Diabetes mellitus is a disease of metabolic dysregulation, most notably abnormal glucose metabolism, accompanied by characteristic long-term complications [1]. Diabetes is one of the most prevalent chronic diseases. As of 2013, 382 million people have been suffering from diabetes worldwide [2]. Rate of diabetes is higher in the developing countries [3]. According to a survey carried out by the Diabetic Association of Pakistan prevalence of diabetes in Pakistan is around 10% [4]. According to World Health Organization (WHO) Pakistan is currently 8th in the world ranking of diabetes. Considering rising trend of diabetes prevalence it will become 4th by the year 2025 with nearly 14.3 million diabetics [5]. Diabetes resulted in 1.5 million deaths in 2012, making it the 8th leading cause of death. More than 80% of diabetic deaths occur in low and middle-income countries [6]. The increase morbidity rate of diabetes in developing countries is most likely due to trend of urbanization and lifestyle changes, including changes in dietary habits. This has suggested an environmental (i.e., dietary) effect, but there is little understanding of the mechanism as well [7]. Patient counselling is important in adequate management of diabetes mellitus. The ultimate goal of this counselling is to provide information directed at encouraging the safe and appropriate use of drugs, thereby enhancing therapeutic outcomes [8]. Diabetes management depends not only on drug therapy but also on physical exercise, diet, and other lifestyle changes. Several studies have confirmed that the complications of diabetes can be reduced by proper control of blood glucose. Patients’ understanding regarding disease improves when pharmacists provide them with useful, practical information [9-11]

Patient education is an important intervention for prevention of complications [12,13]. A study conducted in Nepal using the same procedure of KAP questionnaire it clearly indicates the need for educational interventions to improve the knowledge, attitude and practices of the diabetic patients [14].

Study design: Descriptive cross-sectional study.

Setting: Tertiary health care centres of twin cities (Rawalpindi and Islamabad) of Pakistan.

Respondent: Diabetic patients seeking health care from tertiary health care settings.

Ethical requirements: Consent was taken from the patients. Permission was granted by the ethical committee of The University of Lahore Islamabad campus.

Data collection tool: Structured questionnaires were administered to diabetic patients however questions were asked verbally to illiterate patients.

Tool validity: Focus group discussion and pilot testing were carried out to determine reliability of data collection tool.

Data analysis: Data was coded and analysed by SPSS (version 16). Descriptive statistics were applied to find frequency and chi square test was applied to determine the association between dependent and independent variables.

Sample technique and sample size: Five well known tertiary health care centres (public/ private) of Rawalpindi and Islamabad were visited from where patients were selected using convenient sampling technique. There were 250 diabetic patients conveniently selected who were seeking health care in outpatient department and diabetic clinics within tertiary health care hospitals during April to June, 2015.

In our study 250 diabetic patients were selected among which 63.6% (n=159) were male and rest of 36.4% (n=91) were female. Sociodemographic characteristics are shown in Table 1 and 2 Most of the patients had positive family history of diabetes (59% n=147) whereas 41% patients had no family history of disease.

Table 1: Socio demographic characteristics.

Table 2: Family history.

Knowledge regarding diabetes was assessed by asking questions given in Table 3. Only 35% (n=87) patients knew that diabetes is characterized by higher blood glucose level than normal. Majority of patients (36% n=90) characterized diabetes by increase urination. Knowledge regarding normal blood glucose level range was also assessed. Out of 250 patients only 35% (n=88) knew the normal range of blood glucose level rest of the patients were unaware as indicated in Table 3-5.

Table 3: Assessing knowledge of diabetic patients.

Table 4: Assessment of attitude of diabetic patients.

Table 5: Assessment of practice of diabetic patients.

Attitude and practice were also assessed as given in Table 4 and 5. Most of the patients didn’t know whether the medicine should be continued or not. Among rest of patients most of them thought that once the blood glucose level get normalized medicine should be stopped immediately. More than half of the studied patients (53%) were not following the planned diet. Only 30% (n=74) patients were practicing exercise regularly Table 6-14.

Table 6: Knowledge regarding normal blood glucose value among diabetic patients of different genders.

Table 7: Exercise practice among diabetic patients of different genders.

Table 8: Blood pressure monitoring practice among diabetic patients of different age groups.

Table 9: Knowledge regarding diabetic complication among diabetic patients of different educational status.

Table 10: Compliance to anti diabetic medication among diabetic patients of different educational status.

Table 11: Attitude regarding management of diabetes among diabetic patients of different educational status.

Table 12: Compliance to dietary modification among diabetic patients of different educational status.

Table 13: Dietary practice among diabetic patients of different educational status.

Table 14: Exercise practice among diabetic patients of different educational status.

Chi-square test was applied to determine association between variables (dependent and independent). Significant association was found between Gender and Knowledge (Table 6) Most of females didn’t know normal value of blood glucose level (P=0.001) and significant association was found between Gender and Exercise habit (P=0.023), i.e., females were less likely to follow exercise practice than males (Table 7). Moreover significant association was found between Age and B.P monitoring frequency (P<0.001). Diabetic patients between 12-25 ages monitored their last B.P value most recently, i.e., 1 week ago. Patients between 46-55 ages were more likely to take medicine regularly (Table 8). Patients who were more educated had better knowledge regarding disease aetiology, normal fasting blood glucose value, potential complications moreover they had regular exercise practice and better compliance to medication (Table 9-11,14). Education status appeared to be associated with positive attitude regarding disease management (P=0.004) and compliance to planned diet (P=0.04) (Table 12 and 13).

Lack of awareness among diabetic patients is the prime factor causing diabetic complications. Education and awareness regarding disease aetiology, risk factors, management, complications and life style modification should be provided to patients for achieving better outcome. The results also reflected the loopholes in our health care system regarding patients counselling. It highlighted the need for educational intervention such as public awareness programs regarding diabetes management. Moreover health care professionals need to be trained enough to provide counselling in effective manner.

Impact of education and counselling practices need to be assessed by conducting interventional studies in future. Moreover as data has been collected via questionnaire hence practice couldn’t be reliably assessed. In order to assess disease management practices of patients reliably, household data need to be collected in this regard. Large scale study should be conducted in order to design diabetes awareness program at national level.