Open Access Original Article

A Cross-Sectional Study to Assess Awareness of

Risk Factors and Current Behavior Amongst
Individuals with Type 2 Diabetes Mellitus in India
S S. Dariya 1 , Anuj Maheshwari 2, Vijay Viswanathan 3, Anil Kumar Virmani 4 , Mohsin Aslam 5, Alok Modi 6,
Ajoy Kumar Tewari 7, Ashutosh Chaturvedi 8 , Arun Kumar Kedia 9 , G D Ramchandani 10, Rajnish Saxena 11 ,
Jayant K Panda 12 , Ashish Saxena 13 , Akash N. Singh 14 , Bijay Patni 15 , Ashish S. Dengra 16 ,
Dhruvi Hasnani 17 , Vipul Chavda 18 , Kannan Natarajan 19 , Anubha Varma 20 , Aravinda Jagadeesha 21,
Dinesh Agarwal 22 , Nagendra Kumar Singh 23 , L Sreenivasamurthy 24 , Bharat Saboo 25 , Anil Samaria 26 ,
Sandeep Suri 27 , Sajid Ansari 28

1. Internal Medicine, NIMS Medical College and Hospital, Jaipur, IND 2. Internal Medicine, Hind Institute of Medical
Sciences, Lucknow, IND 3. Diabetes and Endocrinology, M. V. Hospital for Diabetes, Chennai, IND 4. Internal Medicine,
Dr AK Virmani Clinic, Jamshedpur, IND 5. Internal Medicine, Asian Institute of Gastroenterology, Hyderabad, IND 6.
Internal Medicine, Kevalya hospital, Thane, IND 7. Internal Medicine, Jai Clinic & Diabetes Care Center, Lucknow, IND
8. Internal Medicine, Mahatma Gandhi Hospital, Jaipur, IND 9. Internal Medicine, Lifeworth Hospital, Raipur, IND 10.
Internal Medicine, Ramchadnani Diabetes Care and Research Centre, Kota, IND 11. Diabetes and Endocrinology,
Saxena Diabetes Care Centre, Ajmer, IND 12. Internal Medicine, SCB Medical College and Hospital, Cuttack, IND 13.
Medicine and Metabolic Disease, Clinical Cardiology, Diabetes and Heart Centre, Ludhiana, IND 14. Internal Medicine,
Manjalpur Hospital, Vadodara, IND 15. Internal Medicine, Diabetes Wellness Care, Kolkata, IND 16. Diabetology, Mahi
Diabetes Thyroid Care Research Centre, Jabalpur, IND 17. Diabetology, Rudraksha Institute of Medical Sciences,
Ahmedabad, IND 18. Internal Medicine, Rudraksha Institute of Medical Sciences, Ahmedabad, IND 19. Internal
Medicine, Chandra Chest and Diabetes Care Centre, Chennai, IND 20. Internal Medicine, Moti Lal Nehru Medical
College, Allahabad, IND 21. Internal Medicine, Dr Aravind's Diabetes Centre, Bangalore, IND 22. Internal Medicine,
Marwari Hospital & Research Centre, Gawahati, IND 23. Internal Medicine, Diabetes and Heart Research Centre,
Dhanbad, IND 24. Internal Medicine, Lifecare Hospital and Research centre, Bengaluru, IND 25. Diabetology, Prayas
Diabetes Center, Indore, IND 26. Internal Medicine, J L N Medical College, Ajmer, IND 27. Internal Medicine, Advance
Diabetes & Critical Care, Hisar, IND 28. Internal Medicine, SS Heart Care Centre, Lucknow, IND

Corresponding author: S S. Dariya, [email protected]

Abstract
Introduction: The burden of Type 2 Diabetes Mellitus (T2D) is compounded by serious complications,
including cardiovascular and microvascular diseases, with significant healthcare costs associated with these
complications. Engaging in self-care practices can enhance glycemic control and empower individuals to
make informed health decisions. The present study aims to assess the existing levels of awareness and
understanding of diabetes, focusing on the perception of its risk factors and associated complications.

Methods: This prospective, cross-sectional study involved 2,468 individuals with T2D, recruited from 26
sites across India. Data underwent aggregate-level analysis using Python and was assessed for statistical
significance using the Chi-Square test. Continuous variables (means and standard deviations) were
analyzed, and differences among groups were evaluated using Analysis of Variance (ANOVA). To evaluate
the understanding of diabetes, including its symptoms and complications, all knowledge-related questions
were aggregated into a composite score. Participants were categorized into three groups (high, medium, and
low) based on their knowledge levels. The subject’s variables across 5 dimensions comprising - diabetes
causes and symptoms, medication continuation, diet and lifestyle, hypoglycemia, and complications from
diabetes were assessed. The highest achievable score is 26, while the lowest is 0. Based on this knowledge
score, individuals were classified into three groups as follows

High - Participants scoring 80% or more correct answers. Score >20

Medium - Participants scoring 40% to 80%, Score between 11 and 20

Low - Participants scoring between 0 and 10 i.e. <40%

Results: The average participant age was 54.1 years, with a male-to-female ratio of 60:40. The average
HbA1c level was 8.2%, with 28% maintaining levels within the target range (≤7%) and 22% having levels
above 9%. Overall, 27% of individuals have been classified as “High knowledge,” 48% as “Medium
knowledge,” and 26% as “Low knowledge.” Scores were 22.4 (1.2) for high knowledge, 15.9 (2.9) for medium,
and 6.2 (3.0) for low. Diabetic complications are significantly higher in the high-knowledge group.
Adherence to diabetes medication was higher in the high (78.5%) and medium (81.6%) knowledge groups
(p<0.001) compared to the low (60.3%) Participants with high and medium knowledge levels demonstrated
significantly greater ownership and use of glucometers compared to those with lower knowledge levels.

Conclusion: Individuals with T2D who experience complications tend to have a greater understanding of

How to cite this article

diabetes and its risk factors than those without complications. This suggests that facing health issues
motivates individuals to seek information, improving their knowledge and influencing better medication
adherence and lifestyle choices. The findings of this study, coupled with existing data, underscores the
urgent need for innovative approaches to engage and motivate individuals through targeted educational
initiatives, comprehensive counseling, regular monitoring, and strategies to improve adherence to
recommended diabetes management practices.

Categories: Other, Internal Medicine, Medical Education

Keywords: risk factors, awareness, knowledge, diabetic complications, type 2 diabetes mellitus

Introduction
The prevalence of Non-Communicable Diseases (NCDs) is on the rise, with India as the primary contributor
in South Asia [1]. ICMR-INDIAB-17 study estimates 101.3 million people with diabetes and 136 million pre-
diabetes in India (overall weighted prevalence: 11.4% and 15.3%, respectively) [2].

Indians appear to have a higher susceptibility to diabetes, primarily due to an elevated degree of insulin
resistance and a stronger genetic predisposition [3]. Contributing to this trend are factors such as obesity
(central obesity, and increased visceral fat), along with the consumption of high-calorie, high-fat, and high-
sugar diets [3,4]. The burden of type 2 diabetes mellitus (T2D) increases due to its association with
macrovascular (cardiovascular (CV), cerebrovascular, and peripheral artery diseases) and microvascular
(diabetic retinopathy, nephropathy, and neuropathy) complications [5]. In a systematic review, the
prevalence rates of chronic diabetes complications were, retinopathy ranging from 4.8% to 21.7%,
nephropathy from 0.9% to 62.3%, and neuropathy from 10.5% to 44.9% [6]. Studies indicate that illness costs
are 1.4 times higher for individuals experiencing complications [7,8].

These statistics highlight the critical importance of quality diabetes management in India to alleviate the
healthcare and economic burdens. Self-management plays a vital role in improving outcomes for individuals
with T2D. By actively engaging in self-care practices, such as monitoring blood glucose levels, adhering to
medication regimens, and maintaining a healthy lifestyle, individuals can achieve better glycemic control
and reduce the risk of complications. Furthermore, self-management fosters a sense of empowerment and
confidence, enabling individuals to make informed decisions about their health and collaborate effectively
with healthcare providers for optimal care.

Studies on Knowledge, Attitude, and Practice (KAP) have yielded substantial evidence emphasizing the
imperative requirement for heightened awareness among the general population and individuals with
diabetes, specifically concerning prevention, managing risk factors, and disease control [9-11]. Effective
education and awareness initiatives can transform the general population's attitudes toward diabetes [12].

We searched PubMed for studies conducted amongst Indians, on the present topic. The focus was to assess
studies conducted recently (last 10 years). There are several single centre and regional studies conducted
over time. Most studies conclude that appropriate knowledge and attitude regarding diabetes mellitus to
some degree exists, but there are important lacunae and practices that are often found wanting. There have
been no large-scale, pan-India studies that have attempted to map the level of knowledge, attitude, and
practices amongst people with T2D. The present study aims to evaluate the current levels of awareness,
perceptions of risk factors, and complications of diabetes while categorizing them based on their awareness
and practices.

Materials And Methods

Study Design and Population
This was a prospective, cross-sectional study amongst individuals with T2D in Urban India. Prior to the main
study, a pilot study with five doctors was conducted, and the questionnaire was validated. The study was
conducted from April 14, 2023, to July 15, 2023. An electronic case report form (eCRF) in the form of a
questionnaire was used to collect data for assessing awareness and attitudes towards T2D management. The
study included individuals aged 18 and older who had been diagnosed with T2D and provided their consent
across 26 centers.

Sampling
The first 100 eligible consecutive people with T2D who visited the study site for routine care during the
recruitment period, and provided informed consent, were included. The recruitment phase identified 2752
subjects, with 2468 meeting all the criteria for inclusion in the final analysis. Given the study's observational
nature, randomization was not employed. As the study focused on a predefined individual cohort with
diabetes, calculations for sample size were deemed unnecessary.

Data Collection Instrument and Variables

2 of 13
 Data has been collected through in person interviews with eligible participants during their outpatient
department (OPD) visits at study sites. All interviews were conducted by a trained interviewer/ site principal
investigator (PI) using a structured questionnaire.

The questionnaire was structured into two distinct sections. Section A comprised clinical data typically
obtained during routine consultations: demographics, vital signs, diagnosis, complications, medication
class, laboratory assessments, and more. Responses were collected in Section B - focusing on their current
behaviors, perceptions, and attitudes regarding various risk factors, alternative medicine, and mobile appl
based programs. The questionnaire has been created by combining several validated scales and through
expert consensus within the study group.

Informed Consent and Ethics Approval

The study was approved by “Tanvir Hospital Institutional Ethics Committee for Biomedical and Health
Research (Registration #EC/NEW/INST/2022/TE/0154) on 31.03.2023, Ref 03/2023. Informed consent was
obtained in writing and clarified verbally, with study details explained. Physicians maintained
confidentiality as per their agreement, and the individual’s data was anonymized using unique physician
identifiers. Data usage was restricted solely to this study, with any further use contingent on additional
written permission to protect privacy and uphold ethical standards.

Statistical Analysis
Data collected underwent aggregate-level analysis using Python software. Categorical data was presented as
frequencies and proportions, with statistical significance assessed using the Chi-Square test. Statistical
analyses and visualizations were performed using Microsoft Office. Significance was determined using
standard hypothesis testing with a threshold of a p-value less than 0.05. All tests adhered to methodological
guidelines to ensure the validity and reliability of the study's conclusions.

Data Presentation and Analysis

This study visually presented data using bar diagrams and tables for better interpretation. Continuous
variables were described by means and standard deviations. Analysis of Variance (ANOVA) was utilized to
compare mean differences among groups.

Creation of composite score and reasoning

To assess individual’s responses to diabetes, its symptoms, and complications, all knowledge questions were
combined into a single score. As this study's main objective is assessment of risk, the weightage is higher for
the same.

Diabetes causes and symptoms - 6

Medication continuation - 1

Diet and Lifestyle - 5

Hypoglycemia - 1

Complications from Diabetes - 13

Each correct response held equal weight in this score. The highest achievable score is 26, while the lowest is
0. Based on this knowledge score, individuals were classified into three groups as follows (note - all scores
are out of maximum possible 26). (Table 1)

Weight Q No. About Diabetes Mellitus Overall (%)

Diabetes is a condition in which the body contains

A higher level of sugar in the blood than normal 65.8%

1 1 A lower level of sugar in the blood than normal 6.4%

Either a higher or a lower level of sugar in the blood than normal 13.2%

I don’t know 14.6%

The major cause of diabetes is

An increased availability of insulin in the body 11.6%

1

3 of 13
 2 A decreased availability of insulin in the body 52.4%

I don’t know 36.0%

The symptom(s) of diabetes is/ are

1 3 Increased frequency of urination 79.8%

1 4 Increased thirst and hunger 74.9%

1 5 Increased tiredness 72.1%

1 6 Slow healing of wounds 61.2%

I don’t know 9.6%

The lifestyle modification(s) required for individuals with diabetes

1 7 Weight reduction 71.8%

1 8 Balanced diet 78.4%

1 9 At least 30 min physical exercise daily 74.0%

1 10 Stop smoking 58.3%

1 11 Stop alcohol intake 56.9%

I don’t know 8.7%

Upon control of diabetes the medicines

Can be stopped immediately 3.4%

1 12 Can be stopped after a month 6.2%

Should continue with medications 54.5%

Not sure 35.9%

Which according to you are complications due to uncontrolled diabetes?

1 13 Eye problems/ Blindness 70.1%

1 14 Amputation 27.2%

1 15 Kidney disease 75.3%

1 16 Heart disease 68.2%

1 17 Neuropathy 44.4%

1 18 Foot Ulcers 64.2%

1 19 Shortness of breath 13.7%

1 20 Chest pain while walking 12.3%

1 21 Sexual problems 13.3%

I don’t know 17.0%

In an individual with diabetes, high blood pressure can increase or worsen

1 22 The risk of heart attack 72.9%

1 23 The risk of stroke 62.9%

1 24 The risk of eye problems 61.5%

1 25 The risk of kidney problems 60.9%

I don’t know 14.0%

Are you aware of blood sugar levels falling below normal when you take medicine?

26 Yes 33.6%

4 of 13
 1
No 62.3%

No data 4.1%

TABLE 1: Scoring System Adopted

High - Participants scoring 80% or more correct answers. Score >20

Medium - Participants scoring 40% to 80%, Score between 11 and 20

Low - Participants scoring between 0 and 10, i.e. <40%

While there are no previous benchmarks or validated composite scoring for this grouping. The study group,
on an extensive review of the results by this grouping, concluded that these groups are significantly different
from each other and have a strong correlation with the behavior, allowing for clinical interpretation and
action planning. The study group strongly recommends a follow-up study to finetune the tool and study its
generalization across individual cohorts - by region, gender, age, etc.

Results
Patient Profile
A total of 2468 people with T2D across 26 centers in India participated in this study. The average age is 54.1
(±12.2) years, with 35% in the <50 years age group. 60% [95% Confidence Interval (CI) (58.1 - 61.9)] of the
sample are males, and 40% [95% CI (38.1 - 41.9)] are females. The average BMI is 27.0 (±9.0) kg/m², with
61.9% in the BMI >25 kg/m2 group. 43.2% have high blood pressure (>140/90 mmHg) during inclusion in this
study. The average duration of T2D is 7.2 (±6.2) years. 79.6% were on Metformin as monotherapy or
combination therapy, 44% on Sulphonylureas (SU), 40.6% on Dipeptidyl-peptidase 4 inhibitors (DPP4i),
27.6% on Sodium-glucose cotransporter 2 inhibitors (SGLT2i) and 15.9% on Insulin. At the time of inclusion
in this study, the mean HbA1c level is 8.2 (±1.9). Only 28% of the participants had their HbA1c levels within
the target range (≤7%), while 22% had HbA1c levels that surpassed 9%. Of the participants, 59.3% have at
least one diabetic complication. Among these complications, neuropathy had the highest prevalence
(38.6%), followed by diabetic foot (21.3%), retinopathy (20.1%), and nephropathy (16.2%). Hypertension is
the most prevalent comorbid condition (59.2%). (Table 2)

5 of 13
 Characteristics N (%)

Age (n=2468)

<50 Years, n (%) 864 (35.0)

50 to 60 Years, n (%) 841 (34.1)

>60 Years, n (%) 763 (30.9)

Average (SD) 54.1 (12.2)

Gender (n=2468)

Male, n (%) 1482 (60)

Female, n (%) 986 (40)

Body Mass Index (BMI) (n=2354)

Underweight (<18.5 kg/m²) 52 (2.2)

Normal weight (18.5-22.99 kg/m²) 368 (15.6)

Overweight (23.0–24.9 kg/m²) 405 (17.2)

Pre-Obesity (25.0–29.9 kg/m²) 1069 (45.4)

Obesity (≥30 kg/m²) 460 (19.5)

Average (SD) 27.0 (9.0)

Blood Pressure (BP) (n=2431)

Optimal BP (SBP<130 & DBP<85) 790 (32.5)

High Normal BP (SBP: 130to139 / DBP: 85 to 89) 573 (23.6)

Grade 1 Hypertension (SBP: 140 to 159 / DBP:90 to 99) 855 (35.2)

Grade 2 Hypertension (SBP≥160 & DBP≥100) 213 (8.8)

Current Medication (n=2468)

Metformin 1964 (79.6)

Sulfonylureas 1086 (44)

Dipeptidyl peptidase 4 (DPP-4) inhibitors 1003 (40.6)

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors 682 (27.6)

Semaglutide 128 (5.2)

Insulin 392 (15.9)

Others 84 (3.4)

Duration (n=2466)

<5 years 944 (38.3)

5 - 10 years 1024 (41.5)

>10 years 498 (20.2)

TABLE 2: Sample Profile

SBP: Systolic blood pressure; DBP: Diastolic Blood pressure

Knowledge Levels Grouping

6 of 13
The average knowledge score is 15.1 (±6.4) out of a maximum of 26.

Further, the participants have been classified into three groups based on their composite score.

High Knowledge group: Composite score: 22.4 (±1.2), cut off > 20, forming 27% of subjects.

Medium Knowledge group: Composite score: 15.9 (±2.9) Score between 11 and 20, forming 48% of subjects.

Low Knowledge group: Composite score: 6.2 (±3.0) cut off ≤ 10, forming 26% of subjects.

Comparison based on knowledge groups

Patient characteristics

Participants with high knowledge levels [mean age 51.7 (12.4) years] are younger than those with medium
knowledge levels [55.4 (11.3) years] and low knowledge levels [54 (13.3) years] (p<0.001). Women have lower
knowledge levels than men (p<0.001). No significant differences (p>0.05) in knowledge levels were noted by
the duration of diabetes (p=0.20), BMI (p=0.98), and current HbA1c levels (p=0.058).

Diabetic complications are significantly higher in higher knowledge group compared to medium and lower
knowledge group (p<0.001) [neuropathy (47% vs. 41.1% vs. 21.3%, p<0.001), diabetic foot (26.3% vs. 20.6% vs.
15.1%, p<0.001), retinopathy (28.9% vs. 17.8% vs. 13.6%, p<0.001), nephropathy (47% vs. 41.1% vs. 21.3%,
p<0.001)]. Similarly, the higher knowledge group had a higher prevalence of co-morbid conditions than other
groups (p<0.001). (Table 3)

7 of 13
 Knowledge Level Grouping (score)

All Low (≤10) Medium (11-20) High (>20)

P-Value
N 2468 634 1179 655

Age (years), mean (SD) 54.1 (12.2) 54.0 (13.3) 55.4 (11.3) 51.7 (12.4) <0.001

Gender

Male % (95% CI) 60 (58.1 - 61.9) 50.3 (46.4 - 54.2) 62.9 (60.1 - 65.7) 64.3 (60.6 - 68.0)
<0.001
Female % (95% CI) 40 (38.1 - 41.9) 49.7 (45.8 - 53.6) 37.1 (34.3 - 39.9) 35.7 (32.0 - 39.4)

Body Mass Index

Mean (SD) 27.0 (9.0) 27.0 (5.0) 26.9 (6.8) 26.9 (14.0) 0.977

HbA1c

Mean (SD) 8.2 (1.9) 8.4 (2.1) 8.1 (1.7) 8.2 (1.9) 0.058

Duration of Diabetes Mellitus

<5 years 944 (38.3) 266 (42.0) 432 (36.7) 246 (37.6)

5-10 years 1024 (41.5) 240 (37.9) 504 (42.8) 280 (42.7) 0.2

>10 years 498 (20.2) 128 (20.2) 241 (20.5) 129 (19.7)

Mean (SD) 7.2 (6.1) 6.9 (6.2) 7.3 (5.9) 7.3 (6.2) 0.428

With any Complications % (95% CI) 59.3 (57.4 - 61.2) 48.9 (45.0 - 52.8) 60.6 (57.8 - 63.4) 67.2 (63.6 - 70.8) <0.001

Diabetes Complications

Neuropathy % (95% CI) 37.3 (35.3 - 39.3) 21.3 (18.1 - 24.5) 41.1 (38.2 - 44.0) 47.0 (43.0 - 51.0)

Diabetic Foot % (95% CI) 20.6 (19.0 - 22.2) 15.1 (12.3 - 17.9) 20.6 (18.3 - 22.9) 26.3 (22.7 - 29.9)

Retinopathy % (95% CI) 19.5 (17.9 - 21.1) 13.6 (10.9 - 16.3) 17.8 (15.6 - 20.0) 28.9 (25.2 - 32.6)
<0.001
Nephropathy % (95% CI) 37.3 (35.3 - 39.3) 21.3 (18.1 - 24.5) 41.1 (38.2 - 44.0) 47 (43.0 - 51.0)

Coronary Heart Disease % (95% CI) 8.5 (7.4 - 9.6) 12.3 (9.7 - 14.9) 8.2 (6.6 - 9.8) 5.1 (3.3 - 6.3)

With any Complication % (95% CI) 75 (73.3 - 76.7) 66.7 (63.0 - 70.4) 77.2 (74.8 - 79.6) 79.2 (76.1 - 82.3)

Co-Morbidity

Hypertension % (95% CI) 57 (55.0 - 59.0) 46.2 (42.3 - 50.1) 60.4 (57.5 - 63.3) 61.9 (58.0 - 65.8)

Dyslipidemia % (95% CI) 28.7 (26.9 - 30.5) 17.5 (14.5 - 20.5) 31.3 (28.6 - 34.0) 35.4 (31.6 - 39.2)
<0.001
Hypothyroidism % (95% CI) 11.1 (9.8 - 12.4) 7.9 (5.8 - 10.0) 11.9 (10.0 - 13.8) 12.9 (10.1 - 15.7)

Hyperthyroidism % (95% CI) 2 (1.4 - 2.6) 1.3 (0.4 - 2.2) 1.5 (0.8 - 2.2) 3.5 (2.0 - 5.0)

Counseling about complication

Yes, recently % (95% CI) 40.1 (38.1 - 42.1) 30.6 (26.9 - 34.3) 38.9 (36.1 - 41.7) 51 (47.1 - 54.9)

Yes, sometime back % (95% CI) 49.3 (47.3 - 51.3) 49.1 (45.1 - 53.1) 50.7 (47.8 - 53.6) 47.1 (43.2 - 51.0) <0.001

No % (95% CI) 10.6 (9.4 - 11.8) 20.4 (17.2 - 23.6) 10.4 (8.6 - 12.2) 1.9 (0.8 - 3.0)

TABLE 3: Patient characteristics comparison based on knowledge level groups

Behavioral differences

Medication adherence: High (78.5%) and medium-knowledge (81.6%) participants have higher all 7-day
adherence to diabetes medication compared to low-knowledge (60.3%) participants (p<0.001).

8 of 13
 Exercise: 39.8% of low, 20.2% of medium, and 8.1% (p<0.001) of high-knowledge participants did no
exercise in the past seven days. On average, participants with high knowledge exercised for more than 30
minutes on 4.7 (2.3) days, while those with low knowledge exercised on 2.8 (2.7) days.

Diet counseling and eating habits: 28.2% of participants with low knowledge have received no diet
counseling in the last year. This is significantly lower (p<0.001) among medium knowledge (10.5%) and high
knowledge participants (7.8%). Amongst participants with high knowledge levels, 59.6% received counseling
from dietitians and 28.5% from doctors. Overall, 87.2% of participants have regular breakfast. This is higher
in participants with high knowledge as against low knowledge (92.9% vs 81.8%, p<0.001).

Self-assessment habit:

a) Ownership and usage of Glucometer: Compared to low-knowledge participants (36.4%), high (65.2%) and
medium-knowledge (67.7%) participants have higher ownership of the glucometer (p<0.001) and usage for
self-assessment of blood glucose (44.7%, 47.7%, 22.7% p<0.001).

b) Diabetic Foot - High and medium-knowledge participants have self-examined their feet more in the last
month than low-knowledge participants (75.6%, 53.4%, 45.1%, p<0.001). Significantly higher (32.3%,
p<0.001) participants with low knowledge have never checked their feet for diabetic foot complications.
(Table 4)

Knowledge Level Grouping (score)

Low Medium High

All P-Value
(≤10) (11-2 (>20)

N 2468 634 1179 655

In the last 7 days, on how many days did you take your diabetes medications as prescribed by the doctor, n

Did not take medications 100 (4.2) 38 (6.3) 46 (4.1) 16 (2.5)

110
Up to 4 days 201 (8.5) 65 (5.7) 26 (4.1)
(18.2)

5 days 143 (6.0) 52 (8.6) 43 (3.8) 48 (7.4)

6 days 141 (5.9) 39 (6.5) 53 (4.7) 49 (7.6) <0.001

1789 363 509

7 days 917 (81.6)
(75.4) (60.3) (78.5)

From whom have you received diet counseling in the last 1 year? n (%)

962 246 183

Doctor 533 (46.7)
(40.2) (40.5) (28.5)

978 155 383

Dietitian 440 (38.5)
(40.9) (25.5) (59.6)

Family member / Friend 76 (3.2) 27 (4.4) 34 (3.0) 15 (2.3) <0.001

Online 27 (1.1) 6 (1.0) 12 (1.1) 9 (1.4)

341 171
No one 120 (10.5) 50 (7.8)
(14.3) (28.2)

Do you have breakfast regularly? n (%)

2081 493 598

Yes 990 (86.9)
(87.2) (81.8) (92.9)
<0.001
305 110
No 149 (13.1) 46 (7.1)
(12.8) (18.2)

How would you classify your appetite, n (%)

1893 446 518

Normal 929 (81.8)
(79.7) (74.2) (81.2)

315 112 <0.001

Poor 147 (12.9) 56 (8.8)
(13.3) (18.6)

9 of 13
Excessive 167 (7.0) 43 (7.2) 60 (5.3) 64 (10.0)

On how many of the last seven days did you participate in at least 30 minutes of physical activity? (Total minutes of continuous activity,
including walking)

Mean days (SD) 3.8 (2.7) 2.8 (2.7) 3.8 (2.7) 4.7 (2.3) <0.001

How many hours of sleep do you typically get in a day?

Mean hours (SD) 7.0 (1.4) 7.1 (1.5) 7.0 (1.5) 7.1 (1.4) 0.105

Do you have a Glucose meter and use the same to regularly monitor blood glucose at home/ place of work, n (%)

981 386 226

No, do not have a Glucose meter 369 (32.3)
(40.9) (63.6) (34.8)

443 83 133
Have a Glucose meter, but rarely use it 227 (19.9)
(18.5) (13.7) (20.5)

693 102 222 <0.001

Have a Glucose meter, but use it sometimes when needed 369 (32.3)
(28.9) (16.8) (34.2)

Have a Glucose meter, and use it regularly, i.e., at least a few times every 280
36 (5.9) 176 (15.4) 68 (10.5)
week (11.7)

Do you have a Blood Pressure monitoring device and use the same to regularly monitor BP at home/ place o work, n (%)

1364 460 367

No, do not have a BP monitoring device 537 (47.3)
(57.1) (75.9) (56.7)

342 113
Have a BP monitoring device but rarely use it 57 (9.4) 172 (15.2)
(14.3) (17.5)

505 71 137 <0.001

Have a BP monitoring device, but use it sometimes when needed 297 (26.2)
(21.1) (11.7) (21.2)

Have BP a monitoring device and use it regularly, i.e., at least a few times
177 (7.4) 18 (3.0) 129 (11.4) 30 (4.6)
every week

When did you check your feet last? n (%)

575 157 162

Within the last seven days 256 (22.5)
(24.0) (25.9) (24.9)

451 66 185
Within the last two weeks 200 (17.6)
(18.8) (10.9) (28.5)

Within the last six months 161 (6.7) 30 (5.0) 103 (9.1) 28 (4.3)

Greater than six months 225 (9.4) 55 (9.1) 130 (11.4) 40 (6.2)
<0.001
345 144
In the last one month 50 (8.3) 151 (13.3)
(14.4) (22.2)

In the last two months 223 (9.3) 52 (8.6) 118 (10.4) 53 (8.2)

413 196
None 179 (15.7) 38 (5.8)
(17.3) (32.3)

TABLE 4: Behaviour and Sleep

Discussion
Early detection and treatment of T2D complications are crucial for preventing progression and enhancing
overall quality of life. With the rising prevalence and a very large uncontrolled T2D population, this study
evaluated the awareness of T2D risk factors and complications. It also examined the current behaviors of
individuals with T2D to gain insights into their adherence to recommended lifestyle modifications and
medications.

In the present study, 25.7% have low knowledge, 47.8% have medium knowledge, and 26.5% have good
knowledge. Our results show an improvement compared to a study by Sękowski et al. [13] (17.3% had good

10 of 13
knowledge, 46.3% had moderate knowledge, and 36.3% had poor knowledge). Chavan et al. [14], a single-
center study with fewer participants, 9.4% had good knowledge, 71.3% had moderate, and 19.2% had poor
knowledge. Mumu et al. [15], in their study, reported that 19% had poor knowledge, 68% had average, and
13% had good knowledge. A study by Theivasigamani et al. [16] reported better results than our study, 40.9%
had good knowledge, 46.3% had average knowledge, and 7.8% had poor knowledge, with no significant
difference in knowledge between the males and females. In the present study, males have a higher level of
knowledge compared to females (p<0.001), which is supported by Deepa et al. [17], Mathur et al. [18], Chavan
et al. [14], Chaudhary et al. [19] and contradicted by Santos et al. [20], Li et al. [21], and Salleh et al. [22]. In
India, knowledge levels tend to be lower in females, possibly due to a greater emphasis on prioritizing family
health over their own. A systematic review (21 articles) has shown that women encounter various barriers in
accessing T2D care, including personal, sociocultural, health system, economic, psychological, and
geographical factors [23].

In the present study, 83% are aware of complications due to diabetes, with the highest being kidney disease
(75.3%). According to Deepa et al. [17], 72.7% of individuals with diabetes reported knowledge about
complications. A study by Syed et al. [24] reported that 47.3% of the respondents were aware of kidney and
eye complications, 23.6% of foot complications, and 17.5% of heart complications. In this study, individuals
with complications exhibited significantly higher levels of knowledge than those without complications. The
presence of complications in individuals with T2D leads to significantly higher levels of knowledge about
diabetes and its associated risk factors compared to individuals without complications. This relationship
suggests that experiencing complications motivates individuals to seek information and education regarding
their condition, thereby enhancing their understanding of the disease and its potential consequences. It is
also improving their behavior about medication adherence and lifestyle choices. The presence of inertia and
ambivalence towards risks is a matter of serious concern. Research supports the notion that many
individuals often delay engagement in regular health-promoting activities until faced with significant health
events or crises. Theoretical models of health motivation indicate that motivation is a critical precursor to
initiating and maintaining health behaviors. However, these models often overlook strategies for engaging
those who are unmotivated until they encounter serious health issues, further underscoring the tendency for
individuals to wait for a crisis before taking action [25,26].

As a self-administered questionnaire, reporting bias cannot be eliminated entirely, and there might be
instances of overestimating compliance. Additionally, various confounding factors, such as economic status,
educational level, and the use of alternative systems of medicine, may be present but have not been
accounted for in this current study. Open-ended questions often depend on the respondent's verbal ability
and memory recall, whereas the respondent can guess specific closed questions. Nevertheless, for extensive
population-based studies like this, employing a questionnaire remains the most practical and viable method
for collecting such data. Additionally, the participants in the study were sourced exclusively from specialist
settings, excluding general practitioners and other healthcare providers who treat individuals with diabetes.
This makes the findings more skewed towards people with diabetes with relatively better access and socio-
economic circumstances.

Conclusions
This study holds significant practical implications for public health interventions in India. The findings from
this study and the existing data clearly suggest that we are lagging in our goal for good glycemic control at
the population level. There is a clear necessity to expand the workforce of diabetes educators nationwide to
address the disease more effectively at a foundational level. We must think of new methodologies of
engaging and motivating for educational initiatives, patient counseling, monitoring, and adherence. Health
inertia is very real, and amongst people with T2D, this invariably leads to very adverse outcomes. As the
next steps, we recommend creating a multi-disciplinary task force to design and test patient intervention
programs and test their effectiveness in a real-world setting.

Additional Information
Disclosures
Human subjects: Consent for treatment and open access publication was obtained or waived by all
participants in this study. Tanvir Hospital Institutional Ethics Committee for Biomedical and Health
Research issued approval EC/NEW/INST/2022/TE/0154. The Tanvir Hospital-Institutional Ethics Committee
for Biomedical & Health Research in its meeting held on 23 March 2023 has reviewed and discussed your
application and study-related documents in detail to conduct the above-mentioned protocol with yourself as
the Principal investigator. The following study-related documents have been reviewed and have been
APPROVED in the presented latest/updated form sent via email. Animal subjects: All authors have
confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance
with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All
authors have declared that no financial support was received from any organization for the submitted work.
Financial relationships: All authors have declared that they have no financial relationships at present or
within the previous three years with any organizations that might have an interest in the submitted work.
Other relationships: All authors have declared that there are no other relationships or activities that could
appear to have influenced the submitted work.

11 of 13
Acknowledgements
The authors acknowledge Karthikayan Visvanathan, Rama Regulla, Naveen Kumar Thattepalli, and Dr
Raghunath Dantu from MEDEVA (www.medeva.io) for the analysis and manuscript editorial support.

References
1. World Health Organization. WHO South-East Asia Region. Noncommunicable diseases in South-East Asia .
Internet. 20212024, 5:
2. Anjana RM, Unnikrishnan R, Deepa M, et al.: Metabolic non-communicable disease health report of India:
the ICMR-INDIAB national cross-sectional study (ICMR-INDIAB-17). Lancet Diabetes Endocrinol. 2023,
11:474-489. 10.1016/S2213-8587(23)00119-5
3. Mohan V: Why are Indians more prone to diabetes? . J Assoc Physicians India. 2004, 52:468-474.
4. Patil R, Gothankar J: Risk factors for type 2 diabetes mellitus: An urban perspective . IJMS. 2019, 19:16-21.
10.25259/IJMS_5_2019
5. van Dieren S, Beulens JWJ, van der Schouw YT, Grobbee DE, Neal B: The global burden of diabetes and its
complications: an emerging pandemic. Eur J Cardiovasc Prev Rehabil. 2010, 1:3-8.
10.1097/01.hjr.0000368191.86614.5a.
6. Govindaswamy S, Dhivya P, Sivaprakasam S: Prevalence and complications of diabetes mellitus In India-A
systematic review. Ind J Pharm Edu Res. 2023, 57:213-225. 10.5530/ijper.57.2s.25
7. Acharya LD, Rau NR, Udupa N, Rajan MS, Vijayanarayana K: Assessment of cost of illness for diabetic
patients in South Indian tertiary care hospital. J Pharm Bioallied Sci. 2016, 8:314-320. 10.4103/0975-
7406.199336
8. Tharkar S, Satyavani K, Viswanathan V: Cost of medical care among type 2 diabetic patients with a co-
morbid condition--hypertension in India. Diabetes Res Clin Pract. 2009, 83:263-267.
10.1016/j.diabres.2008.11.027
9. Al-Maskari F, El-Sadig M, Al-Kaabi JM, Afandi B, Nagelkerke N, Yeatts KB: Knowledge, attitude and
practices of diabetic patients in the United Arab Emirates. PLoS One. 2013, 8:e52857.
10.1371/journal.pone.0052857
10. Gupta R, Shora T, Jan R, Raina S, Mengi V, Khajuria V: Knowledge, Attitude and Practices in Type 2
Diabetes Mellitus Patients in Rural Northern India. Indian Journal of Community Health. 2015, 1:327-333.
11. Kishore J, Kohli C, Gupta N, Kumar N, Sharma P: Awareness, Practices and Treatment Seeking Behavior of
Type 2 Diabetes Mellitus Patients in Delhi. Ann Med Health Sci Res. 2015, 5:266-273. 10.4103/2141-
9248.160184
12. Funnell MM, Anderson RM: MSJAMA: the problem with compliance in diabetes . JAMA. 2000, 4:1709.
10.1001/jama.284.13.1709-JMS1004-6-1
13. Sękowski K, Grudziąż-Sękowska J, Pinkas J, Jankowski M: Public knowledge and awareness of diabetes
mellitus, its risk factors, complications, and prevention methods among adults in Poland—A 2022
nationwide cross-sectional survey. Front Public Health. 2022, 21:1029358. 10.3389/fpubh.2022.1029358
14. Chavan GM, Waghachavare VB, Gore AD, Chavan VM, Dhobale RV, Dhumale GB: Knowledge about diabetes
and relationship between compliance to the management among the diabetic patients from Rural Area of
Sangli District, Maharashtra, India. J Family Med Prim Care. 2015, 4:439-443. 10.4103/2249-4863.161349
15. Mumu SJ, Saleh F, Ara F, Haque MR, Ali L: Awareness regarding risk factors of type 2 diabetes among
individuals attending a tertiary-care hospital in Bangladesh: a cross-sectional study. BMC Res Notes. 2014,
3:1-9. 10.1186/1756-0500-7-599
16. Theivasigamani K, Palaniappan S: Assessment of Knowledge of Diabetes Mellitus among the Rural
Population of Erode District of Tamil Nadu, South India. J Young Pharm. 2022, 28:174-181.
10.5530/097515050532
17. Deepa M, Bhansali A, Anjana RM, et al.: Knowledge and awareness of diabetes in urban and rural India: The
Indian Council of Medical Research India Diabetes Study (Phase I). Indian Council of Medical Research India
Diabetes 4. Indian J Endocrinol Metab. 2014, 18:379-385. 10.4103/2230-8210.131191
18. Mathur P, Leburu S, Kulothungan V: Prevalence, Awareness, Treatment and Control of Diabetes in India
From the Countrywide National NCD Monitoring Survey. Front Public Health. 2022, 14:748157.
10.3389/fpubh.2022.748157
19. Chaudhary F, Chaudhary S: Awareness about diabetes risk factors & complications in diabetic patients: a
cross sectional study. Nishtar Med J. 2010, 3:84-88.
20. Lemes dos Santos PF, dos Santos PR, Ferrari GSL, Fonseca GAA, Ferrari CKB. Knowledge of Diabetes
Mellitus: Does Gender Make a Difference: Osong Public Health Res Perspect . 2014, 5:199-203.
10.1016/j.phrp.2014.06.004
21. Kumar K, Misra S: Sex differences in prevalence and risk factors of hypertension in India: Evidence from the
National Family Health Survey-4. PLoS One. 2021, 13:0247956. 10.1371/journal.pone.0247956
22. Salleh RM, Rahman NAA, Haque M: Knowledge, Attitude and Practice Regarding Type 2 Diabetes Mellitus
Among Outpatients in a Health Center in East-Coast of Peninsular Malaysia. Istanbul Med J. 2019, 20:208-
213. 10.4274/imj.galenos.2018.80557
23. Suresh N, Thankappan KR: Gender Differences and Barriers Women Face in Relation to Accessing Type 2
Diabetes Care: A Systematic Review. Indian Journal of Public Health. 2019, 63:65-72.
10.4103/ijph.IJPH_26_18
24. Syed W, Alharbi MK, Samarkandi OA, et al.: Evaluation of Knowledge, Awareness, and Factors Associated
with Diabetes: A Cross-Sectional Community-Based Study. Int J Endocrinol. 2022, 2022:1921010.
10.1155/2022/1921010
25. Hardcastle SJ, Hancox J, Hattar A, Maxwell-Smith C, Thøgersen-Ntoumani C, Hagger MS: Motivating the
unmotivated: how can health behavior be changed in those unwilling to change?. Front Psychol. 2015,
6:835. 10.3389/fpsyg.2015.00835
26. Balla J, Hagger MS: Protection motivation theory and health behaviour: conceptual review, discussion of

12 of 13
limitations, and recommendations for best practice and future research. Health Psychol Rev. 2024, 1-27.
10.1080/17437199.2024.2413011

13 of 13