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November 2017 -
Volume 15, Issue 9

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From the Editor



Original contribution/Clinical Investigation
Diabetes Mellitus - Knowledge, Management and Complications: Survey report from Faisalabad-Pakistan
Ijaz Anwer, Ahmad Shahzad, Kashmira Nanji, Farah Haider, Muhammad Masood Ahmad

Alanine aminotransferase indicates excess weight and dyslipidemia
Mehmet Rami Helvaci, Orhan Ayyildiz* Mustafa Cem Algin, Yusuf Aydin, Abdulrazak Abyad, Lesley Pocock

Comparative Analysis of Antimicrobial Peptides Gene Expression in Susceptible/Resistant Mice Macrophages to Leishmania major Infection

Hamid Daneshvar, Iraj Sharifi, Alireza Kyhani, Amir Tavakoli Kareshk, Arash Asadi

Does socio-economic status of the patients have effect on clinical outcomes after coronary artery bypass grafting surgery?
Forough Razmjooei, Afshin Mansourian, Saeed Kouhpyma

Comparison of the uterine artery Doppler indices during pregnancy between gestational diabetes and diabetes mellitus and healthy pregnant women
Nazanin Farshchian, Farhad Naleini, Amir Masoud Jaafarnejhad,
Parisa Bahrami Kamangar

Survey single dose Gentamicin in treatment of UTI in children with range of 1 month to 13 years old in Jahrom during 2015
Ehsan Rahmanian, Farideh Mogharab,
Vahid Mogharab

Evaluation of control of bleeding by electro cauterization of bleeding points of amplatz sheath tract after percutaneous nephrolithotomy (PCNL) in Jahrom Peymanieh hospital during year 2015-2016
Ali Reza Yousefi , Reza Inaloo

Comparison of the three-finger tracheal palpation technique with triple ID formula to determine endotracheal tube depth in children 2-8 years in 2016-2017
Anahid Maleki, Alireza Ebrahim Soltani, Alireza Takzare, Ebrahim Espahbodi,
Mehrdad Goodarzi , Roya Noori

Effect of Sevoflurane and Propofol on pulmonary arterial pressure during cardiac catheterization in children with congenital heart diseases
Faranak Behnaz, Mahshid Ghasemi , Gholamreza Mohseni, Azim Zaraki
Population and Community Studies

Prevalence and risk factors of obesity in children aged 2-12 years in the Abu Dhabi Islands
Eideh Al-Shehhi, Hessa Al-Dhefairi, Kholoud Abuasi, Noora Al Ali, Mona Al Tunaiji, Ebtihal Darwish

Study and comparison of psychological disorders in normal students and students with multiple sclerosis in Shahrekord
Neda Ardestani-Samani, Mohammad Rabiei, Mohammad Ghasemi-Pirbalooti, Asghar Bayati, Saeid Heidari-Soureshjani

Comparative study of self-concept, physical self-concept, and time perspective between the students with multiple sclerosis and healthy students in Shahrekord
Neda Ardestani-Samani, Mohammad Rabiei, Mohammad Ghasemi-Pirbalooti, Asghar Bayati, Saeid Heidari-Soureshjani

Relationship between Coping Styles and Religious Orientation with Mental Health in the Students of the Nursing-Midwifery Faculty of Zabol
Nasim Dastras, Mohsen Heidari Mokarrar, Majid Dastras, Shirzad Arianmehr

Tuberculosis in Abadan, Iran (2012-2016): An Epidemiological Study
Ali-Asghar ValiPour, Azimeh Karimyan, Mahmood Banarimehr, Marzieh Ghassemi, Maryam Robeyhavi, Rahil Hojjati,
Parvin Gholizadeh

Family Stability and Conflict of Spiritual Beliefs and Superstitions among Yazdi People in Iran: A Qualitative Study
Zahra Pourmovahed , Seyed Saied Mazloomy Mahmoodabad ; Hassan Zareei Mahmoodabadi ; Hossein Tavangar ; Seyed Mojtaba Yassini Ardekani ; Ali Akbar Vaezi

A comparative study of the self-actualization in psychology and Islam
Simin Afrasibi, Zakieh Fattahi

The effectiveness of cognitive - behavioral therapy in reducing the post-traumatic stress symptoms in male students survivors of earthquake in the central district of Varzeghan
Sakineh Salamat, Dr.Ahad Ahangar, Robab Farajzadeh


Effects and mechanisms of medicinal plants on stress hormone (cortisol): A systematic review
Kamal Solati, Saeid Heidari-Soureshjani, Lesley Pocock

Comparing Traditional and medical treatments for constipation : A Review Article
Mohammad Yaqub Rajput

A review of anti-measles and anti-rubella antibodies in 15- 25 year old women in Jahrom City in 2011
Ehsan Rahmania , Farideh Mogharab, Vahid Mogharab

Review of percutaneous nephrolithotomy in children below 12 years old in Jahrom hospital, during 2010-2014
Ali Reza Yousefi , Reza Inaloo

Physical and mental health in Islam
Bahador Mehraki, Abdollah Gholami

International Health Affairs

The Challenges of Implementation of Professional Ethics Standards in Clinical Care from the viewpoint of Nursing Students and Nurses
Saeedeh Elhami, Kambiz Saberi, Maryam Ban, Sajedeh Mousaviasl, Nasim Hatefi Moadab, Marzieh Ghassemi

Cognitive Determinants of Physical Activity Intention among Iranian Nurses: An Application of Integrative Model of Behavior Prediction
Arsalan Ghaderi, Firoozeh Mostafavi, Behzad Mahaki, Abdorrahim Afkhamzadeh,
Yadolah Zarezadeh , Erfan Sadeghi

Effect of resilience-based intervention on occupational stress among nurses
Hossein Jafarizadeh, Ebrahim Zhiyani, Nader Aghakhani, Vahid Alinejad, Yaser Moradi

Education and Training

Calculation of Salaries and Benefits of Faculty Members in the Ministry of Health and Medical Education of Iran
Abdolreza Gilavand

The effect of education on self-care behaviors of gastrointestinal side effects on patients undergoing chemotherapy
Shokoh Varaei, Ehsan Abadi Pishe, Shadan Pedram Razie, Lila Nezam Abadi Farahani

Creating and Validating the Faith Inventory for Students at Islamic Azad University of Ahvaz
Solmaz Choheili, Reza Pasha, Gholam Hossein Maktabi, Ehsan Moheb

Creating and Validating the Adjustment Inventory for the Students of Islamic Azad University of Ahvaz
Homa Choheili, Reza Pasha, Gholam Hossein Maktabi, Ehsan Moheb

Evaluating the Quality of Educational Services from the Viewpoints of Radiology Students of Ahvaz Jundishapur University of Medical Sciences
Abdolreza Gilavand, Jafar Fatahiasl

An Investigation of Psychosocial aspect of Iranian Nursing Students' Clinical Setting
Mahsa Boozaripour , Zanyar Karimi, Sima Zohari Anbohi, Amir Almasi-Hashiani, Fariba Borhani

Clinical Research and Methods

Comparison of the Antibacterial Effects of Chlorhexidine Mouth washes with Jaftex Mouth wash on Some Common Oral Microorganisms (An in Vitro Study)
Ebrahim Babadi, Zahra Bamzadeh, Fatemeh Babadi

Study of the effect of plasma jet on Fusarium isolates with ability to produce DON toxins
Elham Galin Abbasian, Mansour Bayat, Arash chaichi Nosrati, Seyed Jamal Hashemi, Mahmood Ghoranneviss

The comparison of anti-inflammatory effect in two methods of topical dexamethasone injection and topical application of ginger alcoholic extract after removing mandibular wisdom teeth
Sahar Zandi, Seyyed Muhammadreza Alavi, Kamran Mirzaie, Ramin Seyedian, Narges Aria, Saman Jokar

The effect of curcumin on growth and adherence of major microorganisms causing tooth decay
Leila Helalat, Ahmad Zarejavid, Alireza Ekrami, Mohammd Hosein Haghighizadeh, Mehdi Shiri Nasab

Middle East Quality Improvement Program

Chief Editor -
Abdulrazak Abyad MD, MPH, MBA, AGSF, AFCHSE


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November 2017 - Volume 15, Issue 9

Diabetes Mellitus – Knowledge, Management and Complications: Survey report from Faisalabad-Pakistan

Ijaz Anwer
Ahmad Shahzad
Kashmira Nanji
Farah Haider
Muhammad Masood Ahmad

(1) Anwer Clinic, Peoples Colony Faisalabad;
(2) Al Raheem Clinics, GM Abad, Faisalabad;
(3) Department of Family Medicine, The Aga Khan University, Karachi;
(4) Jinnah Medical and Dental College, Karachi;
(5) Masood Medicare, Mian Colony, Faisalabad

Corresponding author:
Dr. Kashmira Nanji
Department of Family Medicine,
The Aga Khan University,


Diabetes mellitus is a major health problem worldwide that increases morbidity and mortality rates due to its complications. The objective of this study was to assess the knowledge of diabetic patients about their disease, its complications and management.
Methods: A cross-sectional study was conducted in outpatient clinics of Faisalabad, Pakistan during March to May 2017. A total of 691 diabetic patients (verified from physician, medical records) were consecutively approached and a pretested, structured questionnaire was used to collect their information. SPSS version 19.0 was employed for entering and analysis of the data.
Results:: Out of the total 691 patients 43.3% were male and 56.7% female. About 49.1% of the patients were below 50 and 50.9% were above 50 years of age. One third of patients (33.4%) think that diabetes is a communicable disease. The majority of the patients (90%) responded that in diabetes sugar and sweets have to be cut down and 82.6% knew that exercise is important for the management of diabetes. Approximately 58% patients responded that they exercise, while 60.7% replied that they monitor and control their blood pressure.

Conclusion: The overall level of awareness in diabetics was found to be low and there is a need to educate the population on this topic. Public and private health sectors need to offer holistic services and training programs for health care professionals. These programs should focus on improving communication with patients, addressing misconceptions and sharing culturally sound strategies with patients for improvement in diabetes management.

Key words: Diabetes mellitus, Knowledge, Awareness, Complications, Pakistan


Diabetes mellitus is a major public health problem that accounts for increased morbidity and mortality rates worldwide because of its various complications mostly related to the cardiovascular system(1). According to the International Diabetes Federation (IDF) 415 million adults are currently living with diabetes and this figure is expected to increase to 642 million by the year 2040(2). It is also reported that 41.7% of adults with diabetes are undiagnosed(3). Diabetes in Pakistan is increasing at an alarming rate. Currently, in Pakistan there are about 7 million people with diabetes and this number is predicted to rise to 14.4 million by the year 2040. With this, Pakistan will rank 8th in the world in terms of prevalence(4, 5) of this disease.

The risk of diabetes is determined by several factors. Ethnicity, family history of diabetes, and history of gestational diabetes, increasing age, obesity, unhealthy diet, physical inactivity and smoking increase the odds of developing diabetes (6-8). Obesity and physical inactivity are estimated to contribute largely towards the global diabetes burden (9-11).

Studies suggest that diabetes related complications can result in 10 to 30% decrease in life expectancy (1, 12). There is a high burden of diabetes-related complications in Pakistani patients. A study conducted by Chavan et al concluded that there is a lack of knowledge among diabetic patients regarding complications and importance of compliance to diabetic medications(13). Different studies have documented a positive association between patient’s knowledge about diabetes and treatment compliance(1, 14). However, such studies in Pakistan are limited and are mainly focused around major cities.

Diabetes mellitus (DM) requires multifaceted interventions where patients can make decisions about exercise, weight control, blood glucose monitoring, and compliance to treatment and prevention of complications. Awareness about diabetes and its complications will enable the patients to cope and adjust to their illness. Therefore, the objective of this study was to assess the knowledge of diabetic patients about their disease and its management. It may assist physicians and patients to design strategies to delay the progression of DM complications with proper management and patient education.


This cross-sectional study was conducted in the outpatient clinics of Faisalabad Pakistan during March to May 2017. Faisalabad is the third-most-populous city in Pakistan and its residents are comprised of a diverse population belonging to different ethnicities and socio-economic groups. Diabetics patients (verified from physician and the medical record) visiting the outpatient’s clinics of more than 18 years of age and who gave consent to participate were included in the study. However patients suffering from serious co-morbid conditions such as cancer were excluded. A total of 691 patients were consecutively interviewed for this study.

A structured pre-tested questionnaire was formulated after extensive literature search and consensus by study investigators. The final questionnaire was comprised of three sections; the first section included the socio-demographic profile of the participants, the second part had questions about knowledge of diabetes and the third part dealt with questions about patients’ compliance to various management strategies for diabetes. The English version of the questionnaire was translated into Urdu and was then back translated into English to check for consistency between the two versions.

Written informed consent was obtained from all the participants. The data collectors were trained for maintaining confidentiality of the participant. Personal identifiers were removed from study documents. The study was conducted in accordance with the ‘Ethical principles for medical research involving human subjects’ of the Helsinki Declaration. Data was entered and analyzed using the Statistical Package for Social Sciences (SPSS version 19). Frequencies and proportion were reported for all variables of interest. A p- value of less than 0.05 was considered statistically significant throughout the analysis.


A total of 720 patients were approached out of which 691 agreed to participate in the study yielding a response rate of 95% (691/720). Demographic characteristics of the participants are presented in Table 1. Out of the total 691 patients, 43.3% were male and 56.7% female. An almost equal proportion of patients were below 50 (49.1%) and above 50 (50.9%) years of age. Three quarters of the patients had education level below matriculation. The majority (91%) of the patients, were married and 47.8% of the patients were employed. Almost half of the patients (50.1%) responded that they have comorbidities other than diabetes.

Table 1: Socio-demographic characteristics of study participants n=691

Table 2 describes the knowledge of patients regarding diabetes. Over one quarter (26%) think that diabetes is not a curable disease and 68% believe that it runs in families. Interestingly, about one third of the participants (33.4%) think that diabetes is a communicable disease. The majority of the patients (90%) responded that in diabetes sugar and sweets have to be cut down and 82.6% knew that exercise is important for its management. Approximately 63.7% of the patients knew that it is important to maintain a healthy weight among diabetics. About 69.6% patients thought that an individual can become dependent on oral tablets for control of sugar. Upon asking about the risk factors of diabetes the patients responded with the following factors: heart disease (63.4%), stroke (54.6%), blindness (78.4%), amputation (63.4%), impotence (35.3%) and infections (63.5%).

Table 2: Knowledge about diabetes among study participants (n=691)

Table 3 describes management strategies of diabetics. Approximately 58% of the patients responded that they exercise and 81% restrict sweets, sugar and oily foods to manage their blood sugar levels. About 80% patients use tablets to control their blood sugar. Slightly over two fifths of the patients (42.4%) attempted to reduce their weight and a similar proportion were monitoring their cholesterol levels. Approximately 58.7% self-monitored their blood glucose (p-0.24). Three fifths (60.7%) of the patients replied that they monitor and control their blood pressure. The majority of the patients (97.7%) were using allopathic medications to manage diabetes. As far as complications of diabetes is concerned most of the patients responded that they are suffering from nephropathy (14%).

Table 3: Management of Diabetes among study participants (n=691)


The results of the study reveal that the level of awareness of patients about diabetes mellitus, its complications and management is low. There is a need to formally educate the diabetics about the proper management of this disease in order to reduce the mortality and morbidity rates associated with it.

Several studies have concluded that there is significant association between knowledge of diabetes and the adherence to treatment (15-18). Previous studies have found that patients with adequate knowledge level were less likely to be non-adherent (15-19). These observations are consistent with the results obtained in the current study, wherein, the participants having better knowledge about complications of diabetes resulted in a compliance rate of oral hypoglycemics to 80%. This suggests the significance of providing formal knowledge regarding diabetes for better compliance, as chronic diseases such as diabetes require proper education and counseling to prevent long term complications and also to decrease the financial burden of these diseases(20).

A systematic review of 21 studies on barriers and promoters of management of diabetes among South Asians concluded that communication with the healthcare provider was a significant barrier in understanding diabetes education(21). The review further elaborated that for exercise, there is lack of resources in the South Asian countries. Lack of parks and affordable sports clubs are barriers to exercise(21). Moreover, there are some misconceptions about exercise such as fear of injury or worsening health due to lack of proper formal education. In the current study, more than half of the participants responded that they do exercise to manage their blood sugar levels.

A study conducted in 2012 in Ethiopia found that the majority of patients (67%) had good knowledge about reasons for developing acute complications(17). In the present study we also found that the participants had a good knowledge about the complications of diabetes, whereby, 78% of the patients responded that blindness can occur as a complication of diabetes. Though cardiovascular diseases (CVDs) are common complication of diabetes however, in this study 63% patients labeled CVDs to be a complication, and only 35% thought that impotence is also a complication. Therefore, sound education is needed in this regard.

A study conducted by Rahman et al (22) in Peshawar, Pakistan on 561 diabetics reported that the level of awareness regarding diabetes and its management was inadequate among studied participants. Only 13% of the female diabetics were aware of why glycemic control is important, and 32.4% were aware of the complications. Only 10% of respondents knew about blood glucose monitoring(22). This is inconsistent with our study findings as in the current study 58% of the patients were doing self-blood glucose monitoring. Though, in our study we have not stratified the results based on gender, nonetheless the proportions still show a better knowledge of the study participants.

Interestingly, in the current study the patients had better knowledge of diabetes complications as compared to the other studies conducted in Pakistan(22, 23). However, almost half of the participants didn’t reply or said that diabetes is a communicable disease. This shows that the general knowledge regarding diabetes among the population is poor. Some studies have shown that the knowledge level of some health care professionals is also inadequate or outdated (24-27). Therefore, there is a genuine need to update the health care professionals’ knowledge about latest interventions that can assist the diabetics in management of their disease.

Patient Education: It is imperative that a therapeutic patient education program should be planned which is comprehensive and fulfills individual’s clinical and psychological needs, according to the patients’ educational level and cultural background.

Person Centered Approach: It is important that clinicians should follow a person centered approach and should not only focus on the disease but to the patient, asking about their responsibilities, work and also their self-management strategies.

This study had several potential limitations. In this study we did not focus on psychological wellbeing of the patients which is an important aspect and a major factor for non-adherence to treatment. The chance of reporting bias cannot be eliminated as this may have resulted in over estimation of the compliance rate of oral hypoglycemic, exercise and doctors’ visit among the study patients. Moreover, since this study was conducted in an urban city therefore, the results may differ when generalized to a rural population.


The overall level of awareness in diabetics was found to be low and there is a need to educate the population about this disease. Due to low literacy levels and diverse sociocultural backgrounds, it is necessary to design a comprehensive education support program for the patients, which will result in better treatment adherence and positive health outcomes. The public and private health sector needs to offer holistic services and training programs for health care professionals. These programs should focus on addressing misconceptions, improving communication, and sharing culturally sound strategies with patients for improvement in diabetes management.


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