In a country like Saudi Arabia, where diabetes is highly prevalent, proper control is paramount. In the present study, the proportion of adult patients with diabetes attending PCCs in Madinah, Saudi Arabia achieving glycemic goals was deficient (15.7%); i.e., approximately only one in seven patients reached the target. Despite newer therapies and greater availability of diabetes technology, glycemic control remains suboptimal worldwide.1–13 In a previous nationwide cross-sectional study conducted among 28 PCCs all over Saudi Arabia during December 2006, 27% of diabetic patients had reached the target HbA1c of <7%.15 At the diabetes care clinics of the National Guard Health Affairs, Riyadh, diabetes control reached 20.6%.9 In King Khalid University Hospital's PCC, Riyadh, reasonable glycemic control was achieved in 32.3% of patients.10 A similar result was reported from PCCs from the Al-Hasa district of Saudi Arabia.11 Good glycemic control among type 2 diabetes patients was reported to be 23.6% from Diabetes Centre in Madinah.12 In general, the reported achievement of glycemic target in patients with diabetes from different regions ranges of Saudi Arabia ranged from 24-40%.13
Similar results to ours were reported from Pakistan 2 and Sudan 3, in which only 16.6% and 15.0% of the participants, respectively, reached the glycemic target. In a specialized diabetes clinic and research center from Kuwait, the proportion of patients with reasonable glycemic control (HbA1c level < 7%) was 29.5%.4 Glycemic control among Jordanian patients with type 2 diabetes was reported to be 35%.16 A study from Japan reported glycemic control in 44.9% of diabetic patients. 1 In a meta-analysis that included 24 studies from 20 countries, the pooled glycemic target achievement rate was 42.8%, highest in North America and Europe than the rest of the world.5 Contrary to this finding, a recent study from the United States of America (USA) revealed that glycemic control has not improved among type 1 diabetes patients between 2016–2018 compared to the period between 2010–2012 and even has worsened in adolescents. Only 17% of the youths met the HbA1c target of <7.5%, and 21% of the adults met the target of <7.0%.6 Likewise, another study from the USA unveiled the improvement that noticed in glycemic control between 1998 and 2010 has plateaued during 2007-2014.7
We found younger age to be linked with poor glycemic control. In comparison, previous studies observed age younger than 45 years to be associated with a higher risk of inadequate glycemic control.17,18 This finding could be attributed to less adherence to the management plan due to irregularity of their lifetime with active jobs and busy social events.19 Therefore, focusing on this group of patients may be necessary as they would benefit utmost from treatment. Longer duration of diabetes was associated with poor glycemic control, a finding concurrent with many previous studies.16,20 Higher LDL levels were observed in this study to have a significant association with non-glycemic control; a finding that is consistent with many other studies.16,20
Other factors for poor glycemic control that were out of the present study's scope are unhealthy nutritional habits, low physical activity, low medication adherence, irregular follow-up, and psychological stresses. The cost of drugs can be a barrier against optimal glycemic control; however, in Saudi Arabia, visits to the PCCs and medications are provided freely to Saudi patients.
Poor self-monitoring of blood glucose could also account for inadequate glycemic control. Insufficient blood glucose monitoring is a common practice among diabetic patients, which could be related to a needle phobia, busy life, and the expense of blood glucose strips.
Previous findings have shown that patients with more knowledge of diabetes have better glycemic control than those with less knowledge. 21,22 Many studies have demonstrated that knowing the HbA1c level and understanding the individual glycemic target to be associated with better glycemic control.21,22 Awkwardly, less than a third of participants in one study from Saudi Arabia were aware of their HbA1c level and knew the recommended target. The remaining study participants had never heard of HbA1c (32.0 %) or had no awareness of their HbA1c goal (36.1 % ).13 Physicians and diabetes educators should convey to the diabetic patients their HbA1c level at each clinic visit and the target they should achieve to improve glycemic control.
Primary care physicians' knowledge and the application of updated guidelines for the management of diabetes may not be optimal and may add to the hurdle to achieving glycemic control. Clinical inertia is a crucial barrier to achieving euglycemia. Therapy must be intensified whenever glycemic control deteriorates, and referral to a diabetes specialist or an endocrinologist should be performed when glycemic control is deemed complicated. Therapeutic inertia not only affects diabetes management but also affects other cardiovascular diseases such as hypertension and dyslipidemia. Strategic plans to prevail over clinical inertia must include actions that target patients, physicians, and health care systems. Multifactorial interventions that act on different therapeutic goals beyond glycemia are needed.23
In the present study, the control of LDL cholesterol was better than glycemic control, as nearly half of the patients achieved the goal. This result is comparable to the metanalysis mentioned above5 and better than the study from Japan 1, in which only 27.1% achieved the target. Achievement of triglyceride goal was slightly better than LDL (53.3% vs. 46.4% respectively), comparable to the results from a study from Saudi Arabia 10, but less than the results from the metanalysis in which the pooled target achievement was 61.9% (55.2-68.2%).5 HDL-C was the best lipids parameter controlled in the current study as 70.8% achieved the target. This result is better than the metanalysis results, in which 58.2% (51.7-64.4%) reached the goal for HDL-C.5
Blood pressure was the best risk of atherosclerotic cardiovascular diseases controlled in our participants, as the systolic blood pressure was controlled in about two-thirds of the participants, and the diastolic blood pressure was controlled in almost 90 %. This result is comparable to studies from Japan 1 and USA 5, while better than other parts of Saudi Arabia. In the meta-analysis mentioned above, only 29.0% (22.9-35.9%) achieved blood pressure targets, with a greater percentage of people accomplished the targets in North America than in the rest of the world.5
Smoking is an essential risk for cardiovascular diseases, particularly in patients with diabetes. One-quarter of the males in this study were smokers, while smoking was infrequent in females. Quitting smoking is vital for patients with diabetes, and smoking cessation approaches should be implemented.
Despite the inadequate glycemia in our cohort of patients, other cardiovascular diseases risk such as dyslipidemia and hypertension were better controlled. These results are similar to the results of Steno-2 trial, in which the treatment goals for dyslipidemia and hypertension were accomplished without much hassle. However, the most challenging target was achieving the HbA1c goal, as only 15% of the patients in the intensive group reached the glycemic target.23 Controlling dyslipidemia and hypertension in patients with type 2 diabetes has shown to cause more significant reductions in cardiovascular events than controlling hyperglycemia.24,25 Multidisciplinary intervention that targeted hyperglycemia, hypertension, dyslipidemia, and smoking in patients with diabetes is the key to reduce the risk of micro and macrovascular complications, as demonstrated in the Steno-2 trial and the follow-up study.23,24
There are some limitations to this study; cross-sectional studies lack temporality, so cause and effect cannot be assumed. In addition, we did not investigate the factors that influence glycemic control, such as lifestyle: nutritional habits and physical activity, medication adherence, education level, and psychological status. While our results apply to a specific area in Saudi Arabia, the results cannot be fully generalized to other regions. Nonetheless, the present study uncovered the burden of inadequate glycemic control among patients with diabetes in Saudi Arabia. Therefore, this study emphasizes the need for operative strategies that effectively manage diabetes at the PCCs in Saudi Arabia.
In conclusion, glycemic control is inadequate among patients with diabetes following the PCCs in Madinah, Saudi Arabia. Effective and continuous education that raises patients' knowledge about diabetes and promotes behavioral changes and a healthy lifestyle is crucial in diabetes management. A patient-centered approach and individualized management plan considering all risk factors are required. A stepwise, target-driven approach to achieve the goals for blood glucose, blood pressure, and levels of LDL and triglycerides should be applied. A multidisciplinary team, including a physician, diabetes educator, and clinical dietitian, should share managing patients with diabetes. Continuous medical education on diabetes management for primary health care physicians is recommended to ensure updated guidelines application. Further research is needed to find other approaches that improve glycemic control in Saudi Arabia.