Almoutaz Alkhier Ahmed, Diabetologist
Dr.Almoutaz Alkhier Ahmed, Diploma in diabetes, IIWCC; Diabetes Center, Gurayat province, SA

Correspondence:
Diabetic Center
Gurayat North
Saudi Arabia
P.O. Box 672
E-mail: khier2@yahoo.com

INTRODUCTION

Diabetes is one of the growing health problems in the Middle East region in general and Saudi Arabia particularly. Increase of population numbers in the region exposes a large number of the population to diabetes and its complications. The following review discusses the problem of diabetes in Saudi Arabia, diabetic neuropathy, diabetic vasculopathy, diabetic foot and the impact of education on the quality of foot care. According to our knowledge, this is the first review that shows the magnitude of diabetic foot and its risk factors in Saudi Arabia.

Diabetes in Saudi Arabia:
The Kingdom of Saudi Arabia has undergone a lot of changes in different aspects of daily life habits, towards westernisation. According to Khan, increasing trends in the per capita availability of total food (90%), oils and fats (200%), animal fat (171%), animal protein (207%), meat (313%), milk (120%), eggs (648%) and sugar (68%) have been observed in Saudi Arabia over the period of 60th and 70th.⁽¹⁾ These changes in the years in Japan and 200 years in the United Kingdom.⁽²⁾
In recent decades rapid demographic changes have taken place in the form of increasing urbanisation in many parts of Saudi Arabia. Where in the early 1970s, 25% of the Saudi Arabian population lived in urban areas; by the early 1990s more than 75% did so.⁽³⁾ Urbanisation has been accompanied by changes in the patterns of life style. A steady increase in diabetes prevalence has been noted in Saudi Arabia.
In 1982, Bacchus RA, published the first study estimated prevalence of diabetes in Saudi Arabia in a sample of rural men (age 45- 54 years); it was 9.6% and 11% in men >55 years. Fatani et al published a prevalence of 7% and 10.2 % among males aged 35- 54 and > 55 years respectively and 16% and 18.7 % among females aged 35-54 and >55years old respectively.⁽⁴⁾ Abu-Zeid in 1997 found that the prevalence of diabetes among men in southern Arabia Saudi was 17 % and 22 % among men aged 41- 50 years and 51- 60 years respectively and 11% and 26% among women aged 41-50 years and 51-60 years respectively.⁽⁵⁾
In 2004, Al-Nozha reported in his national survey for risk factors for coronary artery diseases that the prevalence of diabetes had reached 23.7 %.⁽⁶⁾
Obesity is another health problem among the Saudi population and considered as a risk factor for diabetes and diabetic foot problems.
El-Hazmi et al reported in their national survey which took place in 1997 that the prevalence of overweight in the Saudi population was 22.23% and 25.20% in males and females respectively while obesity was 13.05% and 20.26% in males and females respectively.⁽⁷⁾ In 2005, Al-Nozha et al reported a new prevalence for overweight and obesity.⁽⁸⁾ For overweight, it was 42.4% and 31.8% for males and females respectively, and for obesity it was 26.4% and 44% for males and females respectively. The prevalence of gross obesity (BMI>40m/kg2) was 3.2%.⁽⁸⁾
The high prevalence of inactivity among Saudis represents a major public health challenge. Al-Nozha et al⁽⁹⁾ showed that the prevalence of inactivity among participants included in the national survey done between 1995- 2000 for the risk of coronary artery diseases in Saudi Arabia was 96.1% which is very high. There were significantly (p<0.001) more inactive females (98.1%) than males (93.9%). Inactivity prevalence increases with increasing age category, especially in males, and decreases with increase of education levels. Inactivity was the highest in the central region (97.3%; 95% CI = 96.8-97.8%) and the lowest in the southern region of Saudi Arabia (94.0%; 95% CI = 93.2-94.8%).⁽⁹⁾

In 2008, Al-Nozha et al⁽¹⁰⁾ published data that showed the prevalence of dyslipideamia among the Saudi population. They found that the prevalence of High Cholesteremia (total cholesterol > or =5.2 mmol/l) was 54% with mean cholesterol level of 5.4+/-1.52 mmol/l. The prevalence of High Cholesteremia among males was 54.9% and 53.2% for females, while 53.4% among urban Saudis and 55.3% for rural Saudis. For hypertriglycemia (total triglycerides > or =1.69 mmol/l) the prevalence was 40.3% with mean triglycerides level of 1.8+/-1.29 mmol/l. Males had a statistically significant higher Hypertriglycemia prevalence of 47.6% compared to 33.7% in females (p<0.0001).

Smoking was another health problem in Saudi Arabia. It is difficult to determine the actual prevalence of smoking due to multiple social and religious barriers, so there has been a considerable variation on the prevalence of smoking among studies done in Saudi Arabia. Al-Haddad NS, Al-Habeeb TA, Abdelgadir MH, Al-Ghamdy YS and Qureshi NA concluded in their study published in 2003 that prevalence of smoking in Al-Gassim region was 52.3%.⁽¹¹⁾ Although 85% were adult smokers, 8.6% began smoking before age 12. Smokers gave overlapping reasons to smoke including peer pressure; non-smokers gave religious and health logics against smoking.⁽¹¹⁾ Of all smokers, 92.8% wanted to learn cessation strategies, 11.8% were ignorant of hazards and 32.4% reported manifestations of nicotine withdrawal.⁽¹¹⁾
In another study done among health staff in a primary care unit in a general hospital in Riyadh, the prevalence of smoking was 19% and 14% for ex-smokers.⁽¹²⁾
Jamal S Jarallaha et al concluded that the overall prevalence of smoking was 21.1% for males and 0.9% for females. Most smokers (78%) were young to middle-aged (21- 50 years old). Smoking prevalence was higher among married people, among uneducated people, and among those in certain occupations: manual workers, businessmen, army officers, and office workers.⁽¹³⁾

In conclusion, the changes in demography of Saudi Arabia, the pattern of life style and adoption of bad medical habits like tobacco smoking were accused of raising the prevalence of type 2 diabetes mellitus in Saudi Arabia and exposing a large number of the population with diabetes to complications of diabetes.

Foot examination and risk categorisation were among the least concerning examination by most of the physicians dealing with diabetes.
In a cross sectional study conducted in Gurayat province among primary care physicians to evaluate the current referral system between the diabetic center and the primary health care centers, only 3 referral forms (from a total of 215 forms) contained data about foot examination.⁽¹⁴⁾
Neuropathy and vasculaopathy were the main determinant risk factors for the occurrence of diabetic foot. Loss of protective sensation stands behind many of diabetic foot ulcers.

Poor glycemic control is considered one of the poor predictors of diabetic foot lesions.
Faiza A Qari and Daad Akbar reported that 79% (27/34) of their studied patients were uncontrolled.⁽¹⁵⁾

Al-Nuaim AR et al in their paper, studied patterns and factors associated with glycemic control of Saudi diabetic patients and reported that 50% of the patients with type 2 they studied have uncontrolled diabetes (Random blood glucose > 10mmol/L).⁽¹⁶⁾ In this study patients with poor glycemic control were significantly older than patients with good glycemic control (P=0.0001).The researchers concluded that underutilised insulin therapy, given the high rate of poor glycemic control and high rate of relative poor glycemic control and high rate of relative occurrence of complications among Saudi diabetic patients. (16) Another study done by Faiza A Qari compared glycemic control among diabetic at university and Erfan private hospital.⁽¹⁷⁾ She concluded that even after great efforts, a target level of HbA1c was not achieved in both groups of patients - in private and governmental hospitals. Only 58% at King Abdulaziz University Hospital versus 54% at Erfan group achieved an acceptable level (HbA1c<8%).⁽¹⁷⁾ Even in primary health care services, glycemic control was not so good. In a study done by Azab AS (18) which targeted patients with diabetes attending primary health care centers in Riyadh (991diabetic patients were involved), 21% of patients achieved excellent glycemic control in the first reading and 25% in the second reading (fasting blood glucose <10mmol/L) while those with poor control represented 49% and 44% of the patients in two readings (fasting blood glucose >10mmol/L).⁽¹⁸⁾

Diabetic neuropathy is a common complication of diabetes mellitus that eventually affects the majority of diabetic patients and is associated with significant morbidity and disability.⁽¹⁹⁾ It affects sensory, autonomic and motor neurons of the peripheral nervous system. Prevalence of diabetic peripheral neuropathy varies widely due to the different diagnostic criteria. Epidemiological cross-sectional studies are the most appropriate to draw valid conclusions regarding the prevalence of diabetic neuropathy if they are population-based and can obtain response rates. In contrast, hospital-based studies may not reflect the true prevalence of this complication. Recommendations for standardised classification of diabetic neuropathy made by the American Diabetic Association and academy of neurology include measurement of at least one parameter of the five main categories: symptom profile, neurological examination, quantitative sensory testing, nerve conduction studies and autonomic function testing.⁽²⁰⁾

It is estimated from a comprehensive collection of epidemiologic studies that the prevalence of neuropathy in diabetes patients is approximately 30% in hospital patients and 20% in community patients.⁽²¹⁾

In 1994, Kumar et al reported a higher prevalence rate (41.6%) of neuropathy among patients with type 2 diabetes in a population-based study in three cities in the United Kingdom.⁽²²⁾ The prevalence was 26% in the Oxford community- based study which did not include patients over 75 years.⁽²³⁾
Nielsen JV reported a prevalence of 38% among Saudi patients with type 2 diabetes within a duration of 10 years.⁽²⁴⁾ In the same study a comparison of 212 Saudi diabetic patients in the age group 46- 69 years were compared with corresponding Swedish patients with type 2 diabetes. No significant difference was noticed between the two groups.⁽²⁵⁾

Abdulrahman Al-Tahan, in his paper published in 1994 in the Saudi medical journal reported that the prevalence of diabetic neuropathy was 33.9% and it was the commonest encountered type of neuropathy among Saudis.⁽²⁵⁾
An interesting paper published in the Bahrain medical bulletin by Daad H Akbar discussed the discordance between symptoms and electrophysiological testing in Saudi diabetics in diagnosing diabetic neuropathy.⁽²⁶⁾ In a cross sectional study of Saudi diabetics with symptoms of neuropathy followed up in medical outpatient clinic at King Abulaziz University Hospital between January 1998 to May 1999, neuropathy was diagnosed using the Mitchigan neuropathy program. The prevalence of Normal nerve conduction was 36% and the abnormal conduction was 64 %.⁽²⁶⁾

Another interesting study was done by Abdulsalam A Al-Sulaiman, Hassan M Ismail, Ali I Al-Sultan⁽³⁷⁾ on nerve conduction abnormalities among newly diagnosed diabetic patients with type 2 diabetes (within 4 weeks from the diagnosis). The researchers found the presence of these abnormalities in all participants (29 patients) which meant that the prevalence of neuropathy based on their criteria was 100%.⁽²⁷⁾

An interesting paper published in the Saudi journal of kidney disease and transplantation found that the prevalence of diabetic neuropathy was 66.8%.⁽²⁸⁾ This study concluded that baseline creatinine clearance and proteinuria, high systolic blood pressure, advanced age and longer duration of diabetes were the most significant risk factors for developing complications.⁽²⁸⁾ The interesting part of this study is that from the following complications; angiography proven coronary artery disease, stroke, myocardial infarction, angina, retinopathy, blindness, peripheral vascular disease, neuropathy, hypertension, diabetic foot, amputation and end stage renal disease, 37% of patients developed > 6 concomitant complications, 28% developed 5 concomitant compilications,17% developed 4 and the rest developed <3.⁽²⁸⁾ This finding may explain the high prevalence of neuropathy among these patients.

Akbar DH, Mira SA, Zawawi TH, Malibary HM, in their paper published in 2000 in the Saudi medical journal pointed to subclinical diabetic neuropathy which they considered as a common complication in Saudi diabetics.⁽²⁹⁾ They conducted a prospective study extended from January 1998 until April 1999. Patients were assessed for diabetic neuropathy using the Michigan Neuropathy Program.⁽³⁰⁾ Symptomatic diabetic neuropathy was found in 56% while sub clinical neuropathy was found in 57% of asymptomatic patients.⁽²⁹⁾
Reported prevalence of neuroarthropathy among diabetic Saudis was very scarce in the literature. The study done by Qidwai SA, Khan MA, Hussain SR and Malik MS, published in the Saudi medical journal in 2001 is among those few studies done on this area.⁽³¹⁾ The researchers conducted a retrospective study based on reviewing medical records of 296 diabetic patients between June of 1998 and July of 1999. Included participants had long standing, poorly controlled diabetes mellitus and associated peripheral neuropathy. Participants were evaluated clinically and radiologically for the presence of neuroarthropathic changes in the feet. The researchers found that the prevalence of diabetic neuropathy was 12.5% and 4% for neuroarthropathy.⁽³¹⁾ The joints involved were tarsometatarsal (76%), metatarsophalangeal (59%), subtalar (47%) and interphalangeal joints (41%).⁽³¹⁾

The prevalence of peripheral vascular disease (PVD) is higher among diabetic than non-diabetic patients in both population and hospital based studies.^(32,33) True prevalence of PAD in people with diabetes has been difficult to determine due to:

- Most of the patients are asymptomatic
- Many do not report their symptoms
- Screening modalities have not been uniformly agreed upon
- Pain perception may be blunted by the presence of PVD

Data from the Framingham Heart Study, revealed that 20% of symptomatic patients with PVD had diabetes.⁽³⁴⁾
When using pulse deficits as criterion for detection of PVD, the researchers on the Rochester, MN which was a population based survey among diabetics diagnosed in 1945 - 1969 found that 8% had PVD at the time of initial diagnosis of diabetes.⁽³⁵⁾

In an epidemiological study involving two residential areas in Chennai in south India with 1,262 participants aged > 20 years using Doppler to detect PVD with a cut value of 0.9, the researchers found that among normoglycemic patients the prevalence of PVD was 2.7%, among those with impaired glucose tolerance 2.9% and among diabetics it was 6.3 %.⁽³⁶⁾

Sulatn O Al-Sheikh et al conducted a prospective cross sectional study which included 471 Saudi patients aged >=45 years attended the primary health care center at king Khalid university hospital between February - March 2006, using ABI<0.9 to define PAD. They found that the prevalence of PAD was 11.7% and 92.7% of them were asymptomatic.⁽³⁷⁾

Faiza A Qari and Daad Akbar retrospectively studied medical notes of 34 diabetic patients admitted to king Abdulaziz University hospital in Jeddah from June 1997 to June 1999 with diabetic foot. They concluded that 50% of those patients suffered from PAD.⁽³⁸⁾

Sulimani RA, Famuyiwa OO, Mekki MO, in their retrospective study which was carried out to estimate the magnitude and pattern of foot lesions seen in King Khalid University hospital among diabetics found that the prevalence of PAD was 54.5%.⁽³⁹⁾

AbdulRashid S and Ashar AK, in their paper published in the Journal of Surgery of Pakistan reported the results of an analysis of 50 cases of amputations done at Al-Noor Specialist Hospital in Mekkah, and found that there were 43/48 (86%) amputations due to diabetes with peripheral neuropathy and circulatory disorder.⁽⁴⁰⁾

Almoutaz A.Ahmed in his review done in 2006 about the epidemiology of diabetes in Gurayat province found that the prevalence of PAD among patients with type 2 diabetes attending the diabetic center in the province was 10.5% using symptoms and pulse deficit as criteria for PVD.⁽⁴¹⁾

Al-Wakeel et al studied 184 diabetic patients with nephropathy between Jan 2003 - June 2006. (42) Researchers found that the prevalence of peripheral vascular disease was 65.7%.⁽⁴²⁾ This study concluded that baseline creatinine clearance and proteinuria, high systolic blood pressure, advanced age and longer duration of diabetes were the most significant risk factors for developing complications.⁽⁴²⁾

Education is one of the important issues that needs to be covered well in patients with diabetes.

The Diabetes Education Study (DIABEDS) was a randomised, controlled trial of the effects of patient and physician education, with patients randomly assigned to experimental and control groups.⁽⁴³⁾ Patients in the randomised experimental group were offered up to seven modules of patient education. The results of the study showed that there were significantly greater reductions in fasting blood glucose between experimental and control group (-27.5 mg/dl versus -2.8 mg/dl, (P<0.05) and glycosylated hemoglobin (- 0.43% versus + 0.35%, P<0.05) as compared with control subjects.

Iftikar Uddin, Tahir J. Ahmed, AbdurRahman A.Kurkuman and Rahila Iftikar found that education is significantly effective in controlling blood glucose (P<0.005). (44) The mean fasting blood glucose before education started among participants was 10.7mmol/L and became 7.3mmol/L after education.⁽⁴⁴⁾

Alkhaldi YM and Khan MY published an interesting paper auditing diabetic a health education program applied to diabetic patients (198 patients) at a large primary health care center in Asir region.⁽⁴⁵⁾ The researchers found that compliance to appointments was good in 60% and poor in 30% of diabetics. Also, they found that 73% of diabetics received at least one health education topic, 27% did not receive any health education at all, and only 33% of diabetic patients had adequate health education. Eighty percent (80%) were questioned about diabetes and 77% were educated about the role of diet. They also found that the essential structure for diabetes education program was found to be unsatisfactory and recommended a structured education program to be applied.

In another interesting study done in a primary health care center in Abha where 475 diabetic patients were registered and followed up, the files of 198 diabetic patients who fulfilled the inclusion criteria set for this study were reviewed.⁽⁴⁶⁾ The aim of this study was to examine the impact of health education delivered in the PHC setting on the control of diabetes and to investigate any gender difference affecting the validity of health education message. Males received significantly more health education sessions (4.2+1.9 versus 1.8+1.3 P<0.01). Females had significantly poorer diet compliance than males (P<0.05). The researchers concluded that the only significant factor predicting poor glycemic control was the sex of the patient showing that females are more prone to hyperglycemia and poor control of their diabetic state than males (OR= 2.84) and recommended that female patients should be taken into account when designing health education messages.
Organised follow up using a structured follow up sheet showed significant outcomes. Moharram MM and Farahat FM⁽⁴⁷⁾ showed that the use of a flow sheet would improve performance of family physicians in diabetes care. Based on a one year intervention study conducted in 7 family practice clinics in Taif Armed Forces Hospitals, Taif, Saudi Arabia from March 2006 to June 2007, the researchers concluded that a flow sheet can be effective in improving quality of care not only for diabetes but also for other chronic conditions.
Mohammed H. AlDoghether, in his study assessed whether it is possible by diabetic foot reminder to improve foot examination of diabetics in primary health care centers.⁽⁴⁸⁾ The researcher used pre and post evaluation to measure the effect of the content of the education on the quality of foot examination. The results showed that there was a dramatic improvement of performing foot examination after using the reminders over 4 months. Further improvement might be expected over applying the reminders for a year or more. The researcher advised that one of the main reasons for the success in implementing the diabetic foot examination reminder is the employment of a multidisciplinary approach.

Literature search for dermatological diseases of the foot among Saudi diabetics refilled very scanty publications.
An interesting national survey done by Sammer K Zimmo published in 2007⁽³¹⁾ reviewed the common dermatological foot diseases among 4401 Saudi individuals. This survey showed that 43% of the participants had foot diseases. The prevalence of fungal infection was 19.9%; and 15.52% of them were suffered from Tinea Pedis, 5.56% from Onychomycosis and 23% from non fungal diseases.
Of all participants 5.5% had warts and 3.68% had corns.
Skin examination showed that 57% of affected patients had planter hyperkeratosis. 45% had fissures, 10% ulceration.
Diabetes was the third prevalent cause for dermatological foot diseases (12%) preceded by dermatological diseases (42%) and obesity (13%).

Ulceration of the foot in diabetes is common and disabling and frequently leads to amputation of the leg.
In a community survey done in UK, the prevalence of diabetic foot ulcers was 5.3% in patients with type 2 diabetes.⁽²⁵⁾ Also they found that 7.4% of patients with type 1 and 2 had a history of active or previous foot ulcers.⁽²⁵⁾ In USA in a hospital based survey done by Ramsey SD and his colleagues found the prevalence was 5.8%.⁽⁵⁰⁾
In another survey done in Netherlands, a mean incidence of new ulceration among patients with type 2 alone was found to be 2.1% annually.⁽⁵¹⁾
In a study done in Iran by Afsaneh Alavi aimed to examine the characteristics of patients with diabetic foot ulcers attending an outpatient diabetic clinic in Kerman province which is located in the southeastern of Iran, the investigator examined 247 patients with diabetes with mean age 52+12years, the prevalence of diabetic foot was 4%, callus 12% and 50% for heal cracks.⁽⁵²⁾
Nielsen JV⁽⁷⁾ found that the prevalence of diabetic foot was 4.7% among a sample of 375 Saudi patients with type 2 diabetes. He did a comparison with a correspondence Swedish diabetic patients (age group 46-69years), prevalence of ulcers was (2.3%) in Saudi group which was significantly lower than in Swedish patients. This finding may explained by different styles of footwear.⁽²⁴⁾
Faiza A Qari and Daad Akbar in their paper reported that 59% of their studied patients had foot ulcers (20/34) and 65% of these patients with ulcers need Debridement.⁽³⁸⁾
In another study done in King Khalid University Hospital, Riyadh from January 2003- June 2006 included 184 diabetic nephropathy patients who were referred to nephrology clinic; the researchers found that the prevalence of diabetic foot was 13.5%.⁽²⁸⁾ Also the researchers in this study concluded that baseline creatinine clearance and proteinuria, high systolic blood pressure, advanced age and longer duration of diabetes were the most significant risk factors for developing complications.⁽²⁸⁾
Qari FA in her study which aimed to know the characteristics and risk factors of 13 diabetic patients undergoing chronic hemodialysis at King Abdulaziz University Hospital in Jeddah⁽⁵³⁾ found that 7.7% of the participants had gangrenous foot. She explained her findings to poor glycemic control, inadequate treatment of hypertension, high smoking rate and inadequate screening for microalbuminuria.⁽⁵³⁾

The high prevalence of diabetes and the increasing prevalence of risk factors for diabetic foot as well as poor constructed educational programs stand behind the growing prevalence of diabetic foot lesions in Saudi Arabia.
Large community base surveys need to be conducted to assess the current situation and auditing the running programs.

1. Khan MA. Dietary energy and protein requirements for Saudi Arabia: a methodological approach. EMMJ; 4(1):68-75.1998.
   
2. Diet, nutrition and the prevention of chronic diseases. Report of a WHO study group. Geneva, world health organization, 1990 (Technical Report Series, No.797).
   
3. JV Nielsen. Diabetes in the Arab World: Prevalence and risk factors. Practical Diabetes International May 1999; 16(3):82-86.
   
4. Fatani HH,Mira SA,El-Zubir AG.Prevalence of diabetes mellitus in rural Saudi Arabia. Diabetes Care 1987; 10(2):180-83.
   
5. Abu-Zeid HAH,Al-Kassab ASK. Prevalence and health-care features of hyperglycemia in semi-urban-rural communities in southern Saudi Arabia. Diabetes Care 1992; 15(4):484-89.
   
6. Al-Nozha MM, Al-Matouq MA, Al-Mazrou YY, et al. Diabetes in Saudi Arabia. Saudi Med J 2004; 25(11): 1603-10.
   
7. M.A.F.El-Hazmi and A.S.Warsy. Obesity in Saudi Arabia. Ann Saudi Med; 17(3):302- 306.1997
   
8. Al-Nozha et al. Obesity in Saudi Arabia. Saudi Med J; 26(5):824-9.2005.
   
9. Al-Nozha et al. Prevalence of physical activity and inactivity among Saudis aged 30-70 years. A population-based cross sectional study. Saudi Med J; 28(4):559-68.
   
10. Al-Nozha et al. Hyperlipidemia in Saudi Arabia. Saudi Medical Journal ; 29(2):282-7.2008.
    
11. Al-Haddad NS, Al-Habeeb TA, Abdelgadir MH, Al-Ghamdy YS, Qureshi NA. Smoking pattern among primary health care attendees, Al-Qassim region, Saudi Arabia. East Mediterr Health J. 2003 Sep-Nov;9(5-6):911-22.
    
12. Siddiqui S, Ogbeide D. Profile of smoking amongst health staff in a primary care unit at a general hospital in Riyadh, Saudi Arabia. Saudi Med J 2001; 22:1101-04.
    
13. Jamal S Jarallaha, Khalid A Al-Rubeaanb, Abdul Rahman A Al-Nuaimb, Atallah A Al-Ruhailyb, Khalid A Kalantana. Prevalence and determinants of smoking in three regions of Saudi Arabia. Tob Control 1999; 8:53-56.
    
14. Almoutaz A Ahmed. Is it a proper referral form. MEJFM; 5(1):27-30. 2007.
    
15. Faiza A Qari and Daad Akbar. Diabetic foot: presentation and treatment. Saudi Med J; 21(5):443-446. 2000.
    
16. Al-Nuaim AR, Mirdas S, Al-Rubean K, Al-Mazrou Y, Al-Attas O, Al-Daghari N. Pattern and factors associated with glycemic control of Saudi diabetic patients. Ann Saudi Med; 18(2):109-12.1998.
    
17. Faiza A Qari. Glycemic control among diabetics at a university and Erfan private hospital. Pak J Med Sci; 21(4):408-412.2005.
18. AZAB Ahmad S. Glycemic control among diabetic patients. Saudi med J; 22, (5):407- 409. 2001
    
19. Ahroni JH, Boyko EJ, Davignon DR et al. The health and functional status of veterans with diabetes. Diabetes Care 1994;17:318-21.
    
20. American diabetes association, American academy of neurology. Consensus on diabetic neuropathy. Diabetes care 1988; 11:592-7.
    
21. Shaw JE, Zimmet PZ. The epidemiology of diabetic neuropathy. Diabetes Rev.1999;7:245-52.
    
22. Kumar S, Ashe HA, Parnell LN et al. The prevalence of foot ulceration and its correlates in type 2 diabetic patients: A population-based study. Diabetic Med 1994; 11:485-4.
    
23. Neil HAW, Thompson AV, Thorogood M,et al. Diabetes in the elderly: The Oxford community diabetes study. Diabetic Med 1989;6:608-13.
    
24. JV Nielsen. Peripheral neuropathy,hypertension,foot ulcers and amputations among Saudi Arabian patients with type 2 diabetes. Diabetes research and clinical practice;41(1):63-69.1998
    
25. Abdulrahman Al-Tahan. The pattern of peripheral neuropathy in Saudi Arabia: the experience at King Khalid University Hospital 1983-1990.Saudi medical journal; 15(2):127-132
    
26. Daad H Akbar. Diabetic neuropathy: discordance between symptoms and electrophysiological testing in Saudi diabetics. Bahrain Med Bull 2002; 24(1):10-12
    
27. Abdulsalam A Al-Sulaiman, Hassan M Ismail,Ali I Al-Sultan. Electrophysiological findings in newly diagnosed Non-Insulin Dependent Diabetes: A prospective study. Ann Saudi Med; 17(4):399-401. 1997
    
28. Al-Wakeel JS, Hammad D, Al Suwaida A, Mitwalli AH, Memon NA, Sulimani F. Microvascular and macrovascular complications in diabetic nephropathy patients referred to nephrology clinic. Saudi J Kidney Dis Transpl; 20(1):77- 85. 2009
    
29. Akbar DH, Mira SA, Zawawi TH, Malibary HM. Subclinical diabetic neuropathy: a common complication in Saudi diabetics. Saudi med j; 21(5):433-7
    
30. A. Moghtaderi, A. Bakhshipour, H. Rashidi. Validation of Michigan neuropathy screening instrument for diabetic peripheral neuropathy. Clinical Neurology and Neurosurgery; 108(5): 477-481.2006
    
31. Qidwai SA, Khan MA, Hussain SR and Malik MS. Diabetic neuroarthropathy. Saudi Med J; 22(2):142-5. 2001
    
32. Orchard TJ, Strandness DE: Assessment of peripheral vascular in diabetes.Report and recommendations of an international workshop. Circulation 88:819-28.1993
    
33. The Diabetes Control and Complication trial research group: The effect of intensive treatment of diabetes on the development and program of long term complications in insulin-dependent diabetes mellitus. New Engl J Med 329:977-86.1993
    
34. Murabito JM, D'Agostino RB, Silbershatz H. Wilson WF: Intermittent Claudication: a risk profile from the Wilson WF :intermittent claudication: a risk profile from the Framingham heart study. Circulation 96:44-49.1997
35. Melton LJ III, Macken KM, Palumbo PJ, Elvback LR: Incidence and prevalence of clinical peripheral vascular disease in a population-based cohort of diabetic patients. Diabetes Care 13:650-54, 1980
    
36. G Premalatha, S Shanthirani, R Deepa, J Markovitz and V Mohan. Prevalence and risk factors of peripheral vascular disease in a selected South Indian population: the Chennai Urban Population Study. Diabetes Care; 23(9): 1295 -1300. 2000
    
37. Sultan O Al-Sheikh, Badr A Aljabri, Lubna A Al-Ansary, Laila A Al-Khayal, Musaad M Al-Salman and Mohammed A Al-Omran. Prevalence of and risk factors for peripheral arterial disease in Saudi Arabia:A pilot cross-sectional study. Saudi Med J; 28(3):412-414.2007
    
38. Faiza A.Qari and Daad Akbar. Diabetic foot: Presentation and treatment.Saudi Med J; 21(5):443-446.2000
    
39. Sulimani RA, Famuyiwa OO, Mekki MO. Pattern of diabetic foot lesions in Saudi Arabia:experience from King Khalid university hospital, Riyadh. Ann Saudi med;11(1):47-50.1991
    
40. AbdulRashid Surahio and Ashar Ahmad Khan. Amputations and diabetes mellitus:an institutional experience.J Surg Pak;13(3):124-7.2008
    
41. Almoutaz Alkhier Ahmed. Epidemiolgy of diabetes in Gurayat province (unpublished).
    
42. Al-Wakeel JS, Hammad D. Al Suwaida A,Mitwalli AH, Memon NA and Ani F. Microvascualr and macrovascular compilictions in diabetic nephropathy patients referred to nephrology clinic. Saudi J Kidney Dis Transpl; 20(1): 77-85. 2009
    
43. SA Mazzuca, NH Moorman, ML Wheeler, JA Norton, NS Fineberg, F Vinicor, SJ Cohen and CM Clark. The diabetes education study: a controlled trial of the effects of diabetes patient education. Diabetes Care; 9, (1) 1-10.1986
    
44. Iftikar Uddin, Tahir J.Ahmed, AbdurRahman A. Kurkuman and Rahila Iftikar. Diabetes education: Its effects on glycemic control. Annals of Saudi Medicine; 21(2-1):120-122.2001
    
45. Alkhaldi YM and Khan MY. Audit of a diabetic health education program at a larg primary health care center in Asir region. Saudi Med J; 21(9):838-42.2000
    
46. Abdelmoneim I, Al-Homrany MA. Education in the management of diabetes at the primary health care level: is there a gender difference?. East Mediterr Health J;8(1):18-23 .2002
    
47. Moharram MM and Farahat FM. Quality improvement of diabetes care using flow sheets in family health practice. Saudi Med J;29(1):98-101.2008
    
48. Mohammed H. Al Doghether. Improving foot examination of diabetics in primary care. Saudi medical journal;24(9):1029-1030.2003
49. Sameer Kh Zimmo. Prevalence of dermatologic foot diseases in Saudi Arabia. Journal of Pan-Arab League of Dermatologists; 18(2):9-13.2007
    
50. Ramsey SD, Newton K, Blough D et al. Incidence outcomes and cost of foot ulcers in patients with diabetes. Diab Care; 22:382-87.1999
51. Muller IS, de Grauw WJC, van Gerwen WHEM et al. Foot Dutch primary health Care Diab Care;25:570-74.2002
    
52. Afsaneh Alavi. Wound Care challenges faced in Iran. Advances in Skin and Wound Care; 20(1):27-28
    
53. Qari FA. Profile of diabetic patients with end-stage renal failure requiring dialysis treatment at King Abdulaziz University Hospital, Jeddah. Saudi J Kidney Dis Transple;13(2):199-202.2002