Abstract
Background
Knowing when to start insulin is central to optimal management of Type 2 diabetes mellitus (T2DM) but a real clinical challenge. Poor glycemic control is critical for development of the deadly diabetic complications.
Objective
The aim of the study was to assess the appropriateness of insulin commencement, adequacy of glycemic control and associated factors among patients with T2DM.
Settings
The study was conducted at three public hospitals in Southwest Ethiopia.
Methods
Cross sectional study was conducted using structured questionnaire and data abstraction format. All patients with T2DM who were available during the data collection period and fulfilling study criteria were included.
Main outcome measure
Multivariable binary logistic regression analysis was done for identifying factors associated with poor glycemic control by taking statistical significance at p value ≤0.05.
Results
One hundred sixty nine patient data was considered for analysis. Insulin was initiated in 28 patients, but only 10(35.7%) insulin commencements were appropriate. More than two third (70.4%) of the studied population had poor glycemic control. Addition of second antidiabetic medication (Adjusted Odds Ratio (AOR) = 2.5, 95% CI = 1.3–6.2) and living in urban areas (AOR = 2.5, 95% CI = 1.1–5.7) were associated with poor glycemic control while having regular diabetic care follow up of every >1 month (AOR = 0.4, 95% CI = 0.2–0.9) was negatively associated with poor glycemic control.
Conclusions
About two third of insulin commencements were inappropriate and majority of patients could not stay on optimal glycemic control. Addition of second antidiabetic medication and living in urban areas were found to be associated with poor glycemic control.
Impact of findings on practice statements
• Initiation of insulin before optimization of oral agents increase cost of care.
• Proper titration of the first oral agent is important prior to adding other antidiabetic agents.
• Emphasis should be given to improve glycemic control, and hence halt subsequent complications.
Keywords: T2DM, Glycemic control, Insulin, Southwest Ethiopia
Introduction
Diabetes mellitus (DM) is a group of metabolic diseases characterized by hyperglycaemia with disturbance of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both [1]. It is a growing public health problem that adversely affects the lives of millions of individuals around the world. It causes significant physical and psychological morbidity, disability and premature mortality among those affected patients and imposes a heavy financial burden on health services [2]. According to the International Diabetes Federation (IDF), 415 million adults, aged 20–79, were estimated to live with diabetes worldwide in 2015, with world prevalence of 8.8%. About 75% live in low- and middle income countries. Ethiopia, which is one of the low income nations, is at a risk of increased diabetes incidence; 2.9% of the population of aged 20–79 years were estimated to live with diabetes in 2015 [3].
The epidemic of Type 2 Diabetes Mellitus (T2DM) threatens to become the major public health problem of this century [4]. When managing T2DM, the general focus is on achieving and maintaining good glycemic control while minimizing the potential for adverse events such as hypoglycemia [5]. The development of long-term complications is influenced by hyperglycemia and poor control of diabetes could accelerate their progression [6].T2DM is a progressive disease and eventually almost all patients will require insulin to maintain good glycemic control. Knowing when and how to start insulin is central to the optimal management of T2DM. The problem is when and how to commence insulin in these patients. Despite the promulgation of various ‘guidelines’, there is no single HbA1c concentration which suits everyone [5, 7].
Aim of the study
To the best of our knowledge, evidence-based research on assessment of timing of insulin initiation and glycemic control among diabetes patients in Ethiopia is scanty. The present study was therefore carried out to assess the appropriateness of insulin initiation and adequacy of glycemic control among ambulatory patients with T2DM in Southwest Ethiopia. The findings will have contribution to the existing body of knowledge in the area and foster timely commencement of insulin and optimal glycemic control among affected patients.
Ethics approval
Ethical clearance and approval of the study protocol was granted from the Ethical Review Board of Mizan Tepi University. The letter of approval and cooperation was written to each respective hospital (Ref. no. CHS/198/2017). Prior to data collection, individual informed verbal consent was obtained from the study patients. No personal identifier was collected and the data maintained confidentially.
Methods
A multi-centred facility based cross sectional study was conducted for a data collection period of 5 months in three hospitals found in Southwest Ethiopia, namely Mizan-Tepi University Teaching Hospital (MTUTH), Tepi Hospital and Gebretsadik Shawo Hospital. All adult patients aged 18 years and above with T2DM who took antidiabetic medications at least for three months and available during the study period were included. Accordingly, 193 patients were included but only 169 patient data was considered for analysis. Therefore, 50, 65 and 54 patients were recruited from MTUTH, Gebretsadik Shawo Hospital and Tepi General Hospital, respectively. Non-cooperative patients and patients with incomplete medical records were excluded from the study. Data was collected using a structured questionnaire and data abstraction format. The standard 8 items Morisky instrument was utilized to assess level of antidiabetic medication adherence.
Patients were recruited to the presented study from chronic care unit of each study setting. As long as study criteria were met, every patient with type 2 diabetes was allowed to be included. First, patients were interviewed after physician visit and then their medical record were reviewed in the same day after the interview. The following measures were taken to maintain the quality of data: Training for data collectors, pre-test on data collection instruments, close supervision during data collection and daily assurance of completeness on the collected data. Data was entered using Epi-Info version 3.5.3 and analyzed with SPSS windows version 22. Frequencies were computed for description of the study population in relation to socio-demographic and other relevant variables. Statistical associations were determined by logistic regression analysis using crude and adjusted odds ratio. Statistical significance was declared at p value ≤0.05 at 95% CI.
Inappropriate insulin initiation was defined as insulin initiated early before optimizing oral hypoglycemic medications or delayed/deferred insulin initiation in patients with poor glycemic control despite optimized treatment with oral hypoglycemic medications. On the other hand poor/ inadequate glycemic control was considered when a patient had mean FBS > 130 mg/dL [8].
Results
Sociodemographic characteristics of study participants
One hundred sixty nine patient data was considered in the analysis. Males comprised the majority of the sex category. Mean age of the studied population was 51.6 years. Majority (82.8%) of the studied population was married. Out of pocket expenses constituted the majority of medical care expense accounting for 89.3% of the studied population. The average cost spent for out of pocket medical care was 160.9 Ethiopian Birr (ETB) (Table 1).
Table 1.
Sociodemographic characteristics of ambulatory patients with type 2 diabetes attending three hospitals at southwest Ethiopia, 2017
| Variables | Category | Frequency | % |
|---|---|---|---|
| Sex | Male | 94 | 55.6 |
| Female | 75 | 44.4 | |
| Age (Years) | ≤ 40 | 37 | 21.9 |
| 41–50 | 48 | 28.4 | |
| 51–60 | 52 | 30.8 | |
| >60 | 32 | 18.9 | |
| Marital Status | Single | 7 | 4.1 |
| Married | 140 | 82.8 | |
| Divorced | 9 | 5.3 | |
| Widowed | 13 | 7.7 | |
| Occupation | Farmer | 39 | 23.1 |
| Gov’t Employee | 32 | 18.9 | |
| Merchant | 33 | 19.5 | |
| Housewife | 46 | 27.2 | |
| Others* | 19 | 11.2 | |
| Educational Status | Cannot read and write | 41 | 24.3 |
| Primary | 72 | 42.6 | |
| Secondary | 27 | 16.0 | |
| Higher Education | 29 | 17.2 | |
| Residence | Rural | 48 | 28.4 |
| Urban | 121 | 71.6 | |
| Monthly family income (ETB) (n = 123) | <1644 | 28 | 22.8 |
| ≥1644 | 95 | 77.2 | |
| Who covers your medical expenses | Free | 12 | 7.1 |
| Out of pocket | 151 | 89.3 | |
| Community health | 4 | 2.4 | |
| NGO | 2 | 1.2 |
ETB Ethiopian Birr, NGO Non-governmental Organization
*construction, Driver, Garage (mechanic), Guard, Metal Work, Teacher
Non-pharmacological approaches of diabetes care
Almost one third of the studied population had ever drunk alcohol regularly, out of which, 10.4% of them continued to drink alcohol to the present day. Likewise, 20.1% and 4.7% of patients ever chewed khat and smoked cigarette on a regular basis, respectively. Four patients (11.8%) and 1(12.5%) patient were currently chewing khat and smoking cigarette from those patients who had ever chewed khat and smoked cigarette, respectively. Majority of the patients (63.3%) and (88.8%) claimed that they were doing a regular exercise and were adhering to dietary recommendations, respectively (Table 2).
Table 2.
Non pharmacological approaches of diabetes care among ambulatory patients with type 2 diabetes attending three hospitals at southwest Ethiopia, 2017
| Variables | Category | Frequency | % |
|---|---|---|---|
| Ever drunk alcohol regularly | Yes | 48 | 28.4 |
| No | 121 | 71.6 | |
| Currently drink alcohol regularly (n = 48) | Yes | 5 | 10.4 |
| No | 43 | 89.6 | |
| Ever chew khat regularly | Yes | 34 | 20.1 |
| No | 135 | 79.9 | |
| Currently chewed khat regularly (n = 34) | Yes | 4 | 11.8 |
| No | 30 | 88.2 | |
| Ever smoked cigarette regularly | Yes | 8 | 4.7 |
| No | 161 | 95.3 | |
| Currently smoke cigarette regularly (n = 8) | Yes | 1 | 12.5 |
| No | 7 | 87.5 | |
| Exercise regularly | Yes | 107 | 63.3 |
| No | 61 | 36.1 | |
| Dietary adherence | Yes | 150 | 88.8 |
| No | 19 | 11.2 | |
| Have glucometer | Yes | 31 | 18.3 |
| No | 138 | 81.7 | |
| Days for SMBG per week (n = 31) | <7 | 28 | 90.3 |
| ≥ 7 | 3 | 9.7 |
SMBG Self-Monitoring of Blood Glucose
Clinical information
The mean duration of type 2 diabetes among the studied population was 3.3 years (SD = 3.3 years). Almost all patients had regular follow up for their disease, and majority of them (78.4%) did this every month. About one third (30.2%) of patients had chronic diabetic complications, diabetic neuropathy being the most common complication. On the other hand, a quarter of the patients had a history of acute diabetic complications, diabetic ketoacidosis being the major one. Half of the studied population had at least one chronic comorbid disease, hypertension being the major comorbid disease accounting for 76.7% of the comorbidity (Table 3).
Table 3.
Clinical Information of ambulatory patients with type 2 diabetes attending three hospitals at southwest Ethiopia, 2017
| Variables | Category | Frequency | % |
|---|---|---|---|
| Any family member with DM | Yes | 28 | 16.6 |
| No | 141 | 83.4 | |
| Duration of DM (Years) (n = 156) | <5 | 126 | 80.8 |
| ≥5 | 30 | 19.2 | |
| Presence of DM regular follow up | Yes | 167 | 98.8 |
| No | 2 | 1.2 | |
| Frequency of DM regular follow up (n = 167) | Monthly | 131 | 78.4 |
| Every 2 months | 20 | 12.0 | |
| Every ≥3 months | 16 | 9.6 | |
| History of hospitalization due to DM Complications, last 12 months | Yes | 29 | 17.2 |
| No | 140 | 82.8 | |
| Presence of Chronic DM Complications | Yes | 51 | 30.2 |
| No | 118 | 69.8 | |
| Type of chronic DM Complications (n = 57) | Retinopathy | 4 | 7.0 |
| Neuropathy | 46 | 80.7 | |
| CAD/MI | 2 | 3.5 | |
| Diabetic Foot Ulcer | 3 | 5.3 | |
| Others* | 2 | 3.5 | |
| History of acute DM complication | Yes | 43 | 25.4 |
| No | 126 | 74.6 | |
| Type of acute DM Complications (n = 43) | DKA | 37 | 86.0 |
| HHS | 6 | 14.0 | |
| Presence of comorbidity | Yes | 86 | 50.9 |
| No | 83 | 49.1 | |
| Type of comorbidity (n = 86) | Hypertension | 66 | 76.7 |
| Heart Failure | 5 | 5.8 | |
| Others ** | 15 | 17.4 |
CAD/MI Coronary Artery Disease/Myocardial Infarction, DKA Diabetic Ketoacidosis, DM Diabetes Mellitus, HHS Hyperglycemic Hyperosmolar State
*Erectile Dysfunction, Gastroparesis
**Asthma, Peptic Ulcer Disease, HIV/AIDS, Tuberculosis, Stroke
Blood glucose measurements and glycemic control
Baseline FBS was recorded for 52.7% of the studied population and the mean FBS value was found to be 244.2 mg/dl. From 28 patients who were treated with basal insulin, the mean baseline FBS value for 23 patients at basal insulin initiation was 393.9 mg/dl. The most three recent mean FBS values for the studied population (from most recent to oldest) were 163.0 mg/dl, 158 mg/dl and 160.4 mg/dl, respectively. Only 22(13.0%) patients stayed on glycemic control (FBS ≤ 130 mg/dl) in all these most three recent measurements (Table 4).
Table 4.
Blood glucose measurements of ambulatory patients with type 2 diabetes attending three hospitals at southwest Ethiopia, 2017
| Variables | Category | Mean(SD) |
|---|---|---|
| Baseline FBS (n = 89) | – | 244.2(93.0) |
| Baseline RBS (n = 32) | – | 393.9(142.9) |
| FBS at basal insulin initiation (n = 23) | – | 257.3(116.8) |
| The last 3 follow ups FBS level before basal insulin initiation | FBS at immediate 1st follow up (n = 13) | 245.3(75.9) |
| FBS at immediate 2nd follow up (n = 13) | 280.2(153.6) | |
| FBS at immediate 3rd follow up(n = 14) | 234.2(113.7) | |
| Most recent FBS values (Recent to oldest) | FBS 1 | 163.0(60.3) |
| FBS 2 | 158.5(63.5) | |
| FBS 3 | 160.4(58.3) |
FBS Fasting Blood Sugar in mg/dl, RBS Random Blood Sugar in mg/dl, SD Standard Deviation
Mean of the most three recent FBS values was calculated for all the studied population. Accordingly, 50(29.6%) and 119(70.4%) patients had good/adequate (FBS ≤ 130 mg/dl) and poor/inadequate (FBS > 130 mg/dl) glycemic control, respectively (Fig. 1).
Fig. 1.
Number of times ambulatory patients, with T2DM attending three hospitals at southwest Ethiopia, stayed on glycemic control out of the three most FBS values, 2017
Out of the three most recent FBS values, for 80(47.3%) patients, none of the three values were inside goal glycemic control. On the other hand, for 30(17.8%) and 37(21.9%) patients, the FBS values were within the goal glycemic level only one and two times, respectively. All the three values were within the goal glycemic level for 22(13.0%) patients (Fig. 1).
Medication and adherence related information
The standard 8 items Morisky instrument was administered to assess level of antidiabetic medication adherence. Accordingly, about half of the studied population had high level of adherence. Forgetfulness was found to be the main reason mentioned for medication non-adherence by the majority of patients (78.3%). Only 16.6% of patients were initiated on basal insulin, for majority of them it was stated as it was not possible to have glycemic control only with the oral hypoglycemic agents. Among these insulin initiations, 18(64.3%) were inappropriate. From these inappropriate insulin initiations/commencements, 16(88.9%) were too early while the rest 2(11.1%) initiations were delayed. There were 117(69.2%) second drug additions among the studied population where only a quarter of them were appropriate (Table 5).
Table 5.
Medication and adherence related information of ambulatory patients with type 2 diabetes attending three hospitals at southwest Ethiopia, 2017
| Variables | Category | Frequency | % |
|---|---|---|---|
| Anti-DM Medication adherence level | Low | 28 | 16.6 |
| Medium | 55 | 32.5 | |
| High | 86 | 50.9 | |
| Reasons for Anti-DM Medication non-adherence (n = 83) | Forgetfulness | 65 | 78.3 |
| Financial constraints | 8 | 9.6 | |
| Others* | 10 | 12.0 | |
| Patient placed regularly on basal Insulin | Yes | 28 | 16.6 |
| No | 141 | 83.4 | |
| Started basal insulin attributed to ADRs with OHAs (n = 28) | Yes | 3 | 10.7 |
| No | 25 | 89.3 | |
| Type of OHA before basal Insulin | Metformin | 20 | 50.0 |
| Glibenclamide | 20 | 50.0 | |
| Appropriateness of insulin initiation (n = 28) | Appropriate | 10 | 35.7 |
| Inappropriate | 18 | 64.3 | |
| Inappropriate insulin commencement (n = 18) | Too early | 16 | 88.9 |
| Delayed | 2 | 11.1 | |
| Second drug addition | Yes | 117 | 69.2 |
| No | 52 | 30.8 | |
| Appropriateness of second antidiabetic drug addition (n = 117) | Appropriate | 30 | 25.6 |
| Inappropriate | 87 | 74.4 |
ADRs Adverse Drug Reactions, DM Diabetes Mellitus, OHAs Oral Hypoglycemic Agents
*distance, fasting, side effect, unavailability, complex regimen, feeling well without treatment, getting worse with treatment
Factors associated with poor glycemic control
On Multivariable binary logistic analysis, patients living in urban areas and patients with addition of a second antidiabetic medication were 2.5(AOR = 2.5, 95% CI = 1.1–5.7) and 2.9(AOR = 2.5, 95% CI = 1.3–6.2) times more likely to have poor glycemic control compared with patients living in rural areas and patients with monotherapy, respectively. On the contrary, patients having regular diabetes care follow ups every >1 month were 0.6 times (60%) less likely to have poor glycemic control compared with patients who had regular diabetes care follow ups every ≤1 month (AOR = 0.4, 95% CI = 0.2–0.9) (Table 6).
Table 6.
Multivariable logistic regression analysis of factors associated with glycemic control among ambulatory patients with T2DM attending three hospitals at southwest Ethiopia, 2017
| Variables | Poor Glycemic Control | COR, 95% CI | AOR, 95% CI | |
|---|---|---|---|---|
| No (%) | Yes (%) | |||
| Residence | ||||
|
Rural Urban |
20(41.7) 30(24.8) |
28(58.3) 91(75.2) |
1.00 2.2(1.1–4.4)* |
1.00 2.5(1.1-5.7)* |
| Ever Used Substance | ||||
|
No Yes |
27(25.7) 23(35.9) |
78(74.3) 41(64.1) |
1.00 0.6(0.3–1.2) |
1.00 0.5(0.2–1.2) |
| Exercise Regularly | ||||
|
No Yes |
21(34.4) 29(27.1) |
40(65.6) 78(72.9) |
1.00 1.4(0.7–2.8) |
1.00 1.2(0.5–2.6) |
| Dietary Non Adherence | ||||
|
No Yes |
45(30.0) 5(26.3) |
105(70.0) 14(73.7) |
1.00 1.2(0.4–3.5) |
1.00 0.8(0.2–2.8) |
| Frequency of DM follow ups | ||||
|
Every ≤1 Month Every >1 Month |
34(25.6) 16(44.4) |
99(74.4) 20(55.6) |
1.00 0.4(0.2–0.9)* |
1.00 0.4(0.2-0.9)* |
| Duration of DM | ||||
|
<5 Years ≥ 5 Years |
41(32.5) 6(20.0) |
85(67.5) 24(80.0) |
1.00 1.9(0.7–5.1) |
1.00 1.9(0.7–5.5) |
| Addition of second antidiabetic medication | ||||
|
No Yes |
23(44.2) 27(23.1) |
29(55.8) 90(76.9) |
1.00 2.6(1.3–5.3)* |
1.00 2.9(1.3-6.2)* |
*Statistically Significant: p value ≤0.05
Discussion
In this study, out of 169 patients with T2DM, only 28(16.6%) patients were placed on basal insulin. Among those, majority of them (25 patients) were placed on basal insulin as it was not possible to achieve goal glycemic control only with the oral hypoglycemic agents, despite insulin was commenced before proper titration of oral agents. But, of these basal insulin initiations, about two third (64.3%) were inappropriate; 88.9% too early and 11.1% delayed, most were initiated before proper titration of oral agents. A similar retrospective study was conducted in US by Bhattacharya et al. among 14,669 patients with T2DM, in which insulin was initiated early in 32% and delayed in 20% of the studied population [9]. On the other hand, another retrospective study conducted by Rubino et al. in UK among patients with 2501 T2DM found that 25% of patients had insulin initiation delayed for at least 1.8 years, and 50% of patients delayed starting insulin for almost 5 years after failure of glycemic control with oral hypoglycemic agents [10]. A second UK study conducted by Alex Wright and colleagues among patients with T2DM identified that early addition of insulin when maximal oral hypoglycemic therapy is inadequate can significantly improve glycemic control [11]. Insulin remains the only glucose-lowering therapy that is efficacious throughout this continuum. However, the timing of introduction of insulin therapy remains to be a challenge. Nevertheless, the early initiation of basal insulin has been shown to improve glycemic control and affect long-term outcomes [12].
Our study revealed that less than a third of the studied population (29.6%) was found to have adequate glycemic control, which is defined as FBS ≤ 130 mg/dl. This result was lower than the results from almost all of the following various studies, which reported a rate ranging from 21.4% to 61.7%: Ethiopia (41.8%), Southwestern Nigeria (40.3%), Tanzania (32.9%), Eastern Nigeria (61.7%), Malaysia (26.9%) and India (21.4%) [13–18]. According to our finding, out of 28 patients who were placed on basal insulin on a regular basis, only four (14.3%) patients had good glycemic control. The management of DM ensures normal FBS levels necessary for short-term and long-term control and reduction of acute and chronic complications [16]. Glycemic control is a strong predictor of diabetes complications, particularly microvascular complications [19]. Failure in achievement of clinical blood glucose targets is therefore of phenomenal importance and can lead to increased hospital visits, preventable emergency admissions and deaths. As such, regular testing of blood glucose is a cornerstone and achievement of adequate glycemic control is a goal for proper diabetes care.
In this study, patients living in urban areas were found to have poor glycemic control compared with patients living in rural areas. On cross tabulation, among patients who were government employees, traders and housewives, each of 93.8%, 90.9% and 71.7% were living in urban areas, respectively. The nature of these jobs might be associated with less exercise which in turn might result in poor glycemic control among this population. Moreover, among patients who were farmers, 74.4% of them were living in rural areas and the nature of this job might contributed to better glycemic control among this population as day to day exercise is the very nature of farming activities. Similar other studies have failed to report any association between these two variables [20–24].
It is obvious that addition of second antidiabetic medication is essential for better glycemic control when it is not possible to achieve goal glycemic level only with one drug. However, in the current study, addition of second antidiabetic medication was found to have a negative association with optimal glycemic control. This is a possibility and might be a result of higher percentage of patients with low level of antidiabetic medication adherence (71.4%), for whom second antidiabetic medication was added. The high percentage of patients with low level of adherence in turn might be due to possible pill burden which is reported in many literatures as it can affect adherence [13–17]. Even, the percentage of patients with chronic comorbid diseases was high (64.0%) among patients with poor glycemic control and on second antidiabetic medication, which may further justify the potential pill burden. On the other hand, presence of comorbidity and level of antidiabetic medication were not included in the final selected multivariable analysis model, hence the association might be confounded so that caution has to be exercised in taking this association. Similar studies reported aaddition of second antidiabetic medication is vital for achieving goal glycemic control [9, 11].
Finally, frequency of regular DM follow up was the other variable found to have a statistically significant association with the level of glycemic control among the studied population. Patients who had every >1 months of regular DM follow up were less likely to have poor glycemic control, compared with patients who had every ≤1 months of regular DM follow up. A study conducted by Goudswaard et al., reported similar finding that more GP visits for diabetes was associated with poor glycemic control [21]. This finding should also be taken with caution. Patients with poor glycemic control will mostly visit their doctors more frequently than those patients who are stable with respect to their blood sugar level. Clinical guidelines support this finding that patients with controlled blood sugar level are only required to have less frequent follow ups (every 3 months) than patients who failed to achieve adequate glycemic control, where it is recommended to have more frequent visits. Hence, the present study revealed that higher percentage of patients with poor glycemic control had more frequent visits (74.4%). Similar other studies have failed to report any association between these two variables [25, 26].
The cross-sectional nature of the study did not allow a follow up, which would have provided a better design for identifying the problem of inadequacy in glycemic control. The limitations of using fasting plasma glucose to assess adequacy of glycemic control was also recognized by the researchers. Adequacy of glycemic control would have been different if the gold standard measure of blood glucose level (HbA1c) was used. Of great concern was non availability of HbA1c assay in the study settings. Number of patients recruited was small; hence care should be exercised in extrapolating study findings as limited sample size can affect the power of study.
Conclusion
About two third of insulin commencements were inappropriate and majority of patients couldn’t stay on optimal/goal glycemic control. Addition of second antidiabetic medication and living in urban areas were found to be associated with poor glycemic control while having regular diabetic care follow up of every >1 month was found to be preventive for poor glycemic control. Interventions that reduce too early and delayed insulin initiations are required to avoid unnecessary medication burden and help achieve and maintain recommended glycemic targets in patients with Type 2 diabetes, respectively. In view of the adverse effects of hyperglycemia leading to severe morbidity and increased mortality among the diabetic patients, a tight control of blood glucose level is mandatory.
Acknowledgements
We would like to extend our gratitude to Mizan Tepi University, Research Directorate for funding this study.
Authors’ contributions
TT: Selecting title, conceiving methodology, facilitating data collection, involved in data analysis, preparing manuscript.
AT: Selecting title, conceiving methodology, facilitating data collection, involved in data analysis, editing manuscript.
HA: Selecting title, conceiving methodology, facilitating data collection, involved in data analysis, editing manuscript.
Data availability
Every material is included in the manuscript and there is no supplementary file to be attached with this manuscript. Every dataset that is necessary to interpret the findings is included in this manuscript.
Compliance with ethical standards
Conflict of interest
The authors declared that they have no conflict of interest.
Consent for publication
Not applicable.
Footnotes
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Contributor Information
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Tessema Tsehay Biru, Email: tessema.tsehay@gmail.com.
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Associated Data
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Data Availability Statement
Every material is included in the manuscript and there is no supplementary file to be attached with this manuscript. Every dataset that is necessary to interpret the findings is included in this manuscript.