INTRODUCTION

Diabetes mellitus is one of the leading non-communicable diseases accounting for significant morbidity and mortality in Kuwait and globally. According to the World Health Organization (WHO), it is one of the top ten causes of death in the world.¹ Moreover, diabetic retinopathy is a leading cause of new onset blindness in many industrialized countries and is an increasingly frequent cause of blindness elsewhere.² According to the Canadian Diabetes Association, about one-third of people who have had diabetes for more than 15 years will develop kidney disease.³

There are two main types of diabetes: Type 1 diabetes which usually develops in childhood and adolescence and Type 2 diabetes which occurs in adulthood and is related to obesity, lack of physical activity, and unhealthy diet. Type 2 is more common representing 90% of diabetic cases worldwide.⁴

According to the International Diabetes Federation (IDF), a rising trend of incidence and prevalence of diabetes is seen in every country around the world. 1 in 9 adults in the Middle East and North Africa has diabetes and more than half of the people with diabetes in this region are unaware that they have it.⁵ Three of the top 10 countries with the highest prevalence of diabetes in 2013 (in adults aged 20 to 79 years) were in the Middle East, i.e. Saudi Arabia (24.0%), Kuwait (23.1%) and Qatar (22.9%).6 In 2013, Kuwait also had the highest prevalence of impaired glucose tolerance worldwide (17.9%).6 In developed countries most people with diabetes are above the age of retirement, whilst in the Arab region nearly three quarters (73.4%) of diabetics are under 60 years of age.⁷ The mean onset age for type II diabetes in Kuwait is 48.63±12.12 years.⁸

Type 2 diabetes has a long asymptomatic pre-clinical phase which frequently goes undetected. Complications are commonly present at the time of diagnosis although the reported rates vary between studies.⁵ Screening can identify individuals with diabetes and treatment can be initiated earlier in the course of the disease to prevent cardiovascular disease (CVD) and other complications. Screening can also detect pre-diabetics who may benefit from interventions to prevent or delay progression to diabetes.

The main objective of this study was to identify staff members who are at high risk of developing diabetes and to screen them for diabetes. The screening project might also help in raising awareness of the risk factors for diabetes and the importance of periodic checking of staff members.

METHOD

This cross-sectional study was carried out among all staff working at the Jaber Al-Ahmed Armed Forces Hospital in the period from 14th October to 18th November, 2012.

Exclusion criteria were established diabetes and pregnancy at the time of the project. Written informed consent was obtained from each participant.

The Finnish questionnaire which is the recommended tool for diabetes risk assessment by IDF, WHO and American Diabetic Association (ADA) was used in the study to assess the risk for diabetes. It has eight scored questions with the total test score providing a measure of the probability of developing Type 2 diabetes over the following 10 years.⁹ Information regarding risk factors and socio-demographic variables was collected in face-to-face interviews conducted by a team of 2 doctors and 4 nurses who received special training in order to collect uniform information from the participants. Weight was measured with light clothing and without shoes. Height was measured without shoes, with the participants standing fully erect on a flat surface and looking straight ahead. Body mass index (BMI) was calculated and evaluated as defined by WHO.¹⁰ Participants were divided into low, slightly elevated, moderate, high or very high risk categories. Staff members belonging to the high or very high risk categories were screened for diabetes using HbA1c as recommended in the updated IDF Guidelines.¹⁰ Based on IDF categorization, participants with an HbA1c of more than 6.5 were considered diabetics and those with HbA1c between 5.7 and 6.5 were considered pre-diabetics.¹¹ Analysis of data was performed using STATA (Version 12). Categorical variables were compared using chi-squared tests and a p-value of less than 0.05 was considered statistically significant.

RESULTS

The total number of staff registered in Jaber Al-Ahmed Armed Forces Hospital was 1,031 and of those 851 were accessible. Out of these, 50 were diabetics, 15 were pregnant, 169 were on leave, 11 were commissioned and 21 refused to participate in the study.

Among the 647 staff members who participated in the study, 308 (48%) were Kuwaiti. 513 (79.3%) of the participants were under 45 years of age and the male to female ratio was 1:1.2. The vast majority of Kuwaiti participants (90.9%) were under 45 years of age compared to 68.7% of the non- Kuwaiti (p<0.001). 23% of the participants were smokers. Only 28.6% of the participants had normal weight and 70.6% were either overweight or obese. More than half the participants had a high waist circumference (Table 1).

Risk assessment showed that 228 participants (35.3%) had a low risk, 274 (42.3%) had a slightly elevated risk, 93 (14.4%) had a moderate risk and 52 (8%) had a high to very high risk.

The prevalence of smoking was higher among Kuwaiti participants (27.6%) compared to non-Kuwaiti (18.9%) (p-value=0.01). 27.6% of Kuwaiti participants had low risk compared to 42.2% of non-Kuwaiti and 9.7% of Kuwaitis belonged to the high risk category compared to 6.5% of non-Kuwaitis (p -value=0.001).

Out of the 52 participants in the high and very high risk categories, one staff member refused blood collection for HbA1c testing. HbA1c testing showed that out of the 51 participants with high or very high risk 6 (11.8%) were diabetics, 26 (51.0%) were pre-diabetics and 19 (37.2%) were normal.

DISCUSSION

The prevalence of diabetes is rapidly increasing globally at an alarming rate.¹² Diabetes has changed from being a mild disorder of the elderly to one of the major causes of morbidity and mortality affecting youth and middle age people.¹³

Type 2 diabetes has a long asymptomatic pre-clinical phase which frequently goes undetected and complications frequently present at the time of diagnosis.¹¹ Chronic hyperglycemia is associated with long-term complications in various organs, especially the eyes, kidneys, nerves, heart, and blood vessels.¹⁴ Individuals with undiagnosed Type 2 diabetes are also at significantly higher risk for stroke, coronary heart disease, and peripheral vascular disease than non-diabetics.¹⁴ Early detection of pre-diabetes and diabetes would be appropriate because the duration of hyperglycemia is a predictor of adverse outcomes, and there are effective interventions to prevent disease progression and to reduce complications.¹⁵

Table 1. Distribution of risk factors among Kuwaiti and non-Kuwaiti employees. *chi-squared test*

*Available in pdf

The IDF recommends that each health service should decide whether to have a program to detect people with undiagnosed diabetes based on the prevalence of undiagnosed diabetes. The decision to conduct such a program should also take into consideration the availability of resources to run the program and to provide the necessary treatment for newly diagnosed patients.¹¹ The IDF also recommends that detection programs start with identifying high-risk individuals using a risk assessment questionnaire to be followed by checking fasting blood glucose or HbA1c in high-risk individuals.¹¹

Our study showed that risk factors for diabetes e.g. overweight and obesity, high waist circumference and smoking, are common among staff members in Jaber Al- Ahmed Armed Forces Hospital.

Although Kuwaiti employees were younger than non-Kuwaiti, they tended to have a higher risk (p<0.001). This is expected with the high prevalence of diabetes among Kuwaitis but can also reflect the fact that immigrant workers especially those working in demanding, non-administrative jobs such as nursing, which is the case in our hospital, are healthier and pass through pre-employment checkup to assess their fitness.

CONCLUSION

Due to the high prevalence of risk factors in our employees and the high prevalence of undiagnosed diabetes and pre-diabetes among those in the high and very high risk categories, we recommend that assessment of these risk factors and screening for diabetes and pre-diabetes should be employed as part of the routine occupational health check-up program in Jaber Al-Ahmed Armed Forces Hospital. This should be followed by planning an intervention program to address these risk factors and help prevent or delay the onset of diabetes among staff members at high risk of diabetes.