Statistical Evaluation of Environmental Factors as Diabetogenic Agent in Type 2 Diabetes Mellitus

Saima Shokat1, Aasma Riaz2, Riffat Iqbal1, Atif Yaqub 1, Samreen Riaz 3

1Department of Zoology Government Collage University, Lahore

2College of Statistical and Actuarial Sciences University of the Punjab, Lahore

3Institute of Microbiology & Molecular Genetics University of the Punjab, Lahore

Corresponding author: *1 saimashokatgcu@gmail.com +923217523784

Citation | Shokat. S, Riaz. A, Iqbal. R, Yaqub. A, Riaz. S, “Statistical Evaluation of Environmental Factors as Diabetogenic Agent in Type 2 Diabetes Mellitus”. International Journal of Innovations in Science and Technology. Vol 4, Issue 1, 2022. Pp: 288-298.

Received | March 10, 2022; Revised | March 20, 2022 Accepted | April 01, 2022; Published | April 03, 2022.

The purpose of this study was to analyze the environmental factors affecting individuals with diabetes. A study was conducted among diabetes patients at the Lahore General Hospital's outdoor clinic. Data was collected using a standardized questionnaire after getting approval of patients being interviewed. SPSS 25.0 was utilized for analysis. Total 1000 people were chosen, 500 of whom were diabetic patients and the rest were non-diabetic. Environmental factors were investigated in a 1000-person research of diabetics and non-diabetics. To determine the relationship between patients with diabetes and environmental factors, the Chi-Square test and Mann-Whitney test were used to compare the effects of age, BMI, and sugar level fasting. The findings reveal that environmental factors play crucial effects on patients in term of age, BMI, and sugar level. I also used the odds ratio on diabetic and non-diabetic patients who have the Stroke, TIA, hypertension, and other environmental factors. The study revealed that diabetes is more persistent in industrial and urban region as 60% of the population living in these areas are under risk of diabetes. Moreover, the results showed that nearly 62% tap water consumers in rural areas were diabetic while 38% filtered water consumers in urban areas were diabetic. Smoking caused diabetes in nearly 22% people, 28% people suffered due to utilization of homeopathic medicines while 35% diabetic patients were found multivitamin consumers. Furthermore, the study depicted that among 1000 individuals under study, 56 % females were diabetic due to environmental factors. Diabetes has a direct relationship with the environment experienced by a patient.

Keywords: Diabetes; Environmental factors; Pakistan; Demographic variables; statistics.

ACKNOWLEDGEMENT:

 I am thankful to

·         Institute of Microbiology and Molecular Genetics,

·         University of the Punjab, Lahore,

 

·         Department of Zoology, Government College University, Lahore,

·         College of Statistical and Actuarial Sciences University of the Punjab, Lahore,

 

 

CONFLICT OF INTEREST:

The author(s) declare that the publication of this article has no conflict of interest.

Project details.                     NA

 

 INTRODUCTION.

Diabetes is a set of diseases marked by imbalance of insulin hormone. The pancreas (an organ beneath the stomach) normally releases insulin to help with the storage and utilization of sugars and fat from the diet. Diabetes develops when the pancreas fails to produce sufficient insulin, or the body fails to respond to insulin effectively [1]. The historic evidence of diabetes can be obtained from 1500 BC in Egyptian literature [2]. Elevated blood sugar is characterized by frequent urination, weight loss, increased hunger and increased thirst [3]. Acute consequences include hyperosmolar hyperglycemia diabetic ketoacidosis, and death. Long-term complications are caused by stroke, cardiovascular disease, chronic kidney illness, vision impairment and foot ulcers [4]. Type 1 diabetes is caused by insulin deficiency [5] while Type 2 diabetes is caused by a gradual decrease in insulin production [6]. Gestational diabetes is diagnosed in the second or third trimester of pregnancy [7]. Diabetes caused by other factors, such as syndromes e.g., neonatal diabetes and (MODY) i.e., maturity onset diabetes of the young, monogenic diabetes, pancreatitis, cystic fibrosis (exocrine pancreas disorders), drug induced diabetes or chemical is caused as a consequence of organ transplantation, or glucocorticoid use or AIDS /HIV treatment[8-10].

The prevalence of "stroke" is rising as a result of "macro vascular problems" while the ratio of coronary heart disease as compared to peripheral vascular disease is also rising.” Coronary diseases include thickening of the artery wall and cell translocation to the site of injury occur [11]. Micro vascular causes include nephropathy (kidney illness), neuropathy (nerve damage), and retinopathy (eye disease) [12]. Diabetic Neuropathy is a type of neuropathy caused by diabetes. Nerve damage affects about 60% of diabetic individuals, and it is a long-term condition linked to diabetes, Moreover Lethargy, numbness and discomfort are disorders can lead to leg cutting [13]. In Diabetic Nephropathy (DN) kidneys are affected by increased sugar level. In diabetic common foot disease, the feet are affected by the fungus infection and at the advance level, cutting of foot can happen [14].

Type 2 diabetes is a complex illness caused by a mix of hereditary and environmental risk factors.  The etiopathogenesis of diabetes is influenced by environmental variables. Polluted air, soil, and water, as well as a bad diet, stress, lack of physical activity, stress, vitamin D insufficiency, enterovirus exposure, and immune cell destruction are all environmental factors leading to Type 2 diabetes [15], [16], it has close association with environmental factors. Dioxin, bisphenol A, herbicides, pesticides and the exposure with the industrial chemicals are the main environmental pollutants [17]. The interplay of environmental, psychosocial and biological factors is thought to be the cause of T2DM [18], [19]. Consequences of air pollution has been linked to altered endothelial function, inflammatory responses, and insulin resistance, as well as an increase in blood pressure[20], [21]. Although arsenic is one of the top 10 environmental toxins, there is conflicting evidence about its influence on type 2 diabetic mellitus and other human health effects. In Teharan, arsenic levels in the urine of newly diagnosed type 2 diabetes people are higher, and this is linked to smoking [22]. In Korean young adults, duration and amount of smoking has close association with the incidence of type 2 diabetes [23]. In the urban areas, people have high prevalence of type 2 diabetes as compared to rural areas and the male population is most affected [24]. Organochlorine pesticides is the risk factor for the type 2 diabetes mellitus [25]. Inorganic arsenic is associated in the prevalence of type 2 diabetes [18].

Environmental factors are the additional risk factors other than genetics and life style in development of diabetes moreover, the prevalence of insulin resistance affects the diabetes [26], [27].  The link between quality of life and psychiatric symptoms in diabetic patients with other chronic physical conditions and socio demographic factors was observed [28]. Endocrine disrupters for example arsenic, Zinc and cadmium interfere in glucose metabolism and act as diabetogenic agent. These endocrine disrupters harm the insulin sensitivity and beta cell function[29]–[38]. Rehman et al., 2021 explained the mechanism that is involved in association of arsenic with diabetes by dysfunction of pancreatic β-cell, disturbed insulin secretion and resistance [39]. While, Inorganic arsenic causes toxicity through polluted water and food consumption. Chronic arsenic exposure causes health effects so, it is very important to know about the metabolism of inorganic arsenic [40]. Researchers found that the insulin resistance of non-diabetic adults may associate the arsenic metabolism with rice consumption [41]. Heavy metals enter the human bodies and disrupt the metabolism of body and are evident of type 2 diabetes in developing countries. Heavy metals as pollutants have drastic health effects on human, woman and children health. It causes toxicity through food, air and drinking water. Demographic factors such as age, obesity, drinking water and life style effects the progression of type 2 diabetes [41]–[49]. The main objective of the study was to identify effect of the environmental factors on patients with type 2 diabetes.

METHODOLOGY.

Investigation site. Diabetic and Endocrine Metabolic Centre. Lahore General Hospital located at G, 152, 1 Canal Rd, Block G 1 Phase 1 Johar Town, Lahore, Punjab 54590

Population size. It was a cross-sectional study and convenient based sampling. The sample size of 1000 people was analyzed for type 2 diabetic and non-diabetic patients of general hospital Lahore, within a time duration of two months for this study i.e., 02-02-2021- 02-04-2021. The data was collected by face-to-face interview along with questionnaires.

Statistical Analysis.  In order to find risk, Bivariate Analysis was applied. Reliability was tested by using Mann-Whitney test. The significance of association between each response and predictor, each variable was tested. Cronbach’s alpha was applied to measure internal consistency, which shows relationship between the set of items in a group. Cronbach’s alpha is a reliability scale which can be written as a function of the number of test items and the average inter-correlation among the items.

Conclusion was based on p-value. If p-value is less than α, then we reject the null hypothesis and conclude that there is significant difference between groups. (Daniel in “Applied Nonparametric Statistics”, 1978)

The association between an exposure and an outcome odds ratio was measured. Odd ratios were used to compare the relative odds of the occurrence of the outcome of interest (e.g., diabetes), given exposure to the variable of interest (e.g., environmental factors). The odds ratio can also be used to determine whether a particular exposure is a risk factor for a particular outcome, and to compare the magnitude of various risk factors for that outcome.

  • OR=1 Exposure does not affect odds of outcome
  • OR>1 Exposure associated with higher odds of outcome

RESULTS AND DISCUSSION.

This study consists of 1000 subjects in which both male and female were included. There were 500 diabetics and 500 non diabetic patients, different factors demographic (age, gender), environmental (smoking, residence area, regularity of medicine, multivitamins consumptions, eating fish, kind of water, kind of medicine and obesity/ BMI), biochemical (sugar fasting level) were determined and it was observed that complications have some association with these factors, significantly Diabetes Mellitus type 2 has association with environmental factors.

Descriptive analysis

             The frequency and %ages of several demographic factors, environmental factor, biochemical factors and risk factors were examined in this section. There were 1000 individuals in this study. The results were debated based on frequency and %ages.

Demographic Factors

Table 1. Gender %age in overall population

Diabetic

%age

Gender

%age

DIABETIC NORMAL

50.00%

50.00%

Male

44.00%

Female

56.00%

The %age of the gender in 1000 respondents (diabetic 500 & non-diabetic 5000) which is 56% females and 44% males.

Table 2. %age of different age group

Variables

Classification

Diabetes

Total

Male

Female

Count

%age

Count

%age

Count

%age

Age

18-35

10

40

15

60

25

5.0

36-55

40

30.7

90

69.3

130

26.0

56-80

160

47.1

180

52.9

340

68.0

Above 80

5

 

  

 

5

1.0

 Environmental factors

Table 3. Environmental Factors in type 2 diabetes (males and female)

 

%age of Environmental Factors determined into diabetic
 

 

Smoking

Residence near industrial area

Regularity Of Insulin In Patient

Multivitamines

Utilization of Homeopathic Medicine

Fish consumption

Diabetic

Yes

22.00%

67.00%

59.00%

35.00%

28.00%

88.00%

NO

78.00%

33.00%

41.00%

65.00%

72.00%

12.00%

Non-Diabetic

Yes

20.00%

60.00%

0.00%

26.00%

80.00%

78.00%

NO

80.00%

40.00%

0.00%

74.00%

20.00%

22.00%

Percentage of smoking, residence, Insulin regularity, multi vitamins consumption, taking Homeopathic medicine and fish consumption in 1000 respondents.

Figure 1. The effect different environmental factors on diabetic and non-diabetic

Figure 1 is showing the effect of various environmental factors and its comparison between diabetic and non-diabetic. High percentage of these environmental factors provide a correlation between environmental factors and increased number in type 2 diabetes.

Table 4. Environmental Factors in Diabetic Males and females

Residency

water consumption

Medications

Rural

33.00%

Tap

62.00%

Takes insulin

15.00%

Urban

67.00%

Filter

38.00%

Takes pills

75.00%

Various environmental factors were determined and their %age was recorded in table.

Table 5.  BMI/Obesity of 1000 subjects (Males & Females)

Variables

Classification

Diabetes

Total

Male

Female

Count

%age

Count

%age

Count

%age

BMI/ Obesity

15-20

120

60

40

40

200

20.0

20-25

140

28

360

72

500

50.0

25-30

110

55

90

45

200

20.0

Above 30

60

60

40

40

100

10.0

BMI/Obesity of 1000 subjects ((Males & Females) categorized in different age groups and recorded.

Biochemical factors

Table 6. Biochemical factor Sugar Fasting Level in male & Female.

Variables

Classification

Diabetes

Total

Male

Female

Count

%age

Count

%age

Count

%age

Sugar fasting level

65-100

200

57.1

150

42.8

350

35.0

101-150

150

33.3

300

66.7

450

45.0

150-200

60

35.2

110

64.7

170

17.0

Above 200

20

66.6

10

33.3

30

3.0

1000 respondents divided into different age groups and Sugar Fasting Level is determined and recorded.

Risk Factors

Table 7. Duration of diabetes

Duration

Non-Diabetic

50%

Less than 1 Year

13.00%

1 to 5 Years

17.00%

5 to 10 Years

7.00%

Greater than10 Years

9.00%

% age of duration of diabetes 50% are normal and other 50% are divided into different age groups.

Table 8. Risk factors due to Diabetes

 

Stroke

TIA

PeripShral Vascular Disease

Hepatitis/Corona Virus/Cancer

Other Major Surgeries Operations Etc

Retinopathy

Hypertention

I.H.D Angina

Myocardial Infection

Congestive Cardiac Failure

Cardiomyopathy

Neuropathy

Numbness/ Tingling In your Feet

Stomach Problem

Diabetic

Yes

25.0%

27.0%

48.0%

0.00%

87.0%

36.00%

41.0%

69.0%

30.0%

35.0%

29.0%

32.0%

34.0%

23.0%

NO

75.0%

73.0%

52.0%

100%

13.0%

64.00%

59.0%

31.0%

70.0%

65.0%

71.0%

68.0%

65.0%

77.0%

Non-Diabetic

Yes

20.56%

20.00%

15.95%

12.00%

25.5%

40.00%

13.0%

50.0%

16.00%

13.90%

86.96%

21.00%

25.07%

40.00%

NO

79.44%

80.00%

84.05%

88.00%

74.43%

60.00%

86.96%

50.00%

84.00%

86.10%

13.04%

79.00%

75.03%

60.00%
                                 

Various Risk Factors are more vulnerable in diabetic patients as compare to non-diabetic.

Figure 2. Comparison of different risk factors in diabetic and non-diabetic.

It shows that different levels of complication of various risk factors which are high in diabetic as compared to non-diabetic Diabetic

Analytical analysis

We analyzed the risk variable of diabetic and non-diabetic by using Bivariate Analysis

Bivariate Analysis.

 In this section association of variables was observed. Hence the significance of association between each predictor and response variable was tested by Pearson chi-square. When value of p was smaller than 0.05, then factors were significant (there is association), if p-value is greater than 0.05, then factors were insignificant (there was no association). Results of bivariate analysis for demographic variables, risk variables are presented in the tables given below:

Cronbach's alpha:

Table 9. The Cronbach’s Alpha 0.705>0.5 indicates that our questionnaire is reliable for the data collection.

Reliability Statistics

Cronbach's Alpha

No of Items

.705

30

 In this section the dependent variable was diabetic and non-diabetic. And different demographic variable were independent variables.

Chi-square test

Table 10.  Association of diabetic or non-diabetic with environmental factors.

No.

Alternative Hypothesis

χ2

P-value
 

There is association between diabetic and non-diabetic and BMI

15.862

0.001
 

There is association between diabetic or non-diabetic and fact of sugar fasting level.

94.24

0.000
 

There is association between diabetic or non-diabetic and type of water used.

10.336

0.001
 

There is association between diabetic or non-diabetic and residence (urban or rural).

9.881

0.003
 

There is association between diabetic or non-diabetic and smoker.

21.906

0.000
 

There is association between diabetic or non-diabetic and residence in industrial area.

6.220

0.013
 

There is no association between diabetic or non-diabetic and stomach problem.

1.019

0.313
 

There is no association between diabetic or non-diabetic and insulin.

117.898

0.000
 

There is association between diabetic or non-diabetic and multi vitamins.

19.525

0.000
 

There is association between diabetic or non-diabetic and homeopathic medicine.

30.951

0.000
 

There is association between diabetic or non-diabetic and eat fish.

10.001

0.004
 

There is association between diabetic or non-diabetic and numbness.

9.929­­

0.003
 

There is association between diabetic or non-diabetic and skin allergy.

75.661

0.000

 Stomach problem have value above than 0.05 so, it has no association with diabetes while all other environmental factors have significant association with DM2.

In this section to check the normality of diabetic or non-diabetic score we use one sample Kolmogorov Simonov test

Table 11. To check the normality of diabetes score

No

Alternative Hypothesis

Kolmogorov Simonov test

p-value
 

Diabetic or non-diabetic are non- normally distributed.

0.361

.000

The diabetic and non-diabetic were non-normal because their p-value was less than 0.05. So, to check the non-normal diabetic or non-diabetic effects on age, BMI and sugar fasting level. Use the Mann-Whitney U test. 

Mann-Whitney u test:

In this section check the diabetic or non-diabetic effects on age, BMI and sugar fasting.

Table 12. Diabetic or Non-diabetic effects on age, BMI and sugar fasting.

No

Alternative hypothesis

Mann-Whitney U

p-value
 

Diabetic and non-diabetic persons have same effect on different age group

893.500

0.003
 

The BMI level of diabetic and non-diabetic patients are same

712.000

0.000
 

The sugar fasting level of diabetic and non-diabetic patients are same.

187.000

0.000

The above table shows that the diabetic or non-diabetic affects people of all age groups, BMI and sugar fasting level

Table 13. Testing of gender with risk factor

                        Rick factor

 Odd ratios (diabetic or non-diabetic)

95% Confidence interval

Lower

Upper

Gender

2.98

.870

3.980

Patient in family

1.080

.511

2.282

Numbness

1.401

0.705

2.784

Stroke

0.151

0.053

0.428

Hypertension

17.955

7.756

41.565

Skin allergy

90.114

20.327

399.483

 Odd ratio of diabetics or non-diabetic with respect to different risk factors

From the above odds ratio results, we can conclude that gender and stroke have low odds of occurrence of diabetes (as OR<1) whereas history of disease in family has almost no effect on the odds of occurrence of diabetes (as OR≈1). Meanwhile the odds of occurrence of diabetes because of Numbness, Hypertension and Skin allergy are higher (as OR>1) where skin allergy has the greatest odds with the value of OR being 141.923

The main goal of this study was to investigate diabetes-related environmental variables. A study was conducted in the city of Lahore to accomplish this goal, with data acquired from the General Hospital. The study's duration was set, and a convenient sampling procedure was applied. The information is gathered through a questionnaire. According to descriptive analysis the family history, residence in urban areas, obesity, smoking, living near industrial area play vital role in type 2 diabetes progressions. People were also affected with skin allergies. The association of type 2 diabetes and risk factors are investigated in Lahore district [50]. It is studied that the smoking is a key contributor in the development of type 2 diabetes [51]. According to this study, out of 1000 individual’s 56 % are females. The previous data correlated our findings that diabetes is more prevalent in urban areas and industrial areas so that environmental factors may play a role as diabetogenic agents [25], [52], [53]. According to previous study, arsenic is a diabetogenic agent which causes the skin allergy [54]–[56] and in our data 60 % people facing this problem because of consumption of polluted water. Out of 1000, 62 % people were tap water consumers. Statistical evaluation helps in proper analysis of data and know about its significance and to judge predictions.

CONCLUSION.

            The findings of this practical based sampling produced information on the environmental variables of a general hospital-based study in Lahore, Pakistan, because the diabetes is most prevalent disease in Lahore. In this hospital mostly patients belong to middle class families which are mostly tap water consumers and are exposed to the environmental factors.  Females were found to be more numerous than males. It's possible that the presence of more females than males is attributable to the population (Hospital) from whom the data was collected, resulting in a larger female-to-male ratio. In the overall analysis, the risk factors of kind of exercise, kidney problems, range of tests, and industry type are all highly associated with Type 2 Diabetes. The data was collected from respondents who lived near industrial areas, consuming polluted water and belong to low socioeconomic status, they were at more threat to type 2 diabetes. Environmental and risk factors have significant association with type 2 patients.

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