Differential Associations Between Pre-diabetes, Diabetes and Stroke Occurrence Among West Africans

Background: There are limited data from Africa on the burden and associations between pre-diabetes (pre-DM), diabetes mellitus (DM) and stroke occurrence in a region experiencing a profound rise in stroke burden.

Purpose: To characterize the associations between stroke and dysglycemic status among West Africans.

Methods: The Stroke Investigative Research and Educational Network (SIREN) is a multicenter, case-control study involving 15 sites in Ghana and Nigeria. Cases include adults aged ≥18 years with clinical and radiological evidence of an acute stroke. Controls were age-and-gender matched stroke-free adults. Detailed evaluations for vascular factors were performed. Pre-diabetes was defined as HBA1c of 5.7%-6.4% or Fasting blood glucose (FBG) 5.6-7.0 mmol/L and DM as HBA1c >6.5% or FBG>7.0 mmol/L. We used conditional logistic regression to estimate adjusted odds ratios (aOR) with 95% Confidence Interval.

Results: Among 2,935 stroke cases the mean age was 60.0 ± 14.2 years with 55.2% being males. By glycemic status, 931 (31.7%) were euglycemic, 633 (21.6%) had Pre-diabetes and 1371 (46.7%) had DM. Of the age- and sex-matched stroke-free controls 69.2% were euglycemic, 13.3% had pre-DM and 17.5% had DM. Pre-DM [aOR (95% CI): 3.68(2.61-5.21)] and DM [4.29 (3.19-5.74)] were independently associated with stroke. The aOR of Pre-DM for ischemic stroke 3.06 (2.01-4.64)] was lower than 4.82 (3.37-6.89) for DM. However, the aOR of Pre-DM for hemorrhagic stroke 6.81 (95% CI: 3.29 - 14.08)] was higher than 3.36 (1.94-5.86) for DM. Furthermore, the aOR of pre-DM for ischemic stroke subtypes were 9.64 (1.30-71.57) for cardio-embolic stroke, 3.64 (1.80-7.34) for small-vessel occlusive disease and 4.63 (0.80-26.65) for large-vessel disease.

Conclusion: Pre-DM is strongly and independently associated with stroke in Africans. Improving glycemic control through screening, healthy lifestyle and pharmacotherapy at a population level may be strategic in reducing the rising burden of stroke in Africa.

References

Sarfo F, Ovbiagele B, Gebregziabher M, Akpa O, Akpalu A, Wahab K . Unraveling the risk factors for spontaneous intracerebral hemorrhage among West Africans. Neurology. 2020; 94(10):e998-e1012. PMC: 7238923. DOI: 10.1212/WNL.0000000000009056. View

Sarfo F, Ovbiagele B, Gebregziabher M, Wahab K, Akinyemi R, Akpalu A . Stroke Among Young West Africans: Evidence From the SIREN (Stroke Investigative Research and Educational Network) Large Multisite Case-Control Study. Stroke. 2018; 49(5):1116-1122. PMC: 5916042. DOI: 10.1161/STROKEAHA.118.020783. View

Coccheri S . Approaches to prevention of cardiovascular complications and events in diabetes mellitus. Drugs. 2007; 67(7):997-1026. DOI: 10.2165/00003495-200767070-00005. View

Feigin V . Stroke epidemiology in the developing world. Lancet. 2005; 365(9478):2160-1. DOI: 10.1016/S0140-6736(05)66755-4. View

Ezejimofor M, Uthman O, Maduka O, Ezeabasili A, Onwuchekwa A, Ezejimofor B . Stroke survivors in Nigeria: A door-to-door prevalence survey from the Niger Delta region. J Neurol Sci. 2016; 372:262-269. DOI: 10.1016/j.jns.2016.11.059. View

Sarfo F, Akassi J, Kyem G, Adamu S, Awuah D, Kantanka O . Long-Term Outcomes of Stroke in a Ghanaian Outpatient Clinic. J Stroke Cerebrovasc Dis. 2017; 27(4):1090-1099. PMC: 5845472. DOI: 10.1016/j.jstrokecerebrovasdis.2017.11.017. View

Whiting D, Guariguata L, Weil C, Shaw J . IDF diabetes atlas: global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract. 2011; 94(3):311-21. DOI: 10.1016/j.diabres.2011.10.029. View

Adeoye A, Akintunde A, Akinyemi J, Fakunle A, Sarfo F, Akpalu A . Determinants of metabolic syndrome and its prognostic implications among stroke patients in Africa: Findings from the Stroke Investigative Research and Educational Network (SIREN) study. J Neurol Sci. 2022; 441:120360. DOI: 10.1016/j.jns.2022.120360. View

Pan X, Li G, Hu Y, Wang J, Yang W, An Z . Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care. 1997; 20(4):537-44. DOI: 10.2337/diacare.20.4.537. View

10.

Akpalu A, Sarfo F, Akinyemi J, Wahab K, Komolafe M, Obiako R . Frequency & factors associated with recurrent stroke in Ghana and Nigeria. J Neurol Sci. 2022; 439:120303. DOI: 10.1016/j.jns.2022.120303. View

11.

Akpalu A, Sarfo F, Ovbiagele B, Akinyemi R, Gebregziabher M, Obiako R . Phenotyping Stroke in Sub-Saharan Africa: Stroke Investigative Research and Education Network (SIREN) Phenomics Protocol. Neuroepidemiology. 2015; 45(2):73-82. PMC: 4604029. DOI: 10.1159/000437372. View

12.

. 2. Classification and Diagnosis of Diabetes. Diabetes Care. 2016; 40(Suppl 1):S11-S24. DOI: 10.2337/dc17-S005. View

13.

Fonville S, Zandbergen A, Koudstaal P, den Hertog H . Prediabetes in patients with stroke or transient ischemic attack: prevalence, risk and clinical management. Cerebrovasc Dis. 2014; 37(6):393-400. DOI: 10.1159/000360810. View

14.

. Guidelines on the management and prevention of prediabetes. Acta Med Indones. 2015; 46(4):348-59. View

15.

Sarfo F, Ovbiagele B . Prevalence and predictors of statin utilization among patient populations at high vascular risk in Ghana. J Neurol Sci. 2020; 414:116838. PMC: 7293931. DOI: 10.1016/j.jns.2020.116838. View

16.

Huang Y, Cai X, Mai W, Li M, Hu Y . Association between prediabetes and risk of cardiovascular disease and all cause mortality: systematic review and meta-analysis. BMJ. 2016; 355:i5953. PMC: 5121106. DOI: 10.1136/bmj.i5953. View

17.

Kernan W, Viscoli C, Inzucchi S, Brass L, Bravata D, Shulman G . Prevalence of abnormal glucose tolerance following a transient ischemic attack or ischemic stroke. Arch Intern Med. 2005; 165(2):227-33. DOI: 10.1001/archinte.165.2.227. View

18.

Nichols G, Hillier T, Brown J . Progression from newly acquired impaired fasting glusose to type 2 diabetes. Diabetes Care. 2007; 30(2):228-33. PMC: 1851903. DOI: 10.2337/dc06-1392. View

19.

Kim H, Kim C, Kim E, Bae S, Choe J, Park J . Impaired fasting glucose and risk of cardiovascular disease in Korean men and women: the Korean Heart Study. Diabetes Care. 2012; 36(2):328-35. PMC: 3554281. DOI: 10.2337/dc12-0587. View

20.

Owolabi M, Sarfo F, Akinyemi R, Gebregziabher M, Akpa O, Akpalu A . Dominant modifiable risk factors for stroke in Ghana and Nigeria (SIREN): a case-control study. Lancet Glob Health. 2018; 6(4):e436-e446. PMC: 5906101. DOI: 10.1016/S2214-109X(18)30002-0. View