The mean HA1C in the current study was 8.8 ± 0.11%. These results agree with a group of studies evaluating HA1C in their patients. A cross-sectional study that included children and adolescents with T1DM visiting the pediatric diabetes clinic at the King Abdulaziz University Hospital (KAUH), Saudi Arabia, reported that glycated hemoglobin (HA1C) level was 8.8% [12]. Also, a Turkish study found that mean hemoglobin A1C level was 8.5 ± 1.6% [13]. Found in multicentered study conducted in Europe, Japan, and the USA that HA1C was 8.6 ± 1.7% (10). A French cross-sectional study which was conducted on children and adolescents with type 1 diabetes found that the mean HA1C was 8.97% [14, 15].
On the other hand, there were some studies which found higher HA1C. Aljabri and Bokhari described HA1C values in a study done in kingdom of Saudi Arabia to be 9.9 ± 2.3% in patients less than 20 years old [16], while Mortensen et al. [17] found that HA1C was 9.1% in Denmark, while another population-based study which was done in Scotland found a value of HA1C to be 9.1% [18].
The current study reported that about quarter of the studied patients were well controlled with HA1C < 7.5, while third of them were moderately controlled with HA1C 7.5–9, and 41.5% were poor controlled with HA1C > 9. Meanwhile Sayed et al. reported that only 31.2% of children and adolescents with T1DM were well controlled in retrospective study that was performed at Jeddah, western Saudi Arabia [19].
During assessment of frequency of SMBG in patients who were compliant on SMBG, it was found that 67.4% of the patients assess blood glucose 3 times per day, while 0.57% assess blood glucose 7 times. None of the patient could afford the financial expense of use of continuous glucose monitoring devices.
Regarding the opinion of the children and their parents about reasons for not achieving good glycemic control and the most influential factors affecting compliance of SMBG, the patients conceded that the cost of strips and glucometers, the fear of pain and injection, psychological frustration, lack of availability of information to deal with high reading, no motivation, and in adequate place to assess SMBG were the main reasons for not practicing regular SMBG. These results agree with a number of other studies found that lack of awareness and cost of glucometers were reported to be the main reasons for not practicing SMBG [20]. Another study reported that specific SMBG information deficits, motivation obstacles, and behavioral skill limitations were identified in a substantial proportion of participants [21]. Non compliance practice of SMBG can be attributed to some causes as the cost of monitoring supplies, lack of diabetes self-management skills, or concerns about the reliability of blood glucose readings [22]. In the same context, Mansour assessed patient opinion for not achieving good glycemic control among a group of patients with HbA1C ≥ 7.30. Some of the patients said that they were unaware of diabetics’ complications. Others reported that strips were not available or could not be used [23].
The factors that influenced SMBG were mainly related to cost, participants’ emotion, and the SMBG process. The barriers identified included are as follows: frustration related to high blood glucose reading, perception that SMBG was only for insulin titration, stigma, fear of needles and pain, cost of test strips and needles, inconvenience, unconducive workplace, and lack of motivation, knowledge, and self-efficacy [24].
In the current study, it was observed that the more the frequency of SMBG daily, the better the HA1C of the patients (p < 0.01). Twenty-eight percent of the patients who assess 3 times daily have HA1C < 7.5, and all patients who assess 6 and 7 times daily have HA1C < 7.5. Our results consistently with a number of studies which found that, more frequent SMBG was significantly associated with better metabolic control. On average, a drop of HA1C of 0.20% for one additional SMBG per day (p < 0.001) could be observed. However, increasing the SMBG frequency above five per day did not result in further improvement of metabolic control (decrease in HA1C). Restricted to the range of 0–5 measurements per day, HA1c decreased by 0.46% per one additional measurement [25].
In another study, a multicenter randomized trial involving subjects on basal–bolus insulin, HA1C ≥ 8.0%, and poorly compliant with SMBG. HA1C levels decreased by about 0.6% in patients who became compliant with SMBG, irrespective of the glucose meter used, while no or only minor changes in HA1C levels were documented in patients who remained not compliant with SMBG during the study [26].
In this study, it was found that adolescent patients aged from 10 to 16 years who have more frequent SMBG and those with less HA1C and less complications have significant better quality of life (p < 0.05). Similarly, Lalić et al. reported that the use of structured SMBG combined with intensive education was associated with clinically significant reductions in HA1C, increased SMBG frequency, and improved quality of life [27]. Also, Vyas et al. reported that the appropriate education and counseling diminish impact of diabetes, improve QOL, and help to achieve desired glycemic (HA1C) level in poorly control T1D patients [28].
