Abstract
Background
Type 2 diabetes is the most common diabetes in the world and constitutes a high percentage of diabetes cases. This study aims to determine the overall prevalence of gastrointestinal complaints in Iranian patients with type 2 diabetes.
Methods
The articles were extracted based on entry and exit criteria by searching the Cochrane (Embase), ScienceDirect databases. Scopus PubMed; And Web of Science (WoS), based on PRISMA 2009. To evaluate the studies, a 22-item STROBE checklist was selected and related items were used.
Results
The probability of publication bias in reporting the results was examined by the Egger test (P = 0.891). The prevalence rate of gastrointestinal complaints in patients with type 2 diabetes in Iran in 10 studies was 52.3% (95% CI: 33.4–70.7%). The results of metargression showed a significant difference between the sample size and the prevalence of gastrointestinal complaints in patients with type 2 diabetes (P < 0.05). and the prevalence of gastrointestinal complaints in patients with type 2 diabetes.
Conclusion
The results of this study report that, the prevalence of gastrointestinal complications in type 2 diabetes patients was high. As a result, appropriate measures should be taken to improve the condition of diabetic patients through appropriate policy-making and providing feedback to hospitals and patients.
Keywords: Gastrointestinal complaints, Diabetes mellitus, Meta-analysis
Background
Diabetes is a chronic metabolic disease that has spread worldwide with increasing urbanization and lifestyle changes [1]. Diabetic mellitus is now a major health, medical, and economic issue for people worldwide. According to the World Health Organization (WHO), the number of people with diabetes will increase to more than 300 million by 2030 [2]. It is estimated that by 2025, more than 75% of all people with diabetes will be in underdeveloped countries [3].
In Iran, 12% of the population over the age of 18 years suffer from this type of DM, and an average of 500,000 individuals are added to the population of patients with DM annually [4]. The prevalence of type 1 and type 2 diabetes is increasing all countries, especially type 2 DM. Indeed, Iran is no exception to this rule, given its growing trend. The most prominent gastrointestinal complaints include delayed gastric emptying, gastroparesis, small and large intestinal motility alteration, gastroparesis with anorexia, nausea, vomiting, early satiety, and bloating. Parasympathetic dysfunction caused by chronic hyperglycemia contributes to gastroparesis emergence, and hyperglycemia directly disrupts gastric emptying. Intermittent nocturnal diarrhea or constipation is a common characteristic of gastrointestinal autonomic neuropathy associated with DM [5].
Recent physiological evidence reports that widespread changes in the reduction and increase in blood sugar levels of individuals affect the sensation of pain in the gastrointestinal tract [6]. Therefore, digestive symptoms are expected to improve by controlling blood sugar. Based on the evidence provided in the reference study, Upper and lower gastrointestinal problems in diabetic patients with complaints, especially neuropathy and nephropathy, and gastrointestinal symptoms related to glycemic control [6].
The prevalence rate of gastrointestinal complaints varies across different ethnic groups [8]. In general, gastrointestinal symptoms occur in 30 to 76% of patients [7–9]. There is some disagreement about the effect between gastrointestinal complaints in diabetic patients and factors like blood glucose control, diabetes form [10–12]. Most gastrointestinal complaints are caused by a decrease in gastrointestinal motility [13]. However, more evidence nowadays suggests that gastrointestinal complaints are multifactorial and that increased blood glucose alone can cause motor impairment [14, 15].
Gastrointestinal complaints in individuals with diabetes are reported to increase mental distress, depression, anxiety, and neuroticism. However, it is questionable whether the mental distress causes gastrointestinal symptoms or the gastrointestinal symptoms cause an increase in anxiety and depression levels [16].
According to a study conducted in 1996, hyperglycemia affects the perception of the pain of the upper gastrointestinal system [17]. In a study on 143 patients with DM, Enck et al. found that the gastrointestinal complaints in patients with type 2 diabetes were not dependent on the presence of neuropathy (this study was performed on the perception of vibration and resolving power). However, in patients with type 1 diabetes, those with neuropathy reported a higher prevalence of gastrointestinal symptoms than those without this complaint [18]. In a study on 114 patients with DM (selected from a diabetes center), Clouse and Lustman reported that gastrointestinal symptoms were poorly dependent on neuropathic complaints [19, 20]. this study was carried out in an effort to determine the prevalence of gastrointestinal complaints among Iranian patients with type 2 DM.
Methods
This study evaluated the overall prevalence of gastrointestinal complaints in patients with type 2 diabetes in Iran based on the articles published in November 2001 and January 2021. In order to do this, search the databases, Including Iranian bases and Google Scholar, Cochrane, Embase, ScienceDirect, Scopus, PubMed, and WoS, were searched with keywords including Prevalence, Complaints, Digestive, Diabetes, and Iran. the questions in this study were selected by PECO criteria.
PECO criteria included: Participants: Iranian population, Exposure: patients with type 2 diabetes mellitus, Comparison: Having gastrointestinal complications, Outcomes: primary outcomes: the overall prevalence of gastrointestinal complications in patients with type 2 diabetes, secondary outcomes: gastroparesis, diabetic enteropathy, nonalcoholic fatty liver in patients with type 2 diabetes mellitus.
Selection of studies and qualitative evaluation of studies
The selection criteria for studies included cross-sectional and availability of their full text. In the first stage of the PRISMA process, all studies in patients with type 2 diabetes in Iran were collected. The exclusion criteria included case reports, duplication of studies, unclear methodology, and observational studies. The studies were searched by NS and MK and if there was disagreement between the researchers, the differences were examined by a third researcher (MM). Quality evaluation based on the criteria is reported in Table 2 based on 22-item STROBE checklist [21].
Table 2.
Evaluate the quality of studies with the STROBE checklist
| Row | Author (s) and year of publication | Introduction | Materials and methods | Results | Discussion and conclusion | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Title and Abstract | Introduction | study method | Performing environment | Contributors | Variables | Data source and measurement method | Bias | Sample size | Quantitative variables | Statistical analysis methods | Descriptive data | Participants’ reports | Report the original data | The main results of the study | Other analyzes | Report key results | Limitations | Interpretation of results | Generalization | Budget | support | ||
| 1 | Ghadiri-Anari, 2018, [22] | + | + | + | + | + | + |
+ + |
– | – |
+ + |
+ | + | + | + | + | – | + | + | + | – | – | + |
| 2 | Alfti Far, 2017, [23] | + | + | + | + | + | + |
+ + |
– | – |
+ + |
+ | + |
+ + |
+ + |
+ + |
– | + | – |
+ + |
– | – | + |
| 3 | Yadolahi, 2012, [24] | + | + | + | + | + | + |
+ + |
– | + |
+ + |
+ | + | + | + | + | + | + | + |
+ + |
– | – | + |
| 4 | Abbasian, 2006, [25] | + | + | + | + |
+ + |
+ + |
+ + |
– | + |
+ + |
+ | + |
+ + |
+ |
+ + |
+ | + | + |
+ + |
– | – | + |
| 5 | Abbasian, 2007, [26] | + | + | + | + | + | + |
+ + |
– | + |
+ + |
+ | + |
+ + |
+ | + | + | + | + |
+ + |
– | – | + |
| 6 | Behrozian, 2006, [27] | + | + | + | + | + | + |
+ + |
– | + |
+ + |
+ | + | + | + | + | + | + | + |
+ + |
– | – | + |
| 7 | Nasiry, 2017, [28] | + | + | + | + | + | + |
+ + |
– | + |
+ + |
+ | + | + | + | + | + | + | + |
+ + |
– | – | + |
| 8 | Shahbazian, 2011, [29] | + | + | + | + | + | + |
+ + |
– | + | + | + | + | + | + | + | + | + | + | + | – | – | + |
| 9 | Cheraghi, 2010, [30] | + | + | + | + | + | + | + | – | + | + | + | + | + | + | + | + | + | + | + | – | – | + |
| 10 | Asgharnezhad, 2019, [31] | + | + | + | + | + | + |
+ + |
– | + | + | + | + | + | + | + | + | + | + | + | – | – | + |
Statistical analysis
The publication bias in the articles reviewed in the meta-analysis was analyzed using the Egger test and in the CMA 2. Based on this analysis (Fig. 1), the publication bias was not statistically significant (P = 0.891).
Fig. 1.
Funnel plot of results of the prevalence of gastrointestinal complaints in patients with type 2 Diabetes Mellitus (DM)
Results
In the present study, all searched articles were examined according to the PRISMA 2009 guidelines. In the initial search, 1011 studies were identified, of which 10 published studies were included in the meta-analysis between November 2001 and January 2021 (Fig. 2).
Fig. 2.
Flow diagram of study selection
Heterogeneity of I2: 98.6 studies was obtained and a stochastic effects model was used to meta-analyze the studies. The total sample size of the selected articles was 2949 in 10 studies, which are reported in Table 1. The STROBE checklist is also reported in Table 2. The smallest and highest sample sizes were related to the studies by Yadolahi et al. (2012) [25] and Behrozian et al. (2006) [28] with 30 and 557 subjects, respectively. According to the results of meta-analysis, the prevalence of gastrointestinal complaints in patients with diabetes type 2 in Iran was 52.3% (95% CI: 33.4–70.7%) (Fig. 3).
Table 1.
Characteristic of included studies Prevalence Digestive Complaints in Patients with Type 2 Diabetes
| Author, year, [Reference] | Mean age (years) | Time of study | City | Sample size | Sex (N, %) | Prevalence % | Quality | |
|---|---|---|---|---|---|---|---|---|
| Female | Male | |||||||
| Ghadiri-Anari, 2018, [22] | 41.8 | 2017 | Yazd | 65 | 50 (76%) | 15 (24%) | 96.9 | High |
| Alfti Far, 2017, [23] | 43.7 | 2016 | Hamadan | 347 | 228 (66%) | 119 (34%) | 14.4 | High |
| Yadolahi, 2012, [24] | 47.2 | 2011 | Isfahan | 30 | – | – | 16.7 | Medium |
| Abbasian, 2006, [25] | 49.6 | 2005 | Shahroud | 349 | 240 (68%) | 109 (32%) | 19.5 | Medium |
| Abbasian, 2007, [26] | 50.2 | 2006 | Shahroud | 299 | – | – | 24.1 | High |
| Behrozian, 2006, [27] | 53.8 | 2005 | Orumieh | 557 | 370 (66%) | 187 (34%) | 77.4 | High |
| Nasiry, 2017, [28] | 56.8 | 2016 | Sari | 176 | 87 (49%) | 89 (51%) | 57.4 | High |
| Shahbazian, 2011, [29] | – | 2010 | Ahwaz | 350 | 239 (68%) | 111 (32%) | 66.9 | High |
| Cheraghi, 2010, [30] | – | 2009 | Shadegan | 521 | 329 (64%) | 192 (36%) | 37.6 | High |
| Asgharnezhad, 2019, [31] | – | 2018 | Rasht | 255 | – | – | 91.4 | High |
Fig. 3.
Prevalence of gastrointestinal complaints in patients with type 2 diabetes mellitus (DM) and 95% confidence interval in Iran. The middle point of each line shows the prevalence of gastrointestinal complaints in each study, and the rhombic figure shows the prevalence of gastrointestinal complaints in patients with type 2 DM in Iran for the whole study
The effect between the study year (P = 0.261) and sample size (P < 0.001) with the prevalence of gastrointestinal complaints was evaluated using meta-regression method and a significant difference was observed in the effect of sample size (Figs. 4 and 5).
Fig. 4.
Meta-regression of the relationship between sample size and prevalence of gastrointestinal complaints in patients with type 2 diabetes mellitus (DM) in Iran
Fig. 5.
Meta-regression of the relationship between the year of study and prevalence of gastrointestinal complaints in patients with type 2 diabetes mellitus (DM) in Iran
Discussion
diabetes is one of the most common diseases in all countries in the world. The American Diabetes Association reported 58 billion dollars was spent on the long-term complaints of diabetes [32, 33].
In the present study, the prevalence of gastrointestinal complaints was 52.3%. In the study by Ko et al., gastrointestinal complaints were estimated to be 70% [34]. In the studies by Mjornheim and Perusicova, the prevalence of gastrointestinal complaints was estimated to be 59% and 60%, respectively, which was approximately similar to that for the patients in the present study [35, 36]. However, in the study by Quan, the prevalence of gastrointestinal complaints was 15 to 25% [37], and this rate was 35% in the study carried out by Clouse [38]. In a study by Nishida et al. in Japan, the prevalence of gastrointestinal complaints in these patients was reported as 21.4% [39].
In a study by Papatheodoridis et al., adults from Greek were studied, 53% of whom had gastrointestinal complaints [40]. In Sweden study, 54.3% had at least one gastrointestinal complaint [41].
The high prevalence of gastrointestinal complaints in the current study was significant. The age of emergence of these complaints was also lower in the present study compared to the reports in American and European countries [42]. The mean age of type 2 diabetes patients in Iran was higher than that in the Western countries as less than a decade. One of the two possible reasons for the lower age of prevalence of type 2 DM in this study was the younger population, ultimately resulting in a higher percentage of the younger patients treated. The second reason is the presumption of some old patients who tolerate type 2 DM until death and refuse to refer for treatment and thus are not included in the statistics of the patients referred. The number of these patients cannot be estimated. However, if the percentage is high enough to disrupt the above conclusions, it indicates a lack of awareness of the effects of type 2 DM treatment.
Based on the study by Anderson et al. (2001), the chance of depression in diabetes patients was twice as high (OR = 2.0, 95%, CI = 1.8–2.2) [43]. According to a study by De Groot et al. (2001), A significant difference was found between depression and diabetes complaints [44]. Depression causes a decline in the QOL of these patients, hence increasing the cost of treatment among these patients [45]. Therefore, precautions must be taken to prevent these complaints.
The prevalence of diabetes has increased in the last century [46, 47]. In many cases, the lack of healthy nutrition and immobility first cause pre-diabetes, and then diabetes emerges [48]. Nutrition treatment, physical activity, and patient training are the basis of DM treatment in all patients [49].
The findings of the present study indicate that interventions in lifestyle changes, as well as control of blood pressure, control of cholesterol, and control of blood glucose in patients are necessary to prevent disease [49].
In the studies reviewed in this study, gastrointestinal symptoms were evaluated based solely on the patient’s history, and no diagnostic examinations were performed to investigate the organic causes of these symptoms. Therefore, some of these symptoms may not be related to DM, so further longitudinal studies are recommended.
Conclusion
Based on the study, the prevalence of gastrointestinal complications in patients with type 2 diabetes was high. As a result, appropriate measures should be taken to improve the condition of diabetic patients through appropriate policy-making and providing feedback to hospitals and patients.
Acknowledgements
This study was extracted from research project No. 980804 approved by the Student Research Committee of Kermanshah University of Medical Sciences, Kermanshah, Iran. The researchers of this study would like to thank the respected authorities of the University for funding the financial costs of the study.
Abbreviations
- DM
Diabetes Mellitus
- SID
Scientific Information Database
- WoS
Web of Science
- STROBE
Strengthening the Reporting of Observational Studies in Epidemiology for cross-sectional Study
- PRISMA
Preferred Reporting Items for Systematic Reviews and Meta-Analysis.
Author contributions
MK, NS, and MM contributed to the design and MM statistical analysis and participated in most study steps. SHSH prepared the manuscript. NS and MM and HA assisted in designing the study and helped in the interpretation of the study. All authors have read and approved the content of the manuscript.
Funding
By Student Research Committee of Kermanshah University of Medical Sciences, Deputy for Research and Technology, Kermanshah University of Medical Sciences (IR) (980804). the deputy of research and technology –Kermanshah University of Medical Sciences had no role in the design of the study and collection, analysis, and interpretation of data and writing of the manuscript.
Data availability
Datasets are available through the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
This study was recorded in the ethics committee of Kermanshah University of medical sciences with the ethics code of (IR.KUMS.REC.1398.815).
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no conflict of interest.
Footnotes
Publisher’s note
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Contributor Information
Mohsen Kazeminia, Email: mohsenkaz221@gmail.com.
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Hakimeh Akbari, Email: anaakbari91@gmail.com.
Masoud Mohammadi, Email: Masoud.mohammadi1989@yahoo.com.
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Associated Data
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Data Availability Statement
Datasets are available through the corresponding author upon reasonable request.