Cardiovascular Journal of Africa: Vol 26 No 4 (July/August 2015)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 4, July/August 2015 188 AFRICA
Review Articles
Glycaemic, blood pressure and cholesterol control in
25 629 diabetics
Y Pinchevsky, N Butkow, T Chirwa, FJ Raal
Abstract
Objective: To examine and compare the extent to which
people with type 2 diabetes (T2DM) are achieving haemo-
globin 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 suboptimal, even across
different settings.
Keywords: type 2 diabetes mellitus, guidelines, goal achievement
Submitted 17/10/14, accepted 17/5/15
Cardiovasc J Afr 2015; 26: 188–192
DOI: 10.5830/CVJA-2015-050
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 HbA1c 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 (HbA 1c, glycated haemoglobin, blood
pressure, systolic, diastolic, lipids, cholesterol, LDL cholesterol).
We also reviewed a selected number of reference lists of other
Department of Pharmacy and Pharmacology, School
of Therapeutic Sciences, Faculty of Health Sciences,
University of the Witwatersrand, Johannesburg, South Africa
Y Pinchevsky, BPharm, MSc (Pharm),
N Butkow, BSc (Hons), PhD
Division of Epidemiology and Biostatistics, School of
Public Health, Faculty of Health Sciences, University of the
Witwatersrand, Johannesburg, South Africa
T Chirwa, BSc, MSc, PGDip, PhD
Carbohydrate and Lipid Metabolism Research Unit, Division
of Endocrinology and Metabolism, Faculty of Health Sciences,
University of the Witwatersrand, Johannesburg, South Africa
FJ Raal, FRCP, FRCPC, FCP (SA), Cert Endo, MMed, PhD