Prevalence of vascular complication among type2 of diabetes mellitus At Aden Abdulle Hospital.

Prevalence of vascular complication among type2 of diabetes mellitus At Aden Abdulle
Hospital.
COVER PAGE

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DECLARATION
We, Group B, declare that this research dissertation on the study Prevalence of vascular
complication among type2 of diabetes mellitus At Aden Abdulle Hospital” is our original work
and to the best of our knowledge, has not been submitted for any award at any academic
institution.
Name of Candidate: --------------------------------------------------
Signed: ----------------------------------------
Date: ----------/------------------------

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SUPPERVISOR APPROVAL
We hereby declare that we have read this senior project and in our opinion, this senior project is
sufficient in terms of scope and quality for the award of Bachelor Degree of (MBBS) and we
accepted for the submission to the examining panel.
Supervisor: Dr.
Signature: ------------------------------ Date: --------/-----------/--------
Head of school of Medicine and surgery
Dr.
Signature: ------------------------------ Date: --------/-----------/--------
Dean of collage of health science
Dr.
Signature: ------------------------------ Date: --------/-----------/--------

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DEDICATION
We dedicate to all our dear lovely parents and all our family members for their endless support
during my academic career.

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ACKNOWLEDGEMENT
Firstly we are greatly indebted to our supervisor Dr.……………………who has tirelessly perused
through this to guide and correct and support us. We appreciate your effort. We cannot fail to
acknowledge our lecturers in the faculty of health science for the knowledge that they passed on
to us, without you this would not be an easy task.
We would like to extend our thanks to some of my Families like, our Dearest mothers, Dear
Fathers, siblings and any member of our families, and also thanks my all friends for their
encouragement.
May ALLAH Bless You All.

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ABSTRACT
Introduction:Diabetes mellitus is chronic metabolic disordercharacterized by hyperglycemia.
Uncontrolled diabetes which leads to damage to small blood vessels (e.g Kidney, eye, and large
blood vessels such as Heart, Brain. (WHO, 2016).
Thereare three main types of diabetes mellitus: type1, type2 and Gestation diabetes, also there
are other types.
Study design: Descriptive study design -Cross sectional
Tool:Data collection form
Collected Data were analyzed using the SPSS version 23.0.
Results: The majority of the respondents were ‘Male’ represented by 68.1 % while females were
minority represented by 31.9%. This clearly shows that most of the respondents were Males. The
majority age group were above 60 year olds (23 which accounts about 33.3%), next were
between 46-60 years (21 individuals which accounts about 30.4%)
75.4% didn’t develop any complication, but about 24.6% did. Out of the 24.6% who developed
complication had suffered different conditions, 3 had problems with the Eyes, 3 with kidneys, 6
with Heart, and 5 of them suffered complication of the Legs.
When asked the question: ‘Do you take medications regularly?’ 43 individuals (62.3%) answered
as Yes, and 26 of them (37.7%) answered as No.
Conclusion:The incidence of mortality and morbidity of Diabetes by any cause has decreased
progressively in the past few decades, and different approaches are done to reduce the follow of
the disease such as: people are learning new ways and ideas to deal with such problems (like
transplanting Beta Cells in the pancreas), early screening can at least decrease the impact and
mortality rate due to those problems, Diabetes is a manageable disease if appropriate
environments (fully-equipped medical centers) and proper care is available, following the
doctor, diet control, exercises and regular medication.
Recommendation:
 The Ministry of Health with the help of other non-governmental agencies or international
organizations should do constant, similar survey from time to time so as to intervene, correct and
develop the hospital status that perform such managements and to help do community awareness
when possible.
 They should do immediate intervention, and do proper management to reduce the possible
complications, and perform operations with passion and care intervene any problem to
patients regardless to their background and relation between them.
 Hospitals and health workers should give people in general and patients/victims in particular
full awareness and health education about the possible risk factors and how to reduce the
frequencies of such conditions.
 They should always give patient education about the possible complications DM has, and
how to reduce and prevent.

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Contents
COVER PAGE..................................................................................................................................................................................I
DECLARATION..............................................................................................................................................................................I
SUPPERVISOR APPROVAL ......................................................................................................................................................II
DEDICATION ...............................................................................................................................................................................III
ACKNOWLEDGEMENT ............................................................................................................................................................IV
ABSTRACT .....................................................................................................................................................................................V
Chapter One ......................................................................................................................................................................................1
1.0 Introduction...................................................................................................................................................................1
1.3.1 General Objective...............................................................................................................................................4
1.3.2 Specific Objectives: ...........................................................................................................................................5
1.6.1 Content of the study...........................................................................................................................................7
1.6.2 Geographical of the scope.................................................................................................................................7
1.6.3 Time of Scope .....................................................................................................................................................7
CHAPTER TWO .............................................................................................................................................................................9
LITERATURE REVIEW ...............................................................................................................................................................9
2.0 INTRODUCTION .......................................................................................................................................................9
2.8.1 Lifestyle Modification .....................................................................................................................................19
2.8.2 Medications .......................................................................................................................................................19
2.8.3 Surgery ...............................................................................................................................................................19
2.10.1 OBESITY...........................................................................................................................................................20
2.10.2 PHYSICAL INACTIVITY/ SEDENTARY LIFESTYLE........................................................................21
2.10.3 DIET ...................................................................................................................................................................21
2.10.4 URBANIZATION............................................................................................................................................22
2.11.1 EXERCISE........................................................................................................................................................23
2.11.2 NUTRITION.....................................................................................................................................................24
2.13.1 Acute Complication .........................................................................................................................................25
2.13.2 Chronic Complication......................................................................................................................................28
CHAPTER THREE.......................................................................................................................................................................31
Methodology...................................................................................................................................................................................31
3.0 Study Area Aden Adde Hospital..................................................................................................................................31
3.1 Research Design..............................................................................................................................................................31

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3.7 The Inclusion and Exclusion Criteria for the Study .............................................................................................33
3.7.1 Inclusion Criteria ..............................................................................................................................................33
3.7.2 Exclusion Criteria.............................................................................................................................................34
CHAPTER FOUR...............................................................................................................................................................................35
Data Presentation Analysis and Interpretation of Data ...........................................................................................................35
4.0 INTRODUCTION ..........................................................................................................................................................35
CHAPTER FIVE ...........................................................................................................................................................................56
Discussion, Conclusion and Recommendations.......................................................................................................................56
5.0 INTRODUCTION .....................................................................................................................................................56
5.1 Over view ....................................................................................................................................................................56
5.2 Findings .......................................................................................................................................................................57
5.3 Conclusions.................................................................................................................................................................59
5.4 Recommendations......................................................................................................................................................60
5.4.1 Government/Ministry of Health.....................................................................................................................60
5.4.2 Health Workers .................................................................................................................................................60
5.4.3 Community ........................................................................................................................................................61
References..................................................................................................................................................................................62
5.5 APPENDIXES.................................................................................................................................................................65
AppendixI: Study Questionnaire...........................................................................................................................................65
APPENDIX II: IMAGES OF ADEN Abdulle HOSPITAL..............................................................................................71
APPENDIXIII: MAP OF CITY.............................................................................................................................................72
APPENDIX IV: MAP OF SOMALIA..................................................................................................................................73
List of Tables and Figures
Table 4.1.....................................................................................................................................................................................36
Figure 4.1....................................................................................................................................................................................36
Table 4.2.....................................................................................................................................................................................37
Figure 4.2....................................................................................................................................................................................37
Table 4.3.....................................................................................................................................................................................38
Figure 4.3....................................................................................................................................................................................38
Table 4.4.....................................................................................................................................................................................39
Figure 4.4....................................................................................................................................................................................39

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Table 4.5.....................................................................................................................................................................................40
Figure 4.5....................................................................................................................................................................................40
Table 4.6.....................................................................................................................................................................................41
Figure 4.6....................................................................................................................................................................................41
Table 4.7.....................................................................................................................................................................................42
Figure 4.7....................................................................................................................................................................................42
Table 4.8.....................................................................................................................................................................................43
Figure 4.8....................................................................................................................................................................................43
Table 4.9.....................................................................................................................................................................................44
Figure 4.9....................................................................................................................................................................................44
Table 4.10...................................................................................................................................................................................45
Figure 4.10..................................................................................................................................................................................45
Table 4.11...................................................................................................................................................................................46
Figure 4.11..................................................................................................................................................................................46
Table 4.12...................................................................................................................................................................................47
Figure 4.12..................................................................................................................................................................................47
Table 4.13...................................................................................................................................................................................48
Figure 4.13..................................................................................................................................................................................48
Table 4.14...................................................................................................................................................................................49
Figure 4.14..................................................................................................................................................................................49
Table 4.15...................................................................................................................................................................................50
Figure 4.15..................................................................................................................................................................................51
Table 4.16...................................................................................................................................................................................51
Figure 4.16..................................................................................................................................................................................52
Table 4.17...................................................................................................................................................................................52
Figure 4.17..................................................................................................................................................................................53
Table 4.18...................................................................................................................................................................................53
Figure 4.18..................................................................................................................................................................................54
Table 4.19...................................................................................................................................................................................54
Figure 4.19..................................................................................................................................................................................55
Table 4.20...................................................................................................................................................................................55
Figure 4.20..................................................................................................................................................................................56

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Chapter One
1.0Introduction
This chapter presents the background information of the study followed by general overview of
problem statement, the purpose of the study, the objectives, and significance of the study, the
scope of the study and definition of terms
1.1 Background
Diabetes, unsurprisingly has had a long record in human history, and cannot be simply called a
modern day disease. Almost three thousand years ago, the Ancient Egyptians recorded in the
Eber‘s papyrus, one of the oldest preserved medical documents, several diseases, among them a
polyuric syndrome‖ similar to modern day diabetes. Later, Araetus of Cappadocia labeled the
polyuric disease as melting down of flesh and limbs into urine. An Arab physician Avicenna,
(960-1037), described the characteristic sweet tasting urine of diabetics. Up into the 11th
century, water tasters were employed to taste the urine of suspected diabetics because of its
sweet taste. Mellitus, the Latin word of honey was added to the term ―diabetes because of the
urine‘s sweet taste. In the nineteenth century, the first chemical tests were used to measure sugar
levels in the urine. At that point, the causes of diabetes were not fully understood, but many
speculated that the kidney was the cause. However in 1848, French researcher Claude Bernard
not only discovered that the liver excreted sugar into the blood, but glucose, the body‘s sugar
was stored in it in another form called glycogen. Later, in 1889, scientists Joseph von Mering
(1849- 1908) and Oscar Minkowsk (1841-1904) discovered the role of the pancreas in diabetes,
specifically its role in the production of insulin. Insulin, a hormone in the body, was found to
regulate the body‘s blood sugar levels. In 1869, Gustav Lagusse, identified the cells, islets of
Langerhans, located in the pancreas as the culprit for diabetes. In an innovative paper ―The
Beneficial Influences of Certain Pancreatic Extracts on Pancreatic Diabetes‖ Federick Banting, in
1921 in a paper descried and explained the role of insulin in diabetes treatment. (Leger, 2010).

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Diabetes mellitus is chronic metabolic disordercharacterized by hyperglycemia. Uncontrolled
diabetes which leads to damage to small blood vessels (e.g Kidney, eye, and large blood vessels
such as Heart, Brain. (WHO, 2016).
Thereare three main types of diabetes mellitus: type1, type2 and Gestation diabetes, also there
are other types.
Type 1 diabetes also called as insulin-dependent or juvenile or childhood-onset diabetes is
characterized by insufficient insulin production in the body. People with type 1 diabetes require
daily administration of insulin to regulate the amount of glucose in their blood. If they do not
have access to insulin, they cannot survive. The cause of type 1 diabetes is unknown and it is not
preventable.
Type 2 diabetes also called non-insulin-dependent or adult onset diabetes, there is not
enoughinsulin production or there's resistance of the body toinsulin. Type 2 diabetes accounts for
the vast majority of people with diabetes around the world.
Gestational diabetes (GDM) is a temporary condition that occurs in pregnancy and carries long
term risk of type 2 diabetes. The condition is present when blood glucose values are above
normal but still below those diagnostic of diabetes. Women with gestational diabetes are at
increased risk of some complications during pregnancy and delivery, as are their infants.
(REPORT, 2016).
The prevalence of diabetes and impaired glucose tolerance (IGT) are estimated for the years
2017 and 2045. The estimates are provided for 221 countries and territories, grouped into seven
IDF regions: Africa (AFR), Europe (EUR), Middle East and North Africa (MENA), North
America and Caribbean (NAC), South and Central America (SACA), South-East Asia (SEA) and
the Western Pacific (WP).425 million people worldwide, or 8.8% of adults 20-79 years, are
estimated to have diabetes. About 79% live in low and middle income countries. The number of
people with diabetes increases to 451 million if the age is expanded to 18-99 years. If these
trends continue, by 2045, 693 million people 18-99 years, or 629 million of people 20-79 years,
will have (diabetesDiabetes Atlas 2017).
The largest increases will take place in regions where economies are moving from low income to
middle income levels. Diabetes estimates have been on the rise for several decades. More than
one-third of diabetes cases are estimated to result from population growth and ageing, 28% from

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an increase in age-specific prevalence and 32% from the interaction of these two. Globally
diabetes results in USD 727 billion being spent yearly by people with diabetes only on
healthcare, which corresponds to one for every eight dollars spent on healthcare (ATLAS, 2017).
Age Distribution
There are 326.5 million people of working age (20-64 years) with diabetes, and 122.8 million
people 65-99 years with diabetes. The number of people of working age with diabetes is
expected to increase to 438.2 million, and the number of people with diabetes 65-99 years will
increase to 253.4 million in 2045. Likewise, the economic burden of diabetes will increase in the
next decades particularly among elder age groups (70-99) with an increase of USD 104 billion
from 2017 to 2045(ATLAS, 2017).
Gender distribution
The prevalence of diabetes for women 20-79 years is estimated to be 8.4% which is slightly
lower than among men 9.1%. There are about 17.1 million more men than women with diabetes
(221.0 million men vs 203.9 million women). The diabetes prevalence in women is expected to
increase to 9.7% in women and to 10.0% in men. The age group 65-79 years shows the highest
diabetes prevalence in both women and men.(ATLAS, 2017)
Urban and Rural environment
In 2017, there are more people between 20-79 years old with diabetes in urban (279.2 million)
versus rural (145.7 million) settings, and the prevalence is higher in urban versus rural (10.2% vs
6.9%). The number of people living with diabetes in urban areas is expected to increase to 472,6
million in 2045 due mainly to global urbanization.(ATLAS, 2017).
Regional Disparities
Age-adjusted comparative prevalence compares diabetes prevalence between countries and
regions. The North America and Caribbean region (NAC) has the highest age adjusted
comparative prevalence 20-79 years in 2017 and 2045 (11.0% and 11.1%). The Africa region
has the lowest prevalence in 2017 and 2045(4.2% and 4.1% = 17.85 million), likely due to

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lower levels of urbanization, under-nutrition, lower levels of obesity and higher rates of
communicable diseases. The largest numbers of people with diabetes from age 20-79 years are in
China, India and the United States in 2017. Across IDF regions, large disparities were observed
in the resources allocated to diabetes. While in the African region ID 444 on average was spent
on people with diabetes yearly, this value was nearly 20 times higher in NAC, where ID 8,396
was spent on people with diabetes.(ATLAS, 2017).
Health nutrition and population statistics (World Bank) has shown that diabetes prevalence in
Somalia (population ages 20 to 79) was 5.1 % in 2015 - the single year for which the data is
available at the moment.(Knoema, 2015). There is no available published data on vascular
complication type2 diabetes mellitus in Somalia.
1.2 Problem Statement
Insulin is a peptide hormone secreted by the β cells of the pancreatic islets of Langerhans and
maintains normal blood glucose levels by facilitating cellular glucose uptake, regulating
carbohydrate, lipid and protein metabolism and promoting cell division and growth through its
mutagenic effects.( Gisela, 2005).
Diabetes mellitus is metabolic disorder characterized by the presence of high blood sugar due to
impairment of insulin secretion, defective insulin action or both.
The chronic hyperglycemia of diabetes is associated with relatively specific long-term micro
vascular complications affecting the eyes, kidneys and nerves, as well as Macro vascular
complicationssuch us Heart and Brain( Goldenberg MD, 2013).
1.3 Objectives of the Study
1.3.1 General Objective
To determine Prevalence of Vascular Complications among Type 2 Diabetes Mellitus Among
patients in Aden Ade Hospital.

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1.3.2 Specific Objectives:
1. To identify prevalence Diabetic Nephropathy among Patients in Aden Ade Hospital.
2. To explore prevalence Diabetic peripheral Neuropathy among Patients in Aden Ade
Hospital.
3. To Clarify effect of cardiovascular Patients type 2 Diabetic in Aden Ade Hospital.
1.4 Research Questions
1. What is the prevalence Diabetic Nephropathy among Patients in Aden Ade Hospital?
2. What is the prevalence Diabetic peripheral Neuropathy among Patients in Aden Ade Hospital?
3. What is the effect of cardiovascular among Patients type 2 Diabetic in Aden Ade Hospital?

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1.5 Conceptual frame work
1. Nephropathy
 Nocturia and polyuria.
 Nausea and vomiting.
 Skin itchy
 Generalized swelling.
2. Peripheral neuropathy:
 Peripheral Neuropathy:
Tingling, Pain, Numbness
or Weakness.
 Foot ulcer
 Gangrene
 Gangrene
Patient of type
2 diabetes
3. Cardiovasculardiseases
 Chest pain or discomfort
 Shortness Of Breath
 Fatigue and weakness

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1.6 Scopeof the study
1.6.1 Content ofthe study
The Variables to be conducted the study Include Prevalence of Vascular Complications among
Type 2 Diabetes Mellitus Among patients in Aden Ade Hospital
1.6.2 Geographical ofthe scope
This study will conduct in Mogadishu; this is selected due to being where find out suitable target.
1.6.3 Time ofScope
This study will be limited from July 2018 to November2018.
1.7 Significance of the study
This research concerned with study Prevalence of Vascular Complications among Type 2
Diabetes Mellitus Among patients in Aden Ade Hospital.
The findings may also contribute literature for academicians who are interesting to carry out for
farther study of this field. The contribution of this research. This study will become reference
later researcher to clarify the prevalence of Vascular Complications among Type 2 Diabetes
Mellitus in Somalia.
This research will be useful to professionals in health centers and other privet hospitals and
clinics to search better way to know the Prevalence of Vascular Complications among Type 2
Diabetes Mellitus. This study will discover after finished important knowledge of this field.
1.8 Definition of Terms
Diabetic: commonly referred to as diabetes, is a group of metabolic disorders in which there
are high blood sugar levels over a prolonged period.
Hyperglycemia: or high blood sugar is an abnormally high blood glucose (blood sugar) level in
the blood. Hyperglycemia is a hallmark sign of diabetes (both type 1 diabetes and type 2
diabetes) and prediabetes. The main symptoms of hyperglycemia are increased thirst and a
frequent need to urinate.

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Vascular: Relating to blood vessels. For example, the vascular system in the body includes all
of the veins and arteries. And, a vascular surgeon is an expert at evaluating and treating problems
of the veins and arteries.
Nephropathy: is chronic loss of kidney function occurring in those with diabetes mellitus.
Neuropathy:is referring to general diseases or malfunction of the nerves.

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CHAPTER TWO
LITERATURE REVIEW
2.0INTRODUCTION
This chapter composed introduction of diabetes mellitus, epidemiology of diabetes mellitus,
factors that increase incidence of diabetes mellitus, symptoms, pathophysiology, management
and role of lifestyle modification in the prevention and management of diabetes mellitus.
2.1DIABETES MELLITUS
Diabetes mellitus (DM), commonly referred to as diabetes, is a group of metabolic disease in
which there are high level of blood sugars over prolonged period. (WHO, 2014).
Diabetes is due to either the pancreas not producing enough insulin or the cells of the body not
responding properly to the insulin produced. (David & Dolores, 2011).
Diabetes is one of the four priority non-communicable diseases (NCDs) identified by the WHO
along with cardiovascular disease (CVD), which includes heart attack and stroke, cancer, and
chronic respiratory disease.
Diabetes is common, chronic, and costly. It is characterized by hyperglycemia (high levels of
glucose in the blood), which results from lack of insulin (type 1 diabetes), or insufficient insulin
and insulin resistance (type 2 diabetes). It has a genetic component and some people are simply
more susceptible to developing diabetes than others.
Type 1 diabetes is thought to be triggered by certain viral infections and sometimes by
environmental toxins. Type 2 diabetes can be triggered by a variety of interrelated factors some
of which are non-modifiable such as increasing age, ethnicity and a family history of diabetes. In
addition, diabetes can first appear during pregnancy. This is known as gestational diabetes
mellitus (GDM). Diabetes is attributable to a variety of genetic, epigenetic, environmental and
biological factors, many of which are outside the control of people who get it(Unger et al. 1998).
Type 1 diabetes is an autoimmune disease. An autoimmune disease results when the body’s
system for fighting infection—the immune system—turns against a part of the body. In diabetes,

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the immune system attacks and destroys the insulin-producing beta cells in the pancreas. The
pancreas then produces little or no insulin. A person who has type 1 diabetes must take insulin
daily to live.
At present, scientists do not know exactly what causes the body’s immune system to attack the
beta cells, but they believe that autoimmune, genetic, and environmental factors, possibly
viruses, are involved. Type 1 diabetes accounts for about 5 to 10 percent of diagnosed diabetes in
the United States. It develops most often in children and young adults but can appear at any age
(National Association of Managed Care Physicians, 2008).
Type 2 diabetes is due to a combination of insulin resistance and insulin deficiency. It accounts
for 95% or more of all diabetes globally. It most commonly occurs in middle-aged and older
people but increasingly affects overweight children, adolescents and young adults. It is
particularly affecting people in the productive years of the life cycle. People with type 2 diabetes
are usually treated with tablets but many also require insulin injections. Type 2 diabetes is a
major cause of heart disease and other complications. It can be prevented or significantly delayed
by simple and cost effective interventions (Diabetes Mellitus – epidemiology. I. World Health
Organization 2014).
Gestational diabetes (GDM) is a temporary condition that occurs in pregnancy and carries long-
term risk of type 2 diabetes (2). The condition is present when blood glucose values are above
normal but still below those diagnostic of diabetes (3). Women with gestational diabetes are at
increased risk of some complications during pregnancy and delivery, as are their infants.
Gestational diabetes is diagnosed through prenatal screening, rather than reported symptoms.
RISK FACTORS FOR DIABETES Type 1. The exact causes of type 1 diabetes are unknown. It
is generally agreed that type 1 diabetes is the result of a complex interaction between genes and
environmental factors, though no specific environmental risk factors have been shown to cause a
significant number of cases. The majority of type 1 diabetes occurs in children and adolescents.
Type 2. The risk of type 2 diabetes is determined by an interplay of genetic and metabolic
factors. Ethnicity, family history of diabetes, and previous gestational diabetes combine with
older age, overweight and obesity, unhealthy diet, physical inactivity and smoking to increase
risk. Excess body fat, a summary measure of several aspects of diet and physical activity, is the
strongest risk factor for type 2 diabetes, both in terms of clearest evidence base and largest

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relative risk. Overweight and obesity, together with physical inactivity, are estimated to cause a
large proportion of the global diabetes burden. Higher waist circumference and higher body mass
index (BMI) are associated with increased risk of type 2 diabetes, though the relationship may
vary in different populations. Populations in South-East Asia, for example, develop diabetes at a
lower level of BMI than populations of European origin (WHO 2014).
Women with GDM and the off spring of GDM pregnancies are at increased risk of developing
type 2 diabetes later in life; Risk factors and risk markers for GDM include age (the older a
woman of reproductive age is, the higher her risk of GDM); overweight or obesity; excessive
weight gain during pregnancy; a family history of diabetes; GDM during a previous pregnancy; a
history of stillbirth or giving birth to an infant with congenital abnormality; and excess glucose
in urine during pregnancy. Diabetes in pregnancy and GDM increase the risk of future obesity
and type 2 diabetes in offspring.
2.2Risk Factors
Modifiable risks for developing type 2 diabetes vary across populations and include obesity,
over-or poor- nutrition (including under-nutrition in the womb and early life), and physical
inactivity.Many of these risks are shared with other NCDs making type2 diabetes an important
and logical entry point for NCD prevention and control. Much of the treatment of diabetes can be
undertaken in tandem with other chronic diseases, thus creating economies of scale and
optimizing health resources. If undiagnosed, untreated or poorly controlled, diabetes can cause
devastating, irreversible complications such as visual impairment and blindness, kidney failure,
heart attack, stroke, lower limb amputation, and erectile dysfunction. While these complications
are predominantly due to persistent hyperglycemia, other factors such as high blood pressure,
lipid disturbances and obesity are important contributors.
Although the exact cause of type 1 diabetes is unknown, factors that may signal an increased risk
include:
 Family history. Your risk increases if a parent or sibling has type 1 diabetes.
 Environmental factors. Circumstances such as exposure to a viral illness likely play some
role in type 1 diabetes.

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 The presence of damaging immune system cells (autoantibodies). Sometimes family
members of people with type 1 diabetes are tested for the presence of diabetes
autoantibodies. If you have these autoantibodies, you have an increased risk of developing
type 1 diabetes. But not everyone who has these autoantibodies develops diabetes.
 Geography. Certain countries, such as Finland and Sweden, have higher rates of type 1
diabetes.
Risk factors for prediabetes and type 2 diabetes
Researchers don't fully understand why some people develop prediabetes and type 2 diabetes and
others don't. It's clear that certain factors increase the risk, however, including:
 Weight. The more fatty tissue you have, the more resistant your cells become to insulin.
 Inactivity. The less active you are, the greater your risk. Physical activity helps you control
your weight, uses up glucose as energy and makes your cells more sensitive to insulin.
 Family history. Your risk increases if a parent or sibling has type 2 diabetes.
 Race. Although it's unclear why, people of certain races including black people, Hispanics,
American Indians and Asian-Americans are at higher risk.
 Age. Your risk increases as you get older. This may be because you tend to exercise less,
lose muscle mass and gain weight as you age. But type 2 diabetes is also increasing among
children, adolescents and younger adults.
 Gestational diabetes. If you developed gestational diabetes when you were pregnant, your
risk of developing prediabetes and type 2 diabetes later increases. If you gave birth to a
baby weighing more than 9 pounds (4 kilograms), you're also at risk of type 2 diabetes.
 Polycystic ovary syndrome. For women, having polycystic ovary syndrome a common
condition characterized by irregular menstrual periods, excess hair growth and obesity
increases the risk of diabetes.

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 High blood pressure. Having blood pressure over 140/90 millimeters of mercury (mm Hg)
is linked to an increased risk of type 2 diabetes.
 Abnormal cholesterol and triglyceride levels. If you have low levels of high-density
lipoprotein (HDL), or "good," cholesterol, your risk of type 2 diabetes is higher.
Triglycerides are another type of fat carried in the blood. People with high levels of
triglycerides have an increased risk of type 2 diabetes. Your doctor can let you know what
your cholesterol and triglyceride levels are.
2.3HISTORY OF DIABETES
Diabetes is one of the first diseases described (Brian C. Leutholtz, 2011) with Egyptian
manuscript from 1500 BCE mentioning “too great emptying of the urine. (Poretsky, 2009).
Around the same period of time Indian physicians also identified the disease and called
Madhumeha or honey urine that can attract aunt. (Poretsky, 2009). The word diabetes was first
described in 250 BCE by the Greek Apollonius of Memphis. (Poretsky, 2009).
The term Mellitus or from honey was added by Thomas Willis in the late 1600s to separate the
condition from diabetes insipidus which is also associated with frequent urination. (Poretsky,
2009). The first clinical description of the disease was stated by the Ancient Greeks physician
Aretaeus of Cappadocia (1st century CE) who noted the excessive amount of urine which passed
through. (Dallas & John, 2011). Diabetes mellitus appears to have been a death sentence in the
ancient era because physicians thought that this disease is incurable. Aretaeus did attempt to treat
it but could not give a good prognosis; he commented that "life (with diabetes) is short,
disgusting and painful. (Medvei & Cornelius, 1993).
The incidence of the disease during the time of Romans decreased and Galen said that he saw
only two cases during his lifetime as a physician.(Poretsky, 2009). The sweet urine symptom of
diabetes is evident in the Chinese name for diabetes, tángniǎobìng (糖尿病), and meaning "sugar
urine disease". This name has also been borrowed into Korean and Japanese. In 1776 Matthew

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Dobson confirmed that the sweet taste comes from an excess of a kind of sugar in the urine and
blood. (Dobson, 1776).
The role of the pancreas in pathogenesis of diabetes was discovered by von Mering and Oskar
Minkowski in 1889 who found that dogs whose pancreas was removed developed all the
signsand symptoms of diabetes and died shortly afterwards. (Von Mehring J & O,
1890).Although diabetes has been recognized for a long time period and treatments of various
efficacy have been known in various regions pathogenesis of diabetes has only been discovered
in early 1900s. The first effective treatment of diabetes was then discovered by two Canadian
physicians Frederick Banting and also Charles Best in 1921. (Poretsky, 2009).
The classification of diabetes mellitus into two distinct groups was first made by Sir Harold
Percival Himsworth and published in January 1936. (Himsworth, 1936).
2.4CLASSIFICATION OF DIABETES MELLITUS
Diabetes mellitus is classified as follows:-
Type 1 DM results from the pancreas's failure to produce enough insulin. This form was
previously referred to as "insulin-dependent diabetes mellitus" (IDDM) or "juvenile
diabetes". The cause is unknown. (WHO, 2013).
Type 2 DM begins with insulin resistance, a condition in which cells fail to respond to
insulin properly (WHO, 2013). As the disease progresses a lack of insulin may also
develop (Tripathy, Chandalia, & Das, 2012). This form was previously referred to as
"non insulin-dependent diabetes mellitus" (NIDDM) or "adult-onset diabetes". The most
common cause is excessive body weight and not enough exercise. (WHO, 2013).
Gestational Formof diabetes is the third main form and occurs when pregnant women
without a previous history of diabetes develop high blood-sugar levels. (WHO, 2013).
Pre-diabetes: Pre-diabetes is a condition in which blood glucose levels are higher than
normal (a fasting glucose level between 100 and 125mg/dl) but not yet diabetic. In this
condition, the cells in the body are becoming resistant to insulin or the pancreas is not
producing sufficient insulin as required. This is also known as impaired fasting glucose

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(IFG) or impaired glucose tolerance (IGT). These are intermediate state of abnormal
glucose regulation between how a body normally uses glucose and diabetes. People with
IFG or IGT are at risk of developing type 2 diabetes, although this is not predictable.
(Asare, 2008).
2.5PATHOPHYSIOLOGY OF DIABETES MELLITUS
Insulin is the principal hormone that regulates the uptake of glucose from the blood into most
cells of the body, especially liver, adipose tissue and muscle, except smooth muscle, in
which insulin acts via the IGF-1. Therefore, deficiency of insulin or the insensitivity of its
receptors plays a central role in all forms of diabetes mellitus. (American diabetic
Association, 2014).
The body obtains glucose from three main places: the intestinal absorption of food; the
breakdown of glycogen, the storage form of glucose found in the liver; and gluconeogenesis,
the generation of glucose from non-carbohydrate substrates in the body. Insulin plays a critical
role in balancing glucose levels in the body. Insulin can inhibit the breakdown of glycogen or
the process of gluconeogenesis, it can stimulate the transport of glucose into fat and muscle
cells, and it can stimulate the storage of glucose in the form of glycogen. (Gardner & Dolores,
2011).
Insulin is released into the blood by beta cells (β-cells), found in the islets of Langerhans in the
pancreas, in response to rising levels of blood glucose, typically after eating. Insulin is used by
about two-thirds of the body's cells to absorb glucose from the blood for use as fuel, for
conversion to other needed molecules, or for storage. Lower glucose levels result in decreased
insulin release from the beta cells and in the breakdown of glycogen to glucose. This process is
mainly controlled by the hormone glucagon, which acts in the opposite manner to insulin.
(Barrett, 2012).
If the amount of insulin available is insufficient, if cells respond poorly to the effects of insulin
(insulin insensitivity or insulin resistance), or if the insulin itself is defective, then glucose will
not be absorbed properly by the body cells that require it, and it will not be stored appropriately

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in the liver and muscles. The net effect is persistently high levels of blood glucose, poor
protein synthesis, and other metabolic derangements, such as acidosis. (Gardner & Dolores,
2011).
When the glucose concentration in the blood remains high over time, the kidneys will reach a
threshold of reabsorption, and glucose will be excreted in the urine (glycosuria). (Murray, 2012).
This increases the osmotic pressure of the urine and inhibits reabsorption of water by the
kidney, resulting in increased urine production (polyuria) and increased fluid loss. Lost blood
volume will be replaced osmotically from water held in body cells and other body
compartments, causing dehydration and increased thirst (polydipsia). (Gardner & Dolores,
2011)
2.6CLINICAL PRESENTATION OF DIABETES MELLITUS
The most specific symptoms of diabetes mellitus include:
Increased or Extreme Thirst: The extreme thirst or unusual demand of drinking water may
suggest a sign of diabetes, especially when it is compounded with frequent urination. The
pancreas of the diabetic patient produces little or no insulin which makes the body absorb extra
water out of the blood to dilute the body glucose. As a result of this, the body becomes
dehydrated and therefore demands more water to replace the one that is losing.
Increased or Frequent Urination: This results from high blood glucose level. When pancreas
secretes little or no insulin, the kidney cannot filter glucose back to the blood. For kidney to
function effectively, the system absorbs more water to dilute the glucose. This keeps the bladder
full and therefore frequent urination.
Unusual Weight Loss: This is mostly identified among type 1 diabetic patients, where the
pathologic process in nearly all the patients is autoimmune destruction of pancreatic islet beta
cell with absolute loss of insulin secretion. In this situation, glucose (energy source) cannot be
transported into the body’s cells and so the body demands for energy source breaks down muscle
tissues and fat for energy. Therefore, the wear out tissues and fat contribute to the weight loss.

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Increased Fatigue: This is as a result of lack of energy in the body. When the body’s source of
energy, glucose, enters into the bloodstream, it is assisted by insulin to be transported into the
cell of the body where energy is produced. The situation where there is little or no secretion of
insulin will make glucose remain in the bloodstream. The cells are then unable to produce energy
for activities of the body.
Other symptoms include tingling or numbness in limbs, blurred vision, skin itching, frequent
infections or cut and bruises that take long time to heal. (ADA, 2008).
However, the clinical Triad of Diabetes are: increase urination, increase thirsty, and also increase
eating (polyuria, Polydipsia, and Polyphagia). (Cooke DW, 2008).
Other non-specific symptoms can also occur which may include blurred vision, lack of sensation
in the peripheral parts of the body, impotence, tingling sensation of the feet and palms and also
many dermatological signs like Acanthosis nigricans.
2.7DIAGNOSIS OF DIABETES MELLITUS
Diabetes mellitus is characterized by recurrent or persistent high blood sugar, and is diagnosed
by demonstrating any one of the following:
Fasting plasma glucose level ≥ 7.0 mmol/l (≥ 126 mg/dl)
Plasma glucose ≥ 11.1 mmol/l (200 mg/dl) two hours after a 75 g oral glucose load as in
a glucose tolerance test.
Symptoms of high blood sugar and casual plasma glucose ≥ 11.1 mmol/l (200 mg/dl)
Glycocylated hemoglobin (HbA1C) ≥ 48 mmol/mol (≥ 6.5 DCCT %). (American
Diabetes Association, 2010).
A positive result, in the absence of unequivocal high blood sugar, should be confirmed by a
repeat of any of the above methods on a different day. It is preferable to measure a fasting
glucose level because of the ease of measurement and the considerable time commitment of
formal glucose tolerance testing, which takes two hours to complete and offers no prognostic
advantage over the fasting test. According to the current definition, two fasting glucose
measurements above 126 mg/dl (7.0 mmol/l) is considered diagnostic for diabetes mellitus. (SH,
M, J, C, D, & Bran, 2001).

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According to the World Health Organization people with fasting glucose levels from 6.1 to
6.9 mmol/l (110 to 125 mg/dl) are considered to have impaired fasting glucose.
People with plasma glucose at or above 7.8 mmol/l (140 mg/dl), but not over 11.1 mmol/l (200
mg/dl), two hours after a 75 g oral glucose load are considered to have impaired glucose
tolerance. Of these two pre diabetic states, the latter in particular is a major risk factor for
progression to full-blown diabetes mellitus, as well as cardiovascular disease. (PL, et al., 2008).
The American Diabetes Association since 2003 uses a slightly different range for impaired
fasting glucose of 5.6 to 6.9 mmol/l (100 to 125 mg/dl).
Glycocyleted hemoglobin is better than fasting glucose for determining risks of
cardiovascular disease and death from any cause. (R, J, & Zimmet, 2009).
2.8TREATMENT OFDIABETES MELLITUS
Diabetes mellitus is a chronic disease, for which there is no known cure except in very specific
situations (WebMD, 2015).
Management focusses on keeping blood sugar levels as close to normal, without causing low
blood sugar. This can usually be accomplished with a healthy diet, exercise, weight loss, and use
of appropriate medications (insulin in the case of type 1 diabetes; oral medications, as well as
possibly insulin, in type 2 diabetes). (Brian C. Leutholtz, 2011).
Learning about the disease and actively participating in the treatment is important, since
complications are far less common and less severe in people who have well-managed blood
sugar levels (DM, et al., 2005).
The goal of treatment is an HbA1C level of 6.5%, but should not be lower than that, and may be
set higher (National Institute for Health and Clinical Excellence, 2008). Attention is also paid to
other health problems that may accelerate the negative effects of diabetes. These include
smoking, elevate cholesterol levels, obesity, high blood pressure, and lack of regular exercise
(National Institute for Health and Clinical Excellence, 2008). Specializedfootwear is widely used

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to reduce the risk of ulceration, or re-ulceration, in at-risk diabetic feet.Evidence for the efficacy
of this remains equivocal.
2.8.1 Lifestyle Modification
People with diabetes can benefit from education about the disease and treatment, good nutrition
to achieve a normal body weight, and exercise, with the goal of keeping both short-term and
long-term blood glucose levels within acceptable bounds. In addition, given the associated
higherrisks of cardiovascular disease, lifestyle modifications are recommended to control blood
pressure. (Kalra, Kalra, & Kumar, 2007).
2.8.2 Medications
Medications used to treat diabetes do so by lowering blood sugar levels. There are a number of
different classes of anti-diabetic medications. Some are available by mouth, such as metformin,
while others are only available by injection such as GLP-1 agonists. Type 1 diabetes can only be
treated with insulin, typically with a combination of regular and NPH insulin, or synthetic insulin
analogs. (National Institute for Health and Clinical Excellence, 2008).
2.8.3 Surgery
A pancreas transplant is occasionally considered for people with type 1 diabetes who have
severe complications of their disease, including end stage kidney disease requiring kidney
transplantation. (American Diabetes Association, 2014).
Weight loss surgery in those with obesity and type 2 diabetes is often an effective measure.
Many are able to maintain normal blood sugar levels with little or no medications following
surgery and long-term mortality is decreased. There is, however, a short-term mortality risk of
less than 1% from the surgery. The body mass index cut offs for when surgery is appropriate are
not yet clear. It is recommended that this option be considered in those who are unable to get
both their weight and blood sugar under control. (JB, Roux, CW, F, & P, 2012).

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2.9PREVENTION OF DIABETES MELLITUS
The only preventable type of diabetes mellitus is type 2 DM which accounts about 90% of
diabetic cases and can often prevented or delayed by maintain normal body weight through
physical activity and consuming healthy diet. (WHO, 2013).
Higher level of physical activity can reduce the risk of type 2 DM by 28%. (Kyu, et al., 2016)
Limiting sugary beverages and eating less amount of red meat and other sources of saturated fat
can also help prevent diabetes (Harvard, 2014). Tobacco smoking is also associated with an
increased risk of diabetes and its complications, so smoking cessation can be an important
preventive measure as well. (Willi C, 2007).
2.10 FACTORS THAT INCREASE INCIDENCE OF DIABETES
Several factors are known to be contributed the development of type 2 DM including obesity,
physical inactivity, diet and urbanization. (Melmed, Polonsky, Larsen, & Kronenberg, 2011).
2.10.1 OBESITY
The WHO defined obesity and overweight as abnormal or excessive fat accumulation that may
impair health. (WHO&IDF, 2006).
Bodyweight is usually measured as BMI (Body Mass Index).BMI is a simple index of weight-
for-height that is commonly used to classify underweight, overweight and obesity in adults. It is
defined as the weight in kilograms divided by the square of the height in meters (kg/m2). (WHO,
2010).
In 2013, an estimated 2.1 billion adults were overweight as compared with 857 million in 1980.
(Ng, et al., 2014).
There is a strong correlation between the increase of obesity and the frequency of type 2 diabetes
mellitus. (Mustafa, Tunga, Levent, Süleyman, & Hayriye, 2005).
Excess body fat is believed to be 64% of cases of diabetes in men and 77% of cases in women.

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(Visscher, Snijder, & Seidell, 2009).
Longstanding obesity is responsible to increased insulin resistance that can develop into type 2
diabetes, most likely because adipose tissue (especially that in the abdomen around internal
organs) is a source of several chemical signals, hormones and cytokines to other tissues.
Inflammatory cytokines such as TNFα may activate the NF-κB pathway which has been linked
to the development of insulin resistance. (Shoelson, Lee, & Goldfine, 2006).
Obesity is the most significant factor leading to type 2 diabetes mellitus. Hence, obesity is the
easiest factor in type 2 diabetes mellitus to intervene. If obesity can be prevented, so can be
type2 diabetes mellitus (Mustafa, Tunga, Levent, Süleyman, & Hayriye, 2005).
2.10.2 PHYSICAL INACTIVITY/ SEDENTARYLIFESTYLE
According to the World Health Organization (WHO), sedentary lifestyle is one of the 10 leading
causes of death and disability. It accounts for 300,000 premature deaths each year in the United
States alone. These deaths are mainly from cardiovascular disease which people with type 2
diabetes mellitus and prediabetes mellitus are at a much higher risk than others. (Jennifer, 2008).
Sedentary life can lead to obesity which is a major factor in developing type 2 diabetes
mellitus.A lack of exercise alone is believed to cause 7% of diabetic cases. (Lee, Shiroma,
Lobelo, Puska, Blair, & Katzmarzyk, 2012).
2.10.3 DIET
Dietary factors are also an important risk factor of developing type 2 diabetes. Consumption of
excess sugar-sweetened drinks is highly associated with an increased risk of diabetes. (Malik,
Popkin, Bray, & Després, 2010).
Also sugar-sweetened drinks can lead to obesity which is another major factor for development
of diabetes mellitus. (Malik, Popkin, Bray, & Després, 2010).
In study done to over 50,000 women who were followed for 8 years, after adjustment for
potential confounders, those consuming ≥ 1 sugar sweetened beverages per day had an
83%greater risk of developing T2DM compared to those consuming <1 sugar sweetened
beverages per month. (Schulze, et al., 2004).

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The type of fats in the diet are also important, with saturated fats and trans fatty acids increasing
the risk of developing diabetes while polyunsaturated and monounsaturated fat decreasing the
risk. (Risérus, Willett, & Hu, 2009).
Eating a lot of white rice appears to play a role in increasing risk of developing type 2 diabetes.
(Hu, Pan, Malik, & Sun, 2012).
2.10.4 URBANIZATION
Urbanization refers to the population shift from rural to urban areas, the gradual increase in the
proportion of people living in urban areas, and the ways in which each society adapts to the
change. (National Library of Medicine, 2014).
Rapid urbanization has led to increased mortality from non-communicable diseases associated
with lifestyle including diabetes, cancer and heart disease. (Allender, Foster, Hutchinson, &
Arambepola, 2008).
Although urbanization is associated with improvements in public hygiene, sanitation and access
to health care, it also entails changes in occupational, dietary and exercise patterns which is more
important of the development of non-communicable diseases including diabetes. (Allender,
Foster, Hutchinson, & Arambepola, 2008).
Urbanization can have mixed effects on health patterns, alleviating some problems and
accentuating others for example, in children urbanization is associated with a lower risk of
under-nutrition but a higher risk of overweight. (Eckert & Kohler, 2014).
Overall, body mass index and cholesterol levels will increase sharply with national income and
the degree of urbanization. (Allender, Foster, Hutchinson, & Arambepola, 2008).

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2.11 ROLE OF LIFESTYLE MODIFICATION IN THE PREVENTION AND
MANAGEMENT OF DIABETES MELLITUS
Exercise training combined with nutritional intervention is the cornerstones of a lifestyle
intervention program for type 2 diabetes mellitus and should therefore be mandatory components
of any lifestyle intervention program. (Herman, 2005).
These two types of lifestyle interventions will lead to weight loss which is important goal for
persons that are obese or overweight particularly in those living with type 2 diabetes mellitus
because it’ll improve glycemic control. (Franz, et al., 2003).
The Diabetes Prevention Project demonstrated that lifestyle modification, including intensive
exercise, is more effective in preventing diabetes than pharmacological therapy, and highlighted
the role of trained professionals in motivating people to follow lifestyle interventions.
Similar results have been reported by the Malmo Study, the Da Qing Study, the Finnish
Diabetes Prevention Study and the Wenying Study. (Kalra, Kalra, & Kumar, 2007).
Although lifestyle intervention improves the condition of the patients with type 2 diabetes
mellitus and prevent those with IGT to develop diabetes there is not enough evidence to
determine if lifestyle interventions affect mortality in those who already have DM2.
(Schellenberg, Dryden, Vandermeer, Ha, & Korownyk, 2013).
2.11.1 EXERCISE
In experimental studies, the physiological pathways linking more exercise with increased insulin
sensitivity and glucose uptake is suggested to include increased capillarisation, oxidative
capacity of mitochondria and also increase Glucose transporter 4 protein (GLUT-4). (Hawley &
Lessard, 2008).
In addition to increasing insulin sensitivity, exercise training has been suggested to be associated
with an increased insulin secretion in patients with type 2 diabetes and with a decrease in healthy
persons. (Dela, Von Linstow, Mikines, & Galbo, 2004).

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Most studies investigating the association of physical activity with glucose metabolism has
included measures of moderate-to-vigorous physical activity due to the health beneficial effects
of the higher physical activity intensities. In cross-sectional and prospective studies, physical
activity of moderate-to-vigorous intensity has been related to better glucose homeostasis (Assah,
Brage, Ekelund, & Wareham, 2008) whereas other studies have found overall physical activity to
be the main determinant of insulin sensitivity. (Balkau, et al., 2008).
2.11.2 NUTRITION
It is a fact that the majority of those diagnosed with type 2 diabetes mellitus, approximately 90%,
are overweight or obese and then there is no doubt any longer that nutrition will play a large role
in controlling the disease. (Caisson, 2010).
Therefore Medical Nutrition Therapy combined with exercise is the mainstay intervention
program for type 2 DM. (Haskell, Lee, Pate, Powell, Blair, & Franklin, 2007).
Also we know that the diet could have high impact to development of diabetes as shown as in
report "Dietary fats and prevention of type 2 diabetes" and also "White rice consumption and risk
of type 2 diabetes: meta-analysis and systematic review". (Hu, Pan, Malik, & Sun, 2012)
(Risérus, Willett, & Hu, 2009).
2.12 SUMMARY OF LITERATURE REVIEW
Diabetes mellitus (DM), commonly referred to as diabetes, is a group of metabolic disease in
which there are high level of blood sugars over prolonged period. (WHO, 2014).
Diabetes is one of the first diseases described (Brian C. Leutholtz, 2011) with Egyptian
manuscript from 1500 BCE mentioning “too great emptying of the urine. (Poretsky, 2009)
According to World Health Organization report in 2016 an estimated 422 Million adults are
living with diabetes globally. (WHO, 2016).
When comparing this data to the 2013 estimation data from International Diabetes Federation
that showed 381 million was living with DM ("Simple treatment to curb diabetes", 2014) you

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can see that the disease is really growing rapidly and it’s believed to project almost double by the
year of 2030.(Wild S, 2004).
The WHO estimates that diabetes resulted in 1.5 million deaths in 2012, making it the 8th
leading cause of death. (WHO, 2016).
Factors which are considered to the cause of this pandemic disease are mainly obesity,
physicalinactivity, diet and urbanization (Melmed, Polonsky, Larsen, & Kronenberg, 2011).
Exercise training combined with nutritional intervention is the cornerstones of a lifestyle
intervention program for type 2 diabetes mellitus and should therefore be mandatory components
of any lifestyle intervention program. (Herman, 2005).
Factors that are believed to be related on growing the disease and its risk factor are the
knowledge, attitude and practice regarding lifestyle modification in diabetic patients.
In a non-randomized study done by Z. Ghazanfari and colleagues, the knowledge, attitudes and
practices regarding lifestyle modifications among type 2 diabetes mellitus were evaluated
following the implementation of a designed educational program on the lifestyle to type 2
diabetes mellitus patients. The outcome was a significant increase in the knowledge (P< 0.001),
attitudes (P< 0.01) and practices (P< 0.01) of the intervention group towards healthy behaviors
regarding nutrition, physical activity and self-care. They concluded that their designed
educational program could improve the lifestyle of patients suffering from type 2 diabetes
mellitus. (Ghazanfari, Ghofranipour, Tavafian, Ahmadi, & Rajab, 2007).
2.13 Complications of Diabetes
2.13.1 Acute Complication
Acute complications are caused by either high or low glucose levels in the blood. Severely
elevated blood sugar levels due to an actual lack of insulin or a relative deficiency of insulin.
Abnormally low blood sugar levels due to too much insulin or other glucose-lowering
medications.

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In patients with type 2 diabetes, stress, infection, and medications (such as corticosteroids) can
also lead to severely elevated blood sugar levels. Accompanied by dehydration, severe blood
sugar elevation in patients with type 2 diabetes can lead to an increase in blood osmolality
(hyperosmolar state). This condition can worsen and lead to coma (hyperosmolar coma). A
hyperosmolar coma usually occurs in elderly patients with type 2 diabetes. Like diabetic
ketoacidosis, a hyperosmolar coma is a medical emergency. Immediate treatment with
intravenous fluid and insulin is important in reversing the hyperosmolar state. Unlike patients
with type 1 diabetes, patients with type 2 diabetes do not generally develop ketoacidosis solely
on the basis of their diabetes. Since in general, type 2 diabetes occurs in an older population,
concomitant medical conditions are more likely to be present, and these patients may actually be
sicker overall. The complication and death rates from hyperosmolar coma is thus higher than in
diabetic ketoacidosis.
Insulin is vital to patients with type 1 diabetes, they cannot live without a source of exogenous
insulin. Without insulin, patients with type 1 diabetes develop severely elevated blood sugar
levels. This leads to increased urine glucose, which in turn leads to excessive loss of fluid
and electrolytes in the urine. Lack of insulin also causes the inability to store fat and protein
along with breakdown of existing fat and protein stores. This dysregulation, results in the process
of ketosis and the release of ketones into the blood. Ketones turn the blood acidic, a condition
called diabetic ketoacidosis (DKA). Symptoms of diabetic ketoacidosis
include nausea, vomiting, and abdominal pain. Without prompt medical treatment, patients with
diabetic ketoacidosis can rapidly go into shock, coma, and even death may result.
Diabetic ketoacidosis can be caused by infections, stress, or trauma, all of which may increase
insulin requirements. In addition, missing doses of insulin is also an obvious risk factor for
developing diabetic ketoacidosis. Urgent treatment of diabetic ketoacidosis involves the
intravenous administration of fluid, electrolytes, and insulin, usually in a hospital intensive care
unit. Dehydration can be very severe, and it is not unusual to need to replace 6-7 liters of fluid
when a person presents in diabetic ketoacidosis. Antibiotics are given for infections. With

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treatment, abnormal blood sugar levels, ketone production, acidosis, and dehydration can be
reversed rapidly, and patients can recover remarkably well.
Hypoglycaemia means abnormally low blood sugar (glucose). In patients with diabetes, the most
common cause of low blood sugar is excessive use of insulin or other glucose-lowering
medications, to lower the blood sugar level in diabetic patients in the presence of a delayed or
absent meal. When low blood sugar levels occur because of too much insulin, it is called an
insulin reaction. Sometimes, low blood sugar can be the result of an insufficient caloric intake or
sudden excessive physical exertion.
Blood glucose is essential for the proper functioning of brain cells. Therefore, low blood sugar
can lead to central nervous system symptoms such as:
 Dizziness,
 Confusion,
 Weakness, and
 Tremors.
The actual level of blood sugar at which these symptoms occur varies with each person, but
usually it occurs when blood sugars are less than 50 mg/dl. Untreated, severely low blood sugar
levels can lead to coma, seizures, and, in the worst case scenario, irreversible brain death.
The treatment of low blood sugar consists of administering a quickly absorbed glucose. These
include glucose containing drinks, such as orange juice, soft drinks (not sugar-free), or glucose
tablets in doses of 15-20 grams at a time (for example, the equivalent of half a glass of juice).
Even cake frosting applied inside the cheeks can work in a pinch if patient cooperation is
difficult. If the individual becomes unconscious, glucagon can be given by intramuscular
injection.
Glucagon is a hormone that causes the release of glucose from the liver (for example, it promotes
gluconeogenesis). Glucagon can be lifesaving and every patient with diabetes who has a history
of hypoglycemia (particularly those on insulin) should have a glucagon kit. Families and friends

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of those with diabetes need to be taught how to administer glucagon, since obviously the patients
will not be able to do it themselves in an emergency situation. Another lifesaving device that
should be mentioned is very simple; a medic-alert bracelet should be worn by all patients with
diabetes.
2.13.2 Chronic Complication
These diabetes complications are related to blood vessel diseases and are generally classified into
small vessel disease, such as those involving the eyes, kidneys and nerves (microvascular
disease), and large vessel disease involving the heart and blood vessels (macrovascular disease).
Diabetes accelerates hardening of the arteries (atherosclerosis) of the larger blood vessels,
leading to coronary heart disease (angina or heart attack), strokes, and pain in the lower
extremities because of lack of blood supply (claudication).
Eye Complications
The major eye complication of diabetes is called diabetic retinopathy. Diabetic retinopathyoccurs
in patients who have had diabetes for at least five years. Diseased small blood vessels in the back
of the eye cause the leakage of protein and blood in the retina. Disease in these blood vessels
also causes the formation of small aneurysms (micro-aneurysms), and new but brittle blood
vessels (neovascularization). Spontaneous bleeding from the new and brittle blood vessels can
lead to retinal scarring and retinal detachment, thus impairing vision.
To treat diabetic retinopathy, a laser is used to destroy and prevent the recurrence of the
development of these small aneurysms and brittle blood vessels. Approximately 50% of patients
with diabetes will develop some degree of diabetic retinopathy after 10 years of diabetes, and
80% retinopathy after 15 years of the disease. Poor control of blood sugar and blood pressure
further aggravates eye disease in diabetes.
Cataracts and glaucoma are also more common among diabetics. It is also important to note that
since the lens of the eye lets water through, if blood sugar concentrations vary a lot, the lens of

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the eye will shrink and swell with fluid accordingly. As a result, blurry vision is very common in
poorly controlled diabetes. Patients are usually discouraged from getting a new eyeglass
prescription until their blood sugar is controlled. This allows for a more accurate assessment of
what kind of glasses prescription is required.
Kidney damage
Kidney damage from diabetes is called diabetic nephropathy. The onset of kidney disease and its
progression is extremely variable. Initially, diseased small blood vessels in the kidneys cause the
leakage of protein in the urine. Later on, the kidneys lose their ability to cleanse and filter blood.
The accumulation of toxic waste products in the blood leads to the need for dialysis. Dialysis
involves using a machine that serves the function of the kidney by filtering and cleaning the
blood. In patients who do not want to undergo chronic dialysis, kidney transplantation can be
considered.
The progression of nephropathy in patients can be significantly slowed by controlling high blood
pressure, and by aggressively treating high blood sugar levels. Angiotensin converting enzyme
inhibitors (ACE inhibitors) or angiotensin receptor blockers (ARBs) used in treating high blood
pressure may also benefit kidney disease in patients with diabetes.
Nerve damage
Nerve damage from diabetes is called diabetic neuropathy and is also caused by disease of small
blood vessels. In essence, the blood flow to the nerves is limited, leaving the nerves without
blood flow, and they get damaged or die as a result (a term known as ischemia). Symptoms of
diabetic nerve damage include numbness, burning, and aching of the feet and lower extremities.
When the nerve disease causes a complete loss of sensation in the feet, patients may not be aware
of injuries to the feet, and fail to properly protect them. Shoes or other protection should be worn
as much as possible. Seemingly minor skin injuries should be attended to promptly to avoid
serious infections. Because of poor blood circulation, diabetic foot injuries may not heal.

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Sometimes, minor foot injuries can lead to serious infection, ulcers, and even gangrene,
necessitating surgical amputation of toes, feet, and other infected parts.
Diabetic nerve damage can affect the nerves that are important for penile erection,
causing erectile dysfunction (ED, impotence). Erectile dysfunction can also be caused by poor
blood flow to the penis from diabetic blood vessel disease.
Diabetic neuropathy can also affect nerves to the stomach and intestines, causing nausea, weight
loss, diarrhea, and other symptoms of gastroparesis (delayed emptying of food contents from the
stomach into the intestines, due to ineffective contraction of the stomach muscles).
The pain of diabetic nerve damage may respond to traditional treatments with certain
medications such as gabapentin (Neurontin), phenytoin (Dilantin), and carbamazepine(Tegretol)
that are traditionally used in the treatment of seizure disorders. Amitriptyline (Elavil, Endep)
and desipramine (Norpraminine) are medications that are traditionally used for depression. While
many of these medications are not indicated specifically for the treatment of diabetes
related nerve pain, they are used by physicians commonly.
The pain of diabetic nerve damage may also improve with better blood sugar control, though
unfortunately blood glucose control and the course of neuropathy do not always go hand in hand.
Newer medications for nerve pain include Pregabalin (Lyrica) and duloxetine (Cymbalta).

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CHAPTER THREE
Methodology
The research methodology aiming for the type of research the researcher did and the methods
was used to carry out it, and contains research design, target population, sampling procedure,
Data collection procedures, data analysis and interpretation
3.0Study Area Aden Adde Hospital
Aden Abdulle Hospital is one of the most known hospital in Mogadishu which has different
department and does different duties and it is as follows:
The hospital has many different departments and specialty doctors for different sectors like:
 Inpatient Department and
 Out Patient Department
3.1 Research Design
A descriptive, survey was conducted to determine the prevalence of Vascular Complication
among type II Diabetes Mellitus patients at Aden Abdulle Hospital in Mogadishu, Somalia.
Qualitative data were collected using a questionnaire involved for determining the prevalence of
Vascular Complication among type II Diabetes Mellitus at Aden Abdulle Hospital in Mogadishu,
Somalia.

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The researcher used qualitative design in cross sectional study because; the cross sectional study
is in depth investigation of an individual, group, institution. The cross sectional helps the
researcher to study multiple entities in depth in order to gain insight into the larger case and to
describe and explain rather than predict a phenomenon. This design is appropriate for rich
understanding of community the prevalence of Vascular Complication among type II Diabetes
Mellitus at Aden Adde Hospital in Mogadishu, Somalia.
3.2 Study population.
A research population is a large collection of individuals that is the main focus of scientific
investigation.Survey were conducted on patients at Aden Abdulle hospital.
3.3 Sampling Techniques
The choice of the health centre was to reduce the time of going to all the health centres and it
was hoped that it would be a good representation of the health facilities.
Simple random sampling technique
Simple random sample is a subset of individuals (a sample) chosen from a larger set
(a population). Each individual is chosen randomly and entirely by chance, such that each
individual has the same probability of being chosen at any stage during the sampling process,
and each subset of k individuals has the same probability of being chosen for the sample as any
other subset of k individuals
3.4 Sample size Determination.
Diabetic patients in Aden Abdulle Hospital were about 84 during the research so to find a sample
size we use Slovin’s formula which was formulated by Slovin in 1960.The Solvin’sformula is a
formula to get the ideal sample size for a given margin of error and population size. Example n
=N/1+N (0.05)2 Where n = sample size, N= number of population, e = margin of error. Therefore
in the following example we will use a 95 percent confidence level with a population size of 84
of the population in the hospital.

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Large sample size
The estimation of sample size was based on estimated prevalence of Vascular Complication
among type II Diabetes Mellitus at Aden Adde Hospital in Mogadishu, Somalia.
The sample size for this study will be 69 respondents; these adult patients will be from Aden
Abdulle Hospital.
3.5 Research instrument
The research instrument used this thesis was questionnaire to collect the items to which
respondents was required to fill in the questions asked by the researcher.
3.6 Validity and reliability
In this research the data we collected will be reliable and truly information that is why we choose
knowledgeable medical staff attitude about prevalence of Vascular Complication among type II
Diabetes Mellitus in order to get improved reliability of the findings.
Reliability is the degree to which an assessment tool produces stable and consistent results
Test retest method is a measure of reliability obtained by administering the same test twice over
a period of time to a group of individuals. The scores from time 1 and time 2 can then be
correlated in order to evaluate the test for stability over time
3.7 The Inclusion and Exclusion Criteria for the Study
3.7.1 Inclusion Criteria
All diabetes mellitus type2 patients ≥ 30 years of age who had the disease > 6 months attending
at the at Aden Abdulle hospital who agree to respond to the questionnaire
n = N = 84 = 69
1+N (0.05)2 1+ 84(0.05)2

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3.7.2 Exclusion Criteria
 Diabetic patients in coma
 Uncooperative patients with diabetes mellitus
 Diabetic patients who refuse to respond to the questionnaire
 Newly diagnosed with type 2 diabetes mellitus
3.8 Data gathering procedure
The data were collected using a close ended questionnaire from patients Aden Adde Hospital in
Mogadishu, Somalia.
Data can be collected using various instruments and techniques, but, this study was conduct
through questionnaire as the main tool for collecting data. Questionnaire is a collection of items
to which a respondent is expected to react in writing (Oso & Onen, 2008). The selections of
these tools have been guided by the nature of data to be collected the time available as well as
the objectives of the study.
3.9 Data analysis
The data collected were entered in excel spread sheet and analyzed.
The results were presented in tables, graphs, and charts by using descriptive statistics.
The data wassummarized to show the mean, mode and standard deviation. The totals were
converted into numbers to enable us to analyze and describe the data systematically to reach
logical conclusions on the effect of the study variables. Data was analyzed and processed
electronically using statistical package for social scientists (SPSS) to analyze the prevalence of
Vascular Complication among type II Diabetes Mellitus at Aden Adde Hospital in Mogadishu,
Somalia.

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CHAPTER FOUR
Data Presentation Analysis and Interpretation of Data
4.0INTRODUCTION
This chapter presents the findings and discussions of the study and it was mainly focused on the
demographic data of the respondents in terms of gender, age, marital status, educational level
and occupation. The presentation, interpretation and analysis of the data collected were in
accordance with the main purpose of the Prevalence of vascular complication among type2 of
diabetes mellitus At Aden Adde Hospital. The presentation and analysis of data was based on
research objectives and questions
This chapter presents and analyses the findings of the study and their interpretation that is based
on the research questions and objectives which include:
 To identify prevalence Diabetic Nephropathy among Patients in Aden Ade Hospital.
 To explore prevalence Diabetic peripheral Neuropathy among Patients in Aden Ade
Hospital.
 Clarify effect of cardiovascular Patients type 2 Diabetic in Aden Ade Hospital.
This part presents the summary of information about the respondents using statistical
frequency table:

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Table 4.1Gender of respondent
Frequency Percent
Male 47 68.1%
Female 22 31.9%
Total 69 100.0%
Table 4.1 and Figure 4.1 shows that the findings of the study indicated the majority of the
respondents were ‘Male’ represented by 68.1 % while females were minority represented by
31.9%. This clearly shows that most of the respondents were Males.
Figure 4.1Gender of respondents

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Table 4.2Age of respondent
Frequency Percent
26-35 14 20.3
36-45 9 13.1
46-60 23 33.3
>60 23 33.3
Total 69 100.0
Table 4.2 and Figure 4.2shows that the findings of the study indicated that the majority age
group were above 60 year olds (23 which accounts about 33.3%), next were between 46-60 years
(23 individuals which accounts about 33.3%), next 26-35 Years old (14 which equals to 20.3%),
then 36-45 (13.1%).
Figure 4.2Age of respondents
0
5
10
15
20
25
26-35 36-45 46-60 >60
Age
Age

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Table 4.3Marital Status
Frequency Percent
Single 11 15.9
Married 32 46.4
Divorced 7 10.1
Widow 19 27.5
Total 69 100.0
Table 4.3 and Figure 4.3 shows thatmost of the respondents were married (32 which is
equivalent to 46.4%), 19 were widow/widower which is about 27.5%, 11 were single which is
15.9% and only 7 were divorced (10.1%).
Figure 4.3Marital Status

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Table 4.4Occupation
Frequency Percent
Professional 21 30.4
Skill Worker 8 11.6
Student 14 20.2
Unemployed 26 37.6
Total 69 100.0
Table 4.4 and Figure 4.4shows thatmost respondents were students of different level which is
about 20.2%, next were professionals 30.4%, least were unemployed and skill workers which is
equivalent to 37.6% and 11.6% respectively.
Figure 4.4Occupation
30%
12%
20%
38%
Occupation
Professional
Skill Worker
Student
Unemployed

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Table 4.5Level of Education
Frequency Percent
Primary 3 4.3
Secondary 27 391
University 23 33.3
Post-graduate 16 23.2
Total 69 100.0
Table 4.5 and Figure 4.5 shows that the education level of the correspondents were great about
44.9% were university students or graduates, about 27.5% were at secondary level and 23.2%
were post-graduates and about 4.3% are primary students/graduates.
Figure 4.5Level of Educations
0
5
10
15
20
25
30
35
Primary Secondary University Post-Graduate
Level Of Education
Level of Education Column1 Column2

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Table 4.6Family income
Frequency Percent
<200$ 14 20.3
200-500$ 40 58.0
>500$ 15 21.7
Total 69 100.0
Table 4.6 and Figure 4.6 shows family income of respondents, about 58% of them got 200-500$
a month, 20.3% got less than 200$ and 21.7% got more than 500 dollars.
Figure 4.6Family income
20%
58%
22%
Family Income
<200$
200-500$
>500

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Table 4.7
Frequency Percent
<1 Yr 5 7.2
1-5 Yrs 18 26.1
5-10 Yrs 22 31.9
>10 Yrs 24 34.8
Total 69 100.0
Table 4.7 and Figure 4.7 shows that the findings from the question ‘How long have you been a
diabetic patient’ most of the respondent’s answers were: <1 Year (7.2%), 1-5 years (26.1%), 5-
10 Years (31.9%) and >10 years were 34.8%.
Figure 4.7

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Table 4.8
Frequency Percent
Yes 27 39.1
No 42 60.9
Total 69 100.0
Table 4.8 and Figure 4.8 shows:The respondents were asked: ‘Have you developed any
complication?’ most of them (42) answered as No which is equivalent to 60.9%, and about 27
persons answered as Yes 39.1% (out of the 39.1% who developed complication had suffered
different conditions, 5 had problems with the Eyes, 7 with kidneys, 9 with Heart, and 6 of them
suffered complication of the Legs).
Figure 4.8
Haveyou developed any Complication
Yes No

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Table 4.9
Frequency Percent
Yes 43 62.3
No 26 37.7
Total 69 100.0
Table 4.9 and Figure 4.9 shows that:When asked the question: ‘Do you take medications
regularly?’ 43 individuals (62.3%) answered as Yes, and 26 of them (37.7%) answered as No.
Figure 4.9
0
5
10
15
20
25
30
35
40
45
Yes No
Do you take Medications Regularly?
Do you take Medications Regularly?

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Table 4.10
Frequency Percent
<1 Yrs 15 21.7
1-5 Yrs 27 39.1
5-10 Yrs 22 31.9
> 10 Yrs 5 7.2
Total 69 100.0
Table 4.10 and Figure 4.10 shows that: ‘How long have you been taking diabetic Medication?’
most of the correspondents (27) took drugs for about 1-5 years, 22 persons answered as 5-10
years, and about 15 respondents had been taking for less than 1 years while 5 of them had been
taking it for more than 10 years, which accounts as: 39.1%, 31.9%, 21.7%, 7.2% respectively.
Figure 4.10

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Table 4.11
Frequency Percent
Yes 41 59.4
No 28 40.6
Total 69 100.0
Table 4.11 and Figure 4.11:The respondents were asked about their family history if they had
diabetic or not? about 41 persons had a family member with Diabetes -59.4% (59.4% of those
whose family members had diabetes were asked Who?, and the replies were: Parents (18),
Grandparents (16) and Siblings (7). and about 28 of them No which equals to 40.6%).
Figure 4.11

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Table 4.12
Frequency Percent
Yes 42 60.9
No 27 39.1
Total 69 100.0
Table 4.12 and Figure 4.12Respondents were asked the question: ‘Do you know the types of
Diabetes’, Most of them knew and replied as YES 42 individuals which is equivalent to 60.9%
(out of those 60.9%, about 88.4% of them had Type II Diabetic and 11.6% of them had Type I.)
and about 39.1% said that they didn’t know ‘No’.
Figure 4.12

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Table 4.13
Frequency Percent
Yes 18 26.1
No 51 73.9
Total 69 100.0
Table 4.13 and Figure 4.13 When asked about Chronic Kidney Failure, we found out that about
51% didn’t have kidney failure but 18% did {11 out of the 18 who had Chronic Failure did
Dialysis (out of those 11 who required dialysis a further question was asked: ‘How often they
received dialysis per week’ and they responded as: Once a week (3), Twice a week (5), thrice a
week (1) and two individuals performed everyday) while the remaining 6 didn’t need to do
dialysis}.
Figure 4.13

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Table 4.14
Frequency Percent
More than Four Times a day 69 100.0
Total 69 100.0
Table 4.14 and Figure 4.14 shows thatall the patients had to urinate more than four times a day.
Figure 4.14

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Table 4.15
Frequency Percent
Yes 11 15.9
No 58 84.1
Total 69 100.0
Table 4.15 and Figure 4.15indicates: when asked ‘Do you feel numbness or loss of sensation of
the legs?’ the patients replied as both Yes -11 (about 11 patients claimed that they feel lower
limb numbness, 8 of the 11 felt the numbness in both legs while 2 left it at the left leg and only 1

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person felt at the right leg only and when asked about the duration we found: 9 patients as less
than 1 year whereas only 2 had that feeling for about 1 to 3 years) and No - 58, with No being
the highest.
Figure 4.15
Table 4.16
Frequency Percent
Yes 21 30.4
No 48 69.6
Total 69 100.0
Table 4.16 and Figure 4.16indicates: when the patients were asked about their eye health status,
21 of them mentioned that they had problems with their eyes (12 out of the 21 patients with eye

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52
problems had Visual Disturbance and 2 individuals claimed that Diabetes caused them blindness
of one eye, while 7 of them said that they had eye irritation) and 48 said they didn’t.
Figure 4.16
Table 4.17
Frequency Percent
Yes 4 5.8
No 65 94.2
Total 69 100.0

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Table 4.17 and Figure 4.17 shows thatif any member of the patients ever had a coma due to
Diabetes? and the most response we got was No about 65 of the respondents never experienced
coma which accounts for 94.2%, but 4 of them said yes (5.8).
Figure 4.17
Table 4.18
Frequency Percent
Yes 27 39.1
No 42 60.9
Total 69 100.0
0
10
20
30
40
50
60
70
No Yes
Have you had a Coma due to Diabetes?
Coma?

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Table 4.18 and Figure 4.18 shows that the findings of the study asked whether they had
problems with infections and majority group said No with a percent of 60.9% and 39.1% told
they had which were about 27 patients, (the 27 patients who experienced infections suffered
from: Burning of Urination (12 persons), Frequent Cold (2), Itching (5) and 6 individuals had all
these conditions but 2 felt none of the symptoms).
Figure 4.18
Table 4.19
Frequency Percent
Yes 17 24.6
No 52 75.4
Total 69 100.0

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Table 4.19 and Figure 4.19 shows that the findings of the study indicated the majority of the
respondents didn’t have Heart Attack 52 (75.4%), while 17 patients (24.6%) had felt a heart
attack (those 17 patients who had a heart attack showed different durations: less than one year: 6
individuals, 2 to 4 years: 6 patients, and 5 persons had the heart attack more than 5 years).
Figure 4.19
Table 4.20
Frequency Percent
No 69 100.0
Total 69 100.0
Table 4.20 and Figure 4.20Denotes whether the patients had experienced a Stroke or not, but
None of them ever had it.

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Figure 4.20
CHAPTER FIVE
Discussion, Conclusion and Recommendations
5.0INTRODUCTION
5.1 Over view
This chapter will focus on the findings, conclusions and recommendations of the thesis.

Prevalence of vascular complication among type2 of diabetes mellitus At Aden Abdulle Hospital.

Prevalence of vascular complication among type2 of diabetes mellitus At Aden Abdulle Hospital.

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