Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
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Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




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On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
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Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2009 | Month : August | Volume : 3 | Issue : 4 | Page : 1633 - 1640

The Impact of Two Diabetes Educational Programs on Patients with Diabetes in Malaysia

AL-HADDAD MA*, IBRAHIM M I M ** , SULAIMAN S A S ***, MAARUP N ****

*,**Discipline of Social and Administrative Pharmacy,***Discipline of Clinical Pharmacy,[School of Pharmaceutical Sciences].**** Health Center, Universiti Sains Malaysia, 11800 Penang,(Malaysia)

Correspondence Address :
Mahmoud Al-Haddad,
School of Pharmaceutical Sciences,
Universiti Sains Malaysia, 11800 Penang,
Malaysia. Email:dr_mahmoud77@hotmail.com
Tel: +6 012 5534547

Abstract

Aims: This study was conducted to measure the effectiveness of 2 different diabetes educational programs (less structured vs structured).
Setting: Universiti Sains Malaysia Health Center.
Design: Prospective observational study design.
Methods and Materials: Patients were invited to attend one monthly session of an educational program for a period of 4 months. The first group attended the less structured program while the second group attended the structured program. Patients’ glycated hemoglobin (HbA1c), Body Mass Index (BMI) and Blood Pressure (BP) were compared at the baseline, end of the program and after four months of the end of the program.
Statistical Analysis: Repeated Measures ANOVA test was used to compare the three periods while Mann Whitney U test was used to compare between both groups. All data were analyzed using SPSS version 12 at a significance level of less than 0.05.
Results: Results showed that HbA1c level significantly increased in the less structured group while significantly reduced in the structured group. BMI showed a slight increase in both groups, but was not statistically significant. On the other hand, systolic BP showed a significant reduction in the less structured group while no significant reduction was found in the structured group. Diastolic BP reduced slightly in both groups but was not statistically significant. Structured diabetes educational program was shown to be more effective than the less structured program. Patients’ BMI has been increased slightly which requires further research to find the reasons behind that. Most other results showed improvements even though some of them were not statistically significant.
Conclusion: This study provides evidence on the effectiveness of diabetes educational program as well as the importance of communication skills in developing any patient-educational programs. As result, it can be used as a guideline for the policymakers in Malaysia for developing diabetes educational programs at the national level.

Keywords

diabetes; education; structured program; Malaysia; outcomes

How to cite this article :

AL-HADDAD MA,IBRAHIM M I M ,SULAIMAN S A S ,MAARUP N . THE IMPACT OF TWO DIABETES EDUCATIONAL PROGRAMS ON PATIENTS WITH DIABETES IN MALAYSIA . Journal of Clinical and Diagnostic Research [serial online] 2009 August [cited: 2018 Sep 26 ]; 3:1633-1640. Available from
http://www.jcdr.net/back_issues.asp?issn=0973-709x&year=2009&month=August&volume=3&issue=4&page=1633-1640&id=542

Background
Diabetes is of high prevalence worldwide. In 2005, the number of diabetic patients in the US reached up to an alarming 20.8 million (1). In the year 2000, data from 12 countries in the Western Pacific region showed that the prevalence of diabetes among adults exceeded 8% (2). In 1993, the prevalence of diabetes in Malaysia was 8.2% (urban areas) and 6.7% (rural areas), 8.9% in Singapore and 10.9% in Japan (2). The first and second National Health and Morbidity surveys found that the prevalence of diabetes in Malaysia increased from 6.3% in 1985 (3) to 8.3% in 1996 (4).

The estimated lifetime risk for developing diabetes in the US was found to be 33% for men and 39% for women (5). Many factors play a major role in the increase of the prevalence of diabetes. Some of these factors are ageing, which is estimated to increase in Malaysia (6), over weight, stress and intake of large amounts of unhealthy food.

The patient’s adherence to the recommendations of their healthcare providers is one of the main contributing factors for diabetes management. Therefore, improvement of lifestyle would not only benefit patients by preventing the development of diabetes complications, but it also improves the patient’s quality of life by improving their physical activities and weight reduction (7). Thus, the essence of diabetes management and education has been explored.

Diabetes management is not an easy task as patients need to change their lifestyle, change their daily food habits and physical activities (8), learn how to deal with diabetes medications, learn how to deal with complications and how to monitor blood glucose levels (9) which make diabetes management more difficult. Therefore, the responsibility of health professionals is to help patients make decisions that meet with their goals and overcome barriers through professional advice, education and support (10).

Thus, the main objective of this study is to measure the impact of two different diabetes educational programs on HbA1c, body mass index (BMI) and blood pressure (BP) on diabetic patients.


Material and Methods

The course includes a group-based one monthly teaching session (90–120 min each) for a period of four months. Patients were then followed up for four months after completing their fourth (last) session.

Study Design
A prospective observational study design was used to make a comparison between two different diabetes self management programs (DSMPs) at the Universiti Sains Malaysia (USM) Health Center.

Study Population
Staff, dependents and pensioners who were type 2 diabetics at the USM main campus were eligible to be included in this study. They were expected to be able to attend all the classes and also to be able to communicate in the Malaysian national language.

Program structures
The Diabetes Self Management Program was launched in August 2005. During this period, patients were invited to attend the educational sessions. They were given four different sessions on diabetes education. Surprisingly, the HbA1c levels of the patients at the end of the program were higher than the baseline. This prompted the researchers and the educators to hold a meeting to investigate the reasons for these negative outcomes. It was concluded that the way classes were conducted, could be the possible reason for these negative outcomes. The classes were mainly a one-way communication in which patients had limited opportunity to share their experiences and opinions during the discussion. As a result, in February 2006, the researchers and educators decided to improve the way the program was conducted. The main change made was, the decision to make the sessions to be conducted in 2-way communications by encouraging patients to participate and to share their experiences with their colleagues and educators. In addition, the researcher and educators gave their contact numbers to patients to assist them at any time when they needed consultation or assistance. This was believed to strengthen the provider-patient relationship which was assumed to increase the patient’s adherence. Therefore, the first group who joined the program in August 2005 was referred to as the less structured group, while those who joined the program in February 2006 were referred to as the structured group.

Patient Recruitment
The less structured program started in August 2005. During this period, a list of patients with diabetes was obtained from the USM Health Center and patients were randomly selected and contacted. During the phone calls, patients were briefed about the program and specific dates were given for their first appointment. During the meeting, patients were given details about the program and verbal informed consent was obtained from them for participation in the study. During the period between August 2005 and February 2006, a total of 33 patients agreed to join the program and successfully completed the 4 sessions. In February 2006, all the patients in the list who had not participated in the previous program were invited. Appointments were given and verbal informed consents were obtained from those who agreed to participate in the study. A total of 41 patients successfully completed the four sessions between February 2006 and January 2007.

Program Instructors
A team of health professionals was involved as diabetes care program educators. This program included two clinical pharmacy lecturers from the School of Pharmaceutical Sciences, one medical doctor, one nurse from the USM Health Center, one pharmacist from the School of Pharmaceutical Sciences and three pharmacists from the National Poison Center, Malaysia. A time table was carefully designed to make sure that each group of patients met at least one pharmacy lecturer, medical doctor and pharmacist during their four sessions.

Program Sessions
Both programs, the structured and the less structured, comprised of four different sessions.

Session One: Diabetes Overview And Diet
During this session, patients were briefed about the chronic nature of the disease, different types of diabetes and the role of insulin in the body. Furthermore, patients were given information on the type and amount of healthy food that should be consumed. They were then taught how to calculate the calories in different types of food.

Session Two: Diabetes Medications
The main purpose of this session was to provide an overview of medications used in the treatment of diabetes and the strategies for self-management of diabetes. Patients were also briefed on the different regimens of oral anti-diabetics and insulin. In addition to that, patients were briefed about drug-food interactions and the side effects of each regimen.

Session Three: Diabetes Complications
This session was aimed to provide an overview of the major complications of diabetes. The intention was not to frighten the patient, but to convey the good news that the self management of diabetes with the goal of optimal diabetes control can help to delay the onset and reduce the severity and the complications associated with the disease. Patients were taught about the long term complications of diabetes and the relationship between diabetes and high blood pressure, cardiovascular disease, retinopathy and neuropathy. Lastly, patients were taught about the importance of self care management in avoiding the development of diabetes complications.


Session Four: Exercise And Foot Care
This session emphasized on providing patients with an overview of the role of exercise in the management of diabetes and guidelines for safe and effective exercise. Patients were briefed about the role of exercise in delaying or preventing the development of complications. Patients were also taught safe exercising methods and were given practical training in performing some of these safe exercises.

Data Collection Procedure
Classes were conducted every Wednesday. Patients were contacted one day before each class and were reminded to attend their session the following day. Before starting each session, the following measurements were taken from patients, which were considered as key measurements for the program evaluation:
1. At the first session (class), a blood sample was taken for measuring HbA1c. In addition, the patient’s blood pressures (BP) and body mass indexes (BMI) were measured.
2. During the second and third sessions, only BP and BMI were measured.
3. At the last session (4th class), all the samples (HbA1c, BMI, and BP) were taken.
4. Patients were called in four months after the end of the program and all the measurements (HbA1c, BMI, and BP) were taken from them again.

Statistical Analysis
The Repeated measures ANOVA test (11) was used to compare the differences in HbA1c, BMI and blood pressure measurements for the less structured group and the structured group before and after the intervention. Bonferroni post hoc test (11) was used to make the pair-wise comparisons if repeated measures ANOVA showed any significant difference. In addition, the Mann Whitney U test was used to compare between both groups. All analyses were done using the SPSS software package, version 12 at a significance level of 0.05.

Results

Study participants
A total of 74 patients successfully completed the study. Of these, 33 patients (44.6%) were enrolled in the less structured program and 41 patients (55.4%) were involved in the structured program. Two thirds of the participants were males.

(Table/Fig 1) compares the outcome measures of at three different periods for both groups. HbA1c values significantly increased in the less structured group between the baseline and the end of the program (mean difference = 0.743, 95%CI: 0.198 to 1.289, p= 0.016). However, there was no significant difference between the measurements at end of the program and the follow up (p=0.113). On the other hand, the structured group showed a significant reduction in the HbA1c level between the baseline and the end of the program (mean difference = 0.479, 95%CI: 0.137 to 0.857, p=0.004) (5.8% reduction compared to the baseline). There was no significant difference between the measurement at the end of the program and at follow up (p=0.495). Both groups showed no statistically significant differences in BMI measurements during the study period, even though there was a slight increase in the BMI level at the end of the study. In addition, systolic BP showed that only the less structured group had a significant difference during the study period (p=0.026). The Bonferroni post hoc test showed a significant reduction in systolic BP between the end of the program and the follow up period (mean difference = 4.276, 95%CI: 0.586 to 7.966, p=0.006), but no significant difference between baseline and end of the program (p=0.399). The structured group showed no significant difference in systolic BP during the study period (p=0.299). In addition, diastolic BP measurements showed no significant differences during the study period for both groups (p=0.144 and 0.070), respectively.

Comparison Between The Two Groups
(Table/Fig 2) shows the comparison between the 2 groups. HbA1c results showed no significant differences between both groups at the baseline (p=0.969). However, the HbA1c results of the structured group were significantly lower than the less structured group at the end (mean difference = 0.967, 95%CI: 0.234 to 1.701, p=0.011) and follow up periods (mean difference = 1.047, 95%CI: 0.188 to 1.905, p=0.018). On the other hand, BMI and diastolic blood pressure values showed no significant differences between both the groups throughout the program. The systolic blood pressure, at the end of the program, was significantly lower in the structured group than in the less structured group (mean difference = 5.276, 95%CI: 0.536 to 10.017, p=0.029).

Discussion

In this study, we evaluated and compared two different educational programs in two different time periods, which is one of the limitations in our study design. But as mentioned in the methodology, there was no intention to develop 2 different educational programs, but to develop and evaluate an effective diabetes educational program. Following the preliminary evaluation of the initial program, negative outcomes were observed from the HbA1c values of the participants. Thus, a modification of the program was essential and therefore a comparison of the 2 diabetes education programs was justified. In addition, as mentioned in the methodology part, the first group who joined the less structured program was randomly recruited and the remaining patients who were not invited to attend the less structured program were invited to attend the structured program. Therefore, there is no evidence of selection bias among the two groups and this is confirmed by the baseline comparisons of both groups, which showed no significant differences in all the clinical measurements. Therefore, both programs were compared to measure the effectiveness of improving the communication skills between the educators and the patients on their clinical outcomes.

This study has shown a significant increase in HbA1c levels in the less structured group. The patient’s mean HbA1c level increased from 7.85% (range from 5.6% to 10.0%) at the baseline to 8.37% (range 5.3% to 12.4%) at the end of the program. This increase was not anticipated since it was hypothesized that an educational program should improve the HbA1c level of the patients. An ineffective communication with patients may have played an important role in forcing them not to follow the recommendations of their instructors. The structured group showed different results from the other group. Their HbA1c level at the end of the program was significantly lower than that of the baseline (5.85% reduction). It was reduced from 7.86% (range from 5.3% to 11%) at the baseline to 7.40% (range from 5.1% to 11.8%) at the end of the program. These results were anticipated due to improved communication with the patients, giving them more opportunities to discuss their problems, and offering them the freedom of calling the program instructors at any time to discuss any issue related to their health concerns. Well managed diabetes educational programs would lead to better outcomes in HbA1c values, which were found in many other studies (12),(13),(14),(15).

Obesity is common among patients with diabetes. Weight reduction is associated with many health benefits, including the reduction of BP and glycaemic control (16).

Gregg et al found in 2004, that mortality rate ratios were 23% lower in diabetic patients who tried to reduce their weight than those who did not try to lose weight. It has been found that even patients who failed to lose weight, had lower mortality ratios than those who never tried to lose weight. Patients who tried to lose weight by eating healthier foods and performing physical activities may follow healthier life styles, which are not related to weight loss. They may quit smoking and use seat belts while driving, which has an effect on the mortality rates (17). Results of this study showed no significant differences in BMI levels when the two groups were compared. There was a slight reduction in BMI for the less structured group, which reduced from 29.06 kg/m2 to 28.18 kg/m2 (ranged from 21.9 kg/m2 to 41.2 kg/m2), but this was not statistically significant (p=0.388). The structured group showed a slight increase in the mean BMI level between the baseline and the end of the program, 28.03 kg/m2 vs 28.72 kg/m2 respectively, but it was also not significant (p=0.079).

Obese diabetic patients are generally sedentary. Patients with diabetes complications find it difficult to perform regular exercises. Also, patients taking oral hypoglycaemic agents commonly gain weight due to the medications (18). Both groups were overweight and obese, with a mean BMI >28 kg/m2. Patients were given a whole session on meal planning and another session on exercise. In these classes, the disadvantages of overweightness and the complications associated to it were stressed. Even though it appeared that patients found it difficult to change their meal plans, there should probably be additional sessions to discuss with patients their BMI results and to understand their reasons for not reducing their weight. On the other hand, similar findings were found in an empowerment educational program for diabetic patients which was conducted at seven primary care centers in central Sweden, whereby BMI values showed no significant differences between the intervention and control groups (19).

Hypertension in patients with diabetes was found to be significant in a study which was conducted in Malaysia. It was found that a significant proportion of diabetic patients had hypertension which was not managed according to guidelines (20). The less structured group showed a significant reduction in systolic BP between the end of the program and the follow up period. When both groups were compared, it was found that there was no significant difference between baseline systolic blood pressure values, while at the end of the program, it was found that the structured group results were significantly less than those in the less structured group. Similar results were found in the University of North Carolina Enhanced Diabetes Care program which was developed in 3 phases tohelp diabetic patients in controlling their disease. Twelve months after the intervention, systolic BP reduced significantly by 9mmHg (21). Moreover, 4872 patients from 647 physicians were enrolled in the disease management program for diabetic patients. The program was structured with regular visits every three months, as well as with the documentation of risks and intervention parameters. The results showed that the systolic BP reduced significantly from 147mmHg to 140 mmHg (22).

Although there was a slight reduction in diastolic BP within each of the 2 groups at the 3 different periods, these reductions were not significant. Also, there was no significant difference between the groups during the whole study period. Therefore, stressing on the importance of controlling blood pressure should be emphasized during the educational programs.

Study limitations
This study faced many limitations such as the difficulty in recruiting patients, the small sample size and financial constraints, which made it difficult for us to recruit a control group due to the expensive cost of the lab tests. Therefore, it would be difficult to generalize these findings on other settings. In addition, it was difficult to do further analyses and comparisons since we are comparing two different groups with two different time periods but as mentioned earlier, it was not intended to develop and compare two different educational programs.

Recommendations
This study provides policy makers a primary data, an insight about the effectiveness of the diabetes educational program. Future programs are encouraged to focus more on weight reduction, meal planning, and a healthy lifestyle and to practically help patients in controlling their weight and meals.

Conclusion

Conclusion
From the clinical point of view, DSMP was found to be effective. In the structured group, the HbA1c level which is a surrogate indicator for blood glucose level controls, reduced significantly at the end of the program and even after four months of follow up. The importance of the communication between the disease management educators and patients with close monitoring was demonstrated by this study. On the other hand, both groups showed no significant changes in their BMI values. Therefore, emphasizing more on food planning and the importance of weight reduction are very important for the future success of similar programs.

Acknowledgement

This educational program was partially supported by the Secretariat of Healthy Campus and the incentive grant of Universiti Sains Malaysia. Our thanks to the Health Center of University Sains Malaysia, School of Pharmaceutical Sciences and the National Poison Center. Special thanks to: Assoc. Prof. Dr. Mohd Baidi Bahari, Dr. Nurulain bt Abdullah Bayanuddin, Mr. Azaharudin b. Awang Ahmad, Ms. Sulastri bt Samsudin, Ms. Asdariah bt Misnan, Che Gayah bt Omar, Che Rubia, Jameaton and Dr. Mohamed Azmi Hassali who contributed greatly for the success of this program.

Funding
This research was partially funded by the Healthy Campus and incentive grant of Universiti Sains Malaysia.

Conflicts of Interest:
None

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