Mediterranean Journal of Nutrition and Metabolism 8 (2015) 187–197 187

DOI:10.3233/MNM-150040
IOS Press

Effect of education on nutrition and diabetes

status in type 2 diabetics in El Jadida province
of Morocco
Youssef Dinara , Noureddin Elkhoudrib and Rekia Belahsena,∗
a Laboratory of Biotechnology, Biochemistry, & Nutrition, Training and Research Unit on Nutrition & Food Sciences,

Chouaib Doukkali University, School of Sciences, El Jadida, Morocco

b Laboratory of Human Ecology, Faculty of Sciences Semlalia Marrakech, Morocco

Abstract.
STUDY OBJECTIVE: Diabetes is placed throughout the world at the forefront of health concerns because of the complications
it causes and their adverse repercussions on health and economy. In Morocco, it is increasingly high and 90% of the diabetics have
type II Diabetes. This disease may be preventable by the change of life style in diabetics and in populations at-risk. Education
is reported to have positive impact on health. The aim of this study was to investigate the effect of an education program on the
improvement of diabetes care in Moroccan diabetic adults.
MATERIAL AND METHODS: A sample of 240 type II diabetic patients; 20–65 years old, visiting the Azemmour hospital
between January 2011 and March 2012 are divided in two groups: an educated group (EG) that received and a non-educated group
(NEG) that did not receive any training on diabetes and improvement of diabetes care. Data on anthropometrical measurements,
biochemical, socio-demographics and food consumption using 24 h dietary recall were collected in both groups.
RESULTS: The results show that HbAc1 was significantly higher in NEG than in the EG group (9.24% vs. 7.15% respectively).
Globally 57.5% of diabetics cannot balance their diabetes; with high percentage among NEG (76.6%) than EG (23.4%) and in
rural (78.4%) than in urban populations. Compared to the EG, the NEG patients have higher prevalence of physical inactivity,
abdominal obesity, low HDL, high LDL, hypertriglyceridemia, hypertension, higher BMI mean (29.56 vs 26.48 kg/m2 ) and longer
duration of diabetes (9,13 vs 8,17 years respectively). Total food energy intake (TEI) was also higher (2411 ± 196) in the NEG than
in EG (1966 ± 221 Kcal). The contributions of carbohydrates, proteins and lipids to the TEI were respectively (37.39 ± 4.48%),
(22.88% ± 3.24) and (39.37 ± 4.43%); with a low intake of fiber (16.84 ± 3.55) in NEG.
CONCLUSION: The study results show an improvement of diabetes status in the educated patients. The data justify the funda-
mental role of patient education for an effective and efficient management of diabetes. The study recommends also an establishment
of and access to care facilities especially for rural population of diabetic patients.

Keywords: Type 2 diabetes, complications, nutrition, education, Morocco

1. Introduction

Placed at the forefront of non-communicable diseases, diabetes is recognized by international organizations as a

threat to global Heath and continues to preoccupy governments and health policy makers because of its complications
and their adverse impact on health and on the economy.
∗ Corresponding author: Prof. Rekia Belahsen, Laboratory of Biotechnology, Biochemistry & Nutrition, Training and Research Unit on
Nutrition & Food Sciences, Chouaib Doukkali University, School of Sciences, El Jadida, 24000, Morocco. Tel.: +212 523342325/664 97 16 16;
Fax: +212 523 34 21 87/4449; E-mails: [email protected]; or [email protected].

ISSN 1973-798X/15/$35.00 © 2015 – IOS Press and the authors. All rights reserved
188 Y. Dinar et al. / Education and diabetes care in Morocco

Type II Diabetes (T2D) represents 90% of diabetes cases and it is progressing markedly achieving alarming
proportions in the last decades [1]. Globally this pathology is considered by WHO an epidemic, predicted to be the
seventh leading cause of death in the world by 2030 [3]. In the opposite of the type I, type II diabetes is largely
preventable [2] by acting on lifestyle factors [4].
According to the 2013 estimates of the International Diabetes Federation (IDF), approximately 382 million people
suffer from diabetes in the world and 80% of them live in low and middle incomes countries. If no measure is taken
in the future and the increased trend continues, this number will approximately achieve 592 million by the year 2035.
Diabetes has become one of the most common diseases and one of the main causes of premature death in most of
the countries, particularly because of the increased cardiovascular risk [5].
Also, the prevalence of diabetes estimated by IDF in 2013, is 10,7% in the region of North America and the
Caribbean. In Africa, about 20 million adults (4.9%) are affected, 522600 people died of diabetes associated disorder
and 63% have undiagnosed diabetes and already have complications [6–8].
In Europe, 56.3 million of people are diabetic according to the 2013 IFD estimates and 21.2 million do not aware
that they are affected. In the Middle East and Gulf region, very high prevalences are found achieving 23.7% in Saudi
Arabia for example [9, 10].
In Morocco, the IFD estimated the prevalence of diabetes to 7.35% in 2012 corresponding to 1 million and 403
thousands diabetics. A recent study undertaken in the eastern region of Morocco on 1628 subjects, reported that
10.2% of the subjects were diabetic and 8.1% with pre-diabetes, showing that the disease is in continuous progress
[11]. Acting on the main triggering modifiable factors such as obesity or overweight, physical inactivity, unhealthy
diet and smoking can prevent this disease [3]. The awareness and education of people with diabetes can be the basis
of any preventive and therapeutic action against its resurgence [12].
The present study aims to examine the effect of an awareness and education program on diabetes status, nutritional
status and on metabolic control of diabetic patients; the purpose being to evaluate the role of education on self-
management of diabetes.

2. Subject, materials and methods

The study was undertaken between January 2011 and March 2012 and focused on a sample of 240 patients with
already known type II diabetes 20 to 65 years old, 150 female and 90 male. Pregnant women are excluded from the
study. The sample was divided into two groups according to their adherence to the education and awareness program
on diabetes established by the Ministry of Health: a group that followed the programme sessions for at least 2 months
i.e. 8 sessions, called also educated group (EG, n = 95) and a second group of patients who have never attended any
of the program sessions and called non-educated group (NEG, n = 145).
The program on diabetes consists of sessions, using Brochures and leaflets as teaching materials, to raise awareness
on diabetes definition, treatment and care, life hygiene and dietary measures, physical activity, diabetic foot and, acute
and chronic diabetes complications. The sessions are conducted once a week by a staff composed of a technician in
nutrition, comprehensive nurses and two medical practitioners having already benefited from a training organized by
the Ministry of Health on diabetes at the province level.
Venous blood samples were collected for the determination of biochemical parameters. Total cholesterol (CHO),
triglycerides (TG) and high density lipoprotein Cholesterol (CHO-HDL) are determined by enzymatic methods and
the Low Density Lipoprotein Cholesterol (CHO-LDL), was calculated by Friedwal method. The level of blood
glucose was determined in fasting and in postprandial phase by enzymatic method and that of glycated hemoglobin
(HbA1c) by immunological method. All biological analyses are determined using a biochemistry automated anlyzer
(CS-T240). Anthropometrical parameters were also measured on the subjects wearing a minimum of clothing and
without shoes: weight was measured using scales, and expressed in kg at the nearest of 0.5 kg, height (in cm) was
measured using a strait jacket at the nearest of 0.5 cm; the waist circumference (WC) was measured at horizontal
level of the umbilicus and hip circumference (H) at the widest circumference of the hip, using a tape measure and
expressed in (cm). Body mass index (BMI) (weight in kg divided by height square in m2 ) and the waist to hip ratio
(WHR) (WC divided by hip circumference in cm) were calculated [13]. BMI and WC are respectively determining
general and abdominal obesity and fat distribution (WHO, 2003). The risk of obesity is present when the BMI is ≥30
 Y. Dinar et al. / Education and diabetes care in Morocco 189

for both sexes and when the WC is greater than 102 cm in men and 88 cm in women. The subjects systolic (SBP) and
diastolic (DBP) blood pressure are measured in the sitting position after 10 minutes rest using a Vaquez manometer.
Data on food intake are determined using the 24 hours recall method and the food composition is calculated using
the software BILNUT 2.01. (S.C.D.A. NUTRISOFT-BILNUT. Information on the socio-economic and demographic
characteristics was collected using questionnaires and data on smoking and physical inactivity are also collected.
Subjects which do not exceed 150 min per week of physical activity of moderate intensity are considered sedentary
as recommended by most of the international agencies (HAS, IFD and ADA).
Approval of the study protocol and oral consent were obtained from health authority and patient respectively.

2.1. Statistical analysis

Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) program, version 18
(SPSS Inc., Chicago, Illinois, USA). The Mann-Whitney test was used for the comparison of quantitative variables
means of anthropometric parameters according to age groups. Qualitative variables are compared using Chi2 or
Fisher’s test. Logistic regression was used to determine variables predicting uncontrolled diabetes among the study
population with adjusting for different confounding variables. The results are presented as Odds Ratio and confidence
interval at 95%. The threshold of significance was set at p < 0.05.

3. Results

The final study sample was of 240 type 2 diabetic patients divided into two groups, educated group (EG; n = 95)
having followed and the non educated one (NEG; n = 145) who did not follow the education and awareness program
on diabetes. The Table 1 shows data on the sample sociodemographic characteristics. Overall, the average age of the
studied population was 49 years; 59.6% are women and 40.4% men, 49% of the subjects were from rural areas; about
77% were married and 58% were without professional activity (68% of them are within the NEG). The illiteracy rate
was 39%, higher among the NEG compared to the EG (65.2% vs 34.8% respectively).
The Table 1 shows also that the percentage of females was high in EG due to a high participation of women in the
education programme (about 70%). This result can be explained by the availability of women and their interest in
health awareness programs.
The results show that the study subjects had diabetes for on average 9 years, this duration was <5 years in 34%,
of 5–15 years among 44% and >15 years in 22% of subjects. In the NEG about 69% of the subjects had diabetes for
5–15 years.

3.1. Physical activity and tobacco use

Concerning the lifestyle data, as shown in Table 1, 22% of the subjects are smokers and the rate of smoking
was higher in NEG (∼68%) than in the EG (32.1%). Similarly physical inactivity (low physical activity) was more
prevalent in the NEG (77%) compared to the EG (46%).

3.2. Anthropometrical and biochemical parameters

Table 2 shows that more than 70% of the study subjects had overweight or obesity. The NEG had higher rate
overweight and obesity (77.5% vs 22.5%), higher mean BMI (29.6 ± 3.5 vs 26.5 ± 3.43 kg/m2 ), higher mean WC
(98.67 ± 15.4 vs. 89.25 ± 11.50 cm) than EG and 74% of NEG subjects have uncontrolled diabetes. Uncontrolled
diabetes was also more prevalent among women than men (61% vs 39%). The HbA1cmean is higher in NEG than in
the EG (9.16 ± 2.06 vs 7.13 ± 1.47) (Table 2) and the % of diabetics with highest HbA1c rate (>7%) increases with
age (non shown). In addition the mean levels of fasting glucose, postprandial glucose, total cholesterol, triglycerides
and lower mean HDL cholesterol and LDL cholesterol in NEG than in EG. On the other hand, 57% of study sample
are hypertensive with 63% of them belong to NEG.
190 Y. Dinar et al. / Education and diabetes care in Morocco

Table 1
Socio-demographic characteristics of the study subjects

Socio-demographic EG n (%) NEG n (%) χ2 test P

Sex
Male 29 (44,0%) 61 (56,0%) 3.26 0.71
Female 66 (32,2%) 84 (67,8%)
Age 46,45 ± 8,20 51,67 ± 8,30 – 0.000
Area of residency
Urban 80 (65%) 43 (35%) 68.37 0.000
Rural 15 (12,8%) 102 (87,2%)
Marital status
Maried 69 (37,5%) 115 (62,5%) 1.43 0.32
No-maried 26 (46,4%) 30 (53,6%)
Education level
None 32 (34,8%) 60 (65,2%) 2.67 0.44
Primary 26 (48,1%) 28 (51,9%)
Secondary 22 (37,9%) 36 (62,1%)
Superior 15 (41,7%) 21 (58,3%)
Diabetes duration
<5 years 42 (51,2%) 40 (48,8%) 7.83 0.020
5–15 years 33 (31,1%) 73 (68,9%)
>15 years 20 (38,5%) 32 (61,5%)
Sedentarity
Yes 44 (28,2%) 112 (71,8%) 0.0000
No 51 (60,7%) 33 (39,3%) 4.21
Diabetes Family history
Yes 73 (47,1%) 82 (52,9%) 3.28 0.73
No 22 (25,9%) 63 (74,1%)
Professional occupation
Yes 50 (49,5%) 51 (50,5%) 48.3 0.90
No 45 (32,4%) 94 (67,6%)
Smoking status
Yes 17 (32,1%) 36 (67,9%) 3.02 0.08
Non 85 (45,5%) 102 (54,5%)
Abbreviations: EG: Educated Group; NEG: Non Educated Group.

The Table 3 shows the overall recommended therapeutic goals within each group (a rate of HbA1c <7%, a SBP
<135 mm Hg and DBP <85 mm Hg, a rate of LDL-cholesterol<100 mg/dl, a rate of HDL-C >40 mg/dl for men
and >50 mg/dl for women, a fasting blood glucose <126 and a postprandial glucose <190 mg/dl). These goals were
achieved in only 0.68% (1/145) among the NEG and 4,21% (4/95) in the EG. In general, 42.5% only of the study
subjects have their HbA1c controlled (≤7) and about 57% have hypertension that was more prevalent among women
than men (64,7% vs 35.3%). The levels of SBP and DBP were higher in NEG compared to EG (180.44 ± 54.47 vs
102.92 ± 21.08); (145.58 ± 21.20 vs 90.44 ± 12.45) (Tables 2 and 3).

3.3. Complications of diabetes

Table 4 shows that the overall prevalence of complications in NEG exceeds that of EG (52.6% vs 47,4%) as well
as that of each complication, namely nephropathy, retinopathy, neuropathy, the diabetic foot and infections that are
respectively (41.9% vs 58.1%), (58.0 vs 42.0%), (42.9% vs 57.1%), (33.3 vs 66.7%) and (32.4 vs 67.6%) in the EG
and NEG respectively.
 Y. Dinar et al. / Education and diabetes care in Morocco 191

Table 2
Biochemical and anthropometrical parameters

Parametres EG (n = 95) NEG (n = 145) P

FG (mg/dl) 127 ± 45 181 ± 50 0.000
PPG (mg/dl) 164 ± 52 265 ± 58 0.000
HbA1c (%) 7,13 ± 1,47 9,16 ± 2,06 0.000
TC (mg/dl) 179 ± 48 214 ± 59 0.000
TG (mg/dl) 135 ± 45 153 ± 50 0.015
HDL (mg/dl) 40 ± 11 35 ± 11 0.002
LDL (mg/dl) 144 ± 49 131 ± 46 0.000
WC (cm) 89,25 ± 11,50 98,67 ± 15,40 0.000
H (cm) 107,63 ± 12,59 114,64 ± 15,26 0.001
WHR 0,82 ± 0,05 0,85 ± 0,047 0.000
BMI 26,48 ± 3,43 29,56 ± 3,54 0.000
SBP (mmHg) 145,58 ± 21,20 180,44 ± 54,47 0.000
DBP (mmHg) 90,44 ± 12,45 102,92 ± 21,08 0.000
Abbreviations: FG: fasting glucose; PPG: Post- Prandial Glycaemia; HbA1c: Hemoglobin A1c; TC: Total
Cholesterol; TG: Triglycerids; HDL: High Density lipoprotein; LDL: Low Density Lipoprotein; WC: Waist Cir-
cumference; H: Hip Circumference; WHR: Waist to Hip Ratio; BMI: Body Mass Index; SBP: SystolicBlood
Pressure; DBP: Diastolic Blood Pressure; EG: Educated Group; NEG: Non Educated Group.

Table 3
Prevalence of therapeutic goals achievement in the study subjects

Therapeutic goals EG (95) NEG (145) Total (240)

N % N % N %
HbA1C ≤7% 63 66,3 39 26,9 102 42,5
SBP ≤135 mm Hg 47 49,4737 39 26,9 86 35,83
DBP ≤85 mm Hg 27 28,4211 23 15,86 50 20,83
HDL/F >50 mg/dl 24 25,2632 17 11,72 41 17,08
HDL/M >40 mg/dl 15 15,7895 23 15,86 38 15,83
LDL <100 mg/dl 46 48,4211 28 19,31 74 30,83
FG ≤126 mg/dl 52 54,7368 25 17,24 77 32,08
PPG ≤190 mg/dl 68 71,5789 24 16,55 92 38,33
Total Achievement 4 4,21 1 0,69 5 2,08
Abbreviations: SBP: SystolicBlood Pressure; DBP: Diastolic Blood Pressure; HDL/M: HDL in Male; HDL/F:
HDL in Female; LDL: Low Density Lipoprotein; FG: Fasting Glycaemia; PPG: Post Prandial Glyceamia; EG:
Educated Group; NEG: Non Educated Group.

3.4. Daily food intake

As shown in the Table 5 the total energy intake (TEI) was significantly higher in NEG than in the EG (2411 ± 196
vs 1996 ± 221 Kcal). NEG has low contribution of carbohydrates to their TEI (37.39 ± 4.48%). This contribution
is different of the international recommendation that is 50 to 55% of the TEI. The protein and lipids contributed
respectively to 22.8 ± 3.24% and 39.73 ± 4.43% of TEI. On the other hand the NEG subjects have high intake of
SFA and cholesterol and low intake of fiber. The ratio PA/PV (animal to vegetal protein ratio) was also higher in the
NEG than the EG (0.8216 ± 0.1684 vs 0.7253 ± 0.1891).
192 Y. Dinar et al. / Education and diabetes care in Morocco

Table 4
Declared diabetes complications

Diabetes complications EG NEG χ2 test P

n (%) n (%)
Nephropathy
Yes 13 (41,9%) 18 (58,1%) 0,082 0,77
No 82 (39,2%) 127 (60,8%)
Retinopathy
Yes 29 (58,0%) 21 (42,0%) 8,95 0,003
No 66 (34,7%) 124 (65,3%)
Neuropathy
Yes 3 (42,9%) 4 (57,1%) 0,032 0,9
No 92 (39,5%) 141 (60,5%)
Diabetic foot
Yes 3 (33,3%) 6 (66,7%) 0,15 0,9
No 92 (39,8%) 132 (60,2%)
Infections
Yes 12 (32,4%) 25 (67,6%) 0,93 0,33
No 83 (40,9%) 120 (59,1%)
Abbreviations: EG: Educated Group; NEG: Non Educated Group.

Table 5
Dietary intake in the study subjects

Daily dietary intake EG NEG P

Total Enery Intake (TEI)
Kcal 1996,13 ± 221,16 2411 ± 196,2 0.000
Carbohydrates
g/d 209,31 ± 20,92 223,99 ± 21,35 0.000
%TEI 42,33 ± 5,32 37,39 ± 4,48 0.000
Proteins
g/d 94,85 ± 21,21 138,74 ± 25,90 0.000
%TEI 18,86 ± 3,00 22,88 ± 3,24 0.000
PA/PV 0,7253 ± 0,1891 0,8216 ± 0,1684 0.000
Lipids
g/d 82,72 ± 14,79 106,78 ± 16,97 0.000
%AET 37,1185 ± 3,792 39,73 ± 4,43 0.000
SFA(%TEI) 12,44 ± 2,89 14,09 ± 2,89 0.000
MUFA (%TEI) 12,84 ± 2,53 13,02 ± 2,45 0.58
PUFA (%TEI) 11,82 ± 3,71 12,62 ± 4,62 0.15
C mg/d 352,47 ± 79,04 436,93 ± 85,79 0.000
Fiber
g/d 21,78 ± 3,67 16,84 ± 3,55 0.000
Abbreviations: PA/PV: Animal to Vegetal ratio; SFA:Saturated Fatty Acids; MUFA: Monoun-
saturated Fatty acids; PUFA: polyunsaturated Fatty acids; C: Cholesterol; TEI: Total Energy
Intake? EG: Educated Group; NEG: Non Educated Group.
 Y. Dinar et al. / Education and diabetes care in Morocco 193

Table 6
Metabolic imbalance in diabetic patients and risk factors

Variables Controlled Diabetes Uncontrolled Diabetes χ2 test P

(HbA1C ≤7) (HbA1C >7)
Age 46,47 ± 8,06 51,92 ± 8,32 – 0.000
Sex
Male 43 (47,8%) 47 (52,2%) 1.64 0.2
Female 59 (39,3%) 91 (60,7%)
Marital status
Maried 74 (40,2%) 110 (59,8%) 1.68 0.19
Non-maried 28 (50,0%) 28 (50,0%)
Area of residence
Urban 81 (65,9%) 42 (34,1%) 56.3 0.000
Rural 21 (17,9%) 96 (82,1%)
Education level
None 18 (19,6%) 74 (80,4%) 38.9 0.000
Primary 29 (53,7%) 25 (46,3%)
Secondary 28 (48,3%) 30 (51,7%)
Superior 27 (75,0%) 9 (25,0%)
Diabetes duration (years)
<5 54 (65,9%) 28 (34,1%) 32.3 0.000
5–15 26 (24,5%) 80 (75,5%)
>15 22 (42,3%) 30 (57,7%)
BMI (kg/m2 )
<25 62 (87,3%) 9 (12,7%) 84.051 0.000
25–30 22 (20,6%) 85 (79,4%)
> = 30 18 (29,0%) 44 (71,0%)
Fasting Glyceamia
<126 mg/dl 18 (29,0%) 44 (71,0%) 1.53 0.000
≥126 mg/dl 25 (15,3%) 138 (57,5%)
PPG
<190 mg/dl 86 (95,6%) 4 (4,4%) 1.65 0.000
≥190 mg/dl 16 (10,7%) 134 (89,3%)
Physical Activity
Yes 71 (84,5%) 13 (15,5%) 93.39 0.000
No 31 (19,9%) 125 (80,1%)
Total Energy Intake (Kcal) 2062,18 ± 283,14 2384,30 ± 206,54 – 0.000
Fiber g/d 21,15 ± 4,25 17,05 ± 3,50 – 0.000
Abbreviations: BMI: Body Mass Index; PPG: Post Prandial Glyceamia.

3.5. Metabolic imbalance and associated risk factors in diabetic patients

The HbA1c is a blood test that serves as indicator of glucose control or metabolic imbalance in diabetics. Variables
predicting for HbAc1 control among the study population are studied by adjusting to different confounding factors
in the 2 subjects groups, the group of diabetics having HbA1c control (≤7) and the group of diabetics with metabolic
imbalance (HbA1c >7).
The Table 6 shows a statistically positive association of metabolic equilibrium with physical activity, the area of
residence, the duration of diabetes, PPG, FG, age, the TEI, fiber intake and the education level of the study subjects.
The multiple linear regression analysis showed that the PPG, physical activity, BMI and education level, were the
variables predicting metabolic imbalance in the study diabetic subjects (Table 7). A negative association is also noted
194 Y. Dinar et al. / Education and diabetes care in Morocco

Table 7
Odds ratios of metabolic disequilibrium associated factors

p O.R CI
Education level 0.001 2.96 1.54–5.68
BMI 0.002 9.628 2.317–40.008
PPG 0.000 268.434 36.4–1979.5
Physical Activity 0.001 59.309 5.583–630.09
BMI: Body Mass Index, PPG: Post Prandial Glyceamia. OR: Odds Ratio, CI: Confidence
Intervalle.

between the education level and glycemia imbalance, being educated reduced three times the risk of uncontrolled
diabetes (O.R = 2.96; 95% IC1, 54–5.68).

4. Discussion

In this study we found a higher overall achievement of the therapeutic goals recommended by the education
programme in educated than in non educated diabetic subjects. However these recommended goals were globally –
low as they were achieved in only 0.68% among the NEG and 4,21% in the EG.
This study conducted in the Moroccan province of El-Jadida on a final sample of 240 subjects with type II diabetes,
showed a high participation of women (62,5%). The same observation was reported before by other studies carried
out in Morocco on obesity by Lahmame et al. (2008) and on diabetes and obesity by Ramdani et al. (2008) [14, 15].
This can be explained by the availability of women and their interest in health awareness programs. The high
prevalence of overweight and obesity reported in this population (70%) is also consistent with the literature as type
II diabetes is associated with these two abnormalities [16].
On the other hand, more than 60% of people with type II diabetes do not benefit from a therapeutic education. As
the majority of the study subjects (more than 70%) are of rural origin, this can be related to the problem of access
to care for the populations in rural areas which is still a constraint for the country health system. Bailie et al. (2004)
have also shown the difficulty of providing complete diabetes care in small and remote communities because of
the problems of keeping staff as well as the lack of support offered to clinicians and, in some cases, the refusal of
services [17].
The low percentage of diabetic patients achieving the overall objectives recommended by international bodies has
been already reported in Morocco [18] in a cross-sectional study undertaken on 215 with type I diabetes (TID) and
509 with type II diabetes (TIID) recruited by general practitioners and specialists in the framework of an international
multicentre study (International Diabetes Management Practice Study, IDMPS (Wave 2)). The study reported that
only 0,6% of TID and 0.4% of TIID had reached the recommended goals [18] which is in agreement with the data
reported here and testified the poor quality of care available for diabetic patients population.
In this study, education level is a determining factor for the control of diabetes that may explain the results
reported here concerning the response rate to the educational intervention. In fact 80.4% among the subjects who
had uncontrolled diabetes are illiterate.
While an educational approach is based on the establishment of education, cultural and social diagnosis, to identify
in each patient, the resources, the potential, the needs and the difficulties influencing the learning process [19], in
this study we have not taken into consideration the degree of training of the subjects or the quality of the educational
program. Indeed it is reported in the literature that more patients are being educated, more they follow the dietary
guidelines and they adopt healthy lifestyle [20]. A study conducted by Garay-Sevilla ME et al. (2003) on 156 type
2 diabetic patients has demonstrated that adhering to the dietetic measures was significantly associated with the
socio-economic level (p = 0.001) and that adhering to the treatment appeared to be also associated with the education
level (p = 0.001) [21].
Our results show that globally diabetes complications are more prevalent in the NEG than in EG with HbA1c rates
of 9.16 ± 2.06 vs 7.13 ± 1.47% respectively. This result is consistent with a previous pilot study UKPDS (United
 Y. Dinar et al. / Education and diabetes care in Morocco 195

Kingdom Prospective Diabetes Study) over 20 years (1977–1998) that included 5000 subjects with type II diabetes.
This study demonstrated that improving metabolic control decreases the risk of micro and macro vascular compli-
cations. Also, a reduction of glycosylated haemoglobin by 1% was accompanied by a decrease of the microvascular
complications risk by 30%, myocardial infarction risk by 18% and mortality risk related to diabetes by 25% [22].
On the other hand, Nicolucci et al. [23] in a case-control study conducted on 886 people with diabetes, and multi
complications compared to 1890 control subjects without complication; report that patients without any education
background had increased risk to develop complications.
In the present study there might be an under estimation of the complications prevalence within the NEG as the data
are a self-declaration of complications and the NEG subjects do not benefit from a systematic screening of diabetes
complications and the data are a self-declaration of complications. Therefore there might be an under estimation of
the complications prevalence within this group. Also the sample was not balanced in both EG and NEG groups. This
information has been mentioned during the international study IDMPS stating that 34 to 63% of people with diabetes
have never been screened for complication during the last year [18].
The TEI of about 2411 kcal in the NEG associated with the high prevalence of physical inactivity (72%) reflect
an imbalance between food energy intake and energy expenditure consistent with their metabolic disequilibrium with
high means of PPG (2.65 ± 0,58), HbA1c (9.16 ± 2.06) and BMI (29.6 ± 3.5) in addition to their inadequate intake
of fibers, fruit and vegetables. The imbalance is more marked in NEG subjects who have their dietary intake high in
lipids and protein and low in carbohydrates. In our opinion, there is no data in the literature arguing or suggesting
that diabetics have needs different from those of the general population, the daily intakes in protein, carbohydrates
and lipids being respectively 15%, 55% and 30% of the overall energy intake are recommended. However, generally
the energy distribution must take in account the clinical and metabolic profile as well as each patient dietary habit
[24–27]. Adhering to educational program seems to be imperative to improve these parameters.
There is evidence that an intensive intervention associating healthy diet with physical activity to lifestyle may
lower at least 50% the risk of contracting diabetes, promote weight loss and can prevent the emergence of other
chronic diseases, such as hypertension and cardiovascular disease [28].
The HbA1c that represents 2 to 3 months retrospective and cumulative indicator of glycemia level was considered as
a mean to evaluate the study subjects metabolic equilibrium, the multivariate analysis shows a significant association
between uncontrolled HbA1c (HbA1c >7%) and post-prandial glycemia, physical activity, BMI and education levels.
A good therapeutic education program for diabetic patients focused on self-management, adoption of a non sedentary
lifestyle and weight loss in overweight or obese people would be beneficial. Our results are consistent with those
of Warsi et al. (2004) and Weaver et al. (2014) studies, reporting that diabetic patients involved in self-management
educational programs have their HbA1c decreased [29, 30]. Accordingly we found a strong association between PPG
(the reference is the blood glucose 2 hr after the beginning of lunch) and metabolic equilibrium (O.R = 268.434;
95% CI, 36.4–1979,5). Monnier et al. have also reported that increases of PPG contribute significantly to the 24
hours hyperglycaemia and to uncontrolled diabetes, proportionally to the increase of HbA1c [31]. In the same way,
Avignon et al. (1997) in a transversal study have found a better correlation between PPG and HbA1c rates [32]. It was
also reported [33] that the metabolic equilibrium is more significantly influenced by the control of the postprandial
hyperglycaemia than the control of fasting blood glucose.
Finally, the therapy characteristics as a potential factor on the final results in the EG are not reported in this
study. However the medical follow-up and adaptation of patients’ therapy to their biochemical results (glycemia and
HbAc1) and body weight were among the components included in the educational program. Therefore, patients who
did not attend the education program (NEG) and medical follow-up, have difficulty to adapt themselves their therapy
(i.e. monitoring of their insulinemia), which certainly affect their metabolic equilibrium. This is in accordance with
the studies of Warsi et al. (2004) and Weaver et al. (2014) reporting a reduction of HbA1c in diabetic patients after
self-management education programs.

5. Conclusion

The reported data show that diabetes care is a health problem in the diabetic patients in the study region. The
therapeutic education program has a positive impact on the management of diabetes. The data show also that a
196 Y. Dinar et al. / Education and diabetes care in Morocco

significant proportion of the population of people with diabetes do not benefit from a therapeutic education to
manage this illness and ovoid its associated complications particularly in rural area. In these areas, by facilitating
access to care with ressources and facilities of quality including qualified staff and acquire fungible to ensure the
monitoring and control of diabetes, can lead to the improvement of the diabetic patients status. Establishing a national
therapeutic education program for patients with diabetes mellitus might also be a major factor of primary prevention
by avoiding the occurrence of the disease in the population at risk or secondary prevention to minimize complications
in the long and short term. The culmination to an improvement of diabetes care can also minimize the economic
burden posed by diabetes disease.

Acknowledgments

The authors wish to thank the medical delegation in the province of El Jadida, Ministry of Health of Morocco and
the medical and biomedical team for their cooperation.

References

[1] WHO. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: Diagnosis and classification of diabetes
mellitus. Geneva, World Health Organization, (WHO/NCD/NCS/99.2). 1999.
[2] Amed S, Nuernberger K, McCrea P, et al. Status report on the British Columbia Paediatric Diabètes Program. 2010.
[3] WHO. Global status report on non-communicable diseases (2010) Geneva, World Health Organisation. 2011.
[4] Coutinho M, Gerstein HC, Wang Y, et al. The relation-ship between glucose and incident cardiovascular events. Diabetes Care. 1999;22:
233-40.
[5] Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Research and Clinical Practice.
2010;87(1):4-14.
[6] Plantinga LC, Crews DC, Coresh J, et al. Prevalence of chronic kidney disease in US adults with undiagnosed diabetes or prediabetes. Clin
J Am Soc Nephrol. 2010;5(4):673-82.
[7] Flores-Le Roux JA, Comin J, Pedro-Botet J, et al. Seven-year mortality in heart failure patients with undiagnosed diabetes: An observational
study. Cardiovasc Diabetol. 2011;10:39.
[8] Spijkerman AMW, Dekker JM, Nijpels G, et al. Microvascular complications at time of diagnosis of type 2 diabetes are similar among
diabetic patients detected by targeted screening and patients newly diagnosed in general practice: The hoorn creening study. Diabetes Care.
2003;26(9):2604-8.
[9] Nozha MM, Al-Maatouq MA, Al-Mazrou YY, Al-Harthi SS, et al. Diabetes mellitus in Saudi Arabia Saudi. Medical Journal.
2004;25(11):1603-10.
[10] Boutayeb A, Lamlili MEN, Boutayeb W, Maamri A, Ziyyat A, Ramdani N. The rise of diabetes prevalence in the Arab region. OJEpi.
2012;2(2):55-60.
[11] Avignon A, Radauceanu A, Monnier L. Non fasting plasma glucose is a better marker of diabetic control than fasting plasma glucose in
type 2 diabetes. Diabetes Care. 1997;20:1822-6.
[12] Duncan I, Birkmeyer C, Coughlin S, Qijuan EL, Sherr D, Boren, S. Assessing the value of diabetes education. The Diabetes Educator.
2009;35:752-60.
[13] Basdevant A, Laville M, Ziegler O. Recommandations pour le diagnostic, la prévention et le traitement des obésités. Diab Metab. 1998;24
(Suppl 2):1-48.
[14] Lahmam A, Baali A, Hilali MK, Cherkaoui M, Chapuis-Lucciani N, Boetsch G. Obesity, overweight and body-weightperception in a High
Atlas Moroccan population. Obes Rev. 2008;9:93-9.
[15] Ramdani N, Vanderpas J, et al. Diabetes and obesity in the eastern Morocco Mediterr J Nutr Metab. 2012;5:149-55
[16] Hramiak I, Leiter LA, Paul UR, et al. Assessment of obesity and its complications in adults. JAMC. 2007;176(8):36-39.
[17] RS Bailie, D Si, Robinson GW, et al. A multifaceted health-service intervention in remote Aboriginal communities: 3-year follow-up of
the impact on diabetes care. Med J Aust. 2004;181:195-200.
[18] Farouqi A, Harti M-A, Nejjari. C. Prise en charge du diabète au Maroc: Résultats de l’International Diabetes Management Practices Study
(IDMPS) – Vague 2. Médecine Des Maladies Métaboliques. 2010;4(6):704-11.
[19] Lacroix A, Assal J-P. L’éducation thérapeutique des patients: Nouvelles Approches de la maladie chronique. Éditions Maloine, 2003. pp.
23-35.
[20] Hulshof KF. Diet and other life–style factors in high and low socio-economic groups (Dutch Nutrition Surveillance System). Eur J ClinNutr.
1991;45:441-50.
 Y. Dinar et al. / Education and diabetes care in Morocco 197

[21] Garay-Sevilla ME, Malacara JMH, Gonzalez-Parada F, Jordan-Gines L. The belief in conventional medicine and adherence to treatment in
non-insulindependent diabetes mellitus patients. J Diabetes Complications. 1998;12:239-45.
[22] U.K.P.D.S. Étude internationale: Le contrôle du diabète de type 2. 1998. http://www.diabete.qc.ca/html/recherche/ukpds.html
[23] Nicolucci A, Cavaliere D, Scorpiglione N, Carinci F, Capani F, Tognoni G, et al. A comprehensive assessment of the avoidability of
long-termcomplications of diabetes. A case-control study.Diabetes Care. 1996;19:927-33.
[24] Tuomilehto J, ET Lindstrom J. The major diabetes prevention trials. Curr Diab Rep. 2003;3(2):115-22.
[25] Henry RR. Protein content of the diabetic diet. Diabetes Care. 1994;17:1502-13.
[26] American Diabetes Association. Nutrition recommendations and principles for people with diabetes mellitus. Diabetes Care. 1999;S42-5.
[27] Van Horn L, McCoin M, Kris-Etherton PM, Burke F, Carson JA, Champagne CM Karmally W, Sikand G. The evidence for dietary prevention
and treatment of cardiovascular disease. J Am Diet Assoc. 2008;108:287-331.
[28] Franz MJ, Bantle JP, Beebe CA, Brunzell JD, Chiasson JL, Garg A, Holzmeister LA, Hoogwerf B, Mayer-Davis E, Mooradian AD,
Purnell JQ, Wheeler M. Evidence- based nutrition principles and recommendations for the treatment and prevention of diabetes and related
complications. Diabetes Care. 2002;25:148-98.
[29] Warsi A, Wang PS, Lavalley MP, Avorn J, Solomon DH. Self-management education programs in chronic disease. Arch Intern Med.
2004;164:1641.
[30] Weaver RG, Hemmelgarn BR, Rabi DM, Sargious PM, Edwards AL, Manns BJ, Tonelli M, James MT. Association between participation
in a brief diabetes education programme and glycaemic control in adults with newly diagnosed diabetes. Diabet Med. 2014;31:1610-4.
[31] Monnier L, Lapinsky H, Colette C. Contribution of fasting and postprandial glucose increments to the overall diurnal hyperglycemia of
type 2 diabetic patients. Diabetes Care. 2003;24:881-5.
[32] Paquot N. Le régime alimentaire chez le patient diabétique de type 2. Rev Med Liège. 2005;60:392-4.
[33] Bastyr EJ, Stuart CA, Brodows RG, et al. For the IOEZ Group. Therapy focused on lowering postprandial glucose, not fasting glucose,
may be superior for lowering HbA1c. Diabetes Care. 2000;23:1236-41.