Prevalence of Diabetes Mellitus and its Association with Diabetic Peripheral Neuropathy, Peripheral Vascular Disorder among Security Personnel in United Arab Emirates

Introduction

Diabetes Mellitus (DM) is a metabolic disease that causes an increase in the blood glucose levels.¹ According to the World Health Organization, DM ranked 9th among the top 10 causes of death in 2020, and 8^th in terms of Disability-Adjusted Life Years (DALYS) in 2019.² It consists of numerous categories based on pathogenesis including Type1, Type2, gestational diabetes, along with other disorders (endocrinopathies and steroid use).³ Fasting plasma glucose (FPG) level >126 g/ml or HbA1C level of >6.5% are considered as the criteria for diagnosis of DM.⁴ DM type 2, which is the most common type, is caused by insulin resistance or insufficient production.⁵ It is mostly seen in middle-aged and older adults, who have persistent hyperglycemia caused by dietary choices and a poor lifestyle.³

DM leads to several long-term complications, including both microvasculature diseases, such as diabetic peripheral neuropathy (DPN), and macrovascular diseases, such as peripheral vascular diseases (PVD).⁵ DPN causes damage to the peripheral nerves due to poor or uncontrolled blood glucose levels, with symptoms such as loss of sensation, pain, numbness, tingling, and muscle weakness.⁶ Peripheral vascular disease is a progressive circulation disorder caused by blockage, spasm, or narrowing of the blood vessels. It has been studied that DM also increases the risk of atherosclerosis, which in turn further raises the risk of PVD.⁶

Occupational factors may further increase the likelihood of these complications. Security personnel are tasked with maintaining a safe and secure environment in various sectors such as health, commercial, and residential. This occupational group is frequently exposed to unfavorbale conditions, including prolonged and irregular working hours, extreme weather conditions and night or shift duties. One of the major concerns is that this job often requires them to work in an upright posture for long periods of time, which can be a potential risk to various health conditions.⁷ While prolonged standing has primarily been associated with musculoskeletal and cardiovascular outcomes,⁸ emerging evidences indicate that it may also possibly impair vascular shear dynamics and postprandial glycemia, which creates an indirect path to diabetic complications. This has been supported by research demonstrating that static standing for prolonged hours reduces endothelial shear rate and elevates post-meal glucose and insulin levels in healthy adults.⁹ Furthermore, prolonged postural strain may reduce stability and balance which has been linked to both poorer glycemic control and progression of peripheral neuropathy.¹⁰

According to the International Diabetes Federation (IDF), in 2021, the prevalence of DM in the United Arab Emirates (UAE) was 12.3%.¹¹ DM is a major health concern and is regarded as a key area of research interest in the UAE. Despite the growing burden of DM in UAE, there is a lack of literature focusing on specific occupational groups. To our knowledge, this is the first study to access the prevalence of diabetes and its vascular complications specifically among UAE-based security personnel. This population has unique job-related exposures that may place them at increased risk for developing the complications.

As PVD and DPN usually do not show many symptoms and go unnoticed, the chances of foot complications are higher. In addition, neglected and unattended PVD and DPN can cause diabetic foot ulcers, which can eventually lead to disability with amputation. By identifying both prevalence and complication rates in this group, our study fills a critical gap in literature and provides a foundation for future preventative and workplace-based interventions. Therefore, this study aimed to screen DM cases among security personnel in the UAE and identify its macro-and microvascular complications, particularly PVD and DPN, under the following objectives:

Methods

Study design and settings: This cross-sectional study was conducted at the College of Health Sciences, Gulf Medical University (GMU), Ajman, UAE. The sample and data collection were multicentric from different emirates of the UAE. The study was flexible in that it included every sector where securities were available. Security agencies across the UAE, such as universities, schools, and security accommodations, were contacted to cooperate in providing participants (security personnel). The participants who were willing to participate signed an informed consent form before inclusion in the study. The ethical review board of the GMU approved the study protocol (IRB-COHS-STD-59-NOV-2023) on 22^nd November 2023, following which recruitment and data collection were initiated. This study was conducted between November 2023 and June 2024.

Exclusion criteria

• - Diagnosed/Reported cases of peripheral neuropathy due to conditions other than diabetes

• - Undiagnosed (absence of Lab report) and self-reported cases of diabetes mellitus

Sampling method and sample size: The study used non-probability convenience sampling. According to the reported DM prevalence of 12.3% in UAE,¹¹ the required sample size was calculated to be 166 with a margin of error or absolute precision of $\pm$ 5% at 95% confidence using the Scalex SP calculator.¹²

Study protocol and procedure: Security personnel were recruited and familiarized with the data-collection procedure. They were provided with a written informed consent form and asked to read it carefully, giving them a chance to inquire and ensure their willingness to participate in the study. Demographic data were collected on age, sex, years of experience in the security field, and diabetes duration. Participants who reported DM were asked to confirm by providing the latest laboratory reports (FPG, Post Prandial Blood sugar (PPBS), and HBA1C). A total of 228 security personnel were screened, 166 of whom met the inclusion criteria for further screening for DM, DPN, and PVD. Before measuring blood pressure, the participants were asked to remain relaxed in a high sitting position for 5 mins to ensure that they were in a resting posture. Brachial systolic blood pressure and ankle systolic blood pressure were recorded bilaterally using an Omron 5450 blood pressure monitor, and the means of both sides were noted to ensure accurate readings and to avoid possible errors. The use of this machine was validated to obtain accurate results.^13,14 Ankle Brachial Index (ABI) was calculated as the ratio of ankle systolic pressure to brachial systolic pressure. Following this, the participants were screened for peripheral neuropathy using 10 g Semmes Weinstein monofilament in both feet. To accurately measure the sensory response, a 10 g monofilament was placed perpendicular to the sole, and an even pressure was applied to the great toe and other spots (as shown in Figure 1). Participants were considered positive for peripheral neuropathy if they failed to feel the monofilament sensation in more than one spot, and a 7/10 correct response was considered a delayed response.^15,16 The Michigan Neuropathy Screening Instrument (MNSI) (score ≥7-part A, score > 2-part B) and Vibration Pressure Threshold (score>20 Volts on Biothesiometer) was also used to confirm the presence of peripheral neuropathy.^16,17 Participants who tested positive for peripheral neuropathy were given the Douleur Neuropathique en 4 Questions (DN4) questionnaire to check for the presence, severity, and nature of neuropathy pain if present.

Figure 1. Testing points of monofilament test.

The filled circles indicate the four standard and required testing sites for the monofilament testing, as recommended in diabetic foot screening guidelines. The empty circles represent additional sites that may be tested at the provider’s discretion to further assess sensory loss.

This study used a systematic approach to determine the prevalence of DM among security personnel. All procedures used in this study were standardized, which allowed for accurate findings and analysis and contributed to the reliability and validity of this research.

Statistical analysis: SPSS version 29 was used to conduct statistical analyses. Demographic data, such as age, sex, location, presence of diabetes mellitus, and years of work, were analyzed using descriptive statistics. Following the test of normality, the Pearson correlation test was used to determine the association between diabetes, DPN, and PVD ( Table 4). The level of significance was set at p<0.05.

Results

Sample characteristics: This study recruited 166 security personnel across different sectors, such as health, commercial, and residential. The mean age of the participants was 34.95 $\pm$ 8.15 years. The demographic and clinical characteristics (including BMI, pulse rate, years of experience, and diabetic status) are presented in Table 1. The sex proportion of our sample is shown in Figure 2.1 and the locations of the data collection is illustrated in Figure 2.2.

Figure 2.1. Sex Distribution of participants.

There were 158 males and 8 female security personnel.

Figure 2.2. Geographical distribution of data collection sites.

Data were collected from three of the seven emirates, Ajman, Dubai, and Ras Al Khaimah.

The prevalence of diabetes among the sampled security personnel was found to be 9.6% ( Table 2), DPN was assessed among the 16 diabetic participants using multiple screening tools: Semmes-Weinstein monofilament, MNSI, VPT, and DN4 scale. The monofilament test showed positive responses in 10 out of 16 diabetic cases and 3 non-diabetic participants. The MNSI detected DPN in 7 diabetic participants (Part A mean: 9±3; Part B mean: 3.5±2) and the mean VPT score was 26.44±7.38 Volts, indicating moderate sensory loss. The mean DN4 was 3.75±2.05 consistent with mild to moderate neuropathic pain. These findings are presented in Table 3. The mean ABI value calculated from all participants was 1.29 ± 0.12 which falls within the normal range, indicating no significant arterial insufficiency in this sample. However, subgroup analysis showed relevant associations.

The association between diabetes and its complications is shown in Table 4. A moderate correlation was observed between DM and ABI values (r=0.56, p=0.03), suggesting early changes in the vascular status. A strong correlation was found between the presence of DM and DPN (r=0.83, p<0.001). For this correlation, MNSI score was used as the quantitative measure of neuropathy. Among non-diabetics, no statistically significant correlations were observed.

Discussion

This study aimed to determine the prevalence of diabetes and its complications specifically DPN and PVD among security personnel in the UAE, a profession which is characterized by long standing hours, irregular shifts and exposure to the extremes of environment. The findings revealed a prevalence of 9.6%, which is slightly lower than the national average of 12.3%, as reported by the IDF in 2021.¹¹ However, this value is still notable considering the relatively younger age a normal average BMI of our sample.¹⁸

Importantly, the findings showed a strong association between DM and DPN (r=0.83, p<0.001), which indicate a considerably high burden of neuropathic complications among diabetic security personnel. This aligns with the previous studies reporting DPN as the second most common complication of Type 2 DM and highlights the necessity for proactive screening within occupational health frameworks.^19–21 While the ABI of our sample fell within the normal limits (0.9-1.4),²² a moderate correlation between ABI and diabetes suggests early signs of vascular compromise in diabetic individuals, which may not yet meet the clinical thresholds for PVD but still indicate increased risk.¹⁵ The mean VP among diabetic individuals is consistent with moderate sensory loss, and the DN4 score suggest the presence of mild-moderate neuropathic pain.^16,17,23,24 These values point toward early and potentially progressive complications that require attention.

The occupational context may play a significant role in the observed outcomes. Security personnel are often exposed to extended periods of static standing along with lack of medical monitoring, which has been sure to impair endothelial shear stress and increase postprandial glucose levels.⁹ These physiological disturbances can indirectly increase the chances of development of complications in diabetic individuals.

At the mechanistic level, micro-and macrovascular complications are closely associated with diabetes, mainly due to the presence of chronic hyperglycemia and insulin resistance, which play major roles in initiating the process of these complications. Various mechanisms can lead to complications such as oxidative stress, inflammation, and increased production of glycation end products (AGEs) and their activation (RAGE).^5,25 Despite ongoing researches no definitive prevention for the diabetic neuropathy exists, highlighting the importance of early detection and risk reduction, particularly in high risk occupational groups.^26,27

Limitations and future recommendations: This study has several limitations. First, the instruments used in this study assess DPN are validated for screening, are not the gold standard diagnostic tool for the provisional diagnosis of the condition. Hence, they only serve as a screening tool for detecting the presence of DPN and these results must be verified with appropriate diagnostic measures such as Nerve Conduction Velocity tests (NCV). However, these are the most widely used measures in community-based studies. Second, the study sample was limited to Ajman, Dubai and Ras al Khaimah; therefore, it is difficult to generalize the data to the entire United Arab Emirates. Third, the sample was predominantly male, which reflects the gender distribution of the profession but introduces gender bias. The blood pressure measurements during our study were taken from both the arms and the ankles, and the mean was obtained; however, the measurement was only taken at once and not a minimum of three readings due to time constraints. In addition, we did not perform regression analysis in this study although it could have provided stronger statistical insight into the associations observed. The study did not account for potential confounding factors such as medications, smoking status, dietary habits, genetic factors, sleep, caffeine intake, and stress levels, which may influence glycemic control and vascular health.

Lastly, our study used a cross-sectional design, which limits causal interference. Future longitudinal research is needed to determine whether prolonged occupational exposure among security personnel is a contributing factor in the progression of diabetic complications. Incorporating regression analysis in the future studies would additionally isolate the impact of occupation on the risk of DPN and PVD.

Conclusion

This study adds to our understanding of the prevalence of diabetes and its associated complications among security personnel in the UAE. It was found that the presence of DM among securities is high, with a prevalence of 9.6%, as compared to 12.3% in the whole of UAE. The results indicate that there was a statistically significant association between diabetes mellitus and its complications PVD and DPN, which underscores the necessity of implementing occupational health measures along with preventive strategies for the targeted population.

Addressing and acting on these health conditions will help enhance the overall well-being and productivity of security personnel, resulting in better health outcomes and reduced healthcare costs.

Declarations

Authors contribution

All authors contributed significantly to the manuscript under the specific roles described below.

MA - Mohamed Anas Mohamed: Data curation, formal analysis, Methodology, Writing (original draft), review, and editing.

SM - Saheema Moila Kiriyath: Data curation, formal analysis, Methodology, Writing (original draft), review, and editing.

HD - Huda Mohamed Saddik Sheikh: Data curation, formal analysis, Methodology, Writing – original draft, review, and editing.

AD - Anjela Davis Panattuparambil: Data curation, formal analysis, Methodology, Writing – original draft, review, and editing.

SF - Shahwar Fatima Ansari: Data curation, formal analysis, Methodology, Writing – original draft, review, and editing.

PK - Praveen Kumar Kandakurti: Conceptualization, methodology, supervision, formal analysis, writing – original draft, review and editing, approval of final draft.

KG - Kumaraguruparan Gopal: Methodology, Project Administration, Writing – original draft, writing – review and editing.

AH - Animesh Hazari: Conceptualization, Methodology, Supervision, Formal Analysis, Writing-original draft, review and editing, approval of final draft.