Knowledge, Attitude, and Practice Among Diabetes Mellitus Patients in Tumkur Region: A Cross-Sectional Study

Diabetes mellitus is a group of metabolic diseases characterized by chronic hyperglycaemia resulting from a defect in insulin secretion, insulin action, or both. Metabolic abnormalities in carbohydrates, lipids, and proteins result from the importance of insulin as an anabolic hormone. Low level of insulin to achieve adequate response and or insulin resistance to target tissue, mainly skeletal muscle, adipose tissue, and to lesser extent, liver, at the level of insulin receptors, signal transduction system, and/or effectors enzymes or genes are responsible for these metabolic abnormalities The severity of symptoms is due to the type and duration of diabetes ^[1]. Some of the diabetes patients are asymptomatic, especially those with type 2 diabetes during the early years of the disease; others with marked hyperglycaemia and especially in children with absolute insulin deficiency, may suffer from polyuria, polydipsia, polyphagia, weight loss, and blurred vision. Uncontrolled diabetes may lead to stupor, coma, and, if not treated, death, due to ketoacidosis or rare from nonketotic hyperosmolar syndrome. Optimal management of the patient with DM will reduce or prevent complications, decrease morbidity and mortality, and improve quality of life. Research, clinical trials, and drug development efforts over the past several decades have not only improved health outcomes in patients with DM but also significantly expanded the available therapeutic options. DM is a leading cause of morbidity and mortality world over. It is expected to continue as a major health problem owing to its serious complications, especially end-stage renal disease, IHD, gangrene of the lower extremities, and blindness in the adults. Top 5 countries with the highest prevalence of DM are India, China, US, Indonesia and Japan. In India, its incidence is estimated at 7% of adult population (approximately 65 million affected people), largely due to genetic susceptibility combined with changing life style of low-activity high-calorie diet in the growing Indian middle class. The incidence is somewhat low in Africa. But prevalence of DM is expected to rise in developing countries of Asia and Africa due to urbanisation and associated obesity and increased body weight. The rise in prevalence is more for type 2 diabetes than for type 1 DM. It is anticipated that by the year 2030 the number of diabetics globally will double from the present figure of 250 million ^[2].

Etiological Classification of Diabetes Mellitus:

5. Type 1 Diabetes Mellitus (10%)

(Earlier called insulin-dependent, or juvenile-onset diabetes).

Type 1A DM: Immune–mediated.

Type 1B DM: Idiopathic.

5. Type 2 Diabetes Mellitus (80%)

 (Earlier called non-insulin dependent, or maturity-onset diabetes).

5. Other Specific Types of Diabetes Mellitus (10%)

1. Genetic defect of β-cell function due to mutations in various enzymes [earlier called maturity onset diabetes of the young or MODY (e.g., hepatocyte nuclear transcription factor – HNF, glucokinase).
2. Genetic defect in insulin action (e.g., type A insulin resistance).
3. Diseases of the exocrine pancreas (e.g., chronic pancreatitis, pancreatic tumours).
4. Endocrinopathies (e.g., acromegaly, Cushing’s syndrome, pheochromocytoma)
5. Drug – or chemical-induced (e.g., steroids, thyroid hormone, thiazides, β-blockers etc.)
6. Infections (e.g., congenital rubella, cytomegalovirus).
7.  Uncommon forms of immune-mediated DM (stiff man syndrome, anti-insulin receptor                                                    antibody)
8. Other genetic syndromes (e.g., Down’s syndrome, Klinefelter's syndrome, Turner’s syndrome).

5. Gestational Diabetes Mellitus (4%)

About 4% pregnant women develop DM due to metabolic changes during pregnancy. Although they revert to normal glycaemia after delivery, these women are prone to develop DM later in their lives ^[2].

Signs and Symptoms:

The classic signs and symptoms of untreated diabetes include several distinct and progressive changes in the body. Common manifestations are unexplained weight loss, polyuria (increased urination), polydipsia (increased thirst), and polyphagia (increased hunger). Additional symptoms may include blurred vision, headache, fatigue, delayed healing of wounds, and itchy skin. These symptoms tend to appear rapidly over a few weeks or months in individuals with type 1 diabetes, whereas in type 2 diabetes, they generally develop more gradually and may be subtle or even absent in the early stages ^[4][5][6].

Figure 01: Main symptoms of Diabetes ^[2].

Complications of Diabetes Mellitus

Chronic hyperglycemia in diabetes leads to biochemical and structural changes in various organs, resulting in both acute and chronic complications.

1. Acute Metabolic Complications

• Diabetic Ketoacidosis (DKA): Primarily seen in type 1 diabetes, DKA is caused by severe insulin deficiency and elevated glucagon levels, often triggered by missed insulin doses or stress. It leads to increased lipolysis and release of free fatty acids.
• Hyperosmolar Hyperglycemic State (HHS): Typically, a complication of type 2 diabetes, HHS results from extreme dehydration due to prolonged hyperglycemic diuresis.
• Hypoglycemia: Common in type 1 diabetes, hypoglycemia may occur due to excessive insulin, missed meals, or physical stress. Severe episodes can cause brain damage or rebound hyperglycemia (Somogyi effect).

2. Chronic Systemic Complications

• Atherosclerosis: Accelerated in both type 1 and type 2 diabetes, leading to early, widespread, and complex arterial lesions including thrombosis and calcification.
• Microangiopathy: Characterized by thickened capillary basement membranes in organs like the kidney, retina, and nerves, contributing to organ dysfunction.
• Neuropathy: Most often presents as symmetric peripheral neuropathy, involving demyelination and axonal injury.
• Retinopathy: A leading cause of blindness, it includes background and proliferative lesions. Diabetes also increases the risk of cataracts and glaucoma.
• Infections: Diabetic patients are more prone to infections such as tuberculosis, pneumonia, and skin ulcers due to impaired immune function and poor vascular supply ^[2].

Pathogenesis of Diabetes Mellitus

Depending upon the etiology of DM, hyperglycemia may result from the following:

? Reduced insulin secretion.

? Decreased glucose use by the body.

? Increased glucose production ^[2].

Figure 02: Pathogenesis of Diabetes Mellitus ^[2].

About Knowledge, Attitude & Practice:

Effective lifestyle modifications for blood sugar control include salt restriction, limited alcohol intake, a diet rich in fruits, vegetables, and low fats, maintaining a healthy weight, and regular physical activity. All diabetic patients, regardless of disease severity, should be encouraged to adopt these changes. However, motivating patients remains a major challenge in diabetes management. A KAP (Knowledge, Attitude, Practice) survey helps assess patients' understanding and behaviour toward their condition. It identifies gaps in awareness, misconceptions, and barriers to proper disease management. Studies have shown a strong link between diabetes knowledge and glycaemic control, highlighting the value of education programs. Though simple in design, KAP studies provide critical insights into community-specific beliefs and practices. They uncover baseline health knowledge, reveal local misperceptions, and guide tailored health interventions. Since healthcare behaviours vary by region, findings from other populations may not apply locally. Thus, conducting a KAP study on diabetes in a specific community is essential to inform effective, targeted public health strategies.

METHODOLOGY

5. Study Site: The study was conducted in the Tumkur district, Karnataka.

5. Duration of Study: The study was conducted for a period of 3 months.
5. Study Design: A cross-sectional study
5. Proposed Sample Size: 161 patients.
5. Source of Data:

1. Direct interaction with patients
2. Patient case sheets

5. Study Criteria: The study was carried out by the following inclusion and exclusion criteria.

1. Inclusion Criteria:

1. Patient age more than 18 years old.
2. Both genders.
3. Patient diagnosed with DM for at least 6 months.
4. Those who were willing to participate in the study.
5.  Patients who were on anti-diabetic medications for more than 6 months.

2. Exclusion Criteria:

1. Age below 18 years.
2. Special population (pregnancy and lactating women).
3. Patients who have any communicable disease, like HIV and AIDS.
4. Patient diagnosed with DM below 5 months.
5. Those who were not willing to participate in the study.

5. Study Procedure

• Regarding this project pilot study has been done.
• Collection and review of literature prepare to the project.
• Prepare the study protocol, including study design and design of performance.
• Enrollment of patients according to the inclusion and exclusion criteria.
• Taken patient consent.
• Collection of patient details from direct interaction with the patient and the patient's case sheet.
• Assess the knowledge, attitude, and practice with the help of a questionnaire.
• Provide counselling to the patient.
• Provide information leaflets to patients.
• The obtained information was analyzed and represented in the form of a table and graphs, and the data was analyzed statistically.
• Reports were submitted.

5. Need Of the Study

• DM is a common problem and is the leading cause of morbidity and mortality.
• Knowledge, Attitude & Practice towards DM creates more awareness among the population in general and diabetic patients, particularly regarding prevention and control of risk factors and disease management.
• So, this study has been undertaken to decrease the prevalence rate and reduce many complications and co-morbidities in the diabetic population.
• And also, to improve the patient's knowledge regarding the disease through patient counselling.

5. Materials Used

• Informed consent form
• Patient profile form
• KAP questionnaires
• Patient information leaflet

5. Methods

• Data were collected from patient profile documents.
• The medical history, consisting of inpatient medical records, was reviewed.
• Data was recorded as patient demographic information, clinical status, duration of disease, and type of complication.

5. Annexures

The annexure section includes essential supporting documents used during the study. It contains the informed consent form provided to participants before enrolment. The patient profile form used to collect demographic and clinical data is also attached. A validated KAP (Knowledge, Attitude, Practice) questionnaire is included to assess patient awareness. Additionally, the patient information leaflet used for counselling is provided. These annexures serve as evidence of ethical compliance and structured data collection.

Figure 03:  Annexure 1- Data Collection Form

Figure 04: Annexure 2- Informed Consent Form

RESULTS AND DISCUSSION

A community-based cross-sectional study was conducted over a period of three months among patients diagnosed with Diabetes Mellitus in the Tumkur region. A total of 161 participants were included in the study. Among them, 83 (51.55%) were males and 78 (48.44%) were females, indicating a nearly equal gender distribution. The age of the patients ranged from 18 years to above 50 years. Participants were categorized into four age groups: 2.48% were between 18-29 years, 15.52% between 30-39 years, 32.29% between 40-49 years, and the majority, 49.68%, were aged 50 years and above. This reflects the age-related increase in the prevalence of diabetes, consistent with its classification as a progressive metabolic disorder more common in older adults. Social habits were examined to assess risk factors associated with lifestyle. Most of the patients (72%) reported neither smoking nor alcohol consumption. However, 8.69% were smokers, 3.10% were alcoholics, and 16.14% reported both smoking and alcohol consumption. These habits are known to exacerbate diabetes progression and complications. The high percentage of patients with no such habits may reflect growing awareness or could be due to lifestyle changes post-diagnosis. Regarding co-morbidities, a significant proportion of patients suffered from cardiovascular diseases (65.21%), followed by renal complications (42.85%), hepatic conditions (36%), and central nervous system involvement (29.19%). Diabetic retinopathy was reported by 11.18% of participants, and 3.72% experienced respiratory conditions or infections. Interestingly, 11.8% of the participants did not report any co-morbid condition. The high incidence of cardiovascular and renal diseases is of particular concern, given their strong association with diabetes-related mortality and morbidity. Assessment of blood glucose levels categorized patients into three groups. Only one patient (0.62%) showed hypoglycaemia, while 33 patients (21.11%) were identified as pre-diabetic, and a substantial majority, 127 patients (78.88%), were confirmed diabetic based on fasting blood glucose values. This distribution reinforces the need for early screening and monitoring to identify pre-diabetic individuals and prevent progression to diabetes. In evaluating patient knowledge regarding diabetes, responses revealed that 80.74% of participants had heard of diabetes. However, some misconceptions persisted: 59.62% believed that diabetes is caused by consuming too much sugar, and only 47.2% were aware of normal blood glucose levels. While 64.59% remembered their last blood sugar reading, only 42.85% identified hereditary factors and obesity as major contributors to diabetes onset. About 77.63% correctly recognized symptoms such as frequent urination, increased thirst, and hunger, and 80.12% acknowledged the role of diet and exercise in diabetes management. Notably, 34.16% knew that diabetes can lead to blindness, and 53.41% were aware that smoking and alcohol worsen diabetic conditions. These findings suggest moderate awareness among patients, but emphasize the need for education to address common myths and reinforce accurate knowledge.

Table 01: Assessment of Knowledge

Patient attitudes toward diabetes management were also assessed. A large proportion (81.99%) reported not smoking, and 70.81% did not engage in regular exercise. Just over half (54.65%) believed a special diet was necessary, while 81.98% agreed that regular monitoring of blood sugar levels is important. Fewer patients (38.5%) believed that allopathic medicine is the best treatment option. A good proportion (70.8%) supported the inclusion of green leafy vegetables and fruits in their daily meals, and 79.5% recognized the importance of taking regular medication. However, only 50.93% acknowledged that missing medication could negatively impact disease control, and 76.39% believed in maintaining regular contact with their physician. This highlights a gap between awareness and consistent attitudes necessary for optimal disease management.

Table 02: Assessment of Attitude

When examining patients' practices, 55.9% knew how to check their blood sugar levels, and 63.97% monitored their glucose regularly. Medication adherence was relatively high, 84.47% reported taking their diabetes medication daily. However, only 45.34% took their blood pressure medication regularly, suggesting a lack of integrated care for co-existing conditions. Regarding screening behaviours, 52.79% underwent eye examinations proactively (daily, weekly, or monthly), while 47.21% did so only when experiencing symptoms. Similarly, 65.83% underwent regular urine testing for diabetic nephropathy screening, and 87.57% had their blood sugar levels checked routinely.

Table 03: Assessment of Practice