Diabetes mellitus (DM) has emerged as one of the foremost public health challenges of the twenty-first century, with the global prevalence rising sharply over the last four decades.^[1] The International Diabetes Federation estimated that approximately 537 million adults were living with diabetes worldwide, a figure projected to increase substantially by 2045, with the greatest relative increase expected in low- and middle-income countries.^[2] India, often described as the “diabetes capital of the world,” bears a disproportionately large share of this burden, with national survey data indicating that more than 100 million Indians are currently living with diabetes or prediabetes.^[3]

Cardiovascular disease (CVD) is the single most important cause of morbidity and mortality among individuals with diabetes, accounting for nearly two-thirds of all deaths in this population.^[4] Diabetes independently accelerates the process of atherosclerosis through a combination of chronic hyperglycaemia, dyslipidaemia, hypertension, endothelial dysfunction, and a pro-inflammatory, pro-thrombotic state.^[5] Consequently, international guidelines, including those of the American Diabetes Association and the European Society of Cardiology, classify diabetes as a cardiovascular risk-equivalent condition, warranting aggressive screening and preventive management from the time of diagnosis.^[6]

Despite the well-established link between diabetes and cardiovascular disease, patient awareness regarding this association remains inconsistent across populations. Studies conducted in various Indian settings have repeatedly demonstrated those substantial gaps in knowledge exist regarding the increased cardiovascular risk conferred by diabetes, the significance of blood pressure and lipid control, and the warning symptoms of acute coronary events.^[7] A community-based study from South India reported that fewer than half of known diabetic patients could correctly identify cardiovascular disease as a common complication of diabetes.^[8] Similarly, data from the Indian Council of Medical Research–India Diabetes (ICMR-INDIAB) study highlighted wide regional variation in diabetes-related knowledge and self-care practices across different states of India.^[9]

Preventive behaviours, including adherence to a heart-healthy diet, regular physical activity, tobacco and alcohol cessation, adherence to prescribed medication, and regular self-monitoring of blood glucose and blood pressure, form the cornerstone of cardiovascular risk reduction in diabetic patients.^[10] However, translating awareness into sustained behaviour change remains a challenge, particularly in resource-constrained settings where patient education during routine outpatient consultations is often limited by time constraints and high patient load.^[11] The Chennai Urban Rural Epidemiology Study (CURES) and other Indian cohort studies have shown that adherence to recommended lifestyle modifications among diabetic patients is frequently suboptimal, with a substantial proportion continuing to report sedentary behaviour, poor dietary compliance, and irregular medication use.^[12]

The consequences of inadequate awareness and poor preventive behaviour are reflected in clinical outcomes. National and regional Indian data indicate that a large proportion of diabetic patients do not achieve recommended targets for glycaemic control, blood pressure, and lipid parameters, thereby remaining at persistently elevated cardiovascular risk.^[13] Poor glycaemic control, in particular, has been consistently associated with an increased incidence of both microvascular and macrovascular complications in longitudinal studies conducted in Indian diabetes clinics.^[14] Furthermore, studies have shown that structured patient education programmes and diabetes self-management education can significantly improve awareness, self-care behaviour, and metabolic outcomes among Indian diabetic populations.^[15]

Given the escalating burden of diabetes and its cardiovascular complications in India, and the demonstrated gaps in patient knowledge and preventive practice reported in prior studies, there is a pressing need to systematically evaluate the current status of cardiovascular risk awareness and preventive behaviour among patients attending routine diabetes care and to examine how these factors relate to measurable clinical outcomes. Such clinic-based data can help identify specific, modifiable gaps that could be targeted through structured education and counselling interventions integrated into everyday diabetes care.

1.1 Objectives of the Study

To assess the level of cardiovascular risk awareness, preventive health behaviours, and their association with clinical and biochemical outcomes among patients with type 2 diabetes mellitus attending a tertiary care diabetes outpatient clinic.

2.1 Study Design and Setting This was a clinic-based, cross-sectional, observational study conducted in the Diabetes Outpatient Clinic of the Department of lnternal Medicine. The study was carried out over a period of twelve months, from June 2025 to May 2026, after obtaining approval from the Ethics Committee. 2.2 Study Population The study population comprised adult patients with a confirmed diagnosis of type 2 diabetes mellitus, diagnosed as per American Diabetes Association criteria, attending the diabetes outpatient clinic during the study period. 2.3 Inclusion Criteria (a) Patients aged 30 years and above; (b) Patients with a confirmed diagnosis of type 2 diabetes mellitus for a duration of at least six months; (c) Patients willing to provide written informed consent and able to communicate in the local language or English. 2.4 Exclusion Criteria (a) Patients with type 1 diabetes mellitus or gestational diabetes; (b) Patients with known severe cognitive impairment or psychiatric illness precluding reliable interview; (c) Patients who were critically ill or unable to participate in a structured interview; (d) Patients who declined consent. 2.5 Sample Size Calculation Assuming an expected prevalence of adequate cardiovascular risk awareness of 45% among diabetic patients based on previous Indian studies,[8] with an absolute precision of 6% and 95% confidence level, the minimum required sample size was calculated using the formula n = Z² × p(1-p)/d², yielding a minimum sample of 264 participants. Anticipating a non-response rate of approximately 15%, the final sample size was rounded up to 320 participants. 2.6 Sampling Technique Participants were enrolled using a consecutive sampling technique, whereby all eligible patients attending the diabetes outpatient clinic on designated study days were approached sequentially until the required sample size was achieved. 2.7 Study Tool and Data Collection Data were collected using a pre-tested, structured, interviewer-administered questionnaire, developed after review of existing validated tools used in similar Indian studies and pilot-tested on 30 patients (excluded from the final analysis) to assess clarity and comprehensibility. The questionnaire comprised four sections: Section A: Socio-demographic details (age, sex, education, occupation, socioeconomic status, residence, family history). Section B: Cardiovascular risk awareness, comprising 12 knowledge-based items covering awareness of diabetes as a cardiovascular risk factor, target blood pressure and lipid levels, warning symptoms of myocardial infarction and stroke, and the importance of regular cardiovascular screening. Each correct response was scored 1 and each incorrect/'do not know' response scored 0; total awareness scores were categorised as poor (0–4), moderate (5–8), and adequate (9–12). Section C: Preventive behaviour, assessing dietary practice, physical activity (as per WHO recommendations of ≥150 minutes of moderate activity per week), tobacco and alcohol use, medication adherence (using a modified Morisky Medication Adherence Scale), and frequency of self-monitoring of blood glucose and blood pressure. Section D: Clinical and biochemical parameters, including anthropometry (height, weight, BMI, waist circumference), blood pressure (measured in a seated position after 5 minutes of rest, mean of two readings), and laboratory investigations (fasting and postprandial plasma glucose, HbA1c, fasting lipid profile) retrieved from hospital laboratory records within the preceding three months. 2.8 Operational Definitions Glycaemic control was considered optimal at HbA1c <7%, as per American Diabetes Association targets.[6] Blood pressure control was defined as systolic blood pressure <140 mmHg and diastolic blood pressure <90 mmHg, consistent with Indian hypertension management guidelines. Dyslipidaemia was defined using National Cholesterol Education Program–Adult Treatment Panel III criteria adapted for the Indian population. 2.9 Statistical Analysis Data were entered in Microsoft Excel and analysed using SPSS software, version 26.0 (IBM Corp.). Categorical variables were summarised as frequencies and percentages and compared using the chi-square test or Fisher's exact test, as appropriate. Continuous variables were expressed as mean ± standard deviation and compared using Student's independent t-test for two groups and one-way ANOVA for more than two groups. Pearson/Spearman correlation was used to assess associations between awareness scores and continuous clinical parameters. A p-value of less than 0.05 was considered statistically significant throughout the analysis. 2.10 Ethical Considerations The study protocol was approved by the Ethics Committee prior to commencement. Written informed consent was obtained from all participants after explaining the study objectives, procedures, and their right to withdraw at any stage without affecting their ongoing clinical care. Confidentiality of patient data was maintained throughout the study, and data were used solely for research purposes.

A total of 320 patients with type 2 diabetes mellitus were enrolled in the study. The mean age of participants was 54.6 ± 10.8 years, and the mean duration of diagnosed diabetes was 7.4 ± 5.1 years. Of the participants, 184 (57.5%) were male and 136 (42.5%) were female.

Table 1: Socio-demographic Characteristics of Study Participants (N = 320)

CVD: Cardiovascular disease.

Regarding cardiovascular risk awareness, the mean awareness score was 6.9 ± 2.7 out of a maximum of 12. Based on the pre-defined categorisation, 61 participants (19.1%) had poor awareness, 126 (39.4%) had moderate awareness, and 133 (41.6%) had adequate awareness of cardiovascular risk associated with diabetes.

Table 2: Distribution of Cardiovascular Risk Awareness Domains among Participants (N = 320)

CV: Cardiovascular; ECG: Electrocardiogram.

On chi-square analysis, adequate cardiovascular risk awareness was significantly associated with higher educational status (p<0.001), urban residence (p=0.012), longer duration of diabetes (p=0.004), and presence of a family history of cardiovascular disease (p=0.008). No statistically significant association was observed between awareness level and sex (p=0.192) or socioeconomic status category (p=0.076).

With regard to preventive behaviour, 148 participants (46.3%) reported following a recommended diabetic/heart-healthy diet, while 122 (38.1%) reported engaging in regular physical activity as per WHO recommendations. Current tobacco use was reported by 58 participants (18.1%) and current alcohol use by 74 (23.1%). Optimal medication adherence, as assessed by the modified Morisky scale, was observed in 196 participants (61.2%). Regular self-monitoring of blood glucose (at least once weekly) was practised by 134 participants (41.9%), and regular home blood pressure monitoring was practised by 101 participants (31.6%).

Table 3: Preventive Health Behaviours among Study Participants (N = 320)

Analysis of clinical and biochemical parameters revealed a mean BMI of 26.4 ± 3.8 kg/m² and mean waist circumference of 93.7 ± 9.4 cm. The mean HbA1c was 8.1 ± 1.6%, and only 108 participants (33.8%) achieved the target HbA1c of <7%. Mean systolic and diastolic blood pressures were 136.8 ± 16.2 mmHg and 84.3 ± 9.7 mmHg respectively, with 127 participants (39.7%) achieving the recommended blood pressure target. Dyslipidaemia, defined as LDL cholesterol ≥100 mg/dL and/or triglycerides ≥150 mg/dL, was present in 208 participants (65.0%).

Table 4: Clinical and Biochemical Profile of Study Participants (N = 320)

SD: Standard deviation.

On stratifying clinical outcomes by cardiovascular risk awareness category, participants with adequate awareness had significantly better glycaemic control, blood pressure control, and lipid profiles compared with those with poor or moderate awareness (Table 5).

Table 5: Association of Cardiovascular Risk Awareness with Clinical Outcomes

Chi-square test applied; p<0.05 considered statistically significant. BP: Blood pressure; LDL: Low-density lipoprotein.

A weak-to-moderate positive correlation was observed between cardiovascular risk awareness score and duration of diabetes education exposure (r=0.42, p<0.001), and a significant negative correlation was found between awareness score and HbA1c level (r=−0.36, p<0.001), indicating that higher awareness was associated with better glycaemic control. On multivariate logistic regression adjusting for age, sex, education, and duration of diabetes, adequate cardiovascular risk awareness remained an independent predictor of achieving glycaemic target (Adjusted Odds Ratio 2.31, 95% CI 1.42–3.76, p=0.001) and blood pressure target (Adjusted Odds Ratio 1.89, 95% CI 1.18–3.03, p=0.008).

The present clinic-based observational study evaluated cardiovascular risk awareness, preventive behaviour, and clinical outcomes among 320 patients with type 2 diabetes mellitus attending a tertiary care diabetes clinic. Only 41.6% of participants demonstrated adequate cardiovascular risk awareness, a finding that is broadly consistent with previous Indian studies reporting suboptimal cardiovascular knowledge among diabetic populations.[8,16] A community-based study from Puducherry similarly reported that fewer than half of diabetic participants were aware of the increased cardiovascular risk associated with their condition, attributing this gap largely to inadequate patient counselling during routine consultations.[16] Comparable findings have also been reported from north Indian tertiary care settings, where structured assessment of diabetes-related knowledge revealed considerable deficits, particularly regarding target blood pressure and lipid values.[17] The observed association between higher educational status and better cardiovascular risk awareness in this study mirrors findings from the ICMR-INDIAB study, which demonstrated a strong gradient of diabetes-related knowledge and self-care practice across educational and socioeconomic strata in India.[9] This underscores the importance of tailoring patient education materials to different literacy levels, using simplified language, regional-language pamphlets, and visual aids, particularly for patients with limited formal education, who constituted nearly a third of the present study population. Preventive behaviour indicators in this study, including dietary adherence (46.3%) and regular physical activity (38.1%), were relatively low, echoing observations from the Chennai Urban Rural Epidemiology Study (CURES), which documented persistently poor adherence to lifestyle recommendations among urban South Indian diabetic patients despite reasonable disease awareness.[12] Medication adherence in the present study (61.2%) was comparatively better, which may reflect the relatively higher proportion of urban, more educated participants in this clinic-based sample; nonetheless, more than one-third of patients continued to demonstrate suboptimal adherence, a pattern also reported in other Indian tertiary-care-based adherence studies.[18] Clinical outcomes in the present cohort were suboptimal, with only 33.8% achieving target HbA1c and 39.7% achieving target blood pressure. These figures are comparable to those reported in a large multicentric Indian registry-based study, which found that fewer than 40% of type 2 diabetic patients achieved glycaemic targets despite regular clinic attendance, highlighting a persistent “knowledge-practice-outcome” gap in routine Indian diabetes care.[19] Similar suboptimal control rates have also been reported from a diabetes clinic-based study conducted in eastern India, which attributed poor control largely to irregular follow-up, cost constraints, and limited structured education.[20] A particularly important finding of the present study was the significant association between cardiovascular risk awareness and favourable clinical outcomes, including better glycaemic control, blood pressure control, and lipid profile, as well as a lower prevalence of prior cardiovascular events among those with adequate awareness. This finding is consistent with international evidence demonstrating that structured diabetes self-management education improves both knowledge and metabolic outcomes.[21] Indian intervention studies have similarly shown that structured group education sessions delivered by trained diabetes educators can significantly improve both cardiovascular risk awareness and short-term glycaemic outcomes among urban and semi-urban diabetic populations.[15,22] The independent association of awareness with glycaemic and blood pressure targets observed on multivariate analysis in the present study further supports the causal plausibility of this relationship, although the cross-sectional design precludes definitive causal inference. The relatively high awareness of smoking as a cardiovascular risk factor (83.8%) alongside comparatively low awareness of target lipid values (30.6%) observed in this study suggests that public health messaging regarding tobacco has been more effective than messaging regarding metabolic risk-factor targets, a pattern also noted in a national survey of non-communicable disease risk-factor awareness conducted under the Indian National NCD Monitoring Framework.[23] This disparity indicates a need for more specific, target-oriented patient counselling regarding blood pressure and lipid goals, rather than generic advice about “heart health,” during routine diabetes consultations. The comparatively low proportion of participants practising regular self-monitoring of blood glucose (41.9%) and home blood pressure monitoring (31.6%) is noteworthy, as self-monitoring has been shown in Indian primary-care-based studies to reinforce adherence and facilitate timely dose titration.[24] Strengthening the availability and affordability of self-monitoring devices, along with structured training on their use, may represent a cost-effective strategy to improve both awareness and outcomes in similar clinic populations. Taken together, these findings reinforce the recommendation made in several Indian diabetes care guidelines that cardiovascular risk assessment and structured patient education should be integrated as a routine component of every diabetes clinic visit, rather than being offered only opportunistically.[25] Task-shifting components of this education to trained nurse educators or community health workers, as demonstrated in pilot programmes in southern India, may help overcome the time constraints faced by physicians in high-volume outpatient clinics.[26] 4.1 Strengths of the Study This study benefits from a reasonably large sample size, use of a structured and pre-tested questionnaire, and integration of both self-reported behavioural data and objectively measured clinical and biochemical parameters, allowing meaningful correlation between awareness, behaviour, and outcomes within a single clinic-based cohort. 4.2 Limitations of the Study Several limitations must be acknowledged. First, the cross-sectional design does not allow causal inferences to be drawn between awareness, behaviour, and clinical outcomes. Second, preventive behaviour data were based on self-report and may be subject to recall and social desirability bias. Third, as a single-centre, hospital-based study, the findings may not be fully generalisable to community-dwelling diabetic patients who do not access tertiary care. Finally, dietary and physical activity assessments relied on structured questioning rather than validated quantitative dietary recall or accelerometry, which may have introduced measurement imprecision.

This clinic-based observational study demonstrates that a substantial proportion of patients with type 2 diabetes mellitus attending routine diabetes care have inadequate awareness of their heightened cardiovascular risk, and that this gap in awareness is significantly associated with poorer preventive behaviour and suboptimal glycaemic, blood pressure, and lipid control. Patients with adequate cardiovascular risk awareness were significantly more likely to achieve recommended clinical targets and less likely to have experienced a prior cardiovascular event. These findings highlight an urgent need to integrate structured, target-specific cardiovascular risk education into routine diabetes outpatient care, with particular attention to patients with lower educational attainment and shorter disease duration, who appear to be at greatest risk of inadequate awareness. Strengthening diabetes educator-led counselling, promoting self-monitoring practices, and reinforcing consistent, simplified messaging regarding blood pressure and lipid targets may help narrow the awareness-practice-outcome gap and ultimately reduce the burden of cardiovascular complications among Indian diabetic patients.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

SOURCE OF FUNDING

None declared.

ACKNOWLEDGEMENT

The authors thank the staff of the Diabetes Outpatient Clinic and all patients who participated in this study.