Risk factor management is important in avoiding life-threatening complications and preventing new-onset diabetes. We performed a case-control study in 2013 at ten primary health care centers in Jeddah, Saudi Arabia to determine the common risk factors of diabetes mellitus type 2 (DM2) and the demographic background of adult Saudi patients with DM2. Known diabetic patients were recruited as cases, while nondiabetic attendants were selected as controls. A pretested designed questionnaire was used to collect data from 159 cases and 128 controls. Cases were more likely than controls to be men (
Diabetes mellitus type 2 (DM2) is a metabolic disorder of multiple etiologies due to disturbances of carbohydrate, fat, and protein metabolism. It is characterized by chronic hyperglycemia, and it is associated with cardiovascular and renal complications [
In 2011, it was estimated that 366 million people were diabetic. The expected prevalence of diabetes in 2030 is 366 million, and approximately 530 million people may be diabetic by 2030 [
Although DM2 is associated with complications, it is a preventable disease. Morbidity and mortality can be reduced by secondary prevention through regular screening, early detection of DM and its complications, and appropriate treatment of chronic complications. To control DM, it is necessary to determine associated risk factors. Uncontrollable factors include socioeconomic status, age, sex, genetic susceptibility, and other environmental factors. Controllable risk factors include obesity [
In order to set a program for the screening of DM2 in the prediabetic stage or earlier, it is necessary to define recent risk factors associated with diabetes. To the best of our knowledge, no study has assessed the risk factors for diabetes among low- and middle-income Saudi patients with DM2. Hence, the primary objective of this study was to determine the common risk factors associated with DM2 and the demographic background of adult Saudi patients with DM2 as well as the role of these factors in the development of complications. We also aimed to determine the impact of dietary and nondietary control among diabetic patients. We believe that the results of this study will help healthcare administrators to improve health education and design a community-directed strategy for DM2.
A case-control study was performed at diabetes care centers in Jeddah in 2013. Adult Saudis of both genders who were known diabetic patients were recruited as cases if they had fasting blood glucose levels ≥126 mg/dL (7 mmol/L) or were on hypoglycemic drugs or insulin [
Jeddah is divided into 44 PHCs, which cover four geographical sectors, namely, north, south, east, and west. The ten centers have specialized diabetic care clinics, which are distributed in the four sectors.
To recruit participants, sampling was done in two stages. First, a representative sample of the ten PHCs was selected because they had specialized diabetic clinics. The ten centers are not distributed equally across the four geographical sectors; they are rather distributed according to the population density of the sector. In the second stage, participants were selected based on the days that diabetic patients were scheduled for visits and days that clinics were open for patient follow-up.
We developed a computer-generated simple random sample from each center.
Eligible patients meeting study criteria who consented to participate were recruited. Patients who withdrew from the interview and/or pregnant women were excluded from the study. Ethical clearance was obtained from the Research Ethics Committee of the Directorate of Health Affairs of Jeddah.
The estimated prevalence of DM2 in Saudi Arabia is approximately 24% [
A face-to-face interview was administered to all the participants using a pretested designed questionnaire that was adapted from the World Health Organization STEPwise approach to chronic disease risk factor surveillance (STEPS) [
We recruited 159 cases and 128 controls. The duration of diabetes was as follows: <5 years in 41.4% of the patients, 6–10 years in 28.7% of the patients, 11–15 years in 15.3% of the patients, and >15 years in 14.6% of the patients. Table
Comparison of sociodemographic factors between cases and controls.
Variables | Controls ( |
Cases ( |
|
||
---|---|---|---|---|---|
Count | % | Count | % | ||
Gender | |||||
Male | 19 | 15.1 | 60 | 38.0 |
|
Female | 107 | 84.9 | 98 | 62.0 | |
Age (in years) | |||||
|
9 | 7.4 | 0 | 0.0 |
|
20–30 | 44 | 36.1 | 7 | 4.6 | |
31–40 | 22 | 18.0 | 10 | 6.6 | |
41–50 | 23 | 18.9 | 36 | 23.7 | |
51–60 | 18 | 14.8 | 50 | 32.9 | |
|
6 | 4.9 | 49 | 32.2 | |
Educational level | |||||
Illiterate | 10 | 7.9 | 52 | 34.0 |
|
Primary | 13 | 10.2 | 31 | 20.3 | |
Secondary | 30 | 23.6 | 16 | 10.5 | |
Intermediate | 18 | 14.2 | 24 | 15.7 | |
Bachelor degree | 50 | 39.4 | 27 | 17.6 | |
Master degree | 6 | 4.7 | 3 | 2.0 | |
Region | |||||
Western Region | 46 | 37.7 | 43 | 31.4 | 0.003 |
Eastern Region | 7 | 5.7 | 31 | 22.6 | |
Southern Region | 42 | 34.4 | 42 | 30.7 | |
Northern Region | 11 | 9.0 | 14 | 10.2 | |
Other | 16 | 13.1 | 7 | 5.1 | |
Family history of diabetes in blood relations | |||||
Mother/father/brother/sister | 75 | 58.6 | 114 | 71.7 | 0.020 |
Grandmother/father | 40 | 31.3 | 27 | 17.0 | 0.005 |
Uncle/aunt | 24 | 18.8 | 18 | 11.3 | 0.080 |
Occupation | |||||
Employee | 23 | 18.1 | 35 | 22.6 |
|
Jobless/housewife | 59 | 33.9 | 84 | 54.2 | |
Retired | 7 | 5.5 | 30 | 19.4 | |
Volunteer/student | 54 | 425 | 6 | 3.26 | |
Salary (in Saudi riyals) | |||||
1,000–2,000 | 15 | 12.9 | 21 | 14.2 |
|
2,000–5,000 | 28 | 24.1 | 69 | 46.6 | |
5,000–7,000 | 25 | 21.6 | 30 | 20.3 | |
7,000–10,000 | 17 | 14.7 | 17 | 11.5 | |
|
31 | 26.7 | 11 | 7.4 | |
Marital status | |||||
Single | 36 | 29.8 | 8 | 5.2 |
|
Married | 71 | 58.7 | 113 | 73.4 | |
Divorced/widowed | 14 | 11.6 | 33 | 21.4 | |
Nature of Job | |||||
Physically active work | 12 | 9.4 | 23 | 14.5 | 0.300 |
Physically inactive work | 11 | 8.6 | 12 | 7.5 | |
Not applicable | 105 | 82 | 124 | 78 | |
Do you do household chores? | |||||
Yes | 74 | 58.7 | 68 | 46.9 | 0.060 |
Hypertension | |||||
Yes | 27 | 21.6 | 77 | 49.7 |
|
No | 98 | 78.4 | 78 | 50.3 |
Univariate analysis showing crude association of sociodemographic factors with diabetes mellitus type 2.
Variables | Unadjusted OR (95% CI) |
|
---|---|---|
Gender | ||
Male | 3.45 (1.92–6.18) |
|
Female | Reference | |
Age | ||
|
Reference |
|
41–50 | 6.91 (3.29–14.51) | |
51–60 | 12.25 (5.77–26.03) | |
|
36.03 (13.28–97.73) | |
Educational level | ||
Illiterate | 10.4 (2.22–48.62) |
|
Primary | 4.77 (1.03–22.02) | |
Secondary | 1.07 (0.23–4.84) | |
Intermediate | 2.67 (0.59–12.13) | |
Bachelor degree | 1.08 (0.25–4.66) | |
Master degree | Reference | |
Region | ||
Western Region | Reference | 0.003 |
Eastern Region | 4.74 (1.89–11.88) | |
Southern Region | 1.07 (0.59–1.94) | |
Northern Region | 1.36 (0.56–3.32) | |
Other | 0.47 (0.18–1.25) | |
Occupation | ||
Employee | Reference |
|
Volunteer/student | 0.07 (0.03–0.2) | |
Jobless/housewife | 1.28 (0.68–2.44) | |
Retired | 2.82 (1.06–7.48) | |
Salary (in Saudi riyals) | ||
1,000–2,000 | 3.95 (1.52–10.25) |
|
2,000–5,000 | 6.94 (3.07–15.71) | |
5,000–7,000 | 3.38 (1.42–8.06) | |
7,000–10,000 | 2.82 (1.08–7.37) | |
|
Reference | |
Marital status | ||
Single | Reference |
|
Married | 7.16 (3.15–16.29) | |
Divorced/widowed/separated | 10.61 (3.95–28.51) | |
Family history of diabetes in blood relatives | ||
Mother/father/brother/sister | 1.79 (1.09–2.93) | 0.020 |
Grandmother/father | 0.45 (0.26–0.79) | 0.005 |
Uncle/aunt | 0.55 (0.29–1.07) | 0.080 |
Nature of Job | ||
Physically active work | 1.76 (0.6–5.15) | 0.300 |
No physically active work | Reference | |
Do you do household chores? | ||
Yes | Reference | 0.060 |
No | 1.93 (1.11–3.35) | |
Sometimes | 1.14 (0.58–2.26) | |
Do you have a servant at home? | ||
Yes | 0.87 (0.53–1.43) | 0.580 |
No | Reference | |
Compared to others of your age, you can say you are | ||
More active | 0.74 (0.42–1.32) | 0.590 |
Less Active | 0.91 (0.51–1.63) | |
No difference | Reference | |
Currently smoking | ||
Yes | 3.97 (1.58–9.98) | 0.003 |
No | Reference | |
Hypertension | ||
Yes | 3.58 (2.11–6.09) |
|
No | Reference | |
BMI (in kg/m2) | ||
|
Reference |
|
25–29.9 | 2.32 (1.19–4.49) | |
|
7.64 (3.33–17.54) |
BMI: body mass index; CI: confidence interval; OR: odds ratio.
Diabetic patients were more likely to have hypertension compared with nondiabetic patients (
Cases were more likely to have a body mass index (BMI) ≥ 25 kg/m2 (
Fifteen of the patients (10.1%) had hypothyroidism as against 80.5% (
Conversely, 27.5% of the cases as against 9.5% of the controls did not consume sweets. Among the cases, approximately 6.4% consumed soft drinks daily, 5.8% consumed soft drinks 3–6 times weekly, and 34.0% drank soft drinks <3 times weekly; 53.8% did not consume soft drinks. On the other hand, 17.5%, 17.5%, and 30.2% of the controls drank soft drinks daily, 3–6 times weekly, and <3 times weekly, respectively; 34.9% of the controls did not consume soft drinks.
Table
Clinical finding in control and cases.
Parameter | Mean | SD |
|
Mean | SD |
|
---|---|---|---|---|---|---|
Weight | 65.2 | 16.6 | 92 | 75.4 | 16.5 | 88 |
Height | 158.7 | 9.9 | 85 | 154.6 | 30.8 | 69 |
Blood glucose level (last reading) |
— | — | — | 137.4 | 71.1 | 80 |
Blood glucose level (last reading) |
— | — | — | 143.5 | 95.3 | 35 |
Systolic BP (mmHg) | 119.9 | 18.3 | 61 | 129.9 | 20.3 | 76 |
Diastolic BP (mmHg) | 77.2 | 10.1 | 61 | 81.3 | 23.5 | 77 |
Cholesterol (mg/dL) | 127.4 | 69.8 | 9 | 182.9 | 37.6 | 30 |
Total cholesterol (mg/dL) | 142.3 | 63.3 | 10 | 177.1 | 83.6 | 24 |
HDL (mg/dL) | 40.7 | 7.3 | 12 | 47.6 | 27.2 | 42 |
LDL (mg/dL) | 135.7 | 53.3 | 14 | 111.4 | 36.0 | 41 |
BP: blood pressure; HDL: high-density lipoprotein; LDL: low-density lipoprotein; SD: standard deviation.
By multivariate analysis, we found that cases were more likely to be older than 40 years (
Multivariate logistic regression model for association of risk factors with diabetes among adults.
Variables | Cases (%) | Controls (%) | Adjusted OR |
|
---|---|---|---|---|
Age (in years) | ||||
|
61.5 | 11.2 | Reference |
|
41–50 | 23.7 | 18.9 | 14.84 (3.92–56.23) | |
51–60 | 32.9 | 14.8 | 24.59 (5.88–102.85) | |
|
32.2 | 4.9 | 44.91 (8.12–248.49) | |
Educational level | ||||
Illiterate | 34.0 | 7.9 | 6.04 (0.47–78.49) | 0.050 |
Primary | 20.3 | 10.2 | 8.59 (0.7–104.68) | |
Secondary | 15.7 | 14.2 | 1.11 (0.1–12.01) | |
Intermediate | 10.5 | 23.6 | 3.65 (0.33–40.51) | |
Bachelor degree | 17.6 | 39.4 | 4.74 (0.53–42.41) | |
Master degree | 2.0 | 4.7 | Reference | |
Occupation | ||||
Employee | 22.6 | 18.1 | Reference |
|
Volunteer/student | 3.8 | 42.5 | 0.01 (0.00–0.06) | |
Jobless/housewife | 54.2 | 33.9 | 0.37 (0.1–1.34) | |
Retired | 19.4 | 5.5 | 0.22 (0.05–1.05) | |
Salary (in Saudi riyals) | ||||
1,000–2,000 | 14.2 | 12.9 | 9.97 (1.53–64.79) | 0.010 |
2,000–5,000 | 46.6 | 24.1 | 9.24 (2.17–39.37) | |
5,000–7,000 | 20.3 | 21.6 | 2.4 (0.56–10.31) | |
7,000–10,000 | 11.5 | 14.7 | 7.32 (1.39–38.46) | |
|
7.4 | 26.7 | Reference | |
Marital status | ||||
Single | 5.2 | 29.8 | Reference | 0.040 |
Married | 73.4 | 58.7 | 0.15 (0.03–0.79) | |
Divorced/widowed | 21.4 | 11.6 | 0.09 (0.01–0.61) | |
Currently smoking | ||||
Yes | 16.4 | 4.7 | 13.74 (2.59–72.85) | 0.002 |
No | 83.6 | 95.3 | Reference |
We found that male gender, age > 40 years, low educational attainment (illiterate or having completed primary school), salaries <7000 Saudi riyals, marital status (married or divorced), and smoking status (current smoker) were risk factors associated with DM2 in adult Saudi patients. It is probable that these individuals have the least information about dietary factors and the importance of self-care.
Regarding the nonmodifiable risk factors of DM (age, gender, and genetic factors), our findings that diabetic patients were more likely to be >40 years old and likely to have a family history of diabetes are similar to those reported earlier in the literature. In previous studies [
In the current study, diabetic patients were more likely to be less educated; they were also more likely to have lower annual incomes. In a previous study [
We demonstrated that the prevalence of diabetes was higher in married or divorced persons. Previous findings showed that marital status was not correlated with DM; however, differences in the prevalence of diabetes were slightly more noticeable in widowed or divorced persons [
Current smoking status is an independent modifiable risk factor for DM2 since it is associated with glucose intolerance, impaired fasting glucose, and, consequently, DM2. Our findings are consistent with those of other authors [
We showed that high BMI was significantly associated with diabetes, which might be because obesity enhances insulin resistance. Similar to our findings, previous studies [
Our finding of an increased prevalence of hypertension in diabetic persons is similar to those reported in other studies [
The second part of our study was to evaluate the status of diabetic patients regarding their diet, blood glucose monitoring habits, and awareness about diabetes care. Although we found that diabetic patients who visited clinics took their medicines regularly (93.6%), only half of the cases checked their glucose levels regularly and approximately 58.2% were knowledgeable about diabetic foot care. This is of concern because it is imperative for diabetic patients to be aware of the complications that may arise from diabetes, such as foot ulcers and possible amputation as a result of diabetic foot. We found that among patients who were aware about foot care, only 25.8% wore adequate shoes for diabetic patients. Hence, pharmacological control is not the only means of controlling diabetes, but education and self-awareness are also vital to prevent complications of diabetes.
Diabetic patients also need continuous counseling on the impact of consuming sugary foods and sweets as well as fried and fatty foods. In this study, we found that only 27.5% of diabetic patients did not consume sweets, and only 24.3% did not consume fried or fatty foods. Because the risk for diabetic patients to develop hypertension and associated cardiovascular diseases is doubled, additional measures are essential in these patients.
Massive educational and training programs aimed at counseling diabetic patients about all aspects of self care have to be initiated. Our data provide strong evidence to establish diabetic counseling for patients by nurses and physicians. Physicians have to be aware about these aspects and should be trained to counsel and guide diabetic patients. They should also be able to identify and counsel people who are at risk of developing diabetes. Besides, massive campaigns should be organized and aimed at educating the general population about the risk factors of DM. Young adults should also be informed that modernization, limited physical activity, and, consequently, obesity are triggering factors for the onset of diabetes.
The authors declare that there is no conflict of interests regarding the publication of this paper.
The authors would like to thank Professor B. S. Eldeek for his useful advice in the initial planning of the study.