Introduction

Due to improved clinical practices, now people live long with conditions such as hypertension, diabetes mellitus, HIV/AIDS etc. However, the increasing cases of co-existing non-communicable and communicable diseases is posing a challenge to the management and clinical intervention practices.¹ Specifically, the prevalence of both hypertension and diabetes mellitus increased by 4.5% between 1975 and 2015.² In addition, the World Health Organization (WHO) estimates that 46% of individual older than 25 years suffer from hypertension in sub-Saharan Africa. ^3-5 In Kenya, the overall prevalence ranges from 12.6 to 36.9% ,with more cases observed in urban settings.^3,6,7 However, implementation of interventions is very complicated because about 40% of individuals are unaware of their hypertension status in sub-Saharan Africa (SSA).⁸ Nonetheless, globally and in particular SSA, there is increasing cases of diabetes mellitus and other non-communicable and communicable diseases, therefore there is a need to search for the burden reduction and management strategies. ^9,10

Both hypertension and diabetes mellitus are health conditions caused by genetic factors and unhealthy lifestyle, which includes; heavy consumption of alcohol obesity,^11-14 physical inactivity^15,16 etc. Also, the conditions such as hypertension and diabetes mellitus increase the risk of complications such as severe diseases as Cardio Vascular Diseases (CVDs) and Chronic Kidney Disease (CKD) resulting into deaths over a period of time.^17-19 The co-existence of the conditions presents a big challenge in SSA due to unpreparedness of the health systems.

As much as lifestyle interventions are cost effective in the prevention of hypertension and diabetes mellitus related deaths,^20,21 these have been underutilized in SSA. Consequently, there is a need to have cost effective intergrated management of co-existing non-communicable and communicable diseases. The lessons should be learnt from the devastation of Covid 19 infection among people with the conditions such as hypertension and diabetes mellitus. ²² The data on the risk of death among patients with non-communicable diseases conditions remain poorly understood. Here have used the routine data of the hypertensive patients from a rural based health facility in Western Kenya, determined whether HIV/AIDS increases risk of diabetes among hypertensive patients.

Methods

Study site

The study site was Kabondo sub-county hospital in Homa- Bay County in Western Kenya. The hospital serves diabetes mellitus, hypertensive and HIV/AIDS infection patients.

Study design

A facility cross-sectional survey was conducted between 1^st March 2021 and 22^nd April 2021 among hypertensive patients seeking care at the hospital. The study used quantitative approach and structured questionnaire. The dependent variable was diabetes mellitus and independent variables were age, gender, parity, history of smoking and HIV/AIDS.

Target population

The target population for this study were people suffering from hypertension systolic blood pressure of ≥ 140 mmHg and/or a diastolic blood pressure ≥ 90 mm Hg or it is the use of drug.²³

Sampling technique

Hospital registers for both outpatient and comprehensive care clinic had a total of 385 hypertensive patient during the study period. The patients were expected to attend the facility within the two months of data collection. To be included in the study, individual patient had to have hypertension together with other related morbidities. The diabetic were individuals with the fasting plasma glucose level of equals or greater than 7 mmol/l and HIV positive cases were tested by either DNA/PCR or HIV antibody test. In this study only 240 participants met the set criteria as shown in Figure 1.

Figure 1. Archival and screening process

Data collection and quality control measures

A structured questionnaire was used to collect data. The questionnaires were administered to 240 hypertensive patients to access the risk factors for hypertension. The pilot study was done at nearby sub-county hospital before the actual data collection exercise.

Data analysis

The collected data were checked for completeness, coded, and then entered into excel sheets. The coded data were then imported into the Statistical Package for Social Sciences (SPSS) for analysis. To determine the risk factors associated with hypertension and diabetes Mellitus both bivariate and multivariate logistic regression analysis were used and only P<0.05 was considered statistically significant.

Ethical considerations

Permission to conduct the study was sought from Jaramogi Oginga Odinga University of Science and Technology. Further, approval and clearance was obtained from Jaramogi Oginga Odinga Teaching and Referral Hospital Ethical Review Committee (Ref ERC.IB/Volume.1/688, approval number IERC/JOOTRH/688/2020), Kabondo Sub-Country Hospital administration and the sub county health management team. The purpose of the study was discussed to all study participants prior to obtaining consent. The data collected in this study was handled with utmost confidentiality.

Results

Socio-demographic and comorbidities characteristics

The mean age of the study respondents was 54.84 ± 10.39 with a female population of 154 (64.17%). Of the 240 hypertensive patients, 40% were suffering from both HIV/ AIDS and diabetes mellitus (Table 1).

Association of socio-demographic factors and comorbidities with the diabetes mellitus

The age, history of smoking and HIV/AIDS were associated with Diabetes mellitus (P<0.0001). However, gender and parity were no associated with the diabetes mellitus (Table 2).

Risk factors for diabetes mellitus among the hypertensive patients

In the (Table 3), both bivariate and multivariate logistic regression analyses show that age, smoking and HIV/AIDS are risk factors for Diabetes mellitus, in particular, the risk for Diabetes mellitus increases with age for example, aged 45 to 54 years (COR=4.74, 95%CI=1.34-16.74, P=0.016), aged 55 to 64 (COR=10.80,95%CI=3.00-38.86, P<0.001), aged 65 to 74 (COR=10.58,95%CI=2.67- 41.97, P=0.001) and aged 75 and above COR=9.33,95%CI=1.67-52.06, P=0.011) compared to individuals aged below 45 years. In addition, we observed that hypertensive patients who are smokers were 2.89 times more likely to have diabetes mellitus as compared to non-smokers (COR=2.89, 95%CI=1.63-5.11, P<0.001). Also, Hypertensive patients who were HIV positive were 2.40 times more likely to have diabetes mellitus as compared to hypertensive patients who were HIV negative (COR=2.40, 95%CI=1.40-4.08, P=0.001).

Controlling for age, smoking, and HIV status on multivariate logistic regression analysis, the adjusted odd ratio remained statistically significant for age groups, smoking, and HIV status as shown in Table 3. However, HIV status increased with some folds (AOR=3.30, 95%CI=1.79-6.05, P<0.001) vs (COR=2.40, 95%CI=1.40-4.08, P=0.001). Similarly, the risk of smocking increased from odds ratio of 2.89 to 2.75.

Discussion

The study shows high prevalence of diabetes and HIV/ AIDS infection among the hypertensive patients. In addition, reports age, smoking, and HIV/AIDS as the risk factors for diabetes in this population. Our findings further show increased risk of diabetes due to HIV/AIDS. Our findings demonstrate high prevalence of diabetes and hypertension cases and Indeed, this is in agreement with the worldwide report that showed an increase of 4.5% of two conditions from 1975 to 2015.²⁴ Elsewhere, the increase of the diabetes and hypertension cases have been associated with the aging population, but in SSA there is increase despite the young populations.²⁵ With the high prevalence of HIV/AIDS and improved life span in sub-Saharan Africa, further increase of diabetes and hypertension cases is expected. Studies have reported high prevalence diabetes among the hypertensive patients.^26-29 Also, reported high prevalence of hypertension among the diabetes patients^.26,27,30-36 We observed increasing risk of diabetes in our study population and this is in agreement with the other studies.^37,38 We also observed increased risk of diabetes among the smokers, and this findings is also in agreement with a prospective cohort study that showed a relative risk of type 2 diabetes among women smokers compared with individuals who never smoked.³⁹ Other study on the Japanese population also confirmed that smoking is a risk factor to diabetes.^40,41 Furthermore, we observed increased risk of diabetes among hypertensive patient its due to HIV infection, studies have shown that there is increasing cases of diabetes due to HIV.^42,43

With increasing case of Non Communicable Diseases (NCD) in areas with high burden of infections such as HIV/AIDS, it is important to think of prevention and control strategies, in particular, an infection such as Covid-19, the vulnerable population are those with pre-existing NCDs and those engaged in risky behavior such as smoking and obesity.^44-47

Conclusion

As much as our study demonstrates the potential of the routine data to determine the prevalence of the diabetes and other conditions, and also to assess the risk of diabetes among the hypertensive patients, our study is limited by the relatively small sample size. This mainly because of poor record keeping resulting into incomplete or missing data. Also, due to missing data, we could not associate other comorbidities with the risk of diabetes as reported elsewhere. Also, due to poor records, we could not control for potential confounders. Nonetheless, the study shows high co-existence of hypertension, diabetes mellitus and HIV/AIDS in the population. Also, shows that risk factors of diabetes as age, smoking and HIV/AIDS. The findings of this study suggest the need for improved health promotion and clinical practice for the prevention and treatment of the co-existing health conditions.

References

1. López-Jaramillo P, Gómez-Arbeláez D, López-López J, et al. The role of leptin/adiponectin ratio in metabolic syndrome and diabetes. Horm Mol Biol Clin Investig; 2014:18:1:37-45.

   [Cross Ref] [Pubmed] [Google Scholar]

2. Feigin V. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet; 2016:8:388:10053:1545-1602.

   [Cross Ref] [Pubmed] [Google Scholar]

3. Guwatudde D, Nankya-Mutyoba J, Kalyesubula R, et al. The burden of hypertension in sub-Saharan Africa: A four-country cross sectional study. BMC Public Health; 2015:5:15:1211.

   [Cross Ref] [Pubmed] [Google Scholar]

4. Yoruk A, Boulos PK, Bisognano JD. The state of hypertension in Sub-Saharan Africa: Review and commentary. Am J Hypertens; 2018:10:31:4:387-388.

   [Cross Ref] [Pubmed] [Google Scholar]

5. Hendriks ME, Wit FW, Roos MT, et al. Hypertension in Sub-Saharan Africa: Cross-sectional surveys in four rural and urban communities. PLoS One; 2012:7:3:e32638.

   [Cross Ref] [Pubmed] [Google Scholar]

6. Nduka C, Stranges S, Sarki A, et al. Evidence of increased blood pressure and hypertension risk among people living with HIV on antiretroviral therapy: A systematic review with meta-analysis. J Hum Hypertens; 2016:30:6:355-62.

   [Cross Ref] [Pubmed] [Google Scholar]

7. Beaney T, Schutte AE, Tomaszewski M, et al. May Measurement Month 2017: An analysis of blood pressure screening results worldwide. Lancet Glob Health; 2018:6:7:e736-e743.

   [Cross Ref] [Pubmed] [Google Scholar]

8. Ibekwe R. Modifiable Risk factors of hypertension and socio-demographic profile in Oghara, Delta state; prevalence and correlates. Ann Med Health Sci Res; 2015:5:1:71-7.

   [Cross Ref] [PubMed] [Google Scholar]

9. Zhou B, Lu Y, Hajifathalian K, et al. Worldwide trends in diabetes since 1980: A pooled analysis of 751 population-based studies with 4. 4 million participants. Lancet; 2016:9:387:10027:1513-1530.

   [Cross Ref] [PubMed] [Google Scholar]

10. Federation ID. IDF diabetes atlas 8th edition. International diabetes federation; 2017:905-11.

    [Cross Ref] [Google Scholar]

11. Briasoulis A, Agarwal V, Messerli FH. Alcohol consumption and the risk of hypertension in men and women: A systematic review and meta-analysis. J Clin Hypertens (Greenwich); 2012:14:11:792-8.

    [Cross Ref] [PubMed] [Google Scholar]

12. Baliunas DO, Taylor BJ, Irving H, et al. Alcohol as a risk factor for type 2 diabetes: A systematic review and meta-analysis. Diabetes Care; 2009:32:11:2123-32.

    [Cross Ref] [PubMed] [Google Scholar]

13. Group DS, Nyamdorj R. BMI compared with central obesity indicators in relation to diabetes and hypertension in Asians. Obesity (Silver Spring); 2008:16:7:1622-35.

    [Cross Ref] [PubMed] [Google Scholar]

14. Bell JA, Kivimaki M, Hamer M. Metabolically healthy obesity and risk of incident type 2 diabetes: A meta-analysis of prospective cohort studies. Obes Rev; 2014:15:6:504-15.

    [Cross Ref] [PubMed] [Google Scholar]

15. Huai P, Xun H, Reilly KH, et al. Physical activity and risk of hypertension: A meta-analysis of prospective cohort studies. Hypertension; 2013:62:6:1021-6.

    [Cross Ref] [PubMed] [Google Scholar]

16. Smith AD, Crippa A, Woodcock J, et al. Physical activity and incident type 2 diabetes mellitus: A systematic review and dose-response meta-analysis of prospective cohort studies. Diabetologia; 2016:59:12:2527-254.

    [Cross Ref] [PubMed] [Google Scholar]

17. Hansen TW, Kikuya M, Thijs L, et al. Prognostic superiority of daytime ambulatory over conventional blood pressure in four populations: a meta-analysis of 7,030 individuals. J Hypertens; 2007:25:8:1554-64.

    [Cross Ref] [PubMed] [Google Scholar]

18. Kannel WB, McGee DL. Diabetes and cardiovascular disease. The Framingham study. JAMA; 1979:11:241:19:2035-8.

    [Cross Ref] [PubMed] [Google Scholar]

19. Yamagata K, Ishida K, Sairenchi T, et al. Risk factors for chronic kidney disease in a community-based population: A 10-year follow-up study. Kidney Int; 2007:71:2:159-66.

    [Cross Ref] [PubMed] [Google Scholar]

20. Commodore-Mensah Y, Selvin E, Aboagye J, et al. Hypertension, overweight/obesity, and diabetes among immigrants in the United States: An analysis of the 2010-2016 National Health Interview Survey. BMC Public Health; 2018:20:18:1:773.

    [Cross Ref] [PubMed] [Google Scholar]

21. Saha S, Gerdtham U-G, Johansson P. Economic evaluation of lifestyle interventions for preventing diabetes and cardiovascular diseases. Int J Environ Res Public Health; 2010:7:8:3150-95.

    [Cross Ref] [PubMed] [Google Scholar]

22. Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med; 2020:8:4:e21.

    [Cross Ref] [PubMed] [Google Scholar]

23. Barham A, Ibraheem R, Zyoud SeH. Cardiac self-efficacy and quality of life in patients with coronary heart disease: A cross-sectional study from Palestine. BMC Cardiovasc Disord; 2019:13:19:1:290.

    [Cross Ref] [PubMed] [Google Scholar]

24. Vos T, Allen C, Arora M, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: A systematic analysis for the Global Burden of Disease Study 2015. Lancet; 2016:8:388:10053:1545-1602.

    [Cross Ref] [Pubmed] [Google Scholar]

25. Zhou B, Bentham J, Di Cesare M, et al. Worldwide trends in blood pressure from 1975 to 2015: A pooled analysis of 1479 population-based measurement studies with 19·1 million participants. Lancet; 2017:7:389:10064:37-55.

    [Cross Ref] [Pubmed] [Google Scholar]

26. Bell D. Hypertension and antihypertensive therapy as risk factors for type 2 diabetes mellitus. N Engl J Med; 2000:24:343:8:580.

    [Cross Ref] [Pubmed] [Google Scholar]

27. Petrie JR, Guzik TJ, Touyz RM. Diabetes, hypertension, and cardiovascular disease: Clinical insights and vascular mechanisms. Can J Cardiol; 2018:34:5:575-584.

    [Cross Ref] [PubMed] [Google Scholar]

28. Emdin CA, Anderson SG, Woodward M, et al. Usual blood pressure and risk of new-onset diabetes: Evidence from 4.1 million adults and a meta-analysis of prospective studies. J Am Coll Cardiol; 2015:6:66:14:1552-1562.

    [Cross Ref] [PubMed] [Google Scholar]

29. Kuwabara M, Chintaluru Y, Kanbay M, et al. Fasting blood glucose is predictive of hypertension in a general Japanese population. J Hypertens; 2019:37:1:167-174.

    [Cross Ref] [PubMed] [Google Scholar]

30. Arauz-Pacheco C, Parrott MA, Raskin P. Treatment of hypertension in adults with diabetes. Diabetes Care; 2003:26:Suppl:1:S80-2.

    [Cross Ref] [PubMed] [Google Scholar]

31. Chang SA. Smoking and type 2 diabetes mellitus. Diabetes Metab J;2012:36:6:399-403.

    [Cross Ref] [PubMed] [Google Scholar]

32. Adler AI, Stratton IM, Neil HAW, et al. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): Prospective observational study. BMJ; 2000:12:321:7258:412-9.

    [Cross Ref] [PubMed] [Google Scholar]

33. Hussain MA, Firdous S, Uz ME. Role of clinical pharmacist in patients with diabetes and hypertension: A prospective study. Wjpr; 2019:10:20959:20196:14795.

    [Cross Ref] [Google Scholar]

34. Kim Y-S, Davis SC, Stok WJ, et al. Impaired nocturnal blood pressure dipping in patients with type 2 diabetes mellitus. Hypertens Res; 2019:42:1:59-66.

    [Cross Ref] [PubMed] [Google Scholar]

35. Sun D, Zhou T, Heianza Y, et al. Type 2 diabetes and hypertension: A study on bidirectional causality. Circ Res; 2019:15:124:6:930-937.

    [Cross Ref] [PubMed] [Google Scholar]

36. Sabuncu T, Sonmez A, Eren MA, et al. Characteristics of patients with hypertension in a population with type 2 diabetes mellitus. Results from the Turkish Nationwide Survey of Glycemic and Other Metabolic Parameters of Patients with Diabetes Mellitus (TEMD Hypertension Study). Prim Care Diabetes; 2021:15:2:332-339.

    [Cross Ref] [PubMed] [Google Scholar]

37. Sun H, Saeedi P, Karuranga S, et al. Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes Res Clin Pract; 2022:183:109119.

    [Cross Ref] [PubMed] [Google Scholar]

38. Laakso M, Pyörälä K. Age of onset and type of diabetes. Diabetes Care; 1985:8:2:114-7.

    [Cross Ref] [PubMed] [Google Scholar]

39. Rimm EB, Manson JE, Stampfer MJ, et al. Cigarette smoking and the risk of diabetes in women. Am J Public Health; 1993:83:2:211-4.

    [Cross Ref] [PubMed] [Google Scholar]

40. Kawakami N, Takatsuka N, Shimizu H, et al. Effects of smoking on the incidence of non-insulin-dependent diabetes mellitus. Replication and extension in a Japanese cohort of male employees. Am J Epidemiol; 1997:15:145:2:103-9.

    [Cross Ref] [PubMed] [Google Scholar]

41. Haire-Joshu D, Glasgow RE, Tibbs TL. Smoking and diabetes. Diabetes Care; 1999:22:11:1887-98.

    [Cross Ref] [PubMed] [Google Scholar]

42. Organization WH. World health statistics 2008. World Health Organization; 2008.

    [Cross Ref] [Google Scholar]

43. Remais JV, Zeng G, Li G, et al. Convergence of non-communicable and infectious diseases in low-and middle-income countries. Int J Epidemiol; 2013:42:1:221-7.

    [Cross Ref] [PubMed] [Google Scholar]

44. Hernández-Galdamez DR, González-Block MÁ, Romo-Dueñas DK, et al. Increased risk of hospitalization and death in patients with covid-19 and pre-existing noncommunicable diseases and modifiable risk factors in Mexico. Arch Med Res; 2020:51:7:683-689.

    [Cross Ref] [PubMed] [Google Scholar]

45. Yang J, Zheng Y, Gou X, et al. Prevalence of comorbidities and its effects in patients infected with SARS-CoV-2: A systematic review and meta-analysis. Int J Infect Dis; 2020:94:91-95.

    [Cross Ref] [PubMed] [Google Scholar]

46. Henry BM, Lippi G. Chronic kidney disease is associated with severe coronavirus disease 2019 (COVID-19) infection. Int Urol Nephrol; 2020:52:6:1193-1194.

    [Cross Ref] [PubMed] [Google Scholar]

47. COVID C, Team R, Chow N, et al. Preliminary estimates of the prevalence of selected underlying health conditions among patients with coronavirus disease 2019 - United States, february 12-march 28, 2020. MMWR Morb Mortal Wkly Rep; 2020:3:69:13:382-386.

    [Cross Ref] [PubMed] [Google Scholar]