Med. J. Cairo Univ., Vol. 79, No.
1, June 211-218, 2011
www.medicaljournalofcairouniversity.com
Factors Affecting Compliance of Diabetic Patients toward
Therapeutic Management
NADIA M. TAHA, D.N.Sc.*; MAGDA ABD EL-AZEAZ, D.N.Sc.** and BAHIA G. ABD EL-RAZIK, M.Sc.***
The Department of Medical-Surgical Nursing, Faculty of Nursing, Zagazig*, Ain Shams**, and Mansoura*** Universities
Abstract
Background: The increasing prevalence of diabetes mel-
litus, the emergence of diabetes complications as a cause of
early morbidity and mortality, and the enormous and mounting
burden on health care systems make diabetes a priority health
concern. The main goals of diabetes care are good metabolic
control, and minimization of complications. These are affected
by patient compliance, which is the extent to which a persons
behavior coincides with medical or other health care regimen.
The aim of this study was to assess factors affecting compliance
of diabetic patients toward therapeutic management and
providing guidelines for the patients to improve their compli-
ance toward therapeutic management. Research questions:
What are the factors affecting compliance of diabetic patients?
What is the relationship between diabetic complications and
patient compliance?
Subjects and Methods: A descriptive correlational design
was used to conduct this study. The Subjects a sample of 80
patients with type 2 diabetes mellitus, (23 males and 57
females). The study was carried out at outpatient clinic in
Zagazig University Hospital. Tools for data collection included
a questionnaire interview sheet, to assess the factors affecting
their compliance to treatment regimens of diabetic patients.
Results: The study results revealed that, most of diabetic
patients had unsatisfactory knowledge scores about the disease
and its treatment regimen. But despite of their poor knowledge,
they had inadequate compliance scores. There were a highly
statistical significant positive correlation between knowledge
and compliance of the study sample.
Conclusion and Recommendations: The study concluded
that most type-2 diabetic patients in the study setting have
inadequate compliance and unsatisfactory knowledge regarding
management of DM. Compliance is influenced by patients'
income, disease characteristics, perceived barriers, as well as
knowledge. The low compliance is reflected in high prevalence
of obesity, DM complications, and high blood sugar levels.
Therefore, patient compliance needs to be improved through
patient teaching program especially targeting vulnerable
diabetic patients and their families. Additionally, the barriers
perceived by these patients need to be addressed, especially
the costs of investigations, and the physical barriers related
Correspondence to: Prof. Nadia M. Taha, The Department of
Medical-Surgical Nursing, Faculty of Nursing, Zagazig
University, dr_nadya_mohamed@yahoo.com .
211
to diet and exercise. Further research is needed to develop
and refine interventions to improve compliance of diabetic
patients and to assess the effectiveness of removing perceived
barriers on their compliance.
Key Words: Diabetes mellitus Compliance.
Introduction
DIABETES Mellitus (DM) is a group of metabolic
diseases characterized by elevated level of glucose
resulting from defects in insulin secretion, insulin
action, or both American Diabetes Association, [1] .
It is one of the most prevalent non-communicable
diseases, and its epidemic proportion has placed
it at the forefront of public health challenges cur-
rently facing the world [2] . Studies point to dramatic
increase in diabetes rates during the last decade
all over the world, in both developed and develop-
ing countries. It poses a great burden on individuals,
health care system, and societies in all countries
[3,4] . The World Health Organization (WHO) pro-
jected about 299 million cases of DM by the year
2025 [5,6] .
Diabetes mellitus is classified into two main
subtypes, namely type-1 or insulin dependent DM
and type-2 or non-insulin dependent DM [7] . Type-
1 occurs most commonly in children and adoles-
cents and is characterized by beta cell failure and
treated by insulin. In type-2, patients are often
overweight, older than 30 years of age, over-
produce insulin, have a receptor site defect, and
are treated with oral hypoglycemic agents [8] .
The main goals of diabetes care are good met-
abolic control, and minimization of complications
[9] . These are affected by patient compliance, which
is the extent to which a persons behavior coincides
with medical or other health care regimen. Clinical
experience indicates that no improvement of met-
abolic control is possible without patient compli-
212
ance. Thus, despite the availability of effective
methods of treatment, 50% of diabetic patients fail
to achieve satisfactory glycemic control, which
leads to accelerated development of complications
and increased mortality [10] .
Patient's compliance can be measured by the
accuracy, regularity and willingness he/she dem-
onstrates in execution of the prescribed therapeutic
regimen in terms of taking medications, following
diet, keeping appointments, and executing other
lifestyle changes [11] . Many causes may underlie
poor compliance. These include forgetfulness, poor
rapport with physician, few symptoms, concomitant
chronic illness, perceived lack of effect, real or
perceived side-effects, unclear instructions or
purpose of treatment. They may also involve phys-
ical difficulties such as opening medicine contain-
ers, handling small tablets, swallowing difficulties,
and travel to place of treatment [12] .
Although WHO recently recorded priority status
to diabetes mellitus, many public health planners
remain largely unaware of its magnitude and the
seriousness of its complications. Of equal conse-
quence, there are increasing prevalence rates of
the disease and its long-term costs for both patients
and the health sector [2] .
Significance of the study:
Diabetes mellitus is a chronic illness requiring
a lifetime of special self-management behavior.
Because diet, physical exercise, and physical and
emotional stress can affect diabetic control, patients
must learn to balance these factors. Diabetic patients
must learn daily self-care skills to avoid fluctuations
in blood glucose levels. They must be knowledge-
able about nutrition, exercise, preventive strategies,
and medication adjustment. Given the increasing
incidence of DM, its chronic nature with no cure,
and the associated potential complications, the
purpose of this study is assess factors affecting
compliance of diabetic patients toward therapeutic
management and providing guidelines for the pa-
tients to improve their compliance toward thera-
peutic management.
Aim of the study:
The aim of this study is to assess factors affect-
ing compliance of diabetic patients toward thera-
peutic management and providing guidelines for
the patients to improve their compliance toward
therapeutic management. The research questions
are; what are the factors affecting compliance of
diabetic patients? Is there any relationship between
diabetic complications and patient compliance?
Factors Affecting Compliance of Diabetic Patients
Subjects and Methods
Study design: A descriptive correlational design
was used to conduct this study.
Setting: The study was conducted at the outpa-
tient clinics in Zagazig University Hospital from
Sep. 2008 - Feb. 2009.
Subjects: A convenience sample of 80 patients
with type-2 diabetes mellitus was recruited from
the study. The sample included 23 males and 57
females from the outpatient clinics. The only in-
clusion criterion was being diagnosed as having
type-2 diabetes for at least one year.
Tools for data collection: An interview ques-
tionnaire sheet was used. It consisted of five parts.
The first part was concerned with patients' socio-
demographic data as age, sex, marital status,
educational status, residence, occupation, and
monthly income. It also included details of the
diabetes disease such as duration, mode of dis-
covery, symptoms, and history of complications.
The second part included 27 multiple choice and
open ended questions about knowledge regarding
diabetes, complications, and different manage-
ment strategies. For each item, a correct response
was scored 1 and the incorrect zero. The scores
were summed-up and the total divided by the
number of the items, giving a mean score for the
part. These scores were converted into a percent
score, and means and standard deviations were
computed. Knowledge was considered satisfactory
if the percent score was 50% or more and unsat-
isfactory if less than 50%.
The third part was composed of 31 multiple
choice and open ended questions to determine
patients' compliance to different regimens as self-
care, medication, exercise, follow-up, and self-
testing. The items reported to be done were scored
1 and the items not done were scored 0. For
each area, the scores of the items were summed-
up and the total divided by the number of the
items, giving a mean score for the part. These
scores were converted into a percent score. The
compliance was considered adequate if the percent
score was 60% or more and inadequate if less
than 60%.
The fourth part was intended to identify the
barriers to the compliance. It included four ques-
tions to determine the factors (physical, psycho-
logical, financial, or lack of knowledge) that the
Nadia M. Taha, et al.
patient considered as barriers to compliance to
different treatment regimens including diet, ex-
ercise, medication use, and monitoring blood
glucose level.
The fifth part was for recording patient's weight,
height, and the results of random blood glucose
test.
The study tool was developed by the research-
ers. Its content validity was established by a panel
of five experts in medical-surgical nursing who
reviewed the instrument for clarity, relevance,
comprehensiveness, understandability, applicability,
and ease for administration. Minor modifications
were required. The tool was then pilot-tested on
15 patients from the study settings to test its appli-
cability and determine the time needed for its
filling. According to the answers and comments
of the patients, the researchers modified some of
the questions. The time needed to fill the form
ranged between 30 and 45 minutes according to
patient's condition and level of understanding.
Field work: An official permission was obtained
from the Director of outpatient clinics in Zagazig
University Hospital to facilitate data collection. A
sample of 80 patients was recruited during the
period from September 2008 till the end of February
2009. The aim of the study and components of the
tools were explained to the patients before the
beginning of data collection to obtain their verbal
consent to participate. They were assured that the
information collected would be treated confiden-
tially and would be used only for the purpose of
the study. After completing the interview, assess-
ment of the health status was done through mea-
suring patient's weight, height. A random blood
sugar test was carried out.
Statistical analysis:
Data entry and statistical analysis were done
using SPSS 14.0 statistical software package.
Qualitative categorical variables were compared
using chi-square test. Whenever the expected values
in one or more of the cells in a 2x2 tables was less
than 5, fisher exact test was used instead. Statistical
significance was considered at p-value <0.05.
Results
Eighty patients participated in this study. As
Table (1) shows, more than two thirds of them
(71.2%) were females, and their age ranged between
30 and 75 years. More than half of the patients
were illiterate (52.5%), unemployed (70.0%), from
213
rural areas (68.8%), and with sufficient income
(63.8%).
Regarding the characteristics of DM, Table (2)
illustrates that in more than two thirds (71.2%) of
the patients, the duration of the disease was five
years or more, with mean SD 9.2 6.6 years.
Diabetes was mostly discovered by symptoms
(66.2%). About two thirds or more of the patients
had symptoms (66.2%), complications (81.3%),
and history of hypo (72.5%) and hyperglycemia
(90.0%). Moreover, only 8.8% of them had normal
body mass index (BMI), and more than half (52.5%)
had elevated random blood sugar.
Table (3) demonstrates that more than half of
the patients (56.3%) had inadequate total compli-
ance to diabetes management. The highest compli-
ance was with follow-up (88.8%), and with hypo
(70.0%) and hyperglycemia (73.8%). On the other
hand, the lowest compliance was with self-care
activities (17.5%), and self-testing (36.3%). Pa-
tients' knowledge about diabetes was even lower,
with only 28.8% reaching satisfactory level.
A description of the barriers to compliance
reported by patients is presented in Table (4). It
indicates that most barriers were related to inves-
tigations and medications. The most commonly
reported category of barriers were the physical
ones regarding diet (31.3%), medication (68.8%),
and exercise (55.0%). As for investigations, the
most commonly reported barrier was the financial
one (75.0%).
Table (5) displays the relation between patients'
compliance and their socio-demographic charac-
teristics. It can be noticed that the only relation of
statistical significance was with income (p=0.04).
It is evident that more than half of the patients
with sufficient income had adequate compliance
(58.6%), compared to 35.3% of those with sufficient
income.
Table (6) points to statistically significant re-
lations between patients' compliance and their
disease discovery mode (p=0.02), history of hy-
poglycemia (p=0.005), hyperglycemia (p=0.008),
as well as their perception of barriers related to
diet (p=0.006), and their knowledge (p=0.003). As
indicated in the table, compliance was higher
among those discovered by symptoms, those with
positive history of hypo or hyperglycemia, and
with satisfactory knowledge. On the other had, the
compliance was lower among those who had bar-
riers related to diet.
214 Factors Affecting Compliance of Diabetic Patients

Table (1): Socio-demographic characteristics of patients in Table (3): Compliance to diabetes management and knowledge
the study sample (n=80). among patients in the study sample (n=80).

Items Frequency Percent Items Frequency Percent

Age (years): Compliance with therapeutic

<50 34 42.5
plans regarding:
50+ 46 57.5
Range 30.0-75.0 Hypoglycemia 56 70.0
Mean SD 51.0 10.0
Hyperglycemia 59 73.8
Sex:
Investigations (self-testing) 29 36.3
Male 23 28.8
Female 57 71.2 Medications intake 42 52.5
Marital status: Self-care activities 14 17.5
Single 18 22.5
Married 62 77.5 Follow-up 71 88.8

Residence: Total compliance:

Urban 25 31.2
Rural 55 68.8 Adequate 35 43.7

Education: Inadequate 45 56.3

Illiterate 42 52.5
Educated 38 47.5 Total knowledge:
Secondary 25 31.2 Satisfactory 23 28.8
University 13 16.3
Unsatisfactory 57 71.2
Job status:
Unemployed 56 70.0
Working 24 30.0 Table (4): Barriers to compliance to diabetes management
among patients in the study sample (n=80).
Income:
Sufficient 51 63.8 Barriers to compliance with: Frequency Percent
Insufficient 29 36.2
Diet:
Table (2): Characteristics of diabetic illness among patients None 20 25.0
in the study sample (n=80). Financial 5 6.2
Items Frequency Percent Physical 25 31.3
Psychological 16 20.0
Duration of DM (years):
<5 23 28.8 Lack of knowledge 14 17.5
5+ 57 71.2
Medication:
Range 1-30
MeanSD 9.26.6 None 7 8.8
Financial 1 1.2
Discovery mode:
By symptoms 53 66.2 Physical 55 68.8
By chance 27 33.8 Psychological 15 18.7
Lack of knowledge 2 2.5
Have:
Symptoms 53 66.2 Investigations:
Complications 65 81.3
None 5 6.3
Positive history of hypoglycemia 58 72.5
Positive history of hyperglycemia 72 90.0 Financial 60 75.0
Physical 15 18.7
BMI:
Normal (<25) 7 8.8 Exercise:
Overweight (25-<30) 23 28.7 11.2
None 9
Obese (30+) 50 62.5
Financial 5 6.3
Random blood sugar: Physical 44 55.0
<200 38 47.5
Psychological 22 27.5
200+ 42 52.5
Nadia M. Taha, et al. 215

Table (5): Relation between patients' compliance and their socio-demographic characteristics.
Compliance
X2
Adequate Inadequate p-value
Test
No. % No. %
Age (years):
<50 14 41.2 20 58.8
50+ 21 45.7 25 54.3 0.16 0.69
Sex:
Male 9 39.1 14 60.9
Female 26 45.6 31 54.4 0.28 0.60
Marital status:
Single 8 44.4 10 55.6
Married 27 43.5 35 56.5 0.00 0.95
Residence:
Urban 12 48.0 13 52.0
Rural 23 41.8 32 58.2 0.27 0.61
Education:
Illiterate 17 40.5 25 59.5
Educated 18 47.4 20 52.6 0.39 0.53
Job status:
Unemployed 22 39.3 34 60.7
Working 13 54.2 11 45.8 1.51 0.22
Income:
Sufficient 18 35.3 33 64.7
Insufficient 17 58.6 12 41.4 4.09 0.04*
(*) Statistically significant at p<0.05.

Table (6): Relation between patients' compliance and their disease characteristics, perception
of barriers, and knowledge.
Compliance
X2
Adequate Inadequate p-value
Test
No. % No. %
Duration of DM (years):
<5 8 34.8 15 65.2
5+ 27 47.4 30 52.6 1.05 0.30
Discovery mode:
By symptoms 28 52.8 25 47.2
By chance 7 25.9 20 74.1 5.26 0.02*
Have complications:
No 6 40.0 9 60.0
Yes 29 44.6 36 55.4 0.11 0.75
History of hypoglycemia:
No 4 18.2 18 81.8
Yes 31 53.4 27 46.6 8.06 0.005*
History of hyperglycemia:
No 0 0.0 8 100.0
Yes 35 48.6 37 51.4 Fisher 0.008*
Barriers related to diet:
No 14 70.0 6 30.0
Yes 21 35.0 39 65.0 7.47 0.006*
Barriers related to medication:
No 3 42.9 4 57.1
Yes 32 43.8 41 56.2 Fisher 1.00
Barriers related to investigations:
No 2 40.0 3 60.0
Yes 33 44.0 42 56.0 Fisher 1.00
Barriers related to exercise:
No 4 44.4 5 55.6
Yes 31 43.7 40 56.3 Fisher 1.00
Total knowledge:
Satisfactory 16 69.6 7 30.4
Unsatisfactory 19 33.3 38 66.7 8.74 0.003*
(*) Statistically significant at p<0.05.
216
Discussion
The findings of the current study pointed out
to the low level of adequate compliance among
diabetic patients, with many physical and financial
barriers. Their compliance is related to their income,
mode of discovery of the disease, history of hypo
or hyperglycemia, diet-related barriers, and level
of knowledge about the disease. This low compli-
ance was reflected on the lack of control of diabetes
among them as implied by the high percentages of
complications, obesity, and high random blood
sugar levels.
The compliance of the patients in the present
study was very variable. It was high in certain
areas as follow-up, hypoglycemia and hyperglyce-
mia. The high compliance to follow-up is certainly
attributed to obtaining the medications from the
study setting. On the contrary, their compliance
with self-care activities as diet, exercise, and per-
forming self-testing was low. This reflects a low
level of health behavior, which is expected in a
sample of patients with high percentage of illiteracy.
In accordance with this, Rena, et al. [13] and
Sweileh, et al. [14] confirmed that illiteracy does
negatively affect diabetic patients knowledge and
compliance. Similarly, Abdel Hamid [15] reported
that the educated patients usually pay more attention
to follow the best lifestyle by selecting healthy
food and maintaining physical activity. Further-
more, Hassanein [16] found that the majority of
studied diabetic patients were not performing urine
self-testing as in the present study.
The barriers identified in the current study were
mostly physical and financial ones. The physical
ones were related to diet, exercise, and medications.
These barriers are commensurate with the generally
low socio-economic characteristics of the patients
in the study sample, where most of them were
illiterate, unemployed, and from rural areas. They
may perceive more difficulties in following dietary
and medication regimens for a long-term disease
as DM. Meanwhile, the barrier that had the most
significant impact on compliance of the patients
in the present study was that related to diet. In
congruence with these findings, dietary adherence
has been consistently viewed as the most difficult
aspect of the diabetes regimen Toljamo and Hen-
tinen, [9] . On the same line, O'Rahilly [17] high-
lighted that patient's compliance and subsequent
glycemic control are markedly influenced by bar-
riers related to dietary habits, lifestyle, and treat-
ment regimens.
Also, the fact that more than two thirds of the
present study sample are women and from rural
Factors Affecting Compliance of Diabetic Patients
areas may explain the high perception of physical
barriers related to exercise, as they may find more
difficulties in walking, running or swimming. They
may also perceive house chores as an alternative
of true physical exercise as reported by Ross, et
al. [18] and Elaine, et al. [19] . Additionally, the great
majority of them were either overweight or obese,
which could be an outcome of lack of exercise, or
a factor discouraging exercise. In agreement with
this, Jin J., et al. [20] found that patients with high
BMI scored lower in their perceived compliance
to self-care and self-care abilities, and were more
likely to perceive physical disabilities and barriers
to exercise.
The only factor that constituted a financial
barrier to patients' compliance in the current study
was that of investigations. The majority of them
perceived this barrier, which might be attributed
to the high cost of such investigations that might
not be available at the study setting. The cost of
investigations was found to be an important com-
ponent of the direct costs of care for diabetic
patients [21] . Therefore, home monitoring of blood
glucose with proper diabetes education was rec-
ommended as a cost-effective approach in devel-
oping countries such as Bangladesh [22] .
According to the present study findings, patients
with insufficient income tended to be less compliant
to diabetic management, compared to those with
sufficient income. This might be explained by the
fact that higher income patients have more potential
to consume more food, especially sweets and can-
dies; such items may not be available to those with
insufficient income. In support of this explanation,
studies demonstrated a positive relation between
obesity and socio-economic level (Moore, et al.,
[23,24] ). Moreover, Teresa, et al. [25] mentioned
that people with higher socioeconomic levels are
more likely to develop type-2 diabetes.
The present study also demonstrated that a
positive history of hypo or hyperglycemia had a
positive influence on patients' compliance. This
might be explained by that such experience is
dreadful to the patient so that he/she would do
anything to avoid its recurrence. This is further
confirmed by the finding that patients' compliance
was generally high regarding the guidelines related
to hypo and hyperglycemia.
Knowledge was also found to be positively
related to patient's compliance to diabetes manage-
ment. This is quite plausible since the lack of infor-
mation is a major factor underlying lack of com-
pliance. In agreement with this, Shah, et al. [26]
Nadia M. Taha, et al.
found that higher knowledge scores in a group of
type-2 diabetic patients was associated with better
glycemic control. On the same line, Aslam and
Habib [27] emphasized that DM is a disease that
requires continuing medical care and education to
prevent or reduce the risk of long-term complica-
tions.
Conclusion and Recommendations:
The results drawn from this study lead to the
conclusion that most type-2 diabetic patients in
the study setting have inadequate compliance and
unsatisfactory knowledge regarding management
of DM. Compliance is influenced by patients'
income, disease characteristics, perceived barriers,
as well as knowledge. The low compliance is
reflected in high prevalence of obesity, DM com-
plications, and high blood sugar levels. Therefore,
patient compliance needs to be improved through
patient teaching program especially targeting vul-
nerable diabetic patients and their families. Addi-
tionally, the barriers perceived by these patients
need to be addressed, especially the costs of inves-
tigations, and the physical barriers related to diet
and exercise. Further researches are needed to
develop and refine interventions to improve com-
pliance of diabetic patients and to assess the effec-
tiveness of removing perceived barriers on their
compliance.
References
1- American Diabetes Association: Diagnosis and classifi-
cation of diabetes mellitus, Diabetes Care, 30 (1): S42-
7, 2007.
2- OUSSAMA M.N.: Guidelines for the Prevention, Man-
agement and Care of Diabetes Mellitus. WHO Regional
Office for the Eastern Mediterranean. Diabetes Care, 28
(suppl. 1): 114-20, 2006.
3- NORRIS S., LAU J. and SMITH S.: Self Management
Education for Adults with Type 2 Diabetes. Diabetes Care,
25: 1159-71, 2002.
4- WILD S., ROGLIC G. and GREEN A.: Global prevalence
of diabetes, estimates for the year and projections for
2030. Diabetes Care, 27: 1047-53, 2004.
5- WHO: International Diabetes Federation, Definition and
Diagnosis of Diabetes Mellitus and Intermediate Hyper-
glycaemia. Available at: http://www.who.int/diabetes/
publications/en/, 2006.
6- WHO: "Definition, diagnosis and classification of diabetes
mellitus and its complications: Report of a WHO Consul-
tation. Part 1. Diagnosis and classification of diabetes
mellitus". Available at: http://www.who.int/diabetes/
publications/en/, 2007.
7- BARKER C.R.: Pediatric Primary Care, Ill Child Care.
Philadelphia: Awolters Kluwer Co., pp. 273-88, 2001.
8- GARG S., ZISSER H. and SCHWARTZ S.: Improvement
in Glycemic Excursions with a Transcutaneous, Real-
217
Time Continuous Glucose Sensor: A Randomized Con-
trolled Trial. Diabetes Care, 29: 44-50, 2006.
9- TOLJAMO M. and HENTINEN M.: Adherence to Self
Care and Social Support. Journal of Clinical Nursing, 10
(5): 618-27, 2001.
10- KARDAS P.: Effect of Dosing Frequency of Oral Antidi-
abetic Agents on the Compliance and Biochemical Control
of Type 2 Diabetes. Diabetes Obes. Metab, (7): 722-8,
2005.
11- SOLIMAN H.: Barriers of Compliance among Hyperten-
sive Patients to the Prescribed Therapeutic Regimen.
Unpublished Thesis, Mater Degree. Faculty of Nursing,
Cairo University, 2003.
12- CARACENI, FAINSINGER and FOLEY: Palliative Nurs-
ing, 1 st ed ., Saunders Elsevier Co., pp. 1083-106, 2009.
13- RENA R., MICHAEL G. and LEANN L.: Behavioral
Science Research in Diabetes Lifestyle Changes Related
to Obesity, Eating Behavior and Physical Activity. Diabetes
Care, 24: 117-23, 2001.
14- SWEILEH W.M., AKER O. and HAMOOZ S.: Rate of
Compliance among Patients with Diabetes Mellitus and
Hypertension, College of Pharmacy. Ministry of Health.
Nablus Palestine. An-Najah Univ. J. Res. (N.Sc.), 19: 1-
12, 2005.
15- ABD EL-HAMID S.H.: Self Care Practice among Home
Based Diabetic Elderly in Dakahlia Governorate. Master
Thesis, Alexandria: University of Alexandria, Faculty of
Nursing, 2005.
16- HASSANEIN A.A.: Compliance to Treatment Regimen
among Insulin Dependent diabetic patients, Unpublished
Master Thesis Faculty of Nursing, Zagazig University,
pp. 105-18, 2003.
17- O'RAHILLY S., BARROSO I. and WAREHAM N.:
Genetic Factors in Type 2 Diabetes: The End of the
Beginning? Science, 307: 370-3, 2005.
18- ROSS R., IAN JANSSEN T., JODY D., ANN-M C.,
JENNIFER L., SUZY L., THANH B., SOJUNG L.K.,
KILPATRIC K. and ROBERT H.: Exercise-Induced
Reduction in Obesity and Insulin Resistance in Women:
A Randomized Controlled Trial. Obesity Research, 12:
789-98, 2007.
19- ELAINE H., MORRATO O., JAMES O., HOLLY R. and
PATRICK SULLIVAN W.: Physical Activity in U.S.
Adults with Diabetes and at Risk for Developing Diabetes.
Diabetes Care, 30: 303-4, 2007.
20- JIN J., EDWARD G.S., MINV.S. and CHUEN S.L.:
Factors affecting therapeutic compliance: A review from
the patients perspective. There Clin Risk Manag. 2008
February, 4 (1): 269-86. Published online 2008 February,
2008.
21- RIEWPAIBOON A., PORNLERTWADEE P. and PONG-
SAWAT K.: Diabetes cost model of a hospital in Thailand.
Value Health., 10 (4): 223-30, 2007.
22- KIBRIYA M.G., ALI L., BANIK N.G. and KHAN A.K.:
Home monitoring of blood glucose (HMBG) in Type-2
diabetes mellitus in a developing country. Diabetes Res.
Clin. Pract., 46 (3): 253-7, 1999.
218 Factors Affecting Compliance of Diabetic Patients

23- MOORE S., HALL J.N., HARPER S. and LYNCH J.W.: Overall Diet Quality and Risk of Type 2 Diabetes in
Global and national socioeconomic disparities in obesity, Women. Diabetes Care, 30: 1753-7, 2007.
overweight, and underweight status. J. Obes., 2010 (pii):
26- SHAH J.H., MURATA G.H., DUCKWORTH W.C.,
514-674, www.mcbi.mlm.nih.gov/pubmed, 2010.
HOFFMAN R.M., and WENDEL C.S.: Factors Affecting
Compliance in Type 2 Diabetic Patients: Experience from
24- REHKOPF D.H., LARAIA B.A., SEGAL M., BRAITH-
the Diabetes Outcomes in Veterans Study (DOVES) Int.
WAITE D., and EPEL E.: The relative importance of
J. Diab. Dev. Ctries. Southern Arizona VA Health Care
predictors of body mass index change, overweight and System (JHS & CSW), 23 (Issue 3): 75-82, 2003.
obesity in adolescent girls. Int. J. Pediatr. Obes., 2011.
27- ASLAM M. and HABIB S.S.: Risk factors and health
25- TERESA T., FUNG S., MARJORIE M., CULLOUGH status in diabetic patients. Saudi Med. Journal, 24 (11):
S., ROB M., and FRANK B.: A Prospective Study of 1219-24, 2003.