Journal of Diabetes •• (2016) ••–••

ORIGINAL ARTICLE

Prevalence of diabetes mellitus and its risk factors in urban

communities of north Sudan: Population-based study
Wadie M. ELMADHOUN,1 Sufian K. NOOR,2 Abd Alaziz A. IBRAHIM,3 Sarra O. BUSHARA2 and
Mohamed H. AHMED4
1
Department of Pathology and Medicine, Faculty of Medicine and Health Sciences, Nile Valley University, Atbara, Sudan. 2 Department of
Medicine, Faculty of Medicine and Health Sciences, Nile Valley University, Atbara, Sudan. 3 Federal Ministry of Health, Sudan, and 4 Department
of Medicine, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, Buckinghamshire, UK.

Correspondence: Mohamed H. Ahmed,
Department of Medicine, Milton Keynes
University Hospital NHS Foundation Trust,
Eaglestone, Milton Keynes, MK6 5LD,
Buckinghamshire, UK.
Tel.: +441 9089 6363
Fax: +441 9089 2009
Email: elziber@yahoo.com
Received 25 July 2015; revised 10
November 2015; accepted 6 December
2015.
doi: 10.1111/1753-0407.12364
Abstract: Background: Diabetes mellitus (DM) is a major health problem in
Africa and worldwide. The prevalence of diabetes is expected to increase at
alarming rate in Africa. Its estimated that around 20 million Africans are now
living with diabetes, comprising a challenge for health systems at present and
in the future. The aim of the present study was to determine the prevalence of
undiagnosed and diagnosed DM and impaired glucose tolerance (IGT) in adult
urban communities of the River Nile State (RNS), north Sudan.
Methods: The present study was a cross-sectional community-based study in
which participants were randomly selected from the four main cities of the
RNS, on a house-to-house basis. Blood glucose was tested and all participants
completed a questionnaire to obtain demographic, clinical and social data.
Blood pressure and anthropometric measures were also recorded.
Results: In all, 954 adults (518 females; 54.3%; mean [±SD] age 39.5 ± 16.7
years; range 18–90 years) participated in the survey. The overall prevalence of
DM was 19.1% (182/954), whereas that of IGT was 9.5% (91/954). Among
the diabetic group, 125 (68.7%) had known diabetes, whereas 57 (31.3%) were
newly diagnosed during the study. Increasing age, a family history of diabetes,
central obesity, abnormal body mass index, and hypertension were significant
risk factors for DM.
Conclusions: There is high prevalence of DM and glucose intolerance in the ur-
ban population of the RNS. Screening for diabetes in individuals with any fea-
ture of metabolic syndrome is recommended.
Keywords: diabetes mellitus, obesity, Sudan.

Significant findings of the study: There is a high prevalence of diabetes (19.1%) among the urban population of
north Sudan.
What this study adds: This study uncovers a hidden epidemic of diabetes and urges health policy makers to take
appropriate action.

Introduction that as many as 175 million people with DM world-

Diabetes mellitus (DM) is a common condition and a
significant public health problem that affects approxi-
mately 8.3% of the total world population; its prevalence
is increasing at an alarming rate. 1,2 It is estimated that
382 million people worldwide have diabetes and that
this figure will increase to 592 million by 2035; 2,3
worryingly, the age of onset is falling. 3 It is estimated
wide, or close to half of all people with DM, are
unaware of their disease. 3 Globally, 84% of all people
who are undiagnosed live in low- and middle-income
countries. 3 Type 2 DM accounts for over 90% of
diabetes cases in Sub-Saharan Africa, with the remain-
ing 10% represented by type 1 DM, gestational DM,
and malnutrition-related DM. 4

© 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd
Diabetes in urban north Sudan
In Sub-Saharan Africa, the proportion of people with
undiagnosed DM is high and may reach 90% in some
countries. 5 In Arab countries, the prevalence of DM
ranges from 9.33 % (in Iraq) to 21.1% (in Kuwait). 6,7
The increase in DM prevalence has been attributed to in-
creasing urbanization, aging, obesity, reduced physical
activity, and an unhealthy diet. 8,9
Other identified risk factors for DM include ethnicity,
family history, being a member of a high-risk popula-
tion, a history of gestational DM, hypertension, polycys-
tic ovary syndrome, the presence of vascular disease, and
hyperlipidemia. 3,10
Undiagnosed DM has significant ramifications because
subjects remain untreated and at risk of complications. 11
It is estimated that DM may remain undiagnosed for 10
years or more; at that time, complications of DM would
already have occurred. 12,13
The consequences of DM are widespread. It affects
socioeconomic development, complicates clinical care
with comorbidities, increases healthcare costs, and
limits life expectancy, both for those affected and their
children. 3
In Sudan, the prevalence of DM in adults is 7.74% and
is expected to reach 10.82% in 2035. 3
In a previous study, it was shown that the prevalence
of undiagnosed DM in rural communities of north Su-
dan was 2.6% and that the prevalence of impaired glu-
cose tolerance (IGT) was 1.6%. 14 The same study
identified increasing age and obesity as important risk
factors. 14 In light of the increasing obesity epidemic in
urban regions of Sudan, it is important to assess the
prevalence of DM and IGT in these areas. To that end,
population-based epidemiological information from
both urban and rural regions is essential to explore the
picture of DM in north Sudan.
Therefore, the aim of the present study was to deter-
mine the prevalence of diagnosed and undiagnosed
DM and IGT and the associated risk factors among
urban populations living in the River Nile State (RNS),
north Sudan.
Methods
Settings
This study was conducted in the RNS, which lies in
northern Sudan, bordering Khartoum State in the south
and extending to the Sudanese–Egyptian border in the
north. The RNS covers an area of approximately 124
000 km2 and was populated, in 2015, by 1 387 513 indi-
viduals of different ethnic groups, mainly Ja’alin,
Shaygia, Rubatab, and Manaseer tribes, besides other
Sudanese ethnicities. Most of the population resides be-
side the Nile River. Agriculture has been the major
© 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd
W. M. ELMADHOUN et al.
traditional economic activity in rural areas, whereas em-
ployment and trading are predominant among the urban
population. Recently, traditional gold mining has
emerged as a popular economic activity for many sub-
stantial sectors of the community.
There are six main cities and more than 350 villages in
the RNS, with similar demographic, economic and so-
cial characteristics. The urban population constitutes
34% of the population in the RNS.
Study design
The present study is a descriptive cross-sectional
community-based study, including a house-to-house
survey.
Study duration
The study was conducted from 1 January to 30 April 2015.
Study population, sampling technique, and sample size
Based on population data from the Sudan Central Bu-
reau of Statistics for 2015 (http://www.cbs.gov.sd/en/,
accessed 30 December 2014), and taking into consider-
ation that the urban population of the RNS constitutes
34% of the total and that adults (≥18 years of age) consti-
tute 55.6%, the total urban population of adults in the
RNS consisted of 262 295 individuals, inhabiting 52
459 houses (average five individuals per house). A sam-
ple size of 384 houses was considered representative of
the total urban population.
A multistage cluster random sampling strategy was
used to select study participants from urban locations.
The four main cities were selected to represent the urban
population of the RNS, namely Atbara, Berber, Ed
Damer, and Shendi. The number of houses selected
was proportional to the population size of the city. Then,
each city was divided geographically into four regions:
north, south, west, and east. Two districts were selected
from each geographical area by a simple tossing tech-
nique. Twelve houses were selected from each district.
A house-to-house survey was conducted starting from
house number 5 in the main street in the district; vacant
houses or those who declined to volunteer were replaced
by the house next door. This house-to-house survey
resulted in a sample size of 954 participants.
Inclusion criteria
To be eligible for inclusion, participants had to be
≥18 years of age and to have been living in one of
the cities selected.
W. M. ELMADHOUN et al.
Exclusion criteria
Subjects who were aged <18 years, transient and
rural residents, and/or pregnant were excluded from
the study.
Data collection tools
The World Health Organization (WHO) STEPwise
approach for non-communicable disease surveillance
was used for data collection. 15 The approach has three
levels: a questionnaire to gather demographic and be-
havioral information; physical measurements, including
anthropometric measurements; and biochemical tests. 15
Each participant was questioned to obtain demo-
graphic data and information regarding a past medical
history of diabetes, hypertension, any chronic illness
and drug history. In addition, there were questions
about the common symptoms of diabetes, risk factors
and family history of diabetes. Data were collected
through a standardized, interviewer-administered, pretested
questionnaire.
Blood glucose measurement
Capillary blood glucose was obtained using the finger
prick technique after adequate disinfection by alcohol
swab. Random blood samples were tested for glucose
using a glucometer (Accu-Check Active; Roche Diag-
nostics, Ulm, Germany). Any participant whose blood
glucose concentration was >139 mg/dL was tested again
in the city reference laboratory, where fasting blood glu-
cose (FBG) and 2-h postprandial blood glucose were
measured spectrophotometrically.
The American Diabetes Association (ADA) 2010
criteria were used to define DM and IGT. 16
Impaired glucose tolerance, or prediabetes, was de-
fined as random blood glucose between 140 mg/dL
(7.8 mmol/L) and 199 mg/dL (11.0 mmol/L). Impaired
FBG was defined as FBG between 100 and 125 mg/dL
(6.94 mmol/L).
Diabetes mellitus was diagnosed when a participant
had: (i) symptoms suggestive of diabetes mellitus and
a random blood glucose concentration was ≥200
mg/dL (11.1 mmol/L) on one occasion; (ii) when
FBG was ≥126 mg/dL on one occasion and there were
no symptoms suggestive of diabetes mellitus; or (iii) if
two FBG measurements were ≥126 mg/dL (7.0
mmol/L) or two random blood glucose readings were
≥200 mg/dL (11.1 mmol/L). In addition, if a partici-
pant was known to be diabetic or was already taking
antidiabetic medications, this was considered to be a
diagnosis of diabetes.
© 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd
Diabetes in urban north Sudan
Anthropometric measurements
Anthropometric measurements were made using stan-
dardized and calibrated equipment. Body mass index
(BMI ) was calculated as weight (in kg) divided by height
(in meters) squared and was classified according to the
National Institutes of Health (NIH; Bethesda, MD,
USA) as follows: underweight, BMI <18.5 kg/m2; nor-
mal weight, BMI 18.5–24.9 kg/m2; overweight, BMI
25–29.9 kg/m2; Class 1 obesity, BMI 30–34.9 kg/m2;
Class 2 obesity, BMI 35–39.9 kg/m2; Class 3 or morbid
obesity, BMI ≥40 kg/m2. 17
Waist circumference
Waist circumference was measured using a tape measure
at the level of the umbilicus. According to the Interna-
tional Diabetes Federation guidelines, central obesity
was defined as a waist circumference of ≥94 cm in men
and ≥80 cm in women. 3
Blood pressure measurement
Blood pressure was measured in seated participants
using a calibrated mercury sphygmomanometer, with
an appropriate cuff size. The average of three readings,
each taken after a 5-min rest, was recorded. Blood pres-
sure levels were classified based on the criteria of the Sev-
enth Report of the Joint National Committee for
Prevention, Detection, and Treatment of High Blood
Pressure. 18 Normal blood pressure was defined as sys-
tolic blood pressure (SBP) <120 mmHg and diastolic
blood pressure (DBP) <80 mmHg; prehypertension
was defined as SBP 120–139 mmHg and/or DBP 80–
89 mmHg; and hypertension was defined as SBP ≥140
mmHg and/or DBP ≥90 mmHg.
Ethical issues
Verbal consent was obtained from each participant prior
to enrolment. The following information was given to all
participants to ensure they had the information needed
to provide informed consent: participation is optional
and there is no penalty for refusal. In addition, a com-
plete description of the aims of the study, potential ben-
efits and risks, and assurance of confidentiality of any
information given was provided, as was any other addi-
tional information requested by participants during data
collection. Any individual identified to have high blood
glucose or any other medical problem was offered an op-
tional free-of-charge referral to a local physician for fur-
ther investigation and management during the study
period. Ethics approval for the study was obtained from
the Ethics Committee of the Faculty of Medicine, Nile
Valley University.
Diabetes in urban north Sudan W. M. ELMADHOUN et al.

Statistical analysis Table 1 Sociodemographic characteristics, age- and sex-adjusted

prevalence, glycemic, and blood pressure status of the urban
The data collected were validated, double-checked for population screened for diabetes and impaired glucose tolerance in
consistency and analyzed using SPSS version 21.0 (IBM the River Nile State, Sudan 2015 (n = 954)
Corp., Chicago, IL, USA). Pearson’s Chi-squared test Adjusted prevalence
was used for comparisons between categorical variables. (per 1000 urban population)
The level of significance was set at two-tailed P ≤ 0.05.
No. subjects (%) IGT DM
Frequency, percentage and the mean ± SD were calcu-
lated; in addition, crude and age-adjusted prevalence were Gender
calculated based on the proportion of each age group. Male 436 (45.7) 89 181
Female 518 (54.3) 101 199
Age group (years)
Results 18–25 266 (27.9) 49 19
Sociodemographic characteristics 26–35 204 (21.4) 9 12
36–45 166 (17.4) 96 26
In the present study, there were 518 (54.3%) females and 46–55 148 (15.5) 16 30
436 (45.7%) males. The age range was 18–90 years, with 56–65 98 (10.3) 9 411
66–75 41 (4.3) 122 390
a mean (±SD) age of 39.5 ± 16.7 years. Younger age, be- >75 31 (3.2) 194 290
long to the Ja’alin tribe, and housewives were the most City of residence
common sociodemographic characteristics (Table 1). Shendi 279 (29.2)
Ed Damer 253 (26.5)
Prevalence of DM, IGT, and hypertension Atbara 224 (23.5)
Berber 198 (20.8)
The overall prevalence of DM among the urban popula- Education level
tion in the RNS was 19.1% (182/954), whereas that of Illiterate 190 (19.9)
Primary/khalwa 195 (20.4)
IGT was 9.5% (91/954). This gives a crude prevalence Secondary 238 (24.9)
of 191 per 1000 urban population for DM and 95 per College 331 (34.7)
1000 for IGT. Females had a higher sex-adjusted preva- Occupation
lence of DM (199 per 1000) compared with males (181 Housewife 319 (33.4)
per 1000 population). The most commonly affected age Self-employed 232 (24.3)
Employee 231 (24.2)
group was the 56–65 years group, with an age-adjusted Student 124 (13.0)
prevalence of 411 per 1000 for DM (Table 1). Retired/not working 27 (2.8)
Among the diabetic group, 125 (68.7%) had known dia- Farmer 21 (2.2)
betes and 57 (31.3%) were newly diagnosed during the Tribe
study (Table 1). Therefore, the prevalence of undiagnosed Ja’alin 646 (67.7)
Shaygia 88 (9.2)
(newly diagnosed) DM among the urban population in the Rubatab 51 (5.3)
RNS was 5.97%. Prehypertension and hypertension were Nuba 27 (2.8)
common among study participants (Table 1). Danagla 17 (1.8)
Kwahla 17 (1.8)
Significance of classical symptoms of DM Others 108 (11.3)
Glycemic status
Despite the widespread and non-measurable nature of Normal glucose 681 (71.4)
these symptoms, fatigue, polydipsia, polyuria, and loss IGT 91 (9.5)
Newly diagnosed 57 (6.0)
of weight were significantly higher among the diabetes diabetes
and prediabetes patients than normoglycemic individ- Known diabetic 125 (13.1)
uals (Table 2). Blood pressure status
Normal 214 (22.4)
Risk factors for DM and IGT Prehypertensive 399 (41.8)
Newly diagnosed 214 (22.4)
Age was a significant risk factor for both DM and IGT. hypertension
The highest prevalence of DM was found among the Known hypertensive 127 (13.3)

56–65 years age group (n = 41; 41.9%; Table 3). Regarding 1

gender, there were no significant differences, with DM and
IGT found in 79 (18.1%) and 39 (8.9%) of males, com-
pared with 103 (19.9%) and 52 (10.0%) of females, respec-
tively (P = 0.6). The prevalence of diabetes and IGT by
IGT, impaired glucose tolerance; DM, diabetes mellitus.
residence was significantly greater in Berber city, where
DM was found in 25.3% of participants (50/198) and
IGT was found in 10.1%, followed by Ed Damer (22.1%

© 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd
W. M. ELMADHOUN et al. Diabetes in urban north Sudan

Table 2 Significance of the classical symptoms of diabetes among the urban population screened for diabetes and impaired glucose tolerance
in the River Nile State, Sudan 2015 (n = 954)
2
Symptom Present Normoglycemic IGT DM χ P-value

Fatigue Yes 344 (50.5%) 63 (69.2%) 139 (76.4%) 45.2 <0.0001

No 337 (49.5%) 28 (30.8%) 43 (23.6%)
Polydipsia Yes 149 (21.9%) 26 (28.6%) 89 (48.9%) 52.4 <0.0001
No 532 (78.1%) 65 (71.4%) 93 (51.1%)
Polyuria Yes 129 (18.9%) 19 (20.9%) 100 (54.9%) 98.1 <0.0001
No 552 (81.1%) 72 (79.1%) 82 (45.1%)
Loss of weight Yes 88 (12.9%) 11 (12.1%) 61 (33.5%) 45.2 <0.0001
No 593 (87.1%) 80 (87.9%) 121 (66.5%)
1
Unless indicated otherwise, data show the number of subjects in each group, with percentages in parentheses.
2
IGT, impaired glucose tolerance; DM, diabetes mellitus.

Table 3 Risk factors for diabetes and impaired glucose tolerance among the urban population in River Nile State, Sudan 2015 (n = 954)
2
Normoglycemic IGT DM χ P-value

Gender
Male 318 (72.9%) 39 (8.9%) 79 (18.1%) 0.95 0.6
Female 363 (70.1%) 52 (10.0%) 103 (19.9%)
Age group (years)
18–25 248 (93.2%) 13 (4.9%) 5 (1.9%) 12 <0.0001
26–35 162 (79.4%) 18 (8.8%) 24 (11.8%)
36–45 107 (64.5%) 16 (9.6%) 43 (25.9%)
46–55 80 (54.1%) 24 (16.2%) 44 (29.7%)
56–65 48 (49.0%) 9 (9.2%) 41 (41.9%)
66–75 20 (48.8%) 5 (12.2%) 16 (39.1%)
>75 16 (51.6%) 6 (19.4%) 9 (29%)
City of residence
Shendi 220 (78.9%) 21 (7.5%) 38 (13.6%) 30.7 <0.0001
Ed Damer 159 (22.8%) 38 (15%) 56 (22.1%)
Atbara 174 (77.7%) 12 (5.4%) 38 (17.0%)
Berber 128 (64.6%) 20 (10.1%) 50 (25.3%)
Education level
Illiterate 110 (57.9%) 33 (17.4%) 47 (24.7%) 64.3 <0.0001
Primary/khalwa 119 (61%) 20 (10.3%) 56 (28.7%)
Secondary 170 (71.4%) 20 (8.4%) 48 (20.2%)
College 282 (85.2%) 18 (5.4%) 31 (9.4%)
Family history of DM
Yes 286 (42%) 41 (45.1%) 121 (66.5%) 34.7 <0.0001
No 395 (58%) 50 (54.9%) 61 (33.5%)
Blood pressure
Normal 179 (83.6%) 14 (6.5%) 21 (9.8%) 49.9 <0.0001
Prehypertensive 298 (74.7%) 37 (9.3%) 64 (16.0%)
Hypertensive 204 (59.8%) 40 (11.7%) 97 (28.5%)
Body mass index
Underweight 57 (93.4%) 0 (0.0%) 4 (6.6%) 50.2 <0.0001
Normal 250 (76.5%) 35 (10.7%) 42 (12.8%)
Overweight 235 (70.8%) 22 (6.6%) 75 (22.6%)
Class I obesity 86 (59.3%) 23 (15.9%) 36 (24.8%)
Class II obesity 37 (55.2%) 8 (11.9%) 22 (32.8%)
Morbid obesity 16 (72.7%) 3 (13.6%) 3 (13.6%)
Waist circumference
Male
Normal (<94 cm) 274 (79.7%) 22 (6.4%) 48 (14.0%) 46.7 <0.0001
Abnormal (>94 cm) 43 (48.3%) 15 (18.0%) 30 (33.7%)
Female
Normal (<80 cm) 187 (77.0%) 19 (7.8%) 37 (15.2%)
Abnormal (>80 cm) 177 (63.7%) 34 (12.2%) 67 (24.1%)
1
Unless indicated otherwise, data show the number of subjects in each group, with percentages in parentheses.
2
IGT, impaired glucose tolerance; DM, diabetes mellitus.

© 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd
Diabetes in urban north Sudan
and 15.0% (56/253) for DM and IGT, respectively). The
lowest prevalence of DM was in Shendi city, where DM
and IGT were detected in 13.7% (38/279) and 7.5% of par-
ticipants, respectively (P < 0.0001; Table 3). The lowest
prevalence of IGT was found in Atbara (5.4%), where
the prevalence of diabetes was 17% (38/224). It is worth
mentioning that Ed Damer had the highest prevalence of
IGT (15.0%).
There was an increased risk of DM and IGT among
those with low educational levels (P < 0.0001). The
highest prevalence was noted among those who spent
less than 10 years in education, whereby DM was found
in 56 of 195 participants (28.7%) and IGT was found in
20 of 195 participants (10.3%), followed by the illiterate
group, among which DM was found in 47 participants
(24.7%) and IGT was found in 33 participants (17.4%).
Conversely, among those who had a college education,
DM was detected in 31 participants (9.3%) and IGT
was detected in 18 participants (5.4%).
There was a significant increase in diabetes risk with
increasing BMI. For example, DM and IGT were diag-
nosed in 22 (32.8%) and eight (11.9%) of those with
Class 2 obesity, compared with 42 (12.8%) and 35
(10.7%), respectively, in those with normal weight.
In the underweight group, DM was detected only in
four (6.6%) participants and IGT was not present at all
(P = 0.0001). Similarly, the prevalence of DM and
IGT among those with central obesity was significantly
higher than in those with a normal waist circumference
(P < 0.0001), as indicated in Table 3. The prevalence of
central obesity was higher among men with diabetes
(33.7%) than women with diabetes (24.1%; P < 0.0001).
Abnormal blood pressure and diabetes were significantly
associated, as evidenced by the fact that among individ-
uals with hypertension, 28.5% (97/341) were also
diabetic compared with 9.8% (21/214) of those with
normal blood pressure (P < 0.0001). A positive family
history of diabetes was another risk factor for both
DM and IGT (P < 0.0001; Table 3).
Discussion
In the present cross-sectional community-based study, we
determined that the overall prevalence of DM and IGT
among the urban population in the RNS was 19.1% and
9.5%, respectively. Among the diabetic group, more than
two-thirds were already known diabetics, whereas 6% of
the total study population was newly diagnosed during
the study. In a previous study it was shown that the prev-
alence of undiagnosed diabetes in rural communities of
north Sudan was 2.6%. 14 This higher prevalence of diabe-
tes in urban areas may be explained, in part, by the effect
of urbanization and a sedentary life style.
© 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd
W. M. ELMADHOUN et al.
The prevalence of diabetes in this population of north
Sudan is comparable to that reported in India (18%), 19
urban areas in Iran (18%), 20 and an urban population
in Bangladesh (15%). 21 However, this prevalence is
higher than that reported in an urban population of
Ethiopia (5.1%). 22 This wide difference in prevalence
in two neighboring countries can be attributed to differ-
ences in life style, dietary habits, environmental factors,
or the genetic make-up of the two populations. The prev-
alence of IGT in the present study is also comparable to
that reported in India (8.7%), but less than that reported
in Bangladesh (19%). 19,21
Importantly, the number of people with diabetes in
Sub-Saharan Africa is expected to increase more than
twofold between 2000 and 2030, and this is likely to oc-
cur in urban areas. 23–26 It seems that living in urban
areas constitutes, in itself, a risk factor, although it is as-
sociated with many other dependent variables.
Another important risk factor for the high prevalence
of diabetes is the increasing prevalence of obesity. Sev-
eral studies have reported that obesity is a common
problem in Africa, particularly in urban areas. 27–31
The present study showed that the prevalence of obe-
sity among individuals with diabetes was 34% (61/182
subjects) and the prevalence of overweight among dia-
betics was 41.2% (75/182); the percentage of obese indi-
viduals with IGT was 37.3% (34/91).
Central obesity is an essential component of the meta-
bolic syndrome and there is general agreement in the lit-
erature that the presence of central obesity is a high risk
factor not only for diabetes, but also for non-alcoholic
fatty liver disease (NAFLD). The presence of central
obesity is regarded as a source of insulin resistance and
proinflammatory status. 32,33
The prevalence of DM and IGT in the present study
among those with central obesity was significantly higher
than that in those with a with normal waist circumference
(P < 0.0001). Moreover; the prevalence of central obesity
was higher among men with diabetes (33.7%) than women
with diabetes (24.1%; P < 0.0001), despite the finding that
central obesity is more common among Sudanese women
than men (53.67% [278/518] vs 20.18% [88/436], respec-
tively). This higher central obesity can be attributed to dif-
ferent factors, including a lack of physical activity among
Sudanese women living in urban areas, a high prevalence
of obesity in women, and the fact that most women tend
to put on weight after pregnancy and delivery because of
Sudanese traditions that women should eat high-
carbohydrate diets to nourish their fetuses and newborns.
Several studies have reported a high prevalence of obesity
among women compared with men in Africa. 34–36 There-
fore, screening for diabetes in overweight and obese Suda-
nese individuals should be part of routine clinical practice.
W. M. ELMADHOUN et al.
The high prevalence of diabetes, obesity, and central
obesity among Sudanese individuals living in urban
areas may be attributed to the following: (i) many urban
dwellers lead sedentary life styles, with less physical
activity; (ii) the Sudanese diet contains high levels of car-
bohydrates and red meat; and (iii) people in Sudan prefer
to eat fatty red meat containing high dietary animal
cholesterol.
In light of the high prevalence of diabetes and obesity,
it is important that further studies are undertaken to de-
termine the prevalence of NAFLD and risk factors in
this population. We have recently shown that the preva-
lence of NAFLD among individuals with type 2 diabetes
living in the capital Khartoum was approximately 50%,
whereas the prevalence of NAFLD among non-diabetic
individuals was 20%. 37,38
Hypertension and diabetes are two sides of the same
coin. In the present study, among individuals with diabe-
tes, a new diagnosis of hypertension was established in
30% (54 subjects), whereas the percentage of known
cases of hypertension and prehypertension among dia-
betic patients was 23.5% (43 subjects) and 35% (64 sub-
jects), respectively. Several studies have shown a high
prevalence of hypertension in Africa, especially in urban
regions. 39 This could be due to complex factors, includ-
ing high salt intake, low physical activity, and genetic
vulnerability to high blood pressure. 39
A recently published study determined a high
prevalence of hypertension among rural population of
north Sudan. 40 Taking all these factors into consider-
ation, it is recommended that the presence of features
of metabolic syndrome should warrant screening for
diabetes.
The present study is not without limitations. The study
was a cross-sectional survey, and so we could not take
account of the temporal relationship between potential
risk factors and outcomes. Despite this, we believe that
the study is novel and its findings reflect the trend of an
increasing epidemic of DM in Sudan.
In conclusion, both diagnosed and undiagnosed DM
and IGT have a high prevalence in urban communities
of north Sudan. Increasing age, low educational level, a
family history of DM, and the presence of any compo-
nent of the metabolic syndrome constitutes a risk factor
for DM. We recommend health policy makers be proac-
tive in the prevention and treatment of this common
problem before complications ensue.
Acknowledgement
The authors thank the study participants; without their
contribution this study could not have been performed.
Thanks are also extended to the reference laboratories
© 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd
Diabetes in urban north Sudan
in the RNS for their confirmation of abnormal results.
No funding was received for the study.
Disclosure
None declared.
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