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 Table of Contents 
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 197-201  

Diabetic peripheral neuropathy among Saudi diabetic patients: A multicenter cross-sectional study at primary health care setting


1 Joint Program of Family Medicine Post Graduate Studies, Al-Madinah 41311, Saudi Arabia
2 Family Medicine Department, Prince Mohammed Ben Abdulaziz Hospital NGHA, Al-Madinah 41311, Saudi Arabia
3 Internal Medicine Residency Program, Prince Mohammed Ben Abdulaziz Hospital NGHA, Al-Madinah 41311, Saudi Arabia

Date of Submission21-Oct-2019
Date of Decision04-Dec-2019
Date of Acceptance16-Dec-2019
Date of Web Publication28-Jan-2020

Correspondence Address:
Dr. Rayan Abdullah Sendi
Joint Program of Family Medicine Post Graduate Studies, Al.Madinah 41311
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_927_19

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  Abstract 


Background: Diabetic peripheral neuropathy (DPN) is one of the most common complications of diabetes and is responsible for morbidity and disability among diabetic patients. Objectives: The aim of this study was to assess the prevalence of painful DPN and its associated risk factors in patients with diabetes mellitus. Materials and Methods: A cross-sectional study was conducted among 430 diabetic patients attending primary healthcare centres (PHC) in AL Madinah city, Saudi Arabia. The validated Douleur Neuropathique-4 (DN4) questionnaire was used to identify the presence of painful DPN. Results: The majority were female (54.7%) and had type 2 diabetes mellitus (74.9%). The prevalence of DPN was 30.1% in type 2 diabetic patients and 25.9% in type 1 diabetic patients with an overall prevalence of 29.1%. DPN was associated significantly with age, duration of diabetes milieus, uncontrolled A1c, and positive family history of diabetes mellitus (P < 0.05). All the investigated comorbidities were also associated significantly with DPN (P < 0.05). Conclusions: The prevalence of DPN was 25.9% and was associated with age duration of DM and uncontrolled HbA1c. PHC physicians treating diabetes should be more aware of the importance of screening for DPN and the treatment plan.

Keywords: Diabetic peripheral neuropathy, glycaemic control, pain, primary care


How to cite this article:
Sendi RA, Mahrus AM, Saeed RM, Mohammed MA, Al-Dubai SA. Diabetic peripheral neuropathy among Saudi diabetic patients: A multicenter cross-sectional study at primary health care setting. J Family Med Prim Care 2020;9:197-201

How to cite this URL:
Sendi RA, Mahrus AM, Saeed RM, Mohammed MA, Al-Dubai SA. Diabetic peripheral neuropathy among Saudi diabetic patients: A multicenter cross-sectional study at primary health care setting. J Family Med Prim Care [serial online] 2020 [cited 2020 Feb 21];9:197-201. Available from: http://www.jfmpc.com/text.asp?2020/9/1/197/276811




  Introduction Top


Diabetes mellitus is prevalent worldwide, and Saudi Arabia ranks as the second highest in the Middle East, and the seventh in the world for the rate of diabetes (34.1% in males and 27.6% in females).[1],[2] Diabetic peripheral neuropathy (DPN) is a nerve damaging disorder caused by diabetes and is related to duration and degree of glycemic control.[3] Neuropathy results in significant morbidities such as a pain, loss of sensation, foot ulcers, gangrene, and amputations.[4],[5] The prevalence of DPN internationally ranges between 26.4% and 35.78% and nationally between 19.9% and 35%.[6],[7],[8] The foot ulceration is not only the most common complication of neuropathy but also among the preventable diabetes complications.[9] The prevalence rate of diabetic foot in the world is about 4.6–12%.[10],[11],[12] In the literature, the risk of DNP was found to be associated with age, duration of DM, glycemic control (high level of HbA1c), gender, and smoking.[13] The aim of this study was to assess the prevalence of painful DPN and its associated risk factors in patients with diabetes mellitus attending primary healthcare (PHC) in AL Madinah city, Saudi Arabia.


  Materials and Methods Top


This cross-sectional study was carried out in the PHCs in AL Madinah city. Twelve centers were selected randomly from a total of 40 centers in the city. Thirty-one diabetic patients were selected by systematic random sampling from each health center to get a total sample of 430 patients. Data was collected 5/7 days for 1 week. Patients were included if they met all the following criteria: aged ≥18 years; presenting at an outpatient clinic; current diagnosis of diabetes mellitus type 1 (duration ≥5 years) or type 2 (any duration); no other type of neuropathic pain of non-diabetic origin. Gestational diabetes was excluded. Diagnosis of diabetes mellitus was based on the American Diabetes Association (ADA) guidelines (random blood sugar >200 mg/dL or fasting blood sugar >126 mg/dL).[14]

The first part of the questionnaire included questions on the sociodemographic characteristics, comorbidities, duration, and type of diabetic mellitus. The second part included the validated Douleur Neuropathique-4 (DN4), which was used to identify the presence of painful DPN and is a brief 10-item questionnaire.[15] The first seven items of the DN4 based on patient's interview and the final three items are based on physical examination of sensory function. All questions were answered either “yes” or “no.” “Yes” answer was given 1 point and “No” answer was given zero. The total score ranges from 0 to 10 and a score of 4 or more is considered the cutoff point for the diagnosis of neuropathic pain. The original version was validated by Bouhassira et al. (2005) and the Arabic version used in this study was validated by Harifi et al. (2013).[15],[16] The first three questions investigated the characters of pain (burning, painful cold, and electric shocks), the next four questions investigated the symptoms associated with the pain (tingling, pins and needles, numbness, and itching). The next two questions investigated hypoesthesia to touch and hypoesthesia to prick. The last question investigated if the pain be caused or increased by brushing. The last measure of hemoglobin A1c (HbA1c) for each participant was taken from the hospital records.

This study protocol was approved by the ethical committee of the Institutional Review Board in Al-Madinah. Objectives and benefits of the study were explained to the participants. Participant's confidentiality and anonymity were assured. Signed consent was obtained from those who agreed to participate.

Statistical analysis was carried out by using Statistical Package for the Social Sciences (SPSS ®) software (version 20). Descriptive statistics was employed to obtain frequencies, mean, and standard deviations. Chi-square test was employed to assess association between DPN and categorical data. The accepted level of significance was set below 0.05 (P < 0.05).


  Results Top


The majority were female (54.7%), aged between 46 and 65 years (44%), had type 2 diabetes mellitus (74.9%), and had family history of DM (61.2%). Most of the participants had uncontrolled HA1c (82.1%). The most common reported comorbidity was hypertension (45%) [Table 1].
Table 1: Sociodemographic characteristics of the participants

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The prevalence of DPN was 30.1% in type 2 diabetic patients and 25.9% in type 1diabetic patients with an overall prevalence of 29.1%.

The most common symptoms and signs of pain were tingling (26.7%), hypoesthesia to touch (23.3%), and pins and needles (23%) [Table 2].
Table 2: Symptoms and signs of DPN pain among diabetic patients

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[Table 3] shows factors associated with DPN. The prevalence of DPN increased significantly with increased in the age and all the age groups had higher prevalence of DPN compared to the age group 18–25 years (P < 0.05). The prevalence of DPN increased significantly with increased in the duration of DM (P < 0.05). Patients with uncontrolled A1c had higher prevalence of DPN (39.4%) compared to patients with controlled A1c (14.9%) (OR = 3.7, 95% CI 2.30–6.0).
Table 3: Factors associated with DPN among diabetic patients

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[Table 4] shows the association between comorbidities and DPN. All comorbidities were associated significantly with DPN: hypertension (OR = 2.1, 95% CI1.47–3.44), asthma (OR = 2.3, 95% CI1.15–4.75), thyroid diseases (OR = 2.1, 95% CI 1.08–4.18), cardiac diseases (OR = 2.6, 95% CI1.37–4.92), stroke (OR = 2.4, 95% CI1.14–5.21), and renal diseases (OR = 4.3, 95% CI1.73–10.67).
Table 4: Comorbidities associated with DPN among diabetic patients

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  Discussion Top


The prevalence of DPN was 29.1% in this study, which was higher than a worldwide estimate of DPN prevalence among diabetics (8.1 – 12.2%).[17] In Saudi Arabia, a prevalence of 65.3% has been previously reported for painful DPN in a nationally representative diabetic population in 2010.[18] In other Middle East countries, the prevalence rates of painful DPN were 61.3%, 57.5%, 53.9%, and 37.1% for Egyptian, Jordanian, Lebanese, and Gulf States population, respectively.[19] Similar high prevalence was found in India (69%).[20] Duration of diabetes showed significant association with DPN in this study. It was reported in the literature that the prevalence of neuropathy increases after 5 years of the diagnosis of DM.[21] So it is imperative to perform the neurological testing in the laboratory and scoring systems should also be included. It is better to educate patients to examine their foot at least annually and the early detection of DN makes the healthcare professionals and patients to initiate the preventive measures and can evaluate the therapeutic options. Previous studies found that the prevalence of DNP was higher among females.[22] However, the current study did not find such association and this finding is consistent with a previous study by Popescu et al. (2015).[23] This study found that prevalence of DNP increased by age. This finding is consistent with the previous studies.[23],[24],[25] In the current study, we found a significant association between the HbA1c levels DNP. Similar finding was reported in the previous studies.[23],[26] This study found a significant association between DNP and comorbidities such as hypertension, asthma, thyroid diseases, cardiac diseases, stroke, and renal diseases. A previous study found significant association between DNP and chronic kidney disease but not with hypertension.[23]

The strength of this study is apparent in its large and representative sample size and by using a validated tool. However, several limitations of this study warrant attentions. First, the cross-sectional nature of this study design limits the inference of causal relationship between correlates and DPN. Therefore, our findings need to be confirmed in prospective studies. Second, the diagnosis of DPN was based on a combination of decreased sensation and neuropathic sensory symptoms, without nerve conduction test.

In conclusion, the prevalence of DPN was 30.1% in type 2 diabetic patients and 25.9% in type 1diabetic patients with an overall prevalence of 29.1%. DNP was associated with age duration of DM and uncontrolled HbA1c. PHC physicians treating diabetes should be more aware of the importance of screening for DPN and the treatment plan.

Financial support and sponsorship

Nil.

Conflicts of interest

There is no conflicts of interest.



 
  References Top

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Feldman EL, Callaghan BC, Pop-Busui R, Zochodne DW, Wright DE, Bennett DL, et al. Diabetic neuropathy. Nat Rev Dis Primers 2019;5:41.  Back to cited text no. 1
    
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Al-Ayed MY, Ababneh M, Robert AA, Salman A, Al Saeed A, Al Dawish MA. Evaluation of risk factors associated with diabetic foot ulcers in Saudi Arabia. Curr Diabetes Rev 2019;15:224-32.  Back to cited text no. 5
    
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AlSidr KS, Alotaibi MA, Alotaibi SK, Alhammadi FA, Abdullah M, Alotaibi M, et al. Diabetic foot and its clinical characteristics among uncontrolled diabetic patients in Ad-Dawadmi General Hospital, Riyadh Province, KSA. Saudi J Biomed Res 2019;4:248-53.  Back to cited text no. 8
    
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Saad N, Elhadedy K, Ramadan N, Mohmady O, Farid M. The prevalence and risk categorization of diabetic foot complications in cohort group in, Beni Suif, Egypt. Life Sci J 2013;3:933-42.  Back to cited text no. 9
    
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Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y. Global epidemiology of diabetic foot ulceration: A systematic review and meta-analysis. Ann Med 2017;49:106-16.  Back to cited text no. 10
    
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Shi H. A health needs assessment of adults with diabetic foot disease in the US. Diabetes & metabolic syndrome. Clin Res Rev 2019;13:2152-7.  Back to cited text no. 11
    
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Jeffcoate WJ. Charcot foot syndrome. Diabet Med. 2015;32:760-70.  Back to cited text no. 12
    
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Hébert HL, Veluchamy A, Torrance N, Smith BH. Risk factors for neuropathic pain in diabetes mellitus. Pain 2017;158:560.  Back to cited text no. 13
    
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American Diabetes Association. 3. Prevention or delay of type 2 diabetes: Standards of medical care in diabetes-2019. Diabet Care 2019;42(Suppl 1):S29.  Back to cited text no. 14
    
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Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle J, et al. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain 2005;114:29-36.  Back to cited text no. 15
    
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Harifi G, Ouilki I, El Bouchti I, Ait Ouazar M, Belkhou A, Younsi R, et al. Validity and reliability of the Arabic adapted version of the DN4 questionnaire (Douleur Neuropathique 4 Questions) for differential diagnosis of pain syndromes with a neuropathic or somatic component. Pain Pract 2011;11:139-47.  Back to cited text no. 16
    
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Levterova B, Naydenov V, Todorov P, Leterov G. Prevalence and impact of peripheral neuropathy on quality of life in patients with diabetes mellitus pilot study. Trakia J Sci 2018;16:71-6.  Back to cited text no. 17
    
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Halawa MR, Karawagh A, Zeidan A, Mahmoud AE, Sakr M, Hegazy A; painful diabetic peripheral neuropathy study group. Prevalence of painful diabetic peripheral neuropathy among patients suffering from diabetes mellitus in Saudi Arabia. Curr Med Res Opin 2010;26:337-43.  Back to cited text no. 18
    
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Jambart S, Ammache Z, Haddad F, Younes A, Hassoun A, Abdalla K, et al. Prevalence of painful diabetic peripheral neuropathy among patients with diabetes mellitus in the Middle East region. J Int Med Res 2011;39:366-77.  Back to cited text no. 19
    
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Li L, Chen J, Wang J, Cai D. Prevalence and risk factors of diabetic peripheral neuropathy in type 2 diabetes mellitus patients with overweight/obese in Guangdong province, China. Prim Care Diabet 2015;9:191-5.  Back to cited text no. 20
    
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Feldman EL, Stevens MJ, Thomas PK, Brown MB, Canal N, Greene DA. A practical two-step quantitative clinical and electrophysiological assessment for the diagnosis and staging of diabetic neuropathy. Diabet Care 1994;17:1281-9.  Back to cited text no. 21
    
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Abbott CA, Malik RA, van Ross ER, Kulkarni J, Boulton AJ. Prevalence and characteristics of painful diabetic neuropathy in a large community-based diabetic population in the UK. Diabet Care 2011;34:2220-4.  Back to cited text no. 22
    
23.
Popescu S, Timar B, Baderca F, Simu M, Diaconu L, Velea I, et al. Age as an independent factor for the development of neuropathy in diabetic patients. Clin Int Aging 2016; 11:313.  Back to cited text no. 23
    
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Darivemula S, Nagoor K, Patan SK, Reddy NB, Deepthi CS, Chittooru CS. Prevalence and its associated determinants of Diabetic Peripheral Neuropathy (DPN) in individuals having type-2 diabetes mellitus in Rural South India. Indian J Community Med 2019;44:88-91.  Back to cited text no. 24
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Varghese A, Deepa R, Rema M, Mohan V. Prevalence of microalbuminuria in type 2 diabetes mellitus at a diabetes centre in southern India. Postgrad Med J 2001;77:399-402.  Back to cited text no. 25
    
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Mythili A, Kumar KD, Subrahmanyam KA, Venkateswarlu K, Butchi RG. A comparative study of examination scores and quantitative sensory testing in diagnosis of diabetic polyneuropathy. Int J Diabet Dev Ctries 2010;30:43-8.  Back to cited text no. 26
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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