Epidemiological and Clinical Characteristics of Diabetic Ketoacidosis Among Diabetic Patients in Mogadishu, Somalia.

doi:10.21203/rs.3.rs-8038111/v1

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Epidemiological and Clinical Characteristics of Diabetic Ketoacidosis Among Diabetic Patients in Mogadishu, Somalia.

https://doi.org/10.21203/rs.3.rs-8038111/v1

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Background

Diabetic ketoacidosis (DKA) is a severe complication primarily affecting type 1 diabetes patients, though it can also occur in type 2 diabetes. In Somalia, decades of conflict have weakened the healthcare system, limiting access to regular diabetes care and education, which heightens the risk of DKA. This study explores the epidemiological and clinical characteristics of DKA in diabetic patients at hospitals in Mogadishu, Somalia, to identify patterns, risk factors, and outcomes.

Methods

A cross-sectional study was conducted at Aden Cade, Kalkal, and Martini hospitals involving 140 diabetic patients with DKA. Data were gathered through structured questionnaires and clinical records, and statistical analysis was done using SPSS to assess sociodemographic determinants, clinical presentations, and risk factors for DKA.

Result

The majority of patients were under 18 years old, with 75% having type 1 diabetes. Common symptoms included excessive thirst (92.9%), frequent urination (97.1%), and abdominal pain (95.7%). All patients received insulin therapy, and most were also treated with antibiotics. Half of the patients experienced recurrent DKA episodes after discharge, indicating a need for improved diabetes management and follow-up care

Conclusion

remains a significant public health issue in Mogadishu due to limited healthcare access, insufficient patient education, and poor insulin to treatment. Addressing these challenges through better healthcare infrastructure, patient education, and management protocols could reduce DKA occurrences in Somalia.

Internal Medicine

Diabetic ketoacidosis

Type 1diabetes

Mogadishu

Risk factors

Clinical characteristics

Insulin therapy

Diabetes management

Diabetes is a chronic metabolic disease marked by persistently high blood glucose levels, which, over time, can lead to severe damage to critical organs such as the heart, kidneys, eyes, blood vessels, and nerves (WHO, 2023). Among its types, type 2 diabetes is the most prevalent, particularly among adults. Its global prevalence has increased dramatically over the past three decades across countries of all income levels. Type 1 diabetes, previously referred to as juvenile diabetes, is a lifelong condition where the pancreas produces little or no insulin. Access to affordable treatment, including insulin, is vital for the survival of individuals living with diabetes (WHO, 2023). A serious and potentially life-threatening complication of diabetes is diabetic ketoacidosis (DKA). While it primarily affects individuals with type 1 diabetes, it can also occur in type 2 diabetes under stress conditions such as infections or missed insulin doses. DKA results from an absolute or relative insulin deficiency, leading to hyperglycemia, ketosis, and metabolic acidosis. It remains a significant cause of morbidity and mortality, particularly in resource-constrained regions. The global burden of diabetes is paralleled by a rising incidence of DKA, especially in developing countries where healthcare systems may not be adequately prepared to manage such acute complications. Globally, the prevalence of diabetes mellitus continues to rise at an alarming rate. The International Diabetes Federation (IDF) reported that in 2021, around 537 million adults aged 20–79 were living with diabetes. This number is expected to grow to 643 million by 2030 and 783 million by 2045 (IDF, 2021). Diabetes has become the ninth leading cause of death worldwide, with over 4.2 million deaths recorded in 2019. DKA cases have also risen accordingly, largely driven by poor glycemic control, delayed diagnosis, missed insulin doses, and lack of disease management awareness. In many healthcare systems, DKA contributes significantly to hospital admissions and healthcare costs. In Africa, urbanization, dietary transitions, and increasingly sedentary lifestyles have led to a rapid increase in diabetes cases and its complications. According to the IDF, approximately 24 million people in Africa had diabetes in 2021, with projections estimating this will double by 2045 (IDF, 2021). Urban populations are particularly affected, given the surge in obesity and physical inactivity. However, healthcare infrastructures across much of the continent struggle to keep pace with the growing diabetes burden. Limited access to insulin, inadequate diagnostic services, and lack of patient education continue to fuel high DKA rates. Consequently, mortality rates from DKA in Africa range from 20% to 25%, compared to 1% to 5% in high-income nations (Wolfsdorf et al., 2018). In Somalia, the burden of diabetes is significant, yet comprehensive data remain scarce. Years of civil conflict, underfunded healthcare systems, and political instability have led to fragile health services that are ill-equipped to handle chronic diseases. It is estimated that diabetes affects 4% to 5% of Somali adults, although underreporting is likely due to the absence of nationwide surveillance systems (Hersi et al., 2021). Urbanization and the adoption of Western dietary habits are further driving diabetes prevalence, particularly in cities like Mogadishu. Unfortunately, most patients are unaware of the symptoms and complications of diabetes, including DKA, until emergencies arise. The management of diabetes in Somalia is hampered by the unavailability of insulin, lack of medical equipment, and insufficient trained professionals. Financial constraints and limited education among patients often lead to poor treatment adherence. A study by Mohamed et al. (2020) revealed a high incidence of DKA in hospitals in Mogadishu, with many patients being newly diagnosed diabetics. Late presentation and severe dehydration were common, worsening patient outcomes. The findings emphasized the critical need for early diagnosis, improved access to insulin, and increased community awareness. DKA is now recognized as a major public health concern in Somalia. Many patients reach hospitals in critical condition due to delays in seeking care, often staying at home for extended periods. Dehydration, infection, stress, and missed medications are frequent triggers of DKA. Emergency departments face additional challenges, such as lack of preparedness, insufficient staff training, and poor availability of intravenous fluids and laboratory services. Moreover, there is a notable lack of data regarding the prevalence and risk factors associated with DKA in key hospitals in Mogadishu, including Aden Abdulle Hospital, Kalkal Hospital, and Demartino Hospital. This information gap hinders the development of tailored interventions and effective emergency response strategies. Understanding the prevalence and associated risk factors of DKA is essential for improving resource allocation, emergency preparedness, and patient outcomes in Somalia’s fragile healthcare landscape.

2.1 Study Design the Study Research Design Was a Hospital Based Analytical Cross-Sectional Study, Which Involved to Use of Quantitative About the Epidemiological and Clinical Characteristics of Diabetic Ketoacidosis Among Diabetic Patients in Mogadishu Somalia

2.2 Target Population of the Study The study population diabetic ketoacidosis in diabetic patients attending at Abu Bashir hospital, Kalkal hospital, and martini hospital.

2.3 Geographical area the study was conducted at patients attending at Abu Bashir Hospital, Kalkal hospital, and martini hospital.

2.5 Data collection instruments Data was collected using a structured questionnaire through KOBO Toolbox. The questionnaire consisted of close-ended questions designed to capture all required data. In addition to socio-demographic information, it included questions on general information about diabetic ketoacidosis and other associated conditions.

2.5 Data Analysis the analysis was conducted using SPSS Version 27. Descriptive statistics, including frequency, percentage, and cross-tabulation, were performed to summarize the data. Inferential analysis was carried out using univariate, bivariate, and multivariate analyses. Chi-square tests were applied to examine associations between variables, and odds ratios with 95% confidence intervals (CI).

Table 1 Univariate analysis Socio-demographic characteristics of study respondents

Table 1 shows the socio-demographic characteristics of the study participants. More than (37.1%) aged under 18 years. Most of the respondents (55.0%) were males, Majority of the participants, (50.7%) were married. A larger proportion of the respondents (41.4%) had no formal education. The majority of the respondents were unemployed (47.1%) while household income (>$100-$299) was 50.7%. The respondents (75.0%) were type 1 diabetic mellites, (45.0%) of them were diagnosed less than one year, and respondents (70.7%) were getting primary sources of healthcare in public hospitals. The majority 46.6% had no family history of diabetes, while 42.1%'s level of health literacy regarding diabetes is moderate. The respondents (43.6%) were weekly checking blood glucose levels with 75.7% having no chronic disease. majority of the respondents were living in urban areas (92.0%)

Table 1
Univariate analysis sociodemographic determinants of dka among diabetic patients
Variables		N	%
What is your age group?	Under 18 years	52	37.1%
	18–29 years	39	27.9%
	30–39 years	13	9.3%
	40–49 years	6	4.3%
	59–59 years	12	8.6%
	60 and above years	18	12.9%
	Total	140	100%
What is your gender?	Male	77	55.0%
	Female	63	45.0%
	Total	140	100%
What is your Marital Status	Single	52	37.1%
	Married	71	50.7%
	Divorced	8	5.7%
	Windowed	9	6.4%
	Total	140	100%
What is your highest Level of Education?	No formal education	58	41.4%
	Primary education	24	17.1%
	Secondary education	46	32.9%
	Tertiary education	12	8.6%
	Total	140	100%
What is your employment status?	Employed	21	15.0%
	Self Employed	38	27.1%
	Unemployed	66	47.1%
	Retired	15	10.1%
	Total	140	100%
what is your monthly household income	Less than $100	29	20.7%
	>$100-$299	71	50.7%
	>$300-$499	36	25.7%
	$500 and above	4	2.9%
	Total	140	100%
What type of diabetes do you have	Type 1 diabetes	105	75.0%
	Type 2 diabetes	35	25.0%
	Total	140	100%

Table 2:- Univariate analysis clinical presentations and management outcomes of diabetic ketoacidosis (DKA) among 140 diabetic patients.

In terms of hospitalization frequency for DKA in the past year, 10.7% of patients reported no hospitalizations, 72.1% were hospitalized once, 16.1% were hospitalized 2–3 times, and 0.7% were hospitalized more than three times.Regarding symptoms prior to the DKA episode, 92.9% experienced excessive thirst, and 7.1% did not. Additionally, 97.1% of patients experienced frequent urination, while 2.9% did not. Abdominal pain was reported by 95.7% of patients before the DKA episode, and 4.3% did not experience it.At the time of hospital admission, 67.9% of patients were conscious, while 32.1% were not. Regarding the time taken to seek medical care, 57.9% sought care within 6 hours of symptom onset, 29.3% within 12 hours, 10.0% within 24 hours, and 2.9% sought care after 24 hours.During treatment, all 140 patients (100%) received insulin therapy. Fluid therapy was administered to 99.3% of patients, while 0.7% did not receive it. Antibiotics were administered to 93.3% of patients, and 5.7% did not receive antibiotics.

In terms of care settings, 80.7% of patients were monitored in the intensive care unit, while 19.3% were not. For hospital stays during DKA treatment, 6.4% stayed less than 24 hours, 82.9% stayed 1–3 days, 7.9% stayed 5–7 days, and 2.9% stayed more than 7 days.Complications during or after treatment were reported by 45.0% of patients, while 55.0% did not experience any complications.

Regarding recurrent DKA episodes after discharge, 50.0% of patients experienced recurrence, while the other 50.0% did not. Concerning hospital stays, 77.9% stayed less than 3 days, 19.3% stayed 3–7 days, and 2.9% stayed more than 7 days.When asked about confidence in managing diabetes after the DKA episode, 30.7% of patients were very confident, 57.1% were somewhat confident, and 12.1% were not confident. Following the prescribed management plan after the DKA episode was reported by 84.3% of patients, while 15.7% did not follow the plan.

For regular follow-up appointments, 80.7% of patients attended them, while 19.3% did not. As for the frequency of experiencing hyperglycemia symptoms after DKA treatment, 4.3% reported never experiencing symptoms, 9.3% rarely experienced them, 75.0% sometimes experienced them, and 11.4% experienced them often.

Table 2
Univariate analysis clinical presentations and management outcomes of DKA among diabetic patients
Variable		N	%
How many times have you been hospitalized for DKA in the past year	None	15	10.7%
	1 time	101	72.1%
	2–3 times	23	16.1%
	More than 3 times	1	0.7%
	Total	140	100%
Did you experience excessive thirst prior to the DKA episode?	Yes	130	92.9%
	No	10	7.1%
	Total	140	100%
Did you experience frequent urination prior to the DKA episode?	Yes	136	97.1%
	No	4	2.9%
	Total	140	100%
Did you have abdominal pain before the DKA episode?	Yes	134	95.7%
	No	6	4.3%
	Total	140	100%
Were you conscious upon hospital admission for DKA?	Yes	95	67.9%
	No	45	32.1%
	Total	140	100%
How soon after symptom onset did you seek medical care for DKA?	Within 6 hours	81	57.9%
	Within 12 hours	41	29.3%
	Within 24 hours	14	10.0%
	After 24 hours	4	2.9%
	Total	140	100%
Did you receive insulin therapy during your DKA treatment?	Yes	140	100%
	No	0	0%
	Total	140	100.0%
Was fluid therapy administered?	Yes	139	100%
	No	1	94.3%
	Total	140	100%
Were antibiotics administered?	Yes	132	93.3%
	No	8	5.7%
	Total	140	100%
Were you monitored in the intensive care units	Yes	113	80.7%
	No	27	19.3%
	Total	140	100%
How long was your hospital stay during your DKA treatment?	Less than 24 hours	9	6.4%
	1–3 days	116	82.9%
	5–7 days	11	7.9%
	More than 7 days	4	2.9%
	Total	140	100%
Did you experience any complications during or after your DKA treatment?	Yes	63	45.0%
	No	77	55.0%
	Total	140	100%
How long was your hospital stay for the DKA episode?	Less than 3 days	109	,77.9%
	3–7 days	27	19.3%
	More than 7days	4	2.9%
	Total	140	100%
Have you had a recurrent episode of DKA after discharge?	Yes	70	50.0
	No	70	50.0%
	Total	140	100%
How confident are you in managing your diabetes after your DKA episode?	Very confident	43	30.7%
	Somewhat confident	80	57.1%
	Not confident	17	12.1%
	Total	140	100%
Have you been able to follow the management plan prescribed to you after your DKA episode?	Yes	118	84.3%
	No	22	15.7%
	Total	140	100%
Do you regularly attend follow-up appointments for your diabetes management?	Yes	113	80.7%
	No	27	19.3%
	Total	140	100%
How often do you experience symptoms of high blood glucose (hyperglycemia) after your DKA treatment?	Never	6	4.3%
	Rarely	13	9.3%
	Sometimes	105	75.0%
	Often	16	11.4%
	Total	140	100%

Table 3:bivariate analysis Correlation Between Gender and Primary Source of Healthcare

Table 3
bivariate analysis correlation between gender and primary source of healthcare
Variables		What is your primary source of healthcare?		P value
Variables		Public hospital	Private hospital	P value
Gender	categories	N (%)	N (%)	0.588
	Male	53(37.86%)	24(17.14%)
	Female	46(32.86%)	17(12.14%)

This table assesses the primary source of healthcare (public or private hospitals) by gender. A higher proportion of males (37.86%) relied on public hospitals, while 32.86% of females did the same. Both males (17.14%) and females (12.14%) had low utilization of private hospitals.

Table 4:bivariate analysis Correlation Between Type of Diabetes and Recurrent DKA Episodes

Table 4
bivariate analysis correlation between type of diabetes and recurrent episode of dka after discharge
variables		Have you had a recurrent episode of DKA after discharge?		P value
variables		No	Yes	P value
Type of diabetes	Categories	N (%)	N (%)	0.011
	Type 1 Diabetes	46(32.85%)	59(42.14%)
	Type 2 Diabetes	24(17.14%)	11(7.85%)

The table correlates diabetes type with recurrent DKA episodes after discharge. Those with Type 1 Diabetes had the highest recurrence of DKA (42.14%) and also Low Percentage Only 7.85% of individuals with Type 2 Diabetes experienced recurrent DKA. The P-value of (0.011) suggests a statistically significant.

Table 5: bivariate analysis Correlation between excessive thirst prior to the DKA episode and regularly monitor blood glucose levels at home The Table 5 examines the correlation between experiencing excessive thirst prior to a diabetic ketoacidosis (DKA) episode and regularly monitoring blood glucose levels at home, with a p-value of 0.778 indicating no statistically significant association between the two variables. Among patients who experienced excessive thirst before the DKA episode, 42.1% did not regularly monitor their blood glucose levels at home, while 50.7% did. For those who did not experience excessive thirst prior to the episode, 3.7% did not regularly monitor their blood glucose, and 3.57% did.The p-value suggests that there is no significant correlation between having excessive thirst before a DKA episode and the practice of regularly monitoring blood glucose levels at home.

Table 5
bivariate analysis correlation between excessive thirst prior to the dka episode and regularly monitor blood glucose levels at home
		Do you regularly monitor your blood glucose levels at home?		P value
		No	Yes	P value
excessive thirst prior to the DKA episode	Categories	N (%)	N (%)	0.778
	Yes	59(42.1%)	71(50.7%)
	No	5(3.7%)	5(3.57%)

Table 6: bivariate analysis Correlation Between Insulin Therapy and Recurrent DKA Episodes The table presents the correlation between receiving insulin therapy during diabetic ketoacidosis (DKA) treatment and having a recurrent episode of DKA after discharge, with a p-value of 0.0 indicating a statistically significant association. Among patients who received insulin therapy during their DKA treatment, 50% experienced a recurrent episode of DKA after discharge, and 50% did not. The p-value of 0.0 suggests a significant correlation between receiving insulin therapy and the likelihood of experiencing recurrent DKA episodes, although further details would be necessary to understand the nature and direction of this relationship.

Table 6
bivariate analysis correlation between insulin therapy during dka treatment and recurrent episode of dka after discharge
		Have you had a recurrent episode of DKA after discharge?		P value
		No	Yes	P value
insulin therapy during your DKA treatment	Categories	N (%)	N (%)	0.0
insulin therapy during your DKA treatment	Yes	70(50%)	70(50%)

Table 7: bivariate analysis Correlation between excessive thirst prior to the DKA episode and regularly monitor blood glucose levels at home. The table explores the correlation between having other chronic illnesses and experiencing a recurrent episode of diabetic ketoacidosis (DKA) after discharge, with a p-value of 0.011 indicating a statistically significant association. Among patients with chronic illnesses, 0% with renal diseases experienced recurrent DKA, while 0.71% did. For those with hypertension, 10% did not experience recurrent DKA, and 5% did. Among patients with chronic respiratory diseases, 2.1% did not experience recurrent DKA, and 0.71% did. Those with chronic liver diseases had 2.8% without recurrent DKA and none with recurrent episodes. Similarly, 2.8% of patients with cardiovascular diseases did not experience recurrent DKA, and none did. For patients without any chronic illnesses, 32.1% did not experience recurrent DKA, while 43.5% did. The significant p-value suggests that the presence of other chronic illnesses is associated with the likelihood of having a recurrent episode of DKA after discharge.

Table 7
bivariate analysis correlation between other chronic illnesses and recurrent dka
Variables		Have you had a recurrent episode of DKA after discharge?		P value
Variables		No	Yes	P value
Other chronic illnesses	Categories	N (%)	N (%)	0.011
	Yes, renal diseases	0(0.0%)	1(0.71%)
	Yes, hypertension	14(10%)	7(5%)
	Yes, chronic respiratory disease	3(2.1%)	1(0.71%)
	Yes, chronic liver diseases	4(2.8%)	0(0.0%)
	Yes, cardiovascular diseases	4(2.8%)	0(0.0%)
	No	45(32.1%)	61(43.5%)

Table 8:Multivariate analysis of missing insulin doses and the socio-demographic characteristics The multivariate analysis explores the relationship between missing insulin doses and various socio-demographic characteristics. The results are summarized as follows: For age group, the p-value is 0.354, with an adjusted odds ratio (AOR) of 0.906 and a 95% confidence interval (CI) ranging from 0.735 to 1.117. This indicates that age group is not significantly associated with missing insulin doses.Gender has a p-value of 0.673, with an [AOR of 1.178 and a 95% CI of 0.550 to 2.522]. This suggests no significant association between gender and the likelihood of missing insulin doses.Marital status shows a p-value of 0.410, with an [AOR of 1.258 and a 95% CI ranging from 0.728 to 2.173], indicating no significant relationship between marital status and missing insulin doses. The highest level of education has a p-value of 0.001, with an [AOR of 0.511 and a 95% CI of 0.341 to 0.768]. This suggests that individuals with higher levels of education are significantly less likely to miss insulin doses.Employment status has a p-value of 0.143, with an [AOR of 0.756 and a 95% CI ranging from 0.519 to 1.099]. This indicates no significant association between employment status and missing insulin doses.Monthly household income has a p-value of 0.729, with an [AOR of 1.067 and a 95% CI ranging from.

Table 8
multivariate analysis of missing insulin doses and the socio-demographic characteristics
Variables	P-value	AOR	95% Confidence Interval
Variables	P-value	AOR	Lower	upper
age group	.354	.906	.735	1.117
gender	.673	1.178	.550	2.522
marital status	.410	1.258	.728	2.173
highest level of education	.001	.511	.341	.768
employment status	.143	.756	.519	1.099
monthly household income	.729	1.067	.739	1.542

The study reveals that diabetic ketoacidosis (DKA) is predominantly affecting younger individuals, with 37.1%) of patients aged under 18 years having developed DKA. About 65,000 children under 15 years develop type 1 diabetes each year, with up to 80% presenting with DKA. A significant number of patients have no formal education, which may impact their ability to understand and manage diabetes. DKA is more prevalent among people with type 1 diabetes and can also develop in people with type 2 diabetes. The majority of patients have been hospitalized for DKA at least once in the past year, with 92.9% reporting excessive thirst and 97.1% experiencing frequent urination. Abdominal pain is another common symptom, with abdominal pain being the most common. Insulin therapy and antibiotics are the standard of care, with intravenous insulin by continuous infusion being the standard of care.Physical exercise is practiced daily by 57.9% of patients, and 80.7% are non-smokers. Recent infections are reported by 72.1%, while 73.6% have no other chronic illnesses. Stress or emotional distress is experienced by 62.1%, and 58.6% have not received education on managing sick days. The study also found a significant correlation between education level and health literacy regarding diabetes management. Patients with higher education levels were more likely to have a better understanding of diabetes management, while those with poor understanding of DKA symptoms had the lowest confidence.

As highlighted in our study, focused on the sociodemographic determinants, clinical presentations, management outcomes, and risk factors and predictors. To tackle these factors, the findings of this study underscore the importance of socio-demographic factors, education, and lifestyle choices in the management and outcomes of diabetes and DKA. The significant associations between education, employment, and health literacy suggest that targeted interventions to improve education and employment opportunities may positively impact diabetes management. Additionally, the role of physical activity and psychological well-being in reducing hospital stays and preventing recurrent DKA episodes should be prioritized in future interventions. These results highlight the need for a comprehensive approach to diabetes care that considers socio-economic, psychological, and lifestyle factors.

The text emphasizes the importance of enhancing diabetes education, promoting regular insulin use, improving access to diabetes medications, promoting a diabetes-specific diet, strengthening physical activity, addressing psychological stress, enhancing monitoring in healthcare settings, improving understanding of DKA symptoms, addressing socio-demographic disparities, integrating chronic illness management with diabetes care, monitoring and adjusting interventions based on patient feedback, increasing support for newly diagnosed patients, promoting regular healthcare visits, fostering community engagement, and evaluating and improving healthcare systems. These strategies aim to improve patient outcomes, reduce barriers to care, improve patient-provider communication, and ensure responsiveness to the needs of diabetic patients. By addressing these aspects, the healthcare system can better address the needs of diabetic patients and promote overall health.

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The authors declare no competing interests.

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Epidemiological and Clinical Characteristics of Diabetic Ketoacidosis Among Diabetic Patients in Mogadishu, Somalia.

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