Impact of diabetes education on patients suffering from type 2 diabetes in Saudi Arabia

Alruwaili Mofreh,Alatni Adel,Aldhafeeri Khalid,Alharbi Muhammad

1Eradah Hospital for Mental Health, Al-Jouf 72347, Saudi Arabia; 2AlRass General Hospital, 4614 Airport District, Unit N0.8,AlRass,Saudi Arabia; 3Hafer Albatin Central Hospital,Hafar Albatin 31991,Saudi Arabia; 4Ministry of Health,Riyadh 11176,Saudi Arabia.

Abstract

Keywords:Diabetic education,HbA1c,Saudi Arabia,Type 2 diabetes,Cohort study

Introduction

Diabetes is a progressive, debilitating and life-threatening chronic health condition, distinguished by elevated and uncontrolled blood glucose levels resulting from either reduced or defective insulin function or both [1].The disease has indeed reached pandemic proportions [2].Patients affected with diabetes are soaring at an unparalleled speed and is even projected to exceed 550 million by the year 2030[3].The dynamics of diabetes complications include chronic microvascular (nephropathy, retinopathy and neuropathy) and macrovascular complications(peripheral artery disease, coronary artery disease,stroke, diabetic foot and diabetic encephalopathy),infections, physical and mental illness and cancer [4].The hyper-glycemia owing to high amount of circulating blood glucose can be intensified by several exogenous mediators, for instance, physical activity,food consumption, medications, inflammation and stress.The advancing and long-standing feature of the diabetes demands continuing surveillance and medical care.Perhaps timely self-management education and support to the patients could help mitigate the development of severe and chronic complications[5].

Diabetes education is a process of enabling people with knowledge and skill to be able to carry out self-management practice [6], which is crucial for type 2 diabetes management [1].A number of research studies have established that diabetes education substantially enhances the frequency of patients accomplishing therapeutic goals, and improves adherence to medication and self-care routine [7].For poor glycemic controls, Banerjee et al.proved significant improvement in haemoglobin A1c (HbA1c)at 1 year after single one-to-one diabetic health education [8].A cross-sectional longitudinal follow-up study found decreased risk of chronic complications among patients with diabetes education.In fact, the study also reported modest financial strain and improved productivity among patients [7].A randomized clinical trial by Fan et al.(2016)compared the efficacy of personalized diabetes education with that of group focused diabetes education.They concluded personalized diabetes education to be more impactful in controlling type 2 diabetes, evidenced by low body mass index, fasting blood glucose, HbA1c,systolic blood pressure, triglyceride and low-density lipoprotein [9].Of late, Zhang et al.also communicated reduced HbA1c,systolic blood pressure and low-density lipoprotein after education and concluded that systematic health education model is effective in managing type 2 diabetes patients [10].A pilot study on Saudi women also suggested improved blood glucose levels, diabetes knowledge and quality of life among those who received diabetes education program [11].Other studies conducted in Saudi Arabia have also demonstrated the robustness of diabetes health education programs to sustain optimum health in type 2 diabetes patients[12,13].

Research evidence indicates that international guidelines on lifestyle behaviours based diabetes education is more successful when personalised to the cultural and religious background [14, 15].The objective of the present research study was to discover the impact of diabetes education program in terms of diabetes knowledge, health outcomes, satisfaction and quality of life in type 2 diabetes of Al-Jouf Diabetes Centre,Saudi Arabia.

Material and methods

Ethics approval.Ethical approval was obtained from the ethical review committee for the present study(ethical approval number:20-012M).

Study design.Prospective cohort study.

Study setting.Al-Jouf Diabetes Centre,Saudi Arabia.

Study sample.110 newly diagnosed diabetes patients from Al-Jouf Diabetes Centre,Saudi Arabia.

Education programme.The diabetes education program consists of complete information about the diabetes, its types, different symptoms like hyperglycaemia and hypoglycaemia, monitoring and control of blood glucose,and management.In addition,our dietitian also guides patients about the role of diet and exercise in control of diabetes.Diabetes educator educate and trained patients on self-monitoring of blood glucose at home, insulin injection technique.This education program was conducted by our expert team including diabetologist, diabetes educator,podiatrists,dieticians and physiotherapist.

Inclusion and exclusion criteria.All newly diagnosed diabetic patients (within the last three months of diabetes diagnosis).Diagnosis of diabetes was made according to American Diabetic Association 2018 criteria, where diabetes mellitus was defined as HbA1c cut-off greater than or equal to 6.5% and in symptomatic individual a random plasma glucose level of ≥200 [16].And those who attend the diabetes education program session at Al-Jouf Diabetes Centre.Patients not diagnosed in the past three months (from 1st September 2019)and all other regular patients were excluded from the study.

Questionnaire.A predesigned response-based questionnaire was used.The questionnaire comprised of patient demographics followed by 16 questions assessing the impact of diabetes education.Detailed questionnaire has been attached in Supplementary File.Data collection.Data for the purpose of research were retrieved from the medical records of enrolled diabetes patients to understand the effects of health education on blood glucose levels through HbA1c (both baseline and follow-up).The follow-up period for each patient was three months.The case definition of the intervention was defined as those who took the intervention (diabetes education programme sessions)at Al-Jouf Diabetes Centre and at their home by sharing their feedback about that programme and the outcomes of the case definition was the difference in the level of HbA1c pre-and post-intervention.

Statistical analysis.Data of 110 patients were collected on excel and after data cleaning, all the data was transferred to SPSS version 22.Percentage and frequency are reported for categorical variable and mean along with standard deviation (SD) for continuous variables.Chi-square was used to see the difference among categorical variables.Paired t-test was used to compare HbA1c(the main outcome of this study) before and after the intervention while independent sample t-test was used for looking in the mean difference of HbA1c before and after intervention with respect to socio-demographic characteristics.Pvalue of 0.05 and less was considered significant for all the analysis.

Results

Data from 110 newly diagnosed diabetes patients who undertook educational intervention were analysed.Of total 52.7% were males, 78.2% were of age 45 and above, 70.9% were Saudi nationals, 76.4% were married and 59.1%had elementary and high education.(Figure 1).

After giving intervention to 110 patients a questionnaire was filled by all the participants to evaluate the positive outcome of intervention.Of total 78.2% patients reported that checking blood sugar level with care and attention is of considerable importance to them.Moreover, 47.2% patients reported that food choices to achieve optimal blood sugar level was of very much and of considerable importance to them.More than two third 87.3%reported that keeping all reports and recommendation is of considerable importance to them.Hundred percent of the patients reported that taking medication was of considerable importance to them.A very small fraction(20.9%)of patients reported that taking sweets occasionally was of considerable importance to them.Around two third (70.9%) reported that they are recording blood sugar level is of considerable/very important to them.Majority of patients reported that avoiding doctor's appointment (80.9%) does not apply to them and not checking the sugar level (98.2%)somewhat applied to them.While more than half reported that doing exercise (60.9%) and strictly following dietary recommendations (55.5%)somewhat applied to them.Of total 64.5% reported that avoiding physical exercise and 74.5% reported tend to forget exercise does not apply to them.Around two third(72.7%) reported that having real food binges somewhat applied to them while majority (98.2%)believed that seeing the medical doctor somewhat applied to them.Around two third reported that skipping planned physical activity (71.8%) and their self-care for diabetes (73.6%) is poor were somewhat applied to them(Table 1).

With respect to gender, there was significant difference between the blood sugar monitoring and choice of food.Males tend to be more considerate about the above two compared to women withP=0.014 andP= 0.012, respectively.All other attitudes did not differ among the gender (Table 2).There was no difference in patient's attitude with respect to nationality and education.However, with respect to age group,there was significant difference with respect to eating sweet occasionally, patients with age 18-45 reported that it does not or somewhat applied to them withP= 0.023.On the other hand, with respect to marital status, single people significantly tend to be considered skipping physical activity compared to married patients (42.3%vs 22.6%withP=0.049).All other variables did not differ with respect to age group and marital status.

Figure 1 Socio-demographic characteristics of study participants(n=110)

Table 1 Effect of educational intervention on patients’attitude towards diabetes(n=110)

Table 2 Gender difference with respect to effect of intervention on patient’s perception

The mean HbA1c before and after the intervention was 9.19 (SD 1.70) and 7.72 (SD 0.80), respectively.Results of pairedt-test shows a significant reduction in HbA1c following the intervention with a mean reduction of 1.47(t=6.07,DF=38,P＜0.001)

Mean difference in HbA1c before and after intervention was more in males,among Saudi nationals,among patients with age 18-45, those who were married and were more educated.However, the difference was not significant with respect to any socio-demographic variables(Table 3).

Discussion

The current study highlights several important and interesting findings.The main result of this study was that the intervention was very successful and significantly reduce the HbA1c (P＜0.001).However,this significance did not differ among males and females with respect to socio-demographic factors and effectiveness.These findings suggested that this intervention was effective in all age groups and in all socioeconomic condition and can be done in everyone,as insignificant results in the differences between males and females all of them got the benefit of the intervention.Professor Sieradzki stated “Diabetes health education is prerequisite for good glycemic control.A patient with diabetes should know more about their diseases as compare to their physician.”[17]

There are several methodological issues that need to discuss.The first limitation of the study was done on a small sample size and only in one hospital as it was a pilot study.However, our study might be underreported some clinical findings and prone to type 2 error,due to smaller size,single centered and shorter follow-up period.In reality, this type of studies required longer follow-up to check the complications.The other limitation of the study was that we did not measure body mass index of the study population.The strength of the study was that study data collection,and data management was done properly in a hospital.And all information was collected in the same laboratory.The major strength is that the first study to evaluate the effectiveness of diabetes education in Saudi Arabia.

Table 3 Mean difference in HbA1c with respect to socio-demographic variables

For instance, a single center study reported reduction in HbA1c significantly with diabetic health education [7].This is consistent with our results as the HbA1c is significantly reduced in studied population.Likewise, a randomized control trial showed that the diet and education intervention soon after diagnosis of diabetes can improve glycemic control [18].Early diabetic education can also lead to decrease in diabetic related complications.This was also reported in a published research that it not only reduced risk of complication but also financial strain and improved patient productivity[8].Similarly,a study reported that in Saudi Arabia complication of diabetes mellitus cost around 17 billion Saudi Riyals annually in 2014 with a progressive increase in cost up to 43 billion Saudi Riyals with an increase in diabetes [19].It was estimated the approximate health expenditure per diabetic person globally range from 1,583 USD to 2,842 USD [20].Therefore, by implementing early diabetic education in all hospitals and clinics can help in reduction of diabetic burden and related cost.Polish Diabetology Society emphasized that diabetes education is the basis of prevention of diabetes and care[21].

Our study results showed that males are more than females in appreciating the food and diet might help in blood glucose level control.Also found that they were aware of checking blood glucose is important for them.And these two factors were significantly different between males and females,these differences might be related to social factors in the North of Saudi Arabia.Future studies should aim to explore the reason for this difference, usually in all disease's females take care of their health more than males but it seems that because of social factors their male seems to take care more.

Conclusion

This study contributes to the existing published literature on the impact of diabetes education on diabetes patients' wellbeing.Early intervention in newly diagnosed diabetic patient is successful in reducing not only HbA1c but also provoke social change in public health practice by improving diabetic patient's adherence, and knowledge.Results from the current study has potentially important clinical implications and can be conducted in more hospitals.While promising, inferences should be taken tentatively, highlighting a stark need for further focused exploration of how it effects in more longer terms and in other centers also.Future researches should be multicenter using bigger sample size to know whether this intervention is successful.Ministry of health of Saudi Arabia can also generalize this intervention to the Kingdom.

Acknowledgment

All praise is due to Allah alone.I praise him, seek his aid and forgiveness.I thank Allah Almighty for giving me and my colleagues the inspiration, patience, time and strength to have this work accomplished.We especially indebted to Dr.Mohammed Alghamdi the general director of Nursing Affairs At MOH, Dr.Manal Banaser the director of research unit in Nursing Affairs at MOH, Mrs Madeha Alsahemy from the research unit thank you for great support.Also, we heartily thankful to our supervisor Dr.Mohammed Alharbi who clarify our research goal, reinforced our field knowledge, encouraged us through every challenging step.Mrs.Basmah Alruwaili from Diabetic Centre in Aljouf for her great contributions during collecting data.

Lastly, and most importantly, we wish to thank our families, who they constantly have us in their prayers,supported and encouraged us to achieve our goals.To them we dedicate this work.