Glycaemic control in native Kuwaiti Arab patients with type 2 diabetes

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Contents lists available at ScienceDirect

Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd

Original research

Glycaemic control in native Kuwaiti Arab patients with type 2 diabetes Arshad M. Channanath, Jaakko Tuomilehto, Thangavel Alphonse Thanaraj ∗ Dasman Diabetes Institute, P.O. Box 1180, Dasman 15462, Kuwait

a r t i c l e

i n f o

a b s t r a c t

Article history:

Aims: To evaluate the influence of age at diabetes diagnosis, diabetes duration, BMI, comor-

Received 16 May 2018

bidity with hypertension and medication regimen on glycaemic control in native Kuwaiti

Received in revised form

Arab patients with T2D.

28 June 2018

Methods: This cross-sectional study considered 7657 patients from Kuwait Diabetes Registry

Accepted 23 July 2018

and analysed data from their laboratory and hospital records.

Available online xxx

Results: HbA1c and prevalence of hypertension increased significantly with diabetes duration. Duration of diabetes (ˇ = 0.034; P < 0.001) and age at diagnosis (ˇ = −0.03; P < 0.001) were

Keywords:

independently associated with HbA1c. Inadequate glycaemic control was more likely in

Glycaemic

patients diagnosed at <60 than in those ≥60 years of age (OR:1.80, 95%–CI:1.39–2.31). Increas-

Hypertension

ing duration of diabetes witnessed decrease in metformin prescription and increase in

Metformin

sulfonylureas prescription; proportion of patients treated with insulin increased from 5.6% to 44.4% in 9 years of diagnosis. Patients with 9-years duration of diabetes or with combination therapy of insulin–metformin–sulfonylureas differed in mean BMI for adequate or inadequate glycaemic control (29.5 versus 31.2 kg/m2 ; P < 0.001 and 29.8 versus 33.2; P < 0.01, respectively). Conclusions: Only 25.6% of the T2D patients in this ethnic cohort exhibited adequate glycaemic control. The delineated relationship of inadequate glycaemic control with diabetes duration, onset age, obesity and hypertension prevalence has a bearing on diabetes management programs for Arabs. © 2018 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

1.

Introduction

Diabetes is highly prevalent and has high health and economic burdens [1]. The global epidemic of diabetes has not

∗

spared the countries of Arabian Peninsula. The oil-producing Gulf countries, including the state of Kuwait, have experienced rapid socioeconomic transitions over the past few decades of post-oil era. Rapid urbanisation and economic growth have resulted in improved access to modern healthcare and education but have negatively impacted the lifestyle with an increased sedentary behaviour and a shift of eating patterns towards the Western diet [2]. The lifestyle changes have led

Corresponding author. E-mail address: [email protected] (T.A. Thanaraj). https://doi.org/10.1016/j.pcd.2018.07.009 1751-9918/© 2018 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: A.M. Channanath, et al., Glycaemic control in native Kuwaiti Arab patients with type 2 diabetes, Prim. Care Diab. (2018), https://doi.org/10.1016/j.pcd.2018.07.009

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to increased obesity [3,4], which affects an estimated 36% of men and 48% of women in Kuwait [5]. Obesity is considered to contribute to the high prevalence of diabetes in Kuwait [6,7]. The microvascular and macrovascular complications of diabetes can be reduced by effective management with prescription drugs [8,9], dietary interventions and adequate physical activity. Effective glycaemic control is essential for the successful management of diabetes, but the published evidence indicates that glycaemic control is suboptimal in many regions [1] including the Middle East [8,10,11]. Inadequate glycaemic control leads to prolonged periods of hyperglycaemia that increase the risk of serious complications of diabetes. Studies conducted in diverse populations have described factors that affect the success of diabetes treatment. Many therapeutic options are available, but achieving glycaemic targets is complicated by a complex interplay among factors that negatively affect the outcome [1]. Negative attitudes towards diabetes, health beliefs and religious beliefs that influence lifestyle, lack of educational programmes that emphasise the importance of lifestyle modification and the presence of comorbidities are all involved [12–15]. Few investigations of diabetes management have been conducted in Arab populations. This study evaluated glycaemic control in Kuwaitis of Arab ethnicity diagnosed with type 2 diabetes and the influence of age, age at diagnosis, duration of diabetes, sex, body mass index (BMI), the presence of hypertension and the medication regimen.

HbA1c level was used to assess the extent of glycaemic control in our study. The guidelines from American Diabetes Association suggests the adequate control target for HbA1c as ≤7.0% (53 mmol/mol) [19]. Thus, in our study a value of ≥7% (≥53 mmol/mol) for HbA1c indicated inadequate glycaemic control.

2.

Materials and methods

2.5.

2.1.

Ethical statement

Statistical analysis was performed with R (the R Project for Statistical Computing http://www.r-project.org/). P-values <0.05 were statistically significant. Continuous data were reported as mean ± standard deviation, and categorical data were reported as numbers and percentages. Comparison of group means was by two-tailed t-tests. Chi-square tests were used to compare differences in categorical variables. Multiple linear regression was used to evaluate the effects of patient variables on the HbA1c level.

The study was approved by the International Scientific Advisory Board and Ethics Advisory Committee at Dasman Diabetes Institute, Kuwait. Access to data from the Kuwait Health Network was approved by the Ethical Review Committee at Dasman Diabetes Institute.

2.2.

Participants

Cross-sectional data on native Kuwaiti Arabs with type 2 diabetes were retrieved from the Kuwait Health Network (KHN), which is an initiative of the Dasman Diabetes Institute in collaboration with the Ministry of Health (MOH) and the Public Authority of Civil Information (PACI) [16]. The network integrates data from primary care centres and laboratory data from the MOH hospitals across Kuwait using patient-unique national identification numbers provided by PACI for all residents. The cross-sectional data extracted from the KHN registry contained information on age, sex, age at diagnosis, duration of diabetes, HbA1c measurements and diagnosis for hypertension from 7657 patients registered till July 2012. BMI measurements were available for 4599 of these patients; 3068 of these patients also had data on prescribed glucose lowering drugs; and 1667 patients had data on all the features (age at diagnosis, duration of diabetes, medications, BMI and HbA1c levels). The impact of these patient characteristics on glycaemic control was analysed.

2.3.

Medication use

Glucose lowering drugs for managing diabetes used in primary health care in Kuwait are as listed below. Metformin is the most commonly prescribed oral anti-diabetes agent. It is the first-line oral medication recommended for glycaemic control [17]. Sulfonylureas are prescribed as a second-line medication after metformin and are effective only if residual pancreatic ␤-cells are present [18]. Insulin is prescribed when the pancreatic ␤-cells have become non-functional. It is prescribed to patients with type 1 diabetes and to those with type 2 diabetes when the lifestyle interventions (change in diet and physical activity), together with the use of oral glucose lowering drugs do not sufficiently improve glycaemic control. The data set does not include prescriptions for the medication of DPP-4 and SGLT2 inhibitors as use of DPP-4 in countries other than USA and EU was approved after 2011 and that of SGLT2 was approved after 2013.

2.4.

3.

Standards

Statistical analysis

Results

The characteristics and descriptive statistics of participants with adequate and inadequate glycaemic control are shown in Table 1. Nearly three-fourths (74.4%) of the patients had inadequate glycaemic control (HbA1c ≥ 7.0%). The duration of diabetes was longer (9.8 and 6.2 years; P < 0.001) and the age at diagnosis was younger (47.5 and 50.3 years; P < 0.001) in patients with inadequate glycaemic control than in those with adequate control. Multiple linear regression revealed that duration of diabetes (ˇ = 0.034; P < 0.001) and age at diagnosis (ˇ = −0.03; P < 0.001), but not hypertension status or sex, were independently associated with HbA1c level. When the study cohort was stratified by age at diagnosis of diabetes (<60 versus ≥60 years), the proportion of patients with inadequate glycaemic control was greater in the younger than in the older subgroup (81.8% versus 70.3%, P < 0.001). Since the situation of pancreatic reserve at the time of diagnosis was not known, the observation of inadequate control associated with

Please cite this article in press as: A.M. Channanath, et al., Glycaemic control in native Kuwaiti Arab patients with type 2 diabetes, Prim. Care Diab. (2018), https://doi.org/10.1016/j.pcd.2018.07.009

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Table 1 – Descriptive statistics of participants with adequate versus inadequate glycaemic control.

Patients, n (%) Age at diagnosis (years) Duration of diabetes (years) BMI (kg/m2 ) Overweight patients (BMI ≥ 25 & <30 kg/m2 ), n (%) Obese patients (BMI ≥30 kg/m2 ), n (%) Male patients, n (%) Hypertensive patients, n (%)

younger age at the onset of diabetes needs to be further clarified from the standpoint of diabetes duration from diagnosis to the day of assessing the glycaemic control. Upon examining the duration of diabetes in patients with age at diagnosis <50 or ≥50 years, and <60 or ≥60 years, it was found that the <50 onset age group or <60 onset age group showed significantly longer duration of diabetes when compared to the ≥50 and ≥60 age groups; the observed durations of diabetes in the <50 versus ≥50 debut age groups were 11.3 years versus 8.2 years (p < 0.001); and in the <60 versus ≥60 debut age groups were 10.4 years versus 7.3 years (p < 0.001). Thus, duration was a potential confounder in the model for associating the extent of glycaemic control with age at onset. After correction for sex, hypertension status, medications used and duration of diabetes, participants <60 years of age at diagnosis remained at significantly increased odds of inadequate glycaemic control (OR 1.80, 95% CI 1.39–2.31). When the stratification threshold was reduced to 50 years of age at diagnosis, the OR was still significant (OR 1.3, 95% CI 1.1–1.6). The mean HbA1c increased with the duration of diabetes (Table 2). In the first 3 years after diagnosis, about 40% of patients had adequate glycaemic control. The proportion of patients with adequate control decreased in subsequent years, with only 14% having adequate control 9 years after diagnosis. The prevalence of hypertension increased with the duration of diabetes, from 40% in the first year after diagnosis to 67% in 7–9 years. Most patients (74%) were treated with only oral glucose lowering drugs, 11% were treated with insulin alone, and the remaining 15% were treated with combinations of oral drugs and insulin. Patients on insulin monotherapy had the highest mean HbA1c of ≥9.5%, those with sulfonylureas monotherapy had a mean HbA1c of approximately 9.0, and those with metformin monotherapy had a mean HbA1c level of <8.0. Combination therapy was often associated with higher HbA1c levels and a higher prevalence of hypertension. Metformintreated patients had the best glycaemic control, with 34% of those on metformin monotherapy achieving the target HbA1c level (see Table 3). Metformin was the first-line oral glucose lowering medication in the first year of diagnosis, prescribed to 75% of the patients. The percentage decreased considerably with duration whereas the combination therapy of metformin with other drugs increased (Table 4). Sulfonylureas as monoand combined therapy increased from 13.7% of the monotherapy prescriptions in the first year to diagnosis 20.3% at 4 years. Prescription of insulin mono- or combination therapy increased gradually with duration of diabetes and was 44% after 9 years from diagnosis.

HbA1c < 7%

HbA1c ≥ 7%

1957 (25.6) 50.3 ± 12.1 6.2 ± 6.7 31.5 ± 6.4 326 (32.3) 574 (56.9) 812 (41.5) 1134 (58.0)

5700 (74.4) 47.5 ± 11.1 9.8 ± 8.0 31.80 ± 6.2 1059 (29.5) 2186 (60.9) 2555 (44.8) 3432 (60.2)

P-value <0.001 <0.001 0.16 0.09 0.03 0.01 0.08

Patients with adequate or inadequate glycaemic control did not differ in the mean BMI at baseline (P = 0.16, Table 1); however, significant differences were seen between the two groups when only the patients with a duration of >9 years (since diagnosis) were considered (29.5 versus 31.2 kg/m2 , respectively; P < 0.001, Table 2). Patients who had adequate glycaemic control had lower BMI than those who had inadequate control in the groups receiving combination therapy of insulin-sulfonylureas (mean BMI at 26.9 versus 31.4; p < 0.001) or of insulin–metformin–sulfonylureas combination (mean BMI at 29.8 versus 33.2; p < 0.01). Also patients treated with metformin monotherapy had lower BMI among those who had achieved adequate glycaemic control than those with inadequate control (Table 5).

4.

Discussion

Glycaemic management of Kuwaiti native Arabs, as seen in many other countries [2–5], was suboptimal. Overall, only 25.6% of the type 2 diabetes patients in this cohort were adequately controlled. When ADA’s less stringent HbA1c goal of <8% was used, 48.1% of patients were adequately controlled. Patients diagnosed when they were younger than 50 or 60 years of age had inadequate glycaemic control (ORs of 1.80 and 1.30, respectively — with the model corrected for sex, hypertension status, medications used and duration of diabetes) of poor control compared with those diagnosed at an older age. As patients who are younger at diagnosis have fewer comorbidities and complications, it is possible to offer aggressive and individualised treatment to this this higherrisk group [20,21]. Deterioration of glycaemic control occurred with increasing years since diagnosis. As type 2 diabetes is a progressive disease, interventions that initially achieve glycaemic targets are likely to be inadequate within subsequent years [22]. This decline in glycaemic control is usually associated with progressive loss of ␤-cell function [23]. The risk of diabetes-associated complications also increases with the duration of disease and other factors such as age and age at diagnosis contribute to the risk [24,25]. Early lifestyle interventions and pharmacological management are essential. Overweight and obesity have been associated with inadequate glycaemic control [26], The mean BMI in patients prescribed with insulin–sulfonylureas or insulin–metformin–sulfonylureas or in patients with duration of diabetes >9 years with adequate and inadequate glycaemic control differed significantly. The Kuwaiti population has a high prevalence of obesity [27]. The mean BMI of the study cohort was 32 kg/m2 . Obesity and physical inactivity are

Please cite this article in press as: A.M. Channanath, et al., Glycaemic control in native Kuwaiti Arab patients with type 2 diabetes, Prim. Care Diab. (2018), https://doi.org/10.1016/j.pcd.2018.07.009

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Table 2 – Assessment of age at diagnosis, BMI, HbA1c, extent of adequate glycaemic control and prevalence of hypertension in patients over the duration of 9 years since diagnosis of diabetes. Years after diagnosis

Patients (n)

Mean age at diagnosis (years)

Mean BMI (kg/m2 ) of all the patients, and (of patients with adequate versus inadequate control)

Mean HbA1c (%)

Extent of adequate glycaemic control (HbA1c <7%)

Extent of Hypertension in all the patients, and (in patients with adequate versus inadequate control)

First year

1275

50.4 ± 11.5

32.3 ± 6.3 (32.2 ± 6.4, 32.3 ± 6.2)

7.9 ± 2.0

39.5%

39.8% (44.0%, 37.1%)

1–3

864

50.1 ± 11.5

33.0 ± 5.8 (33.2 ± 5.9, 32.9 ± 5.8)

7.8 ± 1.7

38.4%

50.8% (52.0%, 50.1%)

4–6

1338

49.7 ± 11.1

32.2 ± 6.6 (32.1 ± 6.9, 32.2 ± 6.4)

8.1 ± 1.9

30.3%

57.8% (60.3%, 56.7%)

7–9

1604

50.1 ± 11.1

32.0 ± 6.2 (31.5 ± 6.5, 32.1 ± 6.1)

8.6 ± 2

22.2%

67.2% (66.3%, 67.5%)

>9

2576

44.7 ± 10.9

31.0 ± 6.1 (29.5 ± 5.8, 31.2 ± 6.1)

9.0 ± 2

13.9%

68.6% (72.1%, 68.1%)

Table 3 – Extent of glycaemic control and hypertension prevalence in patients administered with different medication regimen. Medication

Patients, n

Mean HbA1c (%)

Extent of adequate glycaemic control (HbA1c < 7%) in patients

Extent of Hypertension in patients

Insulin Metformin Sulfonylurea Insulin and metformin Insulin and sulfonylureas Metformin and sulfonylureas Insulin, metformin and sulfonylurea

345 809 637 167 127 817 166

9.6 ± 2.0 7.8 ± 1.5 8.9 ± 2.1 9.5 ± 2.1 9.3 ± 2.0 8.8 ± 1.9 9.5 ± 2.2

10.4% 34.0% 17.9% 10.8% 8.7% 15.7% 8.4%

66.4% 58.3% 65.5% 75.4% 65.4% 71.5% 74.1%

Table 4 – Variations in proportion of patients administered with different types of medication over a period of 9 years since diagnosis. Medication

Metformin Sulfonylureas Insulin Insulin–metformin Insulin–metformin–sulfonylureas Insulin–sulfonylureas Metformin–sulfonylureas

Proportion of patients administered with the medication in First year

1–3 years

4–6 years

7–9 years

75.2% 13.7% 3.1% 0.0% 0.6% 1.9% 5.6%

60.7% 19.5% 1.5% 1.9% 0.0% 0.7% 15.7%

43.7% 20.3% 2.6% 1.7% 1.5% 1.9% 28.2%

24.7% 21.8% 5.8% 3.1% 5.4% 2.7% 36.5%

>9 years 8.5% 21.4% 20.0% 9.3% 8.5% 6.6% 25.6%

Table 5 – BMI comparisons between patients with adequate or inadequate glycaemic control under different medications. BMI (kg/m2 )

Medication

Insulin Sulfonylurea Metformin Insulin–metformin–sulfonylureas Insulin–sulfonylureas Insulin–metformin Metformin–sulfonylureas

Adequate glycaemic control

Inadequate glycaemic control

30.0 ± 5.5 31.0 ± 6.9 30.6 ± 5.2 29.8 ± 3.9 26.9 ± 1.6 35.9 ± 7.3 31.5 ± 7.2

32.7 ± 6.5 30.1 ± 5.6 31.8 ± 6.1 33.2 ± 6.0 31.4 ± 4.7 34.0 ± 5.9 31.8 ± 6.1

more prevalent in Kuwaiti adults with, than in those without, diabetes, and it is estimated that more than 60% of the diabetes patients in Kuwait do not adhere to diet or exercise programmes [28]. Lack of awareness of the benefits of diet and exercise interventions have contributed to difficulties

P-value

0.03 0.2 <0.01 <0.01 <0.001 0.4 0.7

in weight management and obesity among Arabs [11]. The reasons for suboptimal management of diabetes are manifold, but non-adherence to treatment recommendations is a major issue in Kuwait [29] and other regions [30,31]. Diverse personal, sociocultural, religious and healthcare

Please cite this article in press as: A.M. Channanath, et al., Glycaemic control in native Kuwaiti Arab patients with type 2 diabetes, Prim. Care Diab. (2018), https://doi.org/10.1016/j.pcd.2018.07.009

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system-related factors are known to impede adherence to medication recommendations among Kuwaitis with type 2 diabetes [32]. A general lack of diabetes knowledge among Arab populations in Middle Eastern countries has been acknowledged [14]. It is essential to direct more resources towards development of innovative tools and educational models designed to improve patient adherence. Failure to diagnose diabetes soon after disease onset is also a concern because the subsequent development and presence of complications at the time of diagnosis makes management more difficult [33]. People remaining on inappropriate therapy regimens for too long, which is called as “clinical inertia”, can also result in suboptimal glycaemic control and related complications [34,35]. We observed, in the study cohort, a trend of increasing blood pressure with increasing duration of diabetes regardless of the level of glycaemic control. Hypertension is a highly prevalent comorbidity in Arabs with type 2 diabetes in Kuwait [36] and populations worldwide [37]. The strong epidemiological evidence of an association of hypertension and adverse outcomes of diabetes [38,39] stresses the need of optimal antihypertensive therapy in diabetic patients with hypertension [40]. Metformin was the most prescribed antidiabetic drug in the study population, and a large proportion of patients with metformin monotherapy achieved adequate glycaemic control. Metformin is highly efficient in patients with appropriate insulin production. Metformin reduces insulin resistance and also has some beneficial effects on ␤-cell health [41,42], and combination treatment with sulfonylureas can improve the response of patients with some residual ␤-cells [43]. Patients, from the study cohort, who were prescribed insulin had higher HbA1c levels than other treatment groups. This was expected, since insulin therapy is initiated when oral drugs do not provide sufficient glycaemic control. In the first year of diagnosis, up to 75% of the patients were prescribed metformin, but the percentage decreased considerably with the duration of treatment. An increase in prescriptions of sulfonylureas was seen in the years after diagnosis, and insulin prescriptions increased sharply after seven years from diagnosis. Recent prescription data from a tertiary clinic in Kuwait showed that 54% of diabetes patients were prescribed mono- or combination therapy with DPP-4 inhibitors and 17% were given GLP-1 agonists (unpublished data). In our study cohort, patients treated with insulin–sulfonylureas or insulin–metformin–sulfonylureas combinations and achieved adequate glycaemic control had significantly lower BMIs than those with inadequate control. Previous studies have shown that obesity predicts a poor treatment response to insulin in type 2 diabetes patients regardless of the insulin treatment regimen [44]. In conclusion, glycaemic management of diabetes patients in primary care clinics in Kuwait is suboptimal. Longer disease duration and early onset of diabetes make glycaemic control difficult. Early diagnosis and early initiation of glucose lowering treatment are likely to be helpful. It is important to evaluate the current situation as increasing number of patients are being treated with new classes of glucose lowering drugs in Kuwait. The delineated factors from this ethnic

5

population are of interest to efforts on improving the quality of diabetes care in the Arab countries.

5.

Limitations of the study

Cross-sectional studies, such as the presented one, do not make inferences on causality of the diseases. Potential factors progressively affecting glycaemic control could not be established as the available data did not include continuous laboratory measurements made at regular time intervals. The study suffers from recall bias, due to absence of information on patients’ efforts (such as adherence to medications and lifestyle interventions) to control diabetes. Data on the history of hypoglycaemia, microvascular or macrovascular complications were not available and hence the study could not assess the adjusted degree of glycaemic control (as per the guidelines of American Diabetes Association on HbA1c target levels). Further, the study did not have data (such as C-peptide levels) on pancreatic reserve and hence could not assess the extent of deterioration of beta-cells before the patient was diagnosed and its impact on glycaemic control.

Disclosure JT has received research grants, served as a consultant to and/or a member of advisory boards for, and/or gave lectures organized by AstraZeneca, Bayer, Boehringer Ingelheim, Eli Lilly, Impeto-Medical, Merck, MSD, Sanofi-Aventis, Novo Nordisk and Servier. The other authors declare no conflict of interest.

Acknowledgements The authors thank the members of Kuwait-Scotland eHealth Innovation Network for useful discussions. Aridhia Informatics Ltd, Scotland is acknowledged for carving out research data from the KHN resource. The Kuwait Foundation for the Advancement of Sciences (KFAS) is acknowledged for funding the activities at our institute.

references

[1] L. Blonde, P. Aschner, C. Bailey, L. Ji, L.A. Leiter, S. Matthaei, Global Partnership for Effective Diabetes Management, Gaps and barriers in the control of blood glucose in people with type 2 diabetes, Diabetes Vasc. Dis. Res. 14 (2017) 172–183. [2] L. Klautzer, J. Becker, S. Mattke, The curse of wealth — Middle Eastern countries need to address the rapidly rising burden of diabetes, Int. J. Health Policy Manag. 2 (2014) 109–114. [3] M. Badran, I. Laher, Obesity in Arabic-speaking countries, J. Obes. 2011 (2011) 686430. [4] M. Ng, T. Fleming, M. Robinson, B. Thomson, N. Graetz, C. Margono, et al., Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013, Lancet 384 (2014) 766–781. [5] S. ALNohair, Obesity in gulf countries, Int. J. Health Sci. 8 (2014) 79–83.

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PCD-708; No. of Pages 7

ARTICLE IN PRESS

6

p r i m a r y c a r e d i a b e t e s x x x ( 2 0 1 8 ) xxx–xxx

[6] L. Alhyas, A. McKay, A. Majeed, Prevalence of type 2 diabetes in the States of the co-operation council for the Arab States of the Gulf: a systematic review, PLoS One 7 (2012), e40948. [7] K. Ogurtsova, J.D. da Rocha Fernandes, Y. Huang, U. Linnenkamp, L. Guariguata, N.H. Cho, D. Cavan, J.E. Shaw, L.E. Makaroff, IDF diabetes atlas: global estimates for the prevalence of diabetes for 2015 and 2040, Diabetes Res. Clin. Pract. 128 (2017) 40–50. [8] M. Badedi, Y. Solan, H. Darraj, A. Sabai, M. Mahfouz, S. Alamodi, A. Alsabaani, Factors associated with long-term control of type 2 diabetes mellitus, J. Diabetes Res. 2016 (2016) 2109542. [9] Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group, Lancet 352 (1998) 837–853. [10] N. Al-Zanki, F.A. Al-Sultan, Clinical epidemiology of Type 2 diabetes mellitus in Kuwait, Kuwait Med. J. (2005) 6. [11] J. Al-Kaabi, F. Al-Maskari, H. Saadi, B. Afandi, H. Parkar, N. Nagelkerke, Assessment of dietary practice among diabetic patients in the United Arab Emirates, Rev. Diabet. Stud. 5 (2008) 110–115. [12] M. Khattab, Y.S. Khader, A. Al-Khawaldeh, K. Ajlouni, Factors associated with poor glycemic control among patients with type 2 diabetes, J. Diabetes Complic. 24 (2010) 84–89. [13] A.R. Kamuhabwa, E. Charles, Predictors of poor glycemic control in type 2 diabetic patients attending public hospitals in Dar es Salaam, Drug Healthc. Patient Saf. 6 (2014) 155–165. [14] Z.K. Alsairafi, K.M. Taylor, F.J. Smith, A.T. Alattar, Patients’ management of type 2 diabetes in Middle Eastern countries: review of studies, Patient Preference Adherence 10 (2016) 1051–1062. [15] V.A. Ypinazar, S.A. Margolis, Delivering culturally sensitive care: the perceptions of older Arabian gulf Arabs concerning religion, health, and disease, Qual. Health Res. 16 (2006) 773–787. [16] B. Farran, A.M. Channanath, K. Behbehani, T.A. Thanaraj, Predictive models to assess risk of type 2 diabetes, hypertension and comorbidity: machine-learning algorithms and validation using national health data from Kuwait — a cohort study, BMJ Open 3 (2013). [17] R. Giannarelli, M. Aragona, A. Coppelli, S. Del Prato, Reducing insulin resistance with metformin: the evidence today, Diabetes Metab. 29 (2003), 6S28–35. [18] D. Sola, L. Rossi, G.P. Schianca, P. Maffioli, M. Bigliocca, R. Mella, F. Corliano, G.P. Fra, E. Bartoli, G. Derosa, Sulfonylureas and their use in clinical practice, Arch. Med. Sci. 11 (2015) 840–848. [19] Standards of medical care in diabetes—2016: summary of revisions, Diabetes Care 39 (Suppl. 1) (2016) S4–S5. [20] S.A. Berkowitz, J.B. Meigs, D.J. Wexler, Age at type 2 diabetes onset and glycaemic control: results from the National Health and Nutrition Examination Survey (NHANES) 2005–2010, Diabetologia 56 (2013) 2593–2600. [21] J. Ahmad, M. Zubair, N. Malik, D. Zephy, A. Raghav, Glycemic and non-glycemic targets in younger and older North Indian subjects with type 2 diabetes in a Tertiary care hospital: a 10 year’s retrospective data analysis, Diabetes Metab. Syndr. 10 (2016) S130–S134. [22] V.A. Fonseca, Defining and characterizing the progression of type 2 diabetes, Diabetes Care 32 (Suppl. 2) (2009) S151–S156. [23] C.J. Ostgren, U. Lindblad, J. Ranstam, A. Melander, L. Rastam, Skaraborg Hypertension and Diabetes Project, Glycaemic control, disease duration and beta-cell function in patients with Type 2 diabetes in a Swedish community. Skaraborg Hypertension and Diabetes Project, Diabet. Med. J. Br. Diabet. Assoc. 19 (2002) 125–129.

[24] M.L. Tracey, S.M. McHugh, A.P. Fitzgerald, C.M. Buckley, R.J. Canavan, P.M. Kearney, Risk factors for macro- and microvascular complications among older adults with diagnosed type 2 diabetes: findings from the Irish longitudinal study on Ageing, J. Diabetes Res. 2016 (2016) 5975903. [25] S. Zoungas, M. Woodward, Q. Li, M.E. Cooper, P. Hamet, S. Harrap, S. Heller, M. Marre, A. Patel, N. Poulter, B. Williams, J. Chalmers, ADVANCE Collaborative Group, Impact of age, age at diagnosis and duration of diabetes on the risk of macrovascular and microvascular complications and death in type 2 diabetes, Diabetologia 57 (2014) 2465–2474. [26] American Diabetes Association, 6. Obesity management for the treatment of type 2 diabetes, Diabetes Care 39 (Suppl. 1) (2016) S47–S51. [27] M. Alarouj, A. Bennakhi, Y. Alnesef, M. Sharifi, N. Elkum, Diabetes and associated cardiovascular risk factors in the State of Kuwait: the first national survey, Int. J. Clin. Pract. 67 (2013) 89–96. [28] M. Serour, H. Alqhenaei, S. Al-Saqabi, A.R. Mustafa, A. Ben-Nakhi, Cultural factors and patients’ adherence to lifestyle measures, Br. J. Gen. Pract. 57 (2007) 291–295. [29] H.T. Al-Majed, A.E. Ismael, H.M. Al-Khatlan, M.K. El-Shazly, Adherence of type-2 diabetic patients to treatment, Kuwait Med. J. 7 (2014). [30] J.A. Cramer, A systematic review of adherence with medications for diabetes, Diabetes Care 27 (2004) 1218–1224. [31] W.C. Lee, S. Balu, D. Cobden, A.V. Joshi, C.L. Pashos, Prevalence and economic consequences of medication adherence in diabetes: a systematic literature review, Manag. Care Interface 19 (2006) 31–41. [32] F.B. Jeragh-Alhaddad, M. Waheedi, N.D. Barber, T.P. Brock, Barriers to medication taking among Kuwaiti patients with type 2 diabetes: a qualitative study, Patient Preference Adherence 9 (2015) 1491–1503. [33] M.I. Harris, R.C. Eastman, Early detection of undiagnosed diabetes mellitus: a US perspective, Diabetes Metab. Res. Rev. 16 (2000) 230–236. [34] K. Khunti, M.L. Wolden, B.L. Thorsted, M. Andersen, M.J. Davies, Clinical inertia in people with type 2 diabetes: a retrospective cohort study of more than 80,000 people, Diabetes Care 36 (2013) 3411–3417. [35] S.K. Paul, K. Klein, B.L. Thorsted, M.L. Wolden, K. Khunti, Delay in treatment intensification increases the risks of cardiovascular events in patients with type 2 diabetes, Cardiovasc. Diabetol. 14 (2015) 100. [36] A.M. Channanath, B. Farran, K. Behbehani, T.A. Thanaraj, State of diabetes, hypertension, and comorbidity in Kuwait: showcasing the trends as seen in native versus expatriate populations, Diabetes Care 36 (2013) e75. [37] Y. Song, X. Liu, X. Zhu, B. Zhao, B. Hu, X. Sheng, L. Chen, M. Yu, T. Yang, J. Zhao, Increasing trend of diabetes combined with hypertension or hypercholesterolemia: NHANES data analysis 1999–2012, Sci. Rep. 6 (2016) 36093. [38] American Diabetes Association, Treatment of hypertension in adults with diabetes, Diabetes Care 25 (2002) 199–201. [39] S. Katayama, M. Hatano, M. Issiki, Clinical features and therapeutic perspectives on hypertension in diabetics, Hypertens. Res. 41 (2018) 213–229. [40] A.I. Adler, I.M. Stratton, H.A. Neil, J.S. Yudkin, D.R. Matthews, C.A. Cull, A.D. Wright, R.C. Turner, R.R. Holman, Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study, BMJ 321 (2000) 412–419. [41] G. Patane, S. Piro, A.M. Rabuazzo, M. Anello, R. Vigneri, F. Purrello, Metformin restores insulin secretion altered by chronic exposure to free fatty acids or high glucose: a direct

Please cite this article in press as: A.M. Channanath, et al., Glycaemic control in native Kuwaiti Arab patients with type 2 diabetes, Prim. Care Diab. (2018), https://doi.org/10.1016/j.pcd.2018.07.009

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ARTICLE IN PRESS p r i m a r y c a r e d i a b e t e s x x x ( 2 0 1 8 ) xxx–xxx

metformin effect on pancreatic beta-cells, Diabetes 49 (2000) 735–740. [42] R. Lupi, S. Del Guerra, V. Fierabracci, L. Marselli, M. Novelli, G. Patane, U. Boggi, F. Mosca, S. Piro, S. Del Prato, P. Marchetti, Lipotoxicity in human pancreatic islets and the protective effect of metformin, Diabetes 51 (Suppl. 1) (2002) S134–S137. [43] P.C. Tong, C.C. Chow, L.N. Jorgensen, C.S. Cockram, The contribution of metformin to glycaemic control in patients

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with Type 2 diabetes mellitus receiving combination therapy with insulin, Diabetes Res. Clin. Pract. 57 (2002) 93–98. [44] H. Yki-Jarvinen, L. Ryysy, M. Kauppila, E. Kujansuu, J. Lahti, T. Marjanen, L. Niskanen, S. Rajala, S. Salo, P. Seppala, T. Tulokas, J. Viikari, M.R. Taskinen, Effect of obesity on the response to insulin therapy in noninsulin-dependent diabetes mellitus, J. Clin. Endocrinol. Metab. 82 (1997) 4037–4043.

Please cite this article in press as: A.M. Channanath, et al., Glycaemic control in native Kuwaiti Arab patients with type 2 diabetes, Prim. Care Diab. (2018), https://doi.org/10.1016/j.pcd.2018.07.009