STUDY ON THERAPEUTIC OUTCOME, ATTITUDE AND AWARENESS ABOUT TYPE-2 DIABETES AMONG TYPE-2 DIABETIC FEMALE PATIENTS IN ASEER DIABETIC CENTER

Abstract

Type 2 diabetes mellitus (T2DM) is a global epidemic problem. Obesity is the single most important contributor to insulin resistance. Management of diabetes requires lifestyle modification (eg. dietary changes and physical activity) and adherence to other healthful behaviors, such as medication adherence, and timely medical care. This is a cross sectional retrospective cum prospective study of patients which included all adult type 2 DM patients who were registered in the Aseer diabetic center, Abha, Aseer Region, Kingdom of Saudi Arabia. This study was conducted from July, 2012 to October 2013.As a therapeutic outcome the HbA1c target was not achieved in this group of patients. In all the four visits the mean target value for Glycated hemoglobin (HbA1c) was found to be above 9% and there is no significance difference in reduction of HbA1c after treatment. There is no significance difference or improvement in the lipid profile except total cholesterol and VLDL among this group of patients. Only (31.88%) of the patients was following SMBG. Patients not taking medications in proper time as prescribed were about (30.35%). Forget fullness was the main reason for not taking the medication on time. Increased duration of diabetes and obesity was associated with higher incidence of Hyperglycemia and dyslipidemia. Lack of awareness and poor compliance to therapeutic management created huge burden on healthcare system in the kingdom. Patient education and awareness programs should be done to improve the present situation. [PUBLICATION ABSTRACT]

Headnote

ABSTRACT

Type 2 diabetes mellitus (T2DM) is a global epidemic problem. Obesity is the single most important contributor to insulin resistance. Management of diabetes requires lifestyle modification (eg. dietary changes and physical activity) and adherence to other healthful behaviors, such as medication adherence, and timely medical care. This is a cross sectional retrospective cum prospective study of patients which included all adult type 2 DM patients who were registered in the Aseer diabetic center, Abha, Aseer Region, Kingdom of Saudi Arabia. This study was conducted from July, 2012 to October 2013.As a therapeutic outcome the HbA1c target was not achieved in this group of patients. In all the four visits the mean target value for Glycated hemoglobin (HbA1c) was found to be above 9% and there is no significance difference in reduction of HbA1c after treatment. There is no significance difference or improvement in the lipid profile except total cholesterol and VLDL among this group of patients. Only (31.88%) of the patients was following SMBG. Patients not taking medications in proper time as prescribed were about (30.35%). Forget fullness was the main reason for not taking the medication on time. Increased duration of diabetes and obesity was associated with higher incidence of Hyperglycemia and dyslipidemia. Lack of awareness and poor compliance to therapeutic management created huge burden on healthcare system in the kingdom. Patient education and awareness programs should be done to improve the present situation.

Keywords: Therapeutic outcome; Type-2 Diabetes mellitus; HbA1c; Patient attitude; Awareness; Saudi Arabia.

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a global epidemic with anestimated worldwide prevalence of 6% (246 million people) in 2007, and forecast to rise to 7.3% (380 million) by 2025.1 T2DM is a complex disorder in which the interaction between environmental and genetic factors results in the development of insulin resistance (IR) and β-cell dysfunction. Obesity is the single most important contributor to IR modulating insulin sensitivity via multiple factors including imbalance of hormones (leptin and adiponectin), cytokines (tumour necrosis factor-α, interleukin-6), suppressors of cytokine signaling (SOCS), inflammatory signalling pathways (nuclear factor-KB and IKB Kinase) and retinol binding protein-4.2 According to the American Diabetes Association, the target for long-term glycemic control in patients with diabetes is Glycated hemoglobin (HbA1c) value of less than 7%.3 Since patients with diabetes are at increased risk for cardiovascular events, additional treatment goals include achieving BP less than 130/80mmHg and LDL-C less than 100 mg/dL.3-7 Management of diabetes requires lifestyle modification (eg, dietary changes and physical activity) and adherence to other healthful behaviors, such as medication adherence, and timely medical care.8

The ultimate aim of any prescribed medical therapy is to achieve certain desired outcomes in the patients concerned. Therapeutic compliance not only includes patient compliance with medication but also with diet, exercise, or life style changes. In order to evaluate the possible impact of therapeutic non-compliance on clinical outcomes, numerous studies using various methods have been conducted in the United States (USA), United Kingdom (UK), Australia, Canada and other countries to evaluate the rate of therapeutic compliance in different diseases and different patient populations.9

In type-2 diabetes patient's Total cholesterol, Triglycerides (TGL), Low-density Lipoprotein (LDL), High density Lipoprotein (HDL), and Very Low density Lipoprotein (VLDL) are important biomarkers for lipid metabolism, which varies according to the duration of Diabetes mellitus. In type 2 diabetes mellitus lipid abnormalities are almost the rule. Typical finding are elevation of total and VLDL cholesterol, triglyceride concentration, exaggerated postprandial lipaemia, lowering of HDL cholesterol and a predominance of small, dense LDL particles.10 Triglyceridemia has been associated with increased risk of coronary heart disease both in non diabetic and type-2 diabetic subjects.11

The main objective of the study is to know the "Therapeutic outcome, Attitude and Awareness about Type-2 diabetes among Type-2 Diabetic female patients who were registered in Aseer Diabetic center".

The rapid increase in the prevalence of diabetes mellitus has made this disease one of the fundamental public health problems worldwide. Diabetes requires multi factorial and systematic management aimed not only to control metabolic abnormalities but first of all to prevent or delay the complications. Non-compliance, lack of awareness is believed to be the most common cause of treatment failures. Obesity is one of the most common factors playing important role in glycemic control. Obesity is more common in Saudi females. So this study will give an idea about the therapeutic outcome, awareness and attitude in such population.

PATIENTS AND METHODS

Patients were informed about purpose of the study, confidentiality of the data and anonymity. Only those patients who agreed were interviewed.

This is a cross sectional retrospective cum prospective study of patients which included all adult type 2 DM patients who were registered in the Aseer diabetic center, Abha, Aseer Region, Kingdom of Saudi Arabia. This study was conducted from December 2012 to December 2013. A total number of 343 patient's records were randomly selected from the patient medical records section. Patients of Type-2 DM of age group from 18 years to 80 years of Female sex were included in the study. Medical record of the patients who fulfilled the criteria was reviewed and the data was entered in the specifically designed data collection form. Data obtained from the patient records included: age, duration of DM, family history, BMI (Body Mass Index), type of treatment for diabetes. Measurements included weight, height; BMI (weight in kilograms/height in meters squared) was used to classify patients as normal weight (18.5 to 24.9 kg/m2), overweight (25-29.9 kg/m2) and obesity into (30 to ≥40 kg/m2). The HbA1c value and TGL, T Chol, and LDL were considered as primary outcome measure. Current guidelines for glycemic control recommend HbA1c values < 7% as a treatment goal for most DM patients.12 Glycemic control was grouped into four categories: good (HbA1c < 6-6.9%), acceptable (HbA1c 7%-7.9%), poor (HbA1c >8%-9.9 %) or extremely inadequate (HbA1c ≥ 10 %).Lipid profile values LDL cholesterol < 100 mg/dl, HDL cholesterol >50 mg/dl, TGL<150 mg/dl13 are considered as normal, Patient attitude and adherence data was retrieved from the medical records and discussing with the treating Diabetologist from the center.

Gestational Diabetes Mellitus (GDM), Type-1 diabetes mellitus and patients less than 18 years and more than 80 years were excluded from the study. Among the 343 patients 138 patients were females. Only the 138 female patient's data was analyzed for this study. Also a Questionnaire was developed to know the attitude and awareness among the type-2 Diabetes female patients. Self monitoring blood glucose (SMBG), diet, physical exercise, compliance to drug therapy was considered as most important parameters. The questions were asked to the patients when they came to the clinic in presence of the female nurse. The answers were recorded and statistically analyzed with MicrosoftExcel 2007. Descriptive statistics of Mean, standard deviation (SD) and frequencies were performed using sample one way ANOVA was used to analyze the continuous data; P ≤ 0.05 was considered statistically significant.

RESULTS AND DISCUSSION

A total of 138 female patients were included in this study. Among the 138 patients 112(81.15%) patients answered the questionnaire which is a part of this study. The age of studied patients were between 18-80years, demographic data, Social status of the patients are presented in table 1.

The mean ±SD age was found to be 59.8 (±9.03). Among the type-2 diabetic female patients, almost fifty percentages of them were illiterate (44.44%), and only (17.6%) and (7.4%) of them were literate from High school and College respectively. Most of the patients, n= 68 were married, nearly quarter percentage of them were unmarried, n =23. Urbanization is considered as one of the contributing factor for sedentary life style in the general population and also it is an important factor in glycemic control among the diabetic population. More than 50% of the study population were from urban area where as (34.25%) were from rural areas. Most of the patients (46.30%) were referred from tertiary healthcare center, (31.48%) were from Primary healthcare center and (22.22%) were from the secondary healthcare center.

The therapeutic outcome have been presented in Table 2, The Mean (±SD) HbA1c of studied sample was 9.7(±2.2) %. The HbA1c target was not achieved in this group of patients. In all the four visits the mean target value for HbA1c was found to be above 9% and there was no significance difference in reduction of HbA1c after treatment. Most of the patients were obese and having high BMI, 33.59(±6.27) kg/m2 and Mean duration of Diabetes mellitus was found to be 15.08 (±7.27) years.

The Mean (±SD) Total cholesterol, TGL, LDLHDL showed abnormal values and it was evident that these groups of patients were either non adherent to the therapy or having poor awareness about the diabetes associated complications. The HDL values are ≤ 40mg/dl which is an alarming biomarker in type-2 diabetes patients, which needs more efforts to be done by the healthcare team to bring in to normal range. There is no significant difference or improvement in the lipid profile except total cholesterol (p<0.0310) and VLDL (p<0.0028) among this group of patients.

The most important in the therapeutic management is the attitude of the patient, Table 3. The most important attitude for patients with diabetes mellitus is the SMBG, but only (31.88%) of the patients were following SMBG. Lack of physical exercise was observed in this study group, (71.05%) were not having physical activity and (71.77%) of them were not in diet control. Compliance of the therapy is the major factor in the management of diabetes mellitus, (51.47%) of patients were having compliance to the therapeutic management and (16.66%) of them refused to take insulin according to the advice of the physician and were willing to continue on oral hypoglycemic agents.

In reply to the questionnaire, Table 4, almost all the patients (92%) were not aware about their type of diabetes, Patients who were not aware about disease prognosis were 71.43%, 16.96% of patients did not take proper dose of insulin as prescribed, 30.35% of them were not taking medications in proper time as prescribed. Forget fullness was the main reason for not taking the medication on time. Most of them had housemaids (57.15%) in their homes which might be the reason for reduction in their physical activity.

The results of this study are consistent with those from several other studies in KSA and abroad with regard to the association between type 2 diabetes and age and education.

The management of Diabetes Mellitus not only requires the prescription of the appropriate nutritional and pharmacological regimen by the physician but also intensive education and counseling of the patient. Diabetes is a chronic disease with altered carbohydrate, lipid and protein metabolism. The chronic complications of diabetes are known to affect the quality of life of diabetic patients. Various factors like understanding of the patients about their disease, socioeconomic factors, dietary regulation, self monitoring of blood glucose is known to play a vital role in diabetes management.14

The present study showed that the highest percentage of diabetes was seen in the age group (50-62 year) with a mean age of (59.8±9.03) which reflects almost same observation in other study done in Iraq.15 In our study the obesity is the main contributing factor as found in study done by Nasser M Al-Daghri.16

In our study, compliance with drugs was much better than compliance with diet and visits, this goes with other studies which observed that compliance is better with medical aspect of a regimen (medication) than with life style aspect of diabetic regimen, such as diet and exercise.15

Our study also showed that persons not carrying out any form of regular exercise are at a significantly greater risk, even after adjusting for their dietary habits, age, and family history. Our results are consistent with previous studies17,18 on the role of physical activity: leading a sedentary life increases the risk of diabetes considerably. As found in other study in Saudi arabia16 unhealthy diet and physical inactivity are the most important risk factors of type 2 diabetes reflect in our study also. In a study conducted in Pakistan Talat N, found that duration of diabetes was associated with higher incidence of dyslipidemia.19

This study showed that there is lack of awareness about the type-2 diabetes and its complications. Overall, it was found that diet and lifestyle advice was followed less by all patients. Most of them are having housemaid at homes, which makes the female patients to have greater chance for sedentary life style, which is also an important contributing factor for obesity among the study population.

CONCLUSION

Increased duration of diabetes and obesity was associated with higher incidence of Hyperglycemia and dyslipidemia. Lack of awareness and poor compliance to therapeutic management created huge burden on healthcare system in the kingdom. Patient education and awareness programs should be done to improve the present situation.

ACKNOWLEDGEMENT

Authors acknowledges, Dr Sam Daniel Paulliah for his scientific advice and also the authors acknowledge the Director and staffmembers in the Aseer diabetic center for their cooperation and support during this study. This study is not supported by any funding.

References

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