Awareness and Perceptions of Type 2 Diabetes Risk Factors, Preventability, and Complications Among College Students in Visakhapatnam, India

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1 Applied Research Awareness and Perceptions of Type 2 Diabetes Risk Factors, Preventability, and Complications Among College Students in Visakhapatnam, India International Quarterly of Community Health Education 2016, Vol. 37(1) 27 32! The Author(s) 2016 Reprints and permissions: sagepub.com/journalspermissions.nav DOI: / X journals.sagepub.com/home/qch Randy M. Page 1, Elizabeth Stones 1, Oliver Taylor 1, and Kendra Braudt 1 Abstract In India, often referred to as the diabetes capital of the world, it is imperative to establish the level of knowledge among Asian Indians of Type 2 Diabetes (DM2) in order to plan effective public health programs aimed at prevention of DM2. Using an original survey of 983 college students in Visakhapatnam, Andhra Pradesh, we evaluated individuals knowledge of DM2 including prevalence, risk factors, and prevention. To date, there are only a few studies that look at awareness of diabetes on the community level, and no previous studies have involved sampling college students. Our findings show that although awareness of diabetes is high, only half of the students sampled were aware that DM2 could be prevented and 60% were unaware that little or no exercise was a risk factor. The results suggest that diabetes awareness programs are needed among the college age population in India to prevent DM2. Keywords diabetes, Type 2 diabetes, diabetes prevention, India Introduction Type 2 diabetes (DM2) appears to be the most pronounced in the developing countries of the world, in countries which have large and fast-growing populations. Between 2010 and 2030, it is estimated that DM2 will increase by 69% in developing countries. 1 With every fifth diabetic in the world being Asian Indian, India has been suggested as the diabetic capital of the world. 2 Guariguata et al. 3 cite that 65 million people in India have DM2 and this number is expected to reach 109 million by Several factors have been suggested to account for the high prevalence of DM2 in India. Studies have found that Asian Indians have a particular phenotype that leaves them susceptible to diabetes. 4 Other individual risk factors such as obesity, insulin intolerance, and hypertension may also contribute to the high rates of DM2. 5 Environmental factors including rapid urbanization and socioeconomic and lifestyle transitions are associated with a rising prevalence of diabetes due to an increased consumption of fats in the diet and sedentary lifestyle. 6 Low-birth-weight babies who rapidly gain weight during childhood have been found to be at high risk for diabetes, possibly a reflection of rapid urbanization in India. 4,7 Asian Indians develop DM2 at a younger age and at a lower body mass index compared with western populations. 8 Limaye et al. 9 stress the importance of modifications in lifestyle in the prevention of DM2 such as poor diet, physical inactivity, and obesity and that this can only be achieved if individuals awareness of the preventability and control of the disease is improved. Assessing awareness of preventability and control of DM2 is a critical first step toward designing appropriate health education and intervention programs. A study conducted in India s fourth most populous city, Chennai, found that approximately 25% of survey respondents did not know what diabetes was and 78% were unaware that it is preventable. 10 A more recent study in Chennai showed that knowledge was particularly low in women and the low literate population. 11 There is limited literature on awareness of the preventability and control of DM2 in India, 9 and no studies of college or university students specifically have been reported. University students living in Visakhapatnam, India may represent a population at high risk for diabetes due to factors such as rapid urbanization of the city and other lifestyle factors 1 Department of Health Science, Brigham Young University, Provo, UT, USA Corresponding Author: Randy M. Page, Department of Health Science, Brigham Young University, 2030 Life Science Building, Provo, UT 84602, USA. randy_page@byu.edu

2 28 International Quarterly of Community Health Education 37(1) common among college students that might contribute to diabetes. 12,13 With a higher level of education compared with others of their age, it would be expected that college students would have higher levels of awareness of DM2 relative to those without the opportunity to attend to college. We conducted a questionnaire-based survey to identify awareness in a sample of students attending colleges in Visakhapatnam. The survey was initiated and carried out by American college students interested in diabetes prevention among their crosscultural peers attending Indian universities. Methods Study Area and Population The study was conducted with the cooperation of seven colleges and universities in Visakhapatnam, Andhra Pradesh, India. These colleges and universities helped facilitate the administration of a survey questionnaire to a total of 983 students and represented students studying a wide variety of disciplines. The average age of participants was 19 20, with ages ranging from 16 to 35 years. Of the respondents, 58% were female and 42% were male. All sample members were students. Students attended two major universities in Visakhapatnam (Andhra University and GITAM University) or smaller colleges and universities (Gayatri Vidya Parishad College of Engineering, Samata College, VMC Degree College, Damodaram Sanjivayya National Law University, and Integral Institute of Advanced Management). It is estimated that the total number of students attending these seven universities was 45,000 to 50,000 students. The investigators met with officials at each of the seven universities and asked if they would be willing to be included in the study. The investigators asked if they could survey between 100 and 200 of their students. Each university arranged which classes would be surveyed and helped to facilitate the administration of the survey in those particular classes. As a result, the students in this sample represented students studying business, engineering, law, economics, and zoology. It should be pointed out that this sample of convenience likely was not representative of all students at the seven universities because it did not randomly or systematically sample students at the various universities. Visakhapatnam is the largest city in the state of Andhra Pradesh and has seen rapid urbanization over the past decade experiencing significant growth in the industry and technology fields. The primary languages spoken in Visakhapatnam are Telugu, Hindi, and English. Hinduism is the predominant religion followed by Buddhism and Christianity. Data Collection Survey. The questionnaire developed for this study focused on issues surrounding awareness of DM2 preventability and control and included items taken from a survey of diabetes awareness in Chennai, India, 14 the Australian diabetes knowledge questionnaire, 15 and a study conducted by Al-Balqa Applied University in Jordan. 16 Items were grouped into three areas: risk factors for DM2, preventing DM2, and treatment and control of DM2. Survey instructions stipulated that questions ask about DM2 and not diabetes in general. All items were statements in which respondents had three response options: True, False, ori don t know. The survey questionnaire also included items asking students items such as gender; age; year in college; degree working on; whether been told by a doctor or other health professionals that you have diabetes; type of diabetes you have (Type 1, Type 2, or I don t know); whether a doctor or health professional has told anyone in their immediate family or extended family that they have diabetes; whether they have ever heard of diabetes; whether they have ever heard of prediabetes; and whether they believed that diabetes is increasing. The survey instrument had a total of 34 items. Procedures and analysis. The research investigators distributed the survey in classrooms at the schools and then provided an explanation of the survey. A translator was available to help with any questions student respondents had while taking the survey and served as a liaison between the universities and researchers. The survey took students approximately 15 minutes to complete. Following completion, surveys were collected and entered into an Excel spread sheet for analysis. SAS version 9.4 was used to analyze the data. Approval for this research was obtained by the authors university institutional review board prior to initiating this research. Students were informed orally and in the written introduction to the survey that they did not have to be in the study if they did not want to be and that they could opt out of participation. They were also instructed (orally and in the written introduction to the survey) that The completion of the survey implies your consent to participate. If you choose to participate, please complete the attached survey and place it in the envelope at the front of the classroom when you have completed it. Students were informed that if they did not want to complete the survey that they could return it to the envelope in the same fashion as the students choosing to participate. Students were also instructed not to place their names or any identifying information on the survey, and that their answers will not be linked to them in any way and that they will not be contacted again in the future. Results A total of 983 students from the seven colleges and universities completed the survey questionnaire. Of these students, 41.8% (392) were male, 58.2% (546) were female, and 45 did not report their gender. Students ranged from 16 to 35 years of age, with 71.7% (774) between the ages of 18 to 22 and only 4 students older than 25 years. Approximately three

3 Page et al. 29 quarters (77.3%, n ¼ 710) of the students were working on bachelor s degrees, and 21.6% (n ¼ 199) on master s degrees and 1.1% (n ¼ 10) on a doctoral degree (64 did not report degree). In response to the question, Have you been told by a doctor or health professional that you have diabetes? 11.5% of the respondents said yes (presumed diabetes). Of these, 72.6% did not know what type of diabetes they were told they had, 14.8% said they were told they had Type 2, and 12.6% were told they had Type 1. Of all respondents, 37.7% said that someone in their immediate family has been told by a doctor or other health professional that they have diabetes. In students with presumed diabetes, 52.5% reported having an immediate family member with diabetes, compared with 35.8% of those without presumed diabetes. This difference was significant ( 2 ¼ 13.0, df ¼ 1, p ¼.0015). Overall awareness of diabetes was high with 93.5% of all respondents reporting that they had heard of diabetes. However, 72.2% had heard of prediabetes (the condition of having some insulin resistance and slightly elevated blood glucose levels that can be reversed with dietary or lifestyle changes). Most respondents (94.5%) agreed that an increasing number of people are getting diabetes nowadays. Risk Factors for DM2 Results for awareness of risk factors for DM2 are reported in Table 1. Awareness was highest for the following risk factors (at least a majority of respondents indicated awareness): obesity (63.7%), eating a lot of sweets (68.1%), family history of diabetes (63.2%), and age or found most often in adults over 45 (60.2%). The level of awareness was lower for the following risk factors: little or no exercise (40.5%), hypertension (47.2%), and pregnancy (46.1%), and that DM2 can be found in children (39.0%). Almost 40% (39.7%) did not know that DM2 can be found in children and 27.3% indicated that it was false that it can be found in children. Only 43.9% recognized that that DM2 is contagious as false, with 18.7% believing DM2 to be contagious and 37.4% reporting that they did not know. Only 55.8% reported as false that diabetes is a result of past sins with 15.6% identifying this notion as true and 28.6% reporting that they did not know. Preventing DM2 Only half of the sample (50.1%) identified that DM2 can be prevented. Further, only 29.2% recognized the disease as a chronic disease and 29.8% viewed it as an incurable disease ( cannot be cured ). About half of respondents identified DM2 as blood sugar over healthy levels. Awareness that people with DM2: should exercise was at 69.5% of respondents; should eat a diet low in fat, high in fiber, and low in added sugar was at 74.5% of respondents; and (among those who are overweight) should aim to lose weight was at 60.5%. Approximately one third of respondents (34.0%) held the misconception that soaking feet in water may lower blood sugar levels, with 41.2% not knowing whether this was true or false. Results for awareness of prevention of DM2 are presented in Table 2. Complications of DM2 Less than half of survey respondents recognized that DM2 can impair kidneys (46.8%), eyes (35.4%), nerves (41.9%), and lower limbs such as losing toes (40.3%). More than one third (36.6%) recognized that insulin does not function well in people with DM2 and slightly more than half (52.1%) believed that a lack of insulin is found in DM2. Results concerning complications of DM2 are presented in Table 3. Discussion Citing India with the dubious distinction as a global diabetes capital of the world, Ghadge et al. 17 stress that studies assessing the awareness level of diabetes in various Indian populations are crucial. Information on the level of Table 1. Awareness of Risk Factors for Type 2 Diabetes (DM2). True % (n) False % (n) I don t know % (n) A risk factor for DM2 is obesity (599) (240) (101) A risk factor for DM2 is little to no exercise (374) (389) (160) A risk factor for DM2 is family history of diabetes (593) (260) 9.06 (85) A risk factor for DM2 is eating a lot of sweets (639) (252) 5.11 (48) A risk factor for DM2 is hypertension (444) (298) (199) Diabetes can be found in pregnant women (435) (237) (271) Diabetes is a result of past sins (145) (784) (266) DM2 can be found in children (361) (197) (368) DM2 is found more often in adults over (569) (127) (248) DM2 is contagious (175) (411) (350)

4 30 International Quarterly of Community Health Education 37(1) Table 2. Awareness of Prevention of Type 2 Diabetes (DM2). True % (n) False % (n) I don t know % (n) DM2 can be prevented (476) (169) (305) DM2 is a chronic disease (277) (301) (371) DM2 cannot be cured (283) (437) (229) Soaking feet in water may lower (320) (233) (387) blood sugar levels DM2 is blood sugar over healthy levels (499) (177) (250) People with DM2 should exercise (636) (105) (174) People with DM2 should eat a diet low in (709) (110) (133) fat, high in fiber, and low in added sugar People with DM2, who are overweight, should aim to lose 5% to 10% of their body weight (578) (123) (255) Table 3. Awareness of Complications of DM2. be seen in the kidneys be seen in the eyes be seen in the nerves be seen in the lower limbs (as in losing toes) A lack of insulin is found in DM2 Insulin does not function well in people with DM2 True % (n) False % (n) I don t know %(n) (434) (244) (250) (331) (352) (251) (384) (232) (300) (371) (205) (344) (488) (139) (310) (344) (221) (374) knowledge or awareness of DM2 diabetes, its risk factors, preventability, and complications is useful for planning effective health education and public health programs designed to prevent DM2 diabetes and its complications. Unfortunately, according to Ghadge et al. 17 and others, 4 few studies assessing this awareness have been conducted in India and there are very little data on the level of awareness about diabetes in developing countries like India. Most studies dealing with the awareness of diabetes have focused on diabetic patients and are mostly clinic-based, and not among community populations. Therefore, the current study addressing awareness of DM2 among college and university students in Visakhapatnam is an important step forward. We are not aware of any other studies of DM2 awareness involving Indian college students or studies investigating this topic among young adults in Andhra Pradesh. Although overall awareness of diabetes is high and that diabetes is increasing, our results indicate in this sample of college students that only half viewed DM2 as a disease that can be prevented and only half identified it as a condition in which blood sugar is over healthy levels. Poor awareness about the preventability and nature of diabetes as a disease involving high blood sugar was surprising and suggest the need for increased education about DM2 diabetes in this population. Also needed is more awareness of the modifiable risk factors for primary prevention of DM2. About one third did not indicate awareness of eating a lot of sweets and obesity are risk factors for diabetes, and about 60% do not recognize little or no exercise as a risk factor. Further, only 46% of the students recognized that DM2 can be found in children. Mohan et al. 14 point out that lack of this awareness, such as what was observed in the current study, showing lack of awareness about the preventability of diabetes are concerning in light of the fact that studies such as the Diabetes Prevention Programme, 18 Finnish Diabetes Prevention Study, 19 and Da Qing Study 20 have clearly demonstrated that DM2 is preventable. It is critical that diabetes prevention programs in this population highlight or emphasize the importance of weight management, regular physical activity, and healthy diet in reducing the risk of DM2 beginning in early childhood and throughout the adult years. According to Mohan et al., 4 successful DM2 prevention programs in youth will require a multisectoral approach including health-care providers, schools, governmental and nongovernmental organizations, youth and religious organizations, and parents to curb the epidemic of youth- and adult-onset DM2 diabetes in India. These authors cite strategies for lifestyle modification targeted for youth at high risk of DM2 diabetes but also community health promotion efforts and awareness programs for all children and teens in schools, youth organizations, and recreational centers. Based on our findings in this study, we would add the need to continue these efforts into colleges and universities.

5 Page et al. 31 Our results also show that misconceptions about DM2 were present in the sample. Only 55.8% recognized that the notion of diabetes being a result of past sins was a false notion. A high percent (41.2%) could not disconfirm that that soaking feet in water may lower blood sugar levels, and another 34.0% believed this misconception. These findings, and lack of awareness about the complications of DM2 diabetes, further highlight the need for increased diabetes education among these college students and possibly other students in colleges and universities elsewhere in India. For example, a majority of the students did not know that DM2 can impair kidneys, ears, nerves, and lower limbs and believed that a lack of insulin is found in DM2. A further gauge of demonstrating lack of DM2 awareness in the study was the response by the 11.5% of the sample who reported that they have been told by a doctor or health professional that they have diabetes when they were asked to identify the type of diabetes they had. Almost three quarters (72.6%) reported that they did not know what type of diabetes they had, with 14.8% saying DM2 and 12.6% saying Type 1 diabetes. Items assessing the ethnicity or caste of the participants were not included in the survey instrument. In Andhra Pradesh, Telugu people form the dominant ethnic group, making up more than 80% of the population of the state and Telugu language is predominately spoken in this region of India. Ethnicity is a variable that future investigations of diabetes awareness (and diabetes prevalence) in India should explore. This might also be said for the caste system in India, which is entrenched in Indian society and affects many aspects of life for Indians. We did not include a question regarding castes because many young Indians are trying to step away from caste classifications. That being said it can be assumed those who were surveyed were probably in a higher class or caste because they are able to attend or afford higher education. It is plausible that young adults of lower caste or society status (and unable to attend college or university) might differ in terms of diabetes knowledge and awareness. An important limitation of this study concerns sample selection. The sample for the study, while composed of students from five different colleges and universities in Visakhapatnam, cannot be construed to be representative of all college and university students in the city, the state of Andhra Pradesh, or India in general. Students were not randomly or systematically selected from these colleges and universities but sampling was formed by convenience. In addition to sampling limitations, survey respondents completed a self-report survey instrument. Thus, the study is at risk of the many biases inherent in self-report research. Despite these limitations, this research is an important first step in identifying levels of DM2 awareness in a college population in India. More research is needed with this population on this topic. Also, this study highlights the need for more diabetes awareness activities among college populations in India. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The authors received no financial support for the research, authorship, and/or publication of this article. References 1. Shaw JE, Sicree RA and Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and Diabetes Res Clin Pract 2010; 87: Hoque MA, Islam MS, Khan MAM, et al. 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6 32 International Quarterly of Community Health Education 37(1) 18. Knowler WC, Barrett-Connor E, Fowler SE, et al. Diabetes prevention program research group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 6: Tuomilehto J, Lindstro m J, Eriksson JG, et al. Finnish diabetes prevention study group. Diabetes Care 2003; 26: Li G, Hu Y, Yang W, et al. Effects of insulin resistance and insulin secretion on the efficacy of interventions to retard development of type 2 diabetes mellitus: the DA Qing IGT and diabetes study. Diabetes Res Clin Pract 2002; 58: Author Biographies Randy M. Page is a Professor and Director of Global Health Internship Program at Brigham Young University. Elizabeth Stones is an Undergraduate student in public health and international intern in India during the time that data was collected for the study. Oliver Taylor is an Undergraduate student studying pre-medicine and international intern in India during the time that data was collected for the study. Kendra Braudt is an Undergraduate student in public health and international intern in India during the time that data was collected for the study.