Background: Chronic complications of diabetes mellitus, such as cardiovascular diseases, neuropathy, retinopathy, and nephropathy, have a profound impact on the overall well-being and quality of life of patients. Identifying determinant factors associated with the chronic complication of diabetes mellitus is critical for prevention. This study aimed to identify the determinant factors for chronic complications of Diabetes Mellitus among diabetic patients at Dessie Comprehensive and Specialized Hospital, Northeast Ethiopia.

Methods: An institution-based case control study was conducted from February to June 2021 at Dessie Comprehensive and Specialized Hospital. We included 357 participants with 68 cases and 272 controls (1:4 ratio), selected using consecutive sampling technique. Cases were diabetic patients with chronic complications, while controls were diabetic patients without such complications. Data were collected through interviewer administered questionnaire and review of patient medical records. Binary logistic regression model was used to examine the associated factors. The association was measured using odds ratio with a 95% confidence interval (CI), and statistical significance was declared at a p-value < 0.05.

Result: From the total participants, 191(56.2%) were males and 149 (43.8%), were females. We found that chronic complications of diabetes mellitus were positively associated with being unmarried (adjusted odds ratio (AOR)=4.5[2.1-9.5]), alcohol drinking (AOR=3.8[1.9-7.6]), physical inactivity (AOR=3.1[1.5- 6.4]), more than 10 years duration of diabetes mellitus (AOR=3.1[1.3-7.2]), and body mass index BMI ≥ 25kg/m2 (AOR=2.3[1.2-4.3]).

Conclusion: This study identified significant associations between diabetes mellitus complications and some of the modifiable factors, including alcohol drinking, physical inactivity, and overweight. Clinicians and diabetes mellitus prevention programs should consider these modifiable factors to prevent chronic complications.

• Diabetic complication

• Determinants

• Case-control study

Aragaw YK, Tadese F, Nigatu MD (2025) Determinant of Chronic Complications of Diabetes Mellitus in Northeast Ethiopia, 2024. J Chronic Dis Manag 9(1): 1047.

AOR: Adjusted Odds Ratio; BMI: Body Mass Index; CI: Confidence Interval; CVD: Cardio Vascular Diseases; DALYS: Disability Adjusted Life Years; DM: Diabetes Mellitus; DPN: Diabetic peripheral Neuropathy; DR: Diabetic Retinopathy; DCSH: Dessie Comprehensive Specialized Hospital; ETB: Ethiopian Birr; FBS: Fasting Blood Sugar; HDL: High Density Lipoprotein; HTN: Hypertension; LDL: Low Density Lipoprotein; MGLS: Morisky Green Levine Medication Adherence Scale; OR: Odds Ratio.

Diabetes Mellitus (DM) is a chronic metabolic disorder characterized by elevated blood glucose level [1]. DM occurs when a human body resists insulin, which causes the most common type of DM (type 2 DM), or due to the autoimmune insulin destruction, which causes the less common type 1 DM [1,2]. Both type 1 and type 2 DM shared the characteristics of high blood sugar level and its complications [1,2]. This elevated blood sugar level may cause a serious damage to the vital organs including heart, eyes, and kidneys. Diabetes is a major worldwide public health problem which imposed life treating complications, significant life loses, and economic costs [3,4]. Globally, the prevalence of DM complications are increasing and has caused about 4.2 million deaths [4,5]. DM causes life-threatening chronic macro-vascular and micro vascular complications with an enormous health and economic burden [3-7]. Thus, in an expenditure on medical costs attributed to diabetes include $27 billion for care to directly treat diabetes, $58 billion to treat the portion of diabetes-related chronic complications that are attributed to diabetes, and $31 billon in excess general medical costs [8]. DM complication and diabetes attributable deaths are progressively increasing in low- and middle-income countries [4,9]. Moreover, these complications are more compounded with scarce resource and low health literacy related to DM as indicated by high level of under diagnosis [10]. The magnitude of chronic complications of DM in one of Ethiopian study revealed that Hypertension (27%), eye illness and renal disease (19.1%), were the most common identified long-term effects of diabetes [11] . High rates of obesity, and poor glycaemic control in patients with type 2 diabetes and about 57% of patients are categorised as being a moderate-to-high risk for diabetic problems [12]. Several studies in Ethiopia also reported the magnitude of diabetic complications. A systematic review in 2019 reported that DM complications were 2.7%-25% for retinopathy, 4.8-35% for neuropathy, and 18.2-23.8% for kidney disease [13]. Numerous studies have shown a variety of determinant factors for chronic complications of DM. Among socio-demographic variables older age, educational status, sex, marital status, income of the individual and residence are important factors [14-17]. Behavioural factors such as smoking, higher values of body mass index (BMI), and poor physical exercise are also known for elevating the risk of DM complications [18-24]. In addition, the odds of chronic DM complications were found to be higher among patients with poor adherence to medication, poor glycaemic control, and poor cholesterol control [24]. Family history of DM and its complications were also reported as predictors of chronic DM complications [25]. Disease related factors such as type of diabetic mellitus and duration of diabetes were also found to be significantly associated with chronic complications of DM [21,26-28]. However, these factors tend to vary in different settings depending on the societal lifestyles and cultural activities. Identifying the determinant factors for DM complications in a specific community is essential to inform clinicians, DM patients, and policymakers to take preventive action and make early detection. Therefore, this study aimed at identifying the determinants of chronic complications of diabetes mellitus among adult diabetic patients at Dessie Comprehensive and Specialized Hospital, Northeast Ethiopia, 2021.

Study Area and study period

The study was conducted in Dessie referral Hospital,Dessie town, Amhara Regional State, Ethiopia. Dessie is the center of South Wollo Zone. According to the town administrative health office report, the town is organized in 18 urban and 8 rural kebeles (the smallest administrative unit in Ethiopia). The estimated population size was 239,620 of which, 112,121 were males and 127,499 were females in 2018. From this population 199,976 were in urban and 39,644 in rural areas. There are five hospitals (two governmental and three private), eight health centres and twenty-seven private clinics serving this population.

Study design

An institution based unmatched case control study design was used to identify determinants of common chronic complications among diabetic patients.

Cases: Adult diabetic patients who developed at least one diabetes chronic complications within the past one year (Feb.1st 2020-Apr.30th 2021) diagnosed by physicians and those who were available during the data collection period, February to April, 2021.

Controls: Adult diabetic patients who did not developed diabetes chronic complications within the past one year (Feb.1st 2020-Apr.30th 2021) and those who were available during the data collection period, February to April, 2021.

Sample size

The sample size was determined using Open Epi statistical software with 95% level of confidence, 80% power, 4:1 control to case ratio, and considering 5% non response rate. The final sample size was 357 participants (68 cases and 272 controls).

Sampling Procedure

Cases were selected from diabetic patients with chronic complications by consecutive sampling technique, as the patients come to the hospital in their appointment day, until the predetermined sample size is obtained during the data collection period.Controls were selected from diabetic patients without chronic complications by consecutive sampling technique, as the patients come to the hospital in their appointment day, until the predetermined sample size is obtained during the data collection period.

Variables

Dependent Variable: Chronic complications of diabetes mellitus (at least one of the following: diabetic retinopathy, diabetic nephropathy, diabetic neuropathy and diabetic related cardiac diseases), coded as ‘Yes’ or ‘No’.

Independent Variables: the independent variables were socio-demographic characteristics (age, sex, residence, educational level, marital status, occupational status, and monthly income); behavioural factors (smoking history, drinking history, and physical activity); clinical factors (body mass index, blood pressure, blood sugar level, duration of diabetes, frequency of check-up, drug regimen, type of DM, cholesterol level, triglyceride level, HDL and LDL)

Operational definitions Diabetes Mellitus Complications: Patients with diabetes mellitus who develop one of diabetic complications (Diabetic Neuropathy, Nephropathy, Retinopathy and diabetes related cardiac diseases) Physical activity: Participants who reported regular aerobic exercise (e.g., walking and jogging) of at least 30 min for every 5 days or its equivalent; or whose occupation requires daily physical exertion were considered to be physically active [23].

Triglyceride level: Desirable500mg/dl HDL level: Desirable>50mg/dl, Borderline 35-50mg/ dl, High risk 160mg/dl

Cholesterol level: Desirable 240mg/dl.

BMI: BMI 30 kg/m2 as obesity [28]. We categorized BMI as high (BMI t≥ 25 kg/m2) and low (BMI ≤ 24.9 kg/m2). 

Diabetes Medication Adherence (Morisky Green Levine Medication Adherence Scale score): high adherence 0 points, medium adherence 1-2 points and low adherence 3-4 points [29].

Data collection

The data were collected by face-to-face interview using interviewer administered questionnaire. The questionnaire was prepared based on the existing literatures. The questionnaire was prepared in English, translated to Amharic, and back translated to English. The questionnaire contains socio-demographic variables, behavioural factors and clinical and biologic variables. Clinical data were retrieved from the patient card. Two diploma nurses, under the supervision of one BSc. Nurse collected the data. The data collectors and supervisor took two days training on the data collection materials and procedures.

Ethical Consideration

Ethical clearance was obtained from the Ethical Review Committee of Wollo University, College of Medicine and Health Sciences, School of Public Health (Ref: SPH/ERC/066/21). In addition, letter of permission to conduct the study was obtained from Administrative Health Office of Dessie town and Dessie Comprehensive Specialized Hospital. After explaining the purpose of the study written informed consent was obtained from participants before data collection. The data collectors explained the objective of the study to the participants. Respondents were informed that participating in the study is voluntary and refusal to participate did not compromise the medical care they receive. The right to withdraw from the study at any time during the interview was assured. The interviews were conducted in a private room to maintain the privacy of participants, and personal identifiers were not collected.

Data processing and Analysis

The collected data was entered using Epi-data version 3.1 and exported to SPSS version 23 for analysis. Descriptive analysis was made using frequency, proportion and summary measures. Binary logistic regression was used to analyse determinant factors of DM chronic complications. First bivariate analysis was conducted between each independent variable with the dependent variable and then selected variables were entered in multivariable logistic regression analysis. In the final model, variables with P value < 0.05 were considered as statistically significant. Goodness of fit for the final model was checked using Hosmer and Lemeshow test. Odds ratio with 95% confidence interval was used to show the strength of associations.

Socio-demographic Characteristics

A total of 340 diabetic patients were included, with a response rate of 95%. The mean age was 41±14.42 years, ranging from 18 to 80 years. From the total participants only 195 respondents reported about their income status, with 48.4% of cases reported that their monthly income level was below 1000 Ethiopian Birr (Table 1).

Table 1: Socio-demographic Characteristics of Adult Diabetic Follow up Patients at DSCH, Northeast Ethiopia, 2021 (n=340).

Behavioural factors

From the total respondents, 18.5% controls and 6.2% cases, respectively were smokers. Similarly, 15.6% cases and 45.6% controls were alcohol drinkers. Regarding physical activity, 4.7% of cases and 29.7% of controls were physically active (Table 2).

Table 2: Behavioural factors of Adult Diabetic Follow up diabetic patients at DCSH, Northeast Ethiopia, 2021(n=340).

Clinical factors

Regarding the type of diabetes, 15.3% of cases and 55.9% of controls were type 2 diabetics and 4.7% of cases and 24.1% of controls of the respondents were type 1 diabetic patients. Of these participants, 17.1% cases had monitored their diabetes monthly, while 2.9% had it checked every two months or when they felt sick. Among controls, 63.2% of them monitored every month, as compared to 19.7% of controls who did every two months or when they feel sick. Out of the total participants, 39.7% reported high adherence to their diabetic medications (Table 3).

Table 3: Clinical factors of Adult Diabetic Follow up patients at Dessie referral Hospital, Northeast Ethiopia, 2021(n=340).

Determinants of chronic complications of diabetes mellitus

The final multivariable logistic regression analysis revealed significant associations between certain factors and chronic complications of diabetes mellitus. Employment status was found to be associated with diabetic complications as unemployed participants were 80% less likely to develop diabetic chronic complications compared to employed participants (AOR=0.2, 95% CI: 0.1, 0.8). On the other hand, participants who were physically inactive, drink alcohol, longer duration of diabetes, and higher BMI were more likely to develop DM chronic complications (Table 4).

Table 4: Determinant factors of diabetes complication in patients with diabetes at DCSH, Northeast Ethiopia, 2021(n=340).

This study provides valuable insights into the socio demographic, behavioural, and clinical factors associated with the development of chronic DM complications. We found that being unemployed, alcohol drinking, physical inactivity, DM duration of above 10years, and body mass index BMI ≥25kg/m2 were significantly associated with chronic diabetes mellitus complications. These findings are in line with a case-control study conducted at Debre Markos hospital in Ethiopia [17,30].Parallel to previous studies [20,21,24], our finding showed that the odds of developing diabetic chronic complications were more than three times higher among patients with above 10 years DM duration after diagnosis. Longer disease duration may indicate inadequate disease management, delayed diagnosis, or suboptimal treatment adherence, which can contribute to the development of complications. The odds of developing diabetic complications were more than two times higher among diabetic patients having a high BMI (≥25kg/m2), than diabetic patients with low BMI (≤24.9kg/m2). This is consistent with other studies [20, 21,23,28] . Higher BMI escalates the development of insulin resistance in type 2 diabetes patients [22,23]. Excessive fat deposition, due to insulin resistance, impairs beta cell function, leading to high glucose levels and increased adipose tissue around the abdominal area. This results in a high waist-to-hip ratio, contributing to visceral and peripheral obesity. Such obesity inhibits the normal functioning of organs, especially in cases of central obesity, compromising the overall function of the body [23]. Hence reduction in body weight and having normal BMI in diabetic patients is critical to reduce the devastating impacts of chronic complications. Modifiable behavioural factors such as alcohol consumption and physical activity were also significantly associated with diabetic complications. The odds of having chronic complications of DM were more than two times in physically inactive patients compared to their counter parts. This finding is supported by other previous studies [21,23]. The reason behind is physical activity helps patients with diabetes to reduce their weight and lessen cardiovascular risks, increases glycemic control and insulin sensitivity [31]. Likewise, participants who were alcohol drinkers had 3.8 times higher odds of developing chronic complications. This association may be attributed to the detrimental effects of alcohol on glycaemic control and the increased risk of cardiovascular complications associated with heavy alcohol consumption [32]. A systematic review reported that heavy drinking, particularly in diabetics, also can cause the accumulation of certain acids in the blood that may result in severe health consequences and worsen diabetes-related medical complications [30]. Public health promotion programs focusing on these modifiable factors could help in preventing DM complications. Employment status was found to be significantly associated with diabetic complications. Unemployed participants had 80% lower likelihood of developing chronic complications compared to employed participants. This finding suggests that employment status may influence access to healthcare, self-care practices, and overall disease management, thereby impacting the risk of complications. Unemployed individuals may have more time available for self-care activities and may experience lower levels of stress associated with work-related factors, both of which could contribute to better diabetes control. Conversely, in Japan focusing on public servants found that diabetic complications of type 2 DM was higher among those with low education and low-level work positions, whereas a study focusing on white-collar workers reported an increased incidence only among those working in sales jobs [33]. In this study being unmarried increases diabetes chronic complication by 4.5 times compared to the married diabetic patients and similar with a follow up study [34] . Unlike a study in Gurage zone, Ethiopia, which reported being widowed reduces the complication by 75% compared to the married respondents. This difference may be from variation in the study design and source population.

It is important to note that this study had some limitations. The study was conducted in a specific region and may not be fully representative of other settings in Ethiopia. The data relied on self-reporting, which may introduce the potential for recall bias and social desirability bias. Additionally, the study design was case control, which limits the ability to establish causality between the identified factors and diabetic complications. The relatively small sample size is also important to consider in interpreting the results. For instance, while unemployment is negatively associated with DM complications, there were only six cases and 66 controls in the unemployed sub sample.

This study underscores the importance of addressing various determinants to effectively prevent and manage diabetic complications. The findings highlight the significance of factors such as physical inactivity, alcohol consumption, duration of diabetes, and higher BMI in increasing the risk of complications. By considering these determinants and implementing targeted interventions, healthcare providers can make significant improvements in reducing the burden of complications and improving outcomes for individuals with diabetes. A comprehensive approach that encompasses education, lifestyle modifications, and regular monitoring is crucial for effective diabetes management. Further research with more representative sample is needed for deep understanding of these findings and explore additional factors that may contribute to DM complications in diverse populations.

YKA conceived the study, lead the design of the study, lead in the acquisition of data, analysis and interpretation of data, write-up, and preparation of the manuscript. FT involved in supervision, drafting the write-up, and revised the manuscript contents. Both authors read and approved the final manuscript. MDN also involved in analysis and edition of data, write-up, and preparation of the manuscript.

We would like to acknowledge Dessie town administrative office for providing me the necessary information.

The ethics declaration in our manuscript was conducted according to the norms or standard of “the Declaration of Helsinki”.

1. World Health Organization. Definition and diagnosis of diabetes mellitus and intermediate hyperglycaemia: report of a WHO/ International Diabetes Federation consultation. Geneva: World Health Organization; 2006.
2. Lin X, Xu Y, Pan X, Xu J, Ding Y, Sun X, et al. Global, regional, and national burden and trend of diabetes in 195 countries and territories: an analysis from 1990 to 2025. Sci Rep. 2020; 10: 14790.
3. Williams R, Karuranga S, Malanda B, Saeedi P, Basit A, Besançon S, et al. Global and regional estimates and projections of diabetes- related health expenditure: Results from the International Diabetes Federation Diabetes Atlas, 9th edition. Diabetes Res Clin Pract. 2020; 162: 108072.
4. Saeedi P, Salpea P, Karuranga S, Petersohn I, Malanda B, Gregg EW, et al. Mortality attributable to diabetes in 20-79 years old adults, 2019 estimates: Results from the International Diabetes Federation Diabetes Atlas, 9(th) edition. Diabetes Res Clin Pract. 2020; 162: 108086.
5. Hu G, Jousilahti P, Qiao Q, Katoh S, Tuomilehto J. Sex differences in cardiovascular and total mortality among diabetic and non-diabetic individuals with or without history of myocardial infarction. Diabetologia. 2005; 48: 856-861.
6. van Dieren S, Beulens JW, van der Schouw YT, Grobbee DE, Neal B. The global burden of diabetes and its complications: an emerging pandemic. Eur J Cardiovasc Prev Rehabil. 2010; 17: S3-8.
7. Gregg EW, Sattar N, Ali MK. The changing face of diabetes complications. Lancet Diabetes Endocrinol. 2016; 4: 537-547.
8. Economic costs of diabetes in the U.S. In 2007. Diabetes Care. 2008; 31: 596-615.
9. Liu J, Bai R, Chai Z, Cooper ME, Zimmet PZ, Zhang L. Low- and middle- income countries demonstrate rapid growth of type 2 diabetes: an analysis based on Global Burden of Disease 1990-2019 data. Diabetologia. 2022; 65: 1339-1352.
10. Swaminathan N, Awuah WA, Bharadwaj HR, Roy S, Ferreira T,Adebusoye FT, et al. Early intervention and care for Diabetic Foot Ulcers in Low and Middle Income Countries: Addressing challenges and exploring future strategies: A narrative review. Health Sci Rep. 2024; 7: e2075.
11. Berhe KK, Mselle LT, Gebru HB. The magnitude of chronic diabetes complications and its associated factors among diabetic patients attending the general hospitals in Tigray region, Northern Ethiopia. PLoS One. 2023; 18: e0290240.
12. Nduati JN, Gatimu SM, Kombe Y. Diabetic Foot Risk Assessment among Patients with Type 2 Diabetes in Kenya. East Afr Health ResJ. 2022; 6: 196-202.
13. Bishu KG, Jenkins C, Yebyo HG, Atsbha M, Wubayehu T, GebregziabherM. Diabetes in Ethiopia: A systematic review of prevalence, risk factors, complications, and cost. Obesity Med. 2019; 15: 100132.
14. Ghabban SJ, Althobaiti B, Farouk IM, Al Hablany M, Ghabban A, Alghbban R, et al. Diabetic Complications and Factors Affecting Glycemic Control Among Patients with Type II Diabetes Mellitus Attending the Chronic Illness Clinics at Tabuk, Saudi Arabia. Cureus. 2020; 12: e11683.
15. Chiwanga FS, Njelekela MA. Diabetic foot: prevalence, knowledge, and foot self-care practices among diabetic patients in Dar es Salaam, Tanzania - a cross-sectional study. J Foot Ankle Res. 2015; 8: 20.
16. Kidanie BB, Alem G, Zeleke H, Gedfew M, Edemealem A, AndualemA. Determinants of Diabetic Complication Among Adult Diabetic Patients in Debre Markos Referral Hospital, Northwest Ethiopia, 2018: Unmatched Case Control Study. Diabetes Metab Syndr Obes. 2020; 13: 237-245.
17. Tziomalos K, Athyros VG. Diabetic Nephropathy: New Risk Factors and Improvements in Diagnosis. Rev Diabet Stud. 2015; 12: 110-118.
18. Hao Z, Huang X, Qin Y, Li H, Tian F, Xu R, et al. Analysis of factors related to diabetic retinopathy in patients with newly diagnosed type 2 diabetes: a cross-sectional study. BMJ Open. 2020; 10: e032095.
19. Hintsa S, Dube L, Abay M, Angesom T, Workicho A. Determinants of diabetic nephropathy in Ayder Referral Hospital, Northern Ethiopia: A case-control study. PLoS One. 2017; 12: e0173566.
20. Abdissa D, Hamba N, Kene K, Bedane DA, Etana G, Muleta D, et al. Prevalence and Determinants of Peripheral Neuropathy among Type 2 Adult Diabetes Patients Attending Jimma University Medical Center, Southwest Ethiopia, 2019, an Institutional-Based Cross-Sectional Study. J Diabetes Res. 2020; 2020: 9562920.
21. Hamasaki H. Daily physical activity and type 2 diabetes: A review. World J Diabetes. 2016; 7: 243-251.
22. Tamiru S, Alemseged F. Risk Factors for Cardiovascular Diseases among Diabetic Patients In Southwest Ethiopia. Ethiop J Health Sci. 2010; 20: 121-128.
23. Haque F, Mitra P, Rahim M, Afroz F, Afroze S, Ahmed AKM, et al. Frequency and Risk Factors of Diabetic Complications among Selected Group of Diabetic Patients: Real-life Scenario from a Developing Country, Bangladesh. BIRDEM Med J. 2017; 7.
24. Maghbooli Z, Pasalar P, Keshtkar A, Farzadfar F, Larijani B. Predictive factors of diabetic complications: a possible link between family history of diabetes and diabetic retinopathy. J Diabetes Metab Disord. 2014; 13: 55.
25. Worku D, Hamza L, Woldemichael K. Patterns of diabetic complications at jimma university specialized hospital, southwest ethiopia. Ethiop J Health Sci. 2010; 20: 33-39.
26. Sheleme T, Mamo G, Melaku T, Sahilu T. Prevalence, Patterns and Predictors of Chronic Complications of Diabetes Mellitus at a Large Referral Hospital in Ethiopia: A Prospective Observational Study. Diabetes Metab Syndr Obes. 2020; 13: 4909-4918.
27. Bekele BB. The prevalence of macro and microvascular complications of DM among patients in Ethiopia 1990-2017: Systematic review. Diabetes Metab Syndr. 2019; 13: 672-677.
28. Koschack J, Marx G, Schnakenberg J, Kochen MM, Himmel W. Comparison of two self-rating instruments for medication adherence assessment in hypertension revealed insufficient psychometric properties. J Clin Epidemiol. 2010; 63: 299-306.
29. Emanuele NV, Swade TF, Emanuele MA. Consequences of alcohol use in diabetics. Alcohol Health Res World. 1998; 22: 211-219.
30. Arija V, Villalobos F, Pedret R, Vinuesa A, Timón M, Basora T, et al. Effectiveness of a physical activity program on cardiovascular disease risk in adult primary health-care users: the “Pas-a-Pas” community intervention trial. BMC Public Health. 2017; 17: 576.
31. Ding C, O’Neill D, Bell S, Stamatakis E, Britton A. Association of alcohol consumption with morbidity and mortality in patients with cardiovascular disease: original data and meta-analysis of 48,423 men and women. BMC Med. 2021; 19: 167.
32. Funakoshi M, Azami Y, Matsumoto H, Ikota A, Ito K, Okimoto H, et al. Socioeconomic status and type 2 diabetes complications among young adult patients in Japan. PLoS One. 2017; 12: e0176087.
33. Ramezankhani A, Azizi F, Hadaegh F. Associations of marital status with diabetes, hypertension, cardiovascular disease and all-cause mortality: A long term follow-up study. PLOS ONE. 2019; 14: e0215593.
34. Gebre BB, Assefa ZM. Magnitude and associated factors of diabetic complication among diabetic patients attending Gurage zone hospitals, South West Ethiopia. BMC Res Notes. 2019; 12: 780.