الفهرس 
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Abstract
Diabetes mellitus (DM) is a metabolic disorder characterized by persistent elevation of blood sugar levels, with disturbances of protein, carbohydrate, and fat metabolism, resulting from abnormalities in insulin secretion, insulin action or both. The effects of DM include long term damage, dysfunction, and failure of various organs with decreased life expectancy and poor quality of life.
Pre-diabetes is an intermediate state of hyperglycemia with glucose levels above normal but below the diagnostic cut-off levels of diabetes. It entails three conditions: impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) or both (IFG and IGT). In 2019, the global prevalence of IGT was 7.5%, while it was 9.2% in the Middle East and North Africa (MENA) region.
Pre-diabetes has been reported to be associated with several risks including: progression to diabetes, increased risk of chronic kidney disease and early nephropathy, higher frequency of idiopathic polyneuropathy, painful sensory neuropathy and small fiber neuropathy, increased risk of developing macrovascular diseases, increased prevalence of coronary heart disease, and increased risk of developing retinopathy.
The rationale behind pre-diabetes management is prevention of diabetes and its consequent complications as well as prevention of risks associated with pre-diabetes. Management of pre-diabetes includes lifestyle interventions (healthy diet, increased physical activity, weight loss and smoking cessation), pharmacotherapy and bariatric surgery.
Pharmacy-based intervention (PBI) has been shown to be a potent intervention and attain prominent clinical, social and economic outcomes. PBIs have demonstrated their positive impact on clinical outcomes of patients with diabetes. These positive impacts will likely reduce the burden of diabetes-related complications and will subsequently lead to reductions in diabetes-related morbidity and mortality.
The aim of this study was to study the effect of a pharmacy-based intervention on pre-diabetic pharmacy customers in Alexandria. The specific objectives of the study were:
1. To estimate the prevalence of pre-diabetes among pharmacies’ customers.
2. To assess the effect of an educational program on knowledge of pharmacists regarding pre-diabetes.
3. To assess the effect of a simple diabetes prevention program on the knowledge and blood glucose level of pre-diabetics.
The study was conducted in pharmacies from the eight districts in Alexandria using a cross-sectional approach, followed by an intervention approach (one group pre-test post-test design) among pharmacy customers aged 18 years or above, with one or more risk factors for developing type 2 diabetes mellitus, and living within the catchment area.
For the cross-sectional study, a predesigned interviewing questionnaire was prepared to collect the needed information from the pharmacy customers. It included: socio-demographic data, medical history and risk factors for developing diabetes. Anthropometric measurements were recorded and body mass index (BMI) was calculated. Moreover, fasting blood glucose and oral glucose tolerance test were measured using glucometer and test strips.
For the interventional study, an educational program for pharmacists was designed, implemented and evaluated by the researcher. Thirty pharmacists participated in this educational program and their level of knowledge was measured before and after the program.
A simple diabetes prevention program was designed by the researcher and reviewed by the supervisors. This program aimed to improve the status of pre-diabetes and prevent progression to T2DM. The program included health education leaflet covering the following items: diabetes, pre-diabetes, diagnostic criteria, risk factors, lifestyle interventions (healthy diet, weight reduction, physical activity and smoking cessation). A self-administered knowledge questionnaire was introduced to the pre-diabetic individuals to measure their level of knowledge before the educational session.
Based on the calculated BMI, pre-diabetics received dietary plans to be followed for two weeks and were instructed to receive the new plans on bi-weekly basis, from the pharmacists. The pharmacists were instructed to assure the benefits of following the provided dietary plan, performing physical activity for at least 150 minutes per week, smoking cessation and alcohol abstinence. Pre-diabetics were requested to make follow-up visits to the pharmacy at three and six months to measure the FBG, OGTT and body weight. They also received the same knowledge questionnaire to assess the impact of the program on their level of knowledge.
The study revealed the following main results:
Section I: Effect of the educational program on pharmacists’ level of knowledge regarding diabetes, prediabetes, basic food groups and healthy diet planning
a. Personal characteristics of the pharmacists:
- The age of pharmacists ranged between 23 and 52 years with a mean of 33.47 ± 6.17 years.
- Less than two thirds of the pharmacists (63.3%) were females.
- More than half of the pharmacists (53.3%) had work experience of 10 years or less.
b. Pharmacists’ knowledge about diabetes, pre-diabetes, basic food groups and healthy diet planning before the educational program:
- About two thirds of pharmacists (66.7%) had poor level of knowledge about diabetes classification and preventive measures.
- Four fifths of pharmacists (80.0%) had poor level of knowledge about pre-diabetes, its diagnosis and management.
- Most pharmacists (90.0%) had poor level of knowledge about basic food groups.
- Less than three quarters of pharmacists (73.7%) had poor level of knowledge about healthy diet planning.
- The total knowledge score before the educational program ranged from 4 to 15 with a mean of 8.5 ± 3.03. More than three quarters of the pharmacists (76.7%) had poor level of knowledge, 23.3% had fair level of knowledge, while none of the pharmacists had good level of knowledge.
- No association was found between pharmacists’ age, sex, and years of experience and their level of knowledge.
c. Pharmacists’ knowledge about diabetes, pre-diabetes, basic food groups and healthy diet planning after the educational program:
- The mean knowledge score regarding diabetes and preventive measures, mean knowledge score regarding pre-diabetes diagnosis and management, mean knowledge score regarding basic food groups and mean knowledge score regarding healthy diet planning increased from 1.9 ± 1.03 to 3.2 ± 0.90, from 1.8 ± 0.83 to 3.4 ± 0.89, from 3.1 ± 1.22 to 5.3 ± 1.80 and from 1.7 ± 1.18 to 2.4 ± 1.30, respectively.
- The mean general knowledge score increased from 8.5 ± 3.03 to 14.3 ± 2.85.
- The proportion of pharmacists who had good and fair level of knowledge increased from 0.0% and 23.3% before to 36.7% and 53.3% after the program, respectively.
- The pretest knowledge score was the only predictor for posttest knowledge score of pharmacists.
Section II: Description of studied pharmacy customers
a. Socio-demographic characteristics of pharmacy customers:
- The age of customers ranged between 18 and 80 years with a mean of 37 ± 12.98 years.
- More than half of the customers (56.1%) were females.
- Less than two thirds (62.6%) of the customers were married, while less than one third (29.9%) were single.
- Less than half of the customers (48.9%) had university education or higher, while 8.2% were illiterate or could read and write.
- More than half (59.4%) of the customers were engaged in manual and clerical work, 29% were unemployed, housewives or retired and 11.3% were health care workers.
b. Pre-diabetes risk profile of pharmacy customers:
- About one quarter (25.5%) of the customers reported having chronic diseases; with hypertension being reported by 52.6% of them.
- About three fifths (60.1%) of customers reported having first degree relatives with diabetes.
- About one quarter (24.9%) of pharmacy customers were smokers; and 82.3% of them were cigarette smokers.
- More than one third (34.8%) of the customers reported practicing physical activity for at least 150 minutes per week.
- The proportion of customers who reported having the breakfast, lunch, and dinner meals, were 82.7%, 88.4% and 57.7%, respectively. More than half (54.1%) of them acknowledged to have snacks between the main meals.
- Less than two thirds (63.7%) of customers reported having 3 or more meals and snacks per day.
c. Anthropometric measurements of pharmacy customers:
- Customers’ height ranged from 1.42 to 1.95 m with a mean of 1.68 ± 0.093 m, with the majority (90.7%) of customers’ height ranged between 1.55 to 1.85 m
- Customers’ body weight ranged from 46.3 to 137.4 Kg with a mean of 78.7 ± 15.7 Kg. About two thirds (66.2%) of the customers weighed between 60.0 to 90.0 Kg
- The calculated BMI ranged from 17.3 to 56.3 Kg/m2, with a mean of 28.02 ± 5.48 Kg/m2. Overweight and obese individuals constituted 35.8% and 32.8%, respectively.
- Customers with three or less risk factors constituted 71.8%.
Section III: Prevalence of pre-diabetes and undiagnosed diabetes mellitus among pharmacy customers
- The prevalence of pre-diabetes in the current study was 6.9%.
- The prevalence of undiagnosed diabetes was 7.6%.
- FBG and OGTT can predict almost all cases of pre-diabetes among pharmacy customers. The AUC was 0.995 for FBG and 0.976 for OGTT, (p Area=0.5 was<0.000).
Section IV: Determinants associated with pre-diabetes among the high risk-pharmacy customers
- Age, sex, and level of education, having chronic diseases were associated with pre-diabetes.
- Being overweight or obese and having more than three meals per day were associated with pre-diabetes.
- Six independent variables were significantly affecting the diagnosis of pre-diabetes among studied pharmacy customers. Being aged 46 to 55 years old, having male sex, being illiterate or could read and write and preparatory education, having chronic diseases, being overweight or obese, and having at least 3 meals per day.
Section V: Effect of the intervention program on the pre-diabetic pharmacy customers
- The mean knowledge score significantly increased from 3.35 ± 2.076 before the intervention to 4.20 ± 2.631 and 4.63 ± 2.857, three and six-months after intervention, respectively.
- The mean body weight significantly decreased from 85.33 ± 18.127 Kgs before intervention to 83.69 ± 17.248 Kgs and 82.44 ± 16.928 Kgs, three and six months after intervention, respectively.
- The body mass index significantly decreased from 30.16 ± 6.796 Kg/m2 before intervention to 29.64 ± 6.483 Kg/m2 and 29.22 ± 6.403 Kg/m2, three and six months after intervention, respectively.
- The mean FBG decreased from 113.07 ± 6.905 mg/dL at baseline, reached 108.96 ± 6.892 mg/dL after 3 months, and decreased again to 106.78 ± 8.717 mg/dL after 6 months.
- The mean OGTT values decreased from 157.24 ± 14.071 mg/dL at baseline, to 147.41 ± 14.824 mg/dL after 3 months and reached 142.24 ± 17.355 mg/dL after 6 months.
- Three months after intervention, 35.2% of the prediabetic became normal, and this proportion increased to reach 55.6% after six months.
- With the Kaplan-Meier Survival Analysis procedure the proportion of prediabetics survived normal was .374 at the third month and 0.588 at the sixth month.