167J Contemp Med Sci | Vol. 7, No. 3, May-June 2021: 167–170 Original Risk Factors Associated with Poor Glycemic Control in Patients with Type Two Diabetes Mellitus in Zakho City Brisik H. Rashad1,*, Basheer A. Abdi1, Ibrahim A Naqid1, Nawfal R. Hussein1, Zubaida A. Ibrahim2, Jodi A. Rashad2, Shangist M. Saleem3, Avan S. Saleh3, Alaa A. Mustafa3 1Department of Biomedical sciences, College of Medicine, University of Zakho, Kurdistan Region, Iraq. 2College of Medicine, University of Duhok, Kurdistan Region, Iraq. 3College of Medicine, University of Zakho, Kurdistan Region, Iraq. *Correspondence to: Brisik H. Rashad (Email: brisk.rashad@uoz.edu.krd) (Submitted: 13 April 2021 – Revised version received: 24 April 2021 – Accepted: 29 May 2021 – Published online: 26 June 2021) Introduction DM is a chronic condition caused by relative lack of insulin due to impaired insulin secretion or insulin resistance.1 DM is the ninth major cause of death and with obesity, they represent the biggest epidemics in human history.2, 3 The burden of DM is represented by its enormous breadth as DM has been quadrupled in the past three decades.2 Diabetes was seriously underrated as a global public health issue; it was proposed that the total number of people with diabetes is projected to rise from 171 million in 2000 to 366 million in 2030.4 However, in 2015, there were already 415 million people with diabetes, far above what was predicted in 2000 for 30 years later according to Inter- national Diabetes federation.5 A better understanding of the tra- ditional drivers “risk factors” of the diabetes is required in order to combat the disease.3 There are considerable number of risk factors associated with poor glycemic control including age; sex; family history; smoking history; hypertension; chronic diseases such as Ischemic heart disease, bronchial asthma and thyroid diseases; raised body mass index and raised waist circumfer- ence.6-10 Few studies have been conducted in neighboring coun- tries to Iraq to assess the risk factors associated with poor glycemic control.11-13 The aim of this study was to investigate the prevalence of poor glycemic control in Zakho city in Kurdistan Region of Iraq and to explore the modifiable risk factors that may help controlling the disease. Materials and Methods Study design and setting This retrospective observational study was conducted in Zakho City, Kurdistan Region of Iraq. In the city, diabetes center was established in 2010. All patients with diabetes who receive treatment from governmental hospitals were regis- tered in the center. Patients In this study, we recruited patients with known history of type 2 diabetes (T2DM) receiving oral anti-diabetic medica- tions. Those patients were registered in Zakho Diabetes center with regular visits. Demographic data were collected via face-to-face interview. All patients who were 18 years or older, with type 2 diabetes, registered in the center for at least 12 months, and agreed to participate were included in the study. Controlled diabetes was defined as HBA1C below 7%.14 Anthropometric assessment The measurement of anthropometric indices was conducted by trained personnel. The measurement of participants weight was conducted by a balance while the height of the partici- pants was measured by a wall-fixed tape measure. Then, the waist circumference was measured by a plastic tape measure. The waist circumference was considered at the narrowest level between the lowest rib and iliac crest. Lab measurements Plasma glucose was determined using colorimetric enzymatic method with glucose oxidase. HbA1c concentrations were measured in whole blood samples using high performance liquid chromatography. Hyperlipidemia was confirmed by his- tory taking. Uncontrolled diabetes was defined as HbA1c of 7% or more. Abstract Objectives: The aim of this study was to investigate the prevalence of poor glycemic control in Zakho city and to explore the modifiable risk factors that may help controlling the disease. Methods: We recruited patients with known history of diabetes receiving oral anti-diabetic medications. Those patients were registered in Zakho Diabetes center with regular visits. The measurement of anthropometric indices was conducted by trained personnel. Plasma glucose was determined using colorimetric enzymatic method with glucose oxidase. HbA1c concentrations were measured in whole blood samples using high performance liquid chromatography. Results: In this study, 520 patients were recruited. The average age of the patients was 56.92 ± 9.62. Among those, 190 were male. The blood sugar was controlled in 122 (23.4%) patients. We found a significant association between sex and HbA1C level (p = 0.000; OR = 0.4796; CI = 0.3175–0.7243). In addition, waist circumference was significantly associated with HbA1C levels (p = 0.018; OR = 1.02; CI = 1.0031–1.0373). Conclusions: The vast majority of the patients had uncontrolled diabetes. We found that sex and waist circumference were risk factors for uncontrolled diabetes. Any diabetes controlling program should focus on those two factors. Keywords: Risk factors, Diabetes mellitus, poor glycaemic control, Zakho city ISSN 2413-0516 168 J Contemp Med Sci | Vol. 7, No. 3, May-June 2021: 167–170 Risk factors associated with Type 2 Diabetes mellitus Original B.H. Rashad et al. Ethics The study protocol and informed consent were approved by the Research and Ethics Committee of the College of Medi- cine, Zakho University, Kurdistan Region of Iraq. Informed consent was obtained from all recruited subjects. Statistical analysis Statistical analysis was conducted using Minitab 18. Linear regression was used to investigate the relationship between variables and outcomes when the variables were continuous while chi square test was used for categorical data. P value of <0.05 value was considered as significant. Results Patients In this study, 520 patients with T2DM were recruited. The average age of the patients was 56.92 ± 9.62. Among those, 190 were male. The blood sugar was controlled in 122 patients (Table 1). Amongst our patients, 65.96% had a family history of T2DM. Hypertension (HT) was found in 53.07% of our recruited samples. Out of 520 patients, 13.46% were smokers. Factor affecting sugar level Then, we studied the factors affecting blood sugar levels. We found a significant association between sex and HBA1C level. Our results showed that males were at higher risk of uncontrolled diabetes (p = 0.000; OR = 0.4796; CI = 0.3175– 0.7243) (Table 2). Additionally, waist circumference was significantly associated with HBA1C levels (p = 0.018; OR = 1.02; CI = 1.0031–1.0373). Other variables did not show significant influence on HBA1C levels (Table 2). Other risk factors did not show any significant impact on HBA1C levels. Discussion To prevent organ damage and other complication of diabetes, glycemic control remains the main therapeutic objective.15 It was previously shown that diabetic patients who control their HBA1C below 7% will have less microvascular diabetic com- plications.14 Age, sex, waist circumference, smoking history, family history, body mass index and hypertension were shown to play role in the control of HBA1C.6,9,10,16,17 Studying risk fac- tors associated with poor glycemic control is crucial for the control of diabetes in any society. Therefore; this study was conducted to check the rate of T2DM with good glycemic control and risk factors associated with poor glycemic con- trol. In this study, the mean HBA1C was 8.19 ± 1.6 which was comparable to what was found by Marilia et al.18 In this study, 50.19%, 23.65% and 26.15% of recruited patients had HbA1c < 8.0%, ≥ 8.0 to < 9.0%, and ≥ 9.0%, respectively. Again these results were comparable to Marilia et al., results.18 Addition- ally, 23.46% of the patients were having their HbA1C being controlled which was comparable to a study performed in Saudi Arabia.19 In studies conducted in Turkey, Sudan and Tanzania, 32.5%, 28% and 30% of the patients showed good glycemic control, respectively.20-22 This discrepancy in HbA1C control may be related to cultural and genetic variations. In this study, male to female ratio was 0.57 [male 36.5%, female 63.5%]. This is in contrast to a study that was conducted in The USA and Tanzania where the male to female ratios were 1.15, and 1.5, respectively.23 In contrast to a previous study from Iraq,13 in our study, males were at a statistically signifi- cant increased risk of suboptimal T2DM control in compar- ison to females with, which was also noticed in a study conducted in The USA,23 while in a study conducted in India, male were predominant and a significantly higher risk of poor Table 2. Factor affecting HbA1C levels Factors Controlled Uncontrolled P value OR CI 95% Age (average ± Std) 55.36 ± 10.52 57.25 ± 9.29 0.057 1.0208 0.9992–1.0428 BMI (average ± Std) 30.59 ± 5.49 31.51 ± 5.57 0.102 1.0319 0.9931–1.0723 Waist circumference (average ± Std) 104.4 ± 12.98 107.42 ± 12.58 0.018 1.0200 1.0031–1.0373 Sex (female) 61/122 (50.00%) 269/398 (67.58%) 0.000 0.4796 0.3175–0.7243 IHD 11/122 (9.01%) 58/398 (14.57%) 0.100 1.7214 0.8728–3.3952 Asthma 2/122 (1.63%) 9/398 (2.26%) 0.667 1.3882 0.2959–6.5128 Thyroid dysfunction 3/122 (2.45%) 11/398 (2.76%) 0.854 1.1275 0.3094–4.1083 Hyperlipidemia 39/122 (31.96%) 154/398 (38.69%) 0.175 1.3432 0.8732–2.0662 Family history 75/122 (61.47%) 268/398 (67.33%) 0.235 1.2919 0.8484–1.9672 Smoking 22/122 (18.03%) 48/398 (12.06%) 0.090 0.6097 0.3482–1.0677 HT 60/122 (49.18%) 216/398 (54.27%) 0.325 1.2264 0.8171–1.8406 Table 1. Characteristics of patients recruited in the study Variable No % Sex (female) 330 63.46% IHD 69 13.26% Asthma 11 0.021% Thyroid 14 0.026% Hyperlipidemia 193 37.11% Family history 343 65.96% Smoking 70 13.46% HT 276 53.07% 169J Contemp Med Sci | Vol. 7, No. 3, May-June 2021: 167–170 B.H. Rashad et al. Original Risk factors associated with Type 2 Diabetes mellitus glycemic control was associated with females.6 These varia- tions may be in part related to genetic variation and discrep- ancy of the predominant sex in one study upon the other. Other risk factor which was at statistically significant associa- tion with raised HBA1c% was the central obesity represented by waist circumference, while body mass index was statisti- cally not associated with poor glycemic control, this was con- sistent to a study done in India by Rohit et al.,24 to explain the variation between BMI and waist circumference, it has been suggested that age-related increases in total body fat and vis- ceral adiposity compromise the reliability of BMI as a sensi- tive marker of adiposity in older age groups25. In another study, Kayar et al., study20 found that both BMI and waist cir- cumference were statistically associated with poor glycemic control. In contrast to a previous study in Iraq where younger age was associated with an increased risk of poor glycemic control,13 in our study there was a trend that age increases the chance of uncontrolled diabetes, though this was not statisti- cally significant. In our study, Hypertension, Thyroid dys- function, asthma and ischemic heart disease, hyperlipidemia and family history and smoking history were not statistically associated with poor glycemic control. This in in contrast to other studies where these factors were found to play an impor- tant role in controlling diabetes.6, 13, 21, 22 This is difficult to explain and more studies are needed with larger sample size to explore the role of these factors in controlling diabetes. To conclude, out of 520 patients, 377 (72.5%) patients were having HbA1c% of equal or more than 7% reflecting uncontrolled diabetes. We found that sex and waist circum- ference are risk factors for uncontrolled diabetes. Any dia- betes controlling program should focus on those two factors. Conflicts of Interest The authors declare that there is no conflicts of interest. Acknowledgment We would like to thank the staff of Diabetes Centre/Zakho City for their kind help and support. 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