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 AFRICA 191
studies included in this review from the same locale.27 The three
South African studies included in this review had noticeably fewer
patients at HbA1c goal in comparison with other countries. One
of the reasons for this may have been that all the South African
studies included in this review were from the public sector, which
has often been described as ‘overburdened’, and due to resource
constraints, cannot always offer appropriate levels of healthcare or
access to the most modern diabetes treatments currently available
in South Africa’s private sector or in those high-income countries
included in this study. Furthermore, many of the patients serviced
in South Africa’s public sector settings originate from a lower socio-
economic background, which may indicate lower educational levels
or limited access to healthier lifestyle choices. Perhaps HbA1c level
is still the most challenging of risk factors to control, especially in
less-developed economies.
Study limitations
Studies included in this review differed with regard to guidelines
or targets, however, we tried to overcome this by consistently
capturing and comparing similar risk factors using standardised
units. Patients selected for the studies included in the review
were treated to ‘moving targets’ and therefore studies conducted
in the past five years only (2009–2014) were included, as recent
guidelines have more similar targets.
Some eight out of the 14 studies provided information on
the type of methods used for clinical and laboratory-based
measurements, but with differing levels of detail. Notably, only
two studies confirmed use of DCCT-standardised laboratory
analysers for HbA1c analysis. By converting to similar units
(e.g. LDL-C from mg/dl to mmol/l), target values in this
retrospective study (Table 1) were presented in a format that
would allow for comparison. Ideally, a centralised laboratory
should have been used for measurements included in this study,
however, we relied on previously obtained measurements from
other studies. We therefore cannot guarantee the accuracy or
precision of measurements in the studies selected for this review,
as methodologies may have differed. Studies from resource-
rich settings may have implemented newer, more sophisticated
and improved methods for A1c and LDL-C measurements,
influencing the results of those specific studies.
This review did not stratify the selected individual studies
according to patient profiles, severity of disease, clinical settings
(clinic or hospital) or involvement of specialists (factors affecting
how individuals are managed and able to reach guideline
targets). Although smoking is considered a critical risk factor
in the prevention and management of CVD, it was not included
as a crucial study parameter for this review (partly due to many
studies not reporting this).
Although previously identified as a source of bias, we only
included studies published in English, which according to
an analysis, has little effect on summaries of treatment effect
estimates.28 Publication bias may have occurred in our study in
that a single reviewer (author) carried out the searches without
the use of specific methodology (e.g. Cochrane data system).
Conclusion
The results presented in this study demonstrate that T2DM
patients remain inadequately controlled for their cardiovascular
risk factors. Our review revealed that control of major risk factors
did not differ significantly between countries or healthcare
settings. There is substantial room for improvement in the way
T2DM patients are being managed for their condition. Further
efforts through multidisciplinary action to improve guideline
adherence is critical for the prevention or delay of diabetes-
related complications.
References
1. International Diabetes Federation. IDF Diabetes Atlas, 6th edn.
Brussels, Belgium: International Diabetes Federation, 2013. http://www.
(accessed 16 October 2014).
2. Hall V, Thomsen RW, Henriksen O, et al . Diabetes in sub-Saharan
Africa 1999–2011: epidemiology and public health implications. A
systematic review. BMC Public Health 2011; 11: 564. .
org/10.1186/1471-2458-11-564].
3. Hayat SA, Patel B, Khattar RS, et al. Diabetic cardiomyopathy: mecha-
nisms, diagnosis and treatment. Clin Sci 2004; 107(6): 539–557. [http://
].
4. Colhoun HM, Betteridge DJ, Durrington PN, et al. Primary preven-
tion of cardiovascular disease with atorvastatin in type 2 diabetes in
the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre
randomised placebo-controlled trial. Lancet 2004; 364: 685–696. [http://
(04)16895-5].
5. UK Prospective Diabetes Study (UKPDS) Group. Tight blood pressure
control and risk of macrovascular and microvascular complications
in type 2 diabetes (UKPDS 38). Br Med J 1998; 317: 703–713. [http://
.
6. The 2012 SEMDSA guideline for the management of type 2 diabetes.
J Endocrinol Metab Diabetes S Afr 2012; 17(1): S1–S95. http://www.
(accessed 16 October 2014).
7. Development Policy and Analysis Division (DPAD) of the Department
of Economic and Social Affairs of the United Nations Secretariat (UN/
DESA). World Economic Situation and Prospects 2013. http://www.
class.pdf (accessed 16 October 2014).
8. American Diabetes Association. Standards of medical care in diabe-
tes 2011. Diabetes Care 2011; 34(Suppl 1): S11–S61. .
org/10.2337/dc11-S011].
9. Al-taweel DM, Awad AI, Johnson BJ. Evaluation of adherence to
international guidelines for treating patients with type 2 diabetes melli-
tus in Kuwait. Int J Clin Pharm 2013; 35(2): 244–250. .
org/10.1007/s11096-012-9738-8].
10. Braga MF, Casanova A, Teoh H, et al. Poor achievement of guidelines-
recommended targets in type 2 diabetes: findings from a contemporary
prospective cohort study. Int J Clin Pract 2012; 66(5): 457–464. [http://
].
11. Stark Casagrande S, Fradkin JE, Saydah SH, et al. The prevalence of
meeting A 1C, blood pressure, and LDL goals among people with diabe-
tes, 1988–2010. Diabetes Care 2013; 36(8): 2271–2279. .
org/10.2337/dc12-2258].
12. Goderis G, Borgermans L, Heyrman J, et al. Type 2 diabetes in
primary care in Belgium: need for structured shared care. Exp
Clin Endocrinol Diabetes 2009; 117(8): 367–372.
org/10.1055/s-0028-1103286].
13. Hermans MP, Elisaf M, Michel G, et al. Benchmarking is associated
with improved quality of care in type 2 diabetes: the OPTIMISE rand-
omized, controlled trial. Diabetes Care 2013; 36(11): 3388–3395. [http://