Prevalence and risk factors of diabetic neuropathy in Qassim, Saudi Arabia

Introduction

Diabetes and its complications have become a huge burden. Its prevalence is increasing year after year. Globally, it is affecting around (382) million people. Prevalence rates are variable from one country to another, and Saudi Arabia is considered as one of the top ten countries with a prevalence reaching (23.9%) [1].

One complication is diabetic neuropathy. The commonest and earliest long term complication [2]. The prevalence of diabetic neuropathy among diabetics has been reported as high as (50%) [3].

Diabetic neuropathy is defined as sensorimotor polyneuropathy that is diagnosed in a diabetic patient when other causes are excluded [4]. While the association of pain is not necessary for diagnosis, it can accompany the condition in some cases [5].

The pathogenesis of diabetic neuropathy is believed to be multifactorial. Which develops in the presence of risk factors through multiple pathways, including; oxidative stress, glycation end products and proinflammatory processes [6].

Usually the diabetic patients who have developed neuropathy present with different clinical manifestations such as; numbness, loss of sensation, foot ulcers, and even amputation. With progression of complications, even mortality can result from such conditions [7]. Which makes the early recognition and management of diabetic neuropathy crucial for a better prognosis.

Risk factors represent an important hint to the caring physician to screen and diagnose diabetic neuropathy. The risk factors can be easily identified. Hyperglycemia, high blood pressure, hyperlipidemia and smoking are well known risk factors [8].

Prevention is a key in diabetic neuropathy. Tight glycemic control and lifestyle modification to reduce the cardiovascular risk are the mainstay of prevention. Other options represent symptomatic treatment by foot care, antidepressants and anticonvulsants [9].

As we recognized the necessity of early diagnosis of diabetic neuropathy, and as no such topic has been studied in Qassim region, we conducted this study concerning the prevalence and associated risk factors of diabetic neuropathy.

Methods

Study design

This is a cross-sectional study that used a modified version of Michigan neuropathy score.

In addition to the translation, additional questions were added to the questionnaire regarding personal characteristics (age, sex, and educational level) and diabetic history.

Other added lifestyle questions include; smoking, weight, and height.

The population

All the attendants were invited to participate in the questionnaire as long as they are eligible according to the criteria.

Inclusion criteria included patients diagnosed with type II diabetes mellitus, Age (25-90) of Both genders and all nationalities.

We excluded patients with neurological abnormalities (Epilepsy, Stroke, Parkinson, Cerebral Palsy, etc.) and patients whom age is less than 25 or more than 90.

Sample size

According to the General authority for statistical reports in Saudi Arabia, the general population of Al-Qasim is around (980,000) [10]. Which make the diabetic patients around (234220), considering that diabetes prevalence is (23.9%) [1].

Using an online sample calculator (Raosoft.com), with a margin error of (5%), confidence level (95%), and response distribution of (50%). The required sample size was calculated to be (384).

Tools and data collection

The Michigan neuropathy screening instrument was translated and modified to include more questions regarding sociodemographic characteristics and diabetic history. The total score ranges from zero (0) up to (13). Total scores of 4 or more are considered as abnormal.

The data collection took place in primary health care and diabetic centers in Al-Qasim region. An electronic questionnaire form was developed. Investigator performed individual interviews for each participant. Then, answers were submitted to the unified electronic form.

Statistical analysis

The statistical package for the social sciences (SPSS – version 21.0) were used to analyze the data. Tables and graphs were used to show the participants’ responses and important findings. The Chi-square test was used to detect the significant findings.

Ethical considerations

Prior to collecting data, an ethical approval was obtained from the regional research ethics committee in Qassim province. Centres’ managers were notified to gain permission for data collection. Furthermore, after explaining the nature and purpose of the study, an individual consent was gained from each participant.

Results

A total of (374) diabetic patients has been included in the analysis. The sociodemographic results showed a majority of Saudi patients (97.1%), females represent (54%) of the total sample, about one third (33.2%) are well educated (university or higher), and more than half of our population were from Onaiza province. The mean age in our population was (53.61), with a standard deviation of (11.88), minimum age (25) and the maximum age (88) years.

The screening tool for diabetic neuropathy included a total of (15) questions. The responses are demonstrated in (Table 1). Considering a total score of four or more as abnormal. The overall percentage of abnormal scores was (38.2%). The mean of total scores was (3.09) with a standard deviation of (2.44).

Table 1: Demonstrating (Michigan neuropathy screening instrument) responses
Question	Yes	No
1. Are your legs and/or feet numb?	45.7%	45.3%
2. Do you ever have any burning pain in your legs and/or feet?	45.7%	54.3%
3. Are your feet too sensitive to touch?	26.5%	73.5%
4. Do you get muscle cramps in your legs and/or feet?	26.5%	73.5%
5. Do you ever have any prickling feelings in your legs or feet?	44.4%	55.6%
6. Does it hurt when the bed covers touch your skin?	15.5%	84.5%
7. When you get into the tub or shower, are you able to tell the hot water from the cold water?	94.4%	5.6%
8. Have you ever had an open sore on your foot?	11.2%	88.8%
9. Has your doctor ever told you that you have diabetic neuropathy?	8.6%	91.4%
10. Do you feel weak all over most of the time?	45.7%	54.3%
11. Are your symptoms worse at night?	24.3%	75.7%
12. Do your legs hurt when you walk?	41.7%	58.3%
13. Are you able to sense your feet when you walk?	90.6%	9.4%
14. Is the skin on your feet so dry that it cracks open?	36.4%	63.6%
15. Have you ever had an amputation?	2.9%	97.1%

The prevalence of hypertension among our sample (49.5%). Smoking prevalence was (15.8%), while (8%) were ex-smokers. The duration since the diagnosis of diabetes ranged from one year up to (37) years, with a mean of (11.31) and a standard deviation of (8.28). Upon asking about pharmacological treatment, the responses were variant with the majority indicating multidrug approach to control diabetes. (Table 2)

Medication	Frequency	Percentage (%)
Metformin	96	25.7
Hypoglycemic agent	24	6.4
Insulin	57	15.2
Multidrug	178	47.6
I don’t know	19	5.2

Table 2: Showing the distribution of antidiabetic medications

Significant associations of diabetic neuropathy were found with lower educational levels, presence of hypertension, use of insulin or multidrug, and higher body mass index (BMI). The correlated P-value is mentioned in (Graph 1). Further analysis did not show any significant findings with smoking, age, sex or income.

Graph 1: Association of risk factors with diabetic neuropathy

Discussion

In our study, we have used the Michigan neuropathy screening instrument considering total scores of four or more as abnormal. According to Herman et al. [11] this will make the performance of the instrument better. The overall prevalence of diabetic neuropathy DN considering four or more total scores as abnormal in Herman’s study was (18%). However, our study found that (38.2%) had abnormal total scores. In the UK, the prevalence was found to be (34%), which is similar to the overall prevalence of our study [12]. From a local perspective, the reported number was variable. In a meta-analysis done in middle east countries and North Africa, Saudi Arabia was the highest country of DN prevalence (65.3%) [13]. Moreover, among Saudi diabetics who have the disease for ten years, the prevalence of distal DN is (38%) [14].

This study has focused on the significant association with diabetes neuropathy. Educational level, the BMI, hypertension, use of insulin and/or multidrug approach to controlling diabetes were risk factors significantly associated with total scores of four or more. The mentioned risk factors, are well known and have been highlighted in the literature. While few studies have not indicated any risk factors to predict DN [15], many other major studies have indicated the importance of assessing risk factors in order to suspect DN and perform nerve conduction study accordingly. Factors found to be significant in this study has been supported in addition to other factors such as hyperlipidemia [16-19].

Algeffari [20] in a multicentre cross-sectional study that was carried in Riyadh. The study has indicated smoking and female gender as important predictors to be looked for when considering painful diabetic neuropathy. Although, a similar prevalence to Algeffari was found in our study of about one third of our population, there were no significance found with smoking or female gender on our study.

Advanced age, older duration with diabetes, and insulin use are associations suggested by Wang, et al. in a cross sectional study among Saudi population. However, our study did not show any significance with age as a cofactor for developing the disease. The explanation could rely on the number of patients with type I diabetes mellitus (DM) included in the study. Such finding is predictable in Wang, et al. study as almost (95%) of the participants had type II DM. A well-known risk factor is longer duration since the diagnosis of DM. also, DN is found to be more among patients of DM type II [21]. Thus, it is expected that longer duration with DM type II will be found in older age, which results in the accumulation of two risk factors and make the patient more prone to develop DN.

Our population has a very low percentage (2.9%) in which they have undergone amputation due to complications of DM. However, literature showed that among diabetics in Saudi Arabia (23.5%) ended doing amputation due to diabetic complications. The commonest complication is peripheral diabetic neuropathy. Furthermore, it is the most frequent complication leading to limb amputation [22-23]. In such cases, the importance of patient education and awareness must be fulfilled to prevent foot ulcers and possible amputation [19].

Conclusion

The prevalence of diabetic neuropathy among diabetics of Qassim region is (38.2%). Although, is considered relatively low in compare to previous studies, it is important to predict the condition and diagnose it early for a better prognosis. The common risk factors include; hypertension, high BMI, insulin use, and low education. This emphasizes the importance of implementing a health program to educate diabetic patients about possible complications and neuropathy in specific.

Acknowledgment

The authors would like to thank all the participants and the centres’ staff for their time and cooperation. The authors also would like to five a special acknowledgment for dr. Abdullah Ahmad Alhatlani for his help in data collection. This research project was supported by a grant from the “Research Center of the Female Scientific and Medical Colleges”, Deanship of Scientific Research, King Saud University.

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