GLYCEMIA IN A KUWAITI POPULATION

A dissertation submitted to the faculty at the University of Dundee in partial fulfillment of the requirements for the degree of MSc Diabetes Care and Education

(GM53004 MSc Dissertation)

ACKNOWLEDGEMENTS

I would like to offer my thanks and gratitude to the people who encouraged and supported me throughout the process of this research project.

It is a privilege to have met and worked with Dr. Michael Murphy on this project. His contributions and feedback have been sincerely appreciated and essential to my completion of the course.

I am also very deeply appreciative and humbled by the overwhelming support and motivation my family and friends have provided me.

Finally, I would like to acknowledge The University of Dundee and The Dasman Diabetes Center and the staff for giving me this opportunity to expand my horizons and achieve this amazing accomplishment.

Thank you all.

DECLARATION

This dissertation is the result of the author’s original research. It has been composed by the author and has not been previously submitted for examination, which has led to the award of a degree. The copyright of this thesis belongs to the author under the terms of the United Kingdom Copyright Acts as qualified by the University of Dundee. Due acknowledgement must always be made of the use of any material contained in, or derived from, this thesis.

TABLE OF CONTENTS

ACKNOWLEDGEMENTS ii

DECLARATION iii

LIST OF TABLES vii

LIST OF FIGURES viii

Abstract ix

CHAPTER ONE 12

1.0 INTRODUCTION 12

1.1 Overview 12

1.2 Aims 12

1.3 Glycated haemoglobin (HbA1c) 12

1.3.1 What is Glycated Haemoglobin (HbA1c)? 12

1.3.2 HbA1c Values 13

CHAPTER TWO 15

2.0 LITERATURE REVIEW 15

2.1 Overview 15

2.2 Importance of HbA1c 15

2.3 Demographic and Phenotypic Factors Affecting HbA1c 17

2.4 HbA1c and Age 17

2.5 HbA1c and Gender 19

2.6 HbA1c and Diagnosis 21

2.7 HbA1c and Patient Referral Location 22

CHAPTER THREE 25

3.0 METHODOLOGY 25

3.1 Overview 25

3.2 Sampling of Participants 25

3.3 Collection of HbA1c Samples 25

3.4 Research Design 26

3.5 Measurement of HbA1c 26

3.6 Data Analysis 27

3.7 Demographic Features 27

3.8 Extracting Patient Information 28

3.9 Limitations of the Study 31

3.10 Ethical Approval 31

CHAPTER FOUR 32

4.0 RESULTS 32

4.1 Overview 32

4.2 Gender 32

4.3 Age 35

4.4 Referral Location 37

4.5 Diagnosis 39

CHAPTER FIVE 45

5.0 DISCUSSION 45

5.1 Overview 45

5.2 HbA1c and Gender 45

5.3 HbA1c and Age 47

5.4 HbA1c and Referral Location 50

5.4.1 Inpatient 50

5.4.2 Outpatient 51

5.4.3 Clinic 51

5.5 HbA1c and Diagnosis 52

5.5.1 Lab Examination 52

5.5.2 Diabetes 52

5.5.3 Gastrointestinal Diseases 53

5.5.4 Hypercholesterolemia 53

5.5.5 Hypothyroidism 54

5.5.6 Hypertension 54

5.5.7 Cardiology 55

5.5.8 Kidney Disease 55

5.5.9 Bone Pain and Muscle Cramp 56

5.5.10 Loss of Consciousness, Iron Deficiency Anaemia, Hepatitis C and Urinary Tract Infections 56

5.5.11 Upper Respiratory Tract Infections 57

5.5.12 Weight Issues 58

5.6 Summary of the Findings 58

5.7 Areas of Further Study 59

CHAPTER SIX 61

6.0 CONCLUSION 61

REFERENCES 62

APPENDICES 70

APPENDIX A: GLOSSARY OF TERMS/ABBREVIATIONS 70

APPENDIX B: RESEARCH PROPOSAL 73

APPENDIX C: ETHICAL APPROVAL FORM 83

APPENDIX D: APPROVAL LETTER FROM DASMAN DIABETES INSTITUTE COMMITTEE 89

APPENDIX E: LABORATORY REQUESTS 92

APPENDIX F: EXCEL FILE TEMPLATE (WITH DATA) 93

APPENDIX G: TOSOH MACHINE RESULTS 94

APPENDIX H: OBTAINING CIVIL IDENTIFICATION NUMBERS 95

APPENDIX I: LOCATION DISTRIBUTION 97

LIST OF TABLES

Table 1: Monthly Distribution of HbA1c Results 28

Table 2: Gender Distribution 33

Table 3: Age Summary 35

Table 4: Distribution of Patients in Each Location 38

Table 5: Distribution of Diagnosis 42

LIST OF FIGURES

Figure 1: Patient History System 29

Figure 2: Patient History Search Menu 30

Figure 3: Five Sample Patient Report 30

Figure 4: Graph Showing Summary of Gylcemia According to Gender 33

Figure 5: Graph Showing Glycemia According to Diabetes 44

Glycemia Research

Abstract

Introduction

This project describes the management of diabetes, according to certain demographic factors via the monitoring of HbA1c results over a three-year period (2012-2014). The impact of these factors including age, gender, diagnosis, and referral location on glycemia was established. Patient history records were analyzed to determine factors associated with the lower glycemia levels throughout the two-year period.

Aims

To characterize glycemia in individual patients attending Kuwaiti Inpatient and Outpatient facilities over a two-year period

To establish associations of glycemia with demographic factors (age, sex), clinical diagnosis (diabetes and other medical conditions), and referral location

Methods

A retrospective observational study of glycemia was performed in a population of patients attending Kuwaiti hospital and outpatient facilities between 2012 and 2014. Information collected included age, sex, clinical diagnosis, and referral location. Glycemia was assessed by measurement of non-fasting glycated hemoglobin (HbA1c). Associations of glycemia with demographic and other factors were established-tests and other statistical processes were performed.

Glycemia Study

Results

HbA1c measurements were made in 854 patients between January 2012 and September 2014. Patients were omitted depending on the information available for the various categories. The calculated mean and standard deviation (SD) HbA1c of all patients was 7.81%±1.98.

In total, 305 male patients were analyzed ranging from 13 years old to 89 years old. Their mean HbA1c was 8.06% with an SD of ±0.11.

Overall, 297 female patients were analyzed with ages ranging from 10 years old to 90 years old. Their mean HbA1c was 7.89% with an SD of ±0.33.

Although females experienced more fluctuations in their glycemic control from 2012-2014, they had lower glycemic levels overall compared to the male patients.

The lower HbA1c levels with a decreasing glycemic level trend belonged to the twenty-one to thirty-year-old patients; twelve patients were analyzed and found to have an average HbA1c of 7.96% with an SD of ±0.86. They achieved one of the lowest glycemic values compared to the other age ranges. In the data collected for three years, their HbA1c level continuously decreased to a stable range.

Because the inpatient and polyclinic patients experienced many fluctuations with their results increasing and decreasing in glycemic values, the outpatient patients maintained lower glycemic levels. The outpatient location started with poor HbA1c values of 9.2% and 10.4%respectively, but then decreased the levels and maintained a rather stable level of glycemia with an average HbA1c value of 7.5% in 2014. The overall average for this group was 8.04% with a standard deviation of ±0.99.

Patients categorized as diabetics under the diagnosis portion of their request forms managed their glycemic levels over a three-year period (2012-2014). The patients in this group decreased their glycemic levels gradually over the period of this study. The average HbA1c value from 2012-2013 was 8.37% with an SD of ±0.24 for the diabetic patients, while from 2013-2014 the average HbA1c for diabetic patients was 8.11% with an SD of ±0.11 with a P-value of 0.96 which concludes an insignificant difference.

Conclusion

Female patients (n=297) had lower glycemia than male patients (n=305). This might be because of more hormonal changes in females than males and the lifestyle changes more females tend to make such as dieting. Lower Glycemia was observed in 21-30-year-old patients than any other age group. Glycemia was higher in inpatients than in outpatients because inpatients are more reliant on medications that may alter their glucose levels or be used to maintain a healthy glucose level. HbA1c gradually decreased in glycemic levels for diabetic patients than it did for any other diagnosis. Therefore, as study portrayed the HbA1c levels in various broad categories, future studies ought to focus on one of the groups and analyze it with detail in order to help maintain healthy glycemic levels.