1. Introduction

There are several theories explaining the existence of diabetes among the people of Saudi Arabia. Along with those theories, come the rival discussions about the methods, ways and measures that should be taken to control diabetes and reduce its extreme adverse effects on the population.

Approximately 85% to 90% of people infected diabetes have type two diabetes which results from decreased sensitivity to insulin (called insulin resistance) and impaired beta cell functioning resulting in decreased insulin production[2]. Type two or adult onset diabetes is a common and rapidly increasing disease. Globally, approximately 4 million deaths every year are attributable to complications of diabetes, and it decreases the life expectancy by approximately 15 years. Due to its complications such as degeneration of the retina leading to blindness, kidney disease, coronary heart disease, stroke, amputations of the limbs, problems during pregnancy, and congenital malformations; diabetes causes an enormous burden to health care services and costs[3]. Most populations infect diabetes increasingly and rapidly, and by 2030 the number of infected type two diabetes is predicted to be more than double as compared with the current figure[4]. Type two diabetes develops as a combination of genetic susceptibility and environmental factors, and its rate increases steeply with age.

Type two diabetes is one of the many diseases affecting peoples’ health in many countries especially Saudi Arabia. Taking a special consideration of the cases in Saudi Arabia, various factors have been depicted to predict the poor glycemic control among the citizens in Almadinah diabetic patients.

Saudi society is undergoing tremendous progress such a rapid socioeconomic transition that it is unfair to apply the results of glycemic control studies from western countries to Saudi community, particularly Almadinah society. Few researchers in Saudi Arabia have studied the problem of glycemic control in some areas such as Riyadh and Abha[5]. Nevertheless, none of them has addressed the problem with glycemic control among diabetic patients in Almadinah, Saudi Arabia.

Predictors of poor glycemic control can be deduced from the relationships between the following: glycemic control and socio-demographic characteristics (gender, age, income, occupational status and educational level), glycemic control and the level of physical activity, glycemic control and obesity, glycemic control and dietary intake, and glycemic control and diabetic profile (age at diagnosis, duration of diabetes, type of treatment, complication and family history)[6].

Glycemic control is a medical term that refers to the typical levels of blood sugar in a person with type two diabetes (Diabetes Mellitus)[7]. Good glycemic control is defined as an HbA1c value of 6.5% or less for the past three months. Poor glycemic control, on the other hand, is defined as an HbA1c value of more than 6.5% for the past three months. HbA1c is a test that measures a person’s average blood glucose level for the past two to three months (normal value 7.5%)[8]. Obesity is measured by body mass index (BMI ≥ 30 kg/m²) and can be classified as underweight, normal and obese. The level of physical activity is monitored using the International Physical Activity Questionnaire (IPAQ) to obtain reliable conclusions and can be classified into low, moderate and high physical activity. Dietary intake is calculated depend on patient's activity, Gender and BMI, and patients will be classified to normal and abnormal calories intake.

2. Purpose of the Study

To identify and examine the predictors of poor glycemic control among type two diabetic patients in the Al-Medina Diabetic Centre.

3. Brief of the Literature Review

Poor glycemic controls constitute a major public health problem. Study in United State (US) showed that diabetes controlled rate declined from 44.5% in 1988-1994 to 35.8% in 1999-2000[9]. In Saudi Arabia, diabetes affected 24.7% of the population and cost 51 Billion Saudi Riyal for treatment[10]. Furthermore, the prevalence of poor physical activity and obesity was high in Saudi Arabia which was 96.1% and 35.5% respectively[11, 12]. However, it is very limited information on obesity, physical activity and glycemic control in Saudi. Since, diabetes management includes not only pharmacotherapy but also modification of lifestyles, thus, this study is conducted to determine the relationship between obesity and level of physical activity with glycemic control.

Study showed that the proportion of adult in the U.S. with adequately glycemic controlled decreased between 1988 and 2000 from 44.5% to 35.8%[9].

3.1. Relationship between Socio-demographic Characteristics and Glycemic Control

Study had demonstrated that older individuals (aged ≥ 65 and above) 1.58 times more likely had better glycemic controlled than younger age group[9]. Patients with higher education levels are more likely to have better glycemic control[22]. The majority of diabetic patients (90%) had poor knowledge about their diabetes that influenced to poor glycemic control. In addition, the older patients more likely to have poor over all of knowledge about their diabetes, so there was liner association between education level and glycemic control[23].

Monthly income, self-related health and perceived barriers were also consistently associated with glycemic control[24]. The level of income and occupational status are major factors which influence the occurrence and control of diabetes in Saudi Arabia. Diabetes has been described as a disease which needs large amounts of money to prevent, manage, and treat[25]. Poor people as low income patients cannot meet these demands, and thus the disease in such patients develops very fast and goes beyond control[26].

3.2. Obesity and Dietary Intake in Relation to Glycemic Control

Study showed that, changes in HbA1c are mainly proportional to the random blood glucose level and not associated to circulating insulin or the body mass index. However, the levels were higher in obese diabetes (Type I and II both) than in non-obese. Mechanism of resistance in insulin receptor interactions due to obesity is well known. However, obesity does not seem to affect directly HbA1c. Under such circumstances, the reduction of weight for a diabetic person can improve sugar control by minimizing insulin resistance and thereby can improve HbA1c levels. However, there was a study showed that those with BMI ≥ 30kg/m² 1.57 times more likely had good glycemic control than lower BMI[9].

Increasing in calories intake may be contributed to the rising prevalence of obesity in female in Saudi population and affecting the glycemic control for diabetic patients as well[27]. However, changes in HbA1c are mainly proportional to the random blood glucose level and the levels were higher in obese diabetes (Type I and II both) than in non-obese[28]. Moreover, overweight and obesity are risk factors glycemic control[29].

3.3. Physical Activities in Relation to Glycemic Control

Poor physical activity is associated with HbA1c levels. Low physical activity levels increased the likelihood of poor glycemic control. The American Diabetes Association recommends, persons with type two diabetes engage in at least 150 minutes a week of moderate intensity activity as management to control diabetes.

Six personal barriers, such as having little time, being too tired, not being in good health, lacking energy, lacking motivation, and not liking physical activity, have showed inverse relationships with physical activity[30]. Physical activity may help to improve glycemic control, reduce blood pressure, and positively affect other coronary heart disease risk factors for individuals who already living with type two diabetes[31]. Physical exercise has been found to protect from type two diabetes[32]. Saudi Lifestyle play a vital role in keeping diabetic patients engage regular physical activity. Weather can also be a contributing factor which makes patients unable to perform physical activity such as too hot or too cold. However, the environmental barrier to being physical active. A part from that, diabetes can influence the participation of respondents in physical activity[30].

Poor physical activity is associated with HbA1c levels[33]. The level of glucose in the blood, the amount of fatty acids and glycerol stored within the body cells could be reduced greatly if one participates in physical activities which required for getting energy[34].

3.4. Relationship between Glycemic Control and Diabetic Profile

Study had demonstrated that increased one year duration of diabetes was 1.01 time more likely had better diabetes control[9]. Those taking medications less likely controlled their diabetic as compared with those on diet[9].

Worse quality of life compared with non-diabetic population because of the diabetic complications[35].

A cure for Diabetes has not been found yet. However, it can be controlled. Ways to control diabetes are maintaining blood glucose levels, blood fat levels, and weight. Blood glucose levels can be maintained by following a diet designed by clinicians, exercising, and eating at regular intervals[4]. Current weight management program can produce significant reductions in both weight and HbA1c compared to standard care[13]. Daily Self Monitoring Test in type two diabetes can improve glycemic control[14]. The consumption of low glycemic index, indigenous carbohydrate-rich Caribbean foods may have a positive effect in glycemic control and in the prevention of diabetes. This is noticed in the improvement in glycemic control and a decrease in cardiovascular inflammatory markers[15]. These results should prove the useful and nutritious use of low GI foods by health care professionals, nutritionists, and in diabetes education to delay or prevent the onset of diabetic complications. Intensive blood glucose control in patients with type two diabetes significantly increased, treatment costs much, but substantially the cost of complications reduced and the time free of complications increased[16].

4. Methodology

A cross sectional study was conducted among 152 respondents who were selected through a systematic random sampling. Data were collected by using self-administered questionnaires. The questionnaire consist of five parts, first part was in Socio-demographic profile, second part was in Medical history, third part was international physical activity questionnaire, fourth part was in Anthropometric measurement and part five was dietary intake. Data were analyzed by using descriptive and inferential statistics. Descriptive statistics like frequencies and percentages for qualitative variables (e.g: Glycemic control, gender, level of education, occupational status, monthly income, obesity, level of physical activity, complication of diabetes, and family history of diabetes). For quantitative variable, measures of central tendency and spread of data were used (e.g: age at diagnosis, duration of diabetes and BMI). chi-squared test were used to determine the relationship between glycemic control and socio-demographic characteristics, obesity, level of physical activity and Medical history. The logistic regression using enter method, forward LR, backward LR model were conducted to give the overall prediction of Poor glycemic control.

5. Results

The response rate for this study was 92%. Poor glycemic control proportion among respondents was statistically mentioned in this study with 74%. And most of respondents that were participated consist of female 93 (66.4%), age group (40-60) 54.3%, no formal education 34.3%, no work 61.4%, low monthly income 52.1%. In addition, this study had shown that most respondents were with low physical activity as 88.6%, obese 45% as well, Most of respondents who were participated in this study classified as abnormal dietary intake 69%. There was a significant association between glycemis control and gender ( χ² =7.129, p= 0.008); age group (χ² =19.861, p= 0.001); and level of education (χ² =12.148, p= 0.016). Poor glycemic control was significantly higher among female (80.6%) than male (59.5%). And for age group, poor glycemic control was significantly higher among age group (40–60) years old (59.2%). In level of education, poor glycemic control was significantly higher among patients with no formal education (39.8%).

The results indicated that there was 72.1% of respondents were with diabetic complications, however, there were 58.5% of those patients classified with poor glycemic control, and the significant association between diabetic complications with glycemic control was 0.040. Heart disease was (χ²=0.024, p < 0.876). Neuropathy (χ²=0.300, p < 0.584) and hypertension was (χ²=5.271, p= 0.022). The percentage of poor glycemic control was significantly higher among those with impaired vision (47.1%) than those with no diabetic complications (26.4%) and Heart disease was (10.7%) than those with no diabetic complications (62.8%). Hypertensive was (29.2%) than those with good glycemic control (44.2%). Other complications were having poor glycemic control were (5.7%) than those with no diabetic complications (67.8%). Based on family history of diabetes, the results showed that there were 57.1% of respondents with family history.

The significant association between glycemic control and family history was (χ²=2.575, P= 0.109). Respondents with father's diabetic was (χ²=0.445, P= 0.505). Those with mother's diabetic was (χ²=4.148, P= 0.042). And those with siblings diabetic was (χ²=0.044, P= 0.835). There were (25.7%) of those with family history had classified with poor glycemic control. For Diabetic management, the result indicated that there was a significant relationship between glycemic control and dietary management (χ²=0.017, p < 0.895). Those with insulin therapy (χ²=1.180, p < 0.277). Respondents with combination (diet and oral treatment) (χ²=1.162, p < 0.232). And respondents were with combination (diet and insulin) (χ²=0.017, p < 0.887). Those with dietary management had significantly higher percentage of poor glycemic control (44%) than those with other types of management (26.2%). For Duration of diagnosis, the results showed that there was a significant association with poor glycemic control (z=0.766, p < 0.444). There was a significant in higher duration of diagnosis. However, there was no significant association between age at diagnosis with poor glycemic control (z=9.023, p < 0.001).

The results indicated that there was a significant association between glycemic control and physical activity (χ² =6.448, p = 0.040. Poor glycemic control was significantly higher among patients with low physical activities (76.6%) than other who engaged moderate or/and high activities. In addition, there was a significant relationship between different obesity levels χ² =13.809^a, P= 0.003, Most of the patients are crossed the obesity level as ≥30.

Backward Logistic Regression used from the backward estimation, 11 variables were found to have significant contribution to the model (age, level of education, occupational status, monthly income, BMI, Impaired vision, Family history with mother, Family history with siblings, Oral treatment, combination treatment of diet and oral treatment). This model gave good overall prediction of 97.1% albeit large odds ratios (EXP(B)) values were obtain

6. Conclusions

Diabetes is a complex disease that is caused and influenced by a large number of factors. This study demonstrated that certain demographic factors such as age, sex, level of education, income, and living conditions are some of the major factors that greatly influence the level of glycemic control and the patient’s ability to cope with the disease[19]. Demographic factors also influence other factors such as obesity and physical activity. However, it can be concluded that poor glycemic control may result from one or more of these described factors, all of which show significant influence on the disease. In addition, no single factor is clearly the predominant cause of the disease or its progression. Rather, the combination of a variety of conditions produces a common result[20].

The predictors of poor glycemic control are determined to be poor diet, poor or lack of participation in vigorous physical activity, poor treatment and management, low income, lack of knowledge and education on the issue, and obesity[21].

Obesity is therefore considered to be the principal factor involved in the development of the disease in various settings. Obesity is caused by a poor diet, which can be due to one or more of the other factors described[21].

In conclusion, this study confirmed all of the hypotheses that were proposed. This is because the study shows that there is a significant relationship between glycemic control and socio-demographic characteristics (gender, age, income, occupational status and educational level), obesity, level of physical activity and the Diabetic profile (age at diagnosis, duration of diabetes, type of treatment, complication and family history of diabetic).

This study confirmed all of the hypotheses that were proposed. This is because the study shows that there is a significant relationship between glycemic control and socio-demographic characteristics (gender, age, income, occupational status and educational level), obesity, level of physical activity and the Medical History (age at diagnosis, duration of diabetes, type of treatment, complication and family history of diabetic).

7. Summary

This study indicates the important factors that determine the extent of glycemic control. Measures to reduce the number of cases of poor glycemic control include but are not limited to educating patients and vulnerable populations on how to manage and prevent diabetic complications. Monitoring the diet, cholesterol levels and physical activity were concluded to be vital for the promotion of good glycemic control. Physicians and clinical officers need to educate and constantly check the patients’ medical conditions to maintain normal glucose levels in their patients.

The fact that, the study predicts some factors interrelated that should be considered for patients who have them. Diabetic patients above forty of age, no formal education, low monthly income, obese patients, low physical activity, who had impaired vision and who have family history with mother and siblings as well as efforts should be directed towards looking after and minimize the impact such factors and making sure they don't appear again as poor glycemic control factors. Health care team should be encouraged to educate diabetic patient about factors influence diabetes control to provide health and prevent complications.