Type 2 diabetes mellitus (T2DM) is a major public health problem. It is a progressive and debilitating disease that frequently disables and shortens life expectancy.1
The International Diabetes Federation (2011)2 estimated that the prevalence of diabetes in the United Arab Emirates (UAE) is 19.2%. By 2020, it is estimated that 32% of the population may have diabetes or prediabetes.2 The Ministry of Health in the UAE also reported that T2DM constitutes the fifth leading cause of death in the population.3
Understanding the natural history of T2DM is essential. The slow progression from the earliest detectable glucose disorder to clinical diabetes offers the opportunity to prevent or delay T2DM. Pharmacological and lifestyle intervention studies of people at risk of developing T2DM in Sweden, China, Finland and India have uniformly shown reductions in progression to T2DM.4–7
Early identification of people who are at risk of developing T2DM is a pivotal step in initiating preventative measures, thus avoiding the morbidity and mortality associated with the disease and maximizing the cost-effectiveness of services provided.8 It can support health care decision-making, including the effective and efficient allocation and distribution of health care resources, and planning for effective T2DM prevention interventions.9
A recent study carried out in the primary health care (PHC) centres in Abu Dhabi, UAE, between 2009 and 2010 showed that 14.6% of patients attending the PHC centres had undiagnosed diabetes and 31.0% of patients were at increased risk of developing T2DM. This represents a high proportion of patients living without adequate diabetes intervention at the early stages of this disease.10
The biology and pathogenesis of T2DM is complex, and a number of modifiable and non-modifiable risk factors increase the risk of developing T2DM. Many studies have explored the associations between several factors and the risk of T2DM. The most frequently documented factors are sociodemographic factors (e.g. age, sex, marital status, educational level), lifestyle factors (e.g. physical activity, dietary patterns), family history of diabetes, history of elevated blood glucose, history of hypertension, knowledge and perception levels of the disease and obesity (particularly central obesity).11–13
There is a paucity of research concerning the risk assessment of T2DM in the UAE. This study assesses the risk of developing T2DM and identifies the determinants of this risk. This includes personal characteristics, knowledge, perception and dietary habits.
Study design and setting
A cross-sectional study was carried out in the PHC centres affiliated to the Dubai Health Authority.
Sample size was calculated using the computer program Epi Info™ version 6.04 (Centers for Disease Control and Prevention, Atlanta, GA, USA) using 29.4%14 estimated risk of developing T2DM, 4% degree of precision and a 95% confidence level. The minimum sample size required was 499 participants. The response rate was 96.8% (483/499), as 16 patients refused to participate. The sample size was increased to compensate for non-response rate and totalled 515 participants.
A stratified random sample procedure with proportional allocation was carried out. Stratification was based on the health regions (health region 1 and health region 2) and three centres were selected randomly from each region. The sample size from each centre was proportional to the registered number of persons attending each centre. A systematic random sample was carried out for selection of participants. Every second person was included in the study until the required sample size from each centre was reached.
Data collection plan
Data were collected using a structured interview questionnaire aimed at eliciting the following information:
Personal characteristics including age, sex, nationality, educational level and marital status.
Knowledge of diabetes. Participants were tested on their knowledge of the definition, cause, risk factors, symptoms and complications of diabetes and of preventative measures.15 Each item had three possible answers (no, yes, don’t know). A score of 0 was given for each incorrect answer or ‘don’t know’ and score of 1 for each correct answer. The sum of the scores was calculated and participants’ knowledge was categorized as follows: those achieving a score of < 50% were considered to be in the ‘poor knowledge’ group, those with a score in the range 50–75% were considered to have ‘fair knowledge’ and those with a score of 75% or above were considered to have ‘good knowledge’.
Perception of risk factors for T2DM. Participants were asked if they thought that factors such ‘relatives have the disease’, ‘eat high-fat or very sweet foods’, ‘obese’ and ‘do not practise physical activity’ are associated with a risk of T2DM. Three choices of responses (agree, not sure, disagree) were given for each item. A score of 1 was given for ‘disagree’, a score of 2 was given for ‘not sure’ and a score of 3 was given for ‘agree’. The scores were summed to give a total score and participants’ were classified as follows: those getting a score < 50% were considered as having ‘low perception’, those with scores in the range 50–75% were considered having ‘moderate perception’ and those with a score of 75% or above were considered as having ‘high perception’.
Dietary intake. This section included questions to determine the frequency of intake of foods associated with a risk of diabetes (e.g. refined grains, fried food, soft drinks, red meat and sweets).16 Possible responses for the questions were ‘never’, ‘1–3 days per week’, ‘4–6 days per week’ and ‘daily’.
Risk assessment for developing T2DM. This section included eight questions related to the risk assessment using the Finnish Diabetes Risk Score (FINDRISC). The FINDRISC is a validated, well-established method implemented as a practical screening tool to estimate the 10-year risk of T2DM in an individual and does not require laboratory tests. The FINDRISC test includes questions regarding age, family history of diabetes, physical activity, daily consumption of fruit and vegetables, use of antihypertensive medication, history of high blood glucose, body mass index (BMI) and waist circumference.17
The maximum total score of the FINDRISC questions is 26 points. The risk of developing T2DM within 10 years is categorized as follows: < 7 = low estimated risk, 7–11 = slightly elevated risk, 12–14 = moderate risk, 15–20 = high risk, > 20 = very high estimated risk.
Weight was measured in kilograms to the nearest 0.1 kg using a calibrated electronic weighing scale. Participants were asked to stand on the scale wearing light clothing and with bare feet. To ensure accuracy, the scale was checked for a ‘zero’ reading before each weighing and was calibrated by a nurse with a known weight on the morning of each data collection session. Height was measured in centimetres in the standing position, without shoes and socks, to the nearest 0.1 cm using a height scale attached to the electronic weighing scale. Waist circumference was measured in centimetres using a non-stretchable measuring tape at a level midway between the lower rib margin and iliac crest, with the tape encompassing the body in a horizontal position.18
From these measurements, the BMI was calculated as weight (in kilograms) divided by height (in metres) squared. Participants with BMI < 18.5 kg/m2, 18.5–24.9 kg/m2, 25.0–30.0 kg/m2 or > 30.0 kg/m2 are defined as underweight, normal, overweight or obese respectively.19 For males, waist circumference of < 94 cm is considered low, but a circumference of 94–102 cm is high and > 102 cm is very high. For females, waist circumference of < 80 cm is considered low, 80–88 cm is high and > 88 cm is very high.20
At the end of the interview, each participant knew his or her risk level of developing T2DM. Those with moderate, high and very high risk were advised to follow up with the family physician for further investigations and management.
The procedures used were approved by the Research Ethics Committee (Medical Research Committee, Dubai Health Authority, Dubai, UAE). Verbal and written consent were obtained from each participant and confidentiality of the data was maintained throughout the study.
The collected data were coded and entered into Statistical Package for the Social Sciences (SPSS) version 19 (SPSS Inc., Chicago, IL, USA). The following was carried out:
Ninety-five per cent confidence intervals (95% CI) were calculated for the proportion of risk of developing T2DM.
A chi-squared test was used for testing the categorical variables.
A stepwise logistic regression analysis was carried out for adjustment of the confounders and to delineate the determinants for risk of developing T2DM.
Dependent variable: the risk of developing T2DM was further classified into two categories (low and slightly elevated = 0, moderate, high and very high = 1).
Independent variables: to minimize the effect of multicollinearity among the factors, significant variables from a bivariate analysis were forced into stepwise logistic regression using the forward Wald technique. The independent variables included age, sex, marital status, educational level, knowledge level, perception level, daily consumption of refined grains, daily consumption of fried food, family history of diabetes, physical activity of 30 minutes or more daily, history of high blood glucose, usage of antihypertensive medication regularly, BMI and waist circumference.
A P-value of < 0.05 was used as a cut-off level of significance.
The present study comprised 515 participants, most of whom were in the age range 25 years to < 45 years (64.1%) with a mean age of 33.55 ± 10.67 years. Approximately 62% of participants were female and the majority were local to the UAE (87.0%). It was found that 43.9% of participants had a poor knowledge level about T2DM and 37.3% had a low perception level of the risk factors for T2DM and 38.4% had high perception level of the risk factors for T2DM (Table 1).
SD, standard deviation.
Concerning the level of risk of developing T2DM, Figure 1 shows that 21.6%, 19.4% and 1.9% of participants were found to be at moderate, high and very high risk, respectively, of developing T2DM within 10 years.
Table 2 shows that the percentage of participants with high or very high risk of developing T2DM was highest in the group with poor knowledge (24.8%, compared with 20.7% and 16.9% in the fair knowledge and good knowledge groups respectively). The difference was statistically significant (P = 0.037).
|Personal characteristics||Level of risk of developing T2DM||Total n (%)||P-value|
|Low/slightly elevated (n = 294) (%)||Moderate (n = 111) (%)||High/very high (n = 110) (%)|
|Male||126 (63.6)||33 (16.7)||39 (19.7)||198 (100.0)||0.041a,b|
|Female||168 (53.0)||78 (24.6)||71 (22.4)||317 (100.0)|
|Local||251 (56.0)||100 (22.3)||97 (21.7)||448 (100.0)||0.415a|
|Non-local||43 (64.2)||11 (16.4)||13 (19.4)||67 (100.0)|
|Illiterate/can read and write||10 (35.7)||8 (28.6)||10 (35.7)||28 (100.0)||0.030a,b|
|Primary/preparatory||33 (44.6)||21 (28.4)||20 (27.0)||74 (100.0)|
|Secondary||132 (62.6)||37 (17.5)||42 (19.9)||211 (100.0)|
|University or higher||119 (58.9)||45 (22.3)||38 (18.8)||202 (100.0)|
|Single||89 (69.5)||23 (18.0)||16 (12.5)||128 (100.0)||0.006b,c|
|Married||199 (53.5)||85 (22.8)||88 (23.7)||372 (100.0)|
|Divorced||6 (40.0)||3 (20.0)||6 (40.0)||15 (100.0)|
|Poor||114 (50.4)||56 (24.8)||56 (24.8)||226 (100.0)||0.037a,b|
|Fair||77 (57.0)||30 (22.3)||28 (20.7)||135 (100.0)|
|Good||103 (66.9)||25 (16.2)||26 (16.9)||154 (100.0)|
|Low||95 (49.5)||47 (24.5)||50 (26.0)||192 (100.0)||0.024a,b|
|Moderate||69 (55.2)||27 (21.6)||29 (23.2)||125 (100.0)|
|High||130 (65.7)||37 (18.7)||31 (15.6)||198 (100.0)|
Table 2 shows that participants with a low perception level had almost twice the risk of developing T2DM as those with a high perception level (26.0% and 15.6%, respectively). This difference was statistically significant (P = 0.024).
With regard to levels of risk of developing T2DM and dietary habits, Table 3 shows that participants who ate refined grains on a daily basis had a higher risk of developing T2DM (24.2%) than those who ate refined grains 4–6 days/week, 1–3 days/week or never (22.8%, 5.7% and 14.3%, respectively). This difference, between those who ate refined grains on a daily basis versus those who did not eat refined grains on a daily basis, was also statistically significant (P = 0.018). Furthermore, Table 3 shows that participants who ate fried food on daily basis had a higher risk of developing T2DM (29.3%) than those who ate fried food 4–6 days/week (24.3%), 1–3 days/week (19.9%) or never (13.0%). This difference was statistically significant (P = 0.041).
|Food intake in the last month||Level of risk of developing T2DM||Total n (%)||P-value|
|Low/slightly elevated (n = 294)||Moderate (n = 111)||High/very high (n = 110)|
|Never||4 (57.1)||2 (28.6)||1 (14.3)||7 (100.0)||0.018a,b|
|1–3 days/week||53 (75.7)||13 (18.6)||4 (5.7)||70 (100.0)|
|4–6 days/week||33 (57.9)||11 (19.3)||13 (22.8)||57 (100.0)|
|Daily||204 (53.5)||85 (22.3)||92 (24.2)||381 (100.0)|
|Never||35 (76.1)||5 (10.9)||6 (13.0)||46 (100.0)||0.041b,c|
|1–3 days/week||186 (58.7)||68 (21.4)||63 (19.9)||317 (100.0)|
|4–6 days/week||35 (50.0)||18 (25.7)||17 (24.3)||70 (100.0)|
|Daily||38 (46.3)||20 (24.4)||24 (29.3)||82 (100.0)|
|Never||124 (63.6)||38 (19.5)||33 (16.9)||195 (100.0)||0.057c|
|1–3 days/week||95 (59.7)||33 (20.8)||31 (19.5)||159 (100.0)|
|4–6 days/week||16 (50.0)||7 (21.9)||9 (28.1)||32 (100.0)|
|Daily||59 (45.7)||33 (25.6)||37 (28.7)||129 (100.0)|
|Never||82 (63.1)||26 (20.0)||22 (16.9)||130 (100.0)||0.584c|
|1–3 days/week||190 (54.4)||80 (22.9)||79 (22.7)||349 (100.0)|
|4–6 days/week||15 (60.0)||4 (16.0)||6 (24.0)||25 (100.0)|
|Daily||7 (63.6)||1 (9.1)||3 (27.3)||11 (100.0)|
|Never||41 (64.0)||12 (18.8)||11 (17.2)||64 (100.0)||0.786c|
|1–3 days/week||118 (58.7)||44 (21.9)||39 (19.4)||201 (100.0)|
|4–6 days/week||37 (56.1)||14 (21.2)||15 (22.7)||66 (100.0)|
|Daily||98 (53.2)||41 (22.3)||45 (24.5)||184 (100.0)|
Table 4 shows that participants aged ≥ 65 years had a higher risk of developing T2DM (66.7%) than those aged 45 to < 65 years or 25 to < 45 years (41.1% and 20.9%, respectively). This difference was statistically significant (P ≤ 0.001).
|Finnish diabetes risk score items||Level of risk of developing T2DM||Total n (%)||P-valuea|
|Low/slightly elevated (n = 294)||Moderate (n = 111)||High/very high (n = 110)|
|< 25||81 (75.0)||20 (18.5)||7 (6.5)||108 (100.0)||0.000b|
|25–44||194 (58.8)||67 (20.3)||69 (20.9)||330 (100.0)|
|45–64||18 (26.5)||22 (32.4)||28 (41.1)||68 (100.0)|
|65+||1 (11.1)||2 (22.2)||6 (66.7)||9 (100.0)|
|Underweight/normal (< 18.5/18.5–24.9)||150 (86.7)||14 (8.1)||9 (5.2)||173 (100.0)||0.000b|
|Overweight (25.0–30.0)||95 (63.3)||33 (22.0)||22 (14.7)||150 (100.0)|
|Obese (> 30)||49 (25.5)||64 (33.4)||79 (41.1)||192 (100.0)|
|Normal||148 (91.9)||7 (4.4)||6 (3.7)||161 (100.0)||0.000b|
|High||83 (70.3)||27 (22.9)||8 (6.8)||118 (100.0)|
|Very high||63 (26.7)||77 (32.6)||96 (40.7)||236 (100.0)|
|Physical activity 30 minutes/day|
|Yes||110 (75.3)||24 (16.5)||12 (8.2)||146 (100.0)||0.000b|
|No||184 (49.9)||87 (23.5)||98 (26.6)||369 (100.0)|
|Fruit and vegetable consumption|
|Every day||206 (59.9)||77 (22.4)||61 (17.7)||344 (100.0)||0.017b|
|Not every day||88 (51.5)||34 (19.9)||49 (28.7)||171 (100.0)|
|Antihypertensive medication usage|
|No||266 (58.8)||97 (21.5)||89 (19.7)||452 (100.0)||0.033b|
|Yes||28 (44.4)||14 (22.3)||21 (33.3)||63 (100.0)|
|History of high blood glucose|
|No||272 (62.4)||100 (22.9)||64 (14.7)||436 (100.0)||0.000b|
|Yes||22 (27.9)||11 (13.9)||46 (58.2)||79 (100.0)|
|Family history of diabetes|
|No||98 (81.7)||18 (15.0)||4 (3.3)||120 (100.0)||0.000b|
|Yes, second-degree relative||85 (74.6)||16 (14.0)||13 (11.4)||114 (100.0)|
|Yes, first-degree relative||111 (39.5)||77 (27.4)||93 (33.1)||281 (100.0)|
Moreover, the risk of developing T2DM was eight times higher in obese participants than in underweight/normal-weight participants (41.1% and 5.2%, respectively). The difference was statistically significant (P ≤ 0.001).
In addition, Table 4 illustrates that participants who did not eat fruit and vegetables on a daily basis were more likely to have a high/very high risk of developing T2DM than participants who ate them daily (a risk of 28.7% and 17.7% respectively). This difference was also statistically significant (P = 0.017).
Figure 2 summarizes the prevalence of risk factors assessed in the FINDRISC test among participants at either moderate or high/very high risk of developing T2DM within the next 10 years in Dubai, 2012. The figure demonstrates that, out of 221 participants with a moderate or high/very high risk of developing T2DM, the majority had a high/very high waist circumference (94.1%), positive family history (90.0%) and BMI of 25 kg/m2 or higher (89.6%). More than 80% (83.7%) were found to be physically inactive (< 30 minutes/day).
Regarding the factors that affect the risk of developing T2DM within 10 years, Table 5 shows that there are 10 significant predictors for the risk of developing T2DM. Participants with history of high blood glucose, aged ≥ 45 years, having a high/very high waist circumference and a positive family history of diabetes mellitus had a greater risk of developing T2DM by approximately 10 times than those without a history of high blood glucose, aged < 45 years, having a waist circumference within the normal range and without a family history of diabetes mellitus [odds ratio (OR) = 10.13, 10.22, 16.73 and 17.70, respectively].
|Independent variable||B||P-value||Adjusted OR||95% CI||Model χ2|
|Agea < 45 years||2.324||0.000||10.22||4.54–23.02||0.001b|
|Eating refined grainsa not daily basis||0.775||0.015||2.17||1.16–4.06|
|Eating fried fooda not daily basis||1.029||0.014||2.8||1.24–6.34|
|No family historya||2.874||0.000||17.7||9.22–33.97|
|BMIa within normal range||2.016||0.000||7.51||3.61–15.64|
|Waist circumferencea within normal range||2.817||0.000||16.73||7.29–38.36|
|Physical activitya ≥ 30 min/day||1.509||0.000||4.52||2.32–8.81|
|No history of high blood glucosea||2.316||0.000||10.13||4.21–24.36|
In addition, participants with a poor level of knowledge about T2DM and a low perception level and who ate refined grains or fried food on daily basis had almost double the risk of developing T2DM relative in comparison with participants with a good level of knowledge about diabetes and high perception level and who did not eat refined grains or fried food on daily basis. Furthermore, those who did not practise physical activity for at least 30 minutes per day had a higher risk of developing T2DM (OR = 4.52) than those who did exercise.
Type 2 diabetes mellitus is one of the most prevalent and costly chronic health conditions worldwide. The prevalence of T2DM is increasing to an epidemic level worldwide and, therefore, it is crucial from a clinical and public health perspective to be able to identify those who are at risk.2 An important challenge is how to identify those individuals at risk and to implement interventional methods as quickly as possible.
This study aimed to assess the level of risk of developing T2DM and its determinants among adults attending the PHC centres in Dubai during 2012.
The prevalence of risk of developing T2DM is also rising at an alarming rate in both developed and developing countries. The increasing number of people at risk of developing T2DM presents a global concern as it carries large-scale implications for the future burden on health care.2
Despite encouragement by the World Health Organization for health authorities to screen and identify early those at risk of the disease, 30–50% of people at high risk of developing T2DM remain unidentified at any one time.21
Although high, the level of risk of developing T2DM identified in this study is lower than that found in studies undertaken in Pakistan22 and India,23 but higher than in other studies in Libya,24 Saudi Arabia14 and the UK,25 where 12.3%, 10.7% and 9.8% of participants in each study, respectively, were at a high risk of developing T2DM. This could be due to the high percentages of obesity and physical inactivity among our participants, consequently adding to their risk of developing T2DM.
Age is an important risk factor for developing T2DM. In our study, the risk of developing T2DM increased as participants aged. This finding is consistent with previous studies in Kuwait26 and the UK,25 where older individuals had a higher risk of developing T2DM than younger individuals. This is because older individuals are mainly retired and house bound and hence they are physically inactive, which increases the risk of developing T2DM. In addition, they tend to have other risk factors coexisting, such as being on antihypertensive medication, which increases the risk of developing T2DM significantly.
Knowledge about T2DM plays a vital role in early prevention and detection of the disease. It was observed in this study that poor knowledge levels significantly increased the risk of developing T2DM. On the other hand, in a study carried out in Pakistan,22 participants with good knowledge of T2DM had a higher risk of developing the disease than those with poor knowledge. This difference in findings can be attributed to higher obesity (including central obesity) and unhealthy diet among knowledgeable participants.
Risk perception has emerged as an important factor to motivate preventative health behaviours and disease. It is considered one of the first necessary steps towards adopting health-promoting behaviours.27 Low perception levels were associated with a higher risk of T2DM in previous studies in the USA28 and Thailand,29 and these findings are in accordance with our study.
Daily food intake has a role in the risk of T2DM as some types of food are associated with increased weight, central obesity and insulin resistance, and potential future development of T2DM. There is growing evidence that increased levels of free fatty acids and, more importantly, the relative amounts of saturated and unsaturated fatty acids play an important role in the development of insulin resistance.30
As a result of rapid socioeconomic development in the UAE, dietary patterns have moved from a traditional towards that of a more Western-style diet.31 Western-style diets (high in red and processed meats, French fries and refined grains) have been linked to an increase in the risk of insulin resistance and therefore an increased risk of developing T2DM.32 In agreement with this, we found that participants who consumed refined grains and fried foods on a daily basis were at greater risk of developing T2DM; this is in agreement with previous studies carried out in Pakistan22 and Saudi Arabia.14
With regard to the risk factors for development of T2DM, a study carried out in Kuwait26 reported that participants with a medical history of hypertension or siblings with diabetes had a twofold increased risk of developing diabetes than participants without a medical history of hypertension or siblings with diabetes. Additionally, participants aged 35 years or older, and those with waist circumference ≥ 100 cm, had a higher risk of developing T2DM (OR = 3.72, 6.89 respectively). Similarly, a study in Thailand29 found that other factors, such as being female and having a BMI ≥ 25 kg/m2, were associated with an almost twofold increased risk of developing T2DM. This is consistent with research undertaken in Jordan33 and is supported by our study, which also added more risk factors, such as a poor knowledge level, low perception level, daily consumption of refined grains and fried food, physical inactivity and a history of high blood glucose level.
Identification and screening of individuals with risk factors is urgently needed to allow interventions to reduce the risk of developing T2DM, to prevent or reduce the incidence of T2DM and to reduce the incidence of complications arising from T2DM.
It is possible that our study population included some individuals with undiagnosed T2DM, as no blood glucose tests were carried out. This may have increased the percentage of participants in the high/very high risk category and therefore have caused us to overestimate the number of individuals in this category.
In conclusion, more than 40% of participants in our study were at a moderate or high risk of developing T2DM within 10 years. The most prevalent risk factors among participants with a moderate or high risk were high waist circumference, family history of diabetes, obesity and low physical activity levels.
Based on the results of this study, we recommended that risk assessment questionnaires should be used as an initial step for T2DM screening in PHC centres. Additionally, a structured lifestyle modification programme should be delivered to those at moderate or high risk of developing T2DM in order to improve their health and delay or prevent T2DM.