Saudi Journal of Kidney Diseases and Transplantation

: 2010  |  Volume : 21  |  Issue : 4  |  Page : 678--685

Meeting the American diabetic association standards of diabetic care

Mubashar Kharal1, Abdullah Al-Hajjaj1, Maha Al-Ammri2, Ghada Al-Mardawi2, Hani M Tamim3, Salih Bin Salih1, Muhammad Yousuf1,  
1 Department of Medicine, King Saud Bin Abdulaziz University of Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
2 Department of Pharmacy, King Saud Bin Abdulaziz University of Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
3 Department of Epidemiology and Biostatistics, King Saud Bin Abdulaziz University of Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia

Correspondence Address:
Mubashar Kharal
Assistant Professor of Medicine, King Saud Bin Abdulaziz University of Health Sciences; Consultant, Division of Internal Medicine, Department of Medicine, King Abdulaziz Medical City P.O. Box 22490, Riyadh 11426
Saudi Arabia


Although there are numerous studies on diabetes mellitus in Saudi Arabia, data on the extent to which American Diabetic Association (ADA) standards of diabetic care are met, is scarce. We studied the computerized records of adult diabetic patients followed-up in outpatient internal medicine clinics at our tertiary care center in Riyadh, Saudi Arabia to find out how many of them met the ADA standards of diabetic care regarding fasting blood glucose, HbA1c, LDL-C, hypertension, proteinuria screening and use of anti-platelet, lipid lowering or recommended anti­hypertensive medications. Out of 1,188 type-2 diabetic patients studied, blood pressure readings were available in 1180 (99%) while results of fasting blood glucose, HbA1c, LDL-C and albumi­nuria screening were available for 1123 (95%), 968 (81%), 1037 (87%) and 307 patients, (26%) respectively. Patients achieving the ADA targets for overall, systolic and diastolic blood pressure, fasting blood glucose, HbA1c, LDL-C and albuminuria screening were 39.0%, 40.6%, 74.6%, 25.0%, 21.8%, 55.5% and 34.9%, respectively. For prevention of cardiovascular events, 61.0%, were using angiotensin converting enzyme inhibitors (ACE-I) or angiotensin-2 receptor blockers (ARBs) or both, while 71.5% and 72.3% of our patients were on anti-platelet and statin medica­tions, respectively. In conclusion, as reported in most other studies, we also found that ADA stan­dards of diabetic care are not met in most of our diabetic patients, indicating that these standards are easy to preach than to practice. There is need for further research to investigate the reasons for this failure and to adopt better multi-disciplinary approach and realistic targets in the future.

How to cite this article:
Kharal M, Al-Hajjaj A, Al-Ammri M, Al-Mardawi G, Tamim HM, Salih SB, Yousuf M. Meeting the American diabetic association standards of diabetic care.Saudi J Kidney Dis Transpl 2010;21:678-685

How to cite this URL:
Kharal M, Al-Hajjaj A, Al-Ammri M, Al-Mardawi G, Tamim HM, Salih SB, Yousuf M. Meeting the American diabetic association standards of diabetic care. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2023 Jan 30 ];21:678-685
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Full Text


The number of patients with diabetes mellitus (DM) is predicted to increase from 135 million in 1995 to 300 million in 2025, worldwide. [1] Most of this increase will be in developing countries with prevalence of DM in the Middle East likely to escalate by 163% by year 2030. [2] Diabetes mellitus in Saudi Arabian adults is rapidly increasing with a prevalence of 23.7% in the period between 1995 and 2000. [3]

Diabetes Mellitus in adults is associated with an annual death rate of about 5%, which is ap­proximately double the rate for age and gen­der-matched control subjects without diabetes. Most of this excess mortality risk is attribu­table to macrovascular atherosclerotic disease. [4] Thus, it has been recommended that medical management to decrease cardiovascular risk should start when type-2 DM is diagnosed. [5]

Results from clinical trials over the past de­cade have led to national and international guide­lines that advocate aggressive management of hyperglycemia, hypertension, and dyslipidemia for patients with DM. [6],[7],[8],[9],[10]

Despite many guidelines, patients with dia­betes continue to suffer from high rates of car­diovascular and microvascular complications and can expect a lifespan reduction of 10-15 years. [11],[12] This inability to effectively and widely translate clinical evidence into usual practice represents a major barrier to reducing the burden of diabetes and its complications.

Although there is extensive data on various aspects of DM in Saudi Arabia, knowledge about meeting the American Diabetes Associa­tion (ADA) targets in management of diabetic patients is scarce. Thus, this study was under­taken with a view to determine the extent of achieving ADA targets in type-2 DM by the internists in a tertiary care outpatient setting.

 Patients and Methods

This observational, cross-sectional, retrospec­tive study was conducted on adult patients followed-up at the outpatient internal medicine clinics in The King Fahad National Guard Hos­pital, King Abdulaziz Medical City, Riyadh, Saudi Arabia. This tertiary care center is res­ponsible for treatment of Saudi National Guards and their dependents. All patient data are com­puterized. The study was approved by the ins­titutional research committee. The diabetic pa­tients seen and followed-up in this hospital are usually referred to us when it is difficult to manage them at primary care clinics or family medicine clinics and often, have one or more of the diabetic complications.

A list of patients of either gender, aged 30­years or above, who had visited the internal medicine clinics during the period between August 2005 and January 2006 was generated from the Information Service Department (ISD) in the hospital. Out of these, patients who ful­filled the criteria for DM according to ADA guidelines [13],[14] were included in the study. Data retrieved on computerized Misys CPR system on these diabetic patients included age, gender, presence and control of hypertension, fasting blood glucose, HbA1c, serum low density lipo­protein cholesterol (LDL-C) levels and micro­albuminuria. Medication profile was reviewed through computerized Pharmacy Legacy Sys­tem and specifically noted the use of anti­platelet medications (aspirin or clopidogrel or both), anti-diabetic medications (oral hypogly­cemics, insulin or both), ADA recommended anti-hypertensive medications [angiotensin con­verting enzyme inhibitors (ACEI) or angio­tensin receptor blockers (ARBs) or both) and statins].

Blood pressure was recorded by electronic blood pressure apparatus Dinamap (Datascope Accutore-plus, US) with the patient sitting af­ter a rest of ten minutes. This apparatus was periodically calibrated for accuracy by compa­rison with a mercury syphgmomanometer. In case the initial blood pressure was high, a se­cond reading was taken ten minutes after the first reading for the purpose of the study. Hy­pertension was diagnosed if the patient had blood pressure equal to, or more than 140/90 mmHg or the patient was on anti-hypertensive treatment. Fasting blood glucose (FBG) was measured on serum using Architect c 8000 7M system in mmol/dL. HbA1C was determined on whole blood by ion-exchange high-perfor­mance liquid chromatography using Bio-Rad variant II hemoglobin testing system (US). LDL-C was measured after a 12-hours fast by multiagent LDL assay using direct, quantita­tive method (Architect c 8000 7M system, US). Proteinuria was checked either on first voided, random, morning urine sample by albumin to creatinine ratio or by 24-hour urinary protein by spectrophotometry using Abbott analyzer.

All the data obtained was analyzed by a biomedical statistician using SPSS program ver­sion 13 to find out the number and percentage of patients meeting the 2005 ADA recommen­ded targets [15] regarding overall, systolic and diastolic blood pressure, fasting blood glucose, HbA1c and LDL-C levels. For the purpose of analysis, only the last blood pressure and the laboratory values were used to best reflect the effect of long-term treatment. Categorical data was calculated by number and percentage (%), while continuous data was calculated as mean and standard deviation (SD).


Patient Characteristics

The total number of patients visiting the me­dical outpatient during the study period was 2110. Out of these, 1188 (56.3%) fulfilled the criteria for type-2 DM and were included in the study. Of these diabetic patients, 458 (38.5%) were males and 730 (61.5%) were females, with a male to female ratio of 1:1.6. Hyper­tension was present in 655 (55.1%) of the study patients.

ADA Screening Tests

Out of the 1188 diabetic patients, blood pre­ssure readings were available in 1180 patients (99%) while results for FPG, HbA1c, LDL-C and albuminuria screening were available for 1129 (95%), 968 (81%), 1037 (87%) and 307 (26%) cases, respectively. These data with mean values and standard deviations are given in [Table 1].

Treatment medications

The number and percentage of our study patients on anti-diabetic, recommended anti­hypertensive, anti-platelet and statin medica­tions were 1120 (94.3%), 706 (59.5%), 849 (71.5%) and 859 (72.3%) respectively, as shown in [Table 2]. The different types of anti-diabetic therapy used are shown in [Figure 1]. Patients on ACEI and/or ARB are shown in [Figure 2], while the use of different anti-platelet medications is shown in [Figure 3].

ADA cardiovascular risk target achievement

The percentage of the study patients achie­ving the overall, systolic and diastolic BP, HbA1c and LDL-C targets, as prescribed by the ADA, was 39.1%. 41.3%, 74.9%, 21.8% and 55.5%, respectively [Figure 4].


Despite strong evidence that intensive control of cardiovascular risk factors reduces morbi­dity and mortality in diabetes, our study re­vealed that a large number of patients were not achieving recommended ADA targets of care.

Most of the published studies of adherence of physicians to the recommended standard of diabetes care have been at different levels of care with differences in the guidelines fol­lowed, with only two studies previously re­ported from the Middle East, one from Saudi Arabia, [16] and the other from Lebanon. [17] To our knowledge, our study is the second from Saudi Arabia to report on how the internists in a single tertiary care center adhere to the guide­lines for the management of type-2 DM. In a previously reported study from different cen­ters of Eastern and Western regions of Saudi Arabia, the same treatment targets of overall BP and HbA1c were achieved in 32 and 24% of the patients with type-2 diabetes mellitus, respectively. [16] However, in that study there was no information about how many of the patients were using various anti-diabetic, anti­hypertensive, anti-platelet and statin medica­tions. In a study from a university health cen­ter at Lebanon [17] involving 204 diabetic patients, parameters such as systolic and diastolic blood pressure, fasting blood glucose and HbA1c were met in 55.4%, 65.7%, 17.8% and 28.4% of their patients compared to 47.6%, 74.6%, 25.0% and 21.8% of the patients respectively, in our study. However, in that study all the diabetic patients were mainly followed-up by family physicians with optimal BP target of 135/85 mmHg.

A comparison of achievement of HBA1c and blood pressure targets in our study with other Studies [16],[17],[18],[19],[20],[21],[22],[23] is given in [Table 3], which high­ lights that these targets are increasingly diffi­cult to achieve. While interpreting the results of our study, it is important to note that most of the patients in our study were already ha­ving diabetic complications with multiple asso­ciated co-morbidities, a group with inherent difficulties to achieve the targets of standards of care in any setting. Therefore, these patients are not representative of most of the diabetic patients in primary care settings in Saudi Arabia, where the level of care may be much less.

In the United Kingdom Prospective Diabetes Study (UKPDS), [9] despite the intensive treat­ment used in that study which is not currently possible for routine care of diabetes, HbA1c of 7.0% was achieved in only 50% of patients. Thus, even with such an approach, 50% were unable to reach this target, and after nine years, fewer than 25% of obese subjects main­tained this control. [24] Furthermore, the patients in the UKPDS, all had newly diagnosed type-2 diabetes. As the glycemic control deteriorates further with time when complications ensue, despite progressive requirements for higher doses of hypoglycemic agents, [24] achieving the HbA1c target of 7.0% becomes an uphill task. It is, therefore, not surprising that only 22% of patients with type-2 DM in our clinic popula­tion had an HbA1c [25]

The UKPDS also demonstrated that tight blood pressure control delayed the develop­ment and progression of macrovascular and microvascular disease in type-2 DM. [7] It is im­portant to note that, despite participation in a clinical trial, only 56% of patients in the tight control group and 37% in the less tight control group achieved a blood pressure [26] inves­tigators reported that patients with diabetes and at least one other cardiovascular risk fac­tor (not necessarily hypertension) treated with the ACE-I ramipril were less likely to develop the composite endpoint of myocardial infarc­tion, stroke or death from cardiovascular di­sease, compared with those who received pla­cebo, despite a mean reduction in blood pre­ssure of only 3/2 mmHg. The picture looks dismal if we consider that fewer than 10% reached combined ADA recommended HbA1c, blood pressure and total cholesterol levels in the NHANES study. [20]

Meeting the ADA recommended target level of LDL-C in 55.5% of the patients in our study was slightly better than the 50.5% reported else­where from Saudi Arabia, [16] but less compared to 60.0% and 64.2% in Australian [18] and US [23] studies, respectively.

The use of medications recommended by the ADA for prevention of cardiovascular compli­cations in our type-2 diabetic patients was 61.0%, 71.5% and 72.3% for ACEI or ARBs or both, anti-platelets and statins respectively. This is better than many other studies in type-2 diabetic patients. In a Canadian study of dia­betics with or without atherosclerotic complications, [27] fewer than 25% received an anti­platelet agent or statins, and fewer than 50% received an ACEI. In a Belgian study, [28] only 33.1% and 39.9% were on aspirin and statins respectively, while only 36.0% were on aspirin in a Swedish study. [22]

In the management of a patient with type-2 DM, poly-pharmacy may be unavoidable. Given the cardiovascular risk profile of type-2 DM, up to 10% of patients could require two or three hypoglycemic agents (ultimately inclu­ding insulin), at least three anti-hypertensive agents, two hypolipidemic agents, and aspirin. A high proportion will also require treatment for co-existent cardiovascular disease and co­incidental unrelated chronic disease. It is diffi­cult to see how we can realistically expect pa­tients to comply for long with such a draco­nian regimen requiring so many different me­dications. The development of combination tablets by the pharmaceutical industry seems to be the utmost priority for effective preven­tion of complications of type-2 diabetes, [25] and should be encouraged.

Being a retrospective study, our study had inherent problems. Furthermore, as the data obtained was through electronic records, infor­mation about retinopathy screening, foot exa­mination and neuropathy were not available. This will need either the information about these parameters to be included in the elec­tronic record or patient file audit to get infor­mation in any future study.

In conclusion, our study indicated that the ADA guidelines regarding checking of blood pre­ssure, blood glucose, HbA1c, the use of anti­platelet, ACEI, ARBs and lipid lowering drugs were followed in majority of the cases. How­ever, similar to other studies, we were not faring well regarding proteinuria screening and meeting the ADA targets for HbA1c, blood pressure control and LDL-C lowering, indica­ting that these standards are easy to preach than to practice. Further future studies are needed in Saudi Arabia with improved metho­dology to find out the reasons for this gap between guidelines and practice. There is also need for primary prevention of type-2 diabetes and its complications rather than the secondary pre­vention of established cardiovascular compli­cations.


We thankfully appreciate Jamila Meyer and Marla Perez, secretaries of Department of Me­dicine for their support in preparing the manus­cript and Arvin A. Santos, Graphics Designer, Postgraduate Training Center, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia, for his help with the graphics.


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