Makara J. Health Res.

, 2015, 19(1): 8-14

doi: 10.7454/msk.v19i1.4598

The Relationship between Smoking as a Modifiable Risk Factor and Chronic

Complications on Elderly with Type 2 Diabetes Mellitus

Indang Trihandini

Department of Biostatistics and Population Studies, Faculty of Public Health, Universitas Indonesia,
Depok 16424, Indonesia

e-mail: dini05@ui.ac.id

Abstract
Smoking is known as a variable that can be changed through a specific intervention activity. Recently in Indonesia,
research related to chronic complication among elderly with type 2 Diabetes Mellitus (DM) was not available. This
research has objective in exploring the risk of smoking towards chronic complication among elderly with type 2 DM.
This research was using Riset Kesehatan Dasar (Riskesdas) in 2007. Riskesdas is a representative Indonesia Health
Survey. 1,565 elderly (aged 60++ years) with type 2 DM have selected by random. 70-80% of the elderly have Chronic
Complications and 32.11% of the sample is smokers. The elderly who smoke more than 24 cigarettes per day have risk
2.5 (95% CI, 1.54-3.97), smoker 1-12 cigarettes per day, and smoker 13-24 cigarettes per day have risk 1.3 and 1.6
respectively to get chronic complication compared with those who do not smoke, controlled by age, obesity, and
physical activity. The proportion of smokers among elderly with type 2 DM is high, most of them are low education,
low socioeconomic status, lack of access to the health services, low of physical activity, and low consume vegetables
and fruit. Smoking increases the risk of chronic complication of type 2 DM.

Abstrak

Hubungan antara Merokok sebagai Faktor Risiko yang dapat Dimodifikasi dari berbagai Komplikasi Kronis
pada Lansia dengan Diabetes Mellitus Tipe 2. Merokok dikenal sebagai variabel yang dapat diubah melalui aktifitas
intervensi yang spesifik. Saat ini di Indonesia belum terdapat penelitian mengenai komplikasi kronis di antara para
lansia penderita Diabetes Mellitus (DM) tipe 2. Penelitian ini bertujuan untuk mempelajari risiko dari aktifitas merokok
terhadap komplikasi kronis di antara para lansia penderita DM tipe 2. Penelitian ini menggunakan Riset Kesehatan
Dasar (Riskedas) 2007. Sebanyak 1.565 lansia (usia 60++ tahun) penderita DM tipe 2 dipilih secara acak. Sebanyak 70-80%
dari para lansia tersebut memiliki komplikasi kronis, dan 32,11% sampel penelitian adalah perokok. Para lansia yang
merokok lebih dari 24 batang per hari memiliki risiko 2,5 (95% CI, 1,54-3,97), sementara itu lansia yang merokok 1-12
batang per hari, dan yang merokok 13-24 batang per hari memiliki risiko masing-masing setinggi 1,3 dan 1,6 untuk
terserang komplikasi kronis dibandingkan mereka tidak merokok, terkontrol secara usia, tingkat obesitas, dan aktifitas
fisik. Persentase perokok di antara para lansia penderita DM tipe 2 cukup tinggi. Sebagian besar dari mereka memiliki
tingkat pendidikan, tingkat status sosioekonomi, aktifitas fisik, serta tingkat konsumsi buah dan sayur yang rendah. Mereka
pun kurang memiliki akses terhadap layanan kesehatan. Merokok meningkatkan risiko komplikasi kronis DM tipe 2.

Keywords: diabetes chronic complications, diabetes mellitus tipe 2, elderly, indonesia, smoking

Introduction risk of type 2 diabetes mellitus smokers are depend on

the number of cigarettes smoked, for 1-14 cigarettes
Many researchers discovered that smoking can cause a perday, the risk that possess is 1.39 (1.17 to 1.64), and
type 2 diabetes mellitus since it causes insulin for >25 cigarettes per day, the risk that possess is 1.98
resistance.1,2 Moreover, smoking is also causing death (1.57 to 2.36) compare with non smokers.6
for type 2 diabetes mellitus patients.3,4 The effect of
smoking is significant towards the diabetes mellitus Smoking is not only increasing the chance of people to
type 2’s patients. The risk for diabetes mellitus type 2 be affected by type 2 diabetes mellitus, but also chronic
increases 28% for smoker patients.5 This risk will complication of diabetes that are very dangerous.7,8
reduce simultaneously as the patients quit smoking. The Smoking is a bad habit that will affect the deposition of

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 The Relationship between Smoking as a Modifiable Risk 9

fat in the arteries, which will damage the blood vessels. prevalence of chronic complications of type 2 diabetes,
Therefore, smoking will also cause a hypertension and combination pattern chronic complications of type 2
stroke.7 Due to this situation, the complication of diabetes diabetes mellitus, and relationship of smoking as
mellitus that often time happened is hypertension. modifiable risk towards chronic complications of type 2
Hypertension will also increase the risk of heart attack. diabetes mellitus. The results of this result should
The proportion of smoker in Indonesia continues to produce strategic suggestions to reduce the likelihood of
increase. According to social economic survey in 1995, chronic complications in elderly patients with type 2
the proportion of smokers in Indonesia was 27% and in diabetes mellitus.
2007 it reached 34.2%. Moreover According to Riskesdas
in 2007, the proportion of smoker above 60 years old Methods
was approximately 36%.
This research was using the Baseline Health Research
In 2003, According to Badan Pusat Statistik Indonesia’s Survey (BHRS/Riskesdas) 2007 with a cross-sectional
report, the total of type 2 diabetes mellitus patients was design. Riskesdas 2007 is a community-based research
13.7 million people and estimated to be 20.1 million in that using households and household members samples
2030 with prevalence rate of 14.7% in urban and 7.2% that can represent the population in the district or city.
in rural. The risk of type 2 diabetes mellitus was higher Riskesdas 2007 provides basic health information
for elderly. DM type 2 is one of the chronic diseases that including biomedical measurements. The population
can elevate prevalence of the chronic complication for that used in this study was all the elderly residents (with
elderly.9 This chronic complication disease considered age of 60 years old and above) in Indonesia. Samples in
serious since it closely relates with others chronic diseases the study are the respondents that were selected in the
such as hypertension, heart attack, stroke, blindness due survey Riskesdas 2007 and met the inclusion and
to retinopathy, glaucoma, cataracts, kidney failure, exclusion criteria. Inclusion criteria for the study are the
impotencein men, and disabilitydue towounds that hard respondents that have type 2 diabetes mellitus that
to be healed.9,10 diagnosed by health work force. Exclusion criteria for
the study are the situation where the elderly have BMI
Chronic complications of diabetes mellitus type 2 are (Body Mass Index) below 18.5 and with incomplete
largely caused by genetic factors, poor behavior or data. Total of 1,565 samples were obtained as samples.
lifestyle to maintain health, poor social environment and Data analysis was performed using the software
lack of utilization of health services. Chronic complica- Statistical Package for Social Science (SPSS) version
tions defined as the presence of two or more diseases or 16.0 license Universitas Indonesia. Analysis that
chronic conditions, in which the one is not always more conducted includes descriptive and multivariate complex
significant than others diseases.11,12 Chronic complications survey analysis.
can affect the quality of life, ability to work, disability
and death.9 Data of chronic complications for the Type 2 diabetes mellitus measurement. The
elderly in Bangladesh, as a developing country, reached measurement of type 2 diabetes mellitus are based from
53.8%, most of them are women and people in the lower the diagnosis that being enforced by a doctor.
socioeconomic groups.13,14 Chronic complications are a Respondents were also interviewed for other chronic
challenge for preventive and curative services health diseases that diagnosed by the doctor. In the Riskesdas
provider in Indonesia.15 This kind of conditions can survey (chronic diseases have some of the limitation
trigger the multi use of prescription or polypharmacy. such as, hypertension, heart, and stroke). In this
The uses of a number of drugs also have risks such as research, the analysis of the risk of chronic
increased drug reactions, increased incidence of complications of type 2 diabetes mellitus with the
undesirable drug effects. The condition was more relationship of smoking and 10 other independent
damning in elderly patients since the decrease of variables such as age group, sex, marriage status,
capacity for drug metabolism in the body would socioeconomic status, formal education, body mass
increase the risk of toxic reactions.13 index, fat consumption, fruit, and vegetable
consumption, physical activity, and utilization of health
Indonesia is trying to provide healthy, happy, services had been conducted.
productive and independent life for elderly.16 However,
currently, there are only few data and research related to Dependent variable. The operational definition of
smoking, and chronic complications in elderly patients chronic complications of type 2 diabetes is when the
with type 2 diabetes mellitus in Indonesia. Moreover, respondents suffered from diabetes and at least one
the data and the research arenecessary to describe the other chronic diseases. On the other hand, the
strategic program that requiredin reducing the problems respondents who only have type 2 diabetes without
that arise, such as: Improving health care systems, other chronic diseases complications were not
economic burden and quality of life for elderly in considered aschronic complications. Complications and
Indonesia. Therefore, this study aims to determine the non complications (reference).

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10 Trihandini

Independent variables. The behavior as smoker were the actual condition. On the other hand, the occurrence
categorized by smoker status (whether if they smoked of bias recall when the data collectors asked for the
daily or occasionally), and not smokeas there ference. history of respondend regarding the particular disease
based from diagnosis by health professionals was also
Potential confounders. 1) Age, divided into two limiting this research. Another limitation was the
categories:60-74 years (reference), 75+years; 2) Gender, absence of the question regarding how long the
divided into two categories: male (reference) and respondend had stopped smoking, thus the bias effects
female; 3) Formal education; below high school and of smoking in the blood for ex-smokers were not
graduate or above high school (reference); 4) Marital appropriately measured.
status; single, married (reference) and divorce; 5)
Socioeconomic status was grouped based from Another bias threat was selection bias. According to
expenditure of per capita (expenditure status for Riskesdas’s data, the number of samples that met the
groceries and not groceries for 1 month divided by the inclusion criteria that been diagnosed by health
number of household members). Socioeconomic status professionals for age ≥60 years and have type 2
considered high if spending per capita was equal to or diabetes, were 1,924 samples. However, according to
greater than the median (reference) and socioeconomic inclusion and exclusion criteria that have been
status consider low when spending per capita was less established, samples that used in this study were 1,565
than the median; 6) Nutrition status consist of good samples of appropriate. The rest of the samples, 359
nutrients/normal (18.5-24.9) as reference and excess samples, were excluded from the list because the
nutrients/obesity (>25); 7) Fruit and vegetable respondents surveyed had incomplete data of on
consumption were categorized as 'enough' fruit and important variables required and about 1% had BMI
vegetable consumption when the consumptionof below 18.5. The 359 samples excluded have
vegetables and/or fruit at least 5 servings per day for 7 characteristics as follows: 52.5% are female, 62.5% are
days a week (reference). It categorized as 'not enough' married, 20% are smokers, mean age was 68 years old,
fruit and vegetable consumption when fruit and and 28.6% are obese (incomplete data) and 1% of them
vegetable consumption is less than the requirements have a BMI below 18.5.
mentioned above; 8) Physical activity, it categorized as
'enough' when the activity was performed cumulatively Based on Table 1, the chronic complications status are
150 minutes for five days a week (reference) and ‘not very high in the five groups of smoker, which was about
enough‘ if it performed less than the above conditions; (70-82%). Percentage of the group that has the highest
9) Fat consumption considered as “often” when the complication was the 'Ex-Smokers' with almost 82%.
respondent consumed this food once or more every day The lowest percentages among the groups are 'No
and considered “seldom” if the consumption was not Smoking' and 'smoker 1-12 cigarettes per day'groups.
every day (reference); 10) Health service utilization The average age of the five groups was 67 years.
categorized as'good' if the respondents had been utilized Approximately 70% of men catagorized as 'Ex-
at leastone of health services, such as neighborhood Smokers';' smoker 1-12 cigarettes per day 'and' Smokers
health center, village health post, postdrug, or adrug over 24 cigarettes per day, while the women (about
shop in the last 3 months (reference). This considered as 65%) catagorized as ' No Smoking 'and groups' Smoker
'not good' if they under utilized the health services in the 13-24 cigarettes per day. Two of three research’s
last3 months. samples are from low education in all groups. Low
education mentioned considered as formal education
Statistical Analysis. Complex survey analysis was from junior high school to below. From the total elderly
conducted using chi-square and logistic regression above 50% of them are categorized as of low
models with an alpha of 5%. Stratum: urban and rural, socioeconomic and most of them (over 70%) were still
PSU: Enumeration area (group of 20 RT), Weight married. The percentages of the respondend that have
(Individual). Data collection was conducted in low education and socioeconomic were in line with low
compliance with the standards or ethics when done access in utilizng health services (over 55%). On the
taking the survey. other hand, there were only a few who conducting
regular exercise per week, for only about (1.7-5.7%)
Results and Discussion who do regular exercise per week, the former smoker
was highest group who performing regular exercise per
This research has several of limitation such as the week. Nutrition status of elderly in the research was
classification of chronic complication type 2 Diabetes almost 30-40% catagorized as overweight and obesity
Melitus status. Because not all of chronic complications with a very low vegetables, and low fat food
diseases, such as renal failure, glaucoma, retinopathy, consumption.
impotence, gangrene and tuberculosis, were being
analyzed. Therefore, the precentage of respondent that Table 2 shown that 67.07% of chronic complications
experiencing the complication might be obscured from were the complication of diabetes and hypertension. The

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 The Relationship between Smoking as a Modifiable Risk 11

other description of chronic complications were as The most common complications in this study were
follows: 12.8% was a complication of diabetes, heart hypertension (35.1%), the same result was also reported
and hypertension; 8.9% was complication of diabetes, by Meeuwisse-Pasterkamp,21 which revealed that more
stroke and hypertension; 7.44% combination from than 70% of diabetics’ patients were also suffer from
diabetes and heart diseases; 2.68% was complication of high blood pressure as well. Type 2 diabetes along with
diabetes, heart, stroke and hypertension; 0.85% hypertension would increase the risk of microvascular
complications diabetes and stroke; and the rest was the and macrovascular complications. The increase of 10
diabetes, heart and stroke (0.24%). Broadly speaking, mmHg in systolic was associated with the increase of
hypertension is the most chronic complication that 12% on each diabetes complications, 15% of deaths that
occured on patients with type 2 diabetes, which about related with diabetes, increase of 11% in the occurrence
92%. Elderly people with type 2 diabetes mellitus prone of myocardial infarction and increase of 13% in
to have chronic complications, the results of a study microvascular complications of type 2 diabetes. deaths
reported that 73.1% from 1,565 of the elderly have from heart disease were 2 to 4 times higher in diabetics
chronic complications. In the group of age over 60 years than non-diabetics. Diabetics are 2 to 4 times as well,
old, due to aging, changes in the pancreatic beta cells would develop into a stroke.10,20 Therefore, people with
caused changes in glucose metabolism in old age. In diabetes with hypertension need to extremly maintain
addition, aging was also associated with obesity, their health to avoid other chronic disease caused by this
disease, drug use and reduction of physical activity.17-20 conditions,monitoring the salt intake is required.21,22

Table 1. Characteristics and Behavior

Non Smoker Former Smoker Smoker with 1- Smokerwith 13- Smoker with >24
12 cigarettes/day 24 cigarettes/day cigarettes/day
N 989 223 45 28 280
Age (Rerata) (year) 67.89 68.4 68.06 68.13 67.67
Gender (%)
Female 67 27.9 29.2 62.7 25.9
Male 33 72.1 70.8 37.3 74.1
Formal education (%)
Low 77.1 67 64.5 70.8 32.8
High 22.9 33 35.5 29.2 67.2
Socioeconomic (%)
Low 54.5 54 69.7 58.4 47
High 45.5 46 30.3 41.6 53
Marital status (%)
Married 61.4 77.6 77.2 71 76.3
Divorced/Death 38.6 22.4 22.8 29 23.7
Health service utilization (%)
Not Good 57.2 56.8 54.2 48 62.3
Good 42.8 43.2 45.8 52 37.7
Physical activity (%)
Enough 1.7 5.7 4.6 0 2.6
Not enough 98.3 94.3 95.4 100 97.4
Nutrition status (%)
Good 68.0 62.2 74.2 63.1 70.8
Excess 13.3 17.5 17.5 25.5 14.2
Obesity 18.7 20.3 8.3 11.4 15
Fruit and vegetable consumption (%)
Enough 0.8 0 0 0 0.4
Not enough 99.2 100 100 100 99.6
Fat consumption (%)
Seldom 92.4 90.5 97.1 81.3 92.8
Often 7.6 9.5 2.9 18.7 7.2
Complication status (%)
Non complication 29.7 18.2 29.4 20.6 24.2
Complication 70.3 81.8 70.6 79.4 75.8

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12 Trihandini

Based on Table 3, the combination distribution of the 2.35 times grater risk in getting chronic complications
chronic complications in elderly people with type 2 from type 2 diabetes compared to the 'No Smoker' (95%
diabetes mellitus, which is smoker, has a greater CI OR; 1.5 to 3.7 ). 'Smoker with 1-12 days per cigarettes
proportion in experiencing chronic complications than and 'Smoker with 13-24 cigarettes per day had risk of
those who never smoked. Moreover, those who never getting chronic complications of type 2 diabetes by 1.32
smoked, the proportion in experiencing chronic and 1.64 times (respectively) compared to the 'No
complications of the disease was only 40.99%, while Smoker'. Even 'Former Smokers' was still obtained the
51.99% for smokers (the ratio of the proportion for risk for getting type 2 diabetes chronic complications 1.66
smokers who experience chronic complications of a times compared to the 'Non Smoker'. The size of risk in
disease than nonsmokers was 1.26). For two getting type 2 diabetes chronic complications had already
complications of chronic disease, the proportion of non- been controlled by several variables, such as: age, sex, not
smokers were at 10.32% and 17.67% for smokers (the exercise, and nutrition status.
ratio of smokers who experience chronic complications of
the two diseases than non smokers was 1.71). For the Based on Table 4, it had been proved in this study that
proportion of smokers who have complications from three smoking had a 2.5 times greater risk in getting for the
diseases had the ratio 6 times greater than non smokers. complications of type 2 diabetes mellitus compared to
These conditions did not differ in other pattern of chronic those who did not smoke (OR 95% CI, 1.54 to 3.97) and
complications, except for the combination of diabetes and can be associated with a high mortality rate for people
hypertension. In this pattern the proportion of non with diabetes.2-4 The effects of smoking, even though
smokers is greater than the proportion of smokers. towards the ex-smokers had big influence for occurance of
type 2 diabetes. Risk of incident type 2 diabetes mellitus
To obtain the final model (Table 4), logistic regression increased by 28% among all smokers. The risk decreased
was included on the analysis. The table showed that by the length of time the person quitting smoking.5
'Smokers who smoke more than 24 cigarettesper day' had

Table 2. Chronic Complication Combination towards Elderly with Type 2 Diabetes

The Pattern of Diabetes Melitus Complication Personates

Diabetes and hypertension 67.07%

Diabetes, heart, and hypertension 12.80%
Diabetes, stroke, and hypertension 8.90%
Diabetes and heart 7.44%
Diabetes, heart, stroke, and hypertension 2.68%
Diabetes and stroke 0.85%
Diabetes, hypertension, and stroke 0.24%
Total 100.00%

Table 3. The Distribution of Chronic Complication Combination and Smoking Behavior

The Pattern of Diabetes Melitus Chronic Complication Non Smoker N (%) Smoker and Former Smoker N (%)
Non complication 474 (47.97) 153 (26.51)
Complication 514 (52.03) 424 (73.49)
The status of diabetes melitus chronic complication
Non complication 474 (47.97) 153 (26.51)
One disease 405 (40.99) 300 (51.99)
Two diseases 102 (10.32) 104 (17.67)
Three diseases 6 (0.60) 20 (3.63)
The pattern of diabetes melitus chronic complication
Diabetes and hypertension 401 (78.02) 276 (65.09)
Diabetes, heart, and hypertension 27 (5.25) 38 (8.96)
Diabetes, stroke, and hypertension 41 (7.98) 42 (9.91)
Diabetes and heart 33 (6.42) 46 (10.85)
Diabetes, heart, stroke, and hypertension 7 (1.36) 20 (4.72)
Diabetes and stroke 1 (0.19) 2 (0.47)
Diabetes, hypertension, and stroke 4 (0.78) 0 (0.00)

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 The Relationship between Smoking as a Modifiable Risk 13

Table 4. Multivariat Analysis

Confidence Interval 95% OR

Variables B ρ value OR
Lower Upper
(Intercept) -0.178 0.523 0.837 0.480 1.459
Age 0.495 0.011 1.640 1.127 2.388
Gender 0.529 0.003 1.697 1.215 2.370
Absent of exercise 0.555 0.001 1.742 1.256 2.415
Former smoker 0.512 0.146 1.668 0.832 3.343
Smoker with 1-12 cigarettes/day 0.272 0.570 1.312 0.505 3.407
Smoker with 13-24 cigarettes/day 0.495 0.221 1.640 0.735 3.659
Smoker with >24 cigarettes/day 0.857 0.000 2.357 1.501 3.701
Nutrition status 0.246 0.021 1.279 1.039 1.575

Smoking was not only increased the person's risk of groups. Women (about 65%) were in a 'No Smoking'
type 2 diabetes but also the risk of dangerous and 'Smoker with 13-24 cigarettes/day' groups, the
complication of chronic diabetes.7,8 remaining groups were men (for about 70%). Two-
thirds of the elderly, in this study, were in the lower
Smoking was a risk factor for hypertension, heart educated and socioeconomic groups on all cigarettes’s
disease and stroke. According to American Diabetic categories. 55% of them were lack in utilizing health
Assosiations, cigarette smoke can cause a reduction of services. 30-40% of these elderly had the nutritional
oxygen levels on the tissue, it also increases cholesterol status that categorised as overweight and obesity,
levels and blood pressure, and blood sugar levels.7,8 The although the their intake towards fat were low. The
research, on the last 10 years, had proved the existence vegetables that consumed by elderly were very low, and
of macrovascular complications in patients with type 2 they were also lack of regular activity (exercise).
diabetes who smoking. Smoking is heightens the risk of
macrovascular complications such as hypertension heart The results of multivariate analysis showed that the
disease, stroke, and peripheral vascular disease.This was smoker who smoked more than 24 cigarettes per day
all because smoking made the atherosclerosis. had bigger risk in getting chronic complications of type
Atherosclerosis is the thickening the inner walls of the 2 diabetes of 2.35 times compared with non-smokers
arteries due to plaque deposits. Thus, it can inhibit and (95% CI OR; 1.5 to 3.7) and smokers who only smoked
block the blood supply to the muscle cells. Thickening 1-12 cigarettes per days; smoker who smoked 13-24
of the artery, due to fat deposition in the arteries walls, cigarettes per day smokers had greater risk in getting
would then damage the walls of blood vessels, ongoing chronic complications of type 2 diabetes by 1.32 and
Atherosclerosis chronic might cause many diseases. 1.64 times (respectively) compared with non-smokers.
Therefore the most common complication of diabetes As former smokers remain, they still had higher risk in
mellitus is high blood pressure. High blood pressure getting type 2 diabetes chronic complications of 1.66
would also increase the risk of heart disease.25 times compared with non-smokers.

Patients with type 2 diabetes dan chronic complications Promotive effort, such as providing precautions
frequently would causing polypharmacy, this will lead information regarding the elderly with type 2 diabetes
to the duration of the elderly treatment, and it even might be necessary. There are somc actions that need to
could cause death.26-28 Therefore the integrated health be enforced for instance periodically check the health
care system is required to monitoring the elderly condition (such as weight, waist circumference, blood
treatment.28,29 pressure, and blood sugar levels), reduce the cigarette
smoke, perform physical activity regularly, calorie
Conclusions balanced with healthy diet, have plenty of rest, and
control the stress. Educational objectives fromthese
Characteristics and behavior of elderly people with type actions are the elderly and their families, with
2 diabetes mellitus among the five groups of studies were understandable delivery. Elderly with type 2 diabetes
as follows: the 'No Smoking'; 'Ex-Smokers';' smoker 1-12 complications should control their weight, have light
cigarettes/day;' Smokers 13-24 cigarettes/day and smoker exercise regularly, and avoid smoking.
above 24 cigarettes/day. Approximately 70% of men
that catagorised as 'Ex-Smokers'; 'smoker 1-12 Therefore, the government needs to provide special
cigarettes/day' and 'Smokers over 24 cigarettes/day' had policy that can enhance the elderly or pre elderly
an average age that quite similar one to the other. The patients with type 2 diabetes in particular, thus the
proportion of gender was different among the five number of chronic complications can be reduced, which

Makara J. Health Res. April 2015 | Vol. 19 | No. 1

14 Trihandini

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Makara J. Health Res. April 2015 | Vol. 19 | No. 1