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 DALYS (disability-adjusted life years) in 2019.² It consists of numerous categories based on pathogenesis such as Type1, Type2, and gestational, 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

The disease has long-term complications, including both microvasculature diseases, such as diabetic peripheral neuropathy (DPN), and macrovascular diseases, such as peripheral vascular diseases (PVD).⁵ 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 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

Security personnel oversee upholding a safe and secure environment in various sectors such as health, commercial, and residential. The working conditions of securities can be unfavorable, including extended and irregular working hours, fixed postures, exposure to extreme weather conditions, and night and shift duties. One of the major concerns is that this job requires them to work in an upright posture for prolonged hours, which can be a potential risk to various health conditions.⁷ The associated risk may be higher in the presence of diabetes mellitus (DM).

According to the International Diabetes Federation, in 2021, the prevalence of DM in the United Arab Emirates (UAE) was 12.3%.⁸ DM is a major health concern and is regarded as a key area of research interest in the UAE. According to our literature review, the prevalence of Type 2 DM (T2DM) has not been assessed in specific professions in the UAE. Thus, a knowledge gap was identified, supported by the lack of research on security guards regarding the prevalence of DM and its associated complications. Another factor that adds to studying this population is that the profession necessitates sitting and standing for longer hours, which is a potential risk factor for developing asymptomatic arterial insufficiencies. 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. Thus, screening is recommended before the onset of symptoms for both prevention and management. Therefore, this study aimed to screen DM cases among security personnel in the UAE and identify its macro-and microvascular complications, such as 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,⁸ 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.⁹

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.¹⁰ 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.^11,12 The Michigan Neuropathy Screening Instrument (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.^12,13 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.

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 descriptive data and diabetes profiles of the participants are listed in Table 1. The sex proportion in our sample is shown in Figure 2.1. The locations of the data collection are shown in Figure 2.2.

Figure 2.1. Shows the proportion of males and females among our participants.

There were 158 male and eight female security guards.

Figure 2.2. Shows the geographical distribution of the collected data.

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

The prevalence of diabetes among the security was found to be 9.6% ( Table 2), while the presence of Diabetic Peripheral Neuropathy, measured using Semmes- Weinstein monofilament, MNSI, and VPT, is mentioned in Table 3. The monofilament test showed positive responses in three non-diabetic and ten diabetic patients. The higher mean scores for MNSI and Volts were suggestive of confirmed cases of DPN (7/16) in the diabetic population ( Table 3). Additionally, it was also found that security guards with DPN also had neuropathic pain with a mean DN4 scale score of 3.75 $\pm$ 2.05 ( Table 3). The mean ABI value calculated from all participants was 1.29 $\pm$ 0.12.

Table 4 illustrates the association between diabetic security, ABI, and DPN. A moderate correlation was observed between DM and ABI (r=0.56). This correlation was statistically significant (p=0.03). In contrast, a strong correlation (r=0.83, p<0.001) was observed between the presence of DM and DPN.

Discussion

This study aimed to determine the prevalence of diabetes among security personnel and its association with complications such as PVD and DPN in the UAE. The findings from this study highlight a noteworthy association between DM and its complications in an important population group. Our sample comprised 166 predominantly male participants with a mean age of 34.95±8.15 years. The mean BMI was calculated as 23.41±4.97, which falls within the normal range, but has a tendency toward being overweight.¹⁴ It was noted that the systolic blood pressure measured from the ankle, although high, fell within the normal range (110-170 mmHg),¹⁵ possibly because of decreased arterial compliance in the peripheral arteries. As the compliance of the arteries decreases, especially in the periphery, the pulse pressure increases, which causes an elevation in ankle BP readings. This process is more marked in middle-aged and elderly individuals because of natural stiffening of the arteries. The diabetics in our sample had an average FBS level of 123±37.89 mg/dL, PPBS level of 243±75.11 mg/dL, and HbA1C levels of 7.1±2.03%. A higher value of standard deviation in the demographics of our sample indicates a larger spread of the participants’ data.

As per our review of the literature, few retrospective and descriptive analyses indicated a certain value of prevalence of diabetes mellitus, which differed according to the sample, ranging from 8.6%¹⁶ to 25.1%.¹⁷ IDF, In 2017, reported a 17.3%¹⁸ prevalence of T2DM in UAE adults aged from 20-79. In 2019, it estimated a rate of 16.3% of adults with type 2 diabetes mellitus.¹⁹ A recent report by the IDF in 2021 identified that the prevalence of DM in the UAE is 12.3%.⁸ The prevalence of DM in our sample was 9.6%. The participants with DM had the disease for an average of 6.70±2.73 years and the levels of the FBS, PPBS are indicative of poor glycemic control among them. The study identified a prevalence of 62.5% in the presence of DPN, according to the monofilament test. However, the MNSI and VPT indicated DPN of 43.75% and 56.25%, respectively, which further confirmed the results. These screening tools have shown good reliability and accuracy.^20,21 The mean DN4 results among the participants were 3.75±2.05, indicating moderate pain levels in those with DPN.

The association between DM and DPN was statistically significant (r=0.83, p<0.01), signifying a considerable link between DM and the development of neuropathy ( Table 4). This result is in line with that of a previous study done in UAE, which suggests that DPN is the 2nd most common complication of T2DM.²² The mean ABI recorded in our study was 1.29, which indicates that there was no significant oddity in the status of the peripheral vascular condition among the security personnel because it fell within the normal range (0.9-1.4).²³ However, the moderate correlation between ABI and diabetes (r=0.56) indicated that individuals with diabetes may be at an increased risk of PAD. This aligns with the results of a study which that the risk of developing vascular complications is much higher in diabetic patients.¹¹ Both 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

Recent research has shown that neuropathy is one of the leading complications of diabetes.¹³ AGE-induced damage increases vascular permeability, oxidative stress, and polyol accumulation, which are among the downstream cellular effects of hyperglycemia that are common in prolonged diabetes.²⁴ An absolute treatment approach to prevent the occurrence of neuropathy, mainly due to diabetes, is still in the process of being discovered; hence, decelerating the process of development and preventing the occurrence of complications is extremely important to reduce the severity of neuropathy.¹⁸

Limitations and future recommendations: The instruments used in this study are not the gold standard diagnostic tool for the provisional diagnosis of the condition, but only serve as a screening tool for detecting the presence of DPN. Hence, these results must be verified with appropriate diagnostic measures such as NCV. However, these are the most widely used measures in community-based studies. This profession is predominantly male dominated, indicating the presence of a gender bias. The other limitations of this study include relying on data obtained only from the three emirates, namely, Ajman, Dubai, and Ras al Khaimah; therefore, it is difficult to generalize the data to the entire United Arab Emirates. The study design of this research was cross-sectional; perhaps, a longitudinal study would have provided more precise data along with normal variations. The blood pressure measurements during our study were taken from both the arms and ankles, and a mean was obtained; however, the measurement was only taken at once and not a minimum of three readings due to time constraints and the duty of security guards not allowing them to spare much time. Thus, the Doppler test may be more reliable. Moreover, the major limitation of this study was not considering the presence of confounding factors such as medications, smoking status, dietary habits, genetic factors, sleep, caffeine intake, and stress levels, which contributed significantly to the variations in blood pressure and status of DM.

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.