Journal of Diabetes Mellitus, 2017, 7, 294-301

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Knowledge, Attitudes and Practices Survey in

Management of Type 2 Diabetes
by General Practitioners in Dakar

Abdoulaye Leye*, Nafy Ndiaye, Ngoné Diaba Diack, Michel Assane Ndour, Biram Codou Fall,
Yakham Mohamed Leye, Papa Ousseynou Mane

Internal Medicine and Endocrinology Department, Teaching Hospital of Pikine, Dakar, Senegal

How to cite this paper: Leye, A., Ndiaye, Abstract

N., Diack, N.D., Ndour, M.A., Fall, B.C.,
Leye, Y.M. and Mane, P.O. (2017) Know- Introduction: Considering the global burden of diabetes and lack of specialist
ledge, Attitudes and Practices Survey in in diabetology in our subsaharian area, general practitioners (GPs) play a ma-
Management of Type 2 Diabetes by General
jor role as first referent for care of diabetic people. The aim of this work was
Practitioners in Dakar. Journal of Diabetes
Mellitus, 7, 294-301. to describe knowledge, attitudes and practices of GPs related to management
https://doi.org/10.4236/jdm.2017.74024 of type 2 diabetes. Patients and Methods: It was about a transversal and de-
scriptive survey held between July 14, 2015 and November 1st, 2015 in the
Received: October 8, 2017
medical districts and public corporations of health of Dakar in Senegal. Re-
Accepted: November 5, 2017
Published: November 9, 2017
sults: The population of study was made of 107 males and 40 females GPs.
The majority (82.8%) was graduated since less than five years. Hygienic and
Copyright © 2017 by authors and dietetic measures (HDM) were known and commonly recommended by
Scientific Research Publishing Inc.
77.60% of GPs in their daily practice. The caloric intakes were known by
This work is licensed under the Creative
Commons Attribution International
21.1%. The 30 min of physical activity per day three times in the week was ad-
License (CC BY 4.0). vised by 91.20%. Monotherapy with metformine associated with HDM was
http://creativecommons.org/licenses/by/4.0/ prescribed by 76.90%. Bitherapy with metformine and sulfonylureas asso-
Open Access ciated to HDM were prescribed by 39.50%. Concerning insulin therapy,
mixed insulin twice daily associated with rapid insulin before lunch was pre-
scribed by 49.7%. Use of rapid acting insulin with three injections before each
meal was prescribed by 36.10%. Treatment of the other cardiovascular risk
factors was addressed by 97.30%. Smoking cessation was advised by 37.40%.
Use of sweetened drink and intravenous glucose were most adopted in case of
hypoglycemia, and use of glucagon was adopted by 23.10%. To improve the
diabetic retinopathy 61.2% of GPs recommended tight control of other cardi-
ovascular risk factors. Rigorous glycemic control and regular physical activity
were recommended for painful neuropathy beside analgesics. Smoking cessa-
tion was also recommended by 61.90% for that. Against obstructive arterial
disease of the lower extremities, tight control of blood pressure was recom-

DOI: 10.4236/jdm.2017.74024 Nov. 9, 2017 294 Journal of Diabetes Mellitus

 A. Leye et al.

mended by 69.40% Conclusion: It comes out from these results the need for
reinforcing post graduate trainings on diabetes for our GPs. Moreover, there’s
an urgent need to elaborate and disseminate adapted guidelines and recom-
mendations for improving efficient and standardized strategies for day to day
management of type 2 diabetic people in our country.

Keywords
Knowledge, Attitudes, Practices, Diabetes, General Practitioners

1. Introduction
The dramatic increase in diabetes has occurred in all countries, and in rural as
well as urban areas. According to IDF projections [1], an estimate of 415 million
cases (uncertainty interval: 340 - 536 millions) of diabetes among adults aged
20 - 79 years in 220 countries and territories for 2015 was established. For 2040,
it was estimated that 642 million (uncertainty interval: 521 - 829 millions) people
aged 20 - 79 will have diabetes. Diabetes research includes trying to find a cure
for diabetes, improving diabetes medication and diagnostics, and making the
day to day life of people with diabetes easier to lead.
The epidemiological studies conducted in Africa show that the diagnosis of
diabetes is often ignored (2 to 3 cases not diagnosed for each known case). This
situation had been pointed out since first publications on diabetes in Africa [2].
In most case these patients present themselves with one of the complications of
the diabetes already set up as shown in Senegal [3], where there is less than 10
specialists in diabetology for 14 million inhabitants. So, the general practitioners
are the major actors in the global strategy for caring diabetic patients [4]. The
aim of this survey was to evaluate knowledge, attitudes and practices of the gen-
eral doctors on management of type 2 diabetes with specific focus on managing
hyperglycemia, other cardiovascular risk factors and degenerative complications
prevention.

2. Methodology
2.1. Investigation
It was an observational survey, transversal and descriptive nearby GPs of the
medical districts and public establishments of health of the area of Dakar. After
having presented the aims of the study to the persons in charge of structures in
order to obtain their authorization of investigation, a questionnaire was self-
managed with each GP. The investigation was constituted by a questionnaire
form including questions with multiple choices. The questionnaire consisted of 2
parts, a first part on the socio-professional characteristics of the GPs (sex, se-
niority, place of exercise, previous training on diabetes) and a second part re-
lated to knowledges, attitudes and practices in managing of hyperglycemia, de-

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A. Leye et al.

generative complications as well as the associated cardiovascular risk factors.

2.2. Statistical Analysis

The seizure and the data analysis were carried with the software EPI Info version
3.3.2. This software allowed to calculate the frequencies, the means and the
standard deviations.

3. Results
3.1. Socio-Professional Characteristics
On 170 questionnaires delivered, 152 had been recovered. Only 147 question-
naires were exploitable. The population of study consisted of 107 men (72.80%)
and 40 women (27.20%). According to their seniority of exercise, 82.8% were
graduated since less than 5 years. Eighty GPs (54.4%) had received a continuous
medical training on diabetes.

3.2. Knowledge of the Non Insulinic Treatments of Type 2 Diabetes

The main categories of antidiabetic medicines were known, however there were
confusions between molecules, their side-effects and their counter-indications.
Metformin was regarded as sulfonylurea by 28.60% of respondents. Respectively
20 (13.6%), 16 (10.8%) and 14 (9.5%) GPs considered Glibenclamide, Gliclazide
and Glipizide like biguanides. Only 1 GP had recognized Glipizide as part of the
sulfonylureas. Hypoglycemia was regarded as side-effect of the biguanides by
44.90% of GPs and for 35.5% of GPs, the sulfonylureas were providers of diges-
tive disorders. Table 1 summarizes the distribution of the GPs according to their

Table 1. Distribution of the GPs according to their knowledge of the non insulinic treat-
ments of type 2 diabetes.

Number Percentage
Classes of non insulinic drugs
Biguanides 142 96.6%
Sulfonylureas 146 99.3%
Incretin mimetics 7 7.76%
Alpha-glucosidase Inhibitors 96 65.3%
Glinides 118 80.30%
Main side effect of biguanides
Metformin associated lactic acidosis 66 44.9%
Main side effect of sulfonylureas
Hypoglycemia 140 95.2%
Contraindications of sulfonylureas
Pregnancy 91 61.90%
Liver failure 81 55.1%
Contraindications of biguanides
Kidney failure 89 60.5%

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 A. Leye et al.

knowledge of the non insulinic drugs.

3.3. Practices of the GPs for Management of Hyperglycemia for

Type 2 Diabetic Patients
One hundred fourteen GPs (77.6%) recommended the HDM during all treat-
ment long. Seventy-five (51.0%) found that HDM could be enough to normalize
glycaemia for a long time, and 58 GPs (39.5%) considered it as first line treat-
ment.
For initial monotherapy prescription, 34.7% of GPs recommended to start
metformin after failure of HDM and 76.9% considered the possibility to start
Metformin at diagnosis at the same time with HDM. Use of sulphonylureas as
possible monotherapy after failure of HDM was suggested by 11.6% of GPs and
while for 19.0% of them, it was suggested as first line monotherapy at diagnosis
at the same time with HDM. For 39.5% of GPs, the most recommended bithera-
py was association of metformin plus suphonylureas.

3.4. Practices of Insulin Therapy in Type 2 Diabetes by GPs

Insulin was recommended when failure of non insulinic therapeutics was proven
(87.80%) and in case of severe intercurrent infections (76.90%). Fifty-six doctors
(38.10%) prescribed insulin when HbA1c was higher or equal to 9% and 55
among them (37.4%) prescribed it when the fasting blood glucose was higher
than 3 g/L.
After failure of oral hypoglycemic agent, premixed insulin with 2/3 of total
dose administrated in the morning and 1/3 in the evening associated with a fast
acting insulin before lunch, was adopted by 49.7% of GPs.
For 53 GPs (36.10%), the regimen of insulin therapy suggested was rapid act-
ing insulin three time per day, one injection before each meal then.

3.5. Knowledges and Practices of GPs in Management of the

Degenerative Complications of Type 2 Diabetes
– Diabetic retinopathy
One hundred thirty (88.40%) and 98 (66.70%) GPs had respectively recog-
nized the maintenance of optimal glycemic balance and the maintenance of a
stable blood pressure balance as factors to prevent diabetic retinopathy. Thirty-
six doctors (24.50%) were aware of possibility of photocoagulation with laser.
One hundred thirty-five (91.80%) had recognized that fundus examination of
eye as soon as type 2 diabetes is diagnosed and then each year, as well the most
optimal balance of glycaemia could allow an early tracking and the prevention of
the diabetic retinopathy. Ninety GPs (61.20%) had considered that good control
of cardiovascular risk factors could also allow a prevention of diabetic retinopa-
thy retinopathy.
– Diabetic neuropathy
One hundred eight GPs (73.50%) had adopted the antalgic treatment in case
of painful neuropathy. Only 47 (32.00%) and 27 (18.40%) GPs respectively

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A. Leye et al.

adopted the treatment by nerve sedatives and insulin therapy in case of painful
peripheral neuropathy. For the prevention of neuropathy, 138 (93.90%) and 113
(76.90%) had recognized respectively that rigorous glycemic control and regular
physical activity could allow a prevention of diabetic neuropathy. Smoking ces-
sation also was recommended by 91 (61.90%) GPs for this last objective.
– Diabetic kidney disease
Concerning the measures adopted in the event of nephropathy, the mainten-
ance of an optimal glycemic balance and the maintenance of a perfect blood
pressure balance were recognized respectively by 135 (91.80%) and 102 (69.40%)
GPs. For the maintenance of an optimal blood pressure control, the use of Angi-
otensine converting enzyme inhibitors (ACE inhibitors) was more frequently
adopted (49.00% of GPs) than angiotensin receptor blockers (ARBs) (34.70% of
GPs).
One hundred thirty-three GPs (90.50%) and 123 (83.70%) recognized respec-
tively that the strict control of glycaemia and blood pressure could help to pre-
vent diabetic nephropathy. The reduction of food protein intake ration as a way
to prevent diabetic nephropathy, was recommended by 44 (13.60%) GPs.
– Peripheral artery disease
For the drugs used in case of obliterating arteriopathy of the lower limb, anti-
platelet agents were mostly prescribed (81.60% of GPs) followed by arterial va-
sodilators (52.40% of GPs) and statins (46.90% of GPs). Obtaining a good gly-
cemic control and the correction of a dyslipidemia were recommended by re-
spectively 92.50%, and 81.60% of GPs for better management of peripheral ar-
tery disease. Tight control of glycaemia and blood pressure was also recom-
mended by 69.40% of GPs.
– The diabetic foot
One hundred twenty-nine (87.80%) GPs and 122 (83.00%) respectively
adopted optimized insulin therapy and antibiotic therapy by general route. Pre-
vention with tetanus vaccine was recommended by 80.30% of GPs. For the pre-
vention of the diabetic foot, the daily hygiene of feet and the adequate foot
wearing were applied by respectively 140 (95.20%) and 139 (94.60%) of GPs. The
control of glycemic balance was also recognized by 136 (92.50%) GPs.
Other preventive measures had been recommended by 2.7% of GPs
(self-inspection of feet, avoiding the exposure to sources of heat, never tearing
off a scale, avoiding foot lesions).

3.6. Practices of GPs in Management of Other Cardiovascular Risk

Factors
– Hypertension
In first intention, 98 GPs (66.70%) adopted the treatment by ACE inhibitors
of the and 18 GPs (12.20%) proposed associations of antihypertensive drugs. In
second intention, 49 GPs (33.30%) proposed the use of ARBs.
– Dyslipidemia
The majority of GPs (86.40%) recommended statins and 85.70% of them in-

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 A. Leye et al.

dicated diet against dyslipidemia. The maintenance of good glycemic balance

was advocated by 69 GPs (46.9%).
– Obesity
One hundred thirty-six GPs (92.50%) and 101 (68.70%) respectively advised
regular physical-activity and hypocaloric diet for their obese diabetic patients.
Use of hypolipidemic drugs was advised that by 44 GPs (29.90%) for this situa-
tion of obesity
– Smoking
One Hundred thirty GPs (89.10%) advised immediate smoking cessation and
dedicated tobaccologic consultation was advised by 55 (37.40%) GPs.

4. Discussion
Epidemiological studies made in our African areas emphasize on the significant
role of the GPs in the global strategy of managing type 2 diabetic patients be-
cause of lake of medical doctors in general, and diabetologist in particular [4].
However, that should rest on clear and adapted therapeutic recommendations,
taking into account the associated cardiovascular risk factors. It passes by im-
provement of initial university and post-graduate trainings as demonstrated in
Algeria before [5]. Only one half of our GPs had already received a specific post-
graduate training on type 2 diabetes management.
The place of HDM in type 2 diabetes management is overall well-known by
our GPs as in previous similar study in Senegal [6]. Among them, 39.5% put
forward the HDM associated with Metformin as first step of the treatment as
recommended by ADA/EASD position statement [7]. Monotherapy with sul-
phonylureas was seldom prescribed (19.00%). AMAR-AFO Study found that
sulphonylureas were prescribed in 67.8% of monotherapy, including 54.5% for
glimepiride and 13.3% for gliclazide [4]. Only 7.76% of the GPs knew the exis-
tence of the incretin mimetics. This lack of knowledge could be explained by the
absence of continuous medical training leading to lack of update about new the-
rapeutics. Bitherapy combining sulphonylureas and metformine associated with
HDM was prescribed by 39.50% GPs. This rate was higher the one found in Di-
abCare Senegal study [6] in which bitherapy was prescribed only in 10.1% of the
cases in dedicated centers to diabetes care. No other combination of bitherapy
was proposed in our studies. It could be justified by lack of availability and/or
affordability of other hypoglycemic classes (including incretin mimetics, glinides
and glitazone) in our country. As well, fears and barriers for insulin therapy
doesn’t promote bitherapy with metformin and insulin, comparatively to oral
hypoglycemic agents’ combination, as recently recommended in international
guidelines comparatively to previous ones [7] [8] [9].
The majority of GPs prescribed insulin in the event of proven failure of oral
therapeutic (87.80%) and severe intercurrent infections (76.90%).
For all type 2 diabetic people, a comprehensive approach with multiple facets
must be adopted to reduce the cardiovascular risk. Methods for vascular protec-

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A. Leye et al.

tion include lifestyle modification (food mode, weight loss, rise of the physical
activity, weaning of the tobacco) and pharmacological treatments (antiplatelet
agents, statins, ACE inhibitors, ARBs, control of glycaemia and blood pressure)
[7]. The management of these other cardiovascular risk factors was overall well
known by more than 85% of GPs, despite some misconceptions. An efficient use
of international guidelines requires minimal adaptation to our environment and
resources to make it comprehensive as needed in others developing countries
[10].
The broad outlines for management of degenerative complications were
known. However, there was some mix-up like recommendation by 23.10% of
GPs for the use of glucagon in the event of hypoglycemia occurring in type 2 di-
abetes without consideration of the etiology. This fact, as example of misunders-
tanding among others underline the urgent need for implementation of conti-
nuous medical education programs whose benefit has been demonstrated before
elsewhere [11].

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