A comment on Mokabel et al. (2017).

Sir,

The facility-based study by Mokabel et al. (2017) shows that a diabetic educational program was effective in increasing type 2 diabetes mellitus (DM) patients' knowledge of diabetes, adherence to self-care practices, and health outcomes.[1] These findings corroborate evidence from previous studies and draw much-needed attention toward prioritizing the inclusion of therapeutic patient education for effective diabetes management.[2] The following is a comment on an omission in the methodology and certain conclusions drawn by the authors.

The Mokabel's (2017) study should also have described diabetic health education as part of standard treatment regimen which was being explained to the DM patients by healthcare providers such as doctors, nurses, pharmacists, or health educators at baseline before the intervention. Poor diabetes-related knowledge of the DM patients at baseline suggests ineffective delivery of health communication. However, such findings are more likely to be reported from resource-poor settings with a heavy patient load.[3] The creation of an appropriate diabetic education program also requires an understanding of the inadequacies of the existing strategy for patient education together with validation and pretesting of the health educational material for use in the intervention

In the Mokabel's (2017) study, daily foot care is identified as a significant predictor of improved glycemic control. Foot care in diabetes is required for the reduction of the risk of complications such as diabetic foot but that it has a bearing on glycemic control is not biologically plausible. When the relationship between knowledge of diabetes and biomedical outcomes is transferred across different domains of DM-related self-care practices, the result is spurious association or the lack of it.[4] The observed association in the Mokabel's (2017) study is most likely to be the result of the correlation between daily foot care and adherence to other self-care practices such as a healthy diet which has a direct bearing on the patient's glycemic control

The Mokabel's (2017) study did not find any association between patient compliance and their sociodemographic characteristics. Nevertheless, poor socioeconomic status has been previously identified as a factor significantly associated with poor adherence to medication, but this was not assessed by the authors.[5] Similarly, patients with poor knowledge of diabetes often have a low educational background and are illiterate.[3] Moreover, patients with higher education are at a comparatively better advantage of benefitting from the diabetic educational program intervention than those with little education and low literacy. It is, therefore, important to establish from the Mokabel's (2017) study whether there was an improvement in the study outcomes regardless of the educational status of the patients or whether their education influenced the extent of benefit they had from the diabetic program intervention.

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