Assessment of lifestyle modifications among Sudanese individuals with diabetes: The situation so far and the need to do more
Ahmed O Almobarak1, Safaa Badi2, Wadie M Elmadhoun3, Samar B Siddiq4, Hanan Tahir5, Mugtaba Osman6, Sufian K Noor7, Mohamed Suliman8, Mohamed H Ahmed9
1 Department of Pathology, Faculty of Medicine, University of Medical Sciences and Technology, Sudan
2 Department of Clinical Pharmacy, Faculty of Pharmacy, Omdurman Islamic University, Sudan
3 Faculty of Medicine, Sudan International University, Khartoum, Sudan
4 Department of Research and Training, Alsharg Ahlia College, Kassala, Sudan
5 Dean of graduate college, University of Medical Sciences and Technology, Sudan
6 Armed Forces Centre for Psychiatric Care, Taif, Saudi Arabia
7 Department of Medicine, Faculty of Medicine, Nile Valley University, Atbara, Sudan
8 Imperial College London Diabetes Centre, Al Ain, United Arab Emirates
9 Department of Medicine and HIV Metabolic Clinic, Milton Keynes University Hospital NHS Foundation Trust, Eagelstone, Milton Keynes, Buckinghamshire, UK
|Date of Submission||16-Feb-2020|
|Date of Acceptance||25-Feb-2020|
|Date of Web Publication||28-May-2020|
Dr. Mohamed H Ahmed
Department of Medicine and HIV Metabolic Clinic, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes, Buckinghamshire
Source of Support: None, Conflict of Interest: None
BACKGROUND: Inadequate lifestyle practices among individuals with diabetes may influence the progression of diabetes and its complications. The aim of this study was to assess the lifestyle practices among individuals with diabetes in Sudan.
METHODOLOGY: This was a descriptive, cross-sectional, health facility-based study conducted in 3 diabetes centers treating individuals with diabetes. The data were collected using a standardized pretested metabolic questionnaire about lifestyle and were analyzed by performing descriptive and inferential statistics through SPSS program version 23.
RESULTS: A total of 528 patients with diabetes answered the questionnaire. There were 52.1% of female participants and 72.9% of urban residents. 23.9% were obese, regular exercise was reported by 27.7%, and no exercise by 17%. There was a statistically significant association between lifestyle practices and gender (P < 0.001), age (P < 0.001), educational level (P = 0.002), marital status (P < 0.001), duration of diabetes (P < 0.001), hypertension (P < 0.001), high-density lipoprotein (P < 0.001), low-density lipoprotein (P < 0.001), and HbA1c level (P < 0.001). Logistic regression analysis showed male gender and education were significantly associated with lifestyle changes. Men were more likely to engage in favorable lifestyle practices than women (P < 0.001), while those with no formal education were less likely to engage in healthy lifestyle (P < 0.001).
CONCLUSIONS: Health authorities in Sudan will need to put more efforts into education for promoting self-awareness and good lifestyle practices in the population with diabetes.
Keywords: Exercise, lifestyles, obesity, Sudan
|How to cite this article:|
Almobarak AO, Badi S, Elmadhoun WM, Siddiq SB, Tahir H, Osman M, Noor SK, Suliman M, Ahmed MH. Assessment of lifestyle modifications among Sudanese individuals with diabetes: The situation so far and the need to do more. J Edu Health Promot 2020;9:107
|How to cite this URL:|
Almobarak AO, Badi S, Elmadhoun WM, Siddiq SB, Tahir H, Osman M, Noor SK, Suliman M, Ahmed MH. Assessment of lifestyle modifications among Sudanese individuals with diabetes: The situation so far and the need to do more. J Edu Health Promot [serial online] 2020 [cited 2021 Mar 3];9:107. Available from: https://www.jehp.net/text.asp?2020/9/1/107/285148
| Introduction|| |
Diabetes prevalence has been increasing all over the world but more so in Africa and the MENA regions. According to the latest estimates from the IDF diabetes Atlas More Details of 2019, Sudan is the 3rd highest country in the world in terms of the percentage of patients with diabetes as the prevalence in those aged between 20 and 79 years was estimated at 22.1%. This estimate was based on a number of recent studies including one conducted by our group, which showed that the prevalence of diabetes in the north of Sudan was 19% in urban areas.
Lifestyle changes are one of the cost-effective options for health authorities in low-income countries such as Sudan to promote and spread in order to enhance glycemic control and decrease diabetes complications. Importantly, it was shown that individuals with diabetes who regularly engaged in self-care practices have achieved better glycemic control. This is highly needed in Sudan due to high prevalence of diabetes complications such as retinopathy, nephropathy, ischemic heart disease, and diabetic septic foot., A study from a rural area in India showed that more than 70% of individuals with diabetes had the correct knowledge about the role of diet, exercise, smoking, and alcohol, while 72% had strict drug compliance but only 29.3% of subjects followed a favorable physical exercise schedule. In contrast, in another study from a different area of rural India, Dinesh et al. showed that 24% had good knowledge about diabetes. Importantly, checking feet was only achieved by only 0.5%, capillary glucose testing was achieved by 65%, and only 48% of the respondents were regular in taking drugs and 20.5% exercised for at least 5 days in a week for 20–30 min.
Management of diabetes mellitus requires setting of a proper treatment plan including medications, healthy diet, weight loss, and regular physical activity. Patient adherence, education, and integration into the health-care team are essential for the successful management of diabetes. For instance, adherence to antidiabetic medications and the associated factors among individuals with type 2 diabetes attending Jabir Abu Eliz Diabetes Centre in Khartoum state, Sudan, only 15.0% were highly adherent to diabetes medications while 44.6% reported medium adherence and 40.4% reported low adherence. Knowledge about diabetes and lifestyle has been variable in different studies. In a study from India, majority of respondents (92.2%) had poor knowledge of the benefits of exercise, weight loss, and a healthy diet. The majority (97.7%) demonstrated poor practices in relation to lifestyle modifications, although over four-fifths (84.3%) had a positive attitude toward healthy lifestyle modifications. Furthermore, in another study from India, it was found that the self-care capabilities of 69.2% of the participants were poor, moderate capabilities were found in 23.3%, while good/acceptable capabilities were reported in only 7.5% of the participants. The aim of this study was to assess lifestyle practices among Sudanese individuals with diabetes and its relationship to various patient factors.
| Methodology|| |
This was a descriptive, cross-sectional, health facility-based study of patients with diabetes followed at three diabetes centers in Sudan (two centers in Khartoum and one in Atbara city).
Adult patients of both sexes who are more than 18 years of age and have confirmed diabetes mellitus were recruited. All patients with diabetes who agreed to participate in the study were included. We excluded pregnant ladies, those younger than 18 years old, and those who do not want to participate in the study.
| Materials and Methods|| |
The data were collected through direct interview using predesigned standardized questionnaire. A combined weight and height scale was used for measuring weight and height and body mass index (BMI) was calculated. Glycemic control was determined based on the latest available HbA1c result.
The data were analyzed using the computerized program, Statistical Package for Social Sciences (SPSS, IBM, Chicago, USA, version 25). Results were presented as tables and figures. Chi-square test was used for cross-tabulation at 0.05 margins of error (P value). Descriptive statistics (frequency tables, median, histogram, means, and standard deviation) and inferential statistics (Chi-square test) were performed followed by logistic regression analysis.
Ethical approval was obtained from Sudan Medical and Scientific research institute (SUMASRI)- Institutional Review Board of the faculty of Medicine, University of Medical Sciences and Technology, Khartoum, Sudan (IRB No. 00008867). The information was communicated verbally. Refusal to participate in the study did not deny the patient the appropriate management. The participants did not bear any cost.
| Results|| |
Five hundred and twenty-eight patients with diabetes completed the questionnaires. Sociodemographic characteristics of the participants are shown in [Table 1]: The mean age was 57 years (SD 11.5), while the most common age group was 51–60 years in (34.7%) of the participants. Females were 52.1% while 72.9% of the participants were from urban areas. Regarding education level, highest percentage of the participants (29.2%) were illiterate, while 80.1% of all the participants were married.
|Table 1: Distribution of the participants according to sociodemographic characteristics (n=528)|
Click here to view
The median BMI for the participants was 26.7, 40% of the participants were overweight, 23.9% were obese, while 33.3% were of normal weight [Table 1].
Type of diabetes and duration
(The majority (93.2%) had type 2 diabetes mellitus, while only 6.8% had type 1 [Table 2], while 41.7% of the participants had diabetes for <5 years, 15.5% had diabetes for between 6 and 10 years, while 42.8% had diabetes for more than 10 years. 37.5% of the participants had hypertension, while only 4.5% had ischemic heart diseases. 26.5% had uncontrolled total cholesterol levels, while 44.7% had uncontrolled low-density lipoprotein (LDL) levels. According to HbA1c criteria, only 19.8% of the participants had good diabetes control, while uncontrolled diabetes was seen in 80.2%. 87.5% and 86.2% of the participants had normal levels of serum creatinine and blood urea nitrogen, respectively.
|Table 2: Distribution of the participants according to diabetes type and duration (n=528)|
Click here to view
27.7% of the participants exercise regularly, while more than half (55.3%) sometimes practice exercise and only 17% they said that they do not not practice exercise at all [Table 3]. Cigarette smoking was reported by 22.2% of the participants, while alcohol consumption was reported by 11.4%.
|Table 3: Distribution of the participants according to lifestyle practice (n=528)|
Click here to view
When cross-tabulation and Chi-square tests were performed to determine the associations between different variables, we found that there were statistically significant relationships between the lifestyle practice and gender, age, educational level, marital status, duration of diabetes, hypertension, high-density lipoprotein (HDL), LDL, and HbA1c levels. For example, favorable lifestyle practices were achieved by 62.3% of males and by only 37.7% of females (P < 0.001);. 40% of the participants aged 51–60 years were exercising regularly (P = 0.001), while 47% of those who do not exercise regularly were illiterate (P < 0.001). Furthermore, 84.2% of married participants were exercising regularly (P < 0.001). Duration of diabetes also had an influence on lifestyle practices, for instance, 57% of those with diabetes for 0–5 years were exercising regularly while in those with diabetes for more than 10 years, only 32% were doing regular exercise (P < 0.001) [Table 2], [Table 3], [Table 4]. Among those who engaged in favorable lifestyle practices regularly, only 22% had hypertension, 64% had normal HDL, and 57% had normal LDL levels (P < 0.001, < 0.000, and 0.016, respectively). Uncontrolled diabetes was seen among two-thirds of those who do not practice exercise regularly (P < 0.001).
Gender and education were significantly associated with lifestyle changes. Using logistic regression analysis, the adjusted effect for males was 0.697 (P < 0.001), which means that, adjusting for all factors simultaneously, men are more likely to engage in favorable lifestyle practices than women. Similarly, those with no formal education were less likely than the reference group (university graduates) to engage in healthy lifestyle (effect = −0.973, [P < 0.001]) [Table 4].
| Discussion|| |
Physical activity is a general term that includes all movement that increases energy use and is an important part of the diabetes management plan. International guidelines and several studies recommend that all patients with diabetes should engage in at least 150 min/week of moderate intensity exercise such as brisk walking.,,,, Exercise has been shown to improve blood glucose control, reduce cardiovascular risk factors, contribute to weight loss, and improve well-being.,,,,,,,
In this study, we report that regular exercise was reported by only 27.7% of participants while 55.3% reported performing exercise only sometimes and 17% reported performing no exercise whatsoever. Other studies reported similarly low percentages of patients with diabetes doing regular exercise, Srivastava et al. showed that only 29.3% were engaged in regular physical activity  while Okonta et al. reported that only 8.3% of patients exercised regularly and the majority (94.4%) exercises for <30 min/day or <150 min/week.
Physical activity in Sudanese individuals tends to decrease with obesity, higher education levels, hypertension, older age, and doing sedentary jobs. Gender in Sudan is also an absolute risk factor for physical activity as males have more than three times probability of being physically active than women. This probably contributed to the reported higher prevalence of obesity in women more than men in Sudan. Therefore, it was not surprising in this study to find men were more likely to engage in favorable lifestyle practices than women.
Adherence to lifestyle changes is challenging to individuals with diabetes not only in the Western world but also for those living with diabetes in Africa. For instance, in Ghana, the majority of individuals with diabetes were not adherent to positive lifestyle changes such as exercise, being physically active, and healthy eating despite their knowledge about diabetes. Therefore, it is not surprising that another study from same country, recommended the need for education about physical activity and weight loss. Performance of exercise by patients with diabetes can vary depending on whether they reside in rural or urban areas. In a study from India, Dinesh et al. showed that 20.5% of those residing in a rural area exercised for at least 5 days in a week for 20–30 min. Less physical activity was also reported in urban areas in comparison with rural areas in a study from Sub-Saharan Africa. In this study, we also reported less engagement with physical activity in residents of urban areas compared with those from rural areas. Importantly, several studies have shown that rapid urbanization was associated with an increase in metabolic conditions like type 2 diabetes, hypertension, and obesity., A study from the United States has shown that race can also have an influence on the practice of exercise as more Hispanics achieved the recommended levels of exercise compared with white or African Americans.
The prevalence of smoking in this study was 22.2%, and this was less than the prevalence reported by Awadalla et al. who showed a prevalence of 33.9%. Awadalla et al. showed that smoking in Sudanese individuals with diabetes was associated with an increase in age, male gender, HbA1c, ischemic heart disease and triglyceride levels.
Zhong et al. concluded that best performance in self-management is achieved when those with type 2 diabetes have a high degree of knowledge of diabetes, positive attitudes toward diabetes, strong self-efficacy for self-management, and perceptions of good social support. These observations were also endorsed by Mehata who showed that strong knowledge about diabetes can enhance lifestyle changes significantly. Importantly, adequate support and encouragement provided by the health authorities may have a profound impact on increasing knowledge, attitude, and perception scores and this may lead to better self-care behavior. We showed in this study that individuals with diabetes with no formal education were less likely to engage in healthy lifestyle practices. Therefore, health authorities in Sudan should dedicate more time and resources in order to increase the development of knowledge about diabetes and ultimately this may lead to better self-care behavior. We believe that an important issue as different studies from different countries showed that individuals with diabetes normally do not receive adequate knowledge about diabetes. For instances, In Ethiopia, some individuals with diabetes were reported to lack knowledge about diabetes and as result they were not engaged in physical activity, do not check capillary glucose regularly, and not adhering to healthy dietary habits. Adil et al. also showed low level of knowledge about diabetes in Pakistan and this was negatively associated with low level of healthy lifestyles and adherence to medication. Similar observations were also reported in individuals with diabetes from Bangladesh. It is worth mentioning that patient education and self-empowerment can be associated with positive outcome in term of glycemic control in type 2 diabetes.,,
This study has several limitations. The cross-sectional design does not allow a precise estimation of the temporal relationship between the potential risk factors and outcomes. Also, the study may not represent all Sudan as recruitment of patients was from limited areas in Sudan. Despite these limitations, the study is novel as this first study about lifestyle and diabetes in Sudan and reflects the need for more health education. This can be achieved by health professionals working in diabetes management. Further studies will be needed to monitor the impact of health education in lifestyles among Sudanese individuals with diabetes.
| Conclusion|| |
Engagement in healthy lifestyle practices in Sudanese patients with diabetes is more likely to be reported in male, young individuals, those with a shorter duration of diabetes and married individuals. Lower education levels can negatively influence engagement with a healthy lifestyle. Therefore, health authorities in Sudan need to invest more in education and promotion of better awareness about healthy lifestyle in those with diabetes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, Unwin N, Colagiuri S, Guariguata L, Motala AA, Ogurtsova K, Shaw JE, Bright D, Williams R; IDF Diabetes Atlas Committee Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th
edition. Diabetes Res Clin Pract. 2019 Nov; 157:107843. doi: 10.1016/j.diabres. 2019.107843. Epub 2019 Sep 10.
Elmadhoun WM, Noor SK, Ibrahim AA, Bushara SO, Ahmed MH. Prevalence of diabetes mellitus and its risk factors in urban communities of North Sudan: Population-based study. J Diabetes 2016;8:839-46.
Padma K, Bele SD, Bodhare TN, Valsangkar S, Pradesh A. Evaluation of knowledge and self-care practices in diabetic patients and their role. Natl Med J India 2012;3:3-6.
Awadalla H, Noor SK, Elmadhoun WM, Almobarak AO, Elmak NE, Abdelaziz SI, et al
. Diabetes complications in Sudanese individuals with type 2 diabetes: Overlooked problems in sub-Saharan Africa? Diabetes Metab Syndr 2017;11 Suppl 2:S1047-51.
Beran D, Yudkin JS. Diabetes care in sub-Saharan Africa. Lancet 2006;368:1689-95.
Shrivastava PS, Shrivastava SR, Ramasamy J. An Epidemiological Study to Assess the Knowledge and Self Care Practices among Type 2 Diabetes Mellitus Patients Residing in Rural Areas of Tamil Nadu. Biol Med 2015;S3:002. doi: 10.4172/0974-8369.S3-002.
Dinesh PV, Kulkarni AG, Gangadhar NK. Knowledge and self-care practices regarding diabetes among patients with Type 2 diabetes in Rural Sullia, Karnataka: A community-based, cross-sectional study. J Family Med Prim Care 2016;5:847-52.
] [Full text]
Badi S, Abdalla A, Altayeb L, Noma M, Ahmed MH. Adherence to antidiabetic medications among Sudanese individuals with type 2 diabetes mellitus: A cross-sectional survey. Journal of Patient Experience 2020;7:163-8. [doi: 10.1177/2374373519831073].
Okonta HI, Ikombele JB, Ogunbanjo GA, Health P. Knowledge, attitude and practice regarding lifestyle modification in type 2 diabetic patients. Afr J Prm Heal Care Fam Med 2014;6:2-7.
Karimi F, Abedini S, Mohseni S, Abbas B, Abbas B, Sciences M, et al
. Self-carebehavior of type 2diabetesmellituspatients in Bandar Abbas in 2015. Electron Phys 2017;9:5863-7.
Tabong PT, Bawontuo V, Dumah DN, Kyilleh JM, Yempabe T. Premorbid risk perception, lifestyle, adherence and coping strategies of people with diabetes mellitus: A phenomenological study in the Brong Ahafo Region of Ghana. PLoS One 2018;13:e0198915.
Gato WE, Acquah S, Apenteng BA, Opoku ST, Boakye BK. Diabetes in the Cape Coast metropolis of Ghana: An assessment of risk factors, nutritional practices and lifestyle changes. Int Health 2017;9:310-6.
Assah FK, Ekelund U, Brage S, Mbanya JC, Wareham NJ. Urbanization, physical activity, and metabolic health in sub-Saharan Africa. Diabetes Care 2011;34:491-6.
Fezeu LK, Assah FK, Balkau B, Mbanya DS, Kengne AP, Awah PK, et al.
Ten-year changes in central obesity and BMI in rural and urban Cameroon. Obesity (Silver Spring) 2008;16:1144-7.
Mbanya JC, Motala AA, Sobngwi E, Assah FK, Enoru ST. Diabetes in sub-Saharan Africa. Lancet 2010;375:2254-66.
Khalil S, Almobarak AO, Awadalla H, Elmadhoun WM, Noor SK, Sulaiman AA, et al
. Low levels of physical activity in Sudanese individuals with some features of metabolic syndrome: Population based study. Diabetes Metab Syndr 2017;11 Suppl 2:S551-4.
Ahmed MH, Ali YA, Awadalla H, Elmadhoun WM, Noor SK, Almobarak AO. Prevalence and trends of obesity among adult Sudanese individuals: Population based study. Diabetes Metab Syndr 2017;11 Suppl 2:S963-7.
Awadalla H, Almobarak AO, Ahmed MH. Prevalence of smoking in Sudanese individuals with diabetes and associated complications: Population-based study. Diabetes Metab Syndr 2018;12:749-51.
Zhong X, Tanasugarn C, Fisher EB, Krudsood S, Nityasuddhi D. Awareness and practices of self-management and influence factors among individuals with type 2 diabetes in urban community settings in Anhui Province, China. Southeast Asian J Trop Med Public Health 2011;42:185-6, 184, 187-96.
Mehta NV, Trivedi M, Maldonado LE, Saxena D, Humphries DL. Diabetes knowledge and self-efficacy among rural women in Gujarat, India. Rural Remote Health 2016;16:3629. Available from: http://www.rrh.org.au/journal/article/3629.
[Last accessed on 2020 Jan 02].
Ku GM, Kegels G. Knowledge, attitudes and perceptions of people with type 2 diabetes as related to self-management practices: Results of a cross-sectional study conducted in Luzon, Philippines. Chronic Illn 2015;11:93-107.
American Diabetes Association. 5. Facilitating behaviour change and well-being to improve health outcomes” Standards of Medical Care in Diabetes-2020. Diabetes Care 2020;43 Suppl 1:S48-65.
2018 Physical Activity Guidelines Advisory Committee Scientific Report. Washington, DC, U.S. Department of Health and Human Services; 2018.
Bazargan-Hejazi S, Arroyo J, Hisa S, Brojeni N, Pan D. A racial comparison of differences between self-reported and objectively measured physical activity among US adults with diabetes. Ethn Dis 2017;27:403-10.
Tewahido D, Berhane Y. Self-care practices among diabetes patients in Addis Ababa: A qualitative study. PLoS One 2017;12:e0169062.
Adil MM, Alam AY, Jaffery T. Knowledge of type 2 diabetic patients about their illness: Pilot project. J Pak Med Assoc 2005;55:221-4.
Saleh F, Mumu SJ, Ara F, Begum HA, Ali L. Knowledge and self-care practices regarding diabetes among newly diagnosed type 2 diabetics in Bangladesh: A cross-sectional study. BMC Public Health 2012;12:1112.
Yang S, Hsue C, Lou Q. Does patient empowerment predict self-care behavior and glycosylated hemoglobin in Chinese patients with type 2 diabetes? Diabetes Technol Ther 2015;17:343-8.
Al-Khawaldeh OA, Al-Hassan MA, Froelicher ES. Self-efficacy, self-management, and glycemic control in adults with type 2 diabetes mellitus. J Diabetes Complications 2012;26:10-6.
Yuan X, Wang F, Fish AF, Xue C, Chen T, Liu C, et al
. Effect of case management on glycemic control and behavioral outcomes for Chinese people with type 2 diabetes: A 2-year study. Patient Educ Couns 2016;99:1382-8.
[Table 1], [Table 2], [Table 3], [Table 4]