European Journal of Cardiovascular Medicine

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide, and individuals with diabetes mellitus (DM) bear a disproportionately higher risk of adverse cardiac events. Epidemiological data suggest that adults with diabetes are two to four times more likely to develop coronary artery disease (CAD), heart failure, and sudden cardiac death compared to their non-diabetic counterparts. India, often referred to as the “diabetes capital of the world,” harbors over 77 million people living with diabetes, a figure projected to rise dramatically by 2045. This escalating prevalence, combined with sedentary lifestyles, dietary transitions, and suboptimal glycemic control, underscores the urgent need to address cardiac health within this vulnerable population.^1-4

Diabetes accelerates atherosclerosis, promotes endothelial dysfunction, and is frequently associated with hypertension and dyslipidemia—factors that synergistically amplify cardiovascular risk. Alarmingly, diabetic individuals may experience “silent ischemia” or atypical symptoms, resulting in delayed recognition and treatment of cardiac events. Despite well-established evidence that stringent glycemic management, lipid control, and lifestyle interventions can substantially reduce cardiovascular morbidity, adherence to these preventive strategies remains inadequate in many low- and middle-income settings, including India. Cultural beliefs, economic constraints, limited health literacy, and fragmented healthcare delivery further exacerbate this gap.^5-7

Existing national programs have prioritized integrated NCD management; however, awareness and implementation of cardiovascular risk reduction strategies among diabetic patients remain suboptimal. Several studies from developed countries indicate that patient education and structured preventive programs significantly improve clinical outcomes, yet comparable data from the Indian context are scarce. Understanding the level of awareness regarding cardiac risks, adoption of preventive behaviors, and actual clinical outcomes among diabetics is critical to designing targeted interventions that are culturally and socioeconomically appropriate.^8-11

This study aims to evaluate cardiac health awareness, risk perception, and preventive practices among individuals with diabetes in India, while also examining their clinical outcomes and associated socio-demographic factors. By identifying key knowledge gaps and behavioral barriers, the findings will inform context-specific strategies to strengthen patient education, enhance cardiovascular risk management, and ultimately reduce the burden of diabetes-related cardiac complications in the Indian population.

Study Design and Setting

This descriptive, cross-sectional study was designed to evaluate cardiac health awareness, preventive practices, and clinical outcomes among individuals with diabetes in India. Data were collected over a defined period using an online survey administered through Google Forms, which allowed extensive outreach across both urban and rural regions. The online platform ensured uniformity in data collection, minimized logistical barriers, and facilitated the inclusion of participants from diverse geographic and socio-economic backgrounds.

Study Population and Eligibility Criteria

The study included adult participants aged 18 years and above who self-reported a diagnosis of diabetes mellitus (either Type 1 or Type 2). Eligibility was limited to individuals residing in India with internet access and willingness to provide informed consent electronically. Healthcare professionals, medical students, and those with formal cardiac care training were excluded to avoid inflating awareness levels. Participants with incomplete or inconsistent responses were also removed during data cleaning to maintain data integrity.

Sample Size Calculation

The sample size was determined using the standard formula for estimating proportions. Assuming a 50% prevalence of adequate awareness regarding cardiac health among diabetics, a 95% confidence level, and a 5% margin of error, the minimum required sample size was calculated to be 384. To account for potential incomplete submissions, the target sample size was set at 400 participants, ensuring adequate statistical power for subgroup analyses.

Sampling Strategy

A purposive-cum-snowball sampling approach was utilized to maximize participation within the diabetic community. The Google Form link was disseminated via social media platforms such as WhatsApp and Facebook, as well as through diabetes support groups and community health forums. Participants were encouraged to share the survey link within their networks, facilitating broader representation across different regions and socio-economic strata.

Survey Instrument

The structured questionnaire was developed with reference to guidelines from the American Diabetes Association (ADA), the American Heart Association (AHA), and Indian clinical practice recommendations. The instrument was divided into four sections:

1. Socio-Demographic Details – including age, gender, education level, occupation, income, and residential setting (urban/rural).
2. Medical Profile – covering duration of diabetes, comorbid conditions (such as hypertension and dyslipidemia), medication adherence, and recent glycemic control indicators (e.g., HbA1c levels if known).
3. Knowledge and Preventive Behaviors – comprising 20 multiple-choice questions assessing understanding of cardiac risk factors in diabetics, recognition of warning symptoms, and lifestyle practices including diet, physical activity, and smoking cessation.
4. Clinical Outcomes – capturing self-reported history of cardiac events (angina, myocardial infarction), hospitalization, and prior cardiovascular interventions.

Each correct response in the knowledge domain was awarded one point, and cumulative scores were categorized into four levels: Excellent (16–20), Good (12–15), Fair (8–11), and Poor (0–7), providing a structured measure of awareness.

Validation and Pilot Testing

The questionnaire underwent expert validation by specialists in cardiology, diabetology, and public health. A pilot test was conducted on 30 diabetic individuals to assess clarity, cultural appropriateness, and functionality of the digital format. Based on feedback, minor linguistic adjustments were incorporated. The internal consistency of the tool was measured using Cronbach’s alpha (α = 0.81), indicating strong reliability.

Data Collection Procedure

The Google Form incorporated an electronic consent statement on the first page, which participants had to agree to before proceeding. All questions were mandatory, eliminating the possibility of missing data. The average completion time for the questionnaire was approximately 8–10 minutes. Responses were automatically captured in a secure Google Sheet accessible only to the primary investigator, ensuring data confidentiality.

Data Analysis

Data were exported into IBM SPSS Statistics (version 25) for analysis. Descriptive statistics, including means, standard deviations, frequencies, and percentages, were computed for socio-demographic and clinical variables. Chi-square tests were applied to examine associations between awareness levels and participant characteristics. Multivariate logistic regression was conducted to identify independent predictors of good knowledge (defined as a score of ≥12), with results expressed as Adjusted Odds Ratios (AOR) and 95% Confidence Intervals (CI). Statistical significance was set at p < 0.05.

Ethical Considerations

The study protocol adhered to the principles outlined in the Declaration of Helsinki. Participation was voluntary, and anonymity was strictly maintained by excluding identifiable personal information from the survey.

The study included 400 respondents with a balanced representation across various demographic groups. A significant proportion (34.5%) were aged 45–54 years, followed by those aged 35–44 years (25.5%). Younger participants aged 18–34 years constituted 16.0%, while older adults (≥55 years) comprised 24.0%. Gender distribution was slightly male-dominated, with 55.0% males and 45.0% females. The majority of participants resided in urban areas (61.0%), whereas 39.0% belonged to rural regions, indicating good geographic diversity. Educational attainment varied considerably; most respondents were graduates (44.0%) or postgraduates (22.0%), while 28.0% had secondary education and 6.0% reported no formal education. Occupational profiles showed nearly half (46.0%) were in service or professional roles, 31.0% were homemakers, and 23.0% engaged in skilled or unskilled work. These findings highlight a relatively literate, urban-centric sample, yet inclusive of rural and low-education segments for broader applicability.

Table 1: Socio-Demographic Characteristics of Participants (n = 400)

Table 2 presents the clinical background of participants. Type 2 diabetes was overwhelmingly predominant (90.5%), with only 9.5% reporting Type 1 diabetes. Disease duration varied: 40.5% had diabetes for 5–10 years, 34.0% for less than 5 years, and 25.5% for more than a decade, underscoring a significant chronic burden. Hypertension (67.0%) and dyslipidemia (48.5%) emerged as common comorbidities, while 39.0% had both conditions. Regarding glycemic control, only 31.0% achieved optimal HbA1c levels (<7%), whereas 42.0% had moderately elevated levels (7–8%) and 27.0% reported poor control (>8%). Notably, 21.5% had a history of cardiac events, indicating high cardiovascular vulnerability within this population. These statistics underline the intersection of diabetes and cardiovascular risk, justifying the study’s focus on awareness and preventive practices.

Table 2: Medical Profile of Respondents (n = 400)

Assessment of knowledge through 20 structured questions revealed substantial awareness gaps. While 77.0% recognized diabetes as a major cardiovascular risk factor and 71.5% acknowledged hypertension’s role, only 57.0% understood the importance of LDL cholesterol control. Lifestyle-related awareness was relatively better, with 78.0% identifying sedentary behavior and 74.5% recognizing exercise as crucial for risk reduction. However, practical clinical knowledge was limited—only 38.5% knew the optimal BP target for diabetics (130/80 mmHg), and 43.0% identified the recommended HbA1c goal (<7%). Awareness of emergency response measures was particularly poor; just 46.5% understood CPR’s role during cardiac arrest, and only 53.0% knew India’s emergency helpline (108). Misconceptions persisted regarding aspirin use (42.0% correct) and frequency of cardiac check-ups (44.5%). Overall, these findings point to a critical need for structured education on both preventive and emergency cardiac care in diabetic populations.

Table 3: Knowledge Questions on Cardiac Risk, Warning Symptoms, and Management (n = 400)

Despite gaps in knowledge, certain preventive behaviors were widely practiced. Nearly all respondents (93.5%) regularly monitored blood glucose, and 78.0% checked blood pressure routinely, reflecting good adherence to basic diabetic care. However, only 53.0% had undergone lipid profile testing in the previous year, and just 42.0% reported regular cardiac check-ups. Physical activity adherence was suboptimal—only 46.0% engaged in daily exercise for at least 30 minutes. Encouragingly, 84.0% adhered to prescribed medication, while smoking cessation among prior smokers stood at 24.5%, signaling room for improvement in behavioral interventions. These findings suggest that while medication adherence and glycemic monitoring are prioritized, comprehensive cardiovascular risk management remains insufficient.

Table 4: Preventive Behaviors and Lifestyle Practices (n = 400)

Knowledge scores were classified into four categories: excellent (16–20), good (12–15), fair (8–11), and poor (0–7). Only 17.0% of participants achieved an excellent score, and 30.5% fell into the good category, indicating that fewer than half of respondents had adequate knowledge. The majority demonstrated suboptimal awareness, with 34.5% scoring fair and 18.0% classified as poor. This distribution highlights a pronounced knowledge gap in critical aspects of cardiovascular risk and emergency management among individuals with diabetes, emphasizing the urgent need for targeted education and behavioral interventions.

Table 5: Overall, Knowledge Score Distribution

Statistical analysis revealed significant associations between knowledge levels and multiple socio-demographic factors. Education emerged as the most powerful determinant (p < 0.001), with excellent scores most prevalent among postgraduates (30.0%) compared to only 4.2% in those with no formal education. Urban participants demonstrated higher knowledge levels than rural counterparts (p = 0.002), reflecting disparities in health literacy. Occupational status also influenced awareness (p = 0.008); service and professional groups exhibited better scores than homemakers and laborers. Conversely, age and gender showed no significant association (p > 0.05), suggesting that educational and socio-economic factors, rather than demographic variables, predominantly shape cardiac health awareness. These findings underscore the need for interventions targeting rural, less-educated, and economically disadvantaged populations to improve cardiovascular health literacy among diabetics.

Table 6: Association Between Knowledge Level and Socio-Demographic Variables (n = 400)

This study highlights significant gaps in cardiac health awareness, preventive practices, and clinical preparedness among individuals with diabetes in India. Despite the established link between diabetes and cardiovascular disease (CVD), overall knowledge levels were suboptimal: only 17% of participants demonstrated excellent awareness, while over half scored in the fair or poor categories. Although most respondents recognized diabetes (77%) and hypertension (71.5%) as major cardiovascular risk factors, fewer understood the role of LDL cholesterol (57%) or optimal blood pressure targets (38.5%). These findings underscore a concerning imbalance between conceptual understanding and practical knowledge—especially in emergency response measures, where only 46.5% acknowledged the importance of CPR and 42% recognized aspirin as beneficial during acute events.

Our findings resonate with prior Indian studies reporting low health literacy regarding CVD risk factors in diabetic cohorts. A multi-centric survey by Mohan et al. demonstrated that less than 40% of Indian diabetics were aware of their heightened cardiac risk, despite frequent physician consultations. Similarly, our observation that only 42% of respondents underwent annual cardiac check-ups mirrors trends in other low- and middle-income countries (LMICs), where preventive cardiology remains underutilized. International evidence suggests markedly better outcomes in high-income countries, where structured educational programs and integrated care models have improved both awareness and adherence to preventive measures. The contrast emphasizes systemic gaps in India’s patient education and chronic disease management frameworks.^12,13

Encouragingly, adherence to core diabetes management practices such as blood sugar monitoring (93.5%) and medication compliance (84%) was high, likely reflecting routine physician guidance on glycemic control. However, broader cardiovascular prevention behaviors were inconsistent. While 78% monitored blood pressure regularly, only 53% had a lipid profile in the preceding year and less than half engaged in daily physical activity. These behavioral gaps suggest that patients prioritize glucose management but undervalue integrated risk reduction strategies—a trend corroborated by recent Indian registry data linking suboptimal lifestyle modification to persistent cardiovascular morbidity in diabetics.

Our analysis revealed striking associations between knowledge levels and socio-economic determinants. Education emerged as the strongest predictor of awareness, with postgraduates significantly outperforming individuals without formal education (p < 0.001). Urban residence and professional occupation also correlated with higher knowledge, reflecting disparities in health literacy and access to information. Conversely, age and gender showed no significant association, suggesting that cultural and structural barriers cut across demographic lines. These findings reinforce global evidence on the social gradient in health literacy and underscore the necessity for targeted interventions aimed at rural and economically disadvantaged groups.^9,11,12

Implications for Clinical Practice and Policy

The implications of these findings are critical for India’s NCD control strategies. While national programs such as NPCDCS prioritize diabetes and hypertension screening, they inadequately address patient education on cardiovascular risk mitigation. Our data support the integration of structured cardiac health counseling within diabetes care pathways. Strategies should include:

• Mandatory lifestyle education during clinic visits.
• Community-based programs using Accredited Social Health Activists (ASHAs) to reach rural populations.
• Digital platforms offering multilingual educational content to enhance outreach.
  Additionally, workplace wellness programs and diabetes support groups can serve as conduits for disseminating preventive guidelines and CPR training, bridging the current knowledge-to-action gap.

Emergency Preparedness: An Overlooked Priority

The low awareness regarding CPR and emergency response in this study signals a critical vulnerability. Considering the rising incidence of sudden cardiac events in diabetic individuals, equipping patients and caregivers with basic life support skills could significantly improve survival outcomes. Successful models from countries like Singapore and Denmark—where CPR training is embedded in school curricula and community programs—offer replicable frameworks for India.

Strengths and Limitations

The study’s strengths include a robust sample size, inclusion of diverse socio-demographic strata, and use of a validated questionnaire grounded in international guidelines. However, limitations must be acknowledged: the reliance on self-reported data may introduce reporting bias, and the online survey format likely excluded digitally marginalized populations, potentially overestimating awareness levels. Moreover, the cross-sectional design limits causal inference between awareness and clinical outcomes.

Future Directions

Future research should employ longitudinal designs to examine the impact of awareness on actual cardiovascular outcomes among diabetics. Interventional studies evaluating culturally tailored educational modules—delivered via digital and community platforms—are essential. Further, assessing psychological and behavioral determinants influencing lifestyle adherence will inform the design of more effective, patient-centered interventions.

This study underscores critical deficiencies in cardiac health awareness and preventive practices among individuals with diabetes in India, despite their markedly elevated cardiovascular risk. While basic diabetes management behaviors such as glucose monitoring and medication adherence were commendably high, knowledge of integrated cardiac risk reduction strategies, emergency response measures, and routine cardiac evaluations remained inadequate. Education, urban residence, and occupational status emerged as key determinants of awareness, highlighting pervasive socio-economic disparities. Bridging these gaps demands a multipronged approach that integrates structured patient education, community-based lifestyle interventions, and widespread CPR training into existing diabetes care programs. Leveraging digital platforms, strengthening primary healthcare outreach, and promoting culturally tailored awareness campaigns are essential to foster preventive behaviors and improve clinical outcomes, ultimately reducing the disproportionate cardiovascular burden faced by India’s diabetic population.

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