|Year : 2019 | Volume
| Issue : 2 | Page : 51-55
Diabetes in elderly Nigerians: A survey of a rural area in north-central Nigeria
Evelyn K Chuhwak1, Basil N Okeahialam1, Chika Ogbonna2, Salem D Pam3
1 Internal Medicine Department, University of Jos, Jos, Nigeria
2 Public Health Department, University of Jos, Jos, Nigeria
3 Surgery Department, Jos University Teaching Hospital, Jos, Nigeria
|Date of Submission||19-Aug-2018|
|Date of Decision||02-Aug-2019|
|Date of Acceptance||18-Oct-2019|
|Date of Web Publication||13-Dec-2019|
Evelyn K Chuhwak
P.O. Box 1641, General Post Office, Jos 930001, Plateau State
Source of Support: None, Conflict of Interest: None
Background: The burden of diabetes mellitus in Nigeria has been estimated to be on the increase over the past few decades. Its prevalence has also been noted to vary across rural, semi-urban, and urban areas in the country and also across age groups. This study was conducted as part of a non-communicable disease survey in north-central Nigeria carried out in 2008. Aim: To determine the prevalence of type II diabetes mellitus among elderly individuals in Gindiri—a rural area in Mangu local government area of Plateau State, north-central Nigeria. Methodology: Consecutive subjects were recruited from the study population. A total of 197 subjects were found to be 60 years of age or older and these were screened for the presence of diabetes mellitus. Those found to have diabetes mellitus were referred to the Jos University Teaching Hospital Primary healthcare Centre in Gindiri for follow-up. Results: There were 124 female and 73 male elderly subjects, respectively. Both genders had similar age (P > 0.10), BMI (P > 0.10), and waist/hip ratio. The mean random blood glucose was also similar. Out of the eight subjects who were found to have diabetes, two were old patients already on treatment whereas six were new cases diagnosed on account of a random blood glucose of over 11.1 mmol/L. The prevalence of type II diabetes mellitus among elderly rural dwellers in Gindiri is 4.06%. Conclusion: The prevalence of diabetes mellitus among the elderly in rural Africa is higher than in the general population. The vast majority are asymptomatic and have fewer associated comorbidities which thus leads to delayed hospital presentation. The rate is however much lower than the corresponding prevalence rates among the elderly in more highly urbanized areas of the world. This may be due to differences in diet and lifestyle. It is noted however that the prevalence of diabetes mellitus is increasing in the rural area.
Keywords: elderly, type II diabetes, serum glucose
|How to cite this article:|
Chuhwak EK, Okeahialam BN, Ogbonna C, Pam SD. Diabetes in elderly Nigerians: A survey of a rural area in north-central Nigeria. J Med Trop 2019;21:51-5
|How to cite this URL:|
Chuhwak EK, Okeahialam BN, Ogbonna C, Pam SD. Diabetes in elderly Nigerians: A survey of a rural area in north-central Nigeria. J Med Trop [serial online] 2019 [cited 2020 Apr 10];21:51-5. Available from: http://www.jmedtropics.org/text.asp?2019/21/2/51/272915
| Introduction|| |
The International Diabetes Federation (IDF) projects that by 2030, 9.9% of the global adult population will be affected by diabetes mellitus (552 million individuals).
The Centers for Disease Control and Prevention (CDC) reports that the prevalence of diabetes mellitus is high among the elderly population and estimates that the condition affects 25% of individuals aged 65 years or older. The US prevalence rate of diabetes in elderly is said to range between 22% and 33% depending on the diagnostic criteria employed. 
A study conducted in India found a similarly high diabetes prevalence of 30.42% among the elderly.
The high prevalence of diabetes among the elderly may be due to age-related changes in carbohydrate metabolic pathways but unhealthy lifestyles might be the main predisposing factor. ,
Diabetes mellitus affects between 1% and 7% of rural and urban-dwelling Sub-Saharan Africans, respectively. In some African regions experiencing a greater degree of westernization like South Africa, the prevalence is much higher especially among people of Indian ethnicity and can range between 8% to 13%.
The prevalence of diabetes mellitus in Nigeria has been on the increase over the past six decades. Adadevoh and Osuntokun found rates of <1% in their respective hospital-based studies conducted in Ibadan in the 1960s/70s. Other studies have shown that the rates are higher in urban and semi-urban than rural communities.,, The predominant occupation in rural communities (farming) may help keep the blood glucose under control, that is, physical activity on the farms tends to reduce their probability of gaining excessive weight.  There may be other factors that may help blood glucose regulation in the rural areas such as the typical African high-fiber carbohydrate diet. ,, The blood glucose in rural dwellers may thus be well regulated, explaining the lower prevalence of diabetes in such communities.
A national expert committee on non-communicable diseases survey conducted in 1992 reported the age-adjusted prevalence rate of diabetes mellitus among Nigerians as 2.2%. The lowest rate (0.65%) was found in a rural community in Mangu, north-central Nigeria, while the highest (11%) was in the more urbanized communities in Lagos south-western Nigeria.  The prevalence of diabetes in Jos (geographically located near Mangu) is 3.1%.
There have been no reports on the prevalence of diabetes mellitus among elderly Nigerians. Thus this study among elderly people residing in Gindiri, a village in Mangu local government area of Plateau State, north-central Nigeria, has been undertaken in order to determine the prevalence of diabetes in this peculiar population. This was part of a study on non-communicable diseases in this area, though only diabetes was specifically studied in the elderly. This study will determine the prevalence of diabetes mellitus in the elderly population of the rural area.
| Methodology|| |
The study area was Gindiri, a rural community located in Mangu local government area of Plateau State. The survey was conducted between November 2008 and March 2009. Ethical clearance for the study was obtained from the Ethics Committee of the Jos University Teaching Hospital (JUTH). This study was part of a larger study on non-communicable diseases including hypertension, diabetes, and thyroid diseases.
The population was mobilized through their community leaders. During the registration, socio-demographic information such as name, age, ethnic group, religion, occupation, educational status, smoking, and alcohol use history were obtained. The age of 60 years and above was taken as the cut-off for defining elderly people in this study because the life expectancy of Nigerians is 54.5 years of age.
Anthropometric and clinical measurements were also conducted such as blood pressure, weight and height (for calculation of body mass index), and waist/hip ratios. Every elderly person had their blood glucose analyzed. The blood glucose was estimated in the laboratory for every third sample collected in order to reduce operational cost. The remaining elderly patients were tested by glucometer. The results were compared (laboratory + glucometer) and were found to be similar. The results were interpreted taking cognizance of whether the blood source was venous and arterial.
The blood for laboratory glucose estimation was collected in bottles containing fluoride in order to prevent glycolysis. Both the glucose strip tests and the laboratory estimations were based on the principle of glucose oxidase method for determination of glucose. There were no differences in the values obtained.
| Results|| |
A total of 840 subjects were surveyed. There were 197 elderly people (124 females and 73 males). The mean age (SD) of the elderly subjects was 69.86 (+/−7.90) years, with an age range of 60 years to 94 years. The general characteristics of study subjects are shown in [Table 1],[Table 2],[Table 3].
The sexes were similar in age (P => 0.10).
The mean BMI (SD) of the subjects was 23.73 (+/−4.76) Kg/m2. The mean BMI (SD) of male subjects (22.8+/−3.7 Kg/m2) was apparently less than that of female subjects (24.16+/−5.28 Kg/m2), but this was not statistically significant. The females and males were similar in weight (P > 0.10). However, there were 30 subjects who were overweight, 15 were obese, and 5 subjects had morbid obesity-BMI over 40 Kg/m2. There were 16 male subjects who were overweight and only one male subject with class I obesity (BMI of over 30 Kg/m2).
Waist/hip (W/H) ratio was similar for both male and female subjects, though females’ values were expected to be smaller than those of males. The raw waist measurements of both groups of subjects ranged from 71 cm to 121 cm. The W/H ratio was actually abnormal for sex, but the measurements were within normal limits. For example, a subject had a waist circumference of 74 cm and a hip circumference of 80 cm, resulting in a W/H ratio of 0.93. Many of the subjects had this type of result. Some of the subjects had a ratio of one or above. This finding may thus imply that the W/H ratio might not be a suitable tool for use in the African population.
The mean blood glucose of these subjects was 5.31 (+/−2.44) mmol/L. However, there were six previously undiagnosed subjects (two males, four females) who had a blood glucose of over 11 mmol/L and were diagnosed diabetes. Two individuals were already on treatment for diabetes. These diabetic subjects were requested to attend hospital for registration and follow-up in the JUTH outstation situated within the locality. Six had glucose levels that were abnormal, with a blood glucose level of greater than 6.1 mmol/L, but less than 11.1 mmol/L. These were requested to go for follow-up in the hospital nearby—the primary healthcare center of the JUTH in the locality, where they would undergo an oral glucose tolerance test. The newly diagnosed diabetic (glucose levels greater than 11.1 mmol/L) patients were all over 65 years of age and also asymptomatic for diabetes. The overall prevalence of type II diabetes mellitus in the subjects was 4.06%
Only two subjects had an elevated BP as a comorbidity that needed some monitoring. They were given some medication and encouraged to go for follow-up. The PCV, creatinine, and uric acid levels of most study subjects were within normal limits except for two individuals who had elevated serum uric acid levels of 900 umol/L and 600 umol/L. These were sent to the hospital for further management.
| Discussion|| |
The age of 60 years and above was chosen to define the elderly population in this study due to the relatively lower life expectancy of Nigerians. The mean age of the subjects was 69. 86 years (<70 years of age). It is known that the rate of hospitalizations is increased with advanced age due to increased occurrence of concurrent illnesses like cancer, infection, etc., hence the symptoms of diabetes under these conditions may be masked,, leading to lack of presentation at health facilities.
The findings from this study show that diabetes is present in 4.06% of the elderly population of the study location. Expectedly, this is higher than the age-adjusted diabetes prevalence rate (2.2%) for the Nigerian population.  Conversely, this figure is relatively low compared to findings from studies conducted in more urbanized regions of the world. For instance, the prevalence of diabetes in the elderly was found to be as high as 27% in Monastir City (Tunisia) and Greece respectively. , Similarly, an Indian study reports a diabetes prevalence of 30.42% among the elderly,  while in the US, this ranges between 22% and 33% depending on the diagnostic criteria employed. The relatively higher prevalence of diabetes among elderly individuals in communities maybe due to age-related changes in body composition which result in accumulation of abdominal fat. This is known to be a key factor in the development of diabetes in the aging population.,, In this study, 10.6% of the subjects had a BMI in the obese range with 2.5% of the total elderly population being morbidly obese. These could be future candidates for diabetes and other metabolic comorbidities. ,
Unhealthy lifestyle is reported to be an additional factor associated with impaired glucose tolerance among Americans.  In this study, the subjects did not report sedentary lifestyles as they were all engaged in some form of physical activity in their farms. The serum glucose levels of majority of the study subjects were within normal limits. The effect of occupation, diet, and BMI was however not specifically ascertained in this survey.
It was found that majority (59.4%) of the study population had a BMI that was within the normal range. The few individuals who had elevated blood glucose had a high-normal BMI and were neither hypertensive nor obese.
The W/H ratios in these subjects were relatively high. This was particularly so among females who had given birth. Both males and females however had similar W/H ratios. The raw waist measurements for males and females are similar—this was not in keeping with the European values of 94 cm for males and 80 cm for females. It is therefore suggested that the use of W/H ratios should be discarded in sub-Saharan Africa. The raw values for waist and hip circumference should be used instead, or a new cut-off level of their ratio determined for use among Africans. Another setback of the use of W/H ratios is the need for a large number of subjects for accurate interpretation.
| Conclusion|| |
The prevalence of diabetes among the elderly in rural Africa is higher than in the general population and is associated with fewer comorbidities. The rate is however much lower than the corresponding prevalence rates among the elderly in more highly urbanized areas of the world. This may be due to differences in diet and lifestyle. The prevalence of diabetes mellitus is increasing in the rural areas.
We are grateful to the University of Jos for giving us a grant to carry out research on non-communicable diseases, among which was diabetes. The resident doctors who participated in data collection are also highly appreciated.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jain A, Paranjape S. Prevalence of type II diabetes mellitus in elderly in a primary care facility. Indian J Endocrinol Metab 2013;17:S318-22.
Mozaffarian D, Kamineni A, Carnethon M, Djousse L, Mukamal KJ, Siscovick D. Lifestyle risk factors and new onset diabetes mellitus in older adults: the cardiovascular health study. Ach Intern Med 2009;169:798-807.
Crandall J, Schade D, Ma Y et al.
Diabetes Prevention Program Research Group. The influence of age on the effects of lifestyle modification and metformin in prevention of diabetes. J Gerontol A Biol Sci Med Sci 2006;61:1075-81.
Motala AA. Diabetes trends in Africa. Diabetes Metab Res Rev 2002;18:514-50.
Adadevoh BK. “Temporary diabetes” in adult Nigerians. Trans R Soc Trop Med Hyg 1968;62:528-30.
Osuntokun BO, Akinkugbe FM, Francis TI, Reddy S, Osuntokun O, Taylor GO. Diabetes mellitus in Nigerians: a study of 832 patients. West Afri Med J Niger Pract 1971;20:295-312.
Ohwovoriole AE, Kuti JA, Kabiawu SI. Casual blood glucose levels and prevalence of undiscovered diabetes mellitus in Lagos metropolis Nigerians. Diabetes Res Clin Pract 1998; 4:153-8.
Sabir AA, Balarabe S, Sani AA, Isezuo SA, Bello KS, Jimoh AO. Prevalence of diabetes mellitus and its risk factors among the suburban population of Northwest Nigeria. Sahel Med J 2017;20:168-72. [Full text]
Erasmus RT, Ebonyi E, Fakeye T. Prevalence of diabetes mellitus in a rural Nigerian population. Niger Med Pract 1988;15:28-38.
Seftel HC. Studies of glycosuria and diabetes in non-white population of the Transvaal. S African J Med 1963;37:1231-6.
Tsega E. Porphyria cutanea tarda in Ethiopians. Trans R Soc Trop Med Hyg 1981;75:201-6.
Steyn NP, Mann J, Bennet PH, Temple N, Zimmet P, Tuomilehto J, Lindstrom J, Louheranta A. Diet, nutrition and the prevalence of type 2 DM. Public Health Nutrition 2004;7:147-65.
Akinkugbe OO. The non-communicable diseases in Nigeria − Report of a national survey. Ibadan, Nigeria: Intec printers limited. 1997.
Puepet FH. The prevalence of diabetes mellitus and associated risk factors in adults in Jos. Dissertation, FMCP 1996.
Rizvi Ali A. Nutritional challenges in the elderly with diabetes. Inter J Diabetes Mellitus 2009;1:26-31.
Kirkman MS, Briscoe VJ, Clark N, Flores MS, Herman RD, Haas LB, Halter JB, Kooytkow SKS, Munsh MN, Odegard PS. Diabetes in older adults. Diabetes Care 2012;35:2650-64.
Lionis C, Battuanaki M, Antonaki N, Papavasilio S, Philalithis A. A high prevalence of diabetes in municipality of rural Crete. Greece Diabetes Medicine 2001;18:768-9.
Rockwood K, Tan MH, Philip S, McDowell I. Prevalence of diabetes mellitus in the elderly people in Canada: Report from the Canadian Study of Health and ageing. Age and Aging 1998;27:373-7.
Jain A, Paranjape S. Prevalence of T2D in the elderly in a primary care facility. Indian J Endocrinol Metab 2013;17(Suppl 1):S318-22.
[Table 1], [Table 2], [Table 3]