Introduction
A recent report by WHO indicates that the number of adults living with diabetes has increased by nearly fourfold since 1980 reaching the current estimate of >422 million globally.1 Approximately 80% of these adults live in low-income, middle-income countries, predominantly in South Asia including Nepal.2–4 South Asians living in developed countries such as the UK and the USA, who have their ancestry in the Indian subcontinent, are also at an increased risk of developing diabetes.4–11 Factors that explain why South Asians are at increased risk of developing diabetes compared with other ethnic groups such as Caucasians and Hispanics have been reported by several previous studies.12–20
In addition to genetic factors, lack of awareness about diabetic control and healthy diet, improper lifestyles (eg, not doing regular physical exercise, smoking), inadequate self-help (missing appointments, not complying with treatment regimen), etc, have been shown to be important non-clinical risk factors for the control of diabetes. A recent Cochrane review on data from 33 randomized clinical trials highlights the fact that while the use of pharmacotherapy is important to control blood sugar, blood pressure (BP), cholesterol, etc, there is a lack of evidence that links the non-clinical parameters (eg, self-help, exercise, improved awareness) to diabetic complications, especially in ethnic minority group.21
According to WHO, prevalence of diabetes in Nepal is estimated to rise by more than three times by the year 2030 which is greater than the estimated 2.5 times rise in the prevalence of diabetes in India within the same time frame.22 A geographical variation also exists, that is, in urban areas the prevalence is estimated to be 4.1%23 and 12% in the semiurban areas.24
Management of diabetes has become a major public health challenge for Nepal. One of the main reasons is that a large proportion of patients have poor awareness about diabetes control.25–30 A survey conducted among various healthcare professionals including diabetic specialists, ophthalmologists, and nurses showed that 48.6% of these professionals thought that patients with diabetes definitely lacked awareness of diabetes and its complications in the eye in Nepal.25 Evidence of decreased awareness about diabetes and inadequate self-help have been reported in Nepalese patients with diabetes by a number of hospital and community-based studies.26–30 However, what has not been examined among Nepalese patients with diabetes is whether these factors pertaining to healthy lifestyles (eg, exercising, avoiding smoking), improved self-help (attending appointments, following treatment regimens) and diabetic awareness differ in patients who are on insulin versus tablets/diet treatment, and in patients with longer diabetic duration versus shorter diabetic duration. In countries where resources are stretched, it is important to identify patients who are at risk of developing complications of diabetes and distribute resources appropriately. Patients on insulin or with a longer diabetic duration are at high risk for developing complications if their diabetes becomes uncontrolled.31 This is especially important in countries like Nepal where patients often do not have immediate access to the doctors/hospitals due to deprived economy, difficult geography, or a lack of reliable transport facilities.
In this study, we investigated diabetic awareness, self-help (attending appointments, taking medicine), and lifestyle regimens (exercising, avoiding smoking) in patients on insulin compared with those who were not on insulin, and also in patients with longer duration of diabetes (≥5 years) compared with those with shorter diabetic duration. We examined whether known variables (increased duration of diabetes and use of insulin) that are related to higher risk of diabetic complications32 show differences in parameters such as needing more visits to the hospital for uncontrolled diabetes, compliance with the treatment regimen, and knowledge/awareness profiles so that these specific groups can be targeted for support. We could have defined the high-risk group by HbA1c. However, parameters of knowledge, awareness, and practice in association with HbA1c levels have already been examined in the literature. In addition, not all rural clinics have facilities to carry out HbA1c measures. The study was carried out in Pokhara in the western region of Nepal unlike most of the studies reported above, which were conducted in the capital city, Kathmandu, or its suburbs.