Type 2 diabetes among Sudanese youth: Rate, pattern of prescription, comorbidities, and clinical inertia

Abstract

BACKGROUND

Type 2 diabetes among patients < 40 years is on the rise globally. These patients are prone to rapid β-cell loss, poor glycemic control, metabolic syndrome, and mortality. Few researchers have assessed young-onset type 2 diabetes, the pattern of prescription, and associated cardiovascular risks.

AIM

To assess this in the state of Khartoum, Sudan.

METHODS

This cross-sectional study was conducted among 240 type 2 diabetic patients attending two randomly selected Polyclinics in Omdurman, Sudan during July and August 2022. A structured questionnaire including age, gender, and duration of diabetes, prescribed medications, body mass index, and glycated hemoglobin (HbA1c) was used.

RESULTS

Out of 240 patients with type 2 diabetes 24.6% of all enrolled type 2 diabetes mellitus patients were young-onset cases (aged < 40 years), age, 55.24 ± 10.57, their body mass index (BMI) was 30.09 ± 4.65, the duration of diabetes was10.64 ± 8.23, and HbA1c was 9.37 ± 2.49, 68.3% were on metformin, 53.3% were on sulphonylureas, 49.2% were on insulin, and 10.8% were on pioglitazone. In addition, 50% of the participants were on lipid-lowering medications, and 56.7% on antihypertensive drugs. Interestingly, 57.9% were suffering from dyslipidemia, while only 50% received lipid-lowering medications. Age, HbA1c, and BMI were not significant predictors of diabetes in the young in this model.

CONCLUSION

One in four Sudanese patients were young with poor glycemic control polypharmacy was observed. Antidiabetic medication prescriptions were irrational with high sulphonylureas and pioglitazone, and no prescription of drugs with cardiorenal protection. Two diabetes patients should take the benefit of cardiorenal protective diabetes medications. Furthermore, larger multicenter studies investigating the barriers to good diabetes holistic care are recommended.

Key Words: Type 2 diabetes; Young-onset; Prescription; Cardiovascular risk; Sudan

Core Tip: Type 2 diabetes among Sudanese youth reflects a growing crisis in low-income and conflict-affected settings, where fragile health systems, limited access to medications, and disrupted care amplify poor outcomes. High rates of comorbidities and clinical inertia highlight gaps in early diagnosis and treatment intensification. Strengthening primary care, ensuring drug availability, integrating mobile health, and prioritizing youth-focused prevention are essential to curb disease progression and reduce long-term complications in these vulnerable populations.

INTRODUCTION

The prevalence, expenditure, and mortality of diabetes mellitus are high and rapidly growing across the world. Unfortunately, the data among young age groups are limited, therefore, giving an incomplete picture[1]. Being a vascular disease, type 2 diabetes could affect every organ through microvascular and macrovascular complications, although the prevalence is relatively static in the year 2022, compared to 2017. However, the absolute number has increased with serious consequences[2]. Early onset type 2 diabetes (type 2 diabetes that occurs in those < 40 years) is increasingly reported globally[3,4]. However, studies from Africa are scarce, a study conducted in Ghana reported a prevalence of 26.8%, another study from Uganda compared early onset type 2 diabetes in black Africans residents and their European counterparts and found lower body mass index, higher HbA1c, and a greater degree of beta-cell dysfunction[5]. Importantly, diabetes mellitus is more aggressive at young ages and usually presents with microvascular complications at diagnosis, because the β-cells deteriorate more rapidly, and young patients live longer with diabetes compared to their adult counterparts[6].

A real nightmare within this age group is the association of onset diabetes mellitus with a development of neurodegenerative disorders later in life. A case-control study published recently in the United States found low levels of glial fibrillary acidic protein, Aβ40, and Aβ42 with high pTau181 among young patients with type 1 and type 2 diabetes compared to normal control subjects[7]. Although, no cause and effect were concluded, however, the above trajectory is of great concern. The authors suggested a consideration of cognitive testing in young patients with diabetes.

Furthermore, young-onset diabetes mellitus is considered an adverse phenotype for the development of microvascular complications including aggressive retinopathy, renal involvement increasing the patients suffering, and macrovascular complications. In addition, premature death was common among this important community sector[8,9]. Because of that, diabetes mellitus when affecting this age group, considerably burdens the economy with deleterious consequences.

Due to economic development, low exercise, and unhealthy diets, diabetes mellitus in Africa increased to 19.4 million in 2019 and is projected to reach 28 million, and 41.5 million in the years 2030 and 2035 respectively[10,11]. In Sudan, diabetes mellitus prevalence jumped from 7.7% in 2013 to 19.1% in 2015, while the International Diabetes Federation estimate was 18.9% in the year 2021[12]. Obesity, lifestyle, and urbanization are to blame[13,14]. To the best of our knowledge, no researchers have specifically investigated early onset type 2 diabetes in Sudan. This is a significant knowledge gap, given the rising prevalence of diabetes in Sudan and the potential long-term health and economic consequences of disease onset at a young age. Therefore, a local evidence is highly needed for improving early detection strategies, guiding diabetes prevention programs, and informing healthcare planning and policy development. Because of the above, this study aimed to investigate type 2 diabetes mellitus (T2DM) among individuals younger than 40 years in Omdurman, Sudan.

MATERIALS AND METHODS

This cross-sectional study was conducted at Elnour and Almutakamel Polyclinics in Omdurman, Sudan. The two complexes were randomly chosen from the clinics that follow patients with chronic medical conditions including diabetes and high blood pressure. The patients were approached in a consecutive manner, and the participants were directly interviewed by the second author. The data was collected in July 2022 and August 2022. The participants were interviewed using a structured questionnaire including age, gender, duration of diabetes, prescribed medications, and glycated hemoglobin (HbA1c). The participant’s height and weight were measured to estimate the body mass index. All the patients signed a written informed consent before the interview. We also collected diabetes medications including metformin, sulphonylureas, pioglitazone, insulin, anti-hypertensive drugs, and lipid-lowering medications, in addition to other chronic diseases. The HbA1c was collected from the patient's records.

Inclusion criteria

Adult aged ≥ 18 years. The patients should be diagnosed with type 2 diabetes according to the American Diabetes Association (fasting blood glucose ≥ 126 mg/dL, postprandial blood glucose ≥ 200 mg/dL, random blood glucose ≥ 200 mg/dL with classical hyperglycemia symptoms, and HbA1c ≥ 6.5). We included all adults with type 2 diabetes to calculate the rate of early onset type 2 diabetes and compare early onset with late onset.

Exclusion criteria

Patients < 18 years, patients with type 1 diabetes, and women with gestational diabetes were excluded from the study. Although, we excluded type 1 diabetes, there is a possibility of including those with monogenic diabetes including maturity-onset diabetes of the young due to the unavailability of genetic testing in our setting.

Sample size calculation

The sample size was calculated using the formula: N = Z² × p (1-p)/d² where n = the required sample size, p = prevalence of diabetes in Sudan according to International Diabetes Federation[15]. Z = standard normal value corresponding to a 95% confidence level (1.96), and d = margin of error (5%, 0.05). Therefore, the sample size was 240 participants.

Ethical consideration

The ethical committee of Elnour Polyclinic ethical committee approved the research (Ref. No. R. 2022. 2, dated, July 19, 2022). The study was conducted between July and August 2022 in accordance with the principles of the Declaration of Helsinki. All participants provided written informed consent before enrollment. Participant confidentiality and privacy were maintained throughout the study. Data collection was performed by trained investigators, including the second author, who conducted all interviews and anthropometric measurements using standardized procedures.

Statistical analysis

The data were entered in to an excel sheet, then transferred to the SPSS. The Statistical Package for Social Sciences (SPSS, IBM Version 20, NY, United States) was used for data analysis. The of the currents study were presented as percentages. Binary Logistic regression Analysis was used to assess the association between age, gender, HbA1c, and body mass index. A P value of < 0.5 was considered significant.

RESULTS

Basic characteristics of the study group

In the present study, the age group of the patients ranged from 22-82 years (mean ± SD, 55.24 ± 10.57), their body mass index was 30.09 ± 4.65 (range 18-45), and the duration of diabetes was10.64 ± 8.23, the HbA1c range was from 5.9 to 15.6 with a mean of 9.37 ± 2.49 (Table 1).

Table 1 Basic characteristics of the study group.

Character	Range	mean ± SD
Age	22-82	55.24 ± 10.57
Body mass index	18.0-45	30.09 ± 4.65
Duration of diabetes	1-40	10.64 ± 8.23
HbA1c	5.9-15.6	9.37 ± 2.49

HbA1c: Glycated hemoglobin.

Basic characteristics of the patients with early onset type 2 diabetes

Among the study population, 59 participants (24.6%) were classified as having young-onset type 2 diabetes mellitus (< 40 years of age). Their age ranged from 30-39 years (mean ± SD, 36.5 ± 2.9), their body mass index was 31.0 ± 2.4 (range 25-35), and the duration of diabetes was 5.8 ± 3.7, the HbA1c range was from 7 to 12 with a mean of 9.6 ± 1.1 (Table 2).

Table 2 Basic characteristics of patients with type 2 diabetes < 40 years.

Character	Range	mean ± SD
Age	30-39	36.5 ± 2.9
Body mass index	25-35	31.0 ± 2.4
Duration of diabetes	1-15	5.8 ± 3.7
HbA1c	7-12	9.6 ± 1.1

HbA1c: Glycated hemoglobin.

Medications use

Regarding diabetes treatment, more than two-thirds (68.3%) were on metformin, 53.3% were on sulphonylureas, 49.2% were on insulin, and 10.8% were on pioglitazone.

Comorbidities

In addition, 50% of the participants were on lipid-lowering medications, and 56.7% on antihypertensive drugs. The above findings imply that most of the patients were on polypharmacy. Interestingly, 57.9% were suffering from dyslipidemia, while only 50% received lipid-lowering medications (Table 3).

Table 3 Medications and comorbidities among patients with diabetes.

Character	n (%)
Metformin	164 (68.3)
Sulphonylureas	128 (53.3)
Pioglitazone	26 (10.8)
Insulin	118 (49.2)
Anti-hypertensive drugs	136 (56.7)
Lipid-lowering	120 (50)
Sex, females	154 (64.2) 87.5% in the young
Young age	59 (24.6)
Dyslipidemia	139 (57.9)

Logistic regression analysis

The Binary Logistic Regression Analysis was conducted to examine the association of age, the HbA1c, gender, and body mass index (BMI) in diabetes of the young. Age showed a negative but non-significant association with diabetes in the young (B = -0.057, SE = 0.039, Wald = 2.129, P = 0.145), with an odds ratio (OR) of 0.945 (95%CI: 0.875-1.020), suggesting a small decrease in odds with increasing age, though not statistically reliable. HbA1c was also not significantly associated with the outcome (B = -0.036, SE = 0.033, Wald = 1.200, P = 0.273; OR = 0.964, 95%CI: 0.903-1.029). BMI demonstrated a positive but non-significant relationship (B = 0.064, SE = 0.054, Wald = 1.416, P = 0.234), with an OR of 1.067 (95%CI: 0.959-1.186), indicating slightly higher odds with increasing BMI. Overall, age, HbA1c, and BMI were not significant predictors of diabetes in the young in this model (Table 4).

Table 4 The association between gender, age, body mass index, and glycated hemoglobin.

Character	B	S.E.	Wald	df	Sig.	Exp (B)	95%CI for EXP(B)
Age	-0.057	0.039	2.129	1	0.145	0.945	0.875 to 1.020
HbA1c	-0.036	0.033	1.200	1	0.273	0.964	0.903 to 1.029
BMI	0.064	0.054	1.416	1	0.234	1.067	0.959 to 1.186
Constant	1.948	2.437	0.639	1	0.424	7.017

Binary Logistic Regression Analysis. HbA1c: Glycated hemoglobin; BMI: Body mass index.

DISCUSSION

Type 2 diabetes among those < 40 years of age is rapidly rising mirroring the increasing obesity among this age group. It behaves aggressively with rapid β dysfunction. Patients who suffer type 2 diabetes at younger ages are usually non-adherent to diabetes management including lifestyle changes and diabetes medications. In addition, young-onset type 2 diabetes patients are more prone to macrovascular and microvascular complications and mortality compared to their older counterparts due to a longer period of poor glycemic control[4,16]. In the present study, 24.6% of Sudanese patients in the city of Khartoum were suffering from young-onset type 2 diabetes mellitus. The current findings were higher than the International Diabetes Federation report, in which 16% of patients with type 2 diabetes were aged 20-39 years[15]. The contradicting results could be explained by ethnicity, geographical location, and study quality because Black Africans including the Sudan, Western Pacific, and East Asians showed higher rates of type 2 diabetes compared to other parts of the world[17]. Importantly, young-onset type 2 diabetes is associated with high body mass index, severe insulin resistance, and other metabolic disorders. A recent study published in China[18] that included 1000 participants found that patients with early-onset type 2 diabetes are more prone to metabolic syndrome. The authors observed a non-linear relationship between early-onset type 2 diabetes and triglyceride-BMI (TG-BMI) with a sleeper increase in the restricted cubic spline curves with higher TG-BMI. Our results supported the above findings because the patients suffered from obesity, and more than half of our sample were on lipid-lowering drugs or antihypertensive medications. Al-Saeed et al[19] found higher rates of microvascular complications and mortality among young-onset type 2 diabetic patients. The investigators found the same rate of metabolic syndrome among adolescent type 2 diabetic patients compared to older patients, which was not in line with the current findings. A plausible explanation could be that Al-Saeed et al’s cut-off value was 19-30 years and not < 40 years[19].

The proportion of young-onset T2DM observed in our study differs from reports from China, the United States, and Ghana. Several factors should be should be considered when comparing prevalence estimates across countries. Ethnicity, genetic susceptibility, geographical variation, lifestyles, and healthcare systems. Sedentary lifestyles, unhealthy diet, and increasing body mass index have contributed significantly to the rising burden of diabetes across many African countries, including Sudan. On the other hand, screening programs and greater access to preventive healthcare services could significantly influence disease detection and management patterns in countries with more developed healthcare systems. An important issue is the differences in study design, diagnostic criteria, and population characteristics.

An interesting finding in our data is that although 57.9% of the current sample had dyslipidemia, only 50% were on lipid-lowering drugs leaving a considerable percentage of patients with untreated dyslipidemia. The undertreatmen could be explained by the cost of medications, clinical inertia, lack of accessibility to drugs, and physician non-adherence to cardiovascular risk management guidelines. A comprehensive cardiovascular prevention in patients with diabetes is highly needed. Similarly, Al-Saeed et al[19] observed a lower rate of prescription for dyslipidemia. Non-adherence due to young age, cost, and fear of side effects might explain the findings[20]. In addition, some physicians might be hesitant to prescribe statins to younger age groups opting to advise on lifestyle instead. Although lifestyle, in particular a plant-based diet, and avoidance of unhealthy diets are a cornerstone in dyslipidemia treatment, additional lipid-lowering therapy is vital to reach the recommended low-density lipoproteins target[21,22].

The high uptake of insulin observed in the current survey (49.2%) could be explained by the due to misidentification of the types of diabetes, long disease duration, and delayed diagnosis. Similarly, previous studies found high insulin prescriptions[19,23]. The polypharmacy observed among this sample is explainable due to the high comorbidities found (hypertension and dyslipidemia), however, polypharmacy is a risk factor for non-compliance and poor glycemic control initiating a vicious cycle[24]. A high prevalence of polypharmacy was observed in our previous work among patients with type 2 diabetes with poor glycemic control and diabetes distress in Sudan[25]. The high HbA1c observed in this study, despite the polypharmacy, might be due to the medication inertia (drug intensification delay). High clinical inertia was observed worldwide with a negative impact on glycemic control[26]. Clinical inertia could be at all levels (the patients, the healthcare system, and the treating physician). The matter is extremely serious when clinical inertia is combined with living a longer duration with type 2 diabetes, which is the case of type 2 diabetes within a young age group[27].

The high prescription of metformin is good; however, the high uptake of sulphonylureas, and pioglitazone among obese patients with comorbidities is irrational. Because sulphonylureas are known to increase weight, pioglitazone could induce maculopathy among this sample with a high risk for microvascular complications[28]. The absence of sodium-glucose cotransporter’s inhibitors-2 and glucagon-like peptide-1 agonists from the prescription list among can be explained by cost, lack of insurance coverage, drug availability may also contribute, as SGLT2 inhibitors and GLP-1 receptor agonists are not consistently available in many Sudanese healthcare facilities[29]. Physicians might be more aware about the old drug prescription, and may be unaware about contemporary diabetes management guidelines. A multi factorial program implementation is highly needed, expanding the access to evidence-based therapies and increasing insurance coverage. Continuing medical education programs focusing on contemporary diabetes guidelines and cardiorenal risk reduction are highly needed. Providing essential diabetes drugs by policymakers could help reduce clinical inertia and optimize patient outcomes.

Sudan is a large, low-income country with a lack of a well-formed healthcare infrastructure, a lack of diabetes holistic care[30,31], significant instability in terms of people’s motion, and a shortage of medical personnel. Our data calls for proper distribution of the scarcely available resources to improve diabetes care, foster compliance with medications, and prevent diabetes complications among young patients with type 2 diabetes. The appropriate use of available resources, including the involvement of clinical pharmacists in diabetes care, is essential for proper treatment[32].

We found no association with age, gender, HbA1c, and BMI in the current study, our findings were different from a study conducted in the United States and found more prevalence in females[33]. A study conducted in Ghana[34] found a higher body mass index in early onset type 2 diabetes in contradiction to the current findings. Plausible explanations could be the differences in lifestyle factors, race, and income[35,36].

The strength of this study is that it is the first to assess type 2 diabetes among patients < 40 years and give an example of high prevalence compared to type 2 diabetes in the general population (24.6% vs 18.9%). We also reported the pattern of prescription and comorbidities. The reliance on questionnaires and patient records, as well as conducting the study at two private clinics limited the current results.

Study limitations

The study was limited by the reliance on self-administered questionnaire which is more prone to subjectivity, and the fact that the study was conducted at two randomly selected centers with sampling bias, patients attending these facilities may differ from those receiving care in public hospitals or rural healthcare settings, introducing potential selection bias. In addition, the limited representativeness of subjects recruited from private clinics in which healthcare access, socioeconomic status, and treatment patterns may not reflect those of the general population. Furthermore, the lack of long-term follow-up data prevented the assessment of medication adherence and long-term complications. Due to cross-sectional nature of the study, it is difficult to conclude a cause and effect. Therefore, the results of this study cannot be generalized to include the whole Sudan. The possibility of including monogenic diabetes is unavoidable due to the lack of genetic testing.

CONCLUSION

The current study provides the first available evidence on young-onset type 2 diabetes mellitus in Sudan, one in four of patients with type 2 diabetes developed diabetes before the age of 40 years. The association with prolonged disease exposure could significantly increased risk of long-term complications presenting a major healthcare concerns. There are major treatment challenges including poor glycemic control and a predominant reliance on conventional glucose-lowering therapies, with limited use of novel drugs with cardiac and renal benefits. These patterns may reflect economic barriers, restricted drug availability, and clinical inertia.

Strengthening diabetes prevention programs, early screening, improving access to evidence-based therapies, and enhancing physician education may contribute to better diabetes outcomes. The current study provides valuable local data that can support diabetes management strategies and inform future preventive and treatment strategies in Sudan. Larger multi center prospective studies are needed to further characterize young-onset T2DM and its long-term consequences in the Sudanese population.

ACKNOWLEDGEMENTS

We would like to acknowledge Mohannad Osman from Prince Fahd Bin Sultan University for revising the tables of this manuscript.