Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy Dovepress

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ORIGINAL RESEARCH

Family History, Consanguinity and Other Risk

Factors Affecting the Prevalence of Prediabetes
and Undiagnosed Diabetes Mellitus in Overweight
and Obese Yemeni Adults

1
Butheinah A Al-Sharafi Objective: Overweight and obese adults are at high risk for developing prediabetes and
Ahmed A Qais 1 diabetes. The aim of this study was to measure the prevalence of prediabetes (pre-DM) and
Khalil Salem 2 diabetes (DM) among Yemeni adults who were overweight or obese and had first-degree
Muneer O Bashaaib 2 relatives with DM, consanguinity and other risk factors.
Patients and Methods: This cross-sectional study included 612 adults, all with a BMI≥25 kg/
1
Department of Internal Medicine,
m2. BMI, blood pressure (BP) and waist circumference (WC) were measured in the clinic.
School of Medicine and Health Sciences,
Sana’a University, Sana’a, Yemen; Fasting blood glucose (FBG) was collected for all subjects. The patients either had first-degree
2
Department of Internal Medicine, relatives with diabetes or not, and the subjects answered a questionnaire regarding the consan­
University of Science and Technology
Hospital, Sana’a, Yemen guinity of their parents, exercise, khat chewing, smoking, and eating vegetables and fruits daily.
Results: Of the 612 study participants (32% males and 68% females) aged 20–70 years old,
429 (70.1%) had a family history (FM) of DM ± consanguinity of parents, and 183 (29.9%)
had no FM of diabetes. Multivariate analysis showed significant risk in those with class III
obesity for pre-DM (AOR 3.10 95% CI 1.56–6.18 p value 0.001) and DM (AOR 3.35 95%
CI 1.47–7.65 p value 0.004) and those who had siblings with DM had a risk for pre-DM
(AOR 1.72 95% CI 1.09–2.71 p value 0.02) and DM (AOR 2.24 95% CI 1.25–4.0 p value
0.007). Khat chewing increased the risk for pre-DM (AOR 1.61 95% CI 1.04–2.48 p value
0.032) and for DM (AOR 2.09 95% CI 1.14–3.82 p value 0.017). Having consanguineous
parents plus siblings with DM were associated with a higher risk of DM (p value 0.031).
Conclusion: There is a high prevalence of pre-DM and undiagnosed DM among overweight
and obese Yemeni individuals. Class III obesity, having siblings with DM, chewing khat, and
having consanguineous parents plus siblings with DM all increased the risk. This group
should be screened at an early age for early detection of pre-DM and DM.
Keywords: Yemen, prediabetes, diabetes, prevalence, overweight, obese, consanguinity,
khat-chewing

Introduction
Diabetes mellitus is a group of metabolic disorders with different etiologies defined
by elevated glucose levels in the serum or persistent hyperglycemia. It involves
abnormal insulin action, secretion or both.1 Type 2 DM is a very common form of
the disease, has been predicted to be a heterogeneous group of metabolic and
multifactorial disorders and is associated with serious complications that affect
the lifespan and quality of life.2 Pre-DM and type 2 DM are increasing in pre­
Correspondence: Butheinah A Al-Sharafi
Email balsharafi@hotmail.com valence worldwide. The International Diabetes Federation (IDF) estimates that

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a total of 463 million people have diabetes worldwide. number was seen at the University of Science and
This number is predicted to increase to 454 million Technology Hospital and Ibn Sina Hospital. All the
(8.0%) by 2030 and 548 million (8.6%) by 2045.3 patients were asked to answer a questionnaire, and an
Additionally, it is estimated that globally, 50% of people FBG was measured. Written informed consent was
with diabetes are unaware of their condition.3,4 The esti­ obtained from all the subjects. A total of 612 overweight
mated number of adults aged 20–79 years with impaired and obese subjects aged 20–70 years volunteered to enroll
glucose tolerance is 374 million (7.5% of the world popu­ in the study (all the subjects included in the study had no
lation in this age group). The importance of impaired history of hyperglycemia or DM in the past, and those who
glucose tolerance (IGT) and impaired fasting glucose had a history of hyperglycemia or DM were excluded from
(IFG) is that they signify a risk of developing type 2 the study). Fasting glucose levels were measured by
diabetes, and their detection can lead to interventions that a blood draw (196 males and 416 females). The subjects
can help prevent type 2 DM.3 Progression from predia­ were divided into 2 groups:
betes to type 2 diabetes is linked to the severity of hyper­ Group 1: the control group was overweight or obese
glycemia and associated with risk factors such as age and adults aged ≥20 years with no first-degree relatives with
weight. The cumulative incidence of type 2 diabetes pro­ diabetes (N= 183)
gression five years after diagnosis of IGT or IFG is esti­ Group 2: overweight and obese adults aged ≥ 20 with
mated to be between 26% and 50%, respectively.3 The one first degree relative or more with type 2 diabetes
American Diabetes Association (ADA) advises screening (N= 429)
at any age in adults with a BMI≥ 25 with any of the These groups were further divided into the following
following risk factors: first-degree relative with diabetes; sub-groups
high-risk race/ethnicity; history of cardiovascular disease;
hypertension (140/90 mmHg or on therapy for hyperten­ (a) Having 1 parent ± siblings with type 2 diabetes
sion); HDL cholesterol level <35 mg/dL (0.90 mmol/L) (b) Having 2 parents ± sibling with type 2 diabetes
and/or a triglyceride level >250 mg/dL (2.82 mmol/L); (c) Having 2 parents that were related ±siblings with
women with polycystic ovary syndrome; and physical type 2 diabetes (the degree of consanguinity was
inactivity and other clinical conditions associated with not discussed in detail, just if the parents were
insulin resistance.5 No recent studies have been performed related or not)
in adults in Yemen on the prevalence of pre-DM and type (d) Having siblings only with type 2 diabetes
2 DM among overweight and obese adults. The aim of our
study was to estimate the prevalence of pre-DM and All the subjects were asked to complete a questionnaire
undiagnosed type 2 DM among overweight and obese regarding their family history, history of exercise at least
first-degree relatives of patients with type 2 DM and 30 minutes per day, history of hypertension, eating vege­
among those who had consanguineous parents. This infor­ tables and/or fruit daily, khat chewing and smoking.
mation was recorded in addition to assessing other risk Female participants were also asked if they had a history
factors leading to pre-DM and type 2 DM among those of gestational diabetes.5,6 In the subjects for whom both
with a BMI≥ 25 by measuring the FBG and in those with parents with type 2 DM, they were asked if the parents
an impaired FBG to perform an oral glucose tolerance test were related, but the exact level of the relation was not
(OGTT) or with an FBG≥ 126 mg/dL. The HBA1c was requested. The body mass index (BMI) was calculated
also measured. (kg/m 2). Normal BMI was defined as BMI < 25, over­
weight as BMI 25–29.99, class I obesity BMI 30–34.99,
Patients and Methods class II obesity BMI 35–39.99 and class III obesity ≥ 40
This is a cross-sectional study that was performed at 3 according to the WHO classification.7 Waist circumference
different centers in Sana’a, Yemen, from May 2019 to was measured with a cutoff ≥ 88 cm for females and ≥
July 2021. The majority of the subjects were seen in 102 cm for males as a risk factor for cardiometabolic
a private endocrinology and diabetes center, the accompa­ disease.8 Blood pressure was measured by the nurse in
nying relatives coming with patients with type 2 diabetes the clinic using an electronic sphygmomanometer.
were asked to participate, and posters were put up in the The fasting glucose level was drawn in a plain tube,
clinic encouraging participation in the study. A smaller and after centrifugation, it was analyzed on the same day.

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FBG <100 mg/dL was considered normal, 100–125 mg/dL (70.1%) vs 29.9% with no diabetes in first-degree rela­
IFG and if the FBG was ≥126, the subject was considered tives. Over half of the subjects, 59.3% (N=363), were
to have type 2 diabetes. Subjects with an IFG were khat-chewers, and 19.6% (N=120) were smokers. Only
requested to undergo a standard oral glucose tolerance 18.8% (N=115) reported eating fruits or vegetables daily,
test (OGTT) according to ADA criteria (75 gm glucose 34% (N=208) reported doing at least 30 minutes of exer­
2-hour).5 The HBA1c was measured in patients who had cise daily, and 13.6% had a history of hypertension.
an FBG ≥126 mg/dl or in those with IFG if they were Table 2 shows the different measurements performed
unable to submit to an OGTT, if they were from out of on the subjects. A total of 14.7% had an elevated systolic
town and could not return the next day for an OGTT. blood pressure, and 16.5% had an elevated diastolic blood
A small number of patients (N=21) opted to undergo an pressure. The FBG was normal in 55.4% (N=339), and an
OGTT, and some opted to undergo HBA1c at the same impaired FBG was found in 34% (N=208). Diabetes was
time as the FBG. A level of <5.7% was considered normal, diagnosed when the FBG was ≥ 126 mg/dl, which was
5.7–6.4% prediabetes and ≥ 6.5% diabetes as classified by found in 10.6% (N=65) of the participants.
the ADA.5 Due to a lack of funding, only the FBG and the In patients with a family history of diabetes, the num­
clinic visit were free of charge; if the FBG was abnormal, ber of subjects with a normal FBG was lower than those
any other work-up, such as OGTT and HBA1c, was per­ without a family history of diabetes at 52.4% (N=225) vs
formed at the subjects’ expense. The FBG was performed 62.3% (N=114), but in those with an impaired FBG or an
on a complimentary basis by MedLabs in Sana’a, Yemen.
FBG≥126, the percentage was higher in the group with
The study was conducted in accordance with the principles
a family history of diabetes. In the group with an impaired
and guidelines of the Declaration of Helsinki for medical
FBG, 35.9% (N-154) had a family history of diabetes,
research involving human subjects.
29.5% (N=54) did not, and in the group with an FBG
≥126, 11.7% (N=50) had a family history of DM, and
Statistical Analysis
8.2% (N=15) had no family history (Table 3).
Categorical data are expressed as frequencies and percen­
Subjects who had an IFG were asked to have an OGTT
tages, while numerical variables are described as the
test. In those with a normal FBG, a total of 17 patients had
means and standard deviations. Chi-square tests, chi-
an OGTT, 58.8% were normal, 23.5% had an impaired
square tests with Yates’ correction, Fisher’s tests, and
OGTT, and 17.6% were diabetic. Among those with an
binary logistic regression were used to identify the statis­
IFG, 96 of the subjects had an OGTT, although it was
tical significance of the association between the groups
requested for all patients; some never returned for the
and the outcomes. Variables with a p value of less than
OGTT or HBA1c (N=30), some of the patients had an
0.2 were considered in the multiple logistic regression
model, which was used to calculate the significance of HBA1c instead of an OGTT if they were from out of town
association, the adjusted OR and 95% CI using the for­ and could not return the next day for an OGTT (N=80),
ward method. All tests with a p value <0.05 were consid­ and 2 patients could not be contacted regarding their
ered statistically significant. SPSS version 26 was used to abnormal FBG results.
enter and analyze the data. Figure 1 shows more details on the prevalence of
impaired FBS and type 2 DM, and is clear that type 2
Results DM in siblings was associated with a higher percentage of
A total of 612 subjects volunteered to participate in the type 2 DM in the subjects (19.1%) in comparison to 1
study (196 males and 416 females). The general character­ parent (9.1%) or 2 parents (9.5%) with type 2 DM. In the
istics of the subjects are shown in Table 1. subjects who had both related parents and siblings with
The mean age of the subjects was 39.5 (SD 9.5 95% CI diabetes, the percentage of subjects with type 2 DM
38.8–40.3) and the mean BMI was 32.1 (SD 5.7 95% CI increased to 27.8% (p value 0.031).
31.6–32.5), with 42.6% overweight and 57.4% obese. In Figure 2, we can see that waist circumference was
Among those who were obese, 33.5% (N=205) had class significantly correlated with BMI, but as indicated in
I obesity, 14.1% (N=86) had class II obesity and 9.8% Table 4, it was not significantly correlated with the FBG
(N=60) had class III obesity. The majority of the patients level (p value 0.933 for prediabetes and 0.548 for
had a family history of diabetes in first-degree relatives diabetes).

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Table 1 Characteristics of the Patients (N=612) Table 2 Parameters Measured in Patients

Variable Mean 95% CI of N % Variable Mean (SD) 95% CI of Mean N %
(SD) Mean
Systolic BP 119.2 (18.2) 117.8–120.7
Age (year) 39.5 (9.5) 38.8–40.3 (mmHg)
20–29 77 12.6 ≥ 140 90 14.7
30–39 254 41.5
< 140 522 85.3
40–49 178 29.1
Diastolic BP 77.0 (11.7) 76.1–78.0
≥ 50 103 16.8
(mmHg)
Sex
≥ 90 101 16.5
Male 196 32.0
< 90 511 83.5
Female 416 68.0
FBS (mg/dL) 102.4 (27.5) 100.2–104.6
Exercise
Yes 208 34.0
<100 339 55.4
No 404 66.0 100–125 208 34.0
Fruit and vegetable intake >125 65 10.6
Yes 115 18.8 RBS (mg/dL) 174.7 (86.3) 156.0–193.4
No 497 81.2 <140 31 36.9
Khat chewing 140–200 34 40.5
Yes 363 59.3 > 200 19 22.6
No 249 40.7 Not done 528
Smoking GTT
Yes 120 19.6 Normal 51 43.6
No 492 80.4 Impaired 41 35.0
Height (cm) 158.4 (8.8) 157.7–159.1
Diabetes 21 17.9
Weight (kg) 80.4 (15.0) 79.2–81.6
2
Not done 4 3.4
BMI (kg/m ) 32.1 (5.7) 31.6–32.5
Hba1c (%) 6.5 (1.4) 6.2–6.7
Overweight 261 42.6
< 5.7 28 18.8
Class I obesity 205 33.5
5.7–6.4 69 46.3
Class II obesity 86 14.1
Class III obesity 60 9.8
≥ 6.5 52 34.9
Waist circumference (cm) 98.4 (11.4) 97.5–99.3 Not done 463
F <88, M <102 199 32.5
F ≥ 88, M ≥ 102 413 67.5
Gestational DM
Yes 20 4.8
No 396 95.2 Table 3 Family History of DM and FBS Level
Parent DM Variable DM in Parents/ No DM in Parents/ p value
No DM 230 37.6 Sibling Sibling
1 parent 262 42.8
2 parents 74 12.1 N % N %
2 parents related 46 7.5
FBG (mg/dL) 0.073
Sibling DM
<100 225 52.4 114 62.3
Yes 184 30.1
100–125 154 35.9 54 29.5
No 428 69.9
>125 50 11.7 15 8.2
Family History of DM
(parents/siblings)
Yes 429 70.1
No 183 29.9 regarding pre-DM and DM, although DM was higher in
Hypertension males but did not reach clinical significance (p value
Yes 83 13.6
0.078). A significant risk for DM was found in the age
No 529 86.4
group 40–49 years old and in those with a history of
hypertension.
Multivariate regression analyses were performed to
In Table 4, the univariate analysis of the different risk examine the association of age, khat chewing, class III
factors for prediabetes and diabetes is shown. There was obesity and sibling DM and hypertension with pre-DM
no significant difference between females and males and DM (Table 5). When adjusted for all other variables,

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Figure 1 Prevalence of pre-DM and DM in relation to family history and consanguinity. The figure shows the percentage of subjects with prediabetes and diabetes in relation
to the number of first-degree relatives with diabetes in addition to the presence of consanguinity (p value 0.031).

Figure 2 Waist circumference was significantly correlated with BMI r= 0.65 (p value <0.001).

we observed that age (30–39 years) AOR 0.62 (95% CI obesity AOR 3.35 (95% CI 1.47–7.65), sibling DM AOR
0.4–0.96), khat-chewing AOR 1.61 (95% CI 1.04–2.48), 2.24 (95% CI 1.25–4.00) and hypertension AOR 3.64
Class III obesity AOR 3.10 (95% CI 1.56–6.18) and his­ (95% CI 1.84–7.18).
tory of DM in siblings AOR 1.72 (95% CI 1.09–2.71)
were all significant risk factors for the development of pre- Discussion
DM. Significant risk factors for the development of DM The results of our study show that among overweight and
included age (40–49 years) AOR 1.82 (95% CI 1.0–3.33), obese Yemeni adults aged 20–70 years, the prevalence of
khat-chewing AOR 2.09 (95% CI 1.14–3.82), Class III prediabetes was 34%, and 10.6% had diabetes according to

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Table 4 Univariate Analysis Showing Risk Factors for Pre-DM and DM*
Variable Total Normal Pre-DM DM

N % N % p value OR 95% CI N % p value OR 95% CI

Age (years)
20–29 77 46 59.7 27 35.1 1.00 4 5.2 1.00
30–39 254 159 62.6 70 27.6 0.307 0.75 0.43–1.30 25 9.8 0.294 1.81 0.60–5.46
40–49 178 81 45.5 74 41.6 0.128 1.56 0.88–2.75 23 12.9 0.039 3.27 1.06–10.03
≥ 50 103 53 51.5 37 35.9 0.592 1.19 0.63–2.24 13 12.6 0.087 2.82 0.86–9.26
Sex
Male 196 103 52.6 66 33.7 0.741 1.07 0.73–1.55 27 13.8 0.078 1.63 0.94–2.81
Female 416 236 56.7 142 34.1 1.00 38 9.1 1.00
Exercise
Yes 208 117 56.3 72 34.6 0.981 1.01 0.70–1.44 19 9.1 0.409 0.78 0.44–1.40
No 404 222 55.0 136 33.7 1.00 46 11.4 1.00
Fruit and vegetable intake
Yes 115 64 55.7 37 32.2 0.750 0.93 0.59–1.46 14 12.2 0.619 1.18 0.62–2.26
No 497 275 55.3 171 34.4 1.00 51 10.3 1.00
Khat chewing
Yes 363 187 51.5 130 35.8 0.091 1.36 0.95–1.93 46 12.7 0.020 1.97 1.11–3.50
No 249 152 61.0 78 31.3 1.00 19 7.6 1.00
Smoking
Yes 120 63 52.5 44 36.7 0.462 1.18 0.76–1.81 13 10.8 0.789 1.10 0.56–2.13
No 492 276 56.1 164 33.3 1.00 52 10.6 1.00
BMI (kg/m2)
Overweight 261 145 55.6 92 35.2 1.00 24 9.2 1.00
Class I obesity 205 116 56.6 70 34.1 0.804 0.95 0.64–1.41 19 9.3 0.975 0.99 0.52–1.90
Class II obesity 86 57 66.3 18 20.9 0.021 0.50 0.28–0.90 11 12.8 0.698 1.17 0.54–2.54
Class III obesity 60 21 35.0 28 46.7 0.020 2.10 1.13–3.92 11 18.3 0.008 3.17 1.36–7.39
Waist circumference (cm)
F <88, M <102 199 112 56.3 68 34.2 0.933 0.98 0.68–1.422 19 9.5 0.548 0.84 0.47–1.50
F ≥ 88, M ≥ 102 413 227 55.0 140 33.9 1.00 46 11.1 1.00
Gestational DM
Yes 20 8 40.0 9 45.0 0.180 1.93 0.73–5.12 3 15.0 0.386 2.44 0.62–9.65
No 396 228 57.6 133 33.6 1.00 35 8.8 1.00
Parent DM
No DM 230 131 57.0 75 32.6 1.00 24 10.4 1.00
1 parent 262 144 55.0 93 35.5 0.540 1.13 0.77–1.66 25 9.5 0.862 0.95 0.52–1.74
2 parents 74 40 54.1 26 35.1 0.662 1.14 0.64–2.01 8 10.8 0.844 1.09 0.46–2.62
2 parents related 46 24 52.2 14 30.4 0.959 1.02 0.50–2.09 8 17.4 0.198 1.82 0.73–4.52
Sibling DM 1.019
Yes 184 84 45.7 73 39.7 0.010 1.64 1.13–2.39 27 14.7 0.006 2.16 1.24–3.74
No 428 255 59.6 135 31.5 1.00 38 8.9 1.00
Family history of DM 1.642
Yes 429 225 52.4 154 35.9 0.059 1.45 0.99–2.12 50 11.7 0.095 1.69 0.91–3.14
No 183 114 62.3 54 29.5 1.00 15 8.2 1.00
Hypertension
Yes 83 35 42.2 30 36.1 0.150 1.46 0.87–2.47 18 21.7 <0.001 3.33 1.74–6.35
No 529 304 57.5 178 33.6 1.00 47 8.9 1.00
Systolic BP (mmHg)
≥ 140 90 42 46.7 34 37.8 0.194 1.38 0.85–2.25 14 15.6 0.051 1.94 0.99–3.81
< 140 522 297 56.9 174 33.3 1.00 51 9.8 1.00

(Continued)

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Table 4 (Continued).

Variable Total Normal Pre-DM DM

N % N % p value OR 95% CI N % p value OR 95% CI

Diastolic BP (mmHg)
≥ 90 101 50 49.5 34 33.7 0.615 1.13 0.70–1.82 17 16.8 0.024 2.05 1.09–3.84
< 90 511 289 56.6 174 34.1 1.00 48 9.4 1.00
GTT 1.129
Normal 51 10 19.6 41 80.4 1.00 0 0.0 1.00
Impaired 41 4 9.8 35 85.4 0.232 2.13 0.62–7.41 2 4.9 -
Diabetes 21 3 14.3 16 76.2 0.715 1.30 0.32–5.35 2 9.5 -
Not done 4 0 0.0 4 100.0 0.999 - 0 0.0 -
Hba1c (%) 1.301
< 5.7 28 9 32.1 17 60.7 1.00 2 7.1 1.00
5.7–6.4 69 11 15.9 41 59.4 0.203 1.97 0.69–5.62 17 24.6 0.026 6.96 1.26–38.44
≥6.5 52 0 0.0 22 42.3 0.998 - 30 57.7 0.998 -
Note: * P-value and OR were calculated for Pre-DM and DM patients separately against the Normal.

Table 5 Multivariate Analysis of Risk Factors for Pre-DM and DM

Variable B S.E. Wald p value AOR 95% CI

Lower Upper

Pre-DM against Normal

Age (30–39 years old) −0.48 0.23 4.54 0.033 0.62 0.40 0.96
Khat chewing 0.48 0.22 4.62 0.032 1.61 1.04 2.48
Class III obesity 1.13 0.35 10.32 0.001 3.10 1.56 6.18
Sibling DM 0.54 0.23 5.40 0.020 1.72 1.09 2.71
DM against Normal
Age (40–49 year) 0.60 0.31 3.79 0.051 1.82 1.00 3.33
Khat chewing 0.74 0.31 5.67 0.017 2.09 1.14 3.82
Class III obesity 1.21 0.42 8.22 0.004 3.35 1.47 7.65
Sibling DM 0.80 0.30 7.33 0.007 2.24 1.25 4.00
Hypertension 1.29 0.35 13.80 <0.001 3.64 1.84 7.18

the FBG when using the ADA criteria for diagnosis. Over A recent study performed on Yemeni school-aged chil­
half of our patients were obese (57.4%), and 9.8% of the dren who were 12–13 years old showed that the preva­
patients had class III obesity with a BMI ≥ 40 according to lence of prediabetes as defined by an IFG was 0.86%.10 In
the WHO classification of obesity.7 The group with class neighboring countries such as Saudi Arabia, abnormal
III obesity was found to have a significant association with glucose metabolism in children and adolescents exceeds
prediabetes (p value 0.001) and diabetes (p value 0.004). 10%.11
This is the first study to the best of our knowledge, after In our study, we studied high-risk adults who were
searching the literature, to address the prevalence of pre- overweight or obese with a family history of diabetes in
DM and DM in overweight and obese Yemeni patients. first-degree relatives and some with parents with DM and
The last study performed on the prevalence of type 2 DM related conditions. According to the ADA criteria, these
in Yemen was in 2006 by Gunaid et al, which showed the are people who should be screened at any age.5
overall age-standardized prevalence of diabetes to be 6.3% In our study, in the younger age group, subjects who
and for either IFG/IGT to be 9% for the age range 30–64 were often not screened were aged 20–29 years old, 35.1%
years among Yemeni adults.9 had an IFG, and 5.2% were diabetic. In the 30–39 year-old

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group, the risk of diabetes increased to 9.8%. When com­ be a risk factor for obesity, which is a multifactorial/het­
pared with other studies in Ethiopia among 20–29 year-old erogeneous disease that leads to medical complications
subjects, 1.5% had IFG, and 1% had undiagnosed diabetes, such as type 2 DM.25 Genetic studies have shown ACE
but these included all subjects regardless of BMI.12 In gene polymorphism through allele frequencies to be asso­
Iran, among overweight subjects, the prevalence of pre­ ciated with obesity in the offspring of consanguineous first
diabetes was 31.6% and diabetes was 16%; in obese sub­ cousins in Saudi Arabia.26
jects aged 20–65 years old, the prevalence of prediabetes Consanguinity is common in Yemen and was shown to
was 34.6% and diabetes was 21.1%; and in the younger have an incidence of 44.7% in Sana’a, with 71.6% being
age group (20–34.9 years), 26.9% had prediabetes and first cousin marriages and 32% being all marriages.27 In
3.5% had diabetes, which was lower than in our patients, our study, we asked if the parents were related but did not
but this result was for all BMIs and regardless of family ask the degree of relation between them, but we still found
history.13 Another study in Iran showed that first degree that those with both parents with DM and related parents,
relatives of people with type 2 DM who were overweight the prevalence of diabetes was higher than if not related.
or obese were at much higher risk of diabetes (10.2%) and In addition, if the siblings had DM, the prevalence of
IFG (16.6%) than non-obese relatives in whom the pre­ diabetes increased to 27.8% in this group (p value 0.031).
valence of diabetes was (6.8%) and IFG (14.8%).14 Khat chewing was significantly correlated with
Among Kuwaiti adults, prediabetes was found in 47.9% increased prediabetes and diabetes in our patients, with
according to the FBG criteria and 6.9% had type 2 DM by
over half of our subjects being khat chewers (59.3%). In
FBG, this is in a group of subjects who were primarily
Yemen, it is a common belief among our patients who khat
overweight and obese (43.6% and 37.1%, respectively).15
chewing has a beneficial effect on DM.24 Khat chewing
In a study on adult males in Saudi Arabia in which 32.3%
has been shown to be a risk factor for developing type 2
were overweight and 36.2% were obese, the prevalence of
DM at a younger age in a study in Yemen and increased
prediabetes was 27.6%, and the prevalence of diabetes was
the risk of diabetes in a study in Saudi Arabia.28,29
9.2%.16 In females in Saudi Arabia, a study showed the
Hypertension and diabetes are common diseases, and it
crude prevalence of prediabetes to be 18.8% and diabetes
is recommended that clinicians screen adults with hyper­
to be 3.8% in a group of women in whom 23.4% were
tension and a BMI≥ 25 for DM.5 In our study, we found
overweight and 22.6% were obese.17
hypertension to be significantly correlated with an
A systemic review and meta-analysis of 55 articles on
increased prevalence of diabetes (p value <0.001). Other
prediabetes and undiagnosed type 2 diabetes in the Eastern
studies have shown similar results.30,31
Mediterranean region showed that 12.9% had prediabetes
Central obesity or increased waist circumference (WC)
and 5.4% had diabetes.18 Our patients were all overweight
has been shown to increase the risk of type 2 DM in many
and obese, and in those with one first degree relative or
studies.32–34 Among our patients, we did not find any
more, the risk of prediabetes and diabetes was very high,
at 47.6%. In those with siblings with diabetes, the risk was significant increase in prediabetes and diabetes among
higher than for those with both parents with diabetes our patients with a WC in females ≥ 88 cm and in males
(19.1% vs, 9.5%). Other studies have also shown that in ≥ 102 cm, as recommended by the American Heart
subjects with siblings having a history of type 2 diabetes, Association as a cutoff for increased risk of diabetes,35
the risk of developing diabetes was higher than in those but we did find a significant correlation with BMI (p value
who had parents who were diabetic.19,20 The majority of <0.001).
the adults who volunteered to participate in our study were Exercise improves blood glucose control in type 2
spouses, siblings and offspring of patients with DM. diabetes, and regular exercise may prevent or delay type
Another study has shown that spouses of patients with 2 diabetes development.36,37 Among our patients, only
DM were at higher risk of having diabetes than those 33.9% said they exercised for approximately 30 minutes
whose spouses did not have diabetes.21 a day, and although the percentage of those with diabetes
Consanguinity and a family history of diabetes among was slightly higher in the subjects who did not exercise, it
parents has also been shown to increase the risk of pre­ did not reach clinical significance (11.4% vs 9.1% p value
diabetes in Pakistan and in other studies in Qatar and 0.409), which may be because a detailed history regarding
Saudi Arabia.22–24 Consanguinity has also been found to exercise was not taken during our study.

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Eating a healthy diet is important for preventing cardi­ highest in those with class III obesity, and in those with
ovascular disease, cancer and type 2 DM, and fruits and first-degree relatives, especially for those with siblings and
vegetables (not including potatoes) should make up half of consanguinous parents with DM, the risk was high. Other
a meal.38 When the subjects were asked about eating vege­ risk factors included khat chewing, hypertension, and
tables and fruits, only 115 (18.7%) said they ate vegetables being in the 30–39-year-old age group for prediabetes
or fruit on a daily basis, and most of them complained about and 40–49 years old for diabetes. Further studies are
the cost of fruit with the decreased income due to the war in needed regarding consanguinity and khat chewing and
Yemen. Additionally, many of our patients had limited the relation to pre-DM and type 2 DM in larger popula­
knowledge about what a healthy diet was. tions, including adults with normal weight. Education of
Class III obesity was significantly correlated with an doctors and the general population about screening over­
increase in prediabetes and obesity in our study when com­ weight and obese adults at any age can lead to early
pared with those who were overweight. Having a BMI≥ 25 detection, and interventions in the group with prediabetes
has been associated with an increased risk of prediabetes and can prevent progression to diabetes. Early detection and
diabetes in many studies in the region.39–43 We do not have treatment of diabetes can help prevent the development of
any studies set in Yemen showing the prevalence of obesity complications in these patients.
among the general population, but among patients with dia­
betes, it is lower than that of neighboring countries in the Data Sharing Statement
gulf.44 In 2 previous studies in Yemen, with the first done in The data used to support the findings of this study are
2014, the results showed the prevalence of patients with type available from the corresponding author upon request.
2 DM with a BMI≥ 25 to be 58.3% with 28.8% being obese.
A three-year study published in 2020 did not show Ethics Approval and Informed
a significant increase in obesity among females with type 2
Consent
DM from the previous study (p value 0.117), but among the
This study was approved by the ethical committee at the
males with type 2 DM, the prevalence of obesity increased
University of Science and Technology Hospital. Written
from 32.3% to 33% (p value 0.035).45,46
informed consent was obtained from all the study
The strength of our study is that it is the first to show the
participants.
prevalence of prediabetes and undiagnosed diabetes in over­
weight and obese Yemeni adults with a family history of
Acknowledgments
diabetes. Our study shows that in Yemeni adults who are
We wish to thank Professor Abdullah A. Gunaid for his
overweight and obese, screening should start at an early age,
guidance and advice and Dr. Farouk Al-Qadasi for per­
because these adults are at high risk of developing prediabetes
forming the statistical analysis. Additionally, we would
and diabetes. In adults with first-degree relatives who have
like to thank the nurses in the clinics who helped measure
type 2 DM, consanguinity of the parents, siblings with type 2
the blood pressure, heights and weights of the participants.
DM, khat chewers, and those a history of hypertension are at
We also wish to thank all the participants who had blood
high risk for developing diabetes in the future. The limitations
work performed on their own expense and brought back
of our study are that it was performed on a high-risk group, and
the results to our clinic, and we wish to thank the MedLabs
larger studies in the general population, including those with
laboratory for performing the complimentary FBG for all
a normal BMI, must be performed to measure the overall
the participants we sent to them.
prevalence in Yemen, including people from different areas
of Yemen. In our study, we depended primarily on FBG to
diagnose adults with prediabetes and diabetes, with only
Disclosure
The authors declare that they have no conflicts of interest
a small number undergoing an OGTT or HBA1c due to
in this work.
a lack of funding.

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