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ORIGINAL ARTICLE
Year : 2022 | Volume
: 8
| Issue : 2 | Page : 102-108
The proportion of hand and knee osteoarthritis and its associated risk factors among an urban diabetic population
Barsha Gadapani Pathak, S Rahini, Rukman Mecca Manapurath
Department of Community Medicine, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
Correspondence Address:
Dr. S Rahini
Department of Community Medicine, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijam.ijam_115_21
Introduction: Osteoarthritis (OA) is found to be a leading cause of disability in people with diabetes mellitus (DM). This study aimed to find the proportion of knee OA and hand OA and its risk determinants among people with DM.
Materials and Methods: A cross-sectional study was conducted among 258 diabetic subjects attending the general outpatient department of a tertiary care hospital over 4 months. A predesigned case record form was used to collect details on sociodemographic profiles and various factors related to OA. The American College of Rheumatology criteria were used for the diagnosis of both knee and hand OA. Data analysis was done using the SPSS version 16. Chi-square/Fisher's exact test was used wherever applicable to find the association of various factors with OA.
Results: The overall proportion of OA in diabetic subjects was 48.4%. The proportion of only hand OA was 25.2%, only knee OA was 14.3%, and both hand OA and knee OA were 8.9%. Age, female sex, duration of DM, irregularity in taking diabetic medications, hypertension, menopause, and body mass index were found to be significantly associated with both hand and knee OA. Physical inactivity and previous joint injury were found to be associated with knee OA. An inverse association with alcohol consumption was found. On logistic regression, we found irregularity in taking diabetic medication to be a significant risk factor for hand and knee OA. The duration of DM and taking alternate medications for DM were also found to be significant risk factors for hand OA. Prior knee injury is a significant risk factor for knee OA.
Conclusion: There exists an association between OA and DM, and this suggests the need for early diagnosis, good disease management, and medication adherence and to implement preventive strategies so as to prevent further disabilities and improve quality of life.
The following core competencies are addressed in this article: Patient care and procedural skills, Medical knowledge, Systems-based practice, Practice-based learning and improvement.
Keywords: Diabetes mellitus, hypertension, obesity, osteoarthritis, quality of life
Diabetes mellitus (DM) is a chronic metabolic disorder characterized by either reduced secretion of insulin (Type 1 DM) or insulin resistance (Type 2 DM), leading to hyperglycemia. The global prevalence of DM in 1980 was 108 million which rose to 422 million in 2014 and is expected to rise to 592 million by 2035. The global prevalence of DM among the 20–79 years age group was 463 million in 2019 and is expected to rise to 700 million by 2045 as per the International Diabetes Federation.[1] The prevalence of DM in India is 77 million in 2019 and is expected to increase to 101 million in 2030 and 134 million by 2045, as per the report. India stands second next to only China in terms of the highest number of cases of DM.[2],[3] The most common complications of DM are cardiovascular, nephropathy, retinopathy, and peripheral neuropathy.[4]
Musculoskeletal pain is also a common problem in diabetes patients.[5] However, the epidemiological aspects of musculoskeletal pain are less well established, and it is a major cause of morbidity. Osteoarthritis (OA) is one of the most common causes of musculoskeletal pain in diabetics.[6] In the aged population, OA is considered to be a driving force of increased health costs and a major source of morbidity placed just next to cardiovascular disease, DM II, and dementia.[7] In the recent studies published, diabetes is considered an independent risk factor of OA. In diabetes, there is a deposition of advanced glycated products over the joints which causes the release of inflammatory mediators and damages the cartilage.[8] In addition, hyperglycemia can cause peripheral neuropathy, which leads to biomechanical joint instability and consequently, OA develops over time.
The overall prevalence of OA among diabetes patients is 29.5%.[9] In DM, the prevalence of OA of the hand is 38.4%, OA of the hip is 12.3%, and OA of the knee is 17.2%.[9] One of the most remarkable findings in the latest studies was that diabetes was associated with self-reported hand pain and erosive OA.[10] OA is associated with substantial disease burden due to pain, functional decline, and increase in morbidity. In the major studies conducted all over the world, OA is found as a common disability and painful comorbid condition which has a large impact on quality of life.[11] Besides disability, it also adds to increased economic burden. The treatment received for OA can be expensive for the patients and their families. There is also a terrible loss in work productivity. It is found that diabetic patients suffering from hand OA are also at increased risk of suffering from knee OA. OA knee patients, if left untreated, live a sedentary lifestyle due to the pain and disability associated with it, which can place them at increased risk of cardiovascular and cerebrovascular disorders.[12] Hence, it is very important to evaluate the factors associated with OA in diabetes at an early clinical stage so that necessary interventional strategy can be undertaken. Hence, this study was conducted to evaluate the association of hand OA and knee OA among DM patients and determine the risk factors associated with it.
Materials and MethodsThis was a cross-sectional study design conducted over a period of 4 months from August 2019 to November 2019 at the general outpatient department (OPD) of a tertiary care hospital in the city of Mumbai. It is an 1800-bedded hospital which treats about 1.8 million outpatients and 85,000 in-patients annually. The hospital is funded by the Municipal Corporation of Mumbai and caters to different strata of population and provides all basic and advanced care treatment facilities. The hospital runs a general outpatient unit which provides basic medical services for fever, cold, cough, gastroenteritis, etc., and referral services. The general OPD also maintains a morbidity register and record of all patients attending the clinic.
Diabetic patients presenting to the general OPD were first identified based on the presence of any of the blood sugar reports in the past 1 year or their treatment records for our study purpose. We included diabetic patients above the age group of 21 years of either sex. We excluded patients with rheumatological disorders and those who are either seriously ill requiring immediate care/hospitalization or those who do not give consent for radiological examination. The sample size of 258 was calculated using the formula N = 4PQN/e2 (N-1)+4 PQ, where the prevalence of OA was considered 29.5% as per the previous studies, and allowable error was considered 10%. The study was conducted after taking approval from the institutional ethics committee. The participants were recruited by consecutive sampling technique, which is a type of nonprobability sampling and allows every subject based on the inclusion and exclusion criteria until the required sample size was achieved. After obtaining consent, a history regarding pain or swelling over the joints was obtained, and clinical examination was carried out. Radiological examination of the knee (anteroposterior view) was done with the patient's consent. X-ray hand was not done. We used the American College of Rheumatology (ACR) clinical criteria for the diagnosis of hand OA and ACR clinicoradiographic criteria for the diagnosis of knee OA.[13],[14]
All responses were tabulated using Microsoft Excel Software. Data were analyzed using IBM SPSS Statistics for Windows, Version 16.0 (IBM Corp. Armonk, NY, USA). The categorical variables were described in terms of frequencies and percentages. Chi-square test was applied to find the association of various risk factors on hand OA and knee OA separately, and P < 0.05 was considered statistically significant at 95% confidence limit. Binomial logistic regression was done to assess the effect of risk determinants of OA hand and OA knee among diabetic individuals.
ResultsOut of 258 diabetic subjects, 121 (46.6%) were males and 137 (53.1%) were females. The majority of the study subjects (41.5%) were in the age group of 51–65 years. About 71.7% of the study subjects belonged to upper lower socioeconomic status (SES) as per the modified Kuppuswamy SES scale. Out of 258 study subjects, 10 individuals had Type 1 DM and 248 had Type 2 DM [Table 1].
The overall proportion of OA among 258 diabetic subjects in our study was 125 (48.4%), among which 41 (32.8%) were males and 84 (67.2%) were females. OA hand was found to be in 25.2% (65) of study subjects, out of which 21 were males and 44 were females. The proportion of study subjects with only OA knee was 37 (14.3%), out of which 12 were males and 25 were females. Combined OA hand and OA knee were seen in 23 (8.9%) of the study subjects, with males being 8 (34.8%) and females 15 (65.2%) among them. OA was found to be more in females as compared to males in our study [Figure 1]. [Figure 2] shows narrowing of joint space on knee X-ray.
Figure 1: The proportion of OA hand and OA knee among study subjects. OA: Osteoarthritis
Figure 2: X-ray knee AP view showing narrowing of joint spaces with osteophytes. AP: AnteroposteriorOn univariate analysis, we found age, female sex, duration of DM, irregularity of taking diabetic medications, hypertension, menopause, and increased body mass index to be significantly associated with both OA hand and OA knee. Alcohol consumption was found to have an inverse relationship with both OA knee and OA hand. We found a proportional increase in OA hand and OA knee with an increase in age and more prevalent in females which was found to increase after menopause. Both OA hand and OA knee were found to increase with the increase in the duration of DM. Persons with OA knee were found to be involved with less physical activity and those who had a previous history of injury were at higher risk for OA knee and this association was statistically significant.
Education status and smoking were not found to be significantly associated with both OA knee and OA hand. Occupation, SES, the time between diagnosis of diabetes and treatment, and physical inactivity were associated with OA knee and not associated with OA hand. The type of diabetic medications taken was found to be only associated with OA hand. OA hand was found to be significantly associated with those taking Ayurveda (46.7%) and Unani/homeopathy (45%) as compared to those who take allopathic (24.5%) medications for DM. The allopathic medications commonly taken by the participants were metformin, glimepiride, pioglitazone, rosiglitazone, or gliclazide. The association of OA with bleeding disorder and Type of diabetes could not be found in our study as only two of the study subjects had a bleeding disorder and 10 had Type 1 diabetes.
Binomial logistic regression was done to find the effect of risk factors on OA knee and OA hand among diabetic subjects. Duration of DM and irregularity in taking diabetic medications, taking alternative medications for DM were found to be significantly associated with OA hand, and the previous history of knee injury and irregularity in taking diabetic medications was found to be significantly associated with OA knee as shown in [Table 2].
Table 2: Findings from binary logistic regression for risk factors determining osteoarthritis knee and osteoarthritis hand among diabetic individuals Discussion DM leads to OA by insulin resistance and chronic hyperglycemia which induces oxidative stress and deposition of advanced glycation end products in the joint.[8],[15] In our study, the overall proportion of OA in diabetic subjects was 48.4%, with only OA hand 25.2%, only OA knee 14.3%, combined OA hand and OA knee was 8.9%. Twenty-two of our study subjects had significant radiological changes in the knee. Our study did not find an association between type of DM and OA as there were only 10 participants with Type 1 DM. However, with the increase in the duration of DM, increase in both hand OA and knee OA was found, which is similar to the previous studies.[16],[17] Those who have discontinued the diabetic treatment for a month or skipped medications 2–3 times a week for a month or not taking medicines as per physician's advice were considered to be on irregular treatment. Both hand and knee OA were found to occur more in those who take medicines irregularly. Hand OA was found to increase in those who take Ayurveda, Unani, or Homeopathic medications compared to allopathic medication. Knee OA was found to increase if there is a delay in the initiation of treatment for DM. All these can be attributed to the uncontrolled blood sugar level leading to prolonged hyperglycemia which can further cause an increase in the progression of OA.[8]
Both hand OA and knee OA were found to increase with the increase in age as old chondrocytes secrete inflammatory mediators leading to joint destruction. This is similar to other studies conducted so far.[18],[19] Our study found the prevalence of both hand and knee OA to be more among females as compared to males.[12],[20] Among females, OA was seen more among those who had attained menopause which can be attributed to the hormonal involvement as supported by the literature.[21],[22]
Hypertension plays a role in OA by causing narrowing of blood vessels and thus subchondral ischemia.[23] In our study, hypertension was found to be a significant risk factor for both knee and hand OA.[12],[24] Obesity was found to be a risk factor for both knee OA and hand OA in our study. Various theories have been suggested for the association of OA in obese individuals ‒ mechanical overload over knee joint, high leptin levels in synovial fluids, and release of inflammatory mediators by adipose tissue being few.[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25] Our study did not record serum lipid levels, and hence, we could not find the association of metabolic syndrome with OA as suggested by previous studies.[26],[27],[28] Our study found physical inactivity to be a significant factor associated with knee OA which can be attributed to the pain and disability associated with knee OA.[29]
Those who had a previous history of injury had a higher chance of developing knee OA in our study.[30] Individuals with bleeding disorder are more prone to bleeding within the joints, inadequate treatment of which leads to joint destruction and arthritis.[31] However, our study could not find the association as only two of our study participants had a bleeding disorder. Our study did not find any significant association between smoking and any OA.[32] Hand OA and knee OA were found to have an inverse relationship with alcohol consumption.[29],[32] Studies on smoking and alcohol are limited, and there has been a contradictory finding in many studies, and the reasons are unclear.[33],[34] There was no association between educational status and any OA in our study. Only knee OA was found to be more among unemployed followed by those involved in professional or semiprofessional occupations and those who belonged to upper-middle class followed by lower-middle-class status and these associations were found to be statistically significant. However, our study did not focus much on the association of job nature of the participants[33] with OA.
Strengths and limitations of the study
The main strength of the study is that radiological examination of the knee was done for all study subjects. The study helped in quantifying the problem of OA in diabetics and understanding the importance of early screening for the same. The limitation of the study is the fact that it is a cross-sectional study, and causal association could not be found. Second, it is hospital based, and the sample size is less; hence, the results cannot be generalized to the entire population. Third, our study did not estimate the cardiovascular risk present in these individuals.
Future propositions
This study can be done in a community among a larger population to understand the prevalence of the disease in the community and compare it to the prevalence in other countries. Further, longitudinal studies will help us to understand the causal association better. The occupational association of OA and the association of smoking and alcohol could be further explored. OA of the hip and spine can also be studied.
ConclusionThere is an increased risk of OA in patients with DM and both DM and OA have shared risk factors such as aging and obesity. As OA progresses, it results in disability which causes movement restrictions and affects the daily activities of the individual which, in turn, poses the individual at higher risk of cardiovascular and cerebrovascular incidents. Thus, early screening for OA is important among people with DM which may help prevent disability, help reduce the risk of cardiovascular complications, and further reduce the economic burden of surgery, ultimately improving their quality of life. Maintaining blood sugar levels within normal limits also help in the control of the severity of OA or OA progression.
Financial support and sponsorship
The study was funded by Diamond Jubilee Society Trust (DJST) of Seth G.S Medical College and K.E.M Hospital.
Conflicts of interest
There are no conflicts of interest.
Ethical conduct of research
The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require the Institutional Review Board/Ethics Committee review, and the corresponding protocol/approval number is EC/OA-91/2017.
References
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