucose levels (at least 8 hours) are measured by finger pricks using a blood glucose meter calibrated for blood glucose. 38 If the fasting blood glucose level is <80 or> 130mg/dl, then the code is uncontrolled blood glucose control. Control when the fasting blood glucose value is between 80-130mg/dl 39
The study participants were provided with a clean wooden applicator stick and a clean, dry, leak-proof plastic cup with the subject’s serial number on it for fecal parasite inspection. Instruct them to bring a fresh stool sample of two grams (about the size of a thumb). After detecting worms (eggs and/or larvae) using direct wet mounting techniques, the samples were checked within 30 minutes of sample collection. The remaining samples were stored in a test tube containing 10 mL of 10% formalin to improve the detection rate of parasites, and after treatment with formalin-ether precipitation concentration technology, the Olympus Microscope was used for inspection.
Use a sterile lancet to collect capillary blood samples from fingers to detect malaria. Prepare a thin blood film on the same clean glass without grease, and then air dry. The slides were stained with 10% Giemsa for about 10 minutes, and the species of malaria parasites were screened. When 100 high power fields were examined under an oil immersion objective, the slide was considered negative. 40
Two-day training on data collection tools and methods was given to data collectors and supervisors. Before Chiro General Hospital collected the actual data of 30 diabetic patients, the questionnaire was pre-tested and necessary modifications were made accordingly. The physical measurement is standardized by the relative technical error of the measurement (%TEM). In addition, standard operating procedures are followed in all laboratory sample collection, storage, analysis and recording processes.
The ethics permission has been obtained from the Institutional Health Research Ethics Review Committee (IHRERC) of the former School of Health and Medicine of Am Valley University (IHRERC 115/2020). The college has issued a formal letter of support to GGH and obtained permission from the head of the hospital. Before collecting data, obtain informed, voluntary, written and signed consent from each study participant. Participants were told that all data collected from them would be kept confidential through the use of codes, and no personal identifiers would be used, and would be used only for research purposes. This research was conducted in accordance with the “Declaration of Helsinki”.
Check the integrity of the collected data, encode and enter EpiData version 3.1, and then export to STATA version 16.0 for data management and analysis. Use percentages, proportions, averages, and standard deviations to describe data. After adjusting the hemoglobin level according to the smoking status of the participants and the altitude of the area, the anemia status was determined according to the new WHO classification standard. Fit a two-variable logistic regression model to identify variables for the final multivariate logistic regression analysis. In bivariate logistic regression, variables with p-value ≤ 0.25 are regarded as candidates for multivariate logistic regression. Establish a multivariate logistic regression model to identify factors unrelated to anemia. Use odds ratio and 95% confidence interval to measure the strength of association. The statistical significance level was declared as p-value <0.05.
In this study, a total of 325 adult DM patients participated in the meeting, and the response rate was 98.2%. The majority of participants; males from rural areas are 203 (62.5%), 247 (76%), 204 (62.8%) and 279 (85.5%) are married men, and their race is Oromo. The median age of the participants was 40 years, and the interquartile range (IQR) was 20 years. Approximately 62% of the participants have never received formal education, and 52.6% of the participants are professional farmers (Table 1).
Table 1 Socio-demographic characteristics of adult DM patients treated in a general hospital in eastern Ethiopia in 2020 (N = 325)
Among the study participants, 74 (22.8%) reported that they had smoked at least once in their lives, compared with 13 current smokers (4%). In addition, 12 people (3.7%) are current drinkers, and 64.3% of the study participants are black tea. More than one-third (68.3%) of study participants reported that they always drink coffee after meals. One hundred thirty-three (96.3%) and 310 (95.4%) participants ate fruits and vegetables less than five times a week. Regarding their nutritional status, 92 (28.3%) and 164 (50.5%) participants were overweight and centrally obese (Table 2).
Table 2 Behavioral and nutritional characteristics of adult DM patients treated at the Eastern Ethiopia General Hospital in 2020 (N = 325)
More than 170 (52.3%) patients with type II DM had an average DM duration of 4.5 (SD±4.0) years. Almost 50% of DM patients are taking oral hypoglycemic drugs (glibenclamide and/or metformin), and nearly three-quarters of study participants have uncontrolled blood glucose (Table 3). Regarding comorbidities, 2% of participants had comorbidities. 80 (24.6%) and 173 (53.2%) patients with DM without hypertension were anemia and non-anemia respectively. On the other hand, among DM patients diagnosed with hypertension, 189 (5.5%) and 54 (16.6%) were anemia respectively.
Table 3 Clinical characteristics of adult DM patients treated in a general hospital in eastern Ethiopia in 2020 (N = 325)
The degree of anemia in diabetic patients is 30.2% (95% CI: 25.4-35.4%), and the average hemoglobin level is 13.2±2.3g/dl (males: 13.4±2.3g/dl, females: 12.9±1.7g/dl). Regarding the severity of anemia in DM patients with anemia, there were 64 cases of mild anemia (65.3%), 26 cases of moderate anemia (26.5%), and 8 cases of severe anemia (8.2%). Anemia in men (36.0%) was significantly higher than in women (20.5%) (p = 0.003) (Figure 1). We found a significant positive correlation between the severity of anemia and the duration of diabetes (r = 0.1556, p = 0.0049). This means that as the duration of DM increases, the severity of anemia tends to increase.
Figure 1 Anemia level by gender in adult DM patients treated in a general hospital in eastern Ethiopia in 2020 (N = 325)
Among DM patients, 64% of men and 79.5% of women are non-anemic, while 28.7% and 71.3% of current Khat chewers are anemic. 67% of adult DM patients who used coffee after meals were non-anemic, and 32.9% of them were found to have anemia. Regarding the existence of comorbidities, 72.2% of patients with DM without comorbidities were anemia, and 36.3% of patients with DM comorbidities were anemia. Diabetic patients with DM complications had higher anemia (47.4%) than those without DM complications (24.9%) (Table 4).
Table 4 Factors related to anemia among adult DM patients treated in a general hospital in eastern Ethiopia in 2020 (N = 325)
Fit bivariate and multivariate logistic regression models to examine the association between anemia and explanatory variables. In a bivariate analysis; age, gender, marital status, Khat chewing, coffee after meals, comorbidities, diabetic complications, DM duration and nutritional status (BMI) are significantly related to anemia with p value <0.25, and are Multivariate candidate logistic regression.
In the multivariate logistic regression analysis, men with DM ≥ 5 years of duration, the presence of comorbidities and complications of DM were significantly associated with anemia. Male adult DM patients are 2.1 times more likely to suffer from anemia than females (AOR = 2.1, 95% CI: 1.2, 3.8). Compared with DM patients without comorbidities, DM patients with comorbidities are 1.9 times more likely to be anemia (AOR = 1.9, 95% CI: 1.0, 3.7). Compared with patients with DM duration of 1-5 years, DM patients with DM duration ≥ 5 years are 1.8 times more likely to develop anemia (AOR = 1.8, 95% CI: 1.1, 3.3). The risk of anemia in patients with DM complications is 2.3 times that of colleagues (AOR = 2.3, 95% CI: 1.3, 4.2) (Table 4).
This study evaluated the severity of anemia and related factors in DM patients who were followed up for diabetes at Gelemso General Hospital. The degree of anemia in the current study is 30.2%. According to the WHO classification of public health importance, in the research environment, anemia is a moderate public health problem among adult patients with DM. Gender, duration of DM, the presence of DM complications, and men with DM comorbidities were identified as factors related to anemia.
The degree of anemia in this study is comparable to that of the Ethiopian Dessie Referral Hospital [24], but higher than that of the Ethiopian Fenote Selam Hospital [41] in a local study conducted in China, 42 Australia, 43 and India [44]. , Which is lower than studies conducted in Thailand [45], Saudi Arabia [46] and Cameroon [47]. This difference may be due to the age difference of the study population. For example, unlike the current study that did not include adults over 18 years old, a study in Thailand included adults over 60 years old, while a study in Cameroon included adults over 50 years old. The difference may also be due to decreased kidney function, inflammation, bone marrow suppression, and malnutrition (increasing with age)17.
We are surprised that in our study, male anemia is more common than female. This finding is contrary to other research reports [42,48], in which women are more likely to suffer from anemia than men with diabetes. The possible reason for this difference may be that the men in our study had higher Khat chewing habits, which may cause loss of appetite49, and Khat contains tannins-a substance that reduces the bioavailability of non-heme iron in the diet. 50 Another possible reason is that the higher intake of coffee and tea in men in this study inhibited the absorption of iron from the intestine. 51-54
We found that patients with DM ≥ 5 years are more likely to develop anemia than patients with DM with a course of 1-5 years. This is consistent with studies conducted at Fenote Selam Hospital in Ethiopia, 41 Iraq 55 and the United Kingdom. 17 This may be due to prolonged exposure to hyperglycemia, leading to an increase in inflammatory cytokines with anti-erythropoietin effects, resulting in a decrease in the number. The reduction of circulating red blood cells leads to a reduction in circulating hemoglobin. 35
Consistent with studies conducted in China, 13 anemia in this study was more common in DM patients with complications. Biologically, diabetic complications can severely damage the cell and blood vessel structure of the kidney, systemic inflammation, and the induction of erythropoietin release inhibitors may lead to diabetic anemia. 56 Hypoxia may affect gene expression, metabolism, capillary permeability and cell survival 57. Red blood cell reduction and its antioxidant properties associated with anemia may also cause further complications in diabetic patients58.
In addition, DM patients with comorbidities are more prone to anemia than DM patients without comorbidities. This is comparable to previous similar studies [35,59], which may be due to the impact of comorbidities (such as hypertension) leading to cardiovascular complications, thereby increasing the risk of anemia. 60
As one of the very few laboratory-based studies conducted in Ethiopia, chronic diseases such as DM have become more and more common, which constitutes the strength of this research. On the other hand, this study is a single study based on a hospital and may not represent all patients with DM or patients who are followed up in other medical institutions. The cross-sectional nature of the study design we used does not allow for the establishment of temporal relationships between anemia and factors. Future studies may need to use case controls, cohort studies or other research designs to consider the signs and symptoms of anemia, RBC morphology, serum iron, vitamin B12, and folic acid levels.
In the research environment, anemia is a moderate public health problem among adult DM patients. Gender, duration of DM, the presence of DM complications, and comorbidities were male and were identified as factors related to anemia. Therefore, routine anemia screening and appropriate management for DM patients with long DM duration, comorbidities and complications should be designed to improve the quality of life of patients. Early diagnosis and regular monitoring of DM may also help minimize complications.
Data supporting the results reported in the manuscript can be obtained from the corresponding author according to reasonable requirements.
We would like to thank the head of Gelemso General Hospital, the staff of the Diabetes Clinic, study participants, data collectors and research assistants.
All authors have made significant contributions to the work of the report, whether in terms of concept, research design, execution, data acquisition, analysis and interpretation, or in all these aspects; participated in the drafting, revision or rigorous review of this clause; finally Approved the version to be published; reached an agreement on the journal to which the article was submitted; and agreed to be responsible for all aspects of the work.
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Post time: Feb-19-2021