A case–control study to evaluate hematological indices in blood of diabetic and non-diabetic individuals in Ibb City, Yemen

Diabetes mellitus (DM) is a chronic, metabolic illness characterized by an elevation of blood sugar levels. Patients with diabetes show changes in hematological indices. The study aimed to determine hematological indices, ESR, CRP, blood pressure (BP), and weight and their relationship with a fasting blood sugar (FBS) level and different variables in diabetic mellitus patients (DM) compared with healthy control (HC). A total of 202 participants (102 DM group and 100 HC group) were selected randomly. Data were collected using a questionnaire. Blood samples were collected from different places and investigated in Zain Medical Laboratories in Ibb City, Yemen (September 2022 to May 2023). GraphPad Prim was used to analyze the results. P-value ≤ 0.05 was considered statistically significant. The mean and standard deviation of age, weight, gender, residence, marital status, education levels, economic status, regular exercise, following a strict diet, and family history of diabetes revealed significant differences between DM and HC groups (P < 0.0001, P = 0001, P = 0.0027, P = 0.0002, P < 0.0001, P < 0.0001, P = 0.0002, P = 0.0011, P < 0.0001 and P = 0.0001, respectively). FBS results, systolic and diastolic BP, MCV, WBCs, monocytes, eosinophils, and platelets displayed significant differences between both groups (P < 0.0001, P < 0.0001 and P = 0.0404, P = 0.0191, P < 0.0001, P = 0.0253, P < 0.0001, and P = 0.0229, respectively). ESR exhibited statistical significance (P < 0.0001), while CRP displayed no significance. A Pearson's correlation showed that weight, Hb, RBCs, PCV, and WBCs were statistically negatively correlated with FBS whereas other hematological indices showed no correlation with FBS. In conclusion, DM patients had relatively higher levels of MCV, WBCs, eosinophils, platelets and ESR than the control group.


Methods and materials
A case-control study was conducted in Ibb City et al.Thawrah Hospital, Majd Specialist Hospital, Ibb Medical Center, Al-Kamal Laboratories, Al-Rafah Laboratories, and Zain Medical Laboratories from September 2022 to May 2023.Ibb City is distant from Sana'a, Yemen's capital, about 193 km.
The study participants were selected randomly.To detect the sample size, we followed the thumb rule, suggested by van Voorhis and Morgan, in that at least 30 participants per group are required to detect the real differences that lead to about 80% power of the study if the study contains two or more groups, as well as at least 50 participants per group, are required to detect the correlation relationship 40 .To maximize the reliability of the study, the researchers tried to increase the number of study participants, as suggested by the thumb rule, where 100 participants were required in each group (100 DM and 100 healthy controls).Moreover, for both DM and HC groups, the participants were screened for FBS, and healthy people in a control group who had a high level of sugar; were counted as DM (2 cases).So, the study included 202 participants involving 102 DM group and 100 HC group.Furthermore, the participants were interviewed using a standardized predesigned questionnaire.The questionnaire was translated into Arabic, the Yemen's mother tongue.The data collected included the participant number, weight, age, gender, residence, marital status, education status, socioeconomic status, type of diabetes, family history of diabetes, smoking, qat chewing, tobacco chewing, etc. Approximately, 3ml of blood was collected with EDTA-K3, and 1.28 ml of blood was drawn into a tube containing 0.32 ml 3.8% sodium citrate 4NC.Blood samples were collected from the participants after overnight fasting.The whole blood was tested for completing blood count (CBC) and erythrocyte sedimentation rate (ESR) whereas the serum was used to detect fasting blood sugar (FBS) and C-reactive protein (CRP) CRP.All tests were done in Zain Medical Laboratories (ZML).Additionally, blood pressure (BP) level was measured.
Concerning the inclusion criteria for both DM and HC groups, the participants who were ≥ 16 years of age were included.Moreover, the participants (DM or HC groups) who had any history of chronic liver disease including hepatitis B virus (HBV) and hepatitis C virus (HCV), heart failure, renal disease, malignancy, bleeding disorders, infectious diseases, and pregnant women were excluded.Also, the participants HC group who suffered from tonsillitis, arthritis, and appendicitis were excluded.

Research questions
Based on the previous studies, this study attends to address the following research questions: What are the hematological indices of healthy people?What are the hematological indices of diabetes mellitus patients?Are there any statistically significant differences between healthy and DP patients?

Ethical considerations
The ethical clearance of this study was approved by the Medical Laboratories Department (MDL), Faculty of Medical Sciences, Al-Jazeera University ethical committee after due process was followed (Reference Number: MDLMSJU/0101/2022 on 15 August 2022).The Ethics Committee accorded with the Helsinki Declaration for the Protection of Human Subjects.Informed consent was obtained from all the study participants.

Data analysis
The data obtained from the results of the questionnaires and laboratory tests were evaluated using GraphPad   1.

Sociodemographic characteristics of study participants
In this study, as presented in Table 1, there was a statistically significant between DM and HC groups in age, weight, gender, residence, marital status, education levels, economic status, regular exercise, follow a strict diet, and family history of diabetes.On the other hand, there was no significance between DM group and HC group in employment status, smoking, tobacco chewing, and qat chewing.

Comparison of hematological indices between diabetic mellitus (DM) patients group and healthy control group
In this work, as presented in

Discussion
DM is a chronic illness associated with the elevation of blood glucose levels because the human body cannot produce enough insulin or efficiently employ insulin.Patients with DM showed an important derangement in various hematological indices 4,41 .This study involved a comparison of the FBS levels between HC group and DM group.We noted a significant variance in FBS levels between DM group and HC group (P < 0.0001).Additionally, the study involved a comparison of BP between both groups, where the comparison results showed significant differences among systolic and diastolic pressures with P values < 0.0001 and 0.0404, respectively.This result is in accordance with a study conducted in Gondar; Ethiopia 35 .This might be due to the direct and toxic effects of chronic hyperglycemia on endothelial cells of the vascular which lead to vascular repairs and increased vasoconstriction ultimately affecting BP 35,42 .Likewise, RBC indices had shown non-statistically significant.This result is in agreement with that described by various studies in Sudan, Iran, USA, and Taiwan 37,[43][44][45] .
In this study, an Unpaired T-test displayed that the mean and SD of MCV, the total count of WBCs, eosinophil, and the count of platelet were highly statistical significant in DM group than HC group (P = 0.0191, P < 0.0001, P < 0.0001 and P = 0.0229, respectively).On the other hand, monocyte was statistically significantly low in DM group than in the HC group.However, the mean and SD of Hb level, RBC, PCV, MCH, MCHC, neutrophil, lymphocyte, and basophils in this study were not statistically significant.There are many studies conducted in different countries showing variations in hematologic indices, some studies showed significance, while others did The findings report of monocyte and basophil in Nigeria were significantly low in DM as compared to HC group 47 while other studies in Turkey, Ethiopia, and India in which monocyte was statistically high in DM group as compared to HC group 36,48,49 .The results of the mean of MCV and MCH in Brazil, Ethiopia, Saudi Arabia, India, and Sudan were statistically low in DM compared with HC group 30,[50][51][52][53] .In dissimilarity, a study done in Saudi Arabia exhibited that MCHC was statistically high in DM group compared to HC group 52 .
In our investigation, the WBCs count was elevated in DM.This result was similar to studies conducted in Sudan and Taiwan 37,54 .Concerning both ESR results, after one or two hours were statistically significant.A previous study conducted in Iraq found that ESR was significantly higher 55 .This study also involved comparison of platelet between HC group and DM group.We noted significant variances in platelet between both groups.Regarding CRP assay result, there was no statistical significance.Our study was dissimilar to research carried out in India 38 .The variations might be attributed to dissimilarities in the size of the sample, geographical location, socioeconomic status, laboratory investigative technique used, and dissimilarities among the participants as well as diet, daily behavior, and daily practices of individuals 4 .Moreover, the present study exhibited that the weight, Hb level, RBCs, PCV, and total WBCs count were statistically negatively correlated with FBS in DM.This study did not align with studies done in Poland and Israel, where the levels of FBS proportionally increased for every raise in WBCs count 56,57 .PC between FBS and ESR showed a weak correlation with no relationship.Our results were similar to a study conducted in Pakistan 39 .
Our study concluded that many hematological indices can differentiate DM patients from HC individuals.DM patients had relatively higher levels of MCV, WBCs, eosinophils, platelets, and ESR than the control group.Further studies were recommended to complete what our study lacks such as identification of the relationship between HbA1C and hematological indices.

Limitations
The study limits itself to Ibb City, Yemen which results in producing a small size.This occurs due to the absence of supporting institutions.

Table 1 .
Sociodemographic characteristics of study participants.

Table 3 ,
there were no statistically significant differences between the mean and SD of DM group and HC group respecting Hb level, RBCs count, PCV, MCH, MCHC, neutrophil count, lymphocyte count, and basophil count whereas the findings revealed that the mean and SD of FBS, systolic and diastolic BP, MCV, WBCs count, monocyte count, eosinophil count, platelets count, and 1 h and 2 h ESR had statistical significance between DM group and HC group.Out of the participants, about 53 (51.96%) of DM group were CRP positive, and about 40 (40%) of HC group were CRP positive, there was no significance between DM group and HC group in CRP assay results.

Table 3 .
Comparison of hematological indices between diabetic mellitus (DM) patients group and healthy control group.

Diabetic mellitus (DM) patients Healthy control P-value
www.nature.com/scientificreports/not.The mean and SD of basophil, monocyte, RBCs, MCH, and MCV were statistically variant between DM and HC groups in Dessie and Gondar cities of Ethiopia, Bosnia and Herzegovina, India, Sudan, and Nigeria4,35-37,46,47 .

Table 4 .
Pearson's correlation coefficient (r) of hematological indices with FBS among diabetic group and control group.