Assessment of diabetes self-management among diabetic patients attending Jeddah Care Center for Diabetes, Saudi Arabia.


 Objectives:To assess the levels and the associated demographic factors with diabetic self- management (DSM) among diabetic patients in Saudi Arabia. The impact of implementing DSM practices on glycemic control was additionally investigated.Results:The responses of 349 patients were analyzed (51.0% males and 37.2% obese). The median (IQR) raw DSMS score was 187 (165-205). Higher DSMS scores were reported for young adults (aged 20-29 years), insulin users, employed patients, as well as those with normal body mass index values and normal HbA1c results compared to their counterparts. Low HbA1c values were linearly associated with high scores of the healthy eating (β = -0.014, p=0.018) and physical activity subscales (β = 90-0.009, p=0.042).Keywords : Self-management; diabetes; glycemic control; Saudi Arabia.


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Diabetes is a chronic condition that has detrimental consequences on the well-being of 44 affected patients, their families, societies, and healthcare settings(1). Estimates indicate 45 that the global prevalence of diabetes was 9.3% in 2019, and the figure is projected to 46 reach as high as 10.2% by 2030 (2). In Saudi Arabia, data related to diabetes is relatively 47 scarce, and few nation-wide epidemiological studies have been conducted. Based on 48 available evidence, the prevalence of T2DM has linearly increased from 18.2% in 2005 49 to 31.6% in 2011 (3,4), and the country-based prevalence is on the rise. As with other 50 countries, diabetes in Saudi Arabia is linked to the growing burden of obesity(5). 51 In general, premature mortality attributable to diabetes is associated with the incidence 52 of preventable diabetes-related complications. These include macrovascular and 53 microvascular complications(6). The development of such complications could be 54 delayed or prevented via improving glycemic control and adhering to tailored 55 managemental plans. Therefore, multidisciplinary approach including self-56 management has been cited as a strong determinant of improved health outcomes, better 57 glycemic control and reduced healthcare costs(7-9). As such, diabetes self-management 58 (DSM), defined as the actual performance of self-care activities, plays an integral role 59 in the success of diabetes control and alleviating the impact of disease-related 60 complications. 61 However, DSM is a complex, multifaceted process, in which the patient would be 62 responsible for caring for his condition via distinct skills, confidence, knowledge, and 63 commitment. Each patient has a unique lifestyle, and self-management practices might 64 differ according to demographic and psychosocial variables(10). The present study 65 aimed to assess the level of DSM practice of patients with diabetes in Saudi Arabia. 66 Additionally, we explored the differences in DSM levels across demographic groups of 67 patients and the impact of DSM practices on glycemic control. 68

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A paper based-survey cross-sectional study was carried out during the period between 72 June 2019-2020 at Jeddah Care Center for Diabetes, King Abdul-Aziz Hospital (KAH). 73 Diabetic patients with T1DM and T2DM, who had been receiving treatment for at least 74 6 months before participation were eligible. Males and females aged between 20 and 75 79 years were included. Excluded population: Gestational DM, those with major 76 complications that might have hindered their self-management activities, and those with 77 cognitive impairment or psychiatric illnesses. 78 The sample size was calculated using the OpenEpi online calculator(11). Considering 79 a 95% confidence interval (CI) the required sample size is 384. 450 diabetic patients 80 were targeted, A convenience sample of 349 patients agreed to participate in the study, 81 and a written consent was taken. 82 A semi-structured validated questionnaire developed by Sousa et al (12), consisted of 83 three major domains: 1) demographic characteristics, 2) diabetes-related data and 3) the 84 Diabetes Self-Management Scale (DSMS), which measures the level of DSM. The 85 DSMS comprises of Likert-type 60-item distributed across seven components, 86 including dietary control, physical activity, monitoring blood glucose, taking 87 medication, foot care, problem-solving, and risk reduction. The reliability of the overall 88 DSMS scale was graded as "excellent" ( Table S1). The responses to each item were 89 graded as follow: 1=never, 2=rarely, 3=sometimes, and 4=frequently. Therefore, the 90 total score for each participant ranged between 60 and 240, where high scores have 91 indicated high DSM levels. DSMS's Arabic version has been tested and validated on 92 an Arab population (13). 93 Data was collected by the researchers in the center; for each participant, HbA1c level 94 that had been measured in the past 3 months were obtained from the medical records. 95 Body weight and height were measured according to standard procedure, missing 96 values of body weight and height were due to participants rejection. Different Body 97 Mass Index (BMI) categories were defined according to the World Health 98 Organization's criteria(14). Adequate glycemic control was classified as good 99 (HbA1c≤ 7%) or poor (HbA1c> 7%) (15,16). 100 Numerical variables were presented as means and standard deviations, whereas 101 categorical variables were expressed as frequencies and percentages. Missing-data 102 analysis was carried out for the variables with missing values, including height and 103 body weight, indicating that these data were missing completely at random. 104 Accordingly, the linear interpolation method was used to impute the missing data. The 105 reliability of the questionnaire was assessed using Cronbach's alpha values. Majority of patients had been diagnosed with T2DM (73.1%), and less than half of them 122 had the disease for 6-10 years (40.4%). In general, 50 complications had occurred in 40 123 patients (11.5%), Table 1. Abnormal vision was the most frequently reported 124 complication (34.0%), followed by hypoglycemic attacks (16.0%) and retinal 125 hemorrhage (14.0%) ( Figure S1). The mean value of HbA1C was 8.08% ± 1.69, and 126 47.9% of patients had poor glycemic control ( Table 1). 127 Considering the analysis of two categorical variables, employed diabetic patients scored 128 higher than unemployed patients regarding their self-management practices ( Table 2). For variables with more than two categories, the results of the Kruskal-131 Wallis H test revealed significant differences in the total DSMS scores across subgroups 132 of age (P< 0.0001), treatment type (P< 0.0001), BMI (P= 0.001), and marital status (P= 133 0.026). Pairwise comparisons were carried out to further investigate the sources of 134 differences (Table S2). Using a Bonferroni correction for multiple tests, the findings 135 indicated consistently higher median (IQR) scores of diabetes self-management among 136 single patients compared to widowed patients (P= 0.024), patients with normal BMI 137 values than obese patients (P= 0.001), and patients receiving insulin only than those 138 who had received oral and insulin therapies and exclusive oral therapies (P = 0.001 for 139 both comparisons). Besides, patients aged 20-29 years had higher scores than all other 140 age groups (P≤ 0.001 for all comparisons). Regarding the analysis of DSMS subscales, 141 patients' age and type of treatment accounted for significant differences in six subscales 142 (out of seven), whereas BMI was associated with significant differences in three 143 subscales ( Table S3). As demonstrated in Table 3

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Healthy lifestyle practices are an important determinant of management outcomes in 155 diabetes therapy. Promoting effective self-managemental strategies throughout the 156 lifetime of diabetes, where health and therapeutic challenges may arise at distinct 157 timepoints, can be an integral part of the management plan for those who cannot reach 158 the recommended therapeutic goal. In this study, the raw score of the DSMS scale was 159 187 for the total population, and higher scores were evident in distinct demographic 160 groups, including single and employed participants, young adults (20-29 years), along 161 with those who are receiving insulin therapy, as compared to their counterparts.
162 Furthermore, patients with optimal HbA1c values had higher DSMS scores.
163 Compliance with appropriate dietary practices and physical activity recommendations 164 were significant predictors of good glycemic control. 165 The reported DSMS score in the current study is higher than the mean score reported 166 in previous cross-sectional study among patients attending primary healthcare centers 167 in Jeddah (17). However, we demonstrated a relatively high level of poor glycemic 168 control (48%) among patients with T1DM and T2DM. Similarly, recent studies carried 169 out in Riyadh and Al Kharj showed that 43.13% and 44.5% of patients had uncontrolled 170 diabetes, respectively (18,19). Other national studies have shown alarming levels in 171 T2DM, where suboptimal HbA1c values were reported among 74.0% of patients in 172 Jizan (20) and 73.8% in Al-Madinah(21). Such findings underline the need to find 173 urgent solutions to improve glycemic control via effective self-managemental 174 strategies. 175 The outcomes indicate an association between protective self-management strategies 176 and improved glycemia. More specifically, a negative linear correlation was found 177 between the scores of healthy eating and physical activity and HbA1c levels, indicating 178 an optimal glycemic control in patients with good adherence to these recommendations. Young adults expressed higher compliance levels to self-management practices than 185 other age groups. Supporting diabetic young adults is necessary since they are more 186 likely to develop diabetes-related cardiovascular complications than their counterparts 187 without diabetes(24). Their high DSM scores are possibly because of their increased 188 knowledge regarding the importance of maintaining a healthy lifestyle. Knowledge 189 levels might have played significant roles in promoting DSM practices among 190 employed participants, which was corroborated in a recent study conducted in Riyadh 191 city(25). Employment has been also associated with improved insulin use(26, 27), and 192 this have caused a significant interaction to increase DSM scores among insulin users 193 in our study. Finally, it was not surprising that obese patients had lower DSM scores 194 than those with normal BMI values since the formers are more likely to be 195 noncompliant to healthy lifestyle approaches. Importantly, demographic groups with 196 low DSM scores, including unemployed patients, middle-aged and older adults, obese 197 patients, and non-insulin users should be targeted in future health campaigns to promote 198 their knowledge levels and improve their compliance to DSM practices, considering 199 the established cultural and societal barriers. 200 Based on the findings, self-management in diabetes is a crucial aspect of patient 201 management. A multidisciplinary approach should therefore entail patient-centered 202 empowerment to support behavior change, particularly in terms of diet and physical 203 activity related domains. Understanding patients' needs and priorities are warranted to 204 provide relevant interventions based on autonomy motivation. Ultimately, diabetes self-205 management education and support would improve patients' clinical outcomes and 206 quality of life and reduce healthcare costs (28,29). 207 In conclusion, the levels of DSM were adequate as reported by the diabetic patients in 208 Jeddah. However, based on HbA1c values, approximately half of the patients had poor 209 glycemic control, and they scored lower DSM scores. In addition, distinct demographic 210 groups adhered to adopting adequate DSM practices more frequently than their 211 counterparts, such as young adults, employed participants, and insulin users, possibly 212 due to their increased knowledge. 213

Limitations:
214 This study utilized the DSMS, which showed good to excellent reliability indices. 215 However, there are limitations in the study design that need to be addressed in future 216 work. Firstly, the inherent limitations of self-reported responses (response bias) remain 217 apparent in this study. Secondly, the impact of DSM on complications was not clinically 218 investigated, and the outcomes may not reflect those existing in other patient 219 populations. Thirdly, although missing data analysis indicated that the data were 220 missing completely at random, there is still a possibility of ascertainment bias. 221 However, such data is exclusively related to BMI calculations, which might not impact 222 the primary outcomes. 223