
ISSN: 2641-1725
Setting: this study was conducted at the diabetic and the family medicine outpatient clinics of Suez Canal University Hospitals in Ismailia city, Egypt.
Sample: included 92 type 2 diabetic patients who were selected using purposive sampling technique.
Tools of data collection: A structured interviewing questionnaire about socio-demographic, diabetes history, and clinical characteristics was used to collect data and measurement of blood glucose control through glycated hemoglobin.
Results: Of the total 92 participants, less than two thirds of the participants had poor glycemic control. The differences regarding age, total socio-economic score, duration of the previous diagnosis of diabetes and body mass index between the two groups were not significant. Presence of hypoglycemic attacks and presence of previous surgical history were associated with glycemic control.
Conclusion: Presence of hypoglycemic attacks increases; it affects the normal values of HbA1c negatively while presence of previous surgical history increases; it affects the normal values of HbA1c positively. Recommendations: applying educational program on managing glycemic control and associated factors for type 2 diabetic patients using understandable methods and further researches should be conducted to improve glycemic control for type 2 diabetic patients.
Keywords: Diabetes mellitus; Type 2 diabetes mellitus; Glycemic control
Type 2 Diabetes Mellitus (T2DM) is a heterogeneous and
progressive illness, with an underlying mechanism ranging from
predominantly insulin resistance with relative insulin deficiency,
to predominantly an insulin secretory defect with lesser degrees
of insulin resistance. The spread of T2DM is increasing all over the
world, probably due to the expectations of population’s long life,
a sedentary lifestyle and above all, the increasing rates of obesity.
There are two sub-divisions of T2DM. The “Non-Insulin Requiring”
diabetes, managed by lifestyle measures alone and sometimes
oral drugs, and the “Insulin requiring for diabetes control”, where
insulin is required to control, rather than survival [1].
A recent study proved that the uncontrolled diabetes,
particularly elevated blood sugar over a prolonged period of time
could lead to a number of short and long-term health complications.Such complications were divided traditionally into two main
subtypes: the diabetes specific micro-vascular complications of
retinopathy, nephropathy, and neuropathy; which were caused by
injuries to the small blood vessels; in addition the thrombotic macrovascular
complications of myocardial infraction, hypertension, and
peripheral arterial disease which were presented due to arterial
damage [2].
Glycemic control is extremely fundamental to the management
of T2DM. Diabetes management aims to delay, the onset of disease
complications, and to hinder its progression, mostly by improving
glycemic control and controlling the risk of cardiovascular ailments.
Previous studies have provided evidences of the potential of good
glycemic control to restrict the micro-vascular and macro-vascular
complications of long-suffering diabetic enduring patients [3].
However, majority of the Egyptian diabetic patients cannot maintain
their blood glucose at therapeutic and acceptable level. Therefore,
there is a need to assess factors affecting glycemic control among
type 2 diabetic patients at the local level.
This study was carried out at the Family Medicine Outpatient Clinic and the Endocrine (Diabetic) Outpatient Clinic of Suez Canal University Hospitals at Ismailia city, Egypt. Those two clinics provide research, preventive and curative services according to the patients’ condition. A cross-sectional analytic design was employed including 92 type 2 diabetic patients who were selected using purposive sampling technique in which every participant was included by the following criteria: patients Newly diagnosed with type 2 diabetic accepted to participate in the study; aged 30 years or older; treated with diet regimen and /or oral hypoglycemic agents only; and. Data were collected over a period of three months (from November 2018 to January 2019).
Data were collected through the use of two tools: first tool: A
structured- interview questionnaire which was developed by the
researcher and included socio-demographic knowledge such as
gender, age, educational level, occupational status, and residence;
Socio-economic scale which was developed by El-Gilany et al. [4]
which included 7 domains with a total score of 84. Socio-economic
level was classified into very low, low, middle and high levels
depending on the quartiles of the score calculated to assess socioeconomic
status; and Diabetes history and clinical characteristics
such as Duration of the previous diagnosis of diabetes, family history
of diabetes, presence of diabetes related complications, presence
of previous surgical history, presence of hypoglycemia, smoking
status, following a planned diet, physical activity regularity, glucose
monitoring regularity, treatment regimen, medication adherence
and regular follow up. Second tool: Physical assessment sheet: This tool included Anthropometric measurements like (height, weight,
and body mass index), measurement of blood glucose control
through glycated hemoglobin (HbA1c) level.
Data collected were first coded and analysis was performed
using the Statistical Package for Social Sciences version 22, (SPSS
Inc., and Chicago, IL). Data were presented using descriptive
statistics in the form of frequencies and percentages for qualitative
variables, and means & standard deviations for quantitative
variables as well as inferential statistics. Stepwise Regression
(Forward Selection regression model) was used to select the most
essential independent explanatory variables -in participants and
under their specific situations- that proved they will affect the best
fitted model and consequently the final prediction equation. Hence,
the goal is to produce a good prediction equation with least number
of explanatory/independent variables (X-variables). The concept of
parsimony herein can be explained as the ability to produce the
most outcomes with fewer numbers of parameters. The criteria are
the higher absolute statistical t-value and presence of significance
for the resultant model-chosen-parameters (β-coefficient). The list
of X-variables that is thought they make sense (paper hypothesis),
but for many reasons they are too many to be included in the final
model. Variables Chosen/Entered according to Stepwise Regression
analysis were the “Presence of hypoglycemic attacks” (Model 1)
and the “Presence of previous surgical history” (both in Model 2).
Values are considered as statistically significant at Pα< 0.05.
Ethical considerations:
I. The researcher has considered all ethical issues.
II. The researcher has informed, verbally, of the consents
once elucidative the aim of the study.
III. The researcher assured confidentiality of the data
obtained for the participants and confirmed their rights to
withdraw at any time they want throughout the study.
More than two thirds of the participants (68.5%) were females, likewise slightly less than two thirds of them (64.1%) were in age group (45-64 years) and their mean age was 49.76 ± 9.19 years. Moreover, about two fifth of them (42.4%) were illiterate, less than two thirds were unemployed (63.0%; non-working) furthermore, more than two thirds (68.5%) came from urban areas (Table 1). However, Figure 1 illustrated that more than half of the participants (56.5 %) were of low socio-economic status level (i.e., their scores was 22 – 42); whereas least fraction (the minority of them) (3.3 %) were of very low socio-economic status level (i.e., their score was ≤ 21).
Figure 1: Percentage distribution of the participants by their socio-economic levels (n= 92).
Socio-economic status levels; very low level ≤ 21, low level 22 – 42, intermediate level 43 – 63, and high level 64 – up to 84.
Table 1: Frequency Distribution of the participants according to their socio-demographic characteristics (n= 92).
SD: Standard deviation
As far to distribution of the participants according to their diabetes history (Table 2), half of the participants (54.3%) diagnosed diabetic on or after two years& up to five years )mean 2.58 ± 1.85 years); two thirds of the participants had positive family history of diabetes (66.3%) and less than half of them suffered from diabetic complications(45.7%). In addition, more than half of them (53.3%) had comorbid diseases. Regarding hypoglycemia, roughly two fifth (43.5%) of them had none or rare attacks and more than half (56.5%) of them had previous surgical history. Figure 2 illustrates that less than two thirds (60.9%) of the participants were obese (BMI = ≥ 30 kg/m2) while the minority of them (8.7%) were normal weight (20- 24.9 kg/m2).
Figure 2:Distribution of the participants according to body mass index (n=92).
Socio-economic status levels; very low level ≤ 21, low level 22 – 42, intermediate level 43 – 63, and high level 64 – up to 84This index was used to categorize participants into: Underweight; < 18.5 kg/m2, Normal weight; 18.5 –24.9 kg/m2, Over weight; 25-29.9 kg/m2, Class I Obesity; 30-34.9 kg/m2, Class II Obesity; 35-39.9 kg/m2, Class III Obesity; > 40 kg /m2.
Table 2: Frequency Distribution of the participants according to their diabetes history (n= 92).
SD: Standard deviation
With regard to the distribution of the participants according to their clinical characteristics (Table 3), more than half of the participants (57.6 %) were nonsmokers; 96.7% taken oral hypoglycemic treatment regimen, and the majority (87.0%) were adherent to medication. As regards to glucose monitoring, more than half of them (51.1%) have had checked their blood glucose level regularly. Approximately and surprisengly, the vast majority (94.6%) of them were not following planned diet regimen, more than three quarters (76.1%) did not practice at any regular physical activities though more than half (55.4%) of them were stand firm by themselves to regular follow up schedule. On the contorary,) illustrated that less than two thirds (65.2%) of the participants had poor glycemic control (HbA1c >7%; Figure 3).
Figure 3: Distribution of the participants according to glycemic control (HbA1c level) (n=92).
Glycemic control; Good control ≤ 7%, while Poor control > 7%.
Table 3: Frequency Distribution of the participants according to their clinical characteristics (n= 92).
However, due to sample size eccentricities, statistical analysis revealed non-significant differences regarding age, total socioeconomic scores, duration of the previous diagnosis of diabetes and body mass index between the two groups (i.e. good glycemic control and poor glycemic control; Table 4).
Concerning outputs of stepwise regression analysis, Table 5 displayed the excluded variables (i.e. Gender; Follow-up visits; Smoking status) from the list of X-variables that is thought they make sense (paper hypothesis) in affecting Dependent Variable: (Glycated hemoglobin, HbA1c% level) of type 2 diabetic patients attending the family outpatient clinic and the diabetic outpatient clinic of Suez Canal University Hospitals, Ismailia, Egypt. Results revealed that First: the absolute values of t-test are smaller than those of the chosen variables and second: those excluded variables are not statistically t-test significant. P-value ranged between 0.107 to 0.694). Pertaining to regression diagnostics, it was found that these X-variables have tolerance reached unity or close to unity causing Variance Inflation Factor (VIF) to reach 10 or more. These Variance Inflation Factor (VIF), are far from 5 (optimum VIF value according to data) to be noncollinear. These outputs are evidences of severe collinearity or in other words the omitted X-variables are dependent or they somehow are related to each other, perhaps because they express the opinion of definite/an explicit respondent which makes them express their interconnected specific judgments/ outlooks.
Table 5:Excluded Variables a from the list of X-variables that is thought they make sense in affecting Dependent Variable: (Glycated haemoglobin HbA1c% level) of type 2 diabetic patients attending the family outpatient clinic and the diabetic outpatient clinic of Suez Canal University Hospitals, Ismailia, Egypt.
a. Dependent Variable: Glycated hemoglobin (HbA1c% level).
However, results of Table 6 could be an interpretation for the entered (i.e. non-expelled qualified) independent variables, as they express no-body opinion (i.e. one of them is a quantitative measure whilst the other is a sort of misfortune/calamity explicitly Presence-Of-Hypoglycemic-Attacks and/or Previous-Surgical- History;-respectively) to such an extent that the effects of these entered variables (models 1& 2) on the percent level of Glycated hemoglobin (HbA1c%) were significant.
Table 6: Analysis of variance of the Entered variables (models 1 & 2) that was realized to influence the percent level of Glycated hemoglobin (HbA1c %).
Table 7: Beta Coefficients Analysis of variance of the Entered variables (models 1& 2) that was realized to influence the percent level of Glycated hemoglobin (HbA1c %) using stepwise regression procedure.
a. Dependent Variable: Glycated hemoglobin (HbA1c) (%) level.
From Results Stepwise Regression (Table 7- Model 2) the best fitted model includes, apart from Constant, Presence of hypoglycemic attacks (t-value= -2.367) and Presence of previous surgical history Predictors (t-value= 1.967). The Glycated hemoglobin (HbA1c %) B-value with Presence of hypoglycemic attacks was negative (-0.901+0.381; adverse relationship). That means that as Presence of hypoglycemic attacks increases; it affects the normal values of HbA1c negatively and vice versa. As for Presence of previous surgical history the relationship was positive (0.733+0.373; progressive relationship). That means that as Presence of previous surgical history increases; it affects the normal values of HbA1c positively.
Diabetes self-care has been defined as an evolutionary process
of development of knowledge or awareness by learning to survive
with the complex nature of the diabetes in a social context. There
are seven essential self-care behaviors in people with diabetes
which predict good outcomes which are healthy eating, being
physically active, monitoring of blood sugar, compliant with
medications, good problem-solving skills, healthy coping skills and
risk reduction behaviors. These seven behaviors have been found
to be positively correlated with good glycemic control, reduction
of complications and improvement in quality of life [5] so, this
study aimed to assess factors affecting glycemic control among
type 2 diabetic patients attending Suez Canal University Hospitals
in Egypt. According to socio-demographic characteristics of the
studied sample, the current study revealed that more than two
thirds of the studied sample were females. This trend is consistent
with a number of universal and territorial reports demonstrating
higher predominance of T2DM amongst females. This result is
concurred moreover with the study conducted in India by Dussa et
al. [6] and Mufunda et al. [7] who found that females represented
more than two thirds of their studied sample. The study conducted
in Egypt by Mostafa [8] also revealed that more than three quarters
of their studied sample were females. From the researcher point of
view, this result may be due to female haven’t concerned with their
health because of their excesssive duties.
The former results were inconsistent with, Al-Aboudi et al.
[9] who designated that more than three quarters of their studied
sample were males, and Berhe et al. [10] who assigned that more
than half of their studied sample were males.
As far to age, less than two thirds of the studied samples were
in age grouping ranged from 45 to 64 years (mean age 49.76 ±
9.19 years). This demonstrates that pronounced share of the
individuals with T2DM diabetes are of middle-age, this result was
in agreement with the study titled “Global estimates of diabetes prevalence for 2013 and projections for 2035 for the IDF Diabetes
Atlas” conducted by Guariguata et al. [11] who found that the larger
part of people with DM in Africa are less than 60 years of age with
the most elevated extent of those aged 40-59 years old. Moreover,
this result was in agreement with Mufunda et al. [7] who found that
the mean age of their studied sample was 48 years. On the same
context, three quarters of the studied sample by Mostafa [8] were
40-60 years in age group )mean age was 52.3 ± 8.7 years) and more
than two thirds of Berhe et al. [10] studied samples were within
age grouping of (40 to 69 years), but mean age of Al-Aboudi et al.
[9] studied sample was 54 ± 9.2 years. From the researcher point
of view, this may be due to this age group (middle age) have the
highest percentage of work and stress.
Regarding to the marital status, the majority of the participants
were married. In addition, approximately two fifth of them were
illiterate, less than two thirds were unemployed additionally, more
than two thirds of them came from urban areas and less than two
thirds of them were nuclear family, these results were in agreement
with Megahed [12] who found that less than three quarters of
their studied sample were married, more than half of them were
uneducated, the majority of them were unemployed, less than two
thirds of them were nuclear family and more than half of them were
living in urban areas. These results were also in agreement with
Mostafa [8] who found that the majority of their studied sample
were married, half of them were illiterate, more than three quarters
of them were unemployed. However, Abd El Raziek [13] found that
less than three quarters of their studied sample were married, less
than three quarters of them come from urban area and nearly two
fifth of them were illiterate.
As regards to socio-economic status, it was noted that more
than half of the participants had low socio-economic status level,
this result agreed with Megahed [12] who found that more than
three quarters of their study group had low socio-economic status
level. This result disagreed with Abd El Raziek [13] who found
that nearly two thirds of their studied sample belonged to middle
socio-economic status level. From the researcher point of view,
this is usually a reflection to the fact that more than two thirds of
the studied sample were females and their low educational level
gave them no chance for work which in turn lowers their month
to month pay and this leading to inadequate fund to use in medical
treatment and check up.
As concerning to diabetes history, it was noted that half of the
participants diagnosed diabetic from two years up to five years
with mean 2.58 ± 1.85 years, this result was inconsistent with
Mostafa [8] who found that more than half of their studied sample
had DM since (5-15 years). This result also was conflicting with
Abd El Raziek [13] who found that half of their studied sample
influenced by DM from less than two years. From the researcher
point of view, the differences in these studies might be attributed to
the differences in the patients’ populations and residence.
Regarding to family history of diabetes, it was observed that two
thirds of the participants had positive family history of diabetes,
this result agreed with Mostafa [8] who found that three quarters of
their studied sample had a positive family history of DM. This result
also was consistent with Abd El Raziek [13] who found that less
than three quarters of their studied sample had a positive family
history of DM. From the researcher point of view, this reflects a high
role of inheritance of T2DM.
With regard to diabetes related complications, less than half
of the participants suffered from diabetic complications, this
result was in agreement with Ibrahim [14] who found that half
of their studied sample had diabetes complications. This result
was in contradiction with Berhe et al. [10] who found that as it
were the minority of their studied sample had long term diabetic
complication affirmed medically. From the researcher point of
view, this may be owing to the dissimilarities in healthcare assets,
clinical care, diagnostic criteria and way of life variables. Those
patients winning a low pay commonly have a low educational level,
low information, and less awareness on how to preserve a great
glycemic control leading to these complications.
As concerning to treatment regimen, nearly the entire sample
has taken oral hypoglycemic agents by themselves, this result
concurred with Karaoui et al. [15] who found that the larger parts
of patients were taking oral hypoglycemic agents. This result
coming on the same line with Inzucchi et al. [16] who mentioned
that metformin remains the optimal drug for monotherapy and
its low cost, demonstrated safety record, weight neutrality, and
conceivable benefits on cardiovascular outcomes have secured its
place as the favored introductory medication choice and in any
combination not accomplishing an agreed HbA1c target despite
intensive therapy, basal insulin considered as a fundamental
component of the treatment technique. This result disagreed with,
Megahed [12] who found that less than half of their studied sample
have taken oral hypoglycemic agents by themselves.
Regarding to following planned diet regimens, the vast majority
of the participants were not following planned diet regimens, this
result agreed with, Megahed [12] who found that the vast majority
of them were not taking after arranged count calories regimens.
From the researcher point of view, this might be owing to the
low monthly income amongst majority of the participantsmight
restrain their availability and reasonableness of a well-balanced
diet and sound nourishment.
In accordance with physical activity, the current study
revealed that more than three quarters of the participantsdid not
practice physical exercises; this result disagreed with, Megahed
[12] who found that the minority of their studied sample did not
perform physical activity. From the researcher point of view, this
might be clarified by progressed innovation since most of the
participantsparticularly females went through their times in watching TV or snacking and most of them depend on the mean
of transportation instead of strolling. It appears moreover that
patients with diabetes have not had precise and comprehensive
data about advantages of regular work -out and may need basic
motivators for physical activity.
The current study revealed that the differences regarding age,
total socio-economic score, duration of the previous diagnosis
of diabetes and body mass index between the two groups were
not significant. These results disagreed with Othman et al. [17]
who found that poor glycemic control was more common among
patients who were older (>50 years) and increased duration of
diabetes (>7 years). These results also disagreed with Tabaei
et al. [18] found that age, socioeconomic status and BMI were
significantly associated with glycemic control. The reason for the
diference between this study and other studies may be the variation
in clinical characteristics of the participants.
The present study showed that there was negative association
between occurrence of hypoglycemia and the glycated hemoglobin.
It was clear that expanded recurrence of hypoglycemic attacks
would be related with a lower value of HbA1c This result disagreed
with Retornaz et al. [19] who found that there was no association
between occurrence of hypoglycemia and HbA1c and they proposed
that HbA1c wasn’t the satisfactory marker for the detection of
hypoglycemia risk.
The present study revealed that there was positive association
between presence of previous surgical history and the glycated
hemoglobin. On te same line, Yong et al. [20] mentioned that there
were relationship between poor glycemic control and poor surgical
outcomes.