https://doi.org/10.15218/ejnm.2020.07 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article Physical Activities among Diabetic Patients Attending Diabetic Centers in Kurdistan Region, Iraq ABSTRACT INTRODUCTION Diabetes mellitus is a metabolic disease involving the under production in insulin secretion or action, due to hyperglycemia. When uncontrolled, diabetes mellitus can cause many complications like blindness, renal failure, heart disease, atherosclerosis, and strokes [1]. In addition, exercise and physical activity are the main ways to control blood glucose levels. Exercise can also improve blood circulation, lowers cholesterol and triglyceride levels due to improved muscle tone [2].Nowadays, regu- lar physical activity and exercise enhances body health in a general way and improves quality of life [3]. In type 2 diabetes melli- tus, randomized controlled trials illustrated Background and objective: Physical activity is defined as basic public health for the human body and one of the main treatments for many chronic diseases, especially diabetes melli- tus. The aim of this study to assess the level of physical activity among diabetic patients in Kurdistan and determine the association between levels of physical activity and certain variables of socio-demographic and clinical data. Methods: This cross-sectional study was conducted on 444 diabetes patients in the Kurdi- stan region of Iraq. The data was collected from 20th June to 10th September 2018 through interviews by using a questionnaire checklist. The data was analyzed by using the statistical package for the social sciences program. Results: Nearly half of the participants (49.1%) were middle-aged (36 - 55 years). Majority of them were females (65.1%), married (88.1%) and illiterate (42.3%). Nearly half of them (43.9%) were obese, having high blood glucose levels (76.8%) and half of them (50%) had hypertension. Majority (75.5%) of participants were within high levels of physical activity. A highly significant relationship was found between the level of physical activity and sex (P -value < 0.001), presence other chronic diseases, hypertension and heart disease. There were significant relationships between the body mass index and diagnostic duration of diabetes mellitus with the presence of other chronic diseases, presence hypertension, and heart disease. Conclusion: The majority of diabetic patients had high levels of physical activity, high blood sugar levels, obese, and had many chronic diseases. There was a statistically signifi- cant association between the level of physical activity with some variables of socio- demographic and clinical data. There was a highly significant association between body mass index and diagnostic duration of diabetes mellitus with the presence of other chronic disease. Keywords: Physical Activity; Diabetic Mellitus; Kurdistan Region. Jawdat Mamand Alhagbaker; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. Sideeq Sadir Ali; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. Correspondence: (sideeq.ali@hmu.edu.krd) Bekhal Saber Ahmed; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. 56 Erbil Journal of Nursing & Midwifery Received: 18/9/2019 Accepted: 22/12/2019 Published: 30/5/2020 mailto:sideeq.ali@hmu.edu.krd https://doi.org/10.15218/ejnm.2020.07 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article that physical activity can delay advance- ment of impaired glucose tolerance if com- bined with dietary changes [4]. In spite of this evidence, diabetes organizations very strongly advocate incorporating some level of physical activity in the treatment of dia- betes mellitus [5]. The American Diabetes Association (ADA) Council on Exercise rec- ommended that patients with type 2 dia- betes should perform resistance exercise at least two times per week on the non- consecutive days, but three times a week would be preferred. More ideally, physical activity for patients with type 2 diabetes should incorporate regular aerobic activi- ties [6]. Much of the guidelines about phys- ical activity also applied in patients with type 1 diabetes mellitus. People with type 2 diabetes mellitus should be doing at least 150 min per week of moderate to strong physical activity outside their home at least three days per a week, with no more than two days of consecutive activity [7].Despite groups of diabetes patients (both type 1 and type 2) being afraid that their hyper- glycemia would act as a barrier to perform- ing such physical activity, it is still advised that they are physically active as an im- portant component of their diabetes man- agement [8]. Globally, prevalence of diabe- tes mellitus estimated by World Health Or- ganization (WHO) in 1997 was more than 135 million and expected to increase by the year 2025 by 120% [9]. According to the WHO, prevalence of diabetes mellitus among patients 18 years of age and over was raised; in 1980 it was 4.7% but in 2014 it was 8.5%. According to their estimates, in 2016, diabetes mellitus was considered as the seventh leading cause of death, and estimated 1.6 million persons’ deaths were caused by diabetes mellitus directly [10]. Shaw et al found that the world prevalence of diabetes mellitus among adults (aged 20 –79 years) was 285 million adults (6.4%) in 2010, and will be increased to 439 million (7.7%) by 2030 [11].Prevalence of diabetes increased in all the countries and research- ers noted the role of physical activity among diabetic patients in controlling glu- cose levels and decreasing complications. The researchers intended to assess the lev- els of physical activity and determine the association between levels of physical ac- tivity with socio demographical and clinical data. They also seek to determine the, if any, association between the presence of other diseases with the BMI and diagnostic duration of diabetes mellitus. A cross-sectional study was carried out in the three Diabetes Centers that are availa- ble in the Iraqi Kurdistan Region, namely Layla Qasm Diabetes Center in Erbil City, Diabetes & Endocrine Center in Sulaimania City and Duhok Diabetes Center in Duhok City. Among 88,442 of diabetic patients who were registered in the registrations department of these diabetic centers, 62,767 of them were adults (Erbil 36,325, Sulaimania 3,098 and Duhok 23,344), 444 nonprobability (purposive) adult diabetes patients participated in this study (Erbil 176, Sulaimania 140 and Duhok 128). These diabetic patients were visiting the diabetic centers monthly for their medical checkups. The proportionate of sample size became approximately 400 partici- pants for all three Centers; Erbil, Sulaimani and Duhok were 158, 136 and 106 partici- pants respectively. The sample size was increased to account for a potentially high- er prevalence of diabetes related to undi- agnosed cases in the population. The sam- ple size was estimated and calculated by using the formula for calculating the mini- mum sample size for cross-sectional stud- ies. A sample size of 113 participants was estimated based on having a prevalence of diabetes of 0.08 with a degree of precision of 5% [12]. The inclusion criteria included 57 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2020.07 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article or more days weekly, or 5 or more days of any combination of walking, moderate- intensity or vigorous intensity level activi- ties reaching a minimal total physical activ- ity of at least 600 MET minutes/week, and Category 3; high physical activity level con- ceived as vigorous-intensity activity, at least 3 days reaching a minimal total physi- cal activity of at least 1500 MET-minutes/ week, or 5 or more days of any combina- tion of walking, moderate-intensity or vig- orous intensity activities reaching a mini- mal total physical activity of at least 3000 MET-minutes/week. All of the activities were set apart as IPAQ scoring protocol [13, 14]. The study was carried out from May 1st, 2018 to August 1st, 2019. The da- ta was collected from June 20th to Sep- tember 10th, 2018. Official permission was obtained from the directorates of health from Erbil, Suleimania and Duhok. During the survey, the researchers briefly ex- plained the purpose of the survey, ob- tained verbal consent from each partici- pant, and completed the questionnaire by direct interview. Data was analyzed by the Statistical Package for the Social Sciences (SPSS, version 20). Descriptive and inferen- tial statistics were used in this study with descriptive statistics used for calculating frequencies and percentages of partici- pants. The association between levels of physical activity with the different socio- demographic and clinical characteristics of the participants was assessed by using in- ferential statistics and Chi-Square test. A P value of ≤ 0.05 was considered statistically significant. Table 1 shows the socio-demographic characteristics of diabetic patients. 39.6% of the study participants were in Erbil city. Nearly half of the participants (49.1%) were middle-aged (36 - 55 years old). Ma- jority of the study participants were all diabetic patients who attend the dia- betic center in those Centers that men- tioned above. Patients who refused to par- ticipate and with limited communication wereexcluded. The investigators used the International Physical Activity Question- naire (IPAQ), short form in the survey and data was collected through using the inter- view technique. Part 1: The socio- demographic part, which included data about age, sex, marital status, location of the home, occupational status, and educa- tional level. Part 2: The clinical information part, which included the body mass index (BMI), diagnostic duration of diabetes mellitus, presence of other chronic diseas- es and type of chronic disease. Part 3: The questions of IPAQ short form were about specific types of physical activities during the seven days, under the following four domains: leisure time; domestic and gar- dening; work-related; and transport- related physical activities. Three levels of physical activity were assessed which in- cluded; walking; moderate-intensity activi- ties (e.g., gardening, washing the car or clothes by hand, or bicycling at normal speed); and vigorous-intensity activities (e.g., heavy weightlifting, running or swim- ming). Total physical activity of Metabolic Equivalent Task (MET)-minutes/week = Walking + Moderate + Vigorous MET minutes/week scores. Note: MET scores of 3.3, 4.0 and 8.0 for walking, moderate and vigorous intensity activity, did not reported days per week in which any of walking, moderate and vigorous intensity activity was reported. In regards to these three categories of physical activity, they were defined by IPAQ as Category 1 being low physical activity level, Category 2 being moderate physical activity level including at least 20 minutes of vigorous intensity level activities done per day for 3 or more days per week, or at least 30 minutes of moderate intensity activity per day for five 58 Erbil Journal of Nursing & Midwifery RESULTS https://doi.org/10.15218/ejnm.2020.07 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article diabetes mellitus with some chronic dis- ease and complication of diabetes mellitus. There was a highly significant relationship found between groups diagnostic duration with the presence of heart disease (P-value < 0.001), and high significant relationship found between presence other chronic dis- eases (P-value = 0.001), presence hyper- tension (P-value = 0.007), presence kidney disease (P-value = 0.003), finally, a signifi- cant association was also found with the presence of anemia (P-value = 0.024). 59 Erbil Journal of Nursing & Midwifery female (65.1%). Most of them were mar- ried (88.1%) and from urban areas (83.8%). Finally, 60.6% of them were unemployed and 42.3% of them were illiterate. Table 2 demonstrates the clinical information of the diabetic patients. Around 44% of the diabetic patients were obese and 54.5% were diagnosed between 1 and 9 years duration. Regarding the blood glucose lev- el, majority of the participants (76.8%) had a high blood glucose level. Regarding pres- ence of other diseases, half of them (50%) had hypertension. Table 3 explores the levels of physical activity of diabetic pa- tients with the majority (75.5%) of them being at a high level of physical activity, 15.3% of them were at moderate level of physical activity and 9.2% were at low lev- el of physical activity. Table 4 focuses on the association between socio- demographic data and levels of physical activity of diabetic patients. There was a very high significant association between the sex of patients and the level of physi- cal activity (P-value < 0.001) and another significant association was found between age groups and levels of physical activity with (P-value = 0.032). Table 5 displays the association between some of the clinical information variables with the levels of physical activity. A highly significant rela- tionship was found between levels of physical activities with the presence of other chronic diseases, such as hyperten- sion and heart disease (P-value <0.001). Another significant relationship was found with the presence of retinopathy (P-value = 0.009). Table 6 shows the association between BMI groups with the presence of some chronic disease and complication of diabetes mellitus. There was a highly sig- nificant relationship between BMI with the presence other chronic diseases (P-value =0.002) and presence of hypertension (P- value =0.001).Table 7 shows the relation- ships between duration of diagnoses of Table 1: Socio-demographic characteristics of diabetic patients Socio-demographic Variables N= 444 F (%) Residential area Erbil 176 (39.7) Sulaimania 140 (31.5) Dahuk 128 (28.8) Age Groups 18 - 35 Years Old ( Young Adult ) 20 (4.5) 36 - 55 Years Old (Middle-Aged Adults) 218 (49.1) 56 Years Old and above (Older Adult) 206 (46.4) Sex of Par- ticipants Male 155 (34.9) Female 289 (65.1) Marital Status Married 391 (88.1) Widowed 35 (7.9) Location of Home Urban 372 (83.8) Sub – Urban 53 (11.9) Rural 19 (4.3) Occupation- al Status of Participants Self Employed 44 (9.9) Retired 60 (13.5) Governmental Em- ployee 71 (16) Unemployed 269 (60.6) Educational Status of partici- pants Illiterate 188 (42.3) Can read and write 85 (19.1) Primary School 90 (20.3) Secondary School 36 (8.1) Institute or College 45 (10.1) Total 444 (100 ) https://doi.org/10.15218/ejnm.2020.07 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article 60 Erbil Journal of Nursing & Midwifery Table 2: Medical information of diabetic patients Clinical Information Variables N= 444 F (%) BMI Groups of Participants Under Weight 3 (0.7) Normal Weight 81 (18.2) Over Weight 165 (37.2) Obese 195 (43.9) Diagnostic duration of Diabetes Mellitus 1 - 9 Years 242 (54.5) 10 - 19 Years 154 (34.7) 20 - 29 Years 34 (7.7) 30 - 40 Years 14 (3.2) Level of Blood Glucose Normal level of blood glucose 28 (6.3) Above normal level of blood glucose 75 (16.9) High level of blood glucose 341 (76.8) Presence of other chronic diseases Yes 279 (62.8) No 165 (37.2) Total 444 (100) Type of chronic disease (*N=279) Hypertension 222 (50) Heart disease 109 (24.5) Kidney Disease 45 (10.1) Retinopathy 60 (13.5) Anemia 30 (6.8) Stroke 3 (0.7) Asthma 8 (1.8) Neuropathy 48 (10.8) Table 3: Levels of Physical Activity Physical Activity N= 444 F (%) Low Level of Physical Activity 41 (9.2) Moderate Level of Physical Activity 68 (15.3) High Level of Physical Activity 335 (75.5) Total 444 (100) https://doi.org/10.15218/ejnm.2020.07 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article 61 Erbil Journal of Nursing & Midwifery Table 4: Association between socio-demographic variables and levels of physical activity Clinical Information Variables Sub-groups Levels of physical activity Low Lev- el of Physical Activity (%) Moderate Level of Physical Activity (%) High Level of Physical Activity (%) P-value Age Groups 18 - 35 Years Old ( Young Adult ) (0.5) (0.5) (3.6) 0.032 36 - 55 Years Old (Middle- Aged Adults) (2.5) (7.2) (39.4) 56 Years Old and above (Older Adult) (6.3) (7.7) (32.4) Sex of Participants Male (4.1) (8.3) (22.5) <0.001 Female (5.2) (7.0) (52.9) Widowed (1.4) (1.4) (5.2) Occupational Status of Participants Self Employed (0.2) (2.3) (7.4) 0.395 Retired (1.4) (2.7) (9.5) Governmental Employee (1.6) (2.5) (11.9) Unemployed (6.1) (7.9) (46.6) Educational Status of participants Illiterate (4.5) (4.5) (33.3) 0.484 Can read and write (1.1) (3.4) (14.6) Primary (1.8) (3.6) (14.9) Secondary (0.9) (1.6) (5.6) Institute or College (0.9) (2.3) (7.0) Total (9.2) (15.3) (75.5) https://doi.org/10.15218/ejnm.2020.07 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article 62 Erbil Journal of Nursing & Midwifery Table 5: Association between clinical information and levels of physical activity Levels of physical activity Clinical Information Variables Sub-groups Low Level of Physical Ac- tivity (%) Moderate Level of Physi- cal Activity (%) High Level of Physical Activity (%) P- value BMI Groups of Participants Under Weight (0) (0) (0.7) 0.753 Normal Weight (1.4) (2.3) (14.6) Over Weight (3.6) (5.2) (28.4) Obese (4.3) (7.9) (31.8) Diagnostic Duration of Partici- pants 1 - 9 Years (3.8) (8.6) (42.1) 0.610 10 - 19 Years (4.3) (4.7) (25.7) 20 - 29 Years (0.7) (1.6) (5.4) 30 - 40 Years (0.5) (0.5) (2.3) Did you have Any Other Chronic Diseases Yes (7.9) (11.3) (43.7) <0.001 No (1.4) (4.1) (31.8) Did you have Hypertension No (2.3) (6.1) (41.7) <0.001 Yes (7.0) (9.2) (33.8) Did you have Heart disease No (5.4) (9.7) (60.4) <0.001 Yes (3.8) (5.6) (15.1) Did you have Kidney Disease No (8.1) (14.4) (67.3) 0.432 Yes (1.1) (0.9) (8.1) Did you have Retinopathy No (7.9) (11.5) ( 67.1) 0.009 Yes (1.4) (3.8) (8.3) Did you have Anemia No (8.3) (14.2) (70.7) 0.687 Yes (0.9) (1.1) (4.7) Did you have Stroke No (9.2) (15.1) (75.0) 0.622 Yes (0) (0.2) (0.5) Did you have Neuropathy No (8.1) (13.3) (67.8) 0.723 Yes (1.1) (2.0) (7.7) Normality and abnormality of Blood Sugar Normal level of blood sugar (0.7) (0.7) (3.4) 0.570 Above normal level of blood sugar (0.3) (1.0) (12.9) High level of blood sugar (6.8) (15.0) (59.2) Total (7.8) (16.7) (75.5) https://doi.org/10.15218/ejnm.2020.07 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article 63 Erbil Journal of Nursing & Midwifery Table 6: Association between clinical information and BMI groups Some variable BMI Groups of Participants Under Weight Normal Weight Over Weight Obese P-value (%) (%) (%) (%) Did you have Any Other Chronic Diseases Yes (0) (49.4) (63.0) (69.2) 0.002 No (100) (50.6) (37.0) (30.8) Did you have Hypertension No (100) (64.2) (52.7) (41.0) 0.001 Yes (0) (35.8) (47.3) (59.0) Did you have Heart disease No (100) (82.7) (77.6) (70.3) 0.089 Yes (0) (17.3) (22.4) (29.7) Did you have Kidney Disease No (100) (90.1) (88.5) (90.8) 0.834 Yes (0) (9.9) (11.5) (9.2) Did you have Retinopathy No (100) (88.9) (87.3) (84.6) 0.673 Yes (0) (11.1) (12.7) (15.4) Did you have Anemia No (100) (98.8) (92.1) (91.8) 0.163 Yes (0) (1.2) (7.9) (8.2) Did you have Stroke No (100) (100) (98.8) (99.5) 0.716 Yes (0) (0) (1.2) (0.5) Did you have Neuropathy No (100) (88.9) (88.5) (89.7) 0.081 Yes (0) (11.1) (11.5) (10.3) Table 7: Association between clinical information and group’s diagnostic duration Some variable Diagnostic Duration of Participants 1 - 9 Years 10 - 19 Years 20 - 29 Years 30 - 40 Years P-value (%) (%) (%) (%) Did you have Any Other Chronic Diseases Yes (54.5) (71.4) (76.5) (78.6) 0.001 No (45.5) (28.6) (23.5) (21.4) Did you have Hypertension No (57.0) (44.2) (32.4) (35.7) 0.007 Yes (43.0) (55.8) (67.6) (64.3) Did you have Heart disease No (83.9) (68.2) (55.9) (57.1) <0.001 Yes (16.1) (31.8) (44.1) (42.9) Did you have Kidney Disease No (92.6) (90.3) (76.5) (71.4) 0.003 Yes (7.4) (9.7) (23.5) (28.6) Did you have Retinopathy No (88.8) (85.7) (76.5) (78.6) 0.179 Yes (11.2) (14.3) (23.5) (21.4) Did you have Anemia No (95.9) (91.6) (88.2) (78.6) 0.024 Yes (4.1) (8.4) (11.8) (21.4) Did you have Stroke No (99.2) (99.4) (100) (100) 0.938 Yes (0.8) (0.6) (0) (0) Did you have Neoropathy No (92.6) (85.1) (85.3) (85.7) 0.099 Yes (7.4) (14.9) (14.7) (14.3) https://doi.org/10.15218/ejnm.2020.07 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article 64 Erbil Journal of Nursing & Midwifery Physical inactivity could be a global health problem as most studies focused and dis- cussed leisure time physical activity, while physical activity at work, domestic and amid transport has not been as- sessed [15]. Physical activity in adults with type 2 diabetes significantly increases by interventions of their behavioral [16]. Such activity is linked to improving personal fit- ness and therefore could reduce the com- plications of chronic diseases and disabili- ties preventing an unhealthy weight [3]. The study was assessed by using IPAQ, a suitable instrument and simple measure- ment to assess overall physical activity for diabetic patients. IPAQ also provides information for the best way for control of blood glucose without using prescription drugs. The study determined that most of the study sample had a high level of physi- cal activity. However, the majority of them had other chronic illnesses which further complicated their diabetes symptoms. Moreover, nearly half of them were obese. The reason may be that the majori- ty of them neglected to manage and con- trol their blood glucose because as their blood glucose was high and may have ne- glected taking their medications. This study did not agree with that of Acheam- pong in 2011 which was conducted on 350 diabetic patients in Kumasi, Ghana with more than half of their study sample hav- ing not received formal education at all, and a greater number of these patients not performing any physical exercise [17]. A very high significant relationship was shown between the sex of patients and the level of physical activity as well as be- tween the age groups and the levels of physical activity. This may be due to nearly half the study population being middle aged and the highest level of physical ac- tivity is typically found within this age group. The result agreed with the cross- sectional study conducted on 320 pa- tients with type two diabetes in Hama- dan, Iran; there was a significant (P<0.05) relationship between physical activity level and age group [18], The study was also agreed with a cross- sectional nation-wide study conducted by Sibai et al., 2013 on 2,195 haphazard- ly chosen adults aged 25 years and older in Lebanese governorates. They found in their study that physical activity was sig- nificantly higher among the middle-age group [19].A very high significant associ- ation was found between levels of physi- cal activity and the presence of other chronic diseases, especially with the presence of hypertension and heart dis- ease, as well as with the presence of retinopathy. A high significant associa- tion was found between BMI with the presence of other chronic disease, espe- cially with the presence of hypertension. The reason behind this could be that di- abetes could lead to various complica- tions in the arteries and arterioles mak- ing them more susceptible to developing atherosclerosis. Also, the participants in this study majority of them were obese and high level of blood glucose. The re- sult is similar to the findings of the previ- ous cross-sectional study conducted by Ali et al in determining the prevalence of diabetes mellitus complications among patients in Duhok, Erbil and Suleimania cities of Iraq. Their study showed a sig- nificant association between some dia- betes mellitus complications with demo- graphic variables and showed highly sig- nificant differences in diabetic laborato- ry tests with BMI [9]. In addition, the results of our study were supported by the cross-sectional study conducted in 2009–2010 in Spain by Brugnara et al. In this study, low physical activity especial- ly among women is associated with sev- eral cardiovascular risk factors and could DISCUSSION https://doi.org/10.15218/ejnm.2020.07 Erbil j. nurs. midwifery, Vol. 3, No. (1), May, 2020 Original Article 65 Erbil Journal of Nursing & Midwifery be responsible with an increasing preva- lence of obesity and diabetes [20]. There was a highly significant association found between group’s diagnostic duration with presence of other disease, especially with the presence of heart disease and a high significant association with presence of other chronic diseases, like hypertension, kidney disease, anemia and normality and abnormality of blood sugar. For similar reasons, nearly half of the study group had been diagnosed for diabetes Mellitus be- tween one to nine years ago, but the ma- jority of them had other chronic diseases that indicated diabetes mellitus complica- tions. Nearly half of them were obese and most of them had high blood glucose lev- els. Petrie et al., 2018 reported that diabe- tes and hypertension are closely related together and diabetes is related to an in- creased risk of cardiovascular disease, which is overstated with coexistent hyper- tension [21]. The study was in agreement with the non-experimental, cross-sectional study of Gutierrez et al., (2018) conducted in Tabuk city in Saudi Arabia. In this study, researchers studied 432 participants and the results in their study showed a posi- tive correlation between BMI with hyper- tension and diabetes mellitus (P <0.001); whereas the relationship between hyper- tension and diabetes mellitus was (P <0.001). Thus, this relationship was the strongest correlation observed among those variables [22].In general, the study revealed that the majority of the study group was at a high level of physical activi- ty, while the majority of diabetes patients were overweight and obese, had other chronic diseases, high levels of blood glu- cose, and were illiterate. Not having statis- tically relationships between the levels of physical activity with the majority of the variables may be due to the limitations of the study such as lack of information about factors that controlling blood sugar such as; family history, illness, side effects of steroids or anti-psychotic medication, overconsumption of foods, stress, men- strual periods, pain and dehydration. Al- so, our study only included asking about and not observing the exercise. Patients might not have answered the question correctly or honestly. The study concluded that the physical activity among diabetic patients was high, but because of negligence of other parts of treating diabetes mellitus disease by the patients such as diet and medication, blood sugar remained high, patients re- mained obese and other side effects were present as well. There was a very high significant association between the levels of physical activity and BMI and some side effects, as well as an association be- tween of level of physical activity with the patients’ sex and age. The authors report no conflicts of interest and any sources of financial support. [1] Williams LS, Hopper PD. Understanding Medical-Surgical Nursing. 2nd ed. USA, Philadelphia: F.A. Davis Company Publish- ing; 2003. p. 645-7. [2] Timby BK, Smith NE. Introductory medical- surgical nursing. USA, Philadelphia: 10th ed. Wiley-Blackwell Publishing; 2010. p. 788. [3] Haskell WL, Lee I-M, Pate RR, Powell KE, Blair SN, Franklin BA, et al. 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