CHAPTER ONE

1.0 . INTRODUCTION
This chapter deals with background of the study, problem statement, objectives of the study,
research questions, significance of the study, scope of the study and operational definitions.

1.1. BACKGROUND OF THE STUDY

Diabetes mellitus (DM) is a chronic metabolic disorder characterized by persistent

hyperglycemia.it results from either impaired insulin secretion or impaired insulin efficacy. Is
broadly classified into three types by etiology and clinical presentation, type 1 diabetes, type 2
diabetes, and gestational diabetes (GDM (Aus. der Zeitschrift.2018) Type 2 diabetes is emerging
in Sudan and is associated with obesity. Deregulated lipid metabolism and inflammatory states
are suggested risk factors for cardiovascular disease, which is a leading cause of diabetic death
(Flagged et al., 2015). The prevalence of T2DM is steadily increasing everywhere, most
markedly in the world’s middle-income countries. China is experiencing the world’s largest
diabetes epidemic. The prevalence of T2DM in Mainland China has risen from a low 0.67% in
1980 to an astounding 10.9% in 2013. International Diabetes Federation estimated the number of
Chinese people aged 20–79 years with diabetes to be at 114.4 million in 2017.3 identifying
modifiable risk factors and reducing the prevalence of these factors is essential for the prevention
of T2DM. Dyslipidemia such as elevated triglycerides (TGs) or decreased high-density
lipoprotein cholesterol (HDL-C) is a common feature accompanying T2DM and prediabetic
states. There are several prospective studies that have demonstrated elevated blood TG levels to
increase the risk of diabetes, impaired glucose tolerance11 and impaired fasting glucose. Some
studies have shown that HDL-C is inversely associated with the incidence of T2DM.Insulin
resistance (IR) is a key risk factor for T2DM. The triglyceride to high-density lipoprotein
cholesterol (TG/HDL-C) ratio has been reported to be a surrogate marker of IR.this might be a
simple and reliable method to assess IR. However, only few prospective studies have evaluated
the association between the TG/HDL-C ratio at baseline and the incidence of T2DM. (Liu et al.,
2021).
Globally According to international diabetic federation (IDF), globally, from a total of 5 billion,
an estimated 463 million adults between the ages of 20–79 years (9.3%) have diabetes, and a
total of 4.2 million deaths due to it. More than three fourth of these people live in countries

1
considered to be low and middle income, with prevalence rate of (9.5% and 4%) respectively.
By the year

2
2030 it is projected worldwide that the number of patients with DM will increase and climb
578.4 million, about (2.26%) increase in the prevalence of DM to the current rate. More than 310
million 10.8% of diabetic patients live in urban settings, whereas almost 153 million live in rural
areas. Over the past three decades, globally the prevalence of DM has been gaining momentum
with an estimated 4.7% in the year 1980 to 8.5% in 2014. In 2019 China and India the two most
populous countries in the world) are the leading in the number of people living with DM (more
than 116 million and 77 million A recent report from over Fifty countries shows that 55% of
individuals living with DM, develop an end stage renal disease In western countries one fourth of
patients with T2DM develop diabetic nephropathy with recent study showing that diabetic
nephropathy is the single leading cause of end stage renal disease and replacement.
(Ogurtsova K,2015)
In Africa, Diabetes particularly affects low-income and middle-income countries in terms of
prevalence, mortality, and morbidity. More than 80% of people with diabetes live in developing
countries, where rapid cultural and social changes, including changes in lifestyle, aging
populations, increasing urbanization, dietary changes, and reduced physical activity, all
contribute to the dramatic increase in the epidemic of diabetes. The majority of people with
diabetes in low- income and middle-income countries are under 60 years of age.2 According to
recent estimates, diabetes accounts for 1.4 million cases with 7.7% prevalence and more than
25,000 diabetes- related deaths in Sudan. (Faggad et al., 2015)
In Somalia the frequency of diabetes mellitus in Somalia faces unique challenges in combating
the disease including lack of funding for non-communicable diseases, lack of availability of
studies and guidelines specific to the population, lack of availability of medications, differences
in urban and rural patients, and inequity between public and private sector health care. Because
of these challenges, diabetes has a greater impact on morbidity and mortality related to the
disease in sub- Saharan Africa, especially in Somalia than any other region in the world. (Abdul
Majid et al., 2019),

3
1.2. PROBLEM STATEMENT
Diabetes mellitus type 2 (T2DM) is a disease that worsens over time and is typified by persistent
decrease of endogenous insulin production and insulin resistance. In recent years, T2DM has
affected an increasing number of people. According to reports, in 2013, the estimated prevalence of
diabetes and prediabetes in the adult Chinese population was 11.6% and 50.1%, respectively. Over
90% of instances of diagnosed diabetes mellitus in China are T2DM cases, making it the most
frequent kind of the disease. Early identification of insulin resistance is beneficial since it plays a
significant role in the pathophysiology of type 2 diabetes. One straightforward indicator of insulin
resistance has been suggested: the ratio of triglycerides (TG) to high-density lipoprotein cholesterol
(HDL-C). TG/HDL-C's possible use in identifying insulin resistance. There is insufficient data to
suggest that in Chinese people, the TG/HDL-C ratio serves as a proxy for insulin resistance.
Furthermore, hardly many research including recently diagnosed T2DM patients have been done.
Therefore, in Chinese patients with newly diagnosed T2DM, this study examined the plasma lipid
profiles and investigated the relationship between TG/HDL-C and insulin resistance. (Ren and
others, 2016). Dyslipidemia, characterized by increased triglycerides (TGs) or decreased HDL-C
(high-density lipoprotein cholesterol), is frequently observed in conjunction with type 2 diabetes
and prediabetes. Elevated blood TG levels have been linked to a higher risk of diabetes, reduced
glucose tolerance, and impaired fasting glucose, according to many prospective studies. According
to certain research, HDL-C and the occurrence of type 2 diabetes are inversely correlated.IR, or
insulin resistance, is a a key risk factor for T2DM. The triglyceride to high-density lipoprotein
cholesterol (TG/HDL-C) ratio has been reported to be a surrogate marker of IR. This might be a
simple and reliable method to assess IR.(Zheng et al., 2020) .
1.2. OBJECTIVES

1.2.1. General of objective

The general objective of this study is “assessment of Triglycerides to High Density Lipoprotein
Cholesterol Ratio and C- reactive protein among Type 2 Diabetic at Somali Sudanese hospital”
1.2.2.Specific of objective
1) To measure triglycerides, HDL and CRP among type 2 diabetic patient at Somali Sudanese

4
 hospital.
2) To find out ratio between triglyceride and high-density Lipoprotein (HDL) among type 2
diabetic patient at Somali Sudanese hospital.
3) To assess the relationship between triglyceride, HDL and C-reactive protein with duration of
type ttwo diabetic patients at Somali Sudanese hospital.

1.3. RESEARCH QUESTION

1. What triglycerides and HDL, CRP among type 2 diabetic patient at Somali Sudanese hospital?
2. What is ratio between triglyceride and high-density Lipoprotein
(HDL) at Somali Sudanese Hospital?
3. What is the relationship between triglyceride, HDL and CRP with duration type two
diabetic patients at Somali Sudanese hospital?
1.6 Scope of Study
The study will conduct Somali Sudanese hospital. This hospital is located in Mogadishu, Somalia’s
capital. The researchers will use this hospital because it is the place to treat the Type 2 Diabetic. The
study seeks to assess Triglycerides to High Density Lipoprotein Cholesterol Ratio and C - reactive
protein among Type 2 Diabetic at Somali Sudanese hospital.

1.6.1 Geographical scope

The study will conduct Somali Sudanese hospital. This hospital is located in Mogadishu, Somalia’s
capital.
1.6.2 Content Scope
Assessment the Triglycerides to High Density Lipoprotein Cholesterol Ratio and C- reactive protein
among Type 2 Diabetic
16.3 Time Scope
The study will cover the information from September to December 2023.
1.7 Significance of the Study

This study would be useful for associations in the field of find study also NGOs or other donors’
agencies and international agencies operating Somalia. This study would be useful for
academicians, and community members. The study was also benefited by local community because
it greats conscious awareness of severity of particular problem and also urgency of the need for
solution. The study will also be useful for institution both public and private because it makes them

5
aware of existing issues and also proper ways to come up with a long-lasting solution.

1.8 Operational Definition of Key Terms

1.3.Operational key terms

Type two diabetes: is common condition that causes the level of sugar (glucose) in the blood to
become too high.
C-reactive protein (CRP); test measures the level of C - reactive protein your blood.

Lipoprotein: is a group of soluble proteins that combine with and transport fat or other lipids in
the blood plasma.
Triglycerides: any of group of lipids that are ester formed from one molecule of glycerol and three
molecules of one or more fatty acid.

Cholesterol: is present in tissues and in plasma either as free cholesterol or as storage form
combined with along chain fatty acid as cholesteryl ester.
HDL: a Lipoprotein of blood plasma that is composed of a high proportion of protein with little
triglyceride and cholesterol that is correlated with reduced risk of atherosclerosis.

6
 CHAPER TWO

LITERATURE REVIEW

2.0 INTRODUCTION
Dysregulation of protein, lipid, and carbohydrate metabolism is a hallmark of type 2 diabetes
mellitus (T2DM), which can be brought on by either insulin resistance, decreased insulin
production, or a combination of the two. Out of the three primary forms of diabetes, type 2
diabetes mellitus (T2DM) is far more prevalent than type 1 diabetes mellitus (T1DM) or
gestational diabetes, making up over 90% of all cases. Our knowledge of the onset and evolution
of type 2 diabetes has significantly changed during the past few decades. Its primary cause is
gradually decreased pancreatic β-cell insulin release, often against the backdrop of pre-existing
insulin resistance in adipose, liver, and skeletal muscle. Prediabetes1, 2 is a high-risk disease that
predisposes people to the development of Type 2 Diabetes. It occurs before overt hyperglycemia.
Any one of the following characteristics of prediabetes Individuals with IFG levels are
characterized by fasting plasma glucose levels that are higher than normal but do not meet the
criteria for the diagnosis of diabetes. IGT is characterized by insulin resistance in muscle and
impaired late (second-phase) insulin secretion after a meal, whereas individuals with IFG levels
manifest hepatic insulin resistance and impaired early (first- phase) insulin secretion Individuals
with prediabetes have HbA1c levels between 5.7–6.4%; they represent heterogeneous group with
respect to pathophysiology and are clinically very diverse. Annual conversion rates of
prediabetes to T2DM range from 3% to 11% per year. (Balaji et al., 2014)
Its smallest and most dense lipoprotein particle, synthesized by liver and intestine. Discoidal or
spherical shape, Discoidal represent recent and most active form in removing excess cholesterol
from peripheral cell (Bishop et al.,2018). Plasma levels of high-density lipoprotein (HDLc)
cholesterol are strongly inversely associated with atherosclerotic CVD. 14 The molecular
regulation of HDL metabolism is not fully under stood, but it is influenced by several
extracellular lipase (Jin et al.,2002). there are many scientific studies prove the relationship
between the Low density HDLC and the cardiovascular disease in patients with diabetes mellitus
like (Golay et al.,1987), (Awadalla et al.,2018), (Elnasri and Ahmed.,2008) and others.
Alterations of HDLc in diabetes are probably based on the presence of insulin deficiency or,
more commonly, onhyperinsulinemia and insulin resistance. HDLc (particularly the
7
subfractionHDLc2) concentration is regulated by two endothelial lipolytic enzymes, lipoprotein
lipase and hepatic lipase, both of which are insulin sensitive (Nikkila,1981).
The triglycerides: HDLc ratio recently used as predict subject at increased risk of developing
metabolic and cardiovascular complications. (Tommaso et al.,2013). Also, its prdictive for the
severity of CHD. It could predict in hospital_new onset heart failure incidents of CHD patients
(Yunke et al., 2014). HDLc levels are inversely related to plasma triglycerides levels and there is
a dynamic interaction between HDLc and triglycerides (TGs) rich lipoproteins in vivo
(Lamarche, 1999). The atherogenic link between high Triglycerides and HDLc-cholesterol is due
to higher plasma concentration of Triglycerides-rich; very low-density lipoprotein, that generates
small, dense LDL, during lipid exchange and lipolysis. This LDL particle accumulate in the
circulation and form small dense HDLc particles, which undergo accelerated catabolism, this
dosing the atherogenic circle (Protasio et al., 2008). The treatment of lipids disordered include
statin, one of the most powerful classes of agents for the treatment of cardiovascular diseases the
15 reductions in circulating serum lipid levels that were mediated by inhibition of liver 3-
hydroxy 3-methyl glutaryl coenzyme A (HMG-CoA) reductase (Lefer, 2002). Dietary
supplementation with soluble fiber, such as psyllium husk, oat bran, guar gum and pectin, and
fruit and vegetable fibers, lowers serum LDL cholesterol concentrations by 5 to 10 percent
(Knop,1999).
CRP is an ancient highly conserved molecule and member of pentraxin family of proteins,
secretes by liver in response to trauma, infection, inflammation (Do clos, 2000). Recent evidence
implicates inflammation in the pathogenesis of coronary heart disease; C reactive protein, a
plasma marker of inflammation, is a marker of CHD (Folsom et al.,2002).and others multiple
prospective studies now demonstrate that high sensitivity C reactive protein is a potent predictor
of future cardiovascular events at all level of low-density lipoprotein cholesterol (Ridker,2003).
Elevated HS-CRP was significantly correlate with electrocardiogram; defined coronary artery
disease (Thakur et al., 2011).
2.1 Ratio between triglyceride and high-density Lipoprotein (HDL)
Triglyceride (TG) to high-density lipoprotein cholesterol (HDL-C) ratio has been proposed as a
simple marker of insulin resistance. The potential utility of TG/HDL-C to detect insulin
resistance was firstly reported by McLaughlin in a Caucasian population. Similar results were
found in different racial groups such as Korean. Non-Hispanic Black and Mexican American

8
However, studies showed that TG/HDL-C might not be a marker of insulin resistance for
African populations. It is possible that given the racial variations in both TG and HDL-C levels,
the association between TG/HDL-C and insulin resistance is ethnicity-dependent. There are
limited evidences supporting that the ratio of TG/HDL-C is a surrogate marker of insulin
resistance in Chinese individuals. What’s more, few studies have been conducted in newly
diagnosed T2DM patients. Thus, this study focused on the plasma lipid profiles and explored the
association between TG/HDL-C and insulin resistance in Chinese patients with newly diagnosed
T2DM the ratio of triglyceride to high-density lipoprotein cholesterol levels (TG/HDL-C) was
shown to be associated with IR. However, those studies were mainly cross-sectional and did not
reveal a nonlinear relationship between TG/HDL-C and T2DM incidence (Liu et al.,2021).
Triglyceride (TG) to high-density lipoprotein cholesterol (HDL-C) ratio has been proposed as a
simple marker of insulin resistance. The potential utility of TG/HDL-C to detect insulin
resistance was firstly reported by McLaughlin in a Caucasian population. Similar results were
found in different racial groups such as Korean non-Hispanic Black and Mexican American.
However, studies showed that TG/HDL- C might not be a marker of insulin resistance for
African populations. (Liu et al.,2021).
It is possible that given the racial variations in both TG and HDL-C levels, the association
between TG/HDL-C and insulin resistance is ethnicity-dependent. There are limited evidences
supporting that the ratio of TG/HDL-C is a surrogate marker of insulin resistance in Chinese
individuals. What’s more, few studies have been conducted in newly diagnosed T2DM patients.
Thus, this study focused on the plasma lipid profiles and explored the association between
TG/HDL-C and insulin resistance in Chinese patients with newly diagnosed T2DM. (Elam et
al.,2017).
Triglycerides (TG) and the triglyceride to high-density lipoprotein cholesterol concentration ratio
(TG/HDL-C) have been reported to be closely related to insulin resistance, and use of TG and
TG/HDL-C as surrogates for insulin resistance has been recommended. On the other hand, some
authors have emphasized interethnic differences in lipid profiles and insulin resistance, and
cautioned the use of lipid surrogates for insulin resistance. In fact, recent literature shows that
African Americans have more favorable lipid profiles than whites despite African Americans
being more insulin resistant. Therefore, the aim of our study was to examine how well insulin
resistance could be predicted from TG and TG/HDL-C in a group of young, healthy African

9
American and white participants. (S. Kim-Dorner et al.,2015).

2.3 The relationship between triglyceride, HDL and CRP with duration type two
diabetic patients
Dyslipidemia, characterized by increased triglycerides (TGs) or reduced HDL-C (high-density
lipoprotein cholesterol), is frequently observed in conjunction with type 2 diabetes and
prediabetes. Elevated blood TG levels have been linked to a higher risk of diabetes, reduced
glucose tolerance, and impaired fasting glucose, according to many prospective studies.
According to some research, HDL-C and the occurrence of type 2 diabetes are inversely
correlated. IR is a major risk factor for type 2 diabetes. It has been suggested that TG/HDL-C, or
triglyceride to high-density lipoprotein cholesterol, is a proxy sign of IR. This might be a
straightforward and trustworthy way to evaluate IR. Nevertheless, the relationship between the
incidence of T2DM and the baseline TG/HDL-C ratio has only been assessed in a small number
of prospective investigations. In our understanding, there haveIt is worth noting that the majority
of published studies on this topic were based on a single measure of TG/ HDL-C ratio, failing to
take into account the potential effect of change in the ratios over time. Many covariate data such
as TG, HDL-C and blood pressure are collected regularly in longitudinal studies. They may
fluctuate over time and are commonly addressed as time-dependent (or time-varying) covariates
in statistics. (Liu et al.,2021).
Participants in surveys (1992, 2000, 2009, 2012, and 2017) had laboratory testing and physical
examinations. This cohort's data, which were used in the study, were collected between 1992 and
2017. Participants with diabetes (self-reported history of T2DM or fasting plasma glucose (FPG)
concentration ≥7.0 mmol/L at baseline) were not included in this study. Additionally, 395 people
were not included in the analysis because they were unable to finish the lab tests or had
incomplete baseline TG or HDL-C values. Two individuals who passed away from type 1
diabetes and had no prior history of type 2 diabetes were also eliminated. Thus, in the final
analysis, 1460 people with full data were taken into account. The Declaration of Helsinki's
guiding principles were followed in this investigation. Everyone who took part submitted their
written (Zheng D, Li H, Ai F, et al.,2019).

2.4 RELATED STUDY

The research subjects based on serum TG/HDL-C. When the participants were followed up for
10
four years, 394 of the 7,791 were diagnosed with T2DM. The likelihood of TG/HDL-C and
blood lipids to change during a 4-year period amongst T2DM patients. The participants' mean
age was 56:03±7:82 years, with 2/3 being male (3,613, 33.54%). The TG/HDL-C ratio was
1:10± 0.62. greater TG/HDL-C levels were associated with reduced walking frequency,
hypertension, hyperlipidemia, stroke, and a greater likelihood of being male and smokers.
Furthermore, systolic and diastolic blood pressure, BMI, waist and hip circumferences, the
presence of fatty liver, and the levels of alanine aminotransferase, creatinine, total cholesterol,
TGs, LDL-C, fasting plasma glucose, and hemoglobin A1c were all directly correlated with
serum TG/HDL-C, but in an inverse manner.but inversely proportional to the HDL-C level.
(Thakur et al., 2011).

11
 CHAPTER THREE
RESEARCH DESIGN

3.0 Overview

This chapter will concerning the following main ideas such as Research area, Research design,
Research population, Target population, Inclusion and Exclusion criteria, Sample size
determination, Sampling procedure, Research instrument methods, Data analysis, Ethical
consideration and Research limitation.
3.1 Study design
This study will be descriptive cross-sectional study because it’s easy to use as the information
collect from respondents and it’s not required to make re-investigation over a period of the study.
3.2 Study Area
This Study will conduct in Somalia Sudanese specialized hospital located in Banadir region
specially Hodan district Mogadishu-Somalia.
3.3 Target population
The target population of this study will be type 2 diabetes Mellitus patients attending at Somali
Sudanese Hospital the study population. The sample frame will be one hundred (100) of the
patients of Sudanese Hospital
3.4 Sample size
The sample size of this present study will be duration sample since we don’t know the number of
diabetic patients we shall meet at Somali Sudanese hospital during our study period, therefore
once we know the number of diabetic patients attending at Somali Sudanese specialized hospital
during our study period, later on we will use the solving formula to calculate our suitable sample
size if we needed to meet with the sample size 90 patients in the Sudanese Hospital.
3.5 Sampling procedure

The sampling technique uses in this study will be non-probability sampling technique.
Nonprobability sampling is a method of sampling where the researcher intentionally chooses
whom to include in the study based on their ability to provide necessary data.
3.6 Research instrument
Questionnaire will be suitable instrument to obtain information needed can easily described in
writing. Since the sample size is fairly large and there is limited time, questionnaire will have

12
considered ideal for collecting such data, is suitable tool for collect lot information over short
period of time. Self-developed questionnaire and close end questions will use in the study.

3.7 Laboratory procedure

Approximately 3ml of vein puncture blood will draw in plain tubes these will then centrifuged at
3000rpm for 10minutes Spectrophotometer will employee in analyzing the total cholesterol and
triglyceride, HDL, C-reactive protein serum also taken and type 2 diabetes mellitus. We use
centrifuge, biochemistry Spectrophotometer: is device measures the intensity of electromagnetic
energy at each wavelength of light in a specified region.
3.8 Validity and reliability of the instrument
To establish the reliability of questionnaire the researcher’s used method of expertise judgment
as best method of reliability after the construction of the questionnaire. The researchers
approached supervisor and other experts those have great knowledge about the topic of this study
to ensure the reliability and validity of the researcher instrument. The sample technique and
procedure or mechanisms put in place made the study possible to insure the validity and
reliability as they kicked off the biasness in the research and the advice of experts: which clearly
made the research relevant, specific and logical. In addition, a pilot test will conducted 20
respondents in order to test and prove on the reliability of the questionnaire. To prove the
validity of the data collection instrument scale will used the validity relevance questionnaire and
the total number.
3.9 Data gathering procedure

This study will use primary data. This will collect from respondents in the area of study. Data
will collect using a pre-cod structured questionnaire for the survey, Close-end questions was use.
The close-end questions are questions in which an all-possible answer will pre-specified
and the respondents make the choice from the answers provide. Data collection will do by a
face-to face personal interview method. An informed interviewer visits each respondent. This is
important because it helping the respondent to understand the questions by interpreting them to
fit the respondents‟ understanding. This will done to ensure that the respondent.

3.10 Data analysis

This part will addressed, processing and analysis. The researchers will use to collect data
descriptive statistics to analysis primary data. Descriptive statistics refers to the use for
13
measuring of central tendencies such us mean, mediums, and modes and measurement of
dispersion such as range, quartile, standard deviations and variance to describe a group of
subjects. The data will collect from Somali Sudanese specialized hospital in Hodan district, edit,
collect and tabulate. Data will use manually enter in a statistical package for social analysis
(SPSS) spreadsheet then tabulated using the programmer and analyzing. Statistical package for
social science analysis (SPSS) is computer application that provides statistical analysis of a data.
It allows in-depth data access and preparation, analytical, reporting graphics and reporting tables.
3.11 Ethical considerations
Respect: The researcher will respect respondent’s privacy when entering their private sphere and
when asking questions.
Confidentiality: the researcher will guarantee maximum confidentiality for the participants.
Their information will only be used for the purpose of the study.
Freedom to participate: participants will be informed that they are free to participate. They will
also be informed that they have the right to withdrawal. Informed consent: consent will be
secured from the participants after fully informing the nature, potential risks and benefits of the
study.

14
 QUESTIONNAIRE
SECTION A. SOCIO-DEMOGRAPHIC CHARACTERISTICS
This questionnaire is to assist the researcher to gather some information on their thesis. Thesis titled
‘‘The Triglycerides to High Density Lipoprotein Cholesterol Ratio and C- reactive protein
among Type 2 Diabetic’’ Please complete the following section by ticking, circling the right choice
answer or writing down your answer. The information you provide will only be used for academic
purposes and will be treated with strict confidentiality.

Part A: General Information

1. Name of Respondents (Optional)………….………………………………………..

Please tick in the bracket of one of the answers

1. Gender

1. Female

2. Male

2. Age

1. 18-25
2. 26-34

15
 3. 35-44
4. 45-65
3. Marital status:
1. Mar

ried 2
single
3. Divorced
4. Widowed
4. Level of Education:
1. Primary
2. Secondary
3. University
4. informal
5. Are you employee?
1. Yes
2. No
6. Type of
employee? 1
Health
worker 2
Businessman
3 Teacher
other

SECTION B: PATIENT QUESTIONS

1: How long have you been type two Diabetic patient?

A: 2 to 4 years
B: 6 to 8 years
C: more than 10 years

16
2: do you take any drugs for this disease?
A: Yes B: No

3: How long have you been taking this drug?

A: 2 to 4 years
B: 6 to 8 years
C: more than 10 years
4: Do you do exercise?
A: Yes B: No
5. what kind of exercise do you do?
A:
Gym
B:
walkin
g
C: playing foot ball
6: do you smoke?
A: yes B: No

7.how long have you been smoking?

A: 1 to 3 years B: 4 to 7 years
8: how much packed do you smoke per day?
A: 1 packet
B: 2 to 3
packets C:
more than 4

17
9: do you have any others chronic disease?
A: yes B: No
10: if yes what is your other chronic disease?
A: heart
disease B:
hypertensio
n
C: hepatitis D: other

18
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