Glycaemic, blood pressure and low-density lipoprotein-cholesterol control among patients with diabetes mellitus in a specialised clinic in Botswana: a cross-sectional study

Abstract

ObjectiveControl of glycaemic, hypertension and low-density lipoprotein-cholesterol (LDL-C) among patients with type 2 diabetes mellitus (T2DM) is vital for the prevention of cardiovascular diseases. The current study was an audit of glycaemic, hypertension and LDL-C control among ambulant patients with T2DM in Botswana. Also, the study aimed at assessing factors associated with attaining optimal glycaemic, hypertension and LDL-C therapeutic goals.DesignA cross-sectional study.SettingA specialised public diabetes clinic in Gaborone, Botswana.ParticipantsPatients with T2DM who had attended the clinic for ≥3 months between August 2017 and February 2018.Primary outcome measureThe proportion of patients with optimal glycaemic (HbA1c<7%), hypertension (blood pressure <140/90 mm Hg) and LDL-C (<1.8 mmol/L) control.ResultsThe proportions of patients meeting optimal targets were 32.3% for glycaemic, 54.2% for hypertension and 20.4% for LDL-C. Age≥ 50 years was positively associated with optimal glycaemic control (adjusted OR [AOR] 5.79; 95% CI 1.08 to 31.14). On the other hand, an increase in diabetes duration was inversely associated with optimal glycemic control (AOR 0.91; 95% CI 0.85 to 0.98). Being on an ACE inhibitor was inversely associated with optimal hypertension control (AOR 0.35; 95% CI 0.14 to 0.85). Being female was inversely associated with optimal LDL-C control (AOR 0.24; 95% CI (0.09 - 0.59).ConclusionPatients with T2DM in Gaborone, Botswana, presented with suboptimal control of recommended glycaemic, hypertension and LDL-C targets. These findings call for urgent individual and health systems interventions to address key determinants of the recommended therapeutic targets among patients with diabetes in this setting.

Review of Ongoing Activities and Challenges to Improve the Care of Patients With Type 2 Diabetes Across Africa and the Implications for the Future

“…Published figures suggest a prevalence up to 15% of the diabetes population in Africa have ketosis-prone diabetes (Sobngwi et al, 2002;Mbanya et al, 2010;Sjöholm, 2019); however, this could be an under estimate. In addition, there are also concerns with available resources and copayments within public healthcare systems in Africa leading to continued endorsement and listing of appropriate SUs and metformin rather than funding newer oral medicines such as the DPP4 and SGLT2 inhibitors, as well as concerns with inertia with physicians prescribing insulins rather than again funding newer more expensive oral anti-diabetic medicines (Davies et al, 2018;Mwita et al, 2019).…”

“…This includes addressing sub-optimal management of patients with T2DM with currently only a minority of patients in SSA achieving glycemic control (Mwita et al, 2012;Sobngwi et al, 2012;Kibirige et al, 2014;Pinchevsky et al, 2015;Manne-Goehler et al, 2019). Glycemic control is improved though in specialist centers in SSA (Sobngwi et al, 2012;Mwita et al, 2019;Rwegerera et al, 2019). This reflects the fact that NCDs such as diabetes have been relatively neglected over the last decade across Africa in favor of infectious diseases including human immunodeficiency viruses (HIV), tuberculosis (TB), and malaria due to their burden (Atun et al, 2017;Pastakia et al, 2017;South African Lancet National Commission, 2019).…”

“…Thiazide diuretics and calcium channels blockers rather than angiotensin-converting-enzyme inhibitors (ACE inhibitors) are now considered as the most effective antihypertensives in the Black African population (Choukem et al, 2007;James et al, 2014; SEMDSA Type 2 Diabetes Guidelines Expert Committee, 2017). Consequently, while ACE inhibitors are indicated for patients with diabetes and proteinuria, they have a lesser effect in reducing blood pressure in the Black African population and their prescribing needs to be carefully managed (Mbui et al, 2017;Mwita et al, 2019). There is also typically low use of statins among diabetic patients in Africa, which again needs to be urgently addressed to reduce future CV complications (Sobngwi et al, 2012;Uloko et al, 2012;Mwita et al, 2019).…”

“…Consequently, while ACE inhibitors are indicated for patients with diabetes and proteinuria, they have a lesser effect in reducing blood pressure in the Black African population and their prescribing needs to be carefully managed (Mbui et al, 2017;Mwita et al, 2019). There is also typically low use of statins among diabetic patients in Africa, which again needs to be urgently addressed to reduce future CV complications (Sobngwi et al, 2012;Uloko et al, 2012;Mwita et al, 2019).…”

“…Treatment, including adherence to agreed guidelines for patients with T2DM, and subsequent patient adherence to prescribed medicines, are also generally sub-optimal in LMICs including Africa (Igbojiaku et al, 2013;Awodele and Osuolale, 2015;Fadare et al, 2015;Moosa et al, 2015;Sapkota et al, 2015;Elsous et al, 2017;Abate, 2019;Moosa et al, 2019). A number of factors appear responsible for poor control of T2DM including the age of patients, their lack of perception of the consequences of diabetes, forgetfulness regarding taking medication, adverse effects of the prescribed medicines, living in rural areas, affordability, and issues of motivation including family support (Adegbola et al, 2016;Abate, 2019;Dedefo et al, 2019;Mwita et al, 2019;Rwegerera et al, 2019). There are also concerns with the c o n c o m i t a n t m a n a g e m e n t o f h y p e r t e n s i o n a n d hypercholesterolemia along with controlling HbA1c in patients with T2DM in Africa (Gudina et al, 2011;Sobngwi et al, 2012;Mwita et al, 2019).…”