Prevalence of thyroid disorders among the diabetic population in Arar, Saudi Arabia
===================================================================================

* Haider O. Elmisbah
* Riyad Y. Laham
* Hafiz O. Almisbah
* Hadeel T. Alanazi
* Taif A. Alanazi
* Raghad M. Alanzi
* Wejdan A. Aldahmashi
* Anshoo Agarwal
* Rashad Q. Othman

## Abstract

**Objectives:** To study the prevalence of thyroid disorders (TDs) among the diabetic population in Arar, Saudi Arabia.

**Methods:** A cross-sectional design study carried out in Arar, northern province of Saudi Arabia, from October 2023 to January 2024. A structured questionnaire was used to collect the data. From the diabetic population aged over 18 years old.

**Results:** A total of 501 participants were enrolled. Most fall within the 20-35 age range, comprising 36.5% of the sample. Vitamin D deficiency appears to be the most prevalent comorbid condition. Following closely behind is vitamin B12 deficiency; hypertension and high blood lipids also show notable prevalence rates, affecting 10.5-22.1% of the population. In terms of diabetes, 42.8% of the population has been diagnosed with the condition. Among those with diabetes, the majority (67.6%) have been diagnosed with the second type, while 32.4% have the first type. There is an association between diabetes and TDs, with 51.3% of participants reporting this.

**Conclusion:** The findings indicate that the adults in Arar, Saudi Arabia, lack some knowledge of TDs and their relationship to diabetes.

Keywords:
*   goitre
*   hyperthyroidism
*   hypothyroidism
*   diabetes mellitus
*   hyperglycaemia

**T**hyroid disorders (TDs) and diabetes mellitus (DM) were the most observed endocrine diseases in the practice. In recent decades, there has been a significant rise in the occurrence of TDs globally, with a specific emphasis on the variables that contribute to their development.1 Undiagnosed or untreated TDs can lead to severe consequences and have a significant impact on various aspects of health, such as cardiovascular and metabolic disorders, mental health, and bone health.2,3 Primary TDs commonly stem from causes like autoimmune destruction, radiation-induced thyroiditis, postsurgical hypothyroidism, and anti-thyroid drugs.4,5 Symptoms and signs of hypothyroidism include fatigue, depression, cold intolerance, hoarseness, dry skin, constipation, bradycardia, and hyporeflexia.6,7

It is crucial to establish awareness and educational campaigns to enhance understanding of these disorders, facilitating the prompt detection of undiagnosed cases to prevent further complications. Diabetes mellitus is a prevalent disease that can affect individuals of any age.8 TDs, particularly autoimmune TDs, are the most common endocrine illness in diabetics.9 Both TDs and DM are prevalent across various populations and age groups and there exists an interplay between the 2 conditions, potentially influencing each other.10,11

Numerous studies have been carried out to determine the prevalence of TDs among diabetic patients. Recent research has identified an association between autoimmune hypothyroidism and DM.12 For instance, a study involving 233 Brazilian children and adolescents with DM revealed that 23% of them had TDs, predominantly females.13 In Saudi Arabia, several studies have been undertaken to assess the prevalence of TDs among individuals with type 2 DM.14,15 A study carried out on 200 individuals (100 with type 1 and 100 with type 2 DM) at the Diabetes Centre in Saudi Arabia indicated that 31% of participants had TDs.16

Recent studies have highlighted a significantly increased risk of thyroid cancer in patients with DM.17 Research has specifically indicated a significantly elevated incidence of thyroid cancer among Chinese women diagnosed with type 2 DM.18 As the studies carried out in Saudi Arabia on the prevalence of TDs among patients with DM are scarce, this study aimed to study the prevalence of TDs among the diabetic population in Arar, Saudi Arabia. We also aimed to analyse other disease conditions associated with TDs and to create awareness regarding screening for TDs in the diabetic population.

## Methods

This study adopted a cross-sectional research design to investigate the prevalence of TDs among the diabetic population residing in Arar, Northern Saudi Arabia. The use of a cross-sectional approach enabled the collection of data at a specific point in time, providing a snapshot of prevalence and awareness levels.

The sampling strategy for this study employed a purposive sampling technique. Factors such as age, gender, education, and employment status were considered to ensure a diverse and representative sample of the diabetic adult population in Arar.

We will estimate a sample size using the Raosoft® calculator, with a 5% level of significance, a 5% margin of error, 95% confidence, and an expected response distribution of 50%. So, the calculated sample is 384 participants, and by adding 10% to compensate for the missing and incomplete questionnaires, we need a minimum sample of 403 participants.

Inclusion criteria encompass individuals aged 18 years and older who are residents of Arar during the data collection period.

We exclude those who have cognitive problems or are unable to respond to the questionnaire and those who refuse to participate in the study. We also excluded diabetic people who had undergone bariatric surgery, diabetic people who had undergone thyroid surgery.

The data collection instrument for this study was a previously validated online questionnaire, as employed in studies by Karla et al19 and Misfer et al.20 This questionnaire, crafted in Arabic, encompasses 3 primary sections: socio-demographic data, questions regarding TDs, and their knowledge and awareness on them.

The data collection process was facilitated through the publication of the questionnaire on Google Documents, offering a user-friendly and accessible platform for participants. Electronic distribution of the questionnaire was carried out via popular social media applications to ensure a wide reach within the diabetic adult population of Arar. This approach aligns with contemporary trends in survey administration and enhances the efficiency of data collection.

### Statistical analysis

Quantitative data obtained from the questionnaire underwent the Statistical Package for the Social Sciences statistics for Windows, version 22.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were employed to summarise socio-demographic characteristics and the prevalence of TDs. Inferential statistics, such as Chi-square tests or logistic regression, may be utilised to explore potential associations between socio-demographic variables and awareness levels.

## Results

As shown in Table 1, the majority fall within the 20-35 age range, comprising 36.5% of the sample. The next largest age group is 35-40, accounting for 14.1% of the respondents. Notably, individuals aged 60 and above represent 8.8% of the total sample. In terms of nationality, the overwhelming majority of participants (97.8%) identify as Saudi, while a smaller proportion (2.2%) are non-Saudi. Moreover, 6.1% of respondents did not specify their nationality. The educational level of the participants varies, with the most prevalent category being individuals holding a bachelor’s degree, constituting 55% of the sample. This is followed by those with a secondary education level at 18.7%, and uneducated individuals at 9.2%. The data also indicates a diverse range of occupations among the participants, with employees representing the largest group at 40.6%, followed by those not currently working at 32.4%. Moving on to marital status, the majority of participants (62.8%) are married, while 29.2% are single. Divorced individuals represent 4.1% of the sample and widowed individuals represent 3.9%. The duration of TD among participants varies, with 66.4% reporting that they do not have a thyroid disease. Of those who do, 13.6% have been affected for less than a year, while 10.2% have had the condition for 1-5 years, and 9.7% for more than 5 years. Regarding weight-related parameters, 45.7% of participants are categorised as overweight or obese, while 54.3% are not. The distribution of body mass index (BMI) reveals that 33.8% of participants have a normal BMI, while 32.8% are classified as obese, and 31.6% as overweight. Additionally, 1.7% are underweight. Finally, the data provides insight into participants’ waist circumference, with 26.8% falling within the 70-100 cm range, 29.0% within 100-140 cm, and 27.3% within 140-180 cm. Notably, 15.3% of participants indicated that they did not know their waist circumference.

View this table:
[Table 1](http://smj.org.sa/content/45/6/591/T1)

Table 1 
- Sociodemographic characteristics of the participants (N=411).

As illustrated in Table 2, vitamin D deficiency appears to be the most prevalent comorbid condition, affecting 174 individuals, which accounts for 42.3% of the population under study. Following closely behind is vitamin B12 deficiency, impacting 108 individuals (26.3%). Hypertension (22.1%), high blood lipids (10.5%), and iron deficiency anaemia (14.6%) also show notable prevalence rates. It is noteworthy that 5.6% of the population did not exhibit any of the listed comorbid diseases. In terms of DM, 42.8% of the population has been diagnosed with the condition, while the remaining 57.2% do not have DM. Among those with DM, the majority (67.6%) have been diagnosed with the second type, while 32.4% have the first type.

View this table:
[Table 2](http://smj.org.sa/content/45/6/591/T2)

Table 2 
- Comorbid diseases among the study participants (N=411).

In Table 3, 54.5% of respondents acknowledged the influence of hypothyroidism on cholesterol levels. Furthermore, the survey indicates that 50.9% of participants recognise the connection between a weak thyroid gland and heart disease. The relationship between DM and TDs is also a point of interest, with 51.3% of respondents acknowledging this association. In addition, the hereditary aspect of hypothyroidism is recognized by 43.6% of respondents, shedding light on the genetic predisposition to TDs. Moreover, the data draws attention to the potential consequences of untreated TDs on maternal and foetal health, with 65.2% of respondents acknowledging this serious outcome. The link between TDs and iodine deficiency is recognized by 55.2% of respondents, emphasizing the significance of adequate iodine intake for thyroid health. Furthermore, the survey indicates that certain medications and surgical procedures can contribute to the development of TDs, with 51.3% of respondents acknowledging this association. Moving on to the relationship between DM and TDs, the data reflects a recognition of the biochemical, genetic, and hormonal malfunctions contributing to this association by 47.4% of respondents. Additionally, the survey highlights the similarity in signs and symptoms between diabetes and TDs, with 61.1% of respondents acknowledging this overlap. Moreover, the survey indicates that the combination of diabetes and TDs can mask early diabetes complications, a point recognised by 47.4% of respondents. The potential impact of diabetes treatment on worsening TDs is acknowledged by 36.0% of respondents. Finally, the survey draws attention to the potential impact of anti-thyroid medications on blood sugar control, with 42.3% of respondents recognising this association.

View this table:
[Table 3](http://smj.org.sa/content/45/6/591/T3)

Table 3 
- Participants’ knowledge regarding thyroid disorders in diabetes mellitus patients (N=411).

In Table 4, for individuals with a waist circumference less than 70 cm, the distribution of thyroid presence across different durations is as follows: less than one year (0%), 1-5 years (0.5%), more than 5 years (0%), and no thyroid presence (1.2%). Moving to the 70-100 cm waist circumference category, the distribution of thyroid presence is as follows: less than one year (4.1%), 1-5 years (2.2%), more than 5 years (1.9%), and no thyroid presence (18.5%). Similar distributions are observed for the 100-140 cm and 140-180 cm waist circumference categories, with varying percentages of thyroid presence across different duration groups. The proportions of individuals with and without DM are presented across the various durations of thyroid presence.

View this table:
[Table 4](http://smj.org.sa/content/45/6/591/T4)

Table 4 
- Association between the presence and duration of thyroid disease and the presence of diabetes mellitus and waist circumference (N=411).

In terms of statistical analysis, the *p*-values are included to indicate the significance of the observed associations. It is worth noting that the *p*-values for waist circumference in relation to thyroid presence duration is 0.670 and the presence of DM in relation to thyroid presence duration is 0.205. These values are crucial for determining the statistical significance of the observed relationships and can provide valuable insights into the potential associations between these variables.

## Discussion

Thyroid disorders are becoming more common in Saudi Arabia, especially among women.21 The prevalence of TDs in the country has been the focus of various investigations. A study carried out by Alqahtani et al22 revealed a prevalence rate of 49.8%, with subclinical hypothyroidism accounting for 39.3% of the cases. The prevalence of primary hypothyroidism was 5.3%, subclinical hyperthyroidism was 2.7%, and primary hyperthyroidism was 2.5%. A study carried out with 411 individuals from various age groups found that the prevalence of thyroid diseases was reported to be 44.6%. The duration of sickness varied, ranging from months to years. The study found that 13.6% of the participants had experienced the effects for less than a year, 10.2% for a duration of 1-5 years, and 9.7% for more than 5 years. The results of this study closely correspond to research carried out by Rana et al,23 which emphasised the significant occurrence of thyroid problems in adult Saudi women. The most prevalent type of TD found was subclinical hypothyroidism. Palma et al24 carried out a study that found that subclinical hypothyroidism was the most prevalent condition among diabetic patients. It accounted for 11.8% of instances of TDs and had a prevalence rate of 14.7%. Within our research, 42.8% of the individuals involved exhibited DM, with the majority of cases being attributed to type 2 diabetes (67.6%), while the remaining cases were classified as type 1 diabetes (32.4%). The study also investigated the duration of thyroid problems and DM, and the results revealed a statistically insignificant connection. Previous studies have emphasised the significance of maintaining a heightened level of suspicion for TDs in individuals with diabetes in order to promote early identification and effective treatment.25 Furthermore, case-control studies have demonstrated a significantly higher prevalence of TDs in individuals with type 2 diabetes mellitus (T2DM) compared to those without the condition. The prevailing TDs were subclinical hypothyroidism, followed by overt hypothyroidism and hyperthyroidism.26 Previous studies have identified variations in the prevalence rates of TDs among patients with T2DM.27-29 The results of our research are consistent with previous studies that have found a high occurrence of TDs in patients with T2DM, such as the study carried out by Zhu et al.30 However, our findings differ with those of Khassawneh et al,31 who showed lower rates of prevalence. The high incidence of TDs in our study highlights the significance of carrying out screenings for thyroid abnormalities in this particular group. Furthermore, the participants’ level of awareness regarding TDs in DM was determined to be below the desired level, as more than 50% of participants provided wrong responses to questions testing their awareness. Nevertheless, there was a pretty high level of awareness regarding the typical symptoms of TDs, as almost 75% of individuals correctly recognised weight disturbance, weariness, drowsiness, and dry hair or skin as indicative of TDs. Prior research has emphasised different degrees of knowledge regarding the symptoms of TDs, underscoring the importance of educating the public and raising awareness regarding the early signs of the disease, as well as its risk factors and connection to other chronic ailments, namely, DM.31-33

### Study limitations

The study was carried out in a specific city in Saudi Arabia (Arar), which may limit the generalizability of the findings to other regions or populations with different demographic characteristics or healthcare systems. The study relied on a sample size of 420 participants, which may not be representative of the entire diabetic population in Arar. There could be potential selection bias if certain groups of diabetic individuals were more likely to participate in the study than others. Data collection was based on self-reported information from participants through a structured questionnaire. This method may introduce recall bias or inaccuracies in reporting, particularly when it comes to medical history, or symptoms related to TDs.

In conclusion, although there was no significant association between TDs and diabetes, a considerable prevalence of TDs was reported in patients with diabetes, especially those with T2DM. Thus, it was determined that regular screening for TDs should be carried out in diabetes patients. This intervention will enhance their overall well-being and reduce their incidence of illness and disease. Research indicates that people in Arar have a limited understanding of the correlation between TDs and diabetes.

## Acknowledgment

*The authors gratefully acknowledge AJE ([www.aje.com](https://www.aje.com)) for the English language editing.*

## Footnotes

*   **Disclosure.** Authors have no conflict of interests, and the work was not supported or funded by any drug company.

*   Received February 17, 2024.
*   Accepted April 23, 2024.


*   Copyright: © Saudi Medical Journal

This is an Open Access journal and articles published are distributed under the terms of the Creative Commons Attribution-NonCommercial License (CC BY-NC). Readers may copy, distribute, and display the work for non-commercial purposes with the proper citation of the original work.

## References

1.  1.Taylor PN, Albrecht D, Scholz A, Gutierrez-Buey G, Lazarus JH, Dayan CM, et al. Global epidemiology of hyperthyroidism and hypothyroidism. Nat Rev Endocrinol 2018; 14: 301–316.
    
    [CrossRef](http://smj.org.sa/lookup/external-ref?access_num=10.1038/nrendo.2018.18&link_type=DOI) 
    
    [PubMed](http://smj.org.sa/lookup/external-ref?access_num=29569622&link_type=MED&atom=%2Fsmj%2F45%2F6%2F591.atom) 

2.  2.Diab N, Daya NR, Juraschek SP, Martin SS, McEvoy JW, Schultheiß UT, et al. Prevalence and risk factors of thyroid dysfunction in older adults in the community. Sci Rep 2019; 9: 13156.
    
    

3.  3.Scappaticcio L, Longo M, Maiorino MI, Pernice V, Caruso P, Esposito K, et al. Abnormal liver blood tests in patients with hyperthyroidism: systematic review and meta-analysis. Thyroid 2021; 31: 884–894.
    
    

4.  4.Kut A, Kalli H, Anil C, Mousa U, Gursoy A. Knowledge, attitudes and behaviors of physicians towards TDs and iodine requirements in pregnancy. J Endocrinol Invest 2015; 38: 1057–1064.
    
    

5.  5.Ai J, Leonhardt JM, Heymann WR. Autoimmune thyroid diseases: etiology, pathogenesis, and dermatologic manifestations. J Am Acad Dermatol 2003; 48: 641–659.
    
    [CrossRef](http://smj.org.sa/lookup/external-ref?access_num=10.1067/mjd.2003.257&link_type=DOI) 
    
    [PubMed](http://smj.org.sa/lookup/external-ref?access_num=12734493&link_type=MED&atom=%2Fsmj%2F45%2F6%2F591.atom) 

6.  6.Beck-Peccoz P, Rodari G, Giavoli C, Lania A. Central hypothyroidism - a neglected thyroid disorder. Nat Rev Endocrinol 2017; 13: 588–598.
    
    

7.  7.Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, et al. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid 2016; 26: 1343–1421.
    
    [CrossRef](http://smj.org.sa/lookup/external-ref?access_num=10.1089/thy.2016.0229&link_type=DOI) 
    
    [PubMed](http://smj.org.sa/lookup/external-ref?access_num=27521067&link_type=MED&atom=%2Fsmj%2F45%2F6%2F591.atom) 

8.  8.Sarwar N, Gao P, Seshasai SR, Gobin R, Kaptoge S, Di Angelantonio E, et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet 2010; 375: 2215–2222.
    
    [CrossRef](http://smj.org.sa/lookup/external-ref?access_num=10.1016/S0140-6736(10)60484-9&link_type=DOI) 
    
    [PubMed](http://smj.org.sa/lookup/external-ref?access_num=20609967&link_type=MED&atom=%2Fsmj%2F45%2F6%2F591.atom) 
    
    [Web of Science](http://smj.org.sa/lookup/external-ref?access_num=000279652900018&link_type=ISI) 

9.  9.Chatzigeorgiou A, Harokopos V, Mylona-Karagianni C, Tsouvalas E, Aidinis V, Kamper EF. The pattern of inflammatory/anti-inflammatory cytokines and chemokines in type 1 diabetic patients over time. Ann Med 2010; 42: 426–438.
    
    [CrossRef](http://smj.org.sa/lookup/external-ref?access_num=10.3109/07853890.2010.495951&link_type=DOI) 
    
    [PubMed](http://smj.org.sa/lookup/external-ref?access_num=20568978&link_type=MED&atom=%2Fsmj%2F45%2F6%2F591.atom) 

10. 10.Hage M, Zantout MS, Azar ST. TDs and diabetes mellitus. J Thyroid Res 2011; 2011: 439463.
    
    [PubMed](http://smj.org.sa/lookup/external-ref?access_num=21785689&link_type=MED&atom=%2Fsmj%2F45%2F6%2F591.atom) 

11. 11.Jimoh AK, Ghazali MS, Ogundeji OA, Adeleke BA, Ajani OG, Gabriel-Alayode EO, et al. Spectrum of thyroid function test among type 2 diabetic patients attending a rural health facility, southwest Nigeria: a hospital-based study. SAGE Open Med 2022; 10: 20503121221097625.
    
    

12. 12.Umpierrez GE, Latif KA, Murphy MB, Lambeth HC, Stentz F, Bush A, et al. Thyroid dysfunction in patients with type 1 diabetes: a longitudinal study. Diabetes Care 2003; 26: 1181–1185.
    
    [Abstract/FREE Full Text](http://smj.org.sa/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NzoiZGlhY2FyZSI7czo1OiJyZXNpZCI7czo5OiIyNi80LzExODEiO3M6NDoiYXRvbSI7czoxODoiL3Ntai80NS82LzU5MS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

13. 13.Lu MC, Chang SC, Huang KY, Koo M, Lai NS. Higher risk of TDs in young patients with type 1 diabetes: a 12-year nationwide, population-based, retrospective cohort study. PLoS One 2016; 11: e0152168.
    
    [PubMed](http://smj.org.sa/lookup/external-ref?access_num=27007574&link_type=MED&atom=%2Fsmj%2F45%2F6%2F591.atom) 

14. 14.Khan R, Awadai A, Alghorry N, Albalawi H, Alwadai I, Alatawi M, et al. Prevalence of thyroid disease among type 2 diabetic patients in Tabuk city, Saudi Arabia. IAJPS 2019; 6: 2520–2524.
    
    

15. 15.Hammadi SH, Aljawi RS, Alahdal SS, Allahyani MM, Jazzar NK, Maqbol SM, et al. Prevalence of thyroid dysfunction among type 2 diabetic patients (T2D) in Makkah and Jeddah-KSA. Egypt J Hosp Med 2018; 70: 1312–1316.
    
    

16. 16.Elmenshawi IM, Alotaibi SS, Alazmi AS, Alazmi AM, Alruwaili FR, Alazmi NN, et al. Prevalence of thyroid dysfunction in diabetic patients. J Diabetes Metab Disord Control 2017; 4: 55–60.
    
    

17. 17.Seo YG, Choi HC, An AR, Park DJ, Park YJ, Lee KE, et al. The association between type 2 diabetes mellitus and thyroid cancer. J Diabetes Res 2017; 2017: 5850879.
    
    

18. 18.Fang Y, Zhang X, Xu H, Smith-Warner SA, Xu D, Fang H, et al. Cancer risk in Chinese diabetes patients: a retrospective cohort study based on management data. Endocr Connect 2018; 7: 1415–1423.
    
    [CrossRef](http://smj.org.sa/lookup/external-ref?access_num=10.1530/EC-18-0381&link_type=DOI) 
    
    [PubMed](http://smj.org.sa/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fsmj%2F45%2F6%2F591.atom) 

19. 19.Kalra S, Aggarwal S, Khandelwal D. Thyroid dysfunction and type 2 diabetes mellitus: screening strategies and implications for management. Diabetes Ther 2019; 10: 2035–2044.
    
    [PubMed](http://smj.org.sa/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fsmj%2F45%2F6%2F591.atom) 

20. 20.Alqahtiani NM, Alramadhan ZT, obaid MRB, Kurdi AN, Alhelal AA, Aljaafar FA, et al. Hypothyroidism in Saudi Arabia; prevalence, risk factors, and its relation with diabetes mellitus. Arch Pharma Pract 2020; 11: 56–62.
    
    

21. 21.Alqahtiani NM, Alramadhan ZT, bin Obaid MR, Kurdi AN, Alhelal AA, Aljaafar FA, et al. Hypothyroidism in Saudi Arabia; prevalence, risk factors, and its relation with diabetes mellitus. Arch Pharm Pract 2020; 11: 56–63.
    
    

22. 22.Alqahtani SAM. Prevalence and characteristics of thyroid abnormalities and its association with anemia in Asir region of Saudi Arabia: a cross-sectional study. Clin Pract 2021; 11: 494–504.
    
    

23. 23.Rana H, Mirah JA, Al-Shahrani N, Nouf A, Afrah A, Basma O, et al. Incidence of thyroid diseases in female Saudi adults visiting a tertiary care hospital in Riyadh. Epidemiol Open Access 2017; 7: 286.
    
    

24. 24.Palma CC, Pavesi M, Nogueira VG, Clemente EL, Vasconcellos Mde F, Pereira LC Júnior, et al. Prevalence of thyroid dysfunction in patients with diabetes mellitus. Diabetol Metab Syndr 2013; 5: 58.
    
    [CrossRef](http://smj.org.sa/lookup/external-ref?access_num=10.1186/1758-5996-5-58&link_type=DOI) 
    
    [PubMed](http://smj.org.sa/lookup/external-ref?access_num=24499529&link_type=MED&atom=%2Fsmj%2F45%2F6%2F591.atom) 

25. 25.Yadav A, Yadav GAM, Narsingrao KK, Nanda Kumar LG, Yadav GSN. Prevalence of TDs among patients with diabetes in rural South India. Diabetes Metab Syndr 2021; 15: 885–889.
    
    

26. 26.Khassawneh AH, Al-Mistarehi AH, Zein Alaabdin AM, Khasawneh L, AlQuran TM, Kheirallah KA, et al. Prevalence and predictors of thyroid dysfunction among type 2 diabetic patients: a case-control study. Int J Gen Med 2020; 13: 803–816.
    
    

27. 27.Iwakura H, Takagi T, Inaba H, Doi A, Ueda Y, Uraki S, et al. Thyroid function, glycemic control, and diabetic nephropathy in patients with type 2 diabetes over 24 months: prospective observational study. BMC Endocr Disord 2023; 23: 146.
    
    

28. 28.Al-Geffari M, Ahmad NA, Al-Sharqawi AH, Youssef AM, Alnaqeb D, Al-Rubeaan K. Risk factors for thyroid dysfunction among type 2 diabetic patients in a highly diabetes mellitus prevalent society. Int J Endocrinol 2013; 2013: 417920.
    
    

29. 29.Jali MV, Kambar S, Jali SM, Pawar N, Nalawade P. Prevalence of thyroid dysfunction among type 2 diabetes mellitus patients. Diabetes Metab Syndr 2017; 11: S105–S108.
    
    [CrossRef](http://smj.org.sa/lookup/external-ref?access_num=10.1016/j.dsx.2016.12.017&link_type=DOI) 

30. 30.Zhu Y, Xu F, Shen J, Liu Y, Bi C, Liu J, et al. Prevalence of thyroid dysfunction in older Chinese patients with type 2 diabetes - a multicenter cross-sectional observational study across China. PLoS One 2019; 14: e0216151.
    
    

31. 31.Khassawneh AH, Al-Mistarehi AH, Zein Alaabdin AM, Khasawneh L, AlQuran TM, Kheirallah KA, et al. Prevalence and predictors of thyroid dysfunction among type 2 diabetic patients: a case-control study. Int J Gen Med 2020; 13: 803–816.
    
    

32. 32.Bjoro T, Holmen J, Krüger O, Midthjell K, Hunstad K, Schreiner T, et al. Prevalence of thyroid disease, thyroid dysfunction and thyroid peroxidase antibodies in a large, unselected population. The Health Study of Nord-Trondelag (HUNT). Eur J Endocrinol 2000; 143: 639–647.
    
    [Abstract](http://smj.org.sa/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiZWplIjtzOjU6InJlc2lkIjtzOjk6IjE0My81LzYzOSI7czo0OiJhdG9tIjtzOjE4OiIvc21qLzQ1LzYvNTkxLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

33. 33.Rai S, Sirohi S, Khatri AK, Dixit S, Saroshe S. Assessment of knowledge and awareness regarding TDs among women of a cosmopolitan city of central India. Natl J Community Med 2016; 7: 7–10.