216 J Contemp Med Sci | Vol. 8, No. 4, July-August 2022: 216–219 Original Knowledge and Practice of Physicians About Vitamin B12 Deficiency among Type 2 Diabetes Mellitus Patients in Buraidah, Saudi Arabia Fahad Alruamaykhani*, Unaib Rabbani Family Medicine Academy, Qassim Health Cluster, Buraidah, Saudi Arabia. *Correspondence to: Fahad Alruamaykhani (E-mail: fahad.r.m.k@gmail.com) (Submitted: 13 April 2022 – Revised version received: 08 May 2022 – Accepted: 25 May 2022 – Published online: 26 August 2022) Abstract Objectives: To assess knowledge and practice of physicians regarding Vitamin B12 Screening among Type 2 diabetes mellitus (T2DM) and assess knowledge of physicians about recent American diabetic association (ADA) guidelines updates. Methods: A cross sectional study was conducted at Primary Health Care (PHC) centers in Buraidah, Qassim from January to April 2022. Data was collected using a structured questionnaire which was based on ADA guidelines among all physicians of PHCs. Statistical package for social sciences (SPSS) version 23.0 was used for analysis. Frequencies and percentages were calculated for categorical variables and means with standard deviations were calculated for continuous variables. Results: About 135 (72.2%) physicians would test T2DM patients who are on metformin for Vitamin B12, and only 65 (34.8) would test them annually. Early signs of Diabetic peripheral neuropathy (DPN) are pain, burning sensation, tangling sensation, numbness and loss of protective sensation (LOPS). Only 23 (12.3%) of them knew the all five symptoms. Forty-five (45.5%) of participants would not treat DPN with B12 supplementation. Only (57.2%) order Vit B12 testing for DM2 who are on metformin, and (49.2%), (29.4%) would order them if the patient has neuropathy and on annual basis respectively. Majority of physicians (70.6%) give Vit B12 supplements as treatment of DPN. Conclusion: There is poor knowledge and practices related to B12 deficiency among primary care physicians. This calls for training and educating primary care physicians regarding B12 deficiency screening, neuropathy and their management. There is also need for providing sufficient resources in order to ensure B12 screening in high risk diabetic patients. Keywords: Primary care, B12 screening, B12 supplementation, diabetics, Saudi Arabia ISSN 2413-0516 Background Type 2 Diabetes Mellitus (T2DM) is a major problem world- wide. Its prevalence increasing globally, including Saudi Arabia.1 The World Health Organization (WHO) has reported that Saudi Arabia ranks the second highest in the Middle East, and is seventh in the world for the rate of diabetes. It is esti- mated that around 7 million of the population are diabetic and almost around 3 million have pre-diabetes.2 One of the corner stone medications used for T2DM is Metformin; which is reported to be associated with Vitamin B12 deficiency up to 30% among patients who are in long term Metformin treatment.3–6 A recent report from the Diabetes Prevention Program Outcomes Study (DPPOS) suggesting periodic testing of vitamin B12.7 Long‐term metformin therapy is significantly associated with lower serum vitamin B12 concentration, yet those at risk are often not monitored for B12 deficiency. Prescription of Vitamin B12 supplementation is common practice in physi- cians for diabetics who are on metformin without solid evi- dence of Vitamin B12 levels. A research about the association of metformin use with vitamin B12 deficiency and peripheral neuropathy in Saudi individuals with type 2 diabetes mellitus, found that the prev- alence of B12 deficiency was 7.8% overall, but the B12 defi- ciency was 9.4% and 2.2% in metformin users and non-metformin users, respectively.8 A meta-analysis done 2014, six randomized controlled trials concluded that B12 concentration was significantly lower in metformin users compared to those on placebo (mean difference [MD], –53.93 pmol/L; 95% confidence interval [CI], –81.44 to –26.42 pmol/L, P = 0.0001).9 Testing for levels of and prescription of B12 supplementa- tion have been found to be varying and discordant. A study published in 2017 in Atlanta, Georgia reported that, only 37% of older adults with diabetes receiving metformin were tested for vitamin B12 status after long‐term metformin prescrip- tion.10 Another study conducted in Riyadh 2019 found that among 57.9% of diabetics who were on vitamin B12 supple- mentation, and only 4.4% had available serum vitamin B12 levels. Among physicians 39% do not know about the current ADA recommendation, whereas 17% have no idea about the recommendations.11 There is limited evidence on prescription of B12 screening and supplementation for diabetic patients by physicians in Saudi Arabia. This study therefore aimed to assess knowledge and practice of physicians regarding Vitamin B12 Screening among T2DM and assess Knowledge of physicians about recent ADA guidelines updates. Methodology This cross-sectional study was conducted among physicians working in Primary Health Care (PHC) centers in Buraidah city January to April 2022. Targeted participants were all phy- sicians in PHCs. There are about 40 functional PHC centers in Buraidah and there are 204 physicians working in those PHC centers including family medicine trainees and trainers. Given the limited population of physicians, we included all the primary care physicians who were working in PHC centers of Buraidah for at least one year in our study. We excluded those physicians working in polyclinics in PHC centers and having other specialty. All the eligible physicians were mailto:fahad.r.m.k@gmail.com 217J Contemp Med Sci | Vol. 8, No. 4, July-August 2022: 216–219 F. Alruamaykhani et al. Original Diabetics and B12 Deficiency Management approached in their respective PHC centers and invited to participate in the study. Data was collected using structured questionnaire. The questionnaire was developed based on American Diabetics Association (ADA) guidelines. Questionnaire had three sec- tions. First section included variables related to social and pro- fessional information. Second section assessed the knowledge about vitamin B12 and diabetic Peripheral Neuropathy. Third section was about practice of physician regarding Vitamin B12 screening. After taking permission from the regional director of PHCs, the questionnaire were distributed directly to the phy- sicians by trained data collectors, who were undergraduates medical students. The data was analyzed using Statistical package for social sciences (SPSS) version 23.0. Descriptive analysis was done and calculated frequencies and proportions of categorical var- iables while mean with standard deviations was calculated for continuous variables. Ethical Approval was taken from Qassim Regional Bio- ethics Committee. Informed consent was taken from all par- ticipants and confidentiality was maintained as name and ID of participants was not taken. Approval was also taken from Administration of PHC centers. Results A total of 250 physicians were invited to participate in the study period out of which 187 patients completed the ques- tionnaire (response rate 74.8%). More than half (57.2%) were males. The mean (SD) age was 36.9 (8.55) years. More than half (58.3) of them were Saudis. The professional ranks of the participants were as follows; general practitioners (GPs) 63 (33.7%), residents 61 (32.6%), specialists 44 (23.5%) and con- sultant 19 (10.2%). With mean (SD) experience 9.18 (7.15) years (Table 1). A total of 112 (59.9%) knew that Vitamin B12 Supple- mentation essential to patients who are taking metformin and have B12 deficiency. In terms of routine test for Vit B12, about 135 (72.2%) physicians would test DM2 who are on met- formin, and 65 (34.8) would test them annually. According to ADA 2021 there are five special groups (pregnant or lactating ladies, older adults, vegetarians and people who are on low carb diets) for which multivitamins are recommended. In our sample, 21 (11.2%) were aware of the five groups. Majority of participants (80.2%) knew that Vitamin C and E are not advised for diabetic patients. Early signs of Diabetic peripheral neuropathy (DPN) are pain, burning sensation, tangling sen- sation, numbness and loss of protective sensation (LOPS). Only 23 (12.3%) of them knew the all five symptoms. For- ty-five (45.5%) of participants would not treat DPN with B12 supplementation. More than half of the physicians (50.3%) knew that DMT2 patients on metformin taking larger dosage for long duration, are at higher risk of DPN (Table 2). Regarding the practices of prescription of Vitamin B12 supplement, almost half of participants (48.1%) prescribed B12 supplements for Diabetics who are on metformin, (36.4%) give only to symptomatic patients and (11.8%) would give every DMT2. Of the physicians, only (57.2%) order Vit B12 testing for DMT2 who are on metformin, and (49.2%), (29.4%) would order them if the patient has neuropathy and on annual basis respectively. Seventeen participants (9.1%) prescribe Table 1. Socio-demographic characteristics Variables N (%) Age Mean (SD) 36.9 (8.55) Gender Male Female 107 (57.2) 80 (42.8) Nationality Saudi Non-Saudi 109 (58.3) 78 (41.7) Qualification GP Resident Specialist Consultant 63 (33.7) 61 (32.6) 44 (23.5) 19 (10.2) Experience Mean (SD) 9.18 (7.15) Table 2. Knowledge about B12 deficiency B12 Supplement is required for Every diabetic pt Pts on Metformin Pts with Neuropathy Sx None of the above 8 (4.3) 112 (59.9) 63 (33.7) 4 (2.1) Routine Test for B12 DM T1 DM T2 Both Types IDK 3 (1.6) 135 (72.2) 38 (20.3) 11 (5.9) Routine Test for B12 Every 1 year Every 5 years Every 6 months For symptomatic pts IDK 65 (34.8) 11 (5.9) 4 (2.1) 97 (51.9) 10 (5.3) Indications of MV Supplement One indication Two indications Three indications Four indications Five indications 28 (15.0) 57 (30.5) 58 (31.0) 23 (13.3) 21 (11.2) Vit C and E Supplement are required for DM T1 DM T2 IDK Not advised 1 (0.5) 18 (9.6) 18 (9.6) 150 (80.2) Early signs of DPN One Sign Two Signs Three Signs Four Signs Five Signs 32 (17.1) 44 (23.5) 66 (35.3) 22 (11.8) 23 (12.3) B12 is Treatment of DPN Yes No IDK 96 (51.3) 85 (45.5) 6 (3.2) Metformin related DPN is associated with Longer duration Higher dose Both dose and duration Irrelevant to dose and duration IDK 60 (32.1) 7 (3.7) 94 (50.3) 18 (9.6) 8 (4.3) 218 J Contemp Med Sci | Vol. 8, No. 4, July-August 2022: 216–219 Diabetics and B12 Deficiency Management Original F. Alruamaykhani et al. We found that, in practice 57.2% of the practitioners do routine testing on patients who are on metformin and 49.2%, 29.4% test their patients if they have neuropathy and annually respectively. Compared to the study in Riyadh,11 51.0% order vitamin B12 testing only if they have symptoms of neuropathy and 19.0% routinely order vitamin B12 testing. One explana- tion to the difference in knowledge and practice is lack of resources in PHC settings which may hinder testing of B12 levels. In our study only 12.3% knew the five signs of DPN. This an important finding as this low knowledge of signs of DPN might lead to delay in identification and treatment of DPN. Metformin use has been associated with DPN in prospective study where the prevalence of neuropathy was significantly higher among the patients with low levels of B12.7 This calls for educating primary care physicians regarding the DPN risk factors and sign and symptoms. The study has provided useful information regarding the knowledge and practices of primary care physicians about B12 among diabetic patients. However, there are two limitations should be kept under consideration. First, the knowledge and practices were self-reported and therefore are prone to response bias, as physicians may report better practice then their actual practices. However, we assume this to be of less importance as we ensured complete privacy and anonymity during data collection which would have encouraged respond- ents to give accurate responses. Secondly, this study was con- ducted in one city only, therefore results may not be generalizable to whole region. None the less, this study has provided a base for further research on practices of B12 defi- ciency among diabetic patients. Conclusion This study highlights the fact that there is lack of knowledge about the ADA recommendation by PHC physicians. Routine testing for serum vitamin B12 level is not practiced in our centers. Thus, there is need for doctors involved in the man- agement of diabetes to keep abreast with guidelines and cur- rent recommendations and routinely monitor vitamin B12 levels particularly those who were on long-term use of met- formin and the elderly patients to optimize management of diabetes and its complications. The difference between knowl- edge and practice due to lack of resources in PHC, so we rec- ommend that physicians and managers reach a solution to provide the needed resources. Financial Support and Sponsorship This research did not receive any funding. Conflict of Interest There are no conflicts of interest. Acknowledgment I would like to thank Khalid Alharbi, Ahmad Alshammari, Saif Alshammari, Ghaida Alfarhan, Muath Alharbi, Ahmad Alenezi for helping in data collection for this study.  Table 3. Practice about B12 deficiency I give B12 supplements for Every T2 diabetic pt Pts on Metformin Pts with Neuropathy Sx None of the above 22 (11.8) 90 (48.1) 68 (36.4) 7 (3.7) I Order B12 test for DM T1 DM T2 Both types I don’t order 1 (0.5) 107 (57.2) 26 (13.9) 53 (28.3) I order B12 test Every 1 year Every 5 years Every 6 months For symptomatic pts I don’t order 55 (29.4) 10 (5.3) 6 (3.2) 92 (49.2) 24 (12.89) I give MV for One indication Two indications Three indications Four indications Five indications 35 (18.7) 62 (33.2) 57 (30.5) 16 (8.6) 17 (9.1) I give B12 as treatment for DPN Yes No 132 (70.6) 55 (29.4) Multivitamins to the five recommended groups. Majority of physicians (70.6%) give Vit B12 supplements as treatment of DPN (Table 3). Discussion Type 2 diabetics particularly those on metformin are at risk for metabolically lower levels of vitamin B12. The mechanisms of vitamin B12 deficiency in metformin treatment has not been clear, but the most likely hypothesis is that metformin inter- feres with calcium-dependent membrane action responsible for vitamin B12 intrinsic factor absorption in the terminal ileum.6 In this study we found 59.9% knew that Vit B12 supple- mentation is essential for DMT2 patients who are on met- formin, but only 34.8% knew that it’s recommended to test for it annually. We found only 12.3% knew the 5 signs of DPN. Regarding practice, we found 48.1% of physicians prescribe Vit B12 supplementation for every patient on metformin, but only 29.4% order Vit B12 test on Annual basis. We also found that majority (70.6%) of physicians Give Vit B12 as treatment of DPN. In Previous study11 44.0% of the respondents know the current recommendation of ADA on vitamin B12 screening and supplementation among diabetic patients. 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