Knowledge and practice of primary care physicians towards management of dyslipidemia in individuals with diabetes in Khartoum and Karray localities: a cross-sectional online survey

Introduction

Dyslipidemia is an important cardiovascular risk factor in individuals living with diabetes and represent high burden (1). Other risk factors for dyslipidemia are sedentary life style, obesity and genetic factors (1). The burden of dyslipidemia is high in people with diabetes. For instance, a national cross-sectional chart audit study by Harris et al. in Canada included 2,473 patients with type 2 diabetes showed that 55% of individuals with a diabetes for 2 years had dyslipidemia. This proportion was increased up to 66% in patients with diabetes for 15 years (2). Dyslipidemia is one of the components of metabolic syndrome (3,4) and is a well-recognized risk factor for cardiovascular disease (CVD) (5). CVD is one of leading causes of death in Africa (6). Managing dyslipidemia in patients with diabetes requires multidisciplinary approach. Pharmacotherapy and dietary modifications are integral components of management (7). Weight reduction is one of the most important goals of the treatment of dyslipidemia, because weight reduction will be followed by improvement in lipid profile, insulin sensitivity, and glycemic control (8). Healthy diet is also important for treatment of dyslipidemia in individuals with diabetes (vegetables, whole grain, legumes, and avoid foods that contain sugar and fat) in association with aerobic exercise training (9,10). Importantly, using insulin and antidiabetic medication is also crucial step in management of dyslipidemia (11). Statins is the first-line therapy in management of dyslipidemia (12). The role of physicians and their attitudes in the management of diabetic dyslipidemia cannot be over emphasized (13,14). Physicians’ attitude can affect the efficiency of lipid management (15,16). For instance, Patel et al. reported that physicians’ knowledge of management of lipids was related to their professional status.

In Sudan, diabetes dyslipidemia represents a serious health challenge. For instance, Awadalla showed that low high density lipoprotein (HDL) is a prominent feature in two thirds of individuals with diabetes in Sudan, while high cholesterol and high triglyceride were seen in over one quarter (17). While Almobarak et al. showed that high cholesterol, triglyceride, and low-density lipoprotein were seen in 76.2%, 27.5%, and 48.8% in Sudanese individuals living with type 1 diabetes, respectively (18). Primary care physicians are the first line of health care for managing people with diabetes in many healthcare settings and they have major role in patient care and outcome (19). A study conducted by Peytremann-Bridevaux in Switzerland by described healthcare professionals’ and patients’ and perceptions regarding the difference in the quality of diabetes care (20). Similarly, a study conducted in Norway showed a variation between primary care physicians in the performance of diabetes care processes (21). Said et al. study showed that there is still a gap in knowledge and practice of dyslipidemia management among primary healthcare (PHC) physicians (22). A study conducted in United Arab Emirates showed significantly better lipid control indices achieved in tertiary care centers compared to primary care (23). A study in Saudi Arabia showed different perceptions and attitudes among physicians in due to variable recommendations by international lipid guidelines (24). Larger sample size is required to include much broader group of healthcare physicians and to provide a better overall picture of physician knowledge and practice. Study conducted in China showed low density lipoprotein cholesterol (LDL-C) goal achievement in dyslipidemia patients is associated with physicians’ knowledge of LDL-C guidelines (25). The aim of the current study was to assess the knowledge and practice of primary care physicians in Sudan in the management of dyslipidemia in individuals with diabetes.

Methods

Study setting

The study was a descriptive cross-sectional facility-based study conducted in PHC centers of Ministry of Health (MOH) in Khartoum and Karary localities from May to November 2019. The study population was doctors working in the selected localities during the study period.

Inclusion criteria

Doctors working in MOH in the selected localities during the study period and accepted to participate in the study were included.

Exclusion criteria

Absent doctor and doctors who refused to participate in the study were excluded.

Sample size and sampling technique

The study sample was calculated according to the statistic of PHC centers in the study area.

The total number of doctors was 200. By using the Taro Yamane formula to find sample size: n = N/1 + N (e²), where n = sample size, N = population size, e = the acceptable sampling error which is 5% or −5%, the estimated sample size was 134 participants.

Convenience sampling method was used to select the participated physicians working in the PHC centers in the two localities.

Data collection

Data was collected through a pre-tested, self-administered, online questionnaire. Knowledge and practice were assessed through questions that were designed according to the information mentioned in the diabetes treatment guidelines in The U.S. Preventive Services Task Force (USPSTF) and American diabetes association then the questionnaire was validated by pilot study through distributing the questionnaire to expert endocrinologists as they approved the questionnaire. The questionnaire consisted of three sections: demographic characteristics of the participants, knowledge section and practice section.

Knowledge part

A correct answer was given 1 mark, while no mark was given for each question wrongly answered or left blank. The total score ranged from 0 to 10. The participants were divided into three categories: those who scored [0–3] were categorized as having a low level of knowledge and those who scored [4–6] were categorized as having a moderate level of knowledge, while those who scored [7–10] were categorized as having a high level of knowledge.

Statistical analysis

The study data were organized using the Excel software program and processed using the Statistical Package for the Social Sciences (SPSS), Version 23.0. Statistical associations between pairs of categorical variables with two or three groups were assessed using Chi-squared analysis, and statistical significance was set at P<0.05.

Ethical consideration

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by SUMASRI Institutional Review Board (SIRB) (No. 00008867) and verbal consents were obtained from all individual participants. Research purpose and objectives were explained to participants in clear simple words. SUMASRI is Sudan Medical and Scientific Research Institute, University of Medical Sciences and Technology, Sudan.

Results

Sociodemographic characteristics of the participants

The sample size of the participants was 134; more than two-thirds were females and the median years of experience of the participants were 7 [interquartile range (IQR), 5–10] years. More than half of the participants reported that they see about 21–40 patients with diabetes per month, while only 6.8% reported that they see more than 100 patients. About 81% of the participants had postgraduate studies in family medicine. Similarly, about 80% participated in workshops or other training courses for family doctors; 24.6% of them always attend the workshops. About 60% of the participants stated that they attend conferences (a head-to-head meeting with an invitation) was done for them, but about 59% of them were doing that rarely (Table 1).

Participants’ knowledge of dyslipidemia

The majority 90% of them knew the risk for developing dyslipidemia, while 78% of them states that they you know at what age you should screen diabetics for dyslipidemia but of which only 18% recognized that. Two thirds the participants reported that they know the criteria for metabolic syndrome. Twenty-seven percent of them did not know that diabetes is considered as coronary heart disease (CHD) equivalent. about two third the participants recognized that the primary goal of dyslipidemia treatment is to lower the LDL-C level; 70% of the participants recognized that the low density lipoprotein (LDL) therapeutic targets in diabetics is <100 mg/dL (26,27) and at LDL level 101–129 mg/dL you start therapeutic life style change. Two thirds of them recognized that at LDL level 130 mg/dL or more they should start medications. Interestingly 83% of them recognized that statin is the best drugs for reaching LDL therapeutic target. Only 34% of them stated that they know a local or international guideline for dyslipidemia management, among them 25% stated that they know National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III guidelines. Among those who did not know any guideline for dyslipidemia management 54.4% stated that unavailability of the guidelines the most common barrier while 46% of them attributed that to the lack of skills for searching about them. Only about one third the participants recognized the blood pressure target in diabetics (Table 2).

The median score of knowledge was 8 (IQR, 6–10). Overall, more than two-thirds of the participants revealed a high level of knowledge (69.4%), while 17.2% revealed a moderate level of knowledge.

Participant’s practice towards the management of dyslipidemia

About 60% of the participants screen their patients with metabolic syndrome, and more than three quarters screen their patients with obesity and family history of type 2 diabetes; 53% screen their patients with features of insulin resistance like polycystic ovary syndrome (PCOs). Eighty-six percent and 76% counsel diabetics about the importance of physical exercise and smoking cessation, respectively. Eighty percent routinely measure blood pressure for all diabetic patients, while 79% inform their patients that controlling their lipid profile will substantially decrease morbidity and mortality from atherosclerotic cardiovascular disease (ASCVD). Only 18% of the participants screen the patients with human immunodeficiency virus (HIV), and 38% of screen those on steroid therapy routinely (Table 3).

Test of associations

When the Chi-squared test was performed to determine if there is an association between the participants’ knowledge and gender, age of the participants, if the participants received postgraduate study in family medicine or not, workshops attendance, conferences attendance, years of experience and average number of individuals with diabetes seen per month, we found that knowledge of the participants revealed statistically significant association with postgraduate study in family medicine, workshops attendance, and conferences attendance (with two sided P values <0.001). We found that the physicians who received postgraduate study in family medicine, and those who attended workshops and conferences in family medicine had higher level of knowledge than others.

While when the Spearman correlation test was performed, we found that the knowledge score was correlated with average numbers of individuals with diabetes reviewed per month (correlation coefficients =0.312, P<0.001).

When an ordinal logistic regression was done, dependent variable used in the logistic regression was level of the knowledge. We found that only those having postgraduate study in family medicine had statistically significant results with a high level of knowledge [P=0.005; odds ratio (OR) =5.049; 95% confidence interval (CI): 1.626–15.675], which means those who are having postgraduate study in family medicine are more likely to have high knowledge than those who have not by five times. Furthermore, those who participate in workshops are more likely to have a high level of knowledge by 3.4 times, although the result was statistically insignificant (P=0.07; OR =3.352; 95% CI: 0.890–12.617) (Table 4).

Discussion

Several studies from China, USA and Canada showed that there was tendency not to prescribe lipid lowering medication and those who take them reported did not achieve the desired low lipid level (28-30). Knowledge barriers can be attributed to low familiarity with the guidelines, younger physicians usually have less knowledge of the guideline therefore they are less likely to use them (31,32). Ramsaran et al. emphasized the importance of education in bridging the gap between physicians’ knowledge and practice in management of lipid (33).

This study investigated 134 doctors to assess their knowledge and practice towards managing dyslipidemia in diabetic patients. About two-thirds of the participants recognized that the main aim of management of dyslipidemia is to reduce the plasma level of LDL-C level. Seventy percent of the participants recognized that the LDL therapeutic targets in diabetics is <100 mg/dL, and at LDL level 101–129 mg/dL they should start therapeutic life style change. This is similar to a previous study in China which showed that about 75% of the physicians know the importance of plasma concentration of LDL-C serum in treatment of dyslipidemia. The rate of achievement of the LDL-C goal was higher for the patients whose physicians’ knowledge was consistent with the guidelines (25). This is also similar to a recent study by Almigbal et al. in Saudi Arabia which showed that about 60% of the physicians put LDL-C target for the patients (24). Two-thirds of the participants recognized that they should start medications at LDL level 130 mg/dL or more. Eighty-three percent of them recognized that statin is the best drug for reaching LDL therapeutic targets. This is also similar to Almigbal et al. in Saudi Arabia which showed 78% of the physicians prescribe statin to their patients (24). This reflects good awareness among the studied doctors about the goal of the treatment of dyslipidemia. Previous studies showed that physicians have a key role in management of dyslipidemia (13,14). Furthermore, physicians’ attitude and behavior might have a direct impact on the efficiency of the management of lipid management (15,16). It has been reported that physicians’ knowledge of management of lipid is related to their professional status (34). In our study, only 34.4% of the physicians know local or international guideline for management of dyslipidemia. This may suggest the need for more education in this field. This is different from Zaitoun et al. study in Saudi Arabia which showed that the majority of physicians (77%) knew about the release of the American College of Cardiology (ACC)/American Heart Association (AHA) 2013 guidelines for dyslipidemia but they did not know about the recent recommendations of the ACC/AHA 2013 guidelines for management of dyslipidemia (35). Misperceived cardiovascular (CV) risk by physicians is a major determinant for inappropriate statin prescription. Physicians under-estimated the cardiovascular risk of patients with diabetes and often fail to consider the additional risk factors associated with higher cardiovascular risk (36). Encouraging the PHC physicians to attend conferences and workshops and presenting dyslipidemia management guidelines in electronic versions and one-page summary might improve the accessibility of the guidelines and knowledge of the physicians. About 60% of the PHC physicians screen their patients with metabolic syndrome, and more than three quarters screen their patients with obesity and family history of type 2 diabetes, 53% screen their patients with features of insulin resistance like PCOs. About 76% of PHC physicians counsel diabetics about the importance of physical exercise and smoking cessation, respectively. Eighty percent routinely measure blood pressure for all diabetic patients, while 79% inform their patients that controlling their lipid profile will substantially decrease morbidity and mortality from ASCVD. Only 18% of the participants screen the patients with HIV, and 38% screen those on steroid therapy routinely. Our study which showed that the higher level of knowledge was related to postgraduate study in family medicine. This similar to a previous study conducted in Malaysia showed that the postgraduate primary care trainees have a good level of knowledge toward management of dyslipidemia (22).

This study has some limitations. The relatively small sample size. The study participants were recruited from Khartoum, the capital of Sudan; therefore, conclusions of this study cannot represent the situation in the whole Sudan. This was a cross-sectional study and hence may not allow for the assessment of the temporal relationship. The use of a self-administered questionnaire relies on the participants’ honesty and self-assessment, which may introduce bias. Objective assessments or evaluations of practice, such as audits of patient records or direct observation, could complement the findings. Despite these limitations our study is novel and emphasis the role of training and education for primary care physicians in management of diabetic dyslipidaemia.

Conclusions

Primary care physicians have good knowledge and practice in the management of diabetic dyslipidemia especially those with diploma in family medicine. The efforts of PHC physicians can help in reducing diabetes epidemic and risk of CVD in Sudan. Further exploration into the barriers to applying this knowledge in practice would be valuable. Understanding the factors that hinder or facilitate the effective management of dyslipidemia in diabetic patients could inform targeted interventions. The significant association between knowledge levels and participation in postgraduate studies and professional development activities highlights the importance of continuing education. Future research could explore the specific aspects of these educational activities that are most beneficial, as well as the accessibility and quality of continuing medical education in Sudan. The study’s context in Sudan is unique, and cultural, economic, and healthcare system factors may influence the management of dyslipidemia in diabetic patients. Further research could delve into these contextual influences to provide a more nuanced understanding of the challenges and opportunities in improving care. Future studies are needed to discuss more explicitly the policy and practice implications of their findings, including recommendations for curriculum development, professional development programs, and healthcare policy adjustments.

Acknowledgments

Funding: None.

Footnote

Data Sharing Statement: Available at https://jxym.amegroups.com/article/view/10.21037/jxym-24-24/dss

Peer Review File: Available at https://jxym.amegroups.com/article/view/10.21037/jxym-24-24/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jxym.amegroups.com/article/view/10.21037/jxym-24-24/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by SUMASRI Institutional Review Board (SIRB) (No. 00008867) and verbal consents were obtained from all individual participants. Research purpose and objectives were explained to participants in clear simple words. SUMASRI is Sudan Medical and Scientific Research Institute, University of Medical Sciences and Technology, Sudan.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Pirillo A, Casula M, Olmastroni E, et al. Global epidemiology of dyslipidaemias. Nat Rev Cardiol 2021;18:689-700. [Crossref] [PubMed]
2. Harris SB, Ekoé JM, Zdanowicz Y, et al. Glycemic control and morbidity in the Canadian primary care setting (results of the diabetes in Canada evaluation study). Diabetes Res Clin Pract 2005;70:90-7. [Crossref] [PubMed]
3. Ahmed M, Kumari N, Mirgani Z, et al. Metabolic syndrome; Definition, Pathogenesis, Elements, and the Effects of medicinal plants on it's elements. J Diabetes Metab Disord 2022;21:1011-22. [Crossref] [PubMed]
4. Ahmed M, Ahmed MH. Nonalcoholic fatty liver disease and COVID-19: An epidemic that begets pandemic. World J Clin Cases 2021;9:4133-42. [Crossref] [PubMed]
5. Taskinen MR. Diabetic dyslipidaemia: from basic research to clinical practice. Diabetologia 2003;46:733-49. [Crossref] [PubMed]
6. Mocumbi AO. Lack of focus on cardiovascular disease in sub-Saharan Africa. Cardiovasc Diagn Ther 2012;2:74-7. [PubMed]
7. Chehade JM, Gladysz M, Mooradian AD. Dyslipidemia in type 2 diabetes: prevalence, pathophysiology, and management. Drugs 2013;73:327-39. [Crossref] [PubMed]
8. Jakicic JM, Jackson RE. Weight Management Strategies for the Patient with Diabetes. Curr Cardiol Rep 2021;23:104. [Crossref] [PubMed]
9. Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care 2014;37:S120-43. [Crossref] [PubMed]
10. Mendoza MF, Lavie CJ. Clinical associations between exercise and lipoproteins. Curr Opin Lipidol 2022;33:364-73. [Crossref] [PubMed]
11. Maahs DM, Ogden LG, Dabelea D, et al. Association of glycaemia with lipids in adults with type 1 diabetes: modification by dyslipidaemia medication. Diabetologia 2010;53:2518-25. [Crossref] [PubMed]
12. Reston JT, Buelt A, Donahue MP, et al. Interventions to Improve Statin Tolerance and Adherence in Patients at Risk for Cardiovascular Disease: A Systematic Review for the 2020 U.S. Department of Veterans Affairs and U.S. Department of Defense Guidelines for Management of Dyslipidemia. Ann Intern Med 2020;173:806-12. [Crossref] [PubMed]
13. Duckworth W, Abraira C, Moritz T, et al. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009;360:129-39. [Crossref] [PubMed]
14. Lachin JM, Orchard TJ, Nathan DM, et al. Update on cardiovascular outcomes at 30 years of the diabetes control and complications trial/epidemiology of diabetes interventions and complications study. Diabetes Care 2014;37:39-43. [Crossref] [PubMed]
15. ORIGIN Trial Investigators. Basal insulin and cardiovascular and other outcomes in dysglycemia. N Engl J Med 2012;367:319-28. [Crossref] [PubMed]
16. Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359:1577-89. [Crossref] [PubMed]
17. Awadalla H, Noor SK, Elmadhoun WM, et al. Comparison of serum lipid profile in type 2 diabetes with and without adequate diabetes control in Sudanese population in north of Sudan. Diabetes Metab Syndr 2018;12:961-4. [Crossref] [PubMed]
18. Almobarak AO, Noor SK, Elmadhoun WM, et al. Metabolic control targets in Sudanese adults with type 1 diabetes: A population-based study. J Family Med Prim Care 2017;6:374-9. [Crossref] [PubMed]
19. Vlacho B, Fernandez-Camins B, Canudas-Ventura A, et al. Performance of Primary Care Physicians in the Management of Glycemia, Lipids, and Blood Pressure among People with Type 2 Diabetes: A Cross-Sectional Study. J Clin Med 2024;13:1544. [Crossref] [PubMed]
20. Peytremann-Bridevaux I, Lauvergeon S, Mettler D, et al. Diabetes care: Opinions, needs and proposed solutions of Swiss patients and healthcare professionals: a qualitative study. Diabetes Res Clin Pract 2012;97:242-50. [Crossref] [PubMed]
21. Nøkleby K, Berg TJ, Mdala I, et al. Variation between general practitioners in type 2 diabetes processes of care. Prim Care Diabetes 2021;15:495-501. [Crossref] [PubMed]
22. Said AH, Chia YC. Awareness, knowledge and practice of dyslipidaemia management among postgraduate primary care trainees in Malaysia: a cross-sectional study. BMJ Open 2017;7:e013573. [Crossref] [PubMed]
23. Abdelgadir E, Alsaeed M, Hafidh K, et al. Lipid Control in Patients with Diabetes across Primary and Tertiary Government Health Sectors in Dubai: A Five-year Pattern. Oman Med J 2019;34:290-6. [Crossref] [PubMed]
24. Almigbal TH, Almunif DS, Ali Deshisha E, et al. Physicians' perceptions and beliefs on the current dyslipidemia management practices within Saudi Arabia. Saudi Pharm J 2023;31:101759. [Crossref] [PubMed]
25. Ding R, Ye P, Zhao S, et al. Effect of physician characteristics and knowledge on the quality of dyslipidemia management and LDL-C target goal achievement in China: Subgroup analysis of the Dyslipidemia International Study. J Glob Health 2017;7:020702. [Crossref] [PubMed]
26. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019;139:e1046-81. [PubMed]
27. Matsui S, Kajikawa M, Hida E, et al. Optimal Target Level of Low-density Lipoprotein Cholesterol for Vascular Function in Statin Naive Individuals. Sci Rep 2017;7:8422. [Crossref] [PubMed]
28. Luo JY, Ma YT, Yu ZX, et al. Prevalence, awareness, treatment and control of dyslipidemia among adults in northwestern China: the cardiovascular risk survey. Lipids Health Dis 2014;13:4. [Crossref] [PubMed]
29. Rodriguez CJ, Cai J, Swett K, et al. High Cholesterol Awareness, Treatment, and Control Among Hispanic/Latinos: Results From the Hispanic Community Health Study/Study of Latinos. J Am Heart Assoc 2015;4:e001867. [Crossref] [PubMed]
30. Verhave JC, Troyanov S, Mongeau F, et al. Prevalence, awareness, and management of CKD and cardiovascular risk factors in publicly funded health care. Clin J Am Soc Nephrol 2014;9:713-9. [Crossref] [PubMed]
31. Alhajji S, Mojiminiyi S. Adherence to Current Lipid Guidelines by Physicians in Kuwait. Med Princ Pract 2020;29:436-43. [Crossref] [PubMed]
32. Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282:1458-65. [Crossref] [PubMed]
33. Ramsaran E, Preusse P, Sundaresan D, et al. Adherence to Blood Cholesterol Treatment Guidelines Among Physicians Managing Patients With Atherosclerotic Cardiovascular Disease. Am J Cardiol 2019;124:169-75. [Crossref] [PubMed]
34. ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008;358:2560-72. [Crossref] [PubMed]
35. Zaitoun MF, Iflaifel MH, Almulhim LA, et al. Awareness of Physicians and Clinical Pharmacists About ACC/AHA Guidelines for Dyslipidemia Management: A Cross-Sectional Study. J Pharm Bioallied Sci 2019;11:181-6. [Crossref] [PubMed]
36. Morieri ML, Lamacchia O, Manzato E, et al. Physicians' misperceived cardiovascular risk and therapeutic inertia as determinants of low LDL-cholesterol targets achievement in diabetes. Cardiovasc Diabetol 2022;21:57. [Crossref] [PubMed]