The aim of this systematic review is to assess patient-related factors affecting glycaemic control among people with type 2 diabetes in the Arabian Gulf Council countries. MEDLINE, Embase, PsycINFO, CINAHL, and Cochrane CENTRAL databases were searched from their date of inception to May 2016. Two researchers independently identified eligible studies and assessed the risk of bias. A total of 13 studies met the inclusion criteria. One study was population based, six recruited participants from multiple centres, and the remaining were single centred. The majority of the studies were of low to moderate quality. Factors associated with poor glycaemic control include longer duration of diabetes, low level of education, poor compliance to diet and medication, poor attitude towards the disease, poor self-management behaviour, anxiety, depression, renal impairment, hypertension, and dyslipidaemia. Healthcare providers should be aware of these factors and provide appropriate education and care especially for those who have poor glycaemic control. Innovative educational programs should be implemented in the healthcare systems to improve patient compliance and practices. A variation in the results of the included studies was observed, and some potentially important risk factors such as dietary habits, physical activity, family support, and cognitive function were not adequately addressed. Further research is needed in this area.
Diabetes mellitus is one of the major public health issues of the 21st century [
A recent International Diabetes Federation (IDF) report suggests that the Middle East and North Africa regions, which include the Gulf Cooperation Council (GCC) countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates (UAE)), have the highest prevalence of diabetes (10.7%) in the world next to North America and the Caribbean region (11.5%) [
Diabetes management involves strictly maintaining a person’s blood glucose level close to the normal range. There is a strong relationship between an elevated blood glucose level and the risk of complications and mortality in people with diabetes [
A number of studies have assessed factors associated with poor glycaemic control among people with T2DM in GCC countries sporadically. A systematic approach is needed to summarise their findings in order to identify gaps in the literature and provide guidelines for future research. Thus, the aim of this systematic review is to assess patient-related factors that affect glycaemic control among people with type 2 diabetes in the GCC countries.
A senior librarian (LR), with input from the research team, developed and implemented a comprehensive search using Embase, CINAHL, Cochrane Library, MEDLINE, and PsycINFO from the date of their inception to the 31 of May 2016. The search covered three concepts: T2DM, glycaemic control, and the Arabian Gulf Council countries. For T2DM, the following terms were used in the search combined by “OR”: “diabetes mellitus, type 2” (subject headings [SH]), Hyperglycaemic (SH), “adult-onset diabet
Two reviewers (MJA and AA) independently screened the retrieved articles by title, then by abstract, and finally by reviewing the full text of eligible articles. Any disagreement between the two reviewers was resolved by discussion with a third reviewer (BB).
All observational studies that examined the effect of patient-related factors affecting glycaemic control among adults with T2DM living in the GCC countries were considered for inclusion. Because the majority of people in the GCC countries have T2DM, studies that assessed the level of control among people with diabetes in general (types 1 and 2) were included. Studies were excluded if they did not include adults with T2DM, if the sample was recruited from outside of the GCC countries, and/or if the study did not examine the association between patient-related factors and glycaemic control. Studies that focused only on type 1 diabetes, children with T2DM, gestational diabetes, or adults with impaired glucose tolerance or impaired fasting glucose were excluded. Studies investigating the effectiveness of antidiabetic medications only were also excluded. In addition, articles were excluded if they were reviews or conference presentations.
Two reviewers (MJA and AA) independently extracted the data using a data extraction form. The extracted data include the first author, the year of publication, the name of the country, the sampled population, the number of participants, participants’ gender, participants’ age, the method of assessing glycaemic control, the data collection tool, the risk factors investigated, and the factors found to be associated with glycaemic control.
Two reviewers (MJA and AA) independently assessed the risk of bias of the included studies using the National Heart Lung and Blood Institute (NHLBI) quality assessment tool for observational studies (Tables
Quality assessment tool for observational cohort and cross-sectional studies.
Criteria | Yes | No | Others (CD, NR, and NA) |
---|---|---|---|
(1) Was the research question or objective in this paper clearly stated? | |||
(2) Was the study population clearly specified and defined? | |||
(3) Was the participation rate of eligible persons at least 50%? | |||
(4) Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants? | |||
(5) Was a sample size justification, power description, or variance and effect estimates provided? | |||
(6) For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured? | |||
(7) Was the time frame sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed? | |||
(8) For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure or exposure measured as continuous variable)? | |||
(9) Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants? | |||
(10) Was the exposure(s) assessed more than once over time? | |||
(11) Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants? | |||
(12) Were the outcome assessors blinded to the exposure status of participants? | |||
(13) Was loss to follow-up after baseline 20% or less? | |||
(14) Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)? | |||
Quality rating (good, fair, or poor) (see guidance) | |||
Rater no. 1 initials: | |||
Rater no. 2 initials: | |||
Additional comments (if poor, please state why): |
Quality assessment of case-control studies.
Criteria | Yes | No | Others (CD, NR, and NA) |
---|---|---|---|
(1) Was the research question or objective in this paper clearly stated and appropriate? | |||
(2) Was the study population clearly specified and defined? | |||
(3) Did the authors include a sample size justification? | |||
(4) Were controls selected or recruited from the same or similar population that gave rise to the cases (including the same time frame)? | |||
(5) Were the definitions, inclusion and exclusion criteria, algorithms, or processes used to identify or select cases and controls valid, reliable, and implemented consistently across all study participants? | |||
(6) Were the cases clearly defined and differentiated from controls? | |||
(7) If less than 100 percent of eligible cases and/or controls were selected for the study, were the cases and/or controls randomly selected from those eligible? | |||
(8) Was there use of concurrent controls? | |||
(9) Were the investigators able to confirm that the exposure/risk occurred prior to the development of the condition or event that defined a participant as a case? | |||
(10) Were the measures of exposure/risk clearly defined, valid, reliable, and implemented consistently (including the same time period) across all study participants? | |||
(11) Were the assessors of exposure/risk blinded to the case or control status of participants? | |||
(12) Were key potential confounding variables measured and adjusted statistically in the analyses? If matching was used, did the investigators account for matching during study analysis? | |||
Quality rating (good, fair, or poor) (see guidance) | |||
Rater no. 1 initials: | |||
Rater no. 2 initials: | |||
Additional comments (if poor, please state why): |
Figure
Flow chart of the systematic literature search.
The characteristics of the included studies are described in Table
Included studies and their general features.
Author |
Study design population | Population | Number of participants (male and female) | Age (mean age ± SD) | Glycaemic control measurement method(s) | Risk factors examined | Instrument used to measure risk factors |
---|---|---|---|---|---|---|---|
Ajabnoor |
Case-control | Diabetics attending King Abdulaziz University Hospital diabetic clinic | Cases 73 (23, 50) |
— | HbA1c | Age, gender, FPG, and treatment modality | Questionnaire and lab test |
Binhemd |
Cross-sectional | Females attending Diabetes and Endocrine Centre in Dammam | 300 (0, 300) | 42.6 ± 9.1 | HbA1c | KAP (knowledge, attitude and practice), diabetes type, and diabetes duration | Interview using a questionnaire, anthropometric measures, and lab test |
Al-Nuaim |
Cross-sectional | National (different regions of SA) | 613 (320, 293) | Good control 47.0 ± 14.8 |
RBG | Age, BMI, region, residency, gender, and treatment modalities | Interview using a questionnaire, anthropometric measures, and lab test |
Malik |
Cross-sectional | Patients attending Mafraq Hospital in Abu Dhabi and its surrounding health clinics | 696 | — | FPG | Age, gender, ethnicity, diabetes duration, family history, treatment modalities, and follow-up location | Interview using a questionnaire and lab test |
Abdelmoneim |
Cross-sectional | Patients attending diabetic clinic in a primary healthcare centre | 198 (90, 108) | Males 59.5 ± 8.9 |
FPG | Age, gender, family history, diabetes duration, BMI, cholesterol level, complications, number of health education session, and crowding index | Review of medical records |
Al-Kaabi |
Cross-sectional | Diabetic patients attending outpatient clinic at Tawam Hospital and primary healthcare centres in Al Ain district | 409 (158, 251) | 51.4 ± 11.2 | HbA1c | Age, gender, marital status, level of education, occupation, smoking, eating practice, BMI, abdominal circumference, blood pressure, and lipid profile | Interviewer-administered questionnaire and anthropometric measures. Blood tests from medical records |
Al-Kaabi |
Cross-sectional | Diabetic patients attending outpatient clinic at Tawam Hospital and primary healthcare centres in Al Ain district | 309 (68, 241) | 52 ± 9.9 | HbA1c | Age, gender, nationality, marital status, level of education, employment, income, diabetes duration, smoking, diabetes complications, physical activity, BMI, abdominal circumference, and blood pressure | Interviewer-administered questionnaire and anthropometric measures. Blood tests from medical records |
Al-Lawati |
Cross-sectional | Multicentred (different regions of Oman) | 1266 (570, 696) | 53.3 ± 11.5 | HbA1c | Age, gender, duration of diabetes, treatment modalities, BMI, eGFR, smoking, and healthcare index | Data collected from patients’ medical records |
Al-Hayek |
Cross-sectional | Patients attending Sultan Bin Abdulaziz Humanitarian City, Riyadh | 147 (99, 48) | 57.3 ± 14.4 | HbA1c | Age, gender, marital status, employment, BMI, self-care management behaviour, self-monitoring of blood glucose, medication adherence, anxiety, and depression | Interviewer-administered questionnaire and anthropometric measures. Blood tests from medical records |
Shamsi |
Cross-sectional | Patients attending 5 healthcare centres in Bahrain | 400 (192, 208) | 54.7 ± 9.95 | HbA1c | Dietary practice | Interviewer-administered uestionnaire. Anthropometric measures and blood tests results were collected from medical records |
Al Balushi |
Cross-sectional | Type 2 patients attending Al Dakhliya region primary healthcare centre | 177 (71, 106) | 53 ± 12 | FBG |
Age, gender, diabetes duration, BMI, blood pressure, creatinine, and lipid profile | Data collected from patients’ medical records |
Alrahbi |
Cross-sectional | Patients attending 35 healthcare centres in Muscat and Al Dakhliya | 266 (121, 145) | — | HbA1c | Diabetes self-management | Self-administered questionnaire and blood test for HbA1c |
D’Souza |
Cross-sectional | Patients attending diabetic clinic at a public hospital in Oman | 300 (143, 157) | — | HbA1c | Age, gender, education, diabetes duration, diabetes education, medication, and BMI | Interviewer-administered questionnaire and patient’s medical records for HbA1c |
HbA1c: haemoglobin A1c; FPS: fasting plasma sugar; eGFR: estimated glomerular filtration rate; TTT: treatment.
Of the 13 studies included, seven (53.8%) were of low quality, four (50.8%) were of moderate quality, and two (15.4%) were of high quality (Table
Risk of bias for the included studies.
Study | Criteria 1 | Criteria 2 | Criteria 3 | Criteria 4 | Criteria 5 | Criteria 6 | Criteria 7 | Criteria 8 | Criteria 9 | Criteria 10 | Criteria 11 | Criteria 12 | Criteria 13 | Criteria 14 | Overall quality |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Case-control | |||||||||||||||
Ajabnoor |
Yes | Yes | No | No | NR | Yes | No | NR | Yes | Yes | No | No | — | — | Low |
Cross-sectional | |||||||||||||||
Binhemd |
Yes | Yes | NR | Yes | No | NA | NA | No | Yes | NA | Yes | NA | NA | No | Low |
Al-Nuaim |
Yes | Yes | NR | Yes | No | NA | NA | Yes | Yes | NA | Yes | NA | NA | Yes | High |
Malik |
Yes | No | NR | Yes | No | NA | NA | Yes | Yes | NA | Yes | NA | NA | No | Low |
Abdelmoneim |
Yes | Yes | NR | Yes | No | NA | NA | No | Yes | NA | Yes | NA | NA | Yes | Moderate |
Al-Kaabi |
Yes | Yes | NR | Yes | No | NA | NA | No | No | NA | Yes | NA | NA | Yes | Moderate |
Al-Kaabi |
Yes | Yes | NR | Yes | No | NA | NA | Yes | Yes | NA | Yes | NA | NA | No | High |
Al-Lawati |
Yes | Yes | NR | Yes | No | NA | NA | Yes | Yes | NA | Yes | NA | NA | Yes | Moderate |
Al-Hayek |
Yes | Yes | NR | Yes | No | NA | NA | Yes | Yes | NA | Yes | NA | NA | No | Low |
Shamsi |
Yes | Yes | NR | Yes | No | NA | NA | Yes | Yes | NA | Yes | NA | NA | No | Moderate |
Al Balushi |
Yes | Yes | NR | Yes | No | NA | NA | Yes | Yes | NA | Yes | NA | NA | No | Low |
Alrahbi |
Yes | Yes | NR | Yes | No | NA | NA | Yes | Yes | NA | Yes | NA | NA | No | Low |
D’Souza |
Yes | Yes | NR | Yes | Yes | NA | NA | Yes | Yes | NA | Yes | NA | NA | No | Low |
NR: not reported; NA: not applicable.
The results of the 13 studies included in this review are detailed in Table
Results of the included studies.
Author |
Risk factors examined | Risk factors associated with glycaemic control | Statistical analysis of positive results | Main conclusion | ||||
---|---|---|---|---|---|---|---|---|
Ajabnoor |
Age, gender, duration of diabetes, FPG, and treatment modality | FPG and treatment modalities | FPG/HbA1c correlation |
HbA1c is associated with FBG and treatment modality but not with age, gender, and duration of diabetes | ||||
Treatment modality | Mean HbA1c | |||||||
Insulin | 14.3 ± 1.3 | |||||||
Oral | 17.0 ± 0.0 | <0.001 | ||||||
Diet | 16.3 ± 1.8 | 0.02 | ||||||
Binhemd |
Knowledge, attitude and practice (KAP), diabetes type, and diabetes duration | KAP and diabetes duration | Positive correlation between HbA1c and diabetes duration ( |
The positive correlation between HbA1c and the patients’ practice and attitude reflects the need for continuous patient education, follow-up, and support | ||||
Al-Nuaim |
Age, BMI, region, residency, gender, and treatment modalities | TTT modalities | Adjusted odds ratio and 95% confidence interval (95% CI) of poor glycaemic control | There is a significant relation between glycaemic control and treatment modalities | ||||
TTT modality (ref: diet regimen) | ||||||||
Odds ratio | 95% CI | |||||||
Oral agent | 1.7 | 1.1–2.6 | 0.005 | |||||
Insulin | 2.6 | 1.4–5.0 | ||||||
Malik |
Age, gender, ethnicity, diabetes duration, family history, treatment modalities, and follow-up location | Duration of diabetes, follow-up location, and family history | Control | Odds ratio ( |
Improvements are needed in primary care and in the community-based approach to diabetes control | |||
Fair | Poor | |||||||
Diabetes duration (years) | 1.03 (0.329) | 1.08 (0.007) | ||||||
Follow-up at health centres (ref: hospital) | 1.86 (0.036) | 2.47 (0.001) | ||||||
Family history (ref: none) | 0.62 (0.095) | 0.39 (0.001) | ||||||
Abdelmoneim |
Age, gender, family history, diabetes duration, BMI, cholesterol level, complications, number of health education session, and crowding index | Gender and health education | Odds ratio ( |
Female sex is a significant predictor of poor glycaemic control, and among females, the lower the number of education sessions, the poorer the diabetes control | ||||
Gender (ref: male) | 2.84 (<0.05) | |||||||
Health education among females | 0.28 (<0.05) | |||||||
Health education among males | 1.39 (<0.05) | |||||||
Al-Kaabi |
Age, gender, marital status, level of education, occupation, smoking, eating practice, BMI, abdominal circumference, blood pressure, and lipid profile | Carbonated drinks age | Regression analyses of HbA1c level (adjusted beta coef. ( |
The dietary practice of people with diabetes in the UAE is inadequate and needs improvement | ||||
Number of carbonated drinks | 0.201 (0.029) | |||||||
Age | 0.023 (0.047) | |||||||
Al-Kaabi |
Age, gender, nationality, marital status, level of education, employment, income, diabetes duration, smoking, diabetes complications, physical activity, BMI, abdominal circumference, and blood pressure | No significant association | Multiple regression analysis of HbA1c in relation to age, gender, education, duration of diabetes, and physical activity did not reveal any significant association | The physical activity practice of people with diabetes in the UAE is largely inadequate to meet the recommendations | ||||
Al-Lawati |
Age, gender, duration of diabetes, treatment modalities, BMI, eGFR, smoking, and healthcare index | Age, gender, eGFR, diabetes duration, and TTT modalities | Adjusted odds ratio and |
Younger Omani adults exhibit worse glycaemic levels compared to older adults | ||||
Age (ref: 20–39 yrs) | 40–59 yrs | 1.7 | 0.01 | |||||
60+ yrs | 2.5 | 0.0001 | ||||||
Sex (ref: men) | Women | 1.5 | 0.001 | |||||
Diabetes duration (ref: <5 yrs) | ≥5 yrs | 0.8 | 0.041 | |||||
Treatment type (ref: diet) | Oral | 0.2 | 0.001 | |||||
Insulin ± oral | 0.1 | 0.001 | ||||||
eGFR (ref: <60 ml/min/1.73 m2 | ≥60 ml/min | 1.9 | 0.001 | |||||
Al-Hayek |
Age, gender, marital status, employment, BMI, self-care management behaviour, self-monitoring of blood glucose, medication adherence, anxiety, and depression | Medication adherence, anxiety, and depression | HbA1c < 7% | HbA1c ≥ 7% | Poor diabetes self-care management behaviour, low adherence to medicine, and higher level of anxiety and depression are associated with poor glycaemic control | |||
Medication adherence | 7.4 ± 1.4 | 5.4 ± 1.2 | 0.0007 | |||||
Anxiety | 7.9 ± 1.3 | 10.3 ± 1.7 | 0.0005 | |||||
Depression | 6.9 ± 0.9 | 9.8 ± 1.3 | 0.0002 | |||||
Total hospital anxiety and depression scale (HADS) | 14.8 ± 1.8 | 20.1 ± 2.1 | 0.0001 | |||||
Shamsi |
Dietary practice | Dietary practice | Dietary practice | HbA1c (mean ± SD) | There is a significant relation between the dietary practice and the HbA1c level | |||
Very poor | 10.95 ± 1.56 | 0.006 | ||||||
Poor | 7.46 ± 1.74 | |||||||
Average | 7.46 ± 1.97 | |||||||
Good | 7.31 ± 2.07 | |||||||
Very good | 5.97 ± 1.36 | |||||||
Al Balushi |
Age, gender, diabetes duration, BMI, blood pressure, creatinine, and lipid profile | Total cholesterol, diastolic blood pressure, and LDL | HbA1c < 7% | HbA1c ≥ 7% | There is a significant association between HbA1c and diastolic blood pressure, total cholesterol, and LDL | |||
Diastolic blood pressure, mmHg (mean ± SD) | 80 ± 8 | 84 ± 9 | 0.006 | |||||
Total cholesterol, mmol/l (mean ± SD) | 4.7 ± 0.8 | 5.2 ± 1.3 | 0.002 | |||||
LDL, mmol/l (mean ± SD) | 3.0 ± 1.2 | 3.8 ± 1.0 | 0.034 | |||||
Alrahbi |
Diabetes self-management | No association between diabetes self-management and glycaemic control was found | No association was found | There is no association between diabetes self-management and glycaemic control | ||||
D’Souza |
Age, gender, education, diabetes duration, diabetes education, medication, BMI, and patient empowerment | Age, education, diabetes duration prior to diabetes education, TTT modalities empowerment, effect of diabetes on activities of daily living | HbA1c < 7% | HbA1c ≥ 7% | Interventions to increase the empowerment of people with T2DM should be made for better glycaemic control | |||
Age (no. (%)) | 30–39 yrs | 24 (51.1) | 23 (48.9) | 0.000 | ||||
40–49 yrs | 52 (50.5) | 51 (49.5) | ||||||
50–59 yrs | 36 (39.1) | 56 (60.9) | ||||||
≥60 yrs | 26 (44.8) | 32 (55.2) | ||||||
Education (no. (%)) | Until 8th grade | 56 (47.9) | 61 (52.1) | 0.000 | ||||
High school | 51 (54.3) | 43 (45.7) | ||||||
Diploma/tech | 31 (10.3) | 58 (67.4) | ||||||
Duration of diabetes (no. (%)) | 0–9 yrs | 57 (50.9) | 55 (49.1) | 0.000 | ||||
10–19 yrs | 68 (47.2) | 76 (52.8) | ||||||
≥20 yrs | 13 (29.5) | 31 (70.5) | ||||||
Diabetes education program (no. (%)) | No | 54 (47.0) | 61 (53.0) | 0.000 | ||||
Yes | 84 (45.4) | 101 (54.6) | ||||||
Medications (no. (%)) | Oral | 109 (50.5) | 107 (49.5) | 0.000 | ||||
Insulin and oral | 29 (34.5) | 55 (65.5) | ||||||
Regression analysis | ||||||||
Empowerment and glycaemic control | Beta coef. | |||||||
0.657 | 0.001 |
HbA1c: haemoglobin A1c; FPS: fasting plasma sugar; eGFR: estimated glomerular filtration rate; TTT: treatment; ref: reference.
The association between gender and glycaemic control was evaluated in 10 studies. Of these, one study reported that female gender was associated with poor glycaemic control compared to male gender (adjusted OR: 2.84,
Three out of eight studies that assessed the association between the duration of diabetes and glycaemic control have found an association. Binhemd et al. have reported a positive correlation between the duration and HbA1c level (
Two studies assessed the effect of family history of diabetes on glycaemic control. In one study, no significant association was found [
A number of modifiable factors were found to be associated with glycaemic control. Binhemd et al. reported a negative correlation between HbA1c and patient compliance to management as well as the attitude towards the disease (
In regard to the effect of modality of treatment on glycaemic control, Al-Nuaim et al. found that compared to participants on diet regimen, only the adjusted OR of poor control was 1.65 and 2.64, respectively, for those on oral agent and insulin [
This systematic review summarises patient-related factors affecting glycaemic control among adults with T2DM in the GCC countries. Using a reproducible search strategy and prespecified inclusion/exclusion criteria, we identified 13 articles for inclusion in this review. The quality of the included studies is low to moderate in general, and the effect of some potentially important risk factors (including diet, physical activity, family support, and cognitive impairment) was not adequately investigated.
One cross-sectional study reported that age was associated with poor glycaemic control [
The duration of the disease is another important nonmodifiable risk factor of poor glycaemic control that was identified in three cross-sectional studies [
Compliance to diabetes management including adherence to diet, physical activity, medications, and self-monitoring of blood sugar is crucial in the management of diabetes. This current review shows that compliance to management and adherence to medications were significantly associated with good glycaemic control [
Two recent studies included in this review have found that compared to people with diet regimen only, those who were on oral agent and insulin had higher risk of poor control after adjustment for other risk factors [
Other modifiable risk factors that were found to be associated with glycaemic control in this review include patients’ attitude to diabetes, the location of scheduled follow-up visits (hospital or primary healthcare centres), eGFR, anxiety, depression, diastolic blood pressure level, cholesterol level, LDL level, and patient empowerment for self-management [
In the GCC countries, wives are usually responsible for preparing meals for the whole family, including members with diabetes. For cultural reasons, on the other hand, some women prefer to be accompanied by a relative when they go out for exercise or when they visit healthcare centres. Therefore, it is likely that family support has an important role in the management of diabetes, which should be taken into account when evaluating glycaemic control. This is supported by the results of a systematic review showing a potential importance role of family support in the management of T2DM [
Family support and cognitive function are potentially important risk factors for glycaemic control, which have not been explored in any of the included studies in this systematic review. Thus, the relationship of these factors with control needs a comprehensive investigation in future studies. Further, some of the modifiable risk factors such as the attitude towards the disease, barriers to compliance, anxiety, depression, and patient empowerment were not addressed adequately; hence, they need re-evaluation to build a stronger evidence. Future researchers should also reassess the association between glycaemic control and lifestyle factors using methodologically sound study design.
The strength of this review lies in the systematic, comprehensive, and unbiased approach taken during the literature search, data extraction, and assessment of the risk of bias. As the identified studies were either cross-sectional or case-control studies, a causal relationship between the risk factors and glycaemic control cannot be established. Moreover, because the studies in this review used different statistical methods, it was neither possible to generalise the magnitude of the effect of risk factors on glycaemic control nor possible to conduct a meta-analysis.
No studies assessing the factors affecting glycaemic control in Qatar or Kuwait were identified. Nevertheless, the results of this systematic review can be useful to all of the GCC countries. The populations of the GCC countries share similar cultures and lifestyles, and the healthcare services and medications are free of charge to all citizens.
This systematic review identified the following variables as the risk factors for poor glycaemic control in the GCC countries: low level of education, longer duration of diabetes, poor compliance to diet and medication, poor attitude towards the disease, poor self-management behaviour, anxiety, depression, renal impairment, hypertension, and dyslipidaemia. The policymakers should introduce large-scale awareness program and educational models to improve patient compliance and practices and to support patient empowerment for self-management. Healthcare providers should be aware of these risk factors and provide optimal care and guidelines for enriching self-management of the disease. The existing studies from the GCC have heterogeneity in their methodology, which may be related to the variation in their findings. In addition, some risk factors that may affect glycaemic control such as lifestyle, social support, and cognitive function have not been investigated adequately. Future research should address these issues.
All authors declare that they have no conflicts of interest.
All authors were involved in the conception and design of the study. Mohammed J. Alramadan and Afsana Afroz researched the literature, extracted the data, and assessed the risk of bias. Mohammed J. Alramadan drafted the manuscript. All authors critically reviewed the manuscript and approved the final version.