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Year : 2022  |  Volume : 66  |  Issue : 5  |  Page : 80-86  

Glycemic control and its determinants among people with type 2 diabetes mellitus in Ernakulam district, Kerala

1 Senior Resident, Department of Community Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
2 Associate Professor, Department of Community Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
3 Professor, Department of Community Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
4 Former Professor, Department of Community Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India

Date of Submission12-Aug-2022
Date of Decision18-Aug-2022
Date of Acceptance23-Aug-2022
Date of Web Publication11-Nov-2022

Correspondence Address:
Teena Mary Joy
Department of Community Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.ijph_1104_22

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Background: Diabetes is a public health problem of colossal proportions. The National Family Health Survey 5 (2019–2020) has found high blood sugar levels among 13.5% of women and 15.6% of men in India. The high morbidity and mortality in diabetes mellitus are due to uncontrolled hyperglycemia resulting in micro- and macrovascular changes affecting multiple organs in the body. The objectives of this study were to estimate glycemic control and its determinants among type 2 diabetics in the Ernakulam district. Methods: A community-based cross-sectional study was conducted among 364 type 2 diabetics who had the disease for at least 5 years duration in the Ernakulam district of Kerala. Probability proportional to size cluster sampling technique was adopted. A semi-structured questionnaire was used to collect sociodemographic and behavioral profiles. Participants' HbA1c levels were assessed to determine glycemic control. Results: The proportion of people with good glycemic control was 21.4%. Determinants such as female gender adjusted odds ratio (aOR = 2.36, P = 0.005), body mass index >23 kg/m2 (aOR = 2.71, P = 0.002), combined drug treatment with Oral Hypoglycaemic agents (OHA) and insulin (aOR = 3.76, P = 0.004), and poor compliance with medications (aOR = 1.93, P = 0.030) were found to be significantly associated with poor glycemic control. Conclusions: Poor compliance with medications and unhealthy lifestyle choices has resulted in a high proportion of diabetics with poor glycemic control in the district. Women are particularly more vulnerable to uncontrolled hyperglycemia than males. Type 2 diabetes mellitus people should be encouraged to maintain strict glycemic control, which is an important measure for secondary prevention of complications.

Keywords: Glycemic control, glycated hemoglobin, probability proportional to size sampling, type 2 diabetes mellitus

How to cite this article:
Najeeb SS, Joy TM, Sreedevi A, Vijayakumar K, Syama, Glycaemic Control and Determinants Team. Glycemic control and its determinants among people with type 2 diabetes mellitus in Ernakulam district, Kerala. Indian J Public Health 2022;66, Suppl S1:80-6

How to cite this URL:
Najeeb SS, Joy TM, Sreedevi A, Vijayakumar K, Syama, Glycaemic Control and Determinants Team. Glycemic control and its determinants among people with type 2 diabetes mellitus in Ernakulam district, Kerala. Indian J Public Health [serial online] 2022 [cited 2022 Nov 29];66, Suppl S1:80-6. Available from:

Glycaemic Control and Determinants Team
Sneha G, Steffi AV, Vishnu B
Senior Resident, Department of Community Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India

   Introduction Top

Diabetes mellitus is one of the fastest growing public health challenges of the 21st century and a leading cause of mortality and reduced life expectancy globally.[1] There are approximately 537 million people living with diabetes mellitus according to the International Diabetic Federation Diabetes Atlas 2021 and this number is projected to soar to 783 million by 2045.[2]

Diabetes is a growing concern in millennial India. The National Family Health Survey 5 (2019–2020) has found high blood sugar levels among 13.5% of women and 15.6% of men in India. Although Kerala is said to be a yardstick in many health indicators and literacy, it is infamously dubbed the “diabetes capital” of India, the state has a prevalence of nearly 19.5% in the urban sector and 14.6% in the rural regions which is far higher than the national average. The longer life expectancy of the people and early initiation of disease presents a grim scenario of a longer duration of diabetes with its complications. This demands a dire need for strict glycemic control among diabetic patients in the state.

The evidence accrued in the past few decades has consistently pointed out the significant risk-reduction of microvascular and macrovascular complications of diabetes with strict glycemic control.[3],[4] The glycated hemoglobin (HbA1c) test is an important index of measuring an individual's glycemic control and has the ability to reflect the cumulative glycemic history of the preceding 2–3 months.[5] The estimation of HbA1c levels in a population aids in the identification of the extent of the quality of diabetes management in the community.

Most of the national and international studies which have evaluated the glycemic status of people with diabetes mellitus have been conducted in the outpatient clinic and hospital settings.[6],[7] Similar studies conducted in different parts of Kerala previously have also evaluated outpatient attendees for research purposes.[6],[8] Population-based studies on the extent of glycemic control across different sections of the community is generally deficient. Robust population-based health data would aid in surveillance for planning health services and for evaluating strategies in the prevention and control of diabetes mellitus. This study was hence carried out as a community-based cross-sectional study that aims to capture the proportion of people with type 2 diabetes mellitus (T2DM) having good glycemic control and the factors associated with glycemic control.

   Materials and Methods Top

The study was carried out among people with T2DM residing in Ernakulam district, which is the third-most populous district in Kerala. A community-based cross-sectional study was undertaken covering both rural and urban regions of the Ernakulam district. The data were collected by interviewing the patients from December 2019 to March 2020. This study was approved by the Dissertation Review Committee and ethical clearance was granted by the Institutional Ethical Committee of Amrita School of Medicine. Written informed consent in the local language-Malayalam was obtained from each participant before collecting the data.

Selection and description of participants

Patients with a minimum of 5 years duration of T2DM residing in Ernakulam district and those who consented to participate have been included in the study. Previous studies have shown that patients with recently diagnosed diabetes (duration of disease <5 years) had better glycemic control than those with duration >5 years.[9] However, as the chronicity of the disease increases, the risk of complications also increases. Therefore, people with more than 5 years of diabetes were considered in this study. Bedridden patients and patients who cannot communicate verbally were excluded from the study. The sample size was calculated according to a study done by Unnikrishnan et al. titled “Glycaemic Control among Individuals with Self-Reported Diabetes in India-The Indian Council of Medical Research -India Diabetes (ICMR–INDIAB) Study” which showed the proportion of diabetics with good glycemic control to be 31% among 480 individuals with self-reported diabetes.[10]

The minimum sample size was calculated to be 335. With a 95% confidence interval (CI) and 20% allowable error using the formula,

n = (Z1–α/2) 2 pq/d2; where P = 31%, q = 100–31 = 69, Z1–α/2 = 1.96 and d = 20% of 31 = 6.2.

A sample size of 223 was obtained. Considering design effect of 1.5 to account for the homogeneity due to the cluster sampling technique, the total sample size was 335. The sample size was attained by including 13 clusters with a cluster size of 26 individuals each from various parts of the district of Ernakulam. The population of each division/ward/panchayat varied, therefore probability proportional to size method was adopted. For the identification of clusters to be included in the study, the total population was considered rather than number of diabetic persons with a minimum 5-year duration since the ward/division-wise list was not available.

Technical information

The primary objective of this study was to determine the proportion of subjects with good glycemic control (HbA1c <7%) among those with T2 DM of more than 5 years duration, in the Ernakulam district. The secondary objective of this study was to assess medication adherence, physical activity, perceived stress, sociodemographic status, dietary habits, anthropometric measurements, and duration of illness among the study participants and to examine the association of these factors with glycemic control.

Independent variables such as age, gender, rural/urban residence, education, socioeconomic status, occupational status, marital status, tobacco/alcohol use, self-reported comorbidities, duration of diabetes mellitus, type of antidiabetic medications, family history of diabetes and other comorbidities, medication adherence, and dietary habits were assessed using a semi-structured questionnaire. Physical activity was assessed using the Global Physical Activity Questionnaire (GPAQ) questionnaire and perceived stress by the Perceived Stress Scale (PSS) scale. PSS scores ranging from 0 to 13, 14–26, and 27–40 were considered as low, moderate, and high perceived stress, respectively. GPAQ comprises 16 questions (P1–P16) and Metabolic Equivalents which are commonly used to express the intensity of physical activities, were used for the analysis of GPAQ data. Body mass index (BMI) and blood pressure were measured using standardized measurement techniques.


The values obtained by the cross-sectional study were tabulated using MS EXCEL and analyzed using SPSS Statistics for Windows, version 20(IBM Corp., Armonk, N.Y., USA). Descriptive statistics for continuous data with normal distribution were expressed as mean and standard deviation. Frequency distribution was estimated for categorical data and expressed in percentages. Chi-square test was used to find the association of categorical variables with glycemic control and all variables with a P < 0.05 was considered for the multivariate regression model. Multiple logistic regression was used to identify the independent determinants of glycemic control represented as odds ratio and 95% CI. P < 0.05 was considered statistically significant.

   Results Top

This study was conducted in 13 clusters in the Ernakulam district. Of the total 453 people who were contacted via telephone, 416 consented. Fifty-two participants failed to turn up at the camps organized and hence were not included in the study. This brought the total number of study participants to 364. The mean age of the diabetic study participants was 60 ± 8.9 years. Less than half of the participants (40.7%) belonged to the age group of 61–70 years. More than half of the study participants (58.5%) were women. Half of the study participants hailed from rural areas (51.7%) and 29.9% were residing in municipalities, while another 18.4% were residing in Kochi corporation areas. Close to half of the participants (41.5%) had completed high school education and only around two-tenths of the study population (18.3%) had pursued education beyond high school. About 8.5% of the diabetic patients were graduates and there was only one postgraduate among the participants. It should be noted that a small proportion of the population (5.8%) had no formal schooling. More than a third of the participants (35.4%) were homemakers, 12.4% were retired and a tenth of the population (9.9%) were unemployed. Few of the participants (4.7%) worked in the government sector and 9.9% worked in the private sector, however a significant proportion of them were self-employed (27.7%). Regarding the type of ration cards they owned, more than a third (39.6%) had Non-Priority Subsidy (Blue) ration cards, around another third had Priority House Hold (Pink) cards, 25.3% had the creamy layer Non-Priority Non-Subsidy (White) cards. Only a small proportion (4.9%) owned the Antyodaya Anna Yojana (Yellow) ration cards. This indicates that the majority of participants (64.9%) had Above Poverty Line (APL) status.

The proportion of patients with good glycemic control was found to be 21.4% (CI 17.21, 25.59). According to the American diabetic association Guidelines, HbA1c level <7.0% indicates good glycemic control for adults with diabetes. The mean and standard deviation of HbA1c values among the study participants was found to be 8.87 ± 1.8%. On univariate analysis [Table 1], variables such as gender, the current type of medication, BMI, compliance with medication, perceived stress, and total physical activity, were found to have a significant association with poor glycemic control with a P < 0.05.
Table 1: Univariate analysis of factors associated with glycemic control

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In this study, no statistically significant effect of factors such as alcohol consumption, history of smoking, self-reported co morbidities, family history of diabetes, socioeconomic status, marital status, health-seeking behaviors, and dietary habits on glycemic control were found. The sample size for this study was calculated based on the primary objective, and hence, perhaps a larger sample would likely be needed for ascertaining the relationship between these variables and glycemic control.

For multivariate regression analysis, all variables with a significance of <0.05 in univariate logistic regression were included in the multivariate regression model to find the independent predictors of poor glycemic control. After multivariate analysis [Table 2], factors such as female gender, combined insulin and OHA treatment, BMI >23 kg/m2, and poor medication adherence showed a positive association with poor glycemic control and were found to be significant.
Table 2: Logistic regression analysis for identifying determinants of poor glycaemic control among the study population

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   Discussion Top

The proportion of poor glycemic control (78.6%) in the current study was remarkably high, a finding which is similar to that reported from other parts of the country as well. A hospital-based study done in North Kerala found that 28.3% of persons to have adequate glycemic control.[6] A multicentric study conducted in 2017, which pans across 26 states in India, has reported 23.4% of persons achieving adequate glycemic control.[11] A study conducted by Oluma et al. suggests that an increased duration of diabetes of more than 4 years is more likely to be associated with poor glycemic control compared to a shorter duration of diabetes.[12] This further explains the likelihood of an increased proportion of poor glycemic control in the present study, as the study includes only patients with more than 5 years duration of diabetes. A stark difference was observed between the glycemic control proportions in various other countries compared to India – the prevalence of good glycemic control was 45.6% in Korea,[13] and 62.6% in a nine-country cross-sectional study conducted across Europe.[14] These variations in the glycemic control status reflect the existing socioeconomic disparities and differing quality of health care received by patients globally.

The present study reports a significant association between higher BMI levels (BMI >23 kg/m2) and suboptimal glycemic control. Adjusted odds ratio (aOR = 2.71, 95% CI = 1.43, 4.94, P = 0.002). This finding is consistent with several other studies[15],[16],[17],[18] where obese and overweight individuals have more likelihood of uncontrolled hyperglycemia than diabetic patients who fall in the normal weight category. Evidence suggests that insulin resistance appears to increase incrementally with respect to BMI levels[19] which paves way for uncontrolled hyperglycemia.

The present study findings indicate the female gender to be a factor having a higher risk of poor glycemic control as opposed to patients of the male gender (aOR = 2.36; 95% CI = 1.29,4.33, P = 0.005). Similarly, several studies worldwide have reported a less optimal glycemic control in women than men.[20],[21],[22],[23] However, a Swedish study found better glycemic control among females than males.[24] A study done by Kautzky–Willer et al. reported that the prevalence of overweight or obesity is more among diabetic women than in diabetic men,[25] a finding similar to that of the present study. The results of this study show that diabetic women were found to have a higher BMI than men (aOR = 1.958, 95% CI 1.18, 3.23, P = 0.008). These gendered differences in body mass and composition contribute to the sex-dimorphic diabetes risk.[25]

On examining the association of drug compliance with glycemic control, it was found that poor medication adherence (skipping of one or more doses of prescribed antidiabetic medications in the past 2 weeks) was an unfavorable factor for optimal glucose control (aOR = 1.93, 95% CI = 1.06,3.49, P = 0.030). An inverse association between adherence level and poor control have been reported by similar studies.[26],[27] In this study, good adherence rates were found to increase with progressing disease duration, with those above 10 years duration of diabetes having better drug compliance (61.4%) than those being diagnosed with diabetes for <10 years duration (45.2%). A study by Kirkman et al. found that adherence was associated with older age.[27] This may be probably due to survival bias, where individuals with poor adherence and poor glycemic control might not have survived to an older age due to diabetic complications.

Diabetics who were on combined insulin and OHA treatment were found to be at a higher risk of uncontrolled hyperglycemia (aOR = 3.76, 95% CI = 1.51, 9.35, P = 0.004) as compared to those on OHA or Insulin treatment alone. This finding is in line with the findings of the multicentric ICMR-INDIAB study where the use of insulin has been associated with a higher odds of having inadequate glycemic control, as was also the finding in a randomized controlled trial conducted among the Dutch population.[28],[29] This may be because of the general delay in initiating insulin therapy until patients have failed all the available oral anti-hyperglycemic drugs. Hence, combined insulin and OHA users tend to be patients with more difficult-to-control and severe hyperglycemia, and these individuals have poorer glycemic control than those subject to other treatment modalities.

The study is one among the very few population-based studies conducted in Kerala to estimate glycemic control among T2DM and it is the first of its kind large and comprehensive community-based study, which has been conducted in the populous metropolitan district of Ernakulam. Several independent variables including physical activity, stress, compliance with medication and dietary habits, were considered in this study and the association of these factors with glycemic control has been studied, which captures a holistic perspective of the problem.

The collection of data by a self-reporting questionnaire is subjective and is likely to depend on the recall memory of the participants. Camps were organized to bring together the selected study participants in each cluster, which were conducted during working hours (8 am to 5 pm). It is possible that the timing might have been unfavorable for the employed population, who would have had difficulty in turning up.

   Conclusions Top

There are a high proportion of patients with poor glycemic control among T2DM patients. This underscores the need to build awareness regarding glycemic control so that they are protected from the effects of the potentially avoidable glycemic burden. Innovative research on developing novel drugs should be encouraged which will remove the need of daily dosing in the future, thereby improving medication adherence. Diabetic persons should be encouraged to reduce total daily sedentary time and maintain a healthy BMI. Empowering women to practice self-care by promoting the formation of local women's diabetic groups is of paramount importance as women are the gatekeepers of health in a family; they need to be aware and healthy, for the benefit of themselves and others.


We place on record our gratitude to the DPM, Dr. Mathews Numpelil for the support rendered in organizing the camps. We are grateful to all the health workers and patients who spent their precious time on this study. The authors would like to thank Mr. Rajesh Kolarikkal, Mr. Das Mankidy, and Mr. A Rajan of Lions DIA16895/318 – C for their support to implement this service project.

Financial support and sponsorship

This work was funded by the Lions Club International Foundation (DIA16895/318-C).

Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Table 1], [Table 2]


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