Background In the twenty-first century, diabetes mellitus (DM) is one of the most difficult chronic health issues [1]. DM is a chronic metabolic disorder characterized by hyperglycemia resulting from defects in insulin production, insulin action, or both. Despite advances in DM diagnosis and management, the incidence of DM-related complications remains high [2].   It is becoming more clear that treating the major consequences of diabetes, in addition to curing the current global epidemic, is necessary in the majority of individuals with both type 1 and type 2 diabetes [3]. DM will be a leading cause of morbidity and mortality in the future, the goal of treatment for DM is to prevent mortality and complications by normalizing blood glucose levels. However, blood glucose levels might be increased despite appropriate therapy resulting in complications, such as disturbances in fat metabolism, nerve damage and eye disease [4].   Common complications of diabetes include dysfunctions in the kidney, retina, cardiovascular system, neurons and liver; once again, there are no effective treatments to restore organ damage [5].   Saudi Arabia has the fourth highest incidence of Type 1 Diabetes Mellitus (T1DM) in the world and the highest DM incidence in the Middle East and North Africa (MENA) area, with a prevalence rate of 17.7 percent [6]. The main goals of primary care are to stop diabetic ketoacidosis from getting worse and to reduce the chance of cerebral edema, a rare but potentially fatal complication. The pathogenesis of diabetic ketoacidosis has recently been discussed, including the role of insulin insufficiency, altered glucose metabolism and acid-base abnormalities, severe diabetic ketoacidosis therapy is not without difficulties [7]. Technological developments and monitoring methods have also made it possible to regulate fluid and electrolyte imbalances, insulin therapy and other adjuvant medications more precisely [8].   Since 2017, the charity has been conducting an annual assessment of the general public's understanding of DM and physical activity. The emphasis on learning about physical activity in conjunction with DM stems from the significance of physical activity in managing and preventing DM and the government's prioritization of physical activity in interventional initiatives [9].   Rationale and Knowledge Gap The knowledge about diabetes complications by diabetic patients helps to manage stressful situations. This has been found to lessen diabetic complications. Given the evidence that persons with diabetes frequently lack sufficient understanding regarding the disease's related complications, health education is seen as a crucial element in enhancing knowledge and altering behavior.   Objective Consequently, the primary aim of this study is to know to what extent diabetic patients are aware and perceptive of diabetes complications in the Northern Border region, Saudi Arabia.   Hypothesis Null hypothesis: Diabetic patients have knowledge and awareness about diabetes complications. Alternative hypothesis: Diabetic patients don’t have knowledge and awareness about diabetes complications

Study Design and Participants A quantitative cross-sectional study was conducted in the Northern Border region, Saudi Arabia including adult diabetic patients above 18 years of both genders living in Northern Border region Saudi Arabia, who agreed to complete the survey, were selected through convenient sampling. While the exclusion criteria were living outside the Northern Border region and refusing to complete the survey. The study lasted 7 months.   Using social media sites, a questionnaire was distributed anonymously through an online survey tool [1]. It was developed in Arabic and delivered following the reading and acceptance of informed permission. Pilot was studied and applied by the investigators. The questionnaire covered the following data: patients’ socio-demographic characteristics like age, gender, nationality, education, occupation and family history of diabetes. The second section covered the parameters related to clinical characteristics of participants like the type of diabetes, duration of diabetes, in addition to, the management of blood sugar level. The third one covered participants’ awareness toward diabetic complications in Northern Border region Saudi Arabia such as retinopathy, renal failure and neuropathy.   There was no risk to the participants because it was a descriptive study that helped to determine the awareness of diabetic complications among general population in Northern Border region Saudi Arabia. There is no direct benefit for the patients. However, it might have an indirect benefit for them.   Ethics Approval of Research Before the study began, ethical clearance was requested from the College of Medicine's Ethical Committee (HAP-09-A-043) and issued by Northern Border University's decision no. (26-24-H), dated on 18/3/2024.   Sample Size and Data Analysis Using the Raosoft® calculator, we calculated a sample size of 385 participants with a 50% expected response distribution, a 5% margin of error, a 95% confidence level and a significance level of 5% [10]. To determine the feasibility, applicability and clarity of the tool, a pilot research was carried out on 10% of the collected sample. No changes were made to the study. Data analysis was done using SPSS (version 26) and remained anonymous because the questionnaire does not include any personal information that may be used to identify a participant, such as a name, ID number, or other specific information. The Chi Square test was used to examine the connection. Qualitative variables are represented in the figures as percentages and numerical values (mean, frequency, etc.). Every test utilized in the study had a significance level of 0.05.

Table 1 displays various demographic parameters of the participants with a total number of 385. The age distribution reveals a predominantly older demographic, with 145 (37.7%) of participants over 40 years old, contrasted by a younger segment of 108 (28.1%) aged 18-25. This suggests a potential focus on the health concerns relevant to an aging population. Gender representation skews significantly towards males, comprising 247 (64.2%) of the sample, which may indicate a need for targeted health interventions that take into account male-specific factors. Nationally, most participants identified as Saudi (355, 92.2%), which highlights cultural and regional considerations that may influence health outcomes. Marital status indicates a well-established population, with 287 (74.5%) of participants being married, which could impact the perceived social support structures related to health management. Educational attainment demonstrates a high level of education, as 300 (77.9%) have obtained a university degree or higher, suggesting that the findings may reflect the health literacy levels associated with this educational background. Employment status reveals a strong inclination towards government work, with 247 (64.2%) employed in government roles, potentially linking economic stability to health access and outcomes. Geographically, most participants reside in Arar and Rafha, accounting for a combined (320, 83.1%), which may reflect regional health trends and accessibility to healthcare resources. Notably, 247 (64.2%) reported a family history of diabetes, emphasizing the importance of understanding genetic factors in health research, particularly in a region where lifestyle diseases are increasingly prevalent.   Table 1: Sociodemographic characteristics of participants (n = 385) Parameter N Percentage Age 18-25 108 28.1 26-35 71 18.4 36-40 61 15.8 More than 40 145 37.7 Gender Male 247 64.2 Female 138 35.8 Nationality Saudi 355 92.2 Non-Saudi 30 7.8 Marital state Single 87 22.6 Married 287 74.5 Divorced 8 2.1 Widowed 3 0.8 Educational status University or higher 300 77.9 Secondary school 68 17.7 Preparatory school 10 2.6 Primary school 5 1.3 Illiterate 2 0.5 Occupation An employee of a government company 247 64.2 Employee of a private work 46 11.9 Not working 92 23.9 City Arar 164 42.6 Rafha 156 40.5 Turaif 10 2.6 Al uwayqilah 5 1.3 Other 50 13 Is there a family history of Diabetes? Yes 247 64.2 No 138 35.8   Figure 1: Illustrates the duration of diabetes among participants   As shown in Figure 1, The data indicates that a significant proportion of participants, numbering (262,68.1%), have been living with diabetes for a duration between 1 and 5 years, which underscores a critical window for educational interventions aimed at promoting awareness of potential health risks. Conversely, the figures for individuals with diabetes spanning between 6 to 10 years (45, 11.7% participants) and more than 10 years (78, 20.3% participants) reveal a markedly diminishing representation, suggesting either a possible decline in the population of long-term diabetics or an alarming trend of complications arising in this demographic that warrants further investigation.   Table 2: Parameters related to clinical characteristics of participants (n = 385) Parameter N Percentage Type of diabetes Type 1 255 66.2 Type 2 130 33.8 Duration of diabetes Between 1 and 5 years 262 68.1 Between 6 and 10 years 45 11.7 More than 10 years 78 20.3 Do you measure your blood sugar regularly? Yes 216 56.1 No 169 43.9 How long have you had an HbA1C test? Every 3 months 180 46.8 Every 6 months 91 23.6 Annually 60 15.6 Others 54 14 Do you use a continuous glucose monitor (a small sensor that alerts you when your blood sugar levels are suddenly high or low) at home? Yes 190 49.4 No 195 50.6 Is a blood glucose meter in your home? Yes 232 60.3 No 153 39.7 Do you take your medications regularly as directed by your physician? Yes 270 70.1 No 115 29.9 How long do you visit your doctor? Monthly 2 0.5 Every 3 months 186 48.3 Every 6 months 98 25.5 Others 99 25.7 Having good information about diabetic complications? Yes 270 70.1 No 115 29.9 Do you follow a healthy balanced diet? Yes 231 60 No 154 40 Do you exercise regularly? 30 min daily 162 42.1 Twice per week 65 16.9 3 times per week 63 16.4 Others 17 4.4 No 78 20.3 In your opinion, is there a lack of education for diabetic patients about diabetic complication in Saudi Arabia? Yes 294 76.4 No 91 23.6   As illustrated in Table 2, the data presented provides a compelling overview of the clinical characteristics and health management behaviours of a cohort of 385 participants diagnosed with diabetes. Among those diagnosed, a significant majority (255, 66.2%) reported having Type 1 diabetes, contrasting with (130, 33.8%) who were diagnosed with Type 2 diabetes. The duration of diabetes among participants reveals that a considerable proportion, (262, 68.1%), has lived with the condition for between 1 and 5 years, which emphasizes the need for tailored educational interventions and support systems for relatively newly diagnosed patients. Moreover, the data highlight that only (216,56.1%) of participants regularly measure their blood sugar levels, which raises concerns about self-monitoring practices that are critical for effective diabetes management. Regarding HbA1C testing frequency, nearly half (180, 46.8%) of participants undergo testing every three months, a recommendation consistent with current clinical guidelines for diabetes care, while a substantial minority appears to be less compliant with testing protocols. The use of continuous glucose monitors remains evenly split, indicating a potential opportunity for increased patient education and access to such technology. Furthermore, the majority of participants (270, 70.1%) reported adherence to prescribed medication regimens, which is encouraging, yet nearly (115, 30%) do not meet medication adherence recommendations, highlighting an area for potential improvement in patient management strategies. Regular medical visits vary, with (186, 48.3%) attending every three months, which aligns with standard care recommendations, whereas a concerning (98, 25.7%) of participants indicated less consistent visits. The findings further illustrate participants' awareness of diabetic complications, with (270, 70.1%) reporting sufficient knowledge on this issue; however, a significant majority (294, 76.4%) expressed that educational resources for diabetic patients in Saudi Arabia are lacking. This feedback underscores a critical gap in diabetes education that could be addressed through enhanced community outreach and targeted educational programs designed to empower patients in managing their condition. Lifestyle factors also play a notable role; while (231, 60.0%) of participants claim to follow a healthy diet, exercise practices are relatively varied, with only (162, 42.1%) exercising daily for 30 minutes.   As shown in Figure 2, it is evident from the results that a significant majority of respondents, totaling 304(79%), acknowledged the correlation between diabetes and retinal complications that can ultimately result in blindness. This level of recognition underscores a commendable awareness within the community regarding the serious implications of diabetic conditions. However, it is also concerning that a notable minority-41 (10.6%) individuals indicated they do not recognize this risk, while another 40 (10.4%) respondents are unaware of the complications altogether. These figures highlight critical gaps in knowledge that could potentially hinder early intervention and preventative measures for those at risk.   Figure 2: Illustrates if the participants know that diabetes may affect the retina and lead to blindness   Table 3 reveals the participants' awareness of diabetic complications in the Northern Border region of Saudi Arabia provides insightful observations about public knowledge regarding diabetes-related health issues. Overall, the findings indicate a commendable level of awareness among the participants, with the majority recognizing critical complications such as retinopathy, nephropathy and cardiovascular issues as significant risks associated with diabetes. Specifically, a notable (304, 79.0%) of respondents acknowledged the risk of blindness related to diabetic complications affecting the retina, while (296, 76.9%) recognized the potential for kidney failure. However, the data also reveals areas of concern; for instance, only 234, (60.8%) of participants were aware of the relationship between diabetes and stroke and awareness was slightly lower regarding skin diseases (216, 56.1%) and recurrent infections (204, 53.0%). These figures suggest that while there is a broad understanding of the major complications, specific areas require enhanced educational efforts to thoroughly inform the public. Social media emerged as a prominent source of information (138, 35.8%), complemented by healthcare professionals (153, 39.7%); this underscores the importance of utilizing diverse platforms for disseminating health information.   Table 3: Participants’ awareness towards diabetic complications in Northern Border region Saudi Arabia (n = 385) Parameter N Percentage Do you know that diabetes complications affect the retina and lead to blindness? Yes 304 79 No 41 10.6 I don’t know 40 10.4 Do you know that diabetes complications affect the kidneys and lead to kidney failure? Yes 296 76.9 No 44 11.4 I don’t know 45 11.7 Do you know that diabetes complications affect the heart and lead to its failure? Yes 279 72.5 No 65 16.9 I don’t know 41 10.6 Do you know that one of the diabetes complications is that it causes nerve damage neuropathy? Yes 290 75.3 No 60 15.6 I don’t know 35 9.1 Do you know about the relationship of diabetes complications to stroke? Yes 234 60.8 No 99 25.7 I don’t know 52 13.5 Do you know about the relationship of diabetes to diabetic foot? Yes 286 74.3 No 66 17.1 I don’t know 33 8.6 Do you know about the relationship of diabetes to skin diseases? Yes 216 56.1 No 114 29.6 I don’t know 55 14.3 Do you know about the relationship of diabetes to fertility? Yes 230 59.7 No 105 27.3 I don’t know 50 13 Do you know that recurrent infection one of complications of diabetes? Yes 204 53 No 125 32.5 I don’t know 56 14.5 Do you know that gum disease is one of complications of diabetes? Yes 224 58.2 No 108 28.1 I don’t know 53 13.8 Do you know that diabetic ketoacidosis is a life-threatening emergency complication? Yes 26368.3 No 80 20.8 I don’t know 42 10.9 From where do you know about diabetes complications? Your doctor 15339.7 Awareness messages 73 19 Social media 138 35.8 Heath seminars affiliated with ministry of health 21 5.5 Table 4 shows that having good information about diabetic complications among diabetics has a statistically significant relation to age (p value = 0.010). It also shows statistically insignificant relation to gender, nationality, marital status, educational level, occupational status, city of residence, family history of diabetes, type of diabetes and duration of diabetes. Table 4: Relation between having good information about diabetic complications and sociodemographic characteristics Parameters Having information about diabetic complications Total p-value* No Percentage Yes Percentage N = 385 Percentage Gender Female 40 34.80% 98 36.30% 138 35.80% 0.777 Male 75 65.20% 172 63.70% 247 64.20% Age 18-25 21 18.30% 87 32.20% 108 28.10% 0.01 26-35 18 15.70% 53 19.60% 71 18.40% 36-40 24 20.90% 37 13.70% 61 15.80% More than 40 52 45.20% 93 34.40% 145 37.70% Nationality Saudi 104 90.40% 251 93.00% 355 92.20% 0.397 Non-Saudi 11 9.60% 19 7.00% 30 7.80% Marital status Single 19 16.50% 68 25.20% 87 22.60% 0.173 Married 94 81.70% 193 71.50% 287 74.50% Divorced 1 0.90% 7 2.60% 8 2.10% Widowed 1 0.90% 2 0.70% 3 0.80% Education level University or higher 84 73.00% 216 80.00% 300 77.90% 0.281 Secondary school 25 21.70% 43 15.90% 68 17.70% Preparatory school 2 1.70% 8 3.00% 10 2.60% Primary school 3 2.60% 2 0.70% 5 1.30% Illiterate 1 0.90% 1 0.40% 2 0.50% Occupation status An employee of a government company 68 59.10% 179 66.30% 247 64.20% 0.171 Employee of a private work 19 16.50% 27 10.00% 46 11.90% Not working 28 24.30% 64 23.70% 92 23.90% City Arar 42 36.50% 122 45.20% 164 42.60% 0.075 Rafha 49 42.60% 107 39.60% 156 40.50% Turaif 1 0.90% 9 3.30% 10 2.60% Al uwayqilah 1 0.90% 4 1.50% 5 1.30% Other 22 19.10% 28 10.40% 50 13.00% Is there a family history of Diabetes? Yes 67 58.30% 180 66.70% 247 64.20% 0.115 No 48 41.70% 90 33.30% 138 35.80% Type of diabetes Type 1 80 69.60% 175 64.80% 255 66.20% 0.367 Type 2 35 30.40% 95 35.20% 130 33.80% Duration of diabetes Between 1 and 5 years 80 69.60% 182 67.40% 262 68.10% 0.698 Between 6 and 10 years 11 9.60% 34 12.60% 45 11.70% More than 10 years 24 20.90% 54 20.00% 78 20.30%

DM can lead to various complications that affect multiple systems throughout the body. Among the most significant and chronic complications associated with DM are conditions such include coronary artery disease, nephropathy, diabetic neuropathy and retinopathy.   Each of these complications poses serious health risks and necessitates appropriate medical management and intervention [11]. For instance, research revealed that a notable 35% of individuals with DM in Saudi Arabia are affected by diabetic neuropathy. The study indicated that patients exhibiting poor adherence to their prescribed treatment regimens had a significantly higher likelihood of developing this neuropathic condition [12]. Furthermore, diabetic foot ulcers represent another critical complication of DM that not only leads to significant health problems but also imposes a considerable economic burden due to the associated healthcare costs and partial disability experienced by patients [13]. A comprehensive cross-sectional analysis involving 62,681 individuals with DM, sourced from the Saudi National Diabetes Registry (SNDR), indicated that approximately 3.3% of these patients experienced complications related to diabetic foot [14]. Several risk factors have been identified that increase the likelihood of developing diabetic foot complications, including male sex, the presence of cerebral vascular disease, inadequate glycaemic control, use of insulin therapy and advanced age [15]. A scarcity of information is observed in the literature regarding awareness of diabetic retinopathy among the diabetic individuals in Northern Border, Saudi Arabia. Our study aims to determine the level of awareness of DM and its complications among the general population of Northern Border, Saudi Arabia.   Our study findings show a commendable level of awareness among the participants as the majority of participants (270, 70.1%) reported adherence to prescribed medication regimens, with the majority recognizing critical complications such as retinopathy, nephropathy and cardiovascular issues as significant risks associated with diabetes. Specifically, a notable (304, 79.0%) of respondents acknowledged the risk of blindness related to diabetic complications affecting the retina, while (296, 76.9%) recognized the potential for kidney failure. However, the data also reveals areas of concern; for instance, only (234, 60.8%) of participants were aware of the relationship between diabetes and stroke and awareness was slightly lower regarding skin diseases (216, 56.1%) and recurrent infections (204, 53.0%).   The findings further illustrate participants' awareness of diabetic complications, with (270, 70.1%) reporting sufficient knowledge on this issue; however, a significant majority (294, 76.4%) expressed that educational resources for diabetic patients in Saudi Arabia are lacking. Similarly, a cross-sectional study involving 439 diabetic patients in the Al Jouf and Hail regions, revealed that a significant majority (75.62%) possessed awareness regarding the ocular complications associated with diabetes [16]. As compared to other literature, our findings are marginally higher than the findings from the study conducted in India (50%) [17], the USA (52%) [18] and Oman (72%) [19]. conversely, it was lower than the figures reported in Japan (98%) [20] and Australia (96%) [21].   In a separate cross-sectional descriptive study that focused on 45 healthcare professionals managing diabetes at a tertiary eye hospital in central Saudi Arabia, the findings indicated that, within the preceding year, merely one-third of the participants had undergone screening for diabetic retinopathy. Furthermore, only 29% demonstrated a high level of knowledge concerning diabetic retinopathy and the associated ocular complications of diabetes mellitus [22]. Similarly, another study was carried out a cross-sectional study to evaluate the understanding of DM risk factors among diabetic patients in Arar region, recruiting 702 participants using a systematic random sampling approach. Among these individuals, 12.4% attributed DM to the excessive consumption of sweets. The overall awareness regarding complications of DM was found to be insufficient, with only 24.5% recognizing the potential for retinopathy and a mere 8.3% understanding the risks of sensory loss and numbness in the extremities [23].   Our findings also show that having good information about diabetic complications among diabetics has a significant relation to age (p value = 0.010) with younger patients showing higher knowledge (18-25 years old) similar to a study in Asir region, patients between the ages of 25 and 35 had better awareness levels than patients over the age of 50, with a statistically significant difference (p = 0.049) [1], 48.5% of patients were aware of DM problems; however, elderly patients in their study had higher knowledge levels [24]. In addition, our findings show statistically insignificant relation to gender, nationality, marital status, educational level, occupational status, city of residence, family history of diabetes, type of diabetes and duration of diabetes in contrast to another study showed that a significant positive association between receiving any form of education (general or professional) and higher knowledge [25].   Future Recommendations Given the increasing prevalence of diabetes and its complications globally, it is imperative that public health strategies in Saudi Arabia focus on improving knowledge dissemination regarding diabetes-related health risks. Implementing targeted community outreach, expanding access to educational materials and leveraging both healthcare professionals and digital platforms could significantly bolster awareness and ultimately improve health outcomes for diabetic patients. Future research should continue to explore the factors influencing awareness and compliance to generate tailored interventions that address both the needs and challenges faced by this population. Through improved education and awareness, we have the potential to mitigate the burden of diabetes complications and enhance the quality of life for individuals living with this chronic condition. In addition, these patients need to increase doctor visits, follow instructions, prescribed medications and continue assessment of their health-related consequences.

In conclusion, this study provides crucial insights into the awareness of diabetes complications among adult diabetic patients above 18 years of both genders in the Northern Border region of Saudi Arabia. The findings indicate a commendable level of overall awareness, with a significant proportion of participants recognizing critical complications such as retinopathy, nephropathy and cardiovascular diseases. Notably, approximately (304, 79.0%) of respondents acknowledged the risk of blindness related to diabetic retinopathy, while (296, 76.9%) recognized the potential for kidney failure. However, the study also highlights important gaps in awareness, particularly regarding less recognized complications such as stroke, skin diseases and recurrent infections, which were noted by only 234, 216, 204(60.8%, 56.1% and 53.0%) of participants, respectively.   To enhance diabetes awareness, diabetes screening must be done regularly at every annual checkup, especially for those at high risk. and health care providers must take an active role in educating diabetes. Policymakers should put plans that focus on preventing diabetes, such as programs promoting healthy eating, exercise and weight management in schools and communities and can also distribute them using various media platforms. The sociodemographic distinctions between rural and urban populations may explain for some of the variations in the availability and utilization of health information sources. There can be systemic obstacles like a lack of specialized physicians and restricted.   Acknowledgments The authors extend their appreciation to the Deanship of Scientific Research at Northern Border University, Arar, KSA for funding this research work through project number NBU-FFR-2024-3172-04”