Vol 12, No 3 (2023)
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Glycemic Control and Factors Associated with It Among People with Type 2 Diabetes: A Single-Center, Cross-sectional Study from Ethiopia

Gashaw Mekete Adal, Negesu Gizaw Demissie1, Tesfahun Zemene Tafere2
Clin Diabetol 2023;12(3):179-185.

Abstract

Objective: This study is aimed to assess the glycemic control and factors associated with it among people with type 2 diabetes (T2D) at Debre Tabor comprehensive specialized hospital, northwest Ethiopia. Materials and methods: Institutional-based cross-sectional study using a systematic sampling technique was conducted among 353 T2D patients from 1 September to 30 November 2021 at Debre Tabor comprehensive specialized hospital. A binary logistic regression model was fitted to identify factors associated with suboptimal glycemic control. Results: Nearly one-fourth (23.2%) of T2D patients had suboptimal glycemic control. Duration of T2D < 1 year [adjusted odd ratio (AOR): 1.8; 95% CI: 1.33–15.4] and never being counselled about dietary habits (AOR: 1.4; 95% CI: 1.23–11.6) were positively associated whereas no family history of T2D (AOR: 0.5; 95% CI: 0.4–0.8) was negatively associated with suboptimal glycemic
control. Conclusions: This study revealed that a higher proportion of T2D patients had suboptimal glycemic control. Duration of T2D < 1 year, no family history of T2D, and never being counselled about diet habits were significantly associated with suboptimal glycemic control. Therefore, the Ethiopian Ministry of Health should design initiatives to provide continuous health education focusing on behavioral lifestyle modification. Implementation of HbA1c measurement for estimation of long-term diabetes control is also highly recommended.

RESEARCH PAPER

ISSN 2450–7458
e-ISSN 2450–8187

Glycemic Control and Factors Associated with It Among People with Type 2 Diabetes: A Single-Center, Cross-sectional Study from Ethiopia

Gashaw Mekete Adal1Negesu Gizaw Demissie2Tesfahun Zemene Tafere3
1Department of Nursing and Child Health, Debre Tabor Health Science College, Debre Tabor, Ethiopia
2Department of Medical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
3Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

Address for correspondence:

Tesfahun Zemene Tafere

e-mail: tesfahunzemene4@gmail.com

Clinical Diabetology 2023, 12; 3: 179–185

DOI: 10.5603/DK.a2023.0020

Received: 9.03.2023 Accepted: 22.05.2023

ABSTRACT

Objective: This study is aimed to assess the glycemic control and factors associated with it among people with type 2 diabetes (T2D) at Debre Tabor comprehensive specialized hospital, northwest Ethiopia.

Materials and methods: Institutional-based cross-sectional study using a systematic sampling technique was conducted among 353 T2D patients from 1 September to 30 November 2021 at Debre Tabor comprehensive specialized hospital. A binary logistic regression model was fitted to identify factors associated with suboptimal glycemic control.

Results: Nearly one-fourth (23.2%) of T2D patients had suboptimal glycemic control. Duration of T2D < 1 year [adjusted odd ratio (AOR): 1.8; 95% CI: 1.33–15.4] and never being counselled about dietary habits (AOR: 1.4; 95% CI: 1.23–11.6) were positively associated whereas no family history of T2D (AOR: 0.5; 95% CI: 0.4–0.8) was negatively associated with suboptimal glycemic control.

Conclusions: This study revealed that a higher proportion of T2D patients had suboptimal glycemic control. Duration of T2D < 1 year, no family history of T2D, and never being counselled about diet habits were significantly associated with suboptimal glycemic control. Therefore, the Ethiopian Ministry of Health should design initiatives to provide continuous health education focusing on behavioral lifestyle modification. Implementation of HbA1c measurement for estimation of long-term diabetes control is also highly recommended. (Clin Diabetol 2023; 12; 3: 179–185)

Keywords: type 2 diabetes, suboptimal glycemic control, hypoglycemia, factors, Ethiopia

Background

Currently, type 2 diabetes (T2D) is an expanding global health problem, closely linked to the epidemic of obesity. Individuals with T2D are at high risk for both microvascular complications (including retinopathy, nephropathy, and neuropathy) and macrovascular complications (such as cardiovascular comorbidities), owing to hyperglycemia and individual components of the insulin resistance (metabolic) syndrome [1].

The study conducted in sub-Saharan African countries showed that about 74% of patients had suboptimal glycemic control [2]. In Ethiopia, about 80% of the respondents had uncontrolled fasting blood glucose levels [3]. The overall pooled prevalence of T2D in Ethiopia is 6.5% (95% CI: 5.8%, 7.3%) [4].

Suboptimal glycemic control is one of the major problems that indicate a significant risk factor for the progression and complications caused by diabetes despite its main therapeutic objective for the prevention of organ damage and other complications arising from diabetes [5].

Glycemic control is affected by several factors such as female patients aged ≥ 40 years, the illiterate, and chat chewers being more likely to have suboptimal glycemic control. Moreover, longer disease duration, insulin administration, and albuminuria were significantly associated with suboptimal glycemic control. In contrast, a healthy diet, physical exercise, proper self-monitoring of blood glucose levels, and taking medicines as prescribed significantly increased the likelihood of good glycemic control [6].

The major contributory factors for suboptimal glycemic control are not well documented in Ethiopia specifically in the study area. Therefore, researching challenges and factors associated with suboptimal glycemic control among T2D patients at Debre Tabor comprehensive specialized hospital may help to identify the prevalence and root causes of suboptimal glycemic control.

Materials and methods

Study design and settings

An institutional-based cross-sectional study was conducted among T2D patients from 1 September to 30 November 2021 at Debre Tabor comprehensive specialized hospital, northwest Ethiopia. The hospital is organized into medical, surgical, pediatrics, gynecology, emergency, ophthalmology, and intensive care unit wards. Currently, it has a total of 125 inpatient beds in all wards, and 534 staff providing health care services for about 2,651,350 population. Patients who were diagnosed to have T2D, had at least 6 months follow-up, with at least three consecutive blood glucose measurements at Debre Tabor comprehensive specialized hospital were eligible to be included in the study. Newly diagnosed T2D patients, T2D patients with serious illness conditions, and psychiatric patients were excluded from the study.

Variables and measurements

The dependent variable was suboptimal glycemic control while sociodemographic variables, knowledge of T2D and self-management behavior-related factors were the independent variables.

Operational definitions

Good glycemic control: Average fasting blood glucose measurement between 70 and 130 mg/dL or HbA1c < 7% [7].

Suboptimal glycemic control: A blood glucose measurement of the three consecutive visits >130 or <70 mg/dL or HbA1c > 7% [7].

Data collection tools and procedures

The data collection tool was adopted from standardized interviewer-guided questionnaires and chart reviews by reviewing different literature [7, 8]. The interviewer-guided questionnaires consist of four parts: socio-demographic characteristics, suboptimal glycemic control related factors, self-monitoring of blood glucose (SMBG), self-management behavior of suboptimal glycemic control related factors, while chart review contains laboratory data of T2D patients. T2D patients were face-to-face interviewed and the charts of all patients were reviewed from chronic OPD accordingly to the eligibility criteria. The data collection tool was first prepared in English, translated to Amharic (the local language) then retranslated to English to check for its consistency. Three BSC nurses for data collectors and one BSC nurse for supervisors were recruited.

Data quality assurance and control

Two days of training were given for both data collectors and supervisors by the principal investigator. Before the actual data collection, a pretest was conducted on 5% of the total sample size with similar characteristics to those in the study. Based on their feedback, the necessary modification was done to the items accordingly. Moreover, the internal consistency of the questionnaires was demonstrated through the reliability analysis of Cronbach alpha value of 0.84. The data collection processes were closely supervised by the supervisor and principal investigator.

Ethics approval and consent to participate

All the ethical procedures followed the Declaration of Helsinki. Ethical clearance was obtained from the Research Ethics Committee of Debre Tabor University. Then, participants of the study were informed about the purpose of the study, the importance of their participation, and their right to withdraw at any time. Written informed consent was obtained before data collection. Participants were also informed about their right to withdraw at any time or to skip questions. Finally, the confidentiality of the information was maintained by omitting personal identifiers and using coding.

Statistical analysis

Data processing and analysis

Data were cleaned, entered into Epi data version 3.1 and exported to STATA version 14 statistical software for analysis. Binary logistic regression analysis was computed to identify factors associated with suboptimal glycemic control. Variables with a p-value of less than 0.20 during bivariable regression were entered for multivariable logistic regression analysis. Then an adjusted odd ratio (AOR) with a 95% confidence interval and p-value < 0.05 were considered to declare the significant factors. A scatter plot was used to identify outliers and the model fitness was checked using the Hosmer-Lemeshow goodness of fit test which was 0.83. Finally, findings were presented using texts and tables.

Sample size and sampling procedure

To calculate the sample size, a previous study conducted on the proportion of patients with suboptimal glycemic control with a large proportion of similar characteristics to the current study was considered. Accordingly, the sample size was calculated using a single population proportion formula as

with the assumption of 5% margin of error (d), 95% confidence level, p = 0.65 [7] and 10% non-response, n = 385.

Since the population in the study area was less than 10,000, a reduction formula was employed and the final sample size was 353. Then the study participants were selected using a systematic sampling technique.

Results

Socio-demographic characteristics of the respondents

In this study, a total of 353 type 2 DM patients were enrolled with a response rate of 100%. About 139 (41.4%) were males and the mean age of the study participants was 56.1 ± 9.6 years. More than two third (67.4%) were orthodox in religion and less than half (45%) of the study participants were government employed. The majority of the study participants (79.3%) were urban dwellers and half (50.1%) were higher education level by their educational status. Similarly, about three-fourths (75.1%) of the study participants were married, whereas more than two-thirds (68.8%) of the study participants earned a monthly income of > 96.2 USD (Tab. 1).

Table 1. Socio-Demographic Characteristics of Type 2 Diabetes (T2D) Patients at Debre Tabor Comprehensive Specialized Hospital, Northwest Ethiopia, 2021 (n = 353)

Socio-demographic variables

Frequency n (%)

Age

Mean age

56.1 ± 9.6

Sex

Female

139 (41.4)

Male

197 (58.6)

Religion

Muslim

97 (27.5)

Orthodox

238 (67.4)

Protestant

18 (5.1)

Occupation

Farmer

58 (16.4)

Government employee

159 (45.0)

Housewife

70 (19.8)

NGO employee

11 (3.1)

Private business

55 (15.6)

Educational level

No formal education

54 (15.3)

Can read and write

73 (20.4)

Primary level

17 (4.8)

Secondary level

32 (9.1)

Higher education

177 (50.1)

Residence

Rural

73 (20.7)

Urban

280 (79.3)

Marital status

Never married

8 (2.3)

Married

265 (75.1)

Widowed

35 (9.9)

Divorced

45 (12.7)

Monthly income

< 96.2 USD

110 (31.2)

>96.2 USD

243 (68.8)

Duration of T2D

Mean duration of T2D

9.8 ± 3.2

Family history of T2D

I don’t know

7 (2.0)

No

194 (55.0)

Yes

152 (43.1)

Knowledge of patients on T2D

This study revealed that the overall suboptimal glycemic control was 23.2 % (95%CI: 19.0–27.5). Moreover, 43.6%, 42%, and 16.4% of study participants perceived that the cause of DM was explained by food habits, blood glucose and genetics, respectively. Likewise, 20.7%, 10.8% and 4.2% of study participants perceived that the cause of DM was explained by obesity, physical activity and medications, respectively (Tab. 2).

Table 2. Assessment of Knowledge among Type 2 Diabetes (T2D) Patients at Debre Tabor Comprehensive Specialized Hospital, Northwest Ethiopia, 2021 (n = 353)

Variables

Frequency
n (%)

Family history of T2D

I don’t know

No

Yes

7 (2.0)

194 (55.0)

152 (43.1)

The cause of T2D

Blood glucose

Poor food habit

Genetic

Lack of physical activity

Medication

Obesity

15 (4.2)

154 (43.6)

58 (16.4)

38 (10.8)

15 (4.2)

73 (20.7)

Aware of having T2D

No

Yes

121 (34.3)

232 (65.7)

Aware of the diagnosis of T2D

Blood glucose measurement

96 (27.2)

Hemoglobin A1c measurments

141 (39.9)

Aware of signs and symptoms

56 (15.9)

Aware of the presence of chronic conditions

No

Yes

204 (57.8)

149 (42.2)

Aware of the management of T2D

No

Yes

44 (12.5)

309 (87.5)

Aware of the types of management

Advice

Blood glucose monitoring

Diet

Medication adherence

Physical activity

7 (2.0)

22 (6.2)

7 (2.0)

260 (73.7)

14 (4.0)

Aware of the complication of T2D

Blood pressure

Eye problems

Heart diseases

Kidney problems

Neurological problems

143 (40.5)

125 (35.4)

86 (24.4)

45 (12.7)

54 (15.30

Aware of the history of admission by T2D

No

Yes

309 (87.5)

44 (12.5)

Reason of admission

High blood glucose level

Unknown diabetes

39 (11.0)

4 (1.4)

Ever gotten diabetic education

No

Yes

45 (12.7)

308 (87.3)

Area of education

About lifestyle change

How to manage hypoglycemia

Self-monitoring of blood glucose

Symptoms of hypertenssion

Symptoms of hypoglycemia

25(7.1)

28 (7.9)

57 (16.1)

54 (15.3)

186 (52.7)

Aware of current medication

Insulin

Insulin and other oral hypoglycemic agents

Metformin

Metformin, glibenclamide

Metformin, insulin

64 (18.1)

26 (7.4)

151 (42.8)

109 (30.90

3 (0.8)

Chart review of laboratory data of T2D patients

The mean triglyceride level (TRG) and cholesterol were found to be 116.2904 ± 24.38062 mg/dL and 149.1385 ± 32.55132 mg/dL respectively. The majority (86.7%) had normal 150 (TG) and few of the study participants (4.8%) had a high cholesterol level of 200 mg/dL. The mean (SD) of uric acid level, BUN, AST, and ALT was 3.8808 ± 1.72571 mg/dL, 13.6663 ± ± 5.61604 mg/dL, 27.8275 ± 7.77306 u/L, and 1.0 ± 0.0 u/L), respectively (Tab. 3).

Table 3. Document Review Data of Biochemical Parameters of the Study Participants at Debre Tabor Comprehensive Specialized Hospital, Northwest Ethiopia, 2021 (n = 353)

Laboratory test profiles

Frequency n (%)

Fasting blood glucose

< 70 mg/dL

2 (0.6)

70–125mg/dL

54 (15.3)

≥ 126 mg/dL

297 (84.1)

Triglycerides [mg/dL]

> 150 ( high)

47 (13.3)

≤ 150 (normal)

306 (86.7)

Total cholesterol [mg/dL]

≥ 2000 (high)

47 (13.3)

< 200 (normal)

306 (86.7)

HDL [mg/dL]

< 40 (risk)

17 (4.8)

> 40 (normal)

336 (95.2)

LDL [mg/dL]

>100 (high)

61 (17.3)

< 100 (normal)

292 (82.7)

Uric acid

3.5–7.2 mg/dL (normal)

77 (21.8)

< 3.5 mg/dL (low)

232 (65.7)

7.2 mg/dL (high)

44 (12.5)

Albumin

Albuminuria

350 (99.2)

Normal

3 (0.8)

MCHC [g/dL]

33.4–35.5 (normal)

64 (18.1)

< 33.4 (low)

286 (81.0)

> 35.5 (high)

3 (0.8)

Self-management behavior of glycemic control

The current study revealed that 215 (60.9 %) of the study participants were observed to be adhered to instructions for diet habits. More than half (55%) of the patients were engaged in physical exercise. Moreover, 91 (25.8 %), 52 (14.7 %), and 51 (14.4 %) of the study participants were involved in physical exercise with a frequency of > 5 times, < 2 times, and 2–5 times per week respectively. Whereas, about 282 (77.3%) study participants monitored their blood glucose levels at health institutions by themselves during the last seven days preceding the study (Tab. 4).

Table 4. Self-Management Behavior of Suboptimal Glycemic Control among T2D Patients at Debre Tabor Comprehensive Specialized Hospital, Northwest Ethiopia, 2021 (n = 353)

Variables

Frequency n (%)

Food to strictly exclude from
the daily food menu

Alcohol

9 (2.5)

Banana

27 (7.7)

Cabbage

9 (2.5)

Honey

144 (40.8)

Potatoes

19 (5.4)

Glucosey food

136 (38.5)

Wheat bread

9 (2.5)

Engaging in physical exercise

No

159 (45.0)

Yes

194 (55.0)

Frequency of physical activity/week

< 2 times/week

52 (14.7)

> 5 times/week

91 (25.8)

2–5 times/week

51 (14.4)

Monitor your blood glucose

No

80 (22.7)

Yes

273 (77.3)

Miss medication

No

282 (79.9)

Yes

71 (20.1)

Frequency of missing medication/month

< 2 times/week

16 (4.5)

> 5 times/week

26 (7.4)

2–5 times/week

12 (3.4)

Regularly inspect and care for your foot

No

80 (22.7)

Yes

273 (77.3)

Factors associated with suboptimal glycemic control

Variables with a p-value less than 0.2, such as the occupational status of the study participants, housewife duration of T2D < 1 year, no family history of T2D and never being counselled about healthy diet were candidates for multivariable analysis.

However, duration of T2D < 1 year, no family history of T2D, and never being counselled about a healthy diet were significantly associated with suboptimal glycemic control.

The odds of suboptimal glycemic control was 1.8 times (AOR: 1.8; 95% CI: 1.33–15.4) higher among pa- tients with a duration of T2D < 1 year compared to patients with a duration of T2D > 10 years.

The odds of suboptimal glycemic control was 50% (AOR: 0.5; 95% CI: 0.4–0.8) lower among patients who have no family history of T2D compared to those having a family history of T2D. Likewise, the odds of suboptimal glycemic control was 1.4 times (AOR: 1.4; 95% CI: 1.23–11.6) higher among patients who were not counselled about diet habits compared to their counterparts.

Discussion

The current study revealed that the overall suboptimal glycemic control was 23.2 % (95% CI: 19.0–27.5). This value was lower as compared with the study conducted in sub-Saharan Africa where 70% of patients with T2D failed to achieve good glycemic control (HbA1c < 7%) [9]. The difference might be due to differences in study design, lifestyle, and socioeconomic status.

This finding was also lower as compared with the study done in Ayder comprehensive specialized hospital, Ethiopia which showed that 61.9% of the study participants had suboptimal glycemic control [10]. The difference might be due to socioeconomic status, access to health care, healthcare utilization and use of medication.

The current study revealed that 60.9 % of the study participants had adequate healthy eating plans during the previous week before the study. This finding was higher than the study conducted in Jimma, Ethiopia where 22.9% of study participants had adequate healthy eating plan during the previous week before the study [11]. This inconsistency might be due to differences in the delivery of life modification counselling in the two settings.

In this study, it is shown that more than half of the study participants were engaged in physical exercise. This finding was higher than the study conducted in Jimma, Ethiopia where 22% of study participants were involved in physical activity for more than 3 days during the last seven days preceding the study. This difference might be because of the existence of differences in providing education about the importance of physical exercise to control the glycemic level.

This study revealed that the odds of suboptimal glycemic control was 1.8 times higher among patients with a duration of T2D < 1 year compared to pa- tients with a duration of T2D > 10 years. This finding was inconsistence with the study conducted in Jordan which showed that increased duration of DM was associated with increased odds of suboptimal glycemic control [12]. This inconsistency might be due to differences in exposure to medication and experience and counselling regarding glycemic control.

Moreover, this study showed that the odds of suboptimal glycemic control was 1.4 times higher among patients who were not counselled about diet habits compared to their counterparts. This finding was similar to the study conducted in Jordan where the odds of suboptimal glycemic control was 2.98 times higher among patients who were not counselled about diet habits compared to those who were counselled [12]. This similarity might be due to the similarity in delivering awareness creation for the patients in both countries.

The odds of suboptimal glycemic control was 50% lower among patients who had no family history of T2D compared to those having a family history of T2D. This study was congruent with a systematic review and meta-analysis study conducted in Ethiopia which showed that those participants who had a family history of DM were 6.14 times more likely to have suboptimal glycemic control as compared to their counterparts [4]. Similarly, studies conducted in different places in Ethiopia also supported our results [13–15]. The observed similarity might be attributed to the genetics of diabetes passed from parents and also attributed to shared behavioral risk factors among the families.

Limitation

Because the study used a cross-sectional study design, no causal link could be made between the independent and dependent variables. Finally, recall bias may constrain the subjective nature of some self-reported responses.

Conclusions

This study revealed that about one-fourth of T2D patients had suboptimal glycemic control. Moreover, the duration of T2D < 1 year and ever not being counselled on diet habits were a positive predictor of suboptimal glycemic control whereas having no family history of T2D was a negative predictor of suboptimal glycemic control. Therefore, the Ethiopian Ministry of Health should design initiatives to provide continuous health education focusing on behavioral lifestyle modification like physical activity and dietary modifications to adhere patients to the glycemic control measures. Furthermore, patients should take appropriate self-intervention. Implementation of HbA1c measurement in the routine follow-up of DM patients as a tool for estimation of long-term diabetes control is also highly recommended.

Availability of data and materials

Data will be available upon reasonable request from the corresponding author.

Funding

No funding was secured for this study.

Acknowledgements

We are grateful to Debre Tabor University for its technical support throughout this study.

We would also extend our appreciation to supervisors, data collectors, and study participants.

Conflict of interests

None declared.

References

  1. DeFronzo RA, Ferrannini E, Groop L, et al. Type 2 diabetes mellitus. Nat Rev Dis Primers. 2015; 1: 15019, doi: 10.1038/nrdp.2015.19, indexed in Pubmed: 27189025.
  2. Camara A, Baldé NM, Sobngwi-Tambekou J, et al. Poor glycemic control in type 2 diabetes in the South of the Sahara: the issue of limited access to an HbA1c test. Diabetes Res Clin Pract. 2015; 108(1): 187–192, doi: 10.1016/j.diabres.2014.08.025, indexed in Pubmed: 25697633.
  3. Tekalegn Y, Addissie A, Kebede T, et al. Magnitude of glycemic control and its associated factors among patients with type 2 diabetes at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. PLoS One. 2018; 13(3): e0193442, doi: 10.1371/journal.pone.0193442, indexed in Pubmed: 29505602.
  4. Zeru MA, Tesfa E, Mitiku AA, et al. Prevalence and risk factors of type-2 diabetes mellitus in Ethiopia: systematic review and meta-analysis. Sci Rep. 2021; 11(1): 21733, doi: 10.1038/s41598-021-01256-9, indexed in Pubmed: 34741064.
  5. Haghighatpanah M, Nejad AS, Haghighatpanah M, et al. Factors that Correlate with Poor Glycemic Control in Type 2 Diabetes Mellitus Patients with Complications. Osong Public Health Res Perspect. 2018; 9(4): 167–174, doi: 10.24171/j.phrp.2018.9.4.05, indexed in Pubmed: 30159222.
  6. Saghir S, Alhariri A, Alkubat S, et al. Factors associated with poor glycemic control among type-2 diabetes mellitus patients in Yemen. Tropical Journal of Pharmaceutical Research. 2021; 18(7): 1539–1546, doi: 10.4314/tjpr.v18i7.26.
  7. Fekadu G, Bula K, Bayisa G, et al. Challenges And Factors Associated With Poor Glycemic Control Among Type 2 Diabetes Mellitus Patients At Nekemte Referral Hospital, Western Ethiopia. J Multidiscip Healthc. 2019; 12: 963–974, doi: 10.2147/JMDH.S232691, indexed in Pubmed: 31819470.
  8. Abdissa D, Hirpa D. Poor glycemic control and its associated factors among diabetes patients attending public hospitals in West Shewa Zone, Oromia, Ethiopia: An Institutional based cross-sectional study. Metabol Open. 2022; 13: 100154, doi: 10.1016/j.metop.2021.100154, indexed in Pubmed: 34977524.
  9. Fina Lubaki JP, Omole OB, Francis JM. Glycaemic control among type 2 diabetes patients in sub-Saharan Africa from 2012 to 2022: a systematic review and meta-analysis. Diabetol Metab Syndr. 2022; 14(1): 134, doi: 10.1186/s13098-022-00902-0, indexed in Pubmed: 36127712.
  10. Mideksa S, Ambachew S, Biadgo B, et al. Glycemic control and its associated factors among diabetes mellitus patients at Ayder comprehensive specialized hospital, Mekelle-Ethiopia. Adipocyte. 2018; 7(3): 197–203, doi: 10.1080/21623945.2018.1467716, indexed in Pubmed: 29775127.
  11. Mamo Y, Bekele F, Nigussie T, et al. Determinants of poor glycemic control among adult patients with type 2 diabetes mellitus in Jimma University Medical Center, Jimma zone, south west Ethiopia: a case control study. BMC Endocr Disord. 2019; 19(1): 91, doi: 10.1186/s12902-019-0421-0, indexed in Pubmed: 31464602.
  12. Khattab M, Khader YS, Al-Khawaldeh A, et al. Factors associated with poor glycemic control among patients with type 2 diabetes. J Diabetes Complications. 2010; 24(2): 84–89, doi: 10.1016/j.jdiacomp.2008.12.008, indexed in Pubmed: 19282203.
  13. Woldesemayat B. Prevalence of Diabetes Mellitus and Associated Risk Factors Among Adults Attending at Feres Meda Health Centre, Addis Ababa, Ethiopia, 2017. International Journal of Biomedical Materials Research. 2019; 7(1): 8–15, doi: 10.11648/j.ijbmr.20190701.12.
  14. Wondemagegn AT, Bizuayehu HM, Abie DD, et al. Undiagnosed Diabetes Mellitus and Related Factors in East Gojjam (NW Ethiopia) in 2016: A Community-Based Study. J Public Health Res. 2017; 6(1): 834, doi: 10.4081/jphr.2017.834, indexed in Pubmed: 28480176.
  15. Endris T, Worede A, Asmelash D. Prevalence of Diabetes Mellitus, Prediabetes and Its Associated Factors in Dessie Town, Northeast Ethiopia: A Community-Based Study. Diabetes Metab Syndr Obes. 2019; 12: 2799–2809, doi: 10.2147/dmso.s225854.