Discussion

This study, the first of its kind in Eastern Morocco, describes the socio- demographic, clinical features and complications of 2401 diabetic patients, and provides important data on the frequency of diabetes complications and the associated risk factors. These data will serve as references for later studies and help to develop effective strategies against the development of

diabetes complications, in order to reduce the mortality rate caused by this endocrine disorder and its complications.

Since women have a better attention to their health and are more accustomed to take care of themselves and their family in general, the majority of participants were women (64.7%). Furthermore, numerous studies have revealed that women report higher rates of preventive and therapeutic health care for chronic and acute conditions than men in this region [30] and in other regions of the world [30] [31] [32] [33] [34]. Also, women have got enough time to devote to the follow-up of their diseases due to the fact that the majority of them are unemployed (95.6%). This fact is proved by the shown response to various initiatives and screening campaigns [23].

In this study, we found that 81.1% of diabetics are aged between 50 and 70 years. This can be explained by the fact that 87.5% of diabetics in our sample are type 2, and as is known in the literature, this type of diabetes affects especially adults more than young people [35] [36].

Our results showed that the percentages of illiterate (71.3%) and unemployed (80.6%) people were larger compared to those found (34.4%;

21.5%) in the Eastern region of Morocco in 2014 [37]. This may be due to our sample containing mostly women and elderly.

Moreover, 87.5% of diabetic patients in our sample are type 2, which is similar to other findings in previous studies [21] [38] [39]. This data can be explained in large part by our sample characteristics (age 61.0 ± 14.1 years and 50.9% of patients have a diabetes duration less than 10 years).

The results of our study, which took place in the Eastern region of Morocco especially at the Reference Center for Diabetology and Chronic Diseases, reported a high frequency of overweight and obesity in our sample: (43.4% and 28.5% respectively). These results are nearly the same to those found by our team in the same region (40.3% and 25.1%) [23]. On the other hand, the proportion of obesity was higher among women (36.1%) compared to men (14.5%). This huge rate of obesity in women is similar to that found in other studies in Morocco [16] [40] [41].

In the present study, the data concerning the frequency of hypertension is presented in (Table 1). We found the overall frequency of hypertension to be 42.3%. In a report realized by our team [42] in the East of Morocco, revealed a frequency of hypertension of 31.7% in a population aged 40 years and older, and a high frequency (69.9%) in diabetic subjects of the same population. In the same way other studies published a frequency of hypertension ranged between 49.3% and 70.4% among patients with type 2 diabetes in different Moroccan regions [43] [44] [45]. These alarming rates of hypertension confirm that this disease has become a scourge of health in our study area like all regions of Morocco.

The pathogenesis of diabetes complications is not fully understood, and controversy exists about why they occur in some patients and not in others. This study was undertaken to define more clearly the risk factors

influencing susceptibility to such complications in diabetic patients. In this regard, 32% of the 2401 patients studied had one or more complications.

This frequency is lower than the rates obtained in previous studies (63.8%

in Morocco (Fez) [45], 60% in Algeria [46], 68.7% in Libya [47] and 86% in Oman [48]). This difference in the frequencies of diabetic complications can be largely explained by the methodology of work of each study and the specific characteristics of the population studied.

In our work, DR is the most frequent complication of diabetes. The prevalence of DR shows wide variations between countries of Northern Africa, ranging from 8.1% to 41.5% [18]. In this database, retinopathy was found in 16.8% of patients, which is consistent with previous studies in Arab countries that reported its ranging from 11% to 19% [49] [50] [51]. However, our results are inconsistent with other studies, which found higher prevalence of retinopathy among diabetic patients that ranged from 34.5%

to 48.6% [52]. Besides, DR in the Eastern Mediterranean countries was estimated between 10% - 64% [53]. The divergence in the prevalence of retinopathy may be due to differences in the age structure of different populations and to differences in study methodologies and population samples.

The second common complication of diabetes in our sample was the diabetic nephropathy (12.8%). DN results from the same pathological mechanisms as DR, which makes them appear almost at the same time during the disease; the discovery of one of these complications must necessarily lead to the search for the other.

Studies on this microvascular disease reported various rates of prevalence: 10.8% in Saudi [54], 11.6% in Sudan [55] and 13.1% in Tunisia [56]. In addition, Afifi and colleagues in Egypt [57] performed multiple cross- sectional study between 1996 and 2001 and showed that DN gradually increased from 8.9% in 1996 to 14.5% in 2001, which is similar to our findings. Other data indicated higher rates than ours (25.2% in Libya, 41.7%

in Egypt and 25% in Cameroon) [58] [59] [60]. The rate of nephropathy was lower, and this could be attributed to the fact that 50.9% of patients had a diabetes duration less than 10 years.

Regarding macrovascular complications in our work, the rate of cardiovascular diseases was 5.4%, similar to that showed in Iran (6.5%) [61].

According to some studies realized in the Middle East and North Africa, the macrovascular complications ranged from 9% to 17% in people with diabetes [62] [63] [64]. In Montana American Indians the rate of cardiovascular complications was very high (27%) [65].

Our findings showed a low frequency of neuropathy and diabetes foot complications which reached 3.6% and 2% respectively. In other populations, the prevalence of neuropathy ranged from 21.9% to 66% [66]

[67] [68]. However, a recent study carried out in Iraq [69] reported a prevalence of 2.4% for diabetes foot complications in patients with diabetes which is consistent to our value. The low frequency of neuropathy and

diabetes foot complications probably resulted from the good accompaniment and education of the patients by health professionals of (RCD) in the long- term follow-up of their disease.

Our analysis has showed that age, diabetes duration and a high level of albuminuria were the principal risk factors associated with development of diabetes complications in both T1D and T2D. These findings are consistent with other reports [70]-[77] showing that the risk of developing these complications is positively associated with these variables.

This retrospective study confirms previously reported trends in the relationship between hypertension and diabetes complications [72] [75]. We have found that hypertension in patients with type 1 and type 2 diabetes was significantly (P < 0.001) associated with development of complications.

Furthermore, this association persists after multivariate logistic regression analysis in type 2 diabetes (OR = 1.56; 95% CI: 1.26 - 1.92, P < 0.001).

Consistent with foregoing studies [78] [79], we have found that lower levels of education are significantly (P < 0.01) associated with an increased rate of complications in T1D patients and a higher level of education had a protective effect against diabetic complications in these patients. In the same context, researchers evaluating the relationship between socioeconomic status and diabetic complications indicated that the incidences over 1 to 20 years’ follow-up of end-stage renal disease and coronary artery disease were two to three times greater for T1D individuals with lower level of education, compared to those with higher one [79].

In this paper, the risk of each micro and macrovascular complications of T2D is statistically associated with high HbA1c (P < 0.001). 33.1% of patients with T2D who have complications, have a poor glycemic control (HbA1c > 7%). This result as others [80] [81] [82] has demonstrated that an improved glyceamic control can reduce the incidence and the risk of micro and macrovascular complications in these people.

There is evidence that overweight and obesity are associated with an increased risk of mortality, cardiovascular diseases, and diabetes [12] [83].

Our study has confirmed this data and found overweight and obesity to be strongly associated (P < 0.001) with an increased risk for diabetes complications in patients with T1D.