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Research topics

1. Caffeine and diabetes

2. Smoking and diabetes
3. Smoking and dyslipidemia (from patients’ previous prescriptions-e.g. statins, clofibrate,
cholestyramine etc.)
4. Awareness of modifiable risk factors in diabetic patients
5. Diabetic patients’ knowledge on diabetic foot and its management
6. Asthma and house pets
7. Smoking and sleep quality

Questions for questionnaire

** Citation: Buysse,D.J., Reynolds,C.F., Monk,T.H., Berman,S.R., & Kupfer,D.J. (1989). The Pittsburgh Sleep
Quality Index (PSQI): A new instrument for psychiatric research and practice. Psychiatry Research, 28(2), 193-213.

MSQ: *need patient’s family members -
*** Please decide on one, (from what I have found out, PSQI is more commonly used compared
to the others)

Community Medicine Portfolio

· Acknowledgements
· Table of contents with page numbering
· Section 1— Organization of the clinic
· Section 2---Household Survey
· Section 3---Health related research
· Section 4---Reflections
· References
· Appendix.

Literature review: method, results figures, summary

Research – The steps

● Identify problem to be studied
○ What is the association of hypertension, smoking and sleep quality with diabetes
mellitus Type 2? DARST QUESTIONNAIRE???
● Set objectives
○ To investigate the association of hypertension with diabetes mellitus Type 2
○ To investigate the association of smoking with diabetes mellitus Type 2
○ To investigate the association of sleep quality with diabetes mellitus Type 2
○ To compare the association of hypertension, smoking and sleep quality with
diabetes mellitus Type 2.
● Decide on population and sampling (RAOSOFT, to calculate sample size)
○ Target population: Type 2 diabetic patients in KK Seremban or other area???
○ 18+
○ Convenience sampling, cross sectional study
● Identify variables

● Develop study instrument/questionnaire and pretest

● Collect data
● Data processing, analysis and interpretation
● Report

Report writing made up of 7 components:

1. Abstract
2. Introduction
3. Methodology
4. Results
5. Discussion
6. References
7. Appendix

Questionnaire Development Process

· Understand the objectives of the research.
· Create the Questions:
o Decide on the questions.
o Determine the question type.
o Determine the answer format.
o Decide on the question wording.
o Determine the Question flow and layout.
· Evaluate the Question.
· Pretest and revise.
· Prepare the final copy.
Data Analysis


1. Age + Gender vs DM
Age Gender Type 2 Diabetes Mellitus Total
No Yes

< 30 M 15 0 25

F 10 0

30 - 39 M 3 5 17

F 7 2

40 - 49 M 9 3 30

F 11 7

50 - 59 M 11 16 65

F 14 24

60 - 69 M 16 19 60

F 11 14

70 - 79 M 7 12 40

F 6 15

≥ 80 M 1 3 10

F 2 4

Total 123 124 247


Our study shows that the prevalence of DM increases with age, with the highest prevalence of
diabetes mellitus being in the age group of 50 to 59 years; after which from age 60 years onwards,
the prevalence of DM will decrease.

A study by Veghari stated that there was a positive and significant correlation between age and

blood glucose.1

1. Veghari G, Sedaghat M, Joshaghani H, Hoseini SA, Niknezad F et al.. Association between

socio-demographic factors and diabetes mellitus in the north of Iran: A population-based study.
International Journal of Diabetes Mellitus 2010; 2(3): . (accessed 6 July 2015).


The current study shows no statistical difference in prevalence of type 2 diabetes between
male and female subjects. A study by Gale in 2001 on the European population
correlates with these results.[1] However two other studies on this topic contradict these
results. A study carried out on the Indonesian population showed higher prevalence in
females compared to males.[2] Another study involving the Chinese and Japanese
population found higher prevalence in males rather than females. The variability of these
results could be due to the difference on dietary habits in these populations.

1. Gale, E.A, Gillespie, K.M. Diabetes and gender. Diabetologia. 2001;44(1): 3 - 15.

2. Mihardja, L, Soetrisno, U., et. al Prevalence and clinical profile of diabetes mellitus in
productive aged urban Indonesians. Journal of Diabetic Investigation. 2014;5(5): 507 - 512.

3. Yang, W.Y., Lu, J.M., et. al Prevalence of Diabetes among Men and Women in China.
The New England Journal of Medicine. 2010;1(362): 1090-1101.

2. Ethnic + FHDM vs DM

Ethnic Family history of Type 2 Diabetes Total

Diabetes Mellitus Mellitus

No Yes

Malay With FHDM 20 20 61

Without FHDM 16 5
Chinese With FHDM 24 32 98

Without FHDM 26 16

Indian With FHDM 14 32 78

Without FHDM 19 13

Other With FHDM 3 5 10

Without FHDM 1 1

Total 12 124 247

Chi square value: Ethnic - 4.267, FHDM - 12.809

P – values: Ethnic = 0.23, FHDM = 0.002


While attempting to establish an association between ethnicity and the prevalence of

Diabetes Mellitus, our data showed no statistical significance between the two, with a p-
value>0.05. All 3 races, Malays, Chinese and Indians had very similar representation of
diabetes in our study. This contradicts a number of studies that show a clear disparity
between the 3 races and their association to Diabetes. One such study showed that HbA1c
was higher in Indians and Malays than in Chinese1. Though HbA1c is not an exact measure
of the presence of diabetes, the American Diabetes Assocation and WHO, say it is an
appropriate diagnostic tool1. Another study by Teh, Tey and Ng2, that took data from
Malaysian Population and Family Survey, examined the prevalence of different diseases
between the ethnic groups in the country. An odds ratio calculation of presence of diabetes
between the Malay, Chinese and Indians in the aforementioned study, produced a ratio of
1, 0.86 and 2.71 respectively. This once again contradicts our findings of equal distribution
of diabetes between the ethnic groups.

1. Venkataraman, K, Kao, S.L, Thai , A.C, Salim, A, Lee, J.J.M. Ethnicity modifies the
relation between fasting plasma glucose and HbA1c in Indians, Malays and Chinese.
Diabetic Medicine. 2012;29(7): 911-917.

2. Teh, J.K.L, Tey, N.P, Ng, S.T. Ethnic and Gender Differentials in Non-Communicable
Diseases and Self-Rated Health in Malaysia. Public Library of Science. 2014;9(3).
Overall, our results showed that family history of diabetes mellitus are associated with a
higher incidence of diabetes mellitus(OR = 2.59; 95% CI = 1.53 - 4.38). The result
corresponds with the study conducted by RA Scott et. al. which showed higher incidence of
type 2 diabetes mellitus among individuals with a family history of diabetes mellitus and
that family history is a strong independent risk factor for type 2 diabetes mellitus. Annis
AM et. al. also showed that prevalence of diabetes is more than 4 times higher among
individuals with a family history . In addition, both prevalence and odds ratio significantly
increased with the no. of relatives affected with diabetes.

Summary: (for presentation)

Overall, our results showed that family history of diabetes mellitus are associated with a
higher incidence of diabetes mellitus(OR = 2.59; 95% CI = 1.53 - 4.38). The result
corresponds with the studies conducted by RA Scott et al. and Annis AM et. al. which
showed higher incidence of type 2 diabetes mellitus among individuals with a family history
of diabetes mellitus.

1. Annis AM, Caulder MS, Cook ML, et. al. Family history, diabetes, and other
demographic and risk factors among participants of the National Health and
Nutrition Examination Survey 1999-2002. Prev Chronic Dis[serial online]. 2005
April[cited 7 July 15]. Available from:
2. Scott RA, Langenberg, Sharp SJ, et. al. The link between family history and risk of
type 2 diabetes is not explained by anthropometric, lifestyle or genetic risk factors:
the EPIC-InterAct Study. Diabetologia. 2013 Jan[cited 7 July 15]; 56(1): 60-69.
Available from:
Education vs DM

Type 2 Diabetes Total


Education level No Yes

No education 4 11 15

Primary 18 36 54

Secondary 67 63 130

Tertiary 34 14 48

Total 123 124 247

Chi - Square value: Education - 18.082

P – value: Education = 0.001

Education Type 2 Diabetes Total

level Mellitus (%) (%)

No Yes

No 26.7 73.3 100


Primary 33.3 66.7 100

Secondary 51.5 48.5 100

Tertiary 70.8 29.2 100

Total 123 124 247


Our study shows that the level of education is inversely related to the percentage of diabetic

patients.There was a higher prevalence of diabetics among the illiterate. A study by Sacerdote

and et al. that compared participants with high educational level against participants with a low

educational level of which the latter had a higher risk of T2DM.1 Added to that, the study by

Veghari and et al. showed that there was an association between illiteracy and DM. Lower level

of education is associated with a decreased knowledge of medical conditions. Hence, these

people will lack the knowledge about self care for the prevention or treatment of DM and other


1. Veghari G, Sedaghat M, Joshaghani H, Hoseini SA, Niknezad F et al.. Association

between socio-demographic factors and diabetes mellitus in the north of Iran: A population-
based study. International Journal of Diabetes Mellitus 2010; 2(3): . (accessed 6 July 2015).

2. Sacerdote C, Ricceri F, Rolandsson O, Baldi I, Chirlaque MD, Feskens E and et al..

Lower educational level is a predictor of incident type 2 diabetes in European countries: the

EPIC-InterAct study.. International Journal of Epidemiology 2012; 41(4): . (accessed 6 July 2015).

4. Income vs DM
Reliability Statistics

Cronbach's Alpha N of Items

.741 14

Normality test (Shapiro Wilk) – Skewed distribution

Non parametric analysis

Chi – Square test

5. DM vs Sleep Quality

*also ask for table of sleep quality vs years of diabetes

Diabetic Status Sleep Quality Total

Poor Good

Non Diabetic 80 43 123

Diabetic 95 29 124

Total 175 72 247

Chi square - 4.004 P – Value = 0.04

According to our results, we discovered that poor sleep quality was associated with an
increased prevalence of Type 2 Diabetes Mellitus in the Seremban population who went to
Seremban Health Clinic and Seremban 2 Health Clinic. Subjects with a global PSQI score
of 5 demonstrated a higher association of Type 2 Diabetes Mellitus (OR 1.76, CI 95%)
compared to those with a global PSQI score of < 5.

A cross-sectional study conducted by Lou P et al. in 2008 among the Chinese population
aged 18-75, independently of potential confounders such as age, obesity, family history of
diabetes, alcohol consumption, smoking, physical activities and other health conditions
supports our result.Both poor quality of sleep and short sleep

duration (#6 h) were associated with increased

prevalence of diabetes, with higher rates in relatively

healthy Chinese people. Compared with the group with

good quality of sleep and 6e8 h sleep duration,

diabetes was the most prevalent in individuals with

poor sleep quality and #6 h sleep duration (OR 1.41,

95% CI 1.07 to 1.85) and in those with poor sleep

quality who slept $8 h (OR 1.39, 95% CI 0.85 to

2.26), even after adjustment for a large number of

further possible factors.

[1] A cohort study conducted by Hayashimo et al from 1999 until 2004 which uses data
from participants in a High-risk and Population Strategy for Occupational Health
Promotion Study (HIPOP-OHP) concluded that medium and high frequencies of difficulty
initiating sleep but not sleep duration are associated with higher prevalence of diabetes. [2]
This correlates with our findings as well given that PSQI assesses each individuals sleep
latency as part of the component score which contributes to the global PSQI score.

1. Lou P, Chen P, Zhang L, et al. Relation of sleep quality and sleep duration to type 2
diabetes: a population-based cross-sectional survey. BMJ Open 2012;2:e000956.
2. Hayashino et al.. Relation between Sleep Quality and Quantity, Quality of Life, and Risk of
Developing Diabetes in Healthy Workers in Japna: the High-risk and Population Strategy
for Occupational Health Promotion (HIPOP-OHP) Study. BMC Public Health 2007; 7(129).

Similarly, a review by Surani et al. concluded that up to 33.3% of patients with DM

suffered from concomitant sleep disorders, as compared with 8.2% of controls without
DM. The adjusted odds ratio for insomnia was 1.4 in patients with DM, compared with
people without the disorder.

Surani S. Effect of diabetes mellitus on sleep quality. WJD. 2015;6(6):868.

A cross-sectional study by Shim et al. on outpatients at Ewha Womans University Hospital

in 2008 found that 38.4% of 784 DM patients had poor sleep quality, and 15.8% were at
high risk for obstructive sleep apnoea. No significant differences were observed by sex. The
frequency of risk for OSA was higher among obese patients compared with non-obese
patients (34.8% vs. 9.4%, p < 0.05).

Shim U, Lee H, Oh J, Sung Y. Sleep Disorder and Cardiovascular Risk Factors among
Patients with Type 2 Diabetes Mellitus. The Korean Journal of Internal Medicine.

Rajendran et al. conducted a study on patients at Sri Ramachandra Medical Center in

Chennai, South India to investigate the prevalence and determine the predictors of sleep
dysfunction in patients with T2DM in a southeast Asian Indian population.

69% of patients had a global PSQI score ≥5, indicating that they were "poor
sleepers." (mean, 7.08; standard deviation, 3.89)The global PSQI score positively
correlated with the duration of diabetes and was also independent of other
variables such as age, gender, body mass index, HbA1c, or medications.

Rajendran A, Parthsarathy S, Tamilselvan B, Seshadri K, Shuaib M. Prevalence and

Correlates of Disordered Sleep in Southeast Asian Indians with Type 2 Diabetes. Diabetes
Metab J. 2012;36(1):70.

DMyears vs Sleep quality

Years with Diabetes Type 2 Diabetes Mellitus Total

0 1

<1 25 0 25

1-5 10 7 17

6 - 10 20 10 30

11 - 15 25 40 65
16 - 20 27 33 60

> 20 13 27 40

Total 123 124 247

Chi square - 1.997 P – value = 0.85

6. DM vs HPT

Diabetic Status Hypertension Total

No Yes

Non Diabetic 78 45 123

Diabetic 31 93 124

Total 109 138 247

Chi square - 36.958

P – Value = < 0.001


In our study, our results show that hypertensive subjects are 5.2 times more likely to
develop T2DM than non-hypertensive subjects.

1. Summary: In an observational studies from 36 countries around the world, Colosia A.D et al. showed
that hypertension is prevalent in 50% of diabetic subjects worldwide.
Citation: Colosia A, Khan S, Palencia R. Prevalence of hypertension and obesity in patients with type 2
diabetes mellitus in observational studies: a systematic literature review. Diabetes, Metabolic Syndrome
and Obesity: Targets and Therapy. 2013;:327.

2. Summary: In a cohort study done by Abougalambou et al. on a total of 1077 T2DM patients who
attended diabetes clinic of Universiti Sains Malaysia (USM) teaching hospital in Kelantan, the prevalence
of hypertension (BP > 130/80 or on medication for high blood pressure) was 92.7%.
Citation: Abougalambou S, Abougalambou A. A study evaluating prevalence of hypertension and risk
factors affecting on blood pressure control among type 2 diabetes patients attending teaching hospital
in Malaysia. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2013;7(2):83-86.

3. Summary: In a cross sectional study done on urban Indonesians, Mihardja et al. concluded
that hypertensive patients have 2.2‐fold (95% CI 2.0–2.4) increased risk of hyperglycemia
compared with non-hypertensive patients.

Citation: Mihardja L, Soetrisno U, Soegondo S. Prevalence and clinical profile of diabetes mellitus in
productive aged urban Indonesians. Journal of Diabetes Investigation. 2013;5(5):507-512.
7. DM vs Smoking

Diabetic Status Smoking Total

Never Currently Ex Smoker

Non Diabetic 93 24 6 123

Diabetic 97 10 17 124

Total 190 34 23 247

Chi square - 11.106 P – Value = 0.004

DISCUSSION(LITERATURE VIEW)-ernest: The results show that there are more non-diabetic
patients associated with smoking than diabetic patients. Among the non-smoking subjects, diabetic
patients are equal to the number of non-diabetic patients. Current smokers are mostly non-
diabetic, while lesser diabetic patients as current smokers. The p-value calculated is 0.004 (<0.05),
and therefore is significant and we reject the null hypothesis.

The overall results is in contrast to the journal by Toshimi Sairenchi et al. (1) who concluded that
smoking was independently associated with increased risk of T2DM among elderly women and men
& middle-aged men and women. Julie C Will (2) also shows the positive correlation between
diabetes and smokers. Our study however failed to show the dose-response relation between
number of cigarettes smoked per day and the risk of diabetes. Besides that, our studies have also
failed to show the duration of previous exposure of smoking duration.

1. Toshimi Sairenchi, Hiroyasu Iso, Akio Nishimura, Takako Hosoda, Fujiko Irie, Yoko Saito,
Atsushi Murakami and Hisayuki Fukutomi. Cigarette Smoking and Risk of Type 2 Diabetes
Mellitus among Middle-aged and Elderly Japanese Men and Women.American Journal of
Epidemiology 2004; Volume 160(Issue 2): .
(accessed 7th July 2015).

2. Julie C Will, Division of Nutrition and Physical Activity, National Center for Chronic
Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770
Buford Highway NE, Mailstop K-26, Atlanta, GA 30341–3724, USA.. Cigarette smoking and
diabetes mellitus: evidence of a positive association from a large prospective cohort
study..International Journal of Epidemiology September 5, 2000; Volume 30 (Issue 3): . (accessed 7th July 2015).
Factors Sleep Quality Total

Poor Good

Diabetic 95 29 124

Diabetic + Hypertensive 69 24 93

Diabetic + Smoker(ernest) 9 1 10

Diabetic + Hypertensive + Smoker 8 0 8


Our study shows that 74.2% of subjects with both T2DM and hypertension have poorer sleep quality,
which was evaluated using PSQI. This result is similar as in previous cohort study done by Fiorentini et al.
which concluded a high prevalence of sleep quality disorders in subjects with hypertension and T2DM.
Additionally, the study also suggests poor sleep quality as a significant cause for both hypertension and

Citation: Fiorentini A, Valente R, Perciaccante A, Tubani L. Sleep's quality disorders in patients with
hypertension and type 2 diabetes mellitus. International Journal of Cardiology. 2007; 114(2):E50-E52.

Q26(b) Type 2 Diabetes Total


No Yes

0 50 26 76

1 19 13 32

2 19 20 39

3 35 65 100

Total 123 124 247

Chi - square - 17.726 P – Value = 0.001

Q26(c) Type 2 Diabetes Tot

Mellitus al

No Yes
0 34 22 56

1 22 13 35

2 26 19 45

3 41 79 111

Total 123 124 247

Chi square - 13.547 P – Value = 0.004


Our analysis indicates that frequent night bathroom visits are almost twice more prevalent
in DM patients compared to non-DM patients (71.2% vs 36.9%; p-value = 0.004) due to
nocturia. Nocturia in DM patients can occur in association with polyuria, and the
mechanism is solute diuresis leading to increased urine production. Similar results were
seen in previous study conducted in Australia in 2000 with 74 T2DM patients.

Surani S. Effect of diabetes mellitus on sleep quality. WJD. 2015;6(6):868.

DM Total

0 1

Income 0 75 87 162

1 17 17 34

2 11 10 21

3 7 3 10

4 7 3 10

5 6 4 10

Total 123 124 247

chi - square 4.533, P - value - 0.476

ExerciseGrp * DM Crosstabulation

DM Total

0 1

ExerciseGrp 0 81 91 172

1 42 33 75

Total 123 124 247

Chi - square 1.657 p-value 0.198