Risk Factors Associated to Patients with Type 2 Diabetes in Lahore District

Our research aimed to check the impact of some signifi cant risk variables on diabetes growth and the specifi c goal of this study was to evaluate the connection of industrial fi elds with diabetes risk variables. The current research also informs us about the most important risk factor for male and female people with diabetes. A cross-section and convenient sample of 100 people, male and female, without discernment of risk factors and diabetes mellitus (Meta-Analysis on the eff ect of major risk factors on the diabetic patients form Jinnah Hospital Lahore). The risk factors in the general assessment i.e. lack of exercise, kidney problems, high ranges of tests and residence in industrial areas are found to be signifi cant. Assessment of these factors is helpful in early diagnosis and in prognosis of diabetes.


Introduction
Diabetes mellitus is a wide occurring ailment. Globally more than 400 million individuals have diabetes, and if present studies prevail, the incidence is expected to increase. Diabetes is a signi icant cause of early death, heart attack, and stroke. In 2016, it is the seventh major cause of death [1]. Pakistan with a diabetic population of 5.2 million, 90% of which are Type 2 was ranked 6th in 2000 in a World Health Organization (WHO) list of nations with the largest amount of diabetics [2]. Diabetes is due to either the pancreas not producing enough insulin or the cells of the body not responding properly to the insulin produced [3,11,12]. Worldwide, individuals with diabetes were roughly "171 million (2.8 percent of the world's population)" in the year 2000, and anticipated 366 million individuals will be from developing regions of the world from this igure [4]. Recent studies demonstrate that "environmental chemicals" are a signi icant cause and contributor to increased diabetes proportion [4]. One of the main causes of diabetes and longlasting health conditions is fatness and heavy weight. Diabetes occurs mostly in developing nations between 40-60 years of age and mostly in developed areas over 60 years of age [4].
Sometimes, studies of individuals exposed to elevated concentrations of environmental variables (dioxin, POPs, PCDDs) (TCDD) discovered enhanced rates of type 2 diabetes. Other studies also discovered that diabetes is associated with exposure to environmental variables (dioxin, POPs, PCDDs) in Vietnam (e.g., [5,6] and in veterans exposed to Agent Orange in Korea [7]. Environmental factors (dioxin, POPs, PCDDs)s are mainly by-products of industrial processes but can also result from natural processes, such as volcanic eruptions and forest ires. Environmental factors (dioxin, POPs, PCDDs) are unwanted by-products of a wide range of manufacturing processes including smelting, chlorine bleaching of paper pulp and the manufacturing of some herbicides and pesticides. Uncontrolled waste incinerators (solid waste and hospital waste) are often the worst culprits for releasing environmental variables (dioxin, POPs, PCDDs) owing to incomplete burning. Technology is accessible that enables the controlled incineration of waste with low environmental emissions (dioxin, POPs, PCDDs).
While environmental factors (dioxin, POPs, PCDDs) are formed locally, the distribution of the environment is global. Environmental factors (dioxin, POPs, PCDDs) are discovered in the setting around the globe. Some soils, sediments and foods, particularly dairy products, meat, ish and shell ish, have the largest concentrations of these compounds. In crops, water and air, very small concentrations are discovered.

Motivating background
The irst motivation was from the indings of Chin-Chi, et al. [8] conducted a study to evaluate the epidemiologic and experimental evidence on the relationship of environmental chemicals with obesity, diabetes and metabolic syndrome. They identi ied a total of 29 articles (7 on arsenic, 3 on cadmium, 2 on mercury, 11 on persistent organic pollutants, 3 on phthalates and 4 on bisphenol A) including 7 prospective studies. Considering consistency, temporality, strength, doseresponse, and biological plausibility (confounding), they concluded that the evidence is suggestive but not suf icient for a relationship between arsenic and persistent organic pollutants, and insuf icient for mercury, phthalates and bisphenol A. For cadmium the epidemiologic evidence does not seem to suggest an association with diabetes.
A second motivation stems from the indings of Fernández [9]. Performed a study to evaluate the iron excess and risk of type 2 diabetes mellitus in a prospective cohort of Mediterranean population. He conducted three studies on the PREDIMED cohort with data collected in men and women aged 55 to 80 from centers located in Reus-Tarragona, Pamplona and/or Barcelona. A conditional logistic regression model was itted and adjusted for socio-demographic, anthropometric, lifestyle, dietary and in lammation variables. The methodology included the diagnosis of T2DM based on ADA criteria. These results obtained were that in an adult Mediterranean population at high cardiovascular risk, high dietary iron and body iron stores increase the risk of T2DM after adjustment for potential confounding variables.
Thirdly work of Kanan and Samara, [10] gave us motivation who conducted a study that encompasses the historical presence of PCDDs and PCDFs in the world-wide environment. Information on exposure indicated that the main route of exposure of dioxins/furans to humans is through ingestion, which is discussed in this paper. The extraction methods including USEPA 8290 are the most used with HRGC/HRMS preferred as a detection tool. Moreover, a detailed compilation of studies of the PCDD concentrations and environmental sources from major industrial regions in several countries are presented. In summary, the major sources of dioxins in the worldwide environment include combustion and industrial sources with major challenges related to the lack of data availability in the Middle East especially with the current Warfare conflicts in the region.

Selection of patients
Over 100 Type 2 diabetic patients were included in the study. All other patients having disease other than diabetes were excluded.

Ethical approval of the study
Ethical approval for the study was taken from the Ethical/ Protocol/Synopsis Committee of Jinnah Hospital, Lahore. Pakistan.

Target population
The target population of the present study comprised of all the diabetic patients of the Jinnah Hospital, Lahore.

Sampling
A convenient sampling was used to collect data. 100 patients were included in the study.

Survey method
The success of the survey depends upon the accuracy of data collection. The collection of accurate data depends upon the correct choice of survey method. For current study a questionnaire and face to face interview was used to collect data.

Data collection
For this particular study the face to face interviews were conducted along with the questionnaire. Data was collected within a month. By keeping in mind the dif iculty of understanding and language among senior (old) patients and those who came from rural areas. So it was the best way to ask questions from the patients and ill the questionnaire on our own.

Field experience
There came some dif iculties in ield experience. The respondents' behavior was very good but some of them refused to answer the questions. After explaining the objectives of the study they agreed to co-operate with the interview. Some respondents praised our research topic and some even gave us their contact numbers to inform them the result of our study but it was a good experience on the whole.

Questionnaire
The questionnaire contained a total of 54 questions. First 7 questions were used to collect personal information of the patients, the remaining questions access the factors affecting diabetic patients.

Analysis
Data was analyzed by using multiple tests including tests for associations Pearson's chi-squared test (χ 2 ), the goodnessof-it test and Mann-Whitney U test.

Results and discussions
The study comprises 100 diabetic patients including male and female. Approximately 22 risk factors like age, gender. marital status, profession, performance of exercise, taking proper meals, usage of fast food, eating away from home, usage of tobacco, usage of alcohol and heavy drinkers, usage of cigarettes. cigar, pipe and chew, availability of blood sugar meter, recording sugar levels, usage of medications, living in industrial areas, satisfaction with the sanitation system, usage of processed meat, usage of additives in food like sugar tablets were recorded ( Figure 1). Some of these variables, including age, are regarded as quantitative. All other factors are qualitative, most of which are in dichotomous form (yes/no). This portion of the research is split into two sections in order to present the full and thorough analysis; descriptive and analytical section.

Descriptive analysis
In this section the frequency and percentages of the different environmental factors of diabetes for patients will be discussed. There are 100 subjects (diabetic patients). The debate of the results will base on the frequency (counts), percentages (Table 1).

Inferential analysis
In Table we are testing the association of all the major risk factors with people living in industrial areas. Here from this table we can see that the type of exercise, kidney problems, range of tests and kind of industry are signi icantly associated with whether patients live in an industrial area or not. It can be seen that age, profession and satisfaction with sanitary system is signi icantly associated with marital status while all the other risk factors showed no association with marital status ( Table 2).

Testing of patient's gender with the factors
We have applied Mann-Whitney U test to ind the effect of gender on major risk factors that are physical activities, daily activities, meals, other complications, blood sugar monitoring, medications and environmental factors. There was effect of patients' gender regarding other complications involved in diabetes while there is no effect of gender on physical activities of patients, daily activities of patients, meals taken by patients, blood sugar monitoring, proper medications and environmental factors. It is observed that patients who came from rural areas have a poor environmental exposure and medications are not properly available there whereas patients coming from urban areas have good environmental exposure and can take proper medications.

Summary and conclusions
The primary goal of the research was to identify effect of environmental factors on diabetes patients. To attain this task a time based study had been carried out in the city of Lahore and the data has been collected from The Diabetic Centre, Jinnah hospital Lahore. A sample of 100 patients has been obtained. These patients were considered to be the respondents' once diagnosed by the doctor to be having diabetes. Duration of study was ixed and convenient sampling method was used. The data was gathered through questionnaire and interview.

In Hypothesis Testing following results have been found
Here we have seen that the type of exercise, kidney problems, range of tests and kind of industry are signi icantly associated with whether patients live in an industrial area or not. It was observed that people coming from areas having industries nearby were having certain complications like kidney problems. We conclude that industrial areas have waste discharges; this waste gets in drains and canals and thus   becomes a reason for water pollution and other pollutions too. Drinking water of these areas can cause many problems i.e. kidney problems, diarrhea, nausea etc. This results in the increased range of blood sugar tests of the patients since patients already ill will have less energy and hence their power will be less too. This depends upon the kind of industry that is in their locality.
The variables that are insigni icantly associated with industrial area such as weight loss, weight gain, eyesight, numbness in feet, dental problem etc. indicate that proper medications were used by patients which gave considerably better results even when they were exposed i.e. living in industrial areas.
It can be seen that age, profession and satisfaction with sanitary system is signi icantly associated with marital status. Most of the females were housewives and married whereas only a few were working and single. Only 12 patients said they were satis ied with sanitary system in their area while others were not satis ied. There was effect of patients' gender regarding other complications involved in diabetes whereas medications and environmental factors were affected by the habitat of patients.
There were seven variables. Results from our study suggested that patients' gender had effect on this factor (other complications). It can be said that the complications such as weight loss, weight gain, eyesight, kidney problems, dental problems, numbness/tingling/loss of feeling in feet, wound healing problems were effected by gender of patients ( Figure 1). Male patients suffered from fewer complications as compared to female patients because males were active, most of them were working i.e. laborers, farmers, job holders while most of females were housewives, who were less active as compared to men and hence faced more complications.
The habitat of patients meant whether they lived in rural or urban areas. The risk factor medication was effected by habitat of patients. Patients who lived in urban areas could conveniently buy authorized medicines, which gave better results. There was availability of medical stores and pharmacies in city area whereas patients coming from a rural area faced many problems. The availability of medical stores and pharmacies was not easy for patients living in rural areas. These medical stores and pharmacies were very distant and secondly the medicines available there at those medical stores and pharmacies, situated in rural areas, were not authorized i.e. Insulin was not authorized and hence proper health results could not be seen. This created the effect of habitat on the medications.
The environmental factors include variables that are industrial areas, kind of industries, sanitary system, water, use of processed meat and food additives. There was effect of habitat (urban/rural) on these variables.

Summary
The aim of this research was to study the effects of certain major risk factors on the development of diabetes and the speci ic objectives were to assess the associations of gender of patients with the risk factors of diabetes. After selecting the topic, introduction and literature review of problem was collected from different sources including journals, articles books and electronic media. The questionnaire consisted of the bio-data of persons and following risk factors of (1)physical activities, (2)daily activities, (3)meals, (4)other complications, (4)blood sugar monitoring, (5)medications and (6)environmental factors as demonstrated in igure 1 and table 2. A cross-section and convenient sampling of 100 persons was conducted consisting of both males and females without any discrimination.
After the information was collected, it was selected for statistical analysis according to pre-coded criteria. The speci ied information was then entered into a private computer compatible with IBM. The study was conducted using software S.P.S.S. version 23.0 (Social Science Statistical Package) based on descriptive and analytical bases. In descriptive assessment, frequency distribution, percentages and cross tabs were calculated to verify the connection between distinct information characteristics and, in inferential assessment, chi-square tests were used to verify the importance of distinct factors by relating this statistics with P-value, normality tests were applied to check whether data is normal or not and Mann-Whitney U test was applied to check the effect of different risk factors on the variables.

Conclusion
The results of this cross sectional study provided information regarding the risk factors of Diabetes in Lahore, Pakistan. It is observed that the females (64) were more than males (36) as shown in table 1. The reason for large number of females then males may be the population (Hospital) from which the data was collected therefore ratio of female person was greater than males. In the overall analysis the risk factors i.e. type of exercise, kidney problems, range of tests and kind of industry are signi icantly associated with marital status. Age, profession and satisfaction with sanitary system are signi icantly associated with marital status.
There was effect of patients' gender regarding other complications involved in diabetes whereas medications and environmental factors were affected by the habitat of patients (Table 3a-e).