Assessment of Risk Factors for Type II Diabetes Mellitus on Patients Attending at Three Hospitals in Wolaita Zone, South Ethiopia

Diabetes mellitus is one of the most common chronic metabolic disorders of carbohydrates, proteins and fat in almost all countries, and it continues to be increased in magnitude and clinical significance, as lifestyle changes lead to reduce physical activity and increased obesity. A cross sectional study was conducted from July1 to August 15, 2011 in three Hospitals of Wolaita Zone using purposive sampling technique until required sample size of 348 was achieved. Patients with type II diabetes mellitus were selected based on sample size determination technique for single population. Data were collected using semi-structured questionnaire. The data was analyzed by using SPSS version 16.0. Frequencies and graphs were used to describe selected variables.348 study subjects have participated in the study. As per the age distributions 188 (54 %) of study participants were found to be above age of 50 years. The mean ± SD age of type II patients was 51.9±13.6 and age range between 19 years and 83 years. Hundred and seventy nine (51.4%) of the study participants were males. With respect to educational levels 86 (24.7%) of the study participants have completed primary school (grade 1-4) followed by illiterates 75 (21.6%). Regarding income, 106 (30.5%) of type II diabetic patients have monthly income more than 1500 ETB. A high proportion of risk factors observed in type II diabetes mellitus were being male, older age group greater than 50, overweight and with higher monthly income. The risk rate of type II diabetes mellitus was higher among urban residence, primary level of education. Most of the diabetic cases had BMI >25 kg/m 2 which is a risk factor for the development of type II Diabetes.

22 also a substantial financial cost to diabetes care as well as costs to the lives of people with diabetes (11).

Methods And Materials 2.1. Study Area and Period
Facility based cross sectional study was conducted from July 1 to August 15, 2011, at three Hospitals in Wolaita Zone.

Sample Size Determination and Sampling
Source Population: Diabetic patients registered at three Hospitals in Wolaita Zone. Study Population: All type II diabetic patients who were on follow-up at the diabetic clinics of three Hospitals in Wolaita Zone registered until August 15, 2011.

Inclusion and Exclusion Criteria Inclusion Criteria:
 Only those patients with a pre-hospital diagnosis of type II DM as reported by General Practitioners.  Those who were willing to participate in interview. Exclusion Criteria:  Those patients who were unwilling for the interview.  Patients with type I diabetes.

Sample size determination.
A 29 % expected prevalence of type II diabetes in the diabetic clinics of Addis Ababa was considered based on data from studies on relatively similar populations in Addis Ababa (12). No current data are available on the prevalence of diabetes at three Hospitals in Wolaita Zone. The actual sample size was calculated using the following single population proportion formula. n= (Z α/2 ) 2 X P (1-P) ÷d 2 Where n= required sample size z=1.96 (95% confidence level for two side) p= 29 %( proportion of type 2 diabetes mellitus) d= margin of error (5%) Therefore the value of n was calculated as follows n= (1.96) 2 x0. 29 (1−0.29) ÷0.05 2 =316.4≈ 316 Non-responsive rate 10% of contingency was used. n= 348

Sampling Technique
The study was conducted using purposive sampling techniques until the required sample size was attained. Those study participants who refused to participate in the study were considered non-respondents and the next. Three trained data collector (nurses) and two supervisors were assigned in each health facility. After identifying the study participants, the data collectors were informed the aim of the study, confidentiality issue and informed consent to all of the study participants; interviewer-administered data collection method was employed in selected type II diabetic patients. The principal investigator and the supervisor were supervising collected data and checked their completeness.

Data collection instrument and processing
Questionnaire A standardized interview based on structured questionnaire was carried out by five public health workers who were well trained interview techniques and all questionnaire details, Information was obtained from the interview including history of family, sex, age groups, body built, food habits, income, educational level, physical activity levels, blood pressure and residence. II. Weight Scale  The weight of patients was measured.  The height of patient of patients was measured. BMI was calculated and classified as follow (13).
 Underweight < 18.5 kg m-1  Normal 18.5 -24.9 kg m-1  Overweight 25.0 -29.9 kg m-1  Obese ≥30.0 kg m-1 III. Sphygmomanometers  Patients were announced to avoid having meals at least thirty minute before BP measurements.  A cuff which is attached to a manometer (sphygmomanometer) was wrapped around the upper arm and was inflated until the brachial artery is completely occluded.  The diaphragm of stethoscope is placed over the brachial artery distal to the cuff. First the systolic pressure was estimated by palpitation method end the cuff was then allowed to deflate slowly.  When the cuff reaches systolic pressure, a clear tapping sound was heard in time with the heart beat.
As the cuff deflates further, the sounds became quieter, but became louder again before disappearing altogether. The point at which the sounds disappear is the diastolic pressure  Blood pressure was measured 3 times  Blood pressure was measured on the right arm, with the subject seated after 10 minutes rest, using a standard clinical mercury sphygmomanometer with an appropriate cuff size. Hypertension was diagnosed according to WHO criteria [100] if systolic pressure was ≥ 140 mmHg or diastolic pressure ≥ 90 mmHg.

Data Analysis
The collected data were subjected for statistical analysis. The collected data were coded, checked for completeness and missing value, entered and analyzed by using SPSS version 16.0. Frequencies and graphs were used to describe selected variables.

Operational Definitions of Terms
Risk Factor: Any attribute, characteristic or exposure of an individual, which increases the likelihood of developing the disease of interest. Fasting Blood Glucose: Blood glucose estimation obtained from a subject who has undergone an overnight fast from any food or drink (excluding water or clear, plain tea) for at least 8 hours.

Sedentary Lifestyle (Physical inactivity):
In this study is measured as a response of being always or usually engaged in light/leisure activities for most days of the week or a response of sometimes/never engagement in moderate to intense physical activity. Vigorous (physical activity) -Outside work for most days of the week that would add up to at least three hours (14). Positive Family History of Diabetes: Is a reported history of diabetes in the father, mother, full brother or sister, or the respondent. Heavy Alcohol Consumption: Refers to the average consumption of more than 3 standard alcoholic drinks per day for men (≈30gm of alcohol) or >2 alcoholic drinks (or20 gm alcohol) for women. A standard alcoholic drink is the equivalent of one glass/can/bottle (330ml) of regular beer (with 3% ethanol), one glass (100ml) of wine (10% ethanol) or one glass or measure (40ml) of distilled spirit, each of which adds up to about 10g of ethanol per drink (14). Cigarette Smoking: Refers those have smokes 1-14, 15-24, and ≥25 cigarettes/d, medium, high, very high smokers respectively.

Socio-demographic Characteristics
A total of 348 study participants were interviewed during the study period. The response rate was 90%. Among 348 patients involved in the study majority 179 (51.4%) were males. As per the age distributions 188 (54 %) of study participants were in age group greater than 50 years.  As per the income, 106 (30.5%) of type II diabetic patients have earned monthly income more than 1500 ETB. More than half of type II patients, 277 (79.6%) were urban residents. The majorities 301 (86.5%) of patients were no family history of diabetes mellitus. As far as occupational status is concerned, 119 (34.2%) of the respondents were house wives, followed by Government employee 109 (34.2%). As shown in table 1B, majority 169 (48.6%) of study participants were found to be normotensive.

Frequency Distribution of the Effects of Dietary Habit on Type II Diabetic Patients
As per the dietary habit, 45 (12.9%) of the study participants were usually eat vegetable followed by eating fruit 21 (6.1%). Most 282 (81%) of study participants were usually eat sugar and oil excess. Frequency of eating fruits among type II diabetic patients found that, 229 (65.8%) were eat fruits occasional followed by eating fruits once a day 61 (17.5%). (Table 3)  Of these about 40 (11.5%) were daily smokers followed occasional smokers 34 (9.8%). Regarding khat chewing, 74 (21.3%) of type II patients were found to be khat chewers. Most 40 (11.5%) were chew daily. About 31 (8.9%) of type II patients were chew two times per a week followed by those who chew three times per month 3 (0.9%). About 32 (9.2%) of were started chewing khat more than two years. About 170 (48.9%) of study participants were alcohol drinker. Of these most 86 (24.7%) were drinks daily followed by drinking two times per a week 72 (20.8%). Majority 94 (27.0%) of study participants were drink more than three standard drink. (Table 4)

Discussions
The distribution of type II diabetes mellitus among male and female patients was found to be different. According to the finding of the present study, type II DM is more prevalent among males than in females. This finding is in agreement with the study conducted in India by Muhammad K et al., 2010, which showed that higher prevalence (53.3%) rate among male than relatively lower prevalence 46.6 % among females (15). The above study supports our finding. The possible explanation for this could be due to the fact that males are more exposed to risk factors to DM.
Some other studies are contradicted to the present finding, which showed that higher prevalence in female than males (16). In addition to the above results, there are also other studies which showed that similar prevalence between males and females (17)(18)(19). The women enrolled in this study were mainly housewives whereas men were working outside the home and household income is mostly controlled by men. These factors may have influenced the difference in the diabetes prevalence.
In this study 188 (54.0%) of the study participants belonged to the age group of >50 years. This result is in agreement with the study conducted in India by Muhammad K which showed that majority of the study participants belong to the age group of 60 and above (15). However, this is contradicted with the study conducted by Shobha M et al, where they found that majority of patients belonged to age group 46 to 50 years of age (20). But they specified that there is increased onset of diabetes among younger age group in Indians.
As per distribution of education, 86 (24.7%) were primary level of education (grade 1-4). About 5(1.4%) were MSc holder and above. This is in agreement with the study conducted by Satpute D et al, 2008; showed that diabetes particularly affects high prevalence rate in the people with lower educational levels in Bolivia and in Jamaica (21,22). This is due to the fact that education is very important factors to control feeding style in order to minimize the development type II diabetes mellitus.
The distribution income as far as concerned, 106 (30.5%) were grouped earned monthly income under high income categories and 25 (7.2 %) were grouped under low income categories. This is in agreement with the study conducted in Turkey 2000, which showed that higher percentage diabetes mellitus high under high income categories (23). The possible explanation is may be due to more consumption of non vegetable food who had earned monthly income greater than 1500 ETB.
Out of the total type II diabetic patients who visited the hospitals majority 277 (79.6 %) were urban resident and 71 (20.4%) were rural resident. This is in line with the study conducted by Aboderin in 2001, which showed that high percentage of type II diabetes in urban area (24,25). The possible reasons for high prevalence of type II diabetes in urban area is may be due to easily availability of non vegetable rich food and low working habit in urban.
Most of study participants 301 (86.5%) were not had a family history of diabetes. This study is opposing the finding of Muhammad K et al., 2010 conducted in India, which showed that majority (69.4%) of the respondents were having family history of type II diabetes mellitus (15). This difference is may be due to the fact that the respondents were not well informed about diabetic history of their family.
Out of the total type II diabetic patients 196 (56.3%) were having BMI >25 kg/m 2 , 17 (4.9%) of type II patients were < 18.5kg/m 2 . This is in agreement with other study (26), which reported that type II diabetes is high in obese and overweight type study participants. This is due the fact that there are few insulin receptors, especially in liver, adipose tissue and skeletal muscle in obese than in lean subjects.
In present study, 57 (16.3%) of the diabetic patients were doing physical activities, the rest 291 (83.7%) participants were not involved in physical activities. This is supported with other studies (27,28), which revealed that high percentage of diabetes among low physical activities participants. Other study done by Perry I et al, 1995, showed that Physical inactivity is a well-known risk factor for type II diabetes. The risk of diabetes is reduced by 50% among men who take moderately vigorous exercise (29). Lack of physical activity and unhealthy dietary habits are important modifiable risk factors for diabetes. The highest percentage of type II diabetes among lower level of physical activity is due to the fact that regular physical exercise reduces the risk of development of DM by regulating resistance in target tissue, by reducing body weight may also increases the number of receptors in target tissue.
In this study majority 282 (81%) of participants were usually eat sugar and oil excess. This finding is supported by other studies who reports high prevalence of type II diabetes among non vegetarian (30). The possible justification of the high percentage of type II diabetes mellitus among eating sugar and oil excess is due to high accumulation of fats in the body. Carbohydrate and fat rich foods are increase insulin resistance by accumulation of fat which exposes the participants for development of type II diabetes mellitus.
Per distribution of drinking alcohol, 94 (27%) of the study participants were heavy drunker and 4 (1.1%) were mild drunker. There is study that supports this result (31). Possible explanation of high distribution of type II diabetes mellitus among type II diabetes mellitus is may be due to heavy consumption of alcohol damage beta cells in pancreas.

Conclusions and Recommendations
A high proportion of risk factors observed in type II diabetes mellitus were being male, older age group greater than 50, overweight and with higher monthly income. The rate of type II diabetes mellitus was higher among urban residence. Most of the diabetic cases had BMI >25 kg/m 2 which is a risk factor for the development of type II Diabetes. Dietary habits like eating excess oil and sugar were found to be risk factors for the development of type II diabetes mellitus. Level of education was found to be a very important factor for controlling diabetes mellitus. Chronic disease prevention and control programs, such as health education and promotion of regular physical exercise should be established so as to decrease the high prevalence of some of the modifiable risk factors like overweight and sedentary lifestyle observed in this study. Conflict of interests: No conflict of interest.