Republic of Yemen Hadramout University College of Medicine and Health Sciences Department of Medical Laboratories Sciences Evaluation of Serum Zinc and Iron Levels in Yemeni Patients with Prediabetes and Type 2 Diabetes Mellitus Attending Diabetic Clinic of Ibn-Sina Hospital in Mukalla Prepared by: 1. Ali Abdullah Masood (Chairman) 2. Sara Salmen Bin Haiwel (Co-chairman) 4th Year ـــــــــــــــــ5th Group 8. Eman Obeed Bin Ageel 9. Fatima Awad Masjedi 3. Abdulraouf Abubaker Alamodi 10. Khaled Mohammed Alrrae 4. Abdulsalam Shafeeq Bafreej 11. Mahboba Mohammed Suleman 5. Aisha Hassan Bin salman 6. Ali Daroesh Ghuzi 7. Ashwaq Saleh Baqendwan Under supervision: Dr. Lotfi Saeed Bin Dahman Associate Professor of Medical Biochemistry 2021 - 2022 12. Nadeer Mohammed Waked 13. Omar Aidah Alamodi 14. Wardah Mohammed Baqitian 1. Diabetes Mellitus • Diabetes mellitus (DM), namely type 2 diabetes mellitus (T2DM), constitutes a significant challenge for health systems worldwide. • Estimated prevalence of DM in adults worldwide was 8.3% in 2013 and is expected to increase to 10.1% by 2035 2. Trace Elements • Trace elements are micronutrients required by the body to perform its normal functions such as action or secretion of insulin , chronic excessive or reduced concentrations of these elements can lead t toxic of body health and may lead to sever disorder such as DM, one of these trace elements is zinc (Zn). Introduction 3. Zinc • Zinc (Zn) is an essential part of many enzymes and is a cofactor in many catalytic activities • Zinc plays an important role in glucose metabolism, which is found to enhance insulin sensitivity , Abnormal levels of serum Zn may contribute to the pathogenesis and some complications of T2DM. 4. Iron • Iron (Fe) is important in the synthesis of hemoglobin. Furthermore, it is necessary in the production of elastin, collagen, ascorbic acid synthesis and Zn • It has a role in the development of T2DM through multiple mechanisms, including in the modulation of insulin sensitivity, resistance and causes hepatic dysfunction and oxidative damage to pancreatic cells. Introduction • To our knowledge, there are no previous studies examined the association between these trace elements and T2DM in Yemeni population. Therefore, the present study was aimed to evaluate the association between levels of serum Zn and Fe in adult Yemeni subjects with and without T2DM as well as those with prediabetes. Justification Zinc and Fe play a role in the pathogenesis of DM. Thus, our hypothesis suggests that low Zn levels and high Fe levels may contribute in increased levels of Fasting Blood Glucose (FBG) and HbA1c in individuals with and without T2DM. Hypothesis ? 01 What are the differences between levels of serum Zn and Fe in adult Yemeni subjects with and without T2DM and prediabetes? 02 What are the associations between levels of serum Zn and Fe in adult Yemeni subjects with and without T2DM? 03 What are the associations between levels of serum Zn and Fe in adult Yemeni subjects with prediabetes and T2DM? Research Questions General Objective • To evaluate the association between levels of serum Zn and Fe in adult Yemeni subjects with and without T2DM as well as those with prediabetes. Specific Objectives: • To investigate the differences between levels of serum Zn and Fe among adult Yemeni subjects with and without T2DM and prediabetes. • To determine the associations between levels of serum Zn and Fe among adult Yemeni subjects with and without T2DM. • To ascertain the associations between levels of serum Zn and Fe among adult Yemeni subjects with prediabetes and T2DM. Research Objectives Study Design: • This was cross-section study Study Area: • Diabetic clinic of Ibn-Sina Hospital Study Population and Method: • Adult Yemeni patients with T2DM and prediabetes, aged ≥18 years will be randomly selected. Exclusion criteria: • Patients with : 1. 2. 3. 4. 5. 6. Type 1 Diabetes Mellitus Gestational diabetes mellitus and any other type of diabetes Co-morbidities such as cardiovascular disease Zn and Fe supplements Diagnosed with IDA Blood transfusions Peptic ulcer Research Methodology Sample Size • The sample size was 174, 58 for each group of the tree groups Prediabetes, T2DM and healthy (non-T2DM). Data Collection • Data was collected using self-administrated pre-tested questionnaire. Blood Sample Collection • A venous blood sample of ten milliliter (ml) was taken from each participant, the blood sample was collected by vein puncture with and without anticoagulant. Biochemical Measurements: • Whole blood was used for measuring HbA1c using cobas c 111, serum sample was used for measuring Fasting blood glucose (FBG, total cholesterol (TC), triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C) concentrations, low-density lipoprotein cholesterol (LDL-C), Fe, Zn and CRP using (Mindray BS-240). • Data was analyzed by using statistical package for social science (SPSS) (version25). The continuous normal variables are presented as mean ± standard deviations (SD). • A multivariate analysis (ANOVA) was used to show the mean difference between the study groups. • The Shapiro test was used to analyze the normal distribution of the variables. Frequencies and percentages were done for the categorical variables. Statistical Analysis • Pearson correlation test was performed with CRP, Zn, Fe, as the dependent variables. • Partial correlation test was performed with CRP, Zn, Fe, as the dependent variables adjusted for BMI. • The association of healthy subjects, prediabetes and diabetic patients with high risk factors was analyzed using Chi-square test. • The statistical analysis was conducted at a 95% confidence level. P value<0.05 was considered statistically significant. Statistical Analysis • Ethical approval was granted by the Ethics Committee of College of Medicine and Health Sciences, Hadramout University. • Written consent was obtained from each Participant. • All date research was kept in secure computers. • In addition, the name and any other information that could directly identify the patients and the materials was removed. Ethical Approval The Association between serum Zinc and Iron Levels with study groups Zinc Iron Zinc P=<0.001 Iron P=<0.001 Results HEALTHY SUBJECTS PREDIABETES T2DM Anthropometric and biochemical data of the study groups ALL Healthy Prediabetes T2DM P-value Age (years) 44.8±12.9 36.5±8.5 43.4±12.3* 54.8±10.6*$ <0.001 Weight (kg) 71.8±11.5 71.6±12.7 74.9±10.5*# 69.1±10.8 0.024 BMI (kg/m2) 26.9±4.4 26.2±3.8 28.2±4.9*# 26.3±4.2 0.023 FBG (mg/dl) 137.4±61.3 86.6±6.1 115.3±5.6* Variable 210.4±5.9*$ There was significant difference among study groups for Age, weight, BMI, FBG, HbA1c, CRP, Fe, Zn. <0.001 Results Anthropometric and biochemical data of the study groups Variable ALL Healthy Prediabetes T2DM P-value HbA1c (%) 7±2.7 4.9±0.31 6.7±0.21** 10.3±2.4*$ <0.001 CRP (mg/L) 2.4±1.9 1.69±1.5 1.95±1.4 3.45±0.86*$ 0.039 Iron (mcg/dl) 125.3±35.7 104±27.3 122.4±31.8* 149.6±32.4*$ <0.001 Zinc (ug/dl) 72.2±15.2 85.9±10.2* 72.8±9.4# 57.9±10.6*$ <0.001 On the other hand, no significant difference among study groups for height, SBP, DBP, TC, TG, HDL-C, and LDL-C found. Results Pearson correlation using CRP, iron and zinc as dependent variables in the combined groups studied: CRP Iron Zinc P r P r P BMI (kg/m2) -0.175* 0.021 -0.054 0.481 -0.023 0.761 SBP (mmHg) 0.159* 0.036 0.083 0.278 -0.013 0.860 FBG (mg/dl) 0.152* 0.045 0.543** <0.001 -0.735** <0.001 HbA1c (%) 0.097 0.204 0.553** <0.001 -0.725 <0.001 TC (mg/dl) 0.182* 0.016 0.072 0.346 -0.013 0.867 TG (mg/dl) 0.216** 0.004 0.104 0.172 -0.106 0.163 Iron (mcg/dl) 0.089 0.242 Zinc (ug/dl) 0.001 0.985 r -0.455** <0.001 -0.455** <0.001 Results • Using Pearson correlation analysis, Serum CRP was positively associated with SBP, FBG, TC, TG and negatively associated with BMI. • Serum Fe concentration was positively associated with FBG, HbA1c and negatively associated with Zn • Serum Zn concentration was negatively associated with FBG and Fe. • At the same time, no significant difference was found between CRP, iron and zinc with DBP, HDL-C and LDL-C. Results The association of healthy subjects, prediabetes and diabetic patients with high risk factors. Age as risk factor Healthy Prediabetes T2DM χ2 P-vlaue ≤35 29 (61.7%) 16 (34.0%) 2 (4.3%) 73.87 <0.001 36-44 19 (47.5%) 15 (37.5%) 6 (15.0%) 45-55 10 (20.0%) 20 (40.0%) 20 (40.0%) ≥56 0 (0.00%) 7 (18.9%) 30 (81.1%) Participants ≥56 years significantly had a risk factor for developing T2DM Results The association of healthy subjects, prediabetes and diabetic patients with high risk factors. Healthy Prediabetes T2DM χ2 P-vlaue Low 0 (0.00%) 3 (27.3%) 8 (72.7%) 15.49 0.017 Moderate 8 (28.6%) 8 (28.6%) 12 (42.9%) High 21 (42.9%) 12 (24.5%) 16 (32.7%) Never 29 (33.7%) 35 (40.7%) Physical activity as risk factor 22 (25.6%) Also, participants who did not do any physical activity (never) significantly had a risk factor to be prediabetes and T2DM Results The association of healthy subjects, prediabetes and diabetic patients with high risk factors. Prediabetes T2DM χ2 P-vlaue Normal weight 24 (42.1%) 9 (15.8%) 24 (42.1%) 12.04 0.017 Overweight 27 (30.3%) 37 (41.6%) 25 (28.1%) Obese 7 (25.0%) 12 (42.9%) 9 (32.1%) BMI as risk factor Healthy Furthermore, participants with overweight overweight had significantly a risk factor to be prediabetes T2DM. Results Low Zn level and high Fe contribute increased levels of FBG and HbA1c in T2DM and prediabetes individuals. However, the correlation between low Zn level and high Fe requires further investigations to confirm these finding. Conclusion o Further investigations are needed to validate the correlation between low Zn level and high Fe in prediabetes and T2DM individuals. o Monitoring prediabetes patients with elevated Fe and low Zn levels is the crucial step for the reduction incidence of diabetes. o Do exercise help to lower blood glucose levels. o Overweight individuals should do exercise to reduce higher weight and prevent incidence of diabetes. o Use Zn supplements for patients with prediabetes as anti-inflammatory agents to reduce risk incidence of diabetes. Recommendatio n Praise Allah who bestowing us with wisdom, power, health, strength and patience to carry out this study. We would like to thank our faculty for their encouragement and facilities which gives us opportunity to achieve this study especially the dean: Prof Dr. Samir Yaslam Ba-Othman, Dr. Lotfi Saeed Bin Dahman. Our warmest thanks to Diabetic Clinic of Ibn-Sina Education Hospital, Burj Al-nuwr Laboratories, AlHuda Medical Agency for their help. Acknowledgment Thank You