GENDER WISE PREVALENCE OF COMORBIDITIES AND MEDICATION ADHERENCE AMONG TYPE 2 DIABETICS IN MALAPPURAMHTML Full Text
GENDER WISE PREVALENCE OF COMORBIDITIES AND MEDICATION ADHERENCE AMONG TYPE 2 DIABETICS IN MALAPPURAM
N. V. Fatimathu Zuhara * 1, A. Thahira Banu 1 and Najma Chokli 2
Department of Home Science 1, Gandhigram Rural Institute (Deemed to be University), Dindigul - 624302, Tamil Nadu, India.
Department of Home Science 2, KAHM Unity Women’s College, Manjeri - 676122, Kerala, India.
ABSTRACT: Background: Type 2 diabetes is a major lifestyle disease often seen with comorbidities or complications. This study is conducted to find out the gender-wise prevalence of comorbidities and medication adherence among the diabetics in Malappuram. Methods: A cross-sectional study was conducted among the 179 diabetics selected for the study. A pre-tested interview schedule was used to collect information about their socio-demographic details, clinical characteristics, co-morbidities and awareness on complications. Anthropometric measurements and blood pressure of each patient were recorded. Body Mass Index, Waist Hip Ratio and Household Dietary Diversity Score were calculated. The results were analyzed statistically. Results: The selected diabetics comprised of 46.4% males and 53.6% females. Around 91% of them were sedentary workers. Early-onset of diabetes at the age of 35-45 years was reported among males (p<0.05). Blood sugar monitoring, insulin usage, and exercise were higher among males while the medication regularity was higher among females. Higher prevalence of obesity (62.5%), hypertension (53.1%) and hypercholesterolemia (59.5%) were observed among the female diabetics. The prevalence of retinopathy (15.7%) and heart diseases (13.3%) were higher among the males. 76 percent of diabetics had poor awareness of complications of diabetes in which females outnumbered males (p<0.01). Conclusion: High prevalence of comorbidities and lack of awareness on complications emphasizes the necessity of mass and individual counseling on diabetes and its self-care measures to the diabetics.
Diabetes, Comorbidity, Complication, Medication, Kerala
INTRODUCTION: Type 2 diabetes is an alarming global epidemic increasing due to population growth, aging and obesity. In 2017, the prevalence of diabetes among men and women was 8.9% and 8.4% respectively 1. It is the seventh leading cause of death, and along with obesity and hypertension, it leads to heart diseases, which are the first leading cause of death in the world 2.
India is the second-largest contributor to regional mortality, with one million deaths attributable to diabetes 3. Poor control of diabetes results in complications like cardiovascular diseases, renal dysfunction, leg amputation, and blindness.
Several studies reported the evidence of multiple co-morbidities making diabetes care more difficult, expensive and also increasing the risk of complications 4. The consequences of diabetes can be prevented or delayed with diet, physical activity, regular monitoring, and medication. A detailed study on comorbid conditions will help the health care providers to be vigilant and prepare themselves to meet the demands caused by them 4.
Hence, a community-based study was carried out in the Malappuram district of Kerala to determine the gender-based prevalence of comorbidities and medication adherence among the diabetics.
MATERIALS AND METHODS: Two wards were selected from the randomly selected Kondotty Municipality, situated in the Malappuram district of Kerala. A cross-sectional survey was conducted among the type 2 diabetic patients residing in the randomly selected houses of the wards for three consecutive months. Pregnant women, bedridden or severely ill patients and those who were not willing to participate were excluded from the study. Hence, 179 diabetics in the age group of 30-75 years and willing to participate were included in the study.
A house to house survey was conducted among the selected diabetics to obtain information on personal details, socio-demographic characteristics, family history of diabetes, clinical characteristics, diet and activity pattern, comorbidities or complications and awareness on complications of diabetes using a pre-tested interview schedule. Household Dietary Diversity score (HDDS) for each patient was calculated using FAO-WFP guideline 5.
Physical and Biochemical Parameters: Anthropometric measurements of the diabetic patients were taken as per the WHO protocol 6. Height, waist and hip circumferences of each person with diabetes were measured using a non-stretchable measuring tape, and the bodyweight was assessed with the help of Health genie (HD 221) electronic weighing machine. For each patient, Body Mass Index (BMI) and Waist Hip Ratio (WHR) were calculated. BMI was further categorized into underweight (BMI <18.5kg/m2), Normal (BMI 18.5-22.9 kg/m2), Overweight (BMI 23- 24.9 kg/m2) and Obese (BMI ≥25 kg/m2).
Female patients with waist circumference ≥80cm and WHR >0.85 and male patients with waist circumference ≥90cm and WHR >0.9 were considered as having abdominal obesity 7-9. Blood pressure (BP) of each diabetic patient was obtained using Omron digital blood pressure monitor (HEM-8712, Omron Healthcare Corporation, Kyoto, Japan). The maintenance of blood pressure was recorded as good (BP <130/80 mmHg), satisfactory (BP 130/80 to 139/89 mmHg) and poor (BP≥140/90 mmHg) based on WHO classification 10.
Ethical Considerations: The study protocol was approved by the Institutional Ethical Committee of Gandhigram Rural Institute (Deemed to be University), Tamil Nadu (No. GRI/IECRHAS/ 2018/09). The study participants were enrolled in the study after getting written informed consent from each participant.
Statistical Analysis: The data was analyzed in SPSS (IBM) 23.0 version. Descriptive analysis was carried out to obtain means and standard deviations. The relationship between gender and other variables were determined through Chi-Square tests. The tests were conducted at 95% confidence level and the results with p<0.05 was taken as statistically significant.
Baseline Characteristics of Diabetics: The selected diabetics comprised of 46.4% males and 53.6% females. The mean age of the male diabetics was 54.27 ± 9.89 years, and that of females was 55.27 ± 10.88 years. The socio-economic and demographic characteristics of the people with diabetes are given in Table 1. There was significant difference between male and female patients in their education, occupation, marital status and physical activity (p<0.001).
TABLE 1: SOCIO DEMOGRAPHIC CHARACTERISTICS OF DIABETICS
|Particulars||Category||Male (83)||Female (96)||Total (N=179)||p value|
|Age||31 to 40||6 (7.2)||9 (9.4)||15 (8.4)||0.910|
|41 to 50||28 (33.7)||28 (29.2)||56 (31.3)|
|51 to 60||26 (31.3)||32 (33.3)||58 (32.4)|
|61 to 70||18 (21.7)||19 (19.8)||37 (20.7)|
|71 to 75||5 (6.0)||8 (8.3)||13 (7.3)||0.804|
|Religion||Hindu||15 (18.1)||16 (16.7)||31 (17.3)|
|Muslim||68 (81.9)||80 (83.3)||148 (82.7)||
|Education||Illiterate||0 (0.0)||4 (4.2)||4 (2.2)|
|Primary||31 (37.3)||55 (57.3)||86 (48.0)|
|Secondary||28 (33.7)||30 (31.3)||58 (32.4)|
|Higher secondary & above||24 (28.9)||7 (7.3)||31 (17.3)|
|Occupation||Unemployed||18 (21.7)||92 (95.8)||110 (61.5)||<0.001*|
|Employed||65 (78.3)||4 (4.2)||69 (38.5)|
|Socio economic status||Upper||1 (1.2)||1 (1.0)||2 (1.1)||0.264|
|Upper middle||30 (36.1)||27 (28.1)||57 (31.8)|
|Lower middle||33 (39.8)||33 (34.4)||66 (36.9)|
|Upper lower||19 (22.9)||35 (36.5)||54 (30.2)|
|Marital Status||Unmarried||0 (0.0)||1 (1.0)||1 (0.6)||<0.001*|
|Married||83 (100)||64 (66.7)||147 (82.1)|
|Divorcee||0 (0.0)||1 (1.0)||1 (0.6)|
|Widow/widower||0 (0.0)||30 (31.3)||30 (16.8)|
|Family type||Nuclear||36 (43.4)||28 (29.2)||64 (35.8)||0.072|
|Joint||21 (25.3)||23 (24.0)||44 (24.6)|
|Extended||26 (31.3)||45 (46.9)||71 (39.7)|
|Physical activity||Sedentary||68 (81.9)||95 (99.0)||163 (91.1)||<0.001*|
|Moderate||12 (14.5)||1 (1.0)||13 (7.3)|
|Heavy||3 (3.6)||0 (0.0)||3 (1.7)|
*Highly significant (p<0.001)
Clinical Profile of Diabetics: The study showed an early onset of diabetes in the age of 35- 45 years among most of the males while it was reported as 45-55 years in the majority of the female patients Fig. 1. However, gender was not significantly related to the onset of diabetes (p=0.089; p>0.05). In around 66℅ of diabetics, the disease started between 35-55 years of age.
FIG. 1: AGE OF ONSET OF DIABETES
The duration of diabetes in the majority (60.3%) of the diabetics was less than 7 years. Most of the patients (87.7%) were undergoing allopathy treatment. Five percent of the patients took no treatment in which females outnumbered males. Most of those patients on treatment were taking oral drugs only. Insulin usage was higher among males Table 2. Few people with diabetes stopped their medication once they found their blood sugar levels as normal during monitoring.
Also, more than one-fifth of the patients reported irregular intake of oral medicines in which most of them were males. The regularity of taking medicines was significantly associated with gender (p<0.05). Even though the practice of blood sugar monitoring was more regular among men, there was no significant association between gender and blood sugar monitoring (p>0.05).
TABLE 2: CLINICAL CHARACTERISTICS OF DIABETICS
|Particulars||Category||Male (83)||Female (96)||Total (179)||p value|
|Duration of disease||0 - 4 years||30 (36.1)||46 (47.9)||76 (42.4)||0.305|
|4 -7 years||18 (21.7)||14 (14.6)||32 (17.9)|
|7 - 10 years||2 (2.4)||4 (4.2)||6 (3.4)|
|10 years & above||33 (39.8)||32 (33.3)||65 (36.3)|
|Current medicine||Without medicine||4 (4.8)||10 (10.4)||14 (7.8)||0.263|
|Oral medicine||63 (75.9)||77 (80.2)||140 (78.2)|
|Insulin||8 (9.6)||5 (5.2)||13 (7.3)|
|Oral medicine and insulin||5 (6.0)||3 (3.1)||8 (4.5)|
|Stopped medicine||3 (3.6)||1 (1.0)||4 (2.2)|
|Intake of medicine/ insulin||Regularly||59 (71.1)||81 (84.4)||140 (78.2)||0.003*|
|Irregular||17 (20.5)||4 (4.2)||21 (11.7)|
|No medicine||4 (4.8)||10 (10.4)||14 (7.8)|
|Stopped medicine||3 (3.6)||1 (1.0)||4 (2.2)|
|Monitoring blood sugar||Doctor's advice||19 (22.9)||28 (29.2)||47 (26.3)||0.679|
|Symptomatic||8 (9.6)||8(8.3)||16 (8.9)|
|Irregular||9 (10.8)||13 (13.5)||22 (12.3)|
|Regular||47 (56.6)||47 (49.0)||94 (52.5)|
*Highly significant (p<0.01)
Among the various symptoms of diabetes, fatigue was reported by 33.5% of the patients. Around 10% of diabetics had weight loss. Majority of the diabetics (72.3% males and 62.5% females) had a family history of diabetes Fig. 2. There was no significant association between gender and positive family history of diabetes (p=0.165; p>0.05).
Practices Followed to Control Diabetes: Majority of the diabetics (95.2% males and 89.6% females) used medication to control diabetes Fig. 3. Around 65% males and 61.5% females practiced dietary changes. The mean HDDs of the diabetic population studied was 7.6 ± 0.89. Even though the practice of exercise was higher among males (20.5%), the overall percentage of diabetics performing exercise was less. There was significant relationship between gender and exercise among the diabetics (p<0.05).
Comorbidities Among the Diabetics: Around 63.1% of the diabetics (56.6% males and 68.8% females) had comorbidities or complications Fig. 4. Multiple comorbidities were observed in 39.6% of the diabetics. The maximum number of comorbidities reported among the diabetics was six. High prevalence of hypertension, hypercholesterolemia and thyroid disorders was reported among female diabetics.
Even though the prevalence of comorbidity was higher in females, there was no significant association between gender and the presence of comorbidity (p=0.094; p>0.05). The prevalence of complications of diabetes such as heart diseases, stroke, retinopathy, and neuropathy was higher among the male patients.
FIG. 4: CO MORBIDITIES AMONG DIABETICS BY GENDER
TABLE 3: GENDER-BASED PREVALENCE OF OBESITY AMONG DIABETICS
|Particulars||Category||Male (83)||Female (96)||Total (N=179)||p value|
|BMI (kg/m2)||<18.5||2 (2.4)||3 (3.1)||5 (2.8)||0.606|
|18.5-22.9||22 (26.5)||18 (18.8)||40 (22.3)|
|23-24.9||14 (16.9)||15 (15.6)||29 (16.2)|
|≥25||45 (54.2)||60 (62.5)||105 (58.7)|
|<80 (women) &<90 (men)||22 (26.5)||5 (5.2)||27 (15.1)||<0.001*|
|≥80 (women) & ≥90 (men)||61 (73.5)||91 (94.8)||152 (84.9)|
|WHR||≤0.85 (women) & ≤ 0.9 (men)||53 (63.9)||10 (10.4)||63 (35.2)||<0.001*|
|>0.85 (women) &>0.9 (men)||30 (36.1)||86 (89.6)||116 (64.8)|
|Mean body weight (kg)||69.55±11.9||61.90±12.2||65.45±12.6|
*Highly significant (p<0.001)
Majority of the diabetic patients were obese with high waist circumference Table 3. The prevalence of central obesity was higher among female patients. Although BMI of the diabetics was not significantly related to gender, central obesity among the diabetics was strongly associated with gender (p<0.01). Even though majority (92.3%)of the diabetics with hypertension reported as taking medicines to regulate blood pressure, around 37.7% of the patients showed poor control of blood pressure. The higher percentage of female diabetics reported poor management of blood pressure Table 4. Hence, gender was significantly associated with the control of blood pressure (p<0.05).
TABLE 4: CONTROL OF BLOOD PRESSURE IN DIABETICS BY GENDER
|Particulars||Category||Male (83)||Female (96)||Total (N=179)||p-value|
|<130||34 (41.0)||36 (37.5)||70 (39.1)||0.166|
|130-139||24 (28.9)||19 (19.8)||43 (24.0)|
|≥140||25 (30.1)||41 (42.7)||66 (36.9)|
|<80||12 (14.5)||20 (20.8)||32 (17.9)||0.018*|
|80-89||46 (55.4)||33 (34.4)||79 (44.1)|
|≥90||25 (30.1)||43 (44.8)||68 (38.0)|
Awareness Among the Diabetics: Among the diabetics, 66.3% of males and 84.4% of females were not aware of the complications of diabetes. Awareness of complications of diabetes was significantly associated with gender (p=0.005; p<0.01). There was also a significant difference in the attitude of male and female diabetics regarding the relationship between blood sugar control and the development of complications (p<0.001).
DISCUSSION: Among the diabetic patients selected, the higher percentage of women were noted, as documented in the earlier studies in Kerala 11-13. Early-onset of diabetes at the age of 35-45 years was observed among the males and few diabetics had the disease in 25-35 years. The shift in the age of onset of diabetes at younger age was communicated in the previous studies 14, 15. Lower age at onset of diabetes and poor glycemic control will increase the chances for vascular complications 16.
As stated in the previous studies, most of the patients were on allopathy treatment 12, 17. Few patients received no treatment, and a similar observation was reported in the Ernakulam district of Kerala 18. Majority of the diabetics were on oral medication while very few patients used insulin. Previous studies in Kerala and other parts of world documented the same finding 11, 17-19. This might be credited to the social and mental barriers among the diabetics and health care workers in starting insulin treatment. Among those patients using insulin, men outnumbered women. Few patients stopped taking medicines on their own as their blood sugar level became normal. This is similar to the findings reported in Karnataka and Malaysia 20, 21. Among those under medication, most of them took medication regularly. Regularity in medication was significantly higher among female patients as described in an earlier study conducted in southern India 22. Around half of the patients had regular blood sugar monitoring in which males outweighed females. Better medication adherence and blood sugar monitoring were reported in the previous studies 11, 12, 20-22. But they were found to be poor in a study conducted in rural Kerala 23. Majority of the diabetics had a positive family history of diabetes as reported in earlier studies 13, 16.
Nearly one-third of the patients were dependent on medicines alone to control diabetes without practicing any lifestyle modification. Few patients practiced exercise, and among those practicing dietary modifications, the dietary changes were poor as reported in earlier studies 11, 12, 22. Also, majority of the diabetics were sedentary workers, and similar finding was observed in previous studies 24, 25. Sedentary activity and lack of exercise were significantly higher in female diabetics. Such findings were documented in the previous studies 26, 27.
As communicated in several studies, a high prevalence of comorbidities and complications was reported among the patients 4, 11, 18, 19, 29. More than half of the patients had obesity, hypertension, and hypercholesterolemia. Several other studies also showed that these three diseases are the common comorbid conditions of diabetics 11, 18, 19, 28, 29.
Among the patients, the prevalence of abdominal obesity was higher than that of general obesity as documented in few other studies 13, 30. Moreover, abdominal obesity was observed higher among females than males. Other morbidities such as hypertension, hypercholesterolemia, and thyroid disorders were also higher among women. Previous studies reported higher prevalence of comorbidities among female diabetic patients 26. The prevalence of complications such as heart diseases, retinopathy, stroke, and neuropathy was higher among men. Retinopathy was the most common complication reported among the diabetics, followed by heart diseases and kidney disorders. Also, in some of the previous studies, retinopathy was reported as the most prevalent complication among diabetic patients 16, 31.
Most of the patients were not aware of the complications of diabetes and the need for blood sugar control to prevent or delay complications. Earlier studies also documented poor knowledge of complications of diabetes among diabetic patients 32, 33. The lack of awareness of diabetes and its complications was found higher among female patients. This is in consistent with the previous study done in Kerala, even though few studies from outside India reported better knowledge of diabetes among women 26, 27.
CONCLUSION: Although, better medication adherence was observed among the patients, poor lifestyle modifications and lack of awareness on diabetes and its complications were noted. Moreover, the prevalence of comorbidities and complications were higher among them. Poor awareness of diabetes management and the communication gap with health care providers may be the major contributing factors. Hence, diabetes education programs providing guidance in self-care practices especially lifestyle changes are essential for the diabetic community.
ACKNOWLEDGEMENT: Our sincere thanks to the University Grants Commission for providing UGC- FDP Teacher fellowship to Ms. N. V. Fatimathu Zuhara for the completion of study. We also thank Mr. Muthukumar, Assistant Professor, Gandhigram Rural Institute – (DU), Tamil Nadu for his valuable guidance in the statistical analysis of the data.
CONFLICT OF INTEREST: None
SOURCE OF SUPPORT: UGC-FDP Teacher fellowship was granted.
- Cho NH, Shaw JE, Karuranga S, Huang Y, da Rocha Fernandes JD, Ohlrogge AW and Malanda B: IDF Diabetes Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res Clin Pract 2018; 138: 271-81.
- World Health Organisation: World Health Day 2016: WHO calls for global action to halt halt rise in and improve care for people with diabetes 2016 https://www.who.int/news-room/detail/06-04-2016-world-health-day-2016-who-calls-for-global-action-to-halt-rise-in-and-improve-care-for-people-with-diabetes.
- Sonkar S, Mehrotra S, Kumar A, Sonkar G, Khan MS, Alam R and Khan MM: Validity of Indian Diabetes Risk Score and its association with body mass index and glycosylated hemoglobin for the screening of diabetes in and around areas of Lucknow. J Fam Med Prim Care 2017; 6(2): 366-73.
- Pati S and Schellevis FG: Prevalence and pattern of comorbidity among type 2 diabetics attending urban primary healthcare centers at Bhubaneswar (India). PLoS One 2017; 12(8): e0181661.
- FAO-WFP: Household Dietary Diversity Score and Food Consumption Score : A Joint Statement of FAO and WFP 2012: 1-2.
- Riley L, Guthold R, Cowan M, Savin S, Bhatti L, Armstrong T and Bonita R: The World Health Organization stepwise approach to noncommunicable disease risk-factor surveillance: methods, challenges, and opportunities. Public Health 2016; 106(1): 74-8.
- World Health Organisation IA for the study of O. The Asia-Pacific perspective-Redefining Obesity and its treatment 2000; 18-20.
- World Health Organisation. Waist Circumference and Waist-Hip Ratio: Report of a WHO Expert Consultation. 2011; 27.
- World Health Organisation. Global Report on Diabetes. 2016; 1-84.
- Definition and Classification. J Assoc Physicians India. 2013; 61: 12.
- Bhosale S, Pawar AT and Kumar D: Healthcare-seeking behavior among diabetic patients in Kozhikode, Kerala. Int J Med Sci Public Heal 2017; 6(10): 1524-27.
- Kamaruddeen M: Dietary pattern related to diabetes management among self-reported diabetic patients in Malappuram , Kerala , India Achutha Menon Centre for Health Science Studies 2014; 6: 1-14./
- Ameesh M and Murugan S: Prevalence and its risk factors of diabetic patients in urban area of Palakkad : an observational study. Int J Community Med Public Heal 2017; 4(10): 3721-6.
- Amutha A, Anjana RM, Venkatesan U, Ranjani H, Unnikrishnan R and Narayan KM V: Incidence of complications in young-onset diabetes: Comparing type 2 with type 1 (the young diab study). Diabetes Res Clin Pract 2017; 123: 1-8.
- Nair HD, Sudha V, Binu VS, Lakshmipriya N, Mohan V, Unnikrishnan R, Anjana RM, Deepa M, Rani CSS, Pradeepa R and Subashini S: Incidence of diabetes and prediabetes and predictors of progression among asian indians: 10-year follow-up of the Chennai Urban Rural Epidemiology Study (CURES). Rani Diabetes Care 2015; 38(8): 1441–8.
- Ramachandran A and Snehalatha C: Current scenario of diabetes in India. J Diabetes 2008; 1(1): 18-28.
- Shivashankar M and Dhandayuthapani M: Prevalence of diabetes in Vellore district, Tamil Nadu, India. J Chem Pharm Res 2011; 3(4): 684-96.
- Menon VU, Guruprasad U, Sundaram KR, Jayakumar R V, Nair V and Kumar H: Glycaemic status and prevalence of comorbid conditions among people with diabetes in Kerala. The National Medical Journal of India 2008; 21(3): 112-27.
- Pantalone KM, Hobbs TM, Wells BJ, Kong SX, Kattan MW, Bouchard J, Yu C, Sakurada B, Milinovich A, Weng W, Bauman JM and Zimmerman RS: Clinical characteristics, complications, comorbidities and treatment patterns among patients with type 2 diabetes mellitus in a large integrated health system. BMJ Open Diabetes Res Care 2015; 3(:e000093): 93.
- Jannoo Z and Khan NM: Medication adherence and diabetes self-care activities among patients with type 2 diabetes mellitus. Value Heal Reg Issues 2019; 18: 30-5.
- Deepali BS, Mangala S, Soumya G, Vikyath BR, Aarudhra P, Ankitha M, Deepashree R and Nagashree N: Knowledge of diabetes , its complications and treatment adherence among diabetic patients. Int J Community Med Public Health 2017; 4(7): 2428-34.
- Gopichandran V, Lyndon S, Angel MK, Manayalil BP, Blessy KR, Alex RG, Kumaran V and Balraj V: Diabetes self-care activities: A community-based survey in urban southern India. Natl Med J India 2012; 25(1): 14-7.
- Sankar UV, Lipska K, Mini GK, Sarma PS and Thankappan KR: The adherence to medications in diabetic patients in rural Kerala, India. Asia-Pacific J Public Heal 2015; 27(2): 513-23.
- Subramani R, Devi U and Shankar U: Prevalence of undiagnosed type 2 diabetes and its associated risk factors in rural population of Tamil Nadu. World J Med Sci 2014; 11(2): 222-7.
- Patel M, Patel IM, Patel YM and Rathi SK: A Hospital-based Observational Study of Type 2 Diabetic Subjects from India. Indian J Clin Pract 2013; 24(2): 141-8.
- Mani MP: Impact of gender on care of type-2 diabetes in Varkala, Kerala Master of Public Health 2008; 52-60.
- Siddiqui MA, Khan MF and Carline TE: Gender differences in living with diabetes mellitus. Mat Soc Med 2013; 25(2): 140-2.
- Vijayan M, S GM, John G, Das SS, Pr R and Raghu R: A study on comorbidities and lifestyle associated with diabetes patients. Int Res J Pharm 2013; 4(5): 148–9.
- Arun KS and Rao CPDS: Study of management on comorbid conditions in type-2 diabetes mellitus. Adv Cell Sci Tissue Cult 2018; 2(1): 5-11.
- Vijayakumar G, Manghat S, Vijayakumar R, Simon L, Scaria LM, Vijayakumar A, Sreehari GK, Kutty VR, Rajana A and Jaleel A: Incidence of type 2 diabetes mellitus and prediabetes in Kerala, India: results from a 10-year prospective cohort. BMC Public Health 2019; 19(1): 140.
- Agrawal P, Ola V, Bishnoi P and Gothwal SK: Prevalence of micro and macrovascular complications and their risk factors in type-2 diabetes mellitus. J Assoc Physicians India 2014; 62: 504-8.
- Ramegowda LHC: Effectiveness of health education on knowledge and attitude regarding diabetes in Type II diabetes mellitus patients in Bengaluru. Natl J Community Med 2016; 7(7): 587-91.
- Kurian B, Qurieshi MA, Ganesh R and Leelamoni K: A community ‑ based study on knowledge of diabetes mellitus among adults in a rural population of Kerala. Int J Noncommunicable Dis 2016; 1(2): 59-64.
How to cite this article:
Zuhara NVF, Banu AT and Chokli N: Gender wise prevalence of comorbidities and medication adherence among type 2 diabetics in Malappuram. Int J Pharm Sci & Res 2019; 10(10): 4787-93. doi: 10.13040/IJPSR.0975-8232.10(10).4787-93.
All © 2013 are reserved by International Journal of Pharmaceutical Sciences and Research. This Journal licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.
N. V. F. Zuhara *, A. T. Banu and N. Chokli
Department of Home Science, KAHM Unity Women’s College, Manjeri, Kerala, India.
11 August 2019
24 September 2019
29 September 2019
01 October 2019