Abstract

Introduction: The incidence of diabetes mellitus is increasing day by day for the past few decades.  The increased prevalence can be attributed to the low level of knowledge, appraisal and sedentary lifestyle. Objective: The objective of the study was to identify the major risk factors associated with development of coronary heart disease and appraisal of disease among diabetic patients in twin cities of Pakistan. Methodology: A descriptive cross-sectional study was used. The study respondents were diabetes patients. Heart Fact Questionnaire (HFQ) and Appraisal of Diabetes Questionnaire (ADS) were distributed to a sample of 382 diabetes patients. Mann Whitney and Kruskal Wallis tests (p ≥ 0.05) were used to found out difference among knowledge of risk factors and appraisal of disease with different demographic variables. Results: Most of the respondents 79.8 % (n=308) agreed that family history is a risk factor for developing heart disease. The results showed that 89.1 % (n=344) and 82.1 % (n=317) knew that high blood pressure and cholesterol are risk factors for heart disease, respectively. The results highlighted that 16.1 % (n=62) agreed that diabetes is extremely upsetting but only 1.8% (n=7) of the respondents had complete control over diabetes.Significant difference (p ≥ 0.05) in knowledge and disease appraisal among diabetes patients was observed among patients with different level of qualification and duration of disease. Newly diagnosed patients and those with better qualification levels had relatively better knowledge and disease appraisal. Conclusion: The current study concluded that the knowledge regarding risk factors and disease appraisal was good. Patients who had higher qualification had higher disease appraisal. Age, gender, income level and duration of treatment had no impact on disease appraisal. 

Introduction:

Diabetes mellitus and Coronary heart disease (CHD) are closely linked to each other. The most common cause of increased morbidity and mortality in diabetics is due to coronary heart disease. The death rate is higher in patients diagnosed with both diabetes and coronary vessel disease (CVD) than those only diagnosed with CVD . Diabetes had been considered to be a foremost risk factor for coronary heart disease. It is considered as the major

risk factor in elderly. The burden of both diabetes and CHD is growing substantially, particularly more among women . It has been concluded that the risk of atherosclerosis increases 2 to 3 times in patients diagnosed with diabetes mellitus. The risk of macro vascular complications is twice more than that of micro vascular disease among type 2 diabetes patients in United Kingdom. Smoking, hypertension and high cholesterol levels among diabetes patients have been classified as the major risk factors leading towards coronary heart disease . Patients with diabetes have high chances of developing CHD with a more severe prognosis than the first CHD attack. It is necessary to design interventions to screen high risk patients and treat them effectively in order to lower the mortality and financial burden of the patient . The degree of disease appraisal and ability to cope with disease stress affect control of disease. Appraisal of chronic diseases can lead to better emotional management as increased control of disease . Self-management behaviors can be predicted by understanding individual diabetes appraisal. Appraising diabetes as a challenge is associated to diet adherence. Diabetes-related distress is linked with self-management, and behaviors differ due to type of appraisal .

The incidence of diabetes is increasing in Pakistan and is estimated to be at 6.9%. Pakistan has been ranked 7th in the world in terms of diabetes prevalence . Diabetes has been considered as one of the fundamental risk factors for coronary heart disease. Hyperglycemia has been reported to be responsible for increased risk of coronary heart diseases in Pakistan . A study conducted in Karachi concluded that hypertension, diabetes, obesity and smoking were the major threats found in ambulatory patients suffering from heart diseases . Chronic diseases such as diabetes and hypertension serve as major risk factors for development of coronary heart disease. A study conducted in Peshawar concluded hypertension and diabetes as the major risk factors among individuals hospitalized for treatment of Coronary Artery Disease . Another study concluded that age, physical inactivity, hypertension and diabetes contribute to the increased prevalence of coronary heart disease. Females had higher chances of developing CAD as the prevalence of diabetes was high in them . Timely appraisal of diabetes is necessary for preventing complications. Appraisal of diabetes by patients leads to better self-care practices and better management of hyperglycemia. A study conducted in Lahore concluded that patients who had better self-management through diet reported to experience less diabetic distress and emotional distress . Due to the social stigma, individuals diagnosed with diabetes do not start the therapy prescribed by the healthcare professionals timely. This further aggravates the disease leading to complications such as coronary heart disease. Thus, the present study was designed to identify the major risk factors associated with development of coronary heart disease and appraisal of disease among diabetic patients in Pakistan.

Methodology:

A descriptive cross-sectional study design was used to identify the major risk factors associated with development of coronary heart disease and appraisal of disease among diabetic patients in twin cities of Pakistan. Approval was obtained for the study from the Ethical Committee of Hamdard University (ref no 732). Beside this, approval was also taken from respective authorities of different health care facilities from where data was collected. Consent for participation, informed as well as verbal, was taken from respondents. Study sites for this research included public and private tertiary health care facilities and diabetes clinics located in twin cities of Pakistan. The study respondents included diabetes patients above 18 years of age, both genders and persons who could easily read and write. Any patient having co morbidity or taking drug that can affect blood glucose levels were excluded from the study.

Raosoft® sample size calculator was used for calculation of sample size. Sample size was calculated to be 382 patients to achieve 95% confidence level with 5% margin of error. Convenient sampling technique was used to select respondents present at the time of data collection.

Two different pre validated tools were used for collecting data regarding knowledge of coronary heart disease as risk factor and appraisal of disease among diabetes patients. Written permission had been obtained from the respective organization for using the tools. A pre-validated data collection tool Heart Fact Questionnaire (HFQ) was used to identify the risk factor related to coronary heart disease .This is a 25-item questionnaire which includes questions related to awareness regarding risk factors associated to coronary heart disease and its preventive strategies among diabetes patients. Nominal scale composed of true and false was used. The score assigned for correct answer was “1” and “2” for incorrect. Lower score showed better knowledge regarding associated risk factors with coronary heart diseases. On the other hand Appraisal of Diabetes Questionnaire (ADS) was used to measure the appraisal of disease among diabetes patients. The questionnaire consists of seven items. Liker scale is used for options. Reverse scoring is used for items # 2 and 6. Then composite score is calculated. Lower score indicates more positive appraisal strategy. Pilot testing was conducted at 10% of sample after data collection. The value of Cronbach's alpha was 0.79 for Heart Fact Questionnaire (HFQ) and 0.69 for Appraisal of Diabetes Questionnaire (ADS) which was satisfactory considering that 0.68 is the acceptable cut off value.

The questionnaires were hand delivered to the respondents and to minimize biasness were collected back on the same day. SPSS version 21 was used for statistical analysis after cleaning and coding of the data. Descriptive statistics comprising of frequency and percentages were calculated. Mann Whitney and Kruskal Wallis (p ≥ 0.05) was used to found out difference in knowledge of risk factors and appraisal of disease with different demographic variables.

Results:

Out of 382 respondents, 43.8 % (n=169) were females while 55.2 % (n=213) were males. The age groups of respondents were: 25y-35y (n=28, 7.3 %), 35y-45y (n=107, 27.7 %), 45y-55y (n=125, 32.4%) and 55y-65y (n = 112, 31.6 %). Nearly ninety six percent of the respondents were married. The qualification status of the respondents was: matriculation (n=86, 22.3 %), intermediate (n=80, 20.7%), graduate (n=133, 34.5 %) and post graduates (n=78, 20.4%). Out of the total respondents the newly diagnosed patients were 11.5% (n=44), patients with 1year of disease were 12.7 % (n=49), 1-5years were 31.1 % (n=120) and 6-10years were 43.8 % (n=169). A detail description is given ( Table 1 ).

Table 1 Demographic Characteristics

Indicator n (%)
Gender Male 213 (55.2)
Female 169 (43.8)
Age 25 - 35 Y 28 (7.3)
35 - 45 Y 107 (27.7)
45 - 55 Y 125 (32.4)
55 - 65 Y 122 (31.6)
Marital Status Married 369 (95.6)
Un Married 13 (3.4)
Qualification Matriculation 86 (22.3)
Intermediate 83 (21.5)
Post Graduate 80 (20.7)
Graduate 133 (34.5)
Income Rs 20,000 11 (2.9)
Rs 21 - 35,000 67 (17.4)
Rs 35 - 50,000 176 (45.6)
Rs 50,000 - 80,000 131 (33.9)
Duration of Disease Newly Diagnosed 44 (11.4)
1 Year 49 (12.7)
1 - 5 Year 120 (31.1)
6 - 10 Year 169 (43.8)
Duration of Disease Newly Diagnosed 44 (11.4)
1 Year 49 (12.7)
1 - 5 Year 120 (31.1)
6 - 10 Year 169 (43.8)
Duration of Treatment 1 Year 101 (26.2)
1 - 5 Year 127 (32.9)
6 - 10 Year 79 (20.7)
> 10 Years 75 (19.4)

8 % (n=308) agreed that family history is a risk factor for developing heart disease The results showed that 891 % (n=344) and 821 % (n=317) knew that high blood pressure and cholesterol are risk factors for heart disease, respectively More than half of the respondents 605 % (n=239) thought that good cholesterol, 78 % (n=301) thought bad cholesterol while 839 % (n=324) knew diabetes are the risk factors associated with developing heart disease Most of the respondents 697 % (n=269) agreed that high sugar put strain on the heart More than half of the respondents 565 % (n=218) believed that men with diabetes have higher risk for heart diseases than women ( Table 2)

Table 2 Knowledge Regarding Risk factors associated with Coronary Heart Disease among Diabetes Patient in Pakistan

Risk Factors for Heart Disease Correct n (%) Incorrect n (%)
 Family history 308 (79.8) 74 (19.2)
 Smoking 300 (77.7) 82 (21.2)
 High blood pressure 344 (89.1) 38 (9.8)
 High cholesterol 317 (82.1) 65 (16.8)
 "Good" cholesterol (HDL) 235 (60.9) 147 (38.1)
 "Bad" cholesterol (LDL) 301 (78.0) 81 (21.0)
Obesity 321 (83.2) 61 (15.8)
 Diabetes 324 (83.9) 58 (15.0)
High blood sugar puts a strain on the heart 269 (69.7) 113 (29.3)
Controlled blood sugar levels can reduce risk of heart disease 277 (72.5) 102 (26.7)
 Men with diabetes have a higher risk of heart disease than women with diabetes 218 (56.5) 164 (42.5)

9 % (n=262) agreed that person always knows when they have heart disease Of the total respondents, 762 % (n=294) agreed that the older a person is at greater their risk of having heart disease, 715% (n=276) agreed that   person who stops smoking will lower their risk of developing heart disease and 889 % (n=343) agreed that keeping blood pressure under control can reduce a person's risk for developing heart disease Out of 382 respondents, 736 % (n=284) agreed that eating fatty foods does not affect blood cholesterol levels, 723 % (n=279) believed that regular physical activity can lower a person's chance of getting heart disease while 689 % (n=266) were of the view that only exercising at a gym or in an exercise class will help lower a person's chance of developing heart disease On the other hand, 762 % (n=294) of the respondents, agreed that if blood glucose level is high it can cause cholesterol level to go up and increase risk of heart disease, 707 % (n=273) agreed that people with diabetes tend to have low HDL (good) cholesterol and 855 % (n=330) knew that if a person has diabetes, keeping their cholesterol under control will help to lower their chance of developing heart disease ( Table 3)

Table 3 Knowledge Regarding Preventive Strategies associated with Coronary Heart Disease among Diabetes Patient in Pakistan

Indicator Correct n (%) Incorrect n (%)
A person always knows when they have heart disease. 262 (67.9) 120 (31.1)
 The older a person at greater risk of having heart disease 294 (76.2) 88 (22.8)
 A person who stops smoking will lower their risk of developing heart disease. 276 (71.5) 106 (27.5)
 Keeping blood pressure under control will reduce a person's risk for developing heart disease. 343 (88.9) 39 (10.1)
 Eating fatty foods does not affect blood cholesterol 284 (73.6) 98 (25.4)
 Regular physical activity will lower a person's chance of getting heart disease. 279(72.3) 103(26.7)
 Only exercising at a gym or in an exercise class will help lower a person's chance of developing heart disease. 266 (68.9) 116 (30.1)
 Walking and gardening are considered exercise that will help lower a person's chance of developing heart disease. 323 (83.7) 59 (15.3)
 If your blood sugar is high over several months it can cause your cholesterol level to go up and increase your risk of heart disease. 294 (76.2) 87 (22.5)
 People with diabetes rarely have high cholesterol. 250 (64.8) 132 (34.2)
Diabetes patient keeping their cholesterol under control will help to lower their chance of developing heart disease. 282 (73.1) 99 (25.6)
People with diabetes tend to have low HDL (good) cholesterol. 273(70.7) 109 (28.2)
 A person who has diabetes can reduce their risk of developing heart disease if they keep their blood pressure under control. 330 (85.5) 52 (13.5)
 A person who has diabetes can reduce their risk of developing heart disease if they keep their weight under control. 295 (76.4) 86 (22.3)

1 % (n=62) agreed that diabetes is extremely upsetting but only 18% (n=7) of the respondents had complete control over diabetes Most of the respondents 683 % (n = 261) accepted to have uncertainty in their lives due to diabetes, 675 % (n=258) were extremely likely to have worsen control over their diabetes in coming years while 612 % (n=234) believed that good diabetic control is partially due to their will and partially because of other factors On the other hand, only 179 % (n=69) of the respondents agreed that they were extremely effective in coping their diabetes and 91 % (n=35) agreed that diabetes do not affect their life goals at all ( Table 4)

Table 4 Disease Appraisal among Diabetes Patients in Pakistan

Indicator n (%)
How upsetting is having diabetes for you? Upsetting  Not at all 7 (1.8)
 Slightly upsetting 57 (14.8)
 Moderately upsetting 115 (29.8)
 Very upsetting 141 (36.5)
 Extremely upsetting 62 (16.1)
How much control over your diabetes do you have? Control  Not at all 24 (6.2)
 Slight amount 65 (16.8)
 Moderate amount 162 (42.0)
 Large amount 124 (32.1)
 Extremely large amount 7 (1.8)
How much uncertainty do you currently experience in your life as a result of being diabetic?  Not likely at all 10 (2.6)
 Slightly likely 98 (25.4)
 Moderately likely 170 (44.0)
Very Extremely likely 91 (23.6)
How likely is your diabetes to worsen over the next several years?    Not likely at all 4 (1.0)
 Slightly likely 120 (31.1)
 Moderately likely 175 (45.3)
 Very extremely likely 83 (21.5)
Achieving good diabetic control is due to your efforts as compared to factors which are beyond your control?    Totally because of me 10 (2.6)
 Mostly because of me 138 (35.8)
 Partly because of me 194 (50.3)
 Mostly of other factors 40 (10.4)
How effective are you in coping with your diabetes?  Not likely at all 12 (3.1)
 Slightly likely 118 (30.6)
 Moderately likely 183 (47.4)
Very Extremely likely 69 (17.9)
To what degree does your diabetes get in the way of your developing life goals? Not at all 35 (9.1)
Slightly amount 185 (47.9)
Moderate amount 158 (40.9)
Large amount 14 (3.7)
Extremely large amount 3 (0.8)

05) in knowledge and disease appraisal among diabetes patients was seen among different genders, age groups and marital status However, significant difference (p ≥ 005) in knowledge and disease appraisal among diabetes patients was observed among patients with different level of qualification and duration of disease Newly diagnosed patients and those with better qualification levels had relatively better knowledge and disease appraisal ( Table 5)

Table 5 Knowledge and Disease Appraisal among Diabetes Patients according to Different Demographic characteristics

Variables Knowledge regarding Risk factor Disease Appraisal
n Mean Score Test Statistic P-value n Mean Score Test Statistics P-value
Gender Male = 213 Female = 169 Male = 189.86 Female = 189.05 17564.0 a 0.476 Male = 213 Female = 169 Male = 196.41 Female = 184.22 16768.00 0.138
Age 25 - 35 Y = 28 35 - 45 Y = 107 45 - 55 Y = 125 55 - 65 Y = 122 25 - 35 Y = 181.65 35 - 45 Y = 196.91 45 - 55 Y = 189.42 55 - 65 Y = 184.80 0.865 b 0.836 25 - 35 Y = 28 35 - 45 Y = 107 45 - 55 Y = 125 55 - 65 Y = 122 25 - 35 Y = 162.82 35 - 45 Y = 183.39 45 - 55 Y = 208.66 55 - 65 Y = 186.01 5.926 0.115
Marital Status Married = 369 Un Married = 13 Married = 190.49 Un Married = 161.23 2010.00 a 0.167 Married = 369 Un Married = 13 Married = 194.2 Un Married = 194.8 2347.500 0.451
Qualification Matriculation = 86 Intermediate = 83 Post Graduate = 80 Graduate = 133 Matriculation = 161.58 Intermediate = 199.62 Post Graduate = 206.10 Graduate = 181.87 9.923 b 0.020 Matriculation = 86 Intermediate = 83 Post Graduate = 80 Graduate = 133 Matriculation = 181.39 Intermediate = 202.64 Post Graduate = 174.79 Graduate = 216.01 8.74 0.031
Duration of disease Newly Diagnosed = 44 1 Year = 49 1 - 5 Year = 120 6 - 10 Year = 169 Newly Diagnosezd = 209.61 1 Year = 214.06 1 - 5 Year = 186.25 6 - 10 Year = 179.23 5.64b 0.152 Newly Diagnosed = 44 1 Year = 49 1 - 5 Year = 120 6 - 10 Year = 169 Newly Diagnosed = 178.47 1 Year = 242.02 1 - 5 Year = 184.62 6 - 10 Year = 183.21 12.62 0.005

05)

Discussion:

Globally the prevalence of diabetes is increasing at an alarming rate. Uncontrolled diabetes is considered to be a chief risk factor for progression of coronary artery disease. Knowledge of risk factors and preventive strategies as well as appraisal of disease can lower the risk of developing cardiovascular disease . The results of the current study highlighted that respondents had

adequate knowledge regarding risk factors of coronary heart disease. Majority of the respondents agreed that family history is one of the risk factors leading to coronary heart disease. More than half of the respondents agreed that hypertension and diabetes can lead to coronary heart disease. The results of the present study highlighted that majority of the respondents agreed that high cholesterol and glucose levels can contribute to development of coronary heart diseases. This might be due to the fact that healthcare providers are effectively counseling patients regarding their disease in order to reduce the complications. The results of the study are in line with another study conducted in Oman where respondents considered smoking, diabetes, hypertension and age as major risk factors for development of CHD .

Poor knowledge regarding risk factors can lead to decreased ability of patients to perform self-care activities. The results of the current study highlighted that half of the respondents were of the view that high levels of HDL can cause coronary heart disease. This might be due to the fact that patients have low health literacy levels and are unable to understand their disease. Similar results were observed in a study conducted in Australia where poor knowledge regarding CHD risk factors was reported among diabetics .

The increased awareness of preventive strategies of coronary heart diseases is important owing to the increased prevalence of chronic diseases such as diabetes and hypertension. The results of the current study highlighted that majority of the respondents agreed that increasing age can contribute to development of coronary heart disease. Majority of the respondents agreed that patients can recognize the sign and symptoms of heart disease. Majority of the individuals were of the view that smoking cessation can also help in reducing the chances of coronary heart disease. Similar results were reported from another study . The results of the present study showed that majority of the respondents were of the view that intake of fatty foods does not affect cholesterol levels. Majority of the respondents agreed that only vigorous exercise can lower the chances of developing coronary heart disease. Majority of the respondents agreed that cholesterol levels do not rise due to diabetes and HDL levels remain normal in such patients. Similar results were observed in a study conducted in Nigeria where knowledge regarding prevention of risk factors was poor .

Timely appraisal of the disease can led to better outcomes and quality of life. The results of the present study highlighted that the disease appraisal among diabetics was poor. The results of the current study showed that majority of the respondents found the diagnosis of diabetes upsetting. Majority of the respondents agreed that they had only moderate control over diabetes. Similar results were observed in a study conducted in Malaysia . Majority of the individuals agreed that their diabetes could worsen over time. The results of the study highlighted that majority of the individuals agreed that the control of diabetes is achieved mostly due to other factors and partially because of the patient themselves. The results of the current study showed that majority of the respondents were of the view that they could moderately control their diabetes. Similar results were observed in a study conducted in Brazil where disease appraisal among diabetics was low .

Conclusion:

The current study concluded that the knowledge regarding risk factors and disease appraisal was good. Patients having higher qualification had higher disease appraisal. Age, gender, income level, duration of disease and duration of treatment had no impact on disease appraisal. Appropriate screening and cardiac testing should be conducted. Assessment of parental and patients information regarding primary prevention of cardiovascular disease at intermediate risk must be performed.

References: