The SA Journal Diabetes & Vascular Disease Vol 12 No 2 (December 2015)

26 / 48

REVIEW SA JOURNAL OF DIABETES & VASCULAR DISEASE
68 VOLUME 12 NUMBER 2 • NOVEMBER 2015
Glycaemic, blood pressure and cholesterol control
in 25 629 diabetics
Y Pinchevsky, N Butkow, T Chirwa, FJ Raal
Correspondence to: Y Pinchevsky
N Butkow
Department of Pharmacy and Pharmacology, School of Therapeutic
Sciences, Faculty of Health Sciences, University of the Witwatersrand,
Johannesburg
e-mail:
T Chirwa
Division of Epidemiology and Biostatistics, School of Public Health, Faculty
of Health Sciences, University of the Witwatersrand, Johannesburg
FJ Raal
Carbohydrate and Lipid Metabolism Research Unit, Division of
Endocrinology and Metabolism, Faculty of Health Sciences, University of
the Witwatersrand, Johannesburg, South Africa
Previously published in Cardiovasc J Afr 2015; 26(4): 188–192
S Afr J Diabetes Vasc Dis 2015; 12: 68–71
Abstract
Objective: To examine and compare the extent to which people
with type 2 diabetes (T2DM) are achieving haemoglobin
A1c (HbA1c), blood pressure (BP) and LDL cholesterol (LDL-C)
treatment targets.
Methods: A review of databases (MEDLINE Ovid, Pubmed and
Sabinet) was performed and limited to the following terms:
type 2 diabetes mellitus AND guideline AND goal achievement
for the years 2009 to 2014 (five years).
Results: A total of 14 studies (25 629 patients) were selected
across 19 different countries. An HbA1c level of 7.0% (or less)
was achieved by 44.5% of subjects (range 19.2–70.5%), while
35.2% (range 7.4–66.3%) achieved BP of 130/80 mmHg (or less),
and 51.4% (range 20.0–82.9%) had an LDL-C level of either 2.5
or 2.6 mmol/l (100 mg/dl or less).
Conclusion: Despite guideline recommendations that lowering
of HbA1c, BP and lipids to target levels in T2DM will lead to a
reduction in morbidity and mortality rates, we found that
control of these risk factors remains sub-optimal, even across
different settings.
Keywords: type 2 diabetes mellitus, guidelines, goal achievement
Diabetes mellitus (DM) is a chronic, progressive condition leading
to significant morbidity and premature death, and is an economic
burden to any healthcare system. According to the International
Diabetes Federation (IDF), there were 366 million people living with
diabetes in 2011.1 By 2035, it is predicted that more than half a
billion people will have the disease.
Trends in urbanisation and the adoption of unhealthy Western
lifestyles have begun to affect low- and middle-income countries
(LMICs). A prime example of this is South Africa, which previously
had the dubious pleasure of infectious diseases being the primary
source of mortality. Today, expansion of non-communicable diseases
(NCD) is beginning to manifest and deplete the already strained
health resources available.2
Rather than being limited to glycaemia alone, the management
of type 2 diabetes mellitus (T2DM) includes multiple priorities,
including identification and treatment of other modifiable risk
factors. It is widely accepted that T2DM is associated with
cardiovascular disease (CVD) and increased mortality rates.3
In addition to lifestyle changes, the importance of reduction
in levels of low-density lipoprotein cholesterol (LDL-C) and blood
pressure (BP) has become an essential primary goal for the
prevention of CVD in T2DM.4,5 Furthermore, improved outcomes of
diabetes-related chronic microvascular complications (retinopathy,
neuropathy and nephropathy) are achieved through substantial
reductions in incidence of both hyperglycaemia and hypertension.
It is on the basis of this research that the Society for Endocrinology,
Metabolism and Diabetes of South Africa (SEMDSA) recommends
that most adults with diabetes should aim for an HbA 1c level of
7.0%, BP of 140/80 mmHg and LDL-C level of 2.5 mmol/l or less.6
There are many gaps in the management of T2DM that are
proving difficult to close. Studies have revealed how clinical practice
differs from clinical trials in that T2DM patients often cannot reach
guideline-recommended targets. One of the ways to improve
clinical outcomes is by comparing the performance of one clinical
setting against another. In this study, our aim was to compare the
achievement of the critical quality indicators: glycaemic, BP and lipid
control in T2DM patients from different countries worldwide, in an
attempt to benchmark which approach has been most successful.
Methods
This study was a literature review using Ovid MEDLINE, Pubmed and
Sabinet databases. Studies included were those conducted in the
past five years (2009–2014) and limited to the following key terms:
type 2 diabetes mellitus AND guideline AND goal achievement
(HbA1c, glycated haemoglobin, blood pressure, systolic, diastolic,
lipids, cholesterol, LDL cholesterol). We also reviewed a selected
number of reference lists of other reviews and hand-searched
several medical journals.
Studies that reported achievement of guideline-recommended
targets of major risk factors for T2DM were included. The primary
objective of this review was to provide an overview of achievement
of major risk-factor targets (HbA1c, BP and LDL-C) in the treatment
of a sample of T2DM patients from different parts of the world.
Specifically, the objectives would be addressed through comparison
of the achievement of HbA1c, BP and LDL-C targets, according to
local or international guidelines, across different study samples.
The followingdatawereextracted fromthe studies: author details,
year of publication, study location, cohort size and achievement of
major risk factors (combined systolic and diastolic BP, and HbA1c
and LDL-C levels). As different samples of study countries followed
different guideline targets, flexibilities around these differences was
needed. Studies selected for this article may have differed in the
following parameters: recruitment and randomisation methods,