Telecom provider in the US offering Internet, TV and Voice to both consumer and residential. 13.7 million access lines in 37 states; 6.8 million broadband subscribers; 54 data centers.
Company has flat to slight decline in growth.
Down 30% over the last year, 17% in the last 3 months.
Company cut its dividend in February 2013 and is now trading back down to the pre-cut dividend yield.
As a Canadian I don't know the product offering well like I would Telus / Rogers /Bell, it would be interesting to get someone else's views.
Is the potential for a goodwill write down scaring people away?
I am now invested in both companies and i endorse it as a strong income-investment (app 9 % payout by dividends) with huge upside potential: app 35 % till end of 2017.
I am invested in LVLT long time, but was not in CTL in the past. When the detailed news about the acquisition came out, LVLT surged and CTL tanked, till CTL had a pricelevel with a dividendrate of nearly 10%. 22 US$ to 2,16 annual dividend in first days of November 2016. This was the moment when i also started to add CTL. Over the time - till now - i added app the same amount of money in CTL, that i have invested in LVLT. I think the whole position is hedged in that way (? ) , for the case the acquisition will fail.
Why: In the future the whole dividend amount to pay out is app. 2,4 B $ per year. (CTL payed out 1,2 B in 2015, so concerning the future company 51:49:CTL:LVLT its app 2,4B$). The combined company is strong enough to do so. LVLT (which never paid out any $ dividend in the past) will bring in 1,1 B $ FCF. The synergies are estimated app 0,9 B $ and further CTL did share buybacks per year of app. 0,8 B $ in 2013/14/15. So to my mind .... no problem to stem the 2,4 B$.
Now some negative aspect: soft shrinking revenue at CTL and stagnating or slow growing revenue at LVLT. Concerning LVLT there were several announcements that they expect the revenue increasing over time.. so we will see.. If that happens LVLT and CTL will surge even more to my opinion. Higher interest rates could effect the company cause of the debt.
Further - in summary - the whole company seems cheap to me, with a marketcap of 35B $ combined. I have in my mind that just LVLT invested 90 B $ for their fiber net. Marketcap of 35B$ compared to 4B$ from FCF and synergies, partly used for dividends/buybacks seems very attractiv to me.
Everytime, I hear this message, I tend to run for the exit.
Valuehalla - are you ValueCarl from the original Level 3 posts?
Honestly, I have no position either way. I looked at Level 3 back in the day, I saw the value of the infrastructure, but (stupidly) I never bit.
Hi Ballinvarosig, no..I am not ValueCarl, just entered the forum a few days ago.
But I suggest to invest 50 % in LVLT and 50 % in LVLT. If the acquisition will fail, i think CTL price will rise and LVLT will tank. I have no doubt, that even CTL alone is able to pay the dividend.
On 8th Feb both companies will publish Q4 figures. I plan to swap a positions of LVLT into CTL before 28th Feb. Likely 28th Feb is the ex-div-day for CTL. The lower the CTL price the better the swap.
Definitely not ValueCarl... his signature would have been LVLT^10.
Hi Spekulatius - Any serious theory why you prefer to run to the exit in case of CTL/LVLT or it was just a funny country saying, without any connection to my investmentproposal?
No Valuehalla, my zero-value post above was mostly just a joke for those of us who remember ValueCarl, a different poster who loved LVLT with all of his heart / soul.
I think Spek's comment above is very clear, so not sure what you were asking him.... He expressed no opinion on CTL/LVLT, but when people start making comments (which he quoted for clarity) that the "dividend is safe" that is generally when it no longer is safe.
I owned LVLT briefly years back for a nice gain, but haven't followed for years, I will step out of your discussion now.
Nothing more to say on LVLT / CTL, good luck!


Apparently, Google is forking Webkit and going it's own direction which they're calling "Blink" because of architectural differences and they felt development was moving forward too slowly. Thankfully, this doesn't mean more browser extensions. Surprisingly, Opera, who just recently announced (Feb 2013) they were moving from their own presto engine to webkit has decided to adopt Blink.


Hinted to, mulled over, discussed and grumbled about, the Trump administration steadily continues in its efforts to hollow out Obamacare with a mandate – effective immediately – that will enable many corporations the ability to "opt out" of providing female employees birth control.
Controversial when initially instated under Obama, and not ceasing to inflame the public with its new alterations, the rules regarding such coverage have been met with a decidedly conflicted response.
While this may be a victory for those who truly felt violated by the original policy, there are some aspects that seem to have been overlooked.
For example, it is not as if the original did not allow for exceptions; religious institutions, like churches, were not forced to comply with the supplying of contraceptives. Their workers, at the same time, were still able to notify the government and get the desired product via their insurance company.
Employees received the benefits and their superiors didn't have to be involved in it – religion and the needs of the individual both appeared to be met.
Now, many feel slighted by the revision in that it strips this provision away and gives employers more opportunity to deny coverage. The National Women's Law Center is up in arms and ready to challenge these rules and take legal action, describing them as both unfair and discriminatory.
This issue became especially concerning, and personal, to women who suffer conditions like endometriosis or polycystic ovarian syndrome, disorders they were previously able to treat with birth control but are now uncertain about the financial future of attaining it.
On the other hand, some degree of perspective needs to be preserved.
These changes aren't so drastic as to deny the right to birth control – it's just something that can no longer be obtained for free in some cases. People with legitimate, viable moral objections will no longer be required to cover something they don't believe in, and the majority of women are not expected to be affected by this decision.
It's unfortunate for those who may not have the means to afford this form of contraceptive, but many corporations have assured their employees they will continue to provide. Those who don't may find themselves in a position where they've lost employees to competitors that cater to the worker's needs, and perhaps this issue will resolve itself.
In the meantime, if things proceed as projected, and however many years pass while birthrates go up and resources are strained by a growing population entrenched in poverty, then maybe another set of rules will be released, and America will have another policy to divide over.


text:
<?php
/**
 * A test controller for themes.
 *
 * @package LydiaCore
 */
class CCTheme extends CObject implements IController {

  /**
   * Constructor
   */
  public function __construct() { parent::__construct();
    $this->views->AddStyle('body:hover{background:#fff url('.$this->request->base_url.'themes/base/img/grid_24_30_10.png) repeat-y center top;}');
  }

  /**
   * Display what can be done with this controller.
   */
  public function Index() {
    // Get a list of all kontroller methods
    $rc = new ReflectionClass(__CLASS__);
    $methods = $rc->getMethods(ReflectionMethod::IS_PUBLIC);
    $items = array();
    foreach($methods as $method) {
      if($method->name != '__construct' && $method->name != '__destruct' && $method->name != 'Index') {
        $items[] = $this->request->controller . '/' . mb_strtolower($method->name);
      }
    }

    $data = array(
      'theme_name' => $this->config['theme']['name'],
      'methods' => $items,
    );

    $this->views->SetTitle('Theme')
                ->AddIncludeToRegion('primary', $this->LoadView('index.tpl.php'), $data);
  }

/*
    $this->views->SetTitle(t('Home'))
                ->AddIncludeToRegion('primary', $this->LoadView('index.tpl.php'))
                ->AddIncludeToRegion('sidebar', $this->LoadView('sidebar.tpl.php')
    );
*/

  /**
   * Put content in some regions.
   */
  public function SomeRegions() {
    $this->views->SetTitle('Theme display content for some regions')
                ->AddString('This is the primary region', array(), 'primary');

    if(func_num_args()) {
      foreach(func_get_args() as $val) {
        $this->views->AddString("This is region: $val", array(), $val)
                    ->AddStyle('#'.$val.'{background-color:hsla(0,0%,90%,0.5);}');
      }
    }
  }

  /**
   * Put content in all regions.
   */
  public function AllRegions() {
    $this->views->SetTitle('Theme display content for all regions');
    foreach($this->config['theme']['regions'] as $val) {
      $this->views->AddString("This is region: $val", array(), $val)
                  ->AddStyle('#'.$val.'{background-color:hsla(0,0%,90%,0.5);}');
    }
  }

  /**
   * Display text as h1h6 and paragraphs with some inline formatting. OBSOLETE
   */
  public function H1H6() {
    $this->views->SetTitle('Theme testing headers and paragraphs')
                ->AddIncludeToRegion('primary', $this->LoadView('h1h6.tpl.php'));
  }

  /**
   * Display text to view typographic settings
   */
  public function Typography() {
    $this->views->SetTitle('Theme typography testing')
                ->AddIncludeToRegion('primary', $this->LoadView('typography.tpl.php'))
                ->AddIncludeToRegion('sidebar', $this->LoadView('typography_sidebar.tpl.php'));
  }

}

redpajama_set_name: RedPajamaGithub


text:
Glycaemic control for people with type 2 diabetes in Saudi Arabia – an urgent need for a review of management plan
Mohammed J. Alramadan1,
Dianna J. Magliano1,2,
Turky H. Almigbal3,
Mohammed Ali Batais3,
Afsana Afroz1,
Hesham J. Alramadhan4,
Waad Faozi Mahfoud5,
Adel Mehmas Alragas6 &
Baki Billah1
The aim of this study was to assess inadequate glycaemic control and its associated factors among people with type 2 diabetes in Saudi Arabia.
A cross-sectional study design was used. Adults with type 2 diabetes attending diabetes centres in Riyadh, Hofuf and Jeddah cities were interviewed and their anthropometrics were measured. Their medical records were also reviewed to collect information related to recent lab tests, medications, and documented comorbidities. Multivariable logistic regression were used for data analysis.
A total of 1111 participants were recruited in the study. Mean age was 57.6 (±11.1) years, 65.2% of the participants were females, and mean HbA1c was 8.5 ± 1.9%. About three-fourths of participants had inadequate glycaemic control (≥ 7%). Multivariable analysis showed that age ≤ 60 years, longer duration of diabetes, living in a remote location, low household income, low intake of fruits and vegetable, low level of physical activity, lack of knowledge about haemoglobin A1c, high waist-hip ratio, low adherence to medication, and using injectable medications were independent risk factors for inadequate glycaemic control.
Inadequate glycaemic control is prevalent among people with type 2 diabetes in Saudi Arabia. In order to improve glycaemic control diabetes management plan should aim at controlling the modifiable risk factors which include low intake of fruits and vegetable, low level of physical activity, lack of knowledge about haemoglobin A1c, high waist-hip ratio, and low adherence to medications.
Diabetes mellitus is a major worldwide public health issue. A recent study showed that the prevalence of diabetes mellitus in Saudi Arabia was 13.4% [1], which is higher than the global prevalence of 8.8% and the prevalence in the Middle East of 10.7% [2]. In fact, Saudi Arabia is among the countries with the highest prevalence of diabetes regionally and globally [2], and the prevalence of diabetes in the country is on the rise [3].
The primary goal of the management of diabetes is to maintain blood glucose levels within or close to normal ranges [4]. It is well established that elevated blood glucose level increases the risk of diabetes complications and mortality [5, 6], while intensive glycaemic control substantially lower the risk [7, 8]. Unfortunately, studies from Saudi Arabia showed that half to two-thirds of people with type 2 diabetes mellitus (T2DM) have poor glycaemic control [9,10,11,12,13], and the prevalence of diabetes complications is higher than the global and regional prevalence [14,15,16].
A few studies have examined risk factors of poor glycaemic control among people with T2DM in Saudi Arabia [9, 10, 12, 13, 17]. Many of these studies were limited to a small geographical location and included a relatively small cohort of participants. In addition, some of these studies used random or fasting blood sugar test to assess glycaemic control which is not as accurate as the glycated haemoglobin A1c (HbA1c) level that measures the control over a number of weeks [4]. Moreover, not all potential risk factors of poor control were explored in the previous studies. A systematic review and meta-analysis showed that among other factors, diet and physical activity were significantly associated with glycaemic control [18]. Studies from Saudi Arabia, however, did not adequately explore the effect of physical activity and eating habits.
To achieve glycaemic control goals among people with T2DM, all possible associated risk factors of inadequate control must be identified and considered in the management. The aim of this study was to assess the current status of glycaemic control and to identify risk factors for inadequate control among people with T2DM in Saudi Arabia.
This study was conducted as a part of a research project that examined the status of glycaemic control, diabetes complications and quality of life for people with T2DM in Saudi Arabia. The study methodology has been described in detail in another article [19]. Ethical approval was obtained from the Monash University Human Research Ethics Committee in Australia and the Research Ethics Committee of the Ministry of Health in Saudi Arabia. All the study procedures were carried out in accordance with the principles of the Declaration of Helsinki as revised in 2013.
The study population were people with T2DM aged 18 years and over who were followed up at diabetes centres in three major cities (Hofuf, Riyadh, and Jeddah) in Saudi Arabia. The plan was to recruit 1082 participants based on a sample size calculation with 90% power, 5% significance level, a margin of error of 2.5%, and a prevalence of poor glycaemic control of 50% [9, 20]. Inclusion criteria include documented diagnosis of T2DM, aged 18 years and above, and duration of diabetes of at least 1 year. Pregnant women and participants who did not have a HbA1c test within 1 year were excluded.
Participants were selected randomly from consecutive attendees of the diabetic centres between May 15 and November 30, 2017. After explaining the study and obtaining informed consent in writing, participants were interviewed using a pre-tested structured electronic questionnaire through Research Electronic Data Capture (REDCap) application [19, 21]. The questionnaire collects information related to socio-demographics, lifestyle, medical history, cognitive function, anxiety and depression. Socio-demographic data include gender, date of birth, marital status, education, and income. Lifestyle data include smoking status, physical activity (Global Physical Activity Questionnaire (GPAQ) [22]), and dietary habits. The dietary habit section included 10 questions selected from the UK diabetes and diet questionnaire (UKDDQ) [23] with some modifications to make some points more suitable for the eating habits of the Saudi population. The dietary questions include the frequency of consuming fruits, vegetables, red meat, desserts, date, sugary drinks, butter, bread, and rice and the fat content of consumed milk. The dietary habit variable was measured as a scale between zero and 48, where high score means the individual is following healthy eating habits. Medical history data include the duration of diabetes, modality of treatment, follow-up centre, other comorbidities, medication adherence (the 4-item Morisky Medication Adherence questionnaire) [24], family support in regards to diet and physical activity, and peripheral neuropathy (the Michigan Neuropathy Screening Instrument) [25]. Mental status data include anxiety (Generalized Anxiety Disorder Scale (GAD-2)) [26], depression (the Patient Health Questionnaire-2 (PHQ-2)) [27], and cognitive function (Rowland Universal Dementia Assessment Scale (RUDAS)) [28]. The establishers' permission to use the above-mentioned tools was obtained.
After interviewing participants, their anthropometrics were measured and recorded. Blood pressure was measured three times after sitting for at least 10 min using the Omron BP742N5 Series Upper Arm Blood Pressure Monitor with a cuff that fits standard and large arms. Weight was measured after instructing participants to remove their shoes and outer layers of clothing. Height, waist circumference, and hip circumference were measured twice and if the measurement varied by more than 2 cm, a third measurement was taken. Waist and hip circumference were measured against thin clothing. Participants' medical records were reviewed for most recent lab test results, namely HbA1c, creatinine, cholesterol, high density lipoprotein (HDL), low density lipoprotein (LDL), and triglycerides. Information regarding currently prescribed medication, and documented diagnosis of hypertension, coronary artery disease, retinopathy, and stroke was also collected from medical records.
Glycaemic control was categorised into controlled (HbA1c < 53 mmol/mol (< 7%)), partially controlled (HbA1c 53–63 mmol/mol (7% to < 8%)), and poorly controlled (HbA1C ≥ 64 mmol/mol (≥ 8%)) [4]. A HbA1c cut-off value of > 68 mmol/mol (≥ 9%) was also used to represent very poor control [29]. Using the Global Physical Activity Questionnaire (GPAQ) [22], the total number of minutes of physical activity per week was categorised into ≥150 min and < 150 min [4]. Treatment modalities was categorized as oral tablets only, injectable medications (insulin and glucagon-like peptide-1 receptor agonists) only, and combined (oral tablets and injectable medications). Using the Morisky Medication Adherence questionnaire [24] medication adherence was categorized into adequate (a score of zero), and inadequate (a score of one or more). Hypoglycaemia was defined as episodes of mild or severe hypoglycaemia symptoms including hunger sweating, light headedness, headache, shaking, trembling, weakness, dizziness, confusion, loss of consciousness, and seizures. Family support in regards to healthy diet and physical activity was categorised as good support if healthy diet and physical activity were encouraged all the time, inadequate support if encouragement was sometimes, and poor support if family members rarely or never encouraged healthy diet or physical activity. Participants were considered unaware of HbA1c if they had not heard of HbA1c before or they did not know the recommended HbA1c target for people with diabetes. Body Mass Index (BMI) was categorised according to the current World Health Organization guidelines into normal (< 25.0 kg/m2), pre-obesity (25.0–29.9 kg/m2), and obesity (class I, II and II ≥ 30.0 kg/m2). High waist-hip ratio was defined as a ratio of > 0.96 for men and > 0.98 for women [30]. Hypertension was defined as either a documented diagnosis of hypertension, taking antihypertension medications, or three previous high blood pressure readings (systolic ≥140 or diastolic ≥90) [4]. Dyslipidaemia was defined as any of the following: total cholesterol > 4.0 mmol/L (154.7 mg/dl), LDL > 2.0 mmol/L (77.3 mg/dl), triglycerides > 2.0 mmol/L (177.1 mg/dl), or HDL < 1.0 mmol/L (38.7 mg/dl) [31]. Impaired cognitive function was defined as a score of ≤22 in the Rowland Universal Dementia Assessment Scale (RUDAS) [28]. Depression was defined as a score of three and more using the Patient Health Questionnaire-2 (PHQ-2)) [27]. Anxiety was defined as a score of three and more using the Generalized Anxiety Disorder Scale (GAD-2)) [26]. Macrovascular complications were defined as having one of the following: documented diagnosis of stroke (irreversible cerebrovascular accident), documented diagnosis of coronary artery disease, taking medication for coronary artery disease, underwent a procedure for coronary artery disease, or self-reported lower extremity ulcers or amputations. Microvascular complication was defined as having one of the following: documented diagnosis of retinopathy, the participant had been told by an ophthalmologist that he or she had retinopathy, a score of seven or more using the Michigan Neuropathy Screening Instrument [25], or estimated glomerular filtration rate ≤ 60 ml/min/1.73m2 calculated from serum creatinine using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation [32, 33].
Stata SE version 15.0 was used for data analysis. Data were summarised and presented as a mean (± standard deviation) for numerical data and frequency and percentage for categorical data. ANOVA and chi-square tests were used to examine univariate associations between risk factors and levels of glycaemic control. Potential risk factors with a p-value of 0.2 from univariate analysis were entered into multivariable logistic regression with step wise variable selection [34]. In the regression analysis, glycaemic control was categorised into controlled (HbA1c < 53 mmol/mol (< 7%)) and inadequately controlled (HbA1c ≥ 53 mmol/mol (≥ 7%)). The determinants were also examined for very poor glycaemic control (HbA1c > 68 mmol/mol (≥ 9%)). A p-value of 0.05 or less was considered as statistical significant.
A total of 1111 participants were recruited in this study; 624 participants (56.2%) were from Riyadh, 239 (21.5%) were from Hofuf, and 248 (22.3%) were from Jeddah. Four hundred and-fifty participants (40.5%) were followed up at diabetes centres only, while 125 participants (11.3%) were followed up at both diabetes centres and hospitals and 535 participants (48.2%) were followed up at both diabetes centres and primary healthcare centres. Mean age was 57.6 (±11.1) years, mean duration of diabetes was 13.9 (±8.4) years, and 65.2% (724) of the participants were females, while 34.8% (387) were males. Mean body mass index was 32.9 (±8.1) kg/m2. Mean HbA1c was 69.4 (±15.5) mmol/mol (8.5% (±1.9%)), and 24.1% of participants had good glycaemic control (HbA1c < 53 mmol/mol (< 7%)), 21.7% had partial control (HbA1c 53–63 mmol/mol (7–7.9%)), and 54.2% had poor control (HbA1C ≥ 64 mmol/mol (≥ 8%)). None of the study participants were on insulin pump or continuous glucose monitoring.
Table 1 summarises participants' demographic and lifestyle characteristics by different levels of glycaemic control. There was a higher prevalence of poor glycaemic control among those with lower levels of education (p-value: < 0.001), living in a remote place (p-value: 0.002), and not working including house-wives (p-value: 0.005). A higher proportion of those aged 60 years and younger had poor glycaemic control, however, the association was not statistically significant in univariate analysis. Similarly, gender, nationality, household income, and region were not significantly related to glycaemic control. Regarding lifestyle factors, there was no difference in the mean of healthy eating habit score among different categories of glycaemic control. However, higher proportions of those with less than daily intake of fruits and vegetables had poor glycaemic control (p-value: 0.011). Similarly, higher proportions of those with physical activity less than 150 min per week had poor control (p-value: 0.032). Mean number of sitting hours and smoking did not differ significantly among the categories of glycaemic control.
Table 1 Demographic and lifestyle characteristics by level of glycaemic control
The association between various clinical characteristics and glycaemic control are presented in Table 2. Higher proportions of poor control were among people with longer duration of diabetes (p-value: < 0.001), and who were taking injectable medications (p-value: < 0.001), followed up mainly at primary health care or diabetes centres (p-value: 0.019), used glucometer twice or more a week (p-value: 0.017), and were not aware of HbA1c or the recommended HbA1c target for people with diabetes (p-value: 0.016). Similarly, higher proportions of poor control were among those who had less frequent hypoglycaemia events (p-value: 0.016), macrovascular complications (p-value: 0.019), microvascular complications (p-value < 0.001), and high waist-hip ratio (p-value: 0.001). Other clinical characteristics including family history of diabetes, family support, hypertension, adherence to medication, depression, anxiety, cognitive function, dyslipidaemia, and body mass index, did not appear to have an association with glycaemic control.
Table 2 Clinical characteristics by level of glycaemic control
Figure 1 summarises the results of the multivariable logistic regression analysis. A total of 379 participants (34.1%) had very poor glycaemic control (HbA1c > 68 mmol/mol (> 9%)). Less than daily intake of fruits and vegetables increased the risk of inadequate and very poor control by 60% and 79% respectively. Low level of physical activity was associated with 48% and 62% higher risk of inadequate and very poor control respectively. Inadequate knowledge of HbA1c was associated with 1.9-fold and 2.5-fold higher risk of inadequate and very poor control respectively. High waist-hip ratio increased the risk of very poor control by 72%, while frequent episodes of hypoglycaemia is associated with lower risk of both inadequate and very poor control. Other risk factors that were associated with inadequate and very poor control include younger age, longer duration of diabetes, remote location of residence, and using injectable medications with or without oral tablets.
Adjusted association between risk factors and inadequate (HbA1c ≥ 7%) and very poor (HbA1c ≥ 9%) glycaemic control. Variables introduced in the multivariable analysis were age, gender, education level, location of residence, work status, income, region, intake of fruits and vegetables, physical activity, duration of diabetes, treatment modality, glucometer use frequency, hypoglycaemia, follow-up location, adherence to medication, awareness of HbA1c, BMI, waist-hip ratio, macrovascular complications, microvascular complications and dyslipidaemia
Figure 2 illustrates the adjusted association between risk factors and inadequate control (HbA1c ≥ 7%) for people who were on oral tablets only as well as for those on injectable medications (with or without oral tablets). Among people on oral tablets the risk of inadequate control was higher by: 56% for low intake of fruits and vegetables, 50% for high waist-hip ratio, and by 55% for inadequate adherence to medication. Inadequate knowledge of HbA1c was associated with 2.1-fold increased risk among those on oral tablets, while frequent hypoglycaemia reduced the risk by 58%. Other risk factors of inadequate control among those on oral tablets include younger age and longer diabetes duration. For participants who were on injectable medications, low level of physical activity increased the risk of inadequate control by 2.1-folds, while high waist-hip ratio reduced the risk by 61%. Other risk factors of inadequate control among those on injectable medications were lower household income and followed up mainly at diabetes centres, while people from Jeddah appeared to have lower risk.
Adjusted association between risk factors and inadequate control (HbA1c ≥ 7%) by the modality of treatment. Variables introduced in the multivariable analysis were age, gender, education level, location of residence, work status, income, region, intake of fruits and vegetables, physical activity, duration of diabetes, treatment modality, glucometer use frequency, hypoglycaemia, follow-up location, adherence to medication, awareness of HbA1c, BMI, waist-hip ratio, macrovascular complications, microvascular complications and dyslipidaemia
In this current multi-centre study we have assessed the status of glycaemic control and its associated factors among people with T2DM attending diabetes centres in Saudi Arabia. One important finding was that only 24.1% of people with T2DM achieved the recommended HbA1c level of less than < 53 mmol/mol (< 7%), while the majority (75.9%) did not attained this target. Our findings, however, were comparable to the findings of recent studies from Saudi Arabia and other Arabian Gulf Countries [10,11,12,13, 35,36,37,38,39]. Despite quality health care services and various antidiabetic medications that are available for people with diabetes at no cost, the majority of people with T2DM in Saudi Arabia continue to have inadequate glycaemic control. A possible explanation could be the embracing of unhealthy lifestyle.
Sedentary lifestyle and the consumptions of processed, energy condensed, and fat-rich food have led to the increased prevalence of obesity and diabetes, and have made it difficult for people with diabetes to control their blood sugar. Recent studies showed that more than half of the Saudi population consumed less than one serving of fruits and vegetables per day [40], and 96.1% of them were physically inactive [41]. Furthermore, 51.0% of the adult Saudi population were either overweight or obese [42] and the prevalence of overweight and obesity among people with diabetes was significantly higher than the general population in the country [43, 44]. In addition, studies from Saudi Arabia found an association between low physical activity and poor glycaemic control [10, 13, 35], while a study from Bahrain [45], a country that shares boundaries and similar culture with Saudi Arabia, showed an association between unhealthy eating habits and higher HbA1c among people with T2DM.
Healthy eating habits and regular physical activity are key components in the management of T2DM. The current guidelines for people with diabetes recommend 8–10 servings of fruits and vegetables every day [4]. A serving of fruits is equal to a medium-size apple, orange, or banana, while a serving of vegetables is half a cup of corn, carrot or leafy vegetables. The guidelines also recommend at least 150 min of moderate to vigorous intensity physical activity per week [4]. The majority (77.5%) of participants in this study, however, did not eat fruits and vegetables daily, which has increased their risk of inadequate and very poor glycaemic control. Similarly, more than two-thirds of participants (70.5%) did not achieve the recommended length of time of physical activity per week even though walking for transportation and physical activities at work were included in measuring it. Results of this current study also showed that a low level of physical activity was an independent risk factor for inadequate and very poor glycaemic control. Continuous education programs emphasising the role of lifestyle modification in controlling blood glucose level will be of great benefit for people with T2DM in Saudi Arabia.
Previous studies have shown that the more knowledge of diabetes a person has the more likely that he or she will have lower HbA1c level [17, 46]. Though the participants' knowledge of the disease was not evaluated in this study, their awareness of HbA1c and its recommended level for people with diabetes was assessed as a proxy for knowledge of the disease. Only 31.9% of participants were aware of HbA1c and knew the recommended target (< 53 mmol/mol (< 7%)). The remaining participants either have not heard of HbA1c before (32.0%) or did not know the recommended HbA1c target (36.1%), which was associated with increased risk of inadequate and very poor control after adjustment for other risk factors. This finding is supported by the results of randomised control trials which showed that knowledge of actual and target HbA1c was associated with a significant reduction in HbA1c levels [47, 48]. In order to improve glycaemic control, physicians and health educators should ensure that people with diabetes are fully aware of their actual as well as the target HbA1c they should achieve.
Similar to studies conducted in the Arabian Gulf [49, 50] and other countries [18, 51] we found that younger age groups (≤60 years) were at higher risk of inadequate glycaemic control. Younger people are more likely to be affected by the change in lifestyle and less likely to be adherent to a management plan because of active occupational and social life [52]. Old people, in contrast, are less likely to be affected by the change in lifestyle and more likely to adhere to a management plan because they might be more concerned about their health, especially when they start to have comorbidities and complications [49]. Because of the beneficial effect of optimal glycaemic control on delaying complications, improving quality of life, and extending life expectancy among young people with diabetes [53], the management should aim at tight control once the diagnosis is made.
Another concerning finding of this study is that while the mean age of participants was 57.6 (±11.1) years (median: 57.8, 25th percentile: 51.8, 75th percentile: 63.9 years), they have a relatively long mean duration of diabetes of 13.9 (±8.4) years (median: 13.0, 25th percentile: 6.0, 75th percentile: 20 years). This indicates that the majority of people acquired diabetes in their early 40s. Early onset T2DM is associated with poor glycaemic control and a higher risk of comorbidities and complications [54]. With longer duration of T2DM, on the other hand, there is usually further deterioration of the function of the pancreas and the body's resistance to insulin increases, which makes it more difficult to control blood glucose level. The likelihood of acquiring diabetes complications also increases with longer duration, and complications can negatively affect the control either directly through inflammation and disturbance of the body's metabolism and indirectly through the effect of poly-pharmacy, anxiety, depression and stress. To prevent or delay diabetes and its complications, the healthcare system in Saudi Arabia should fully activate the screening programs and establish an intensive management protocols to identify and treat people at risk of diabetes.
Though BMI did not appear to affect glycaemic control, we found that a high waist-hip ratio was an independent risk factor for inadequate and very poor control. Similar findings were also observed in studies from Japan and the United States [55, 56]. In addition, compared to BMI, a high waist-hip ratio was found to have stronger association with cardiovascular disease among people with type 2 diabetes [57]. Waist-hip ratio is a more accurate measure of central obesity which is strongly linked with T2DM, poor glycaemic control, and cardiovascular disease [58]. Therefore, similar to BMI, waist-hip ratio should be measured and recorded for people with diabetes with every follow up visit, and health care providers should raise the awareness of people with diabetes about high waist-hip ratio and the risk associated with it.
We found that living in a remote village was a strong predictor of inadequate and very poor glycaemic control. People living in remote villages are likely to have a low level of formal education and are likely to have less access to fresh healthy food options. Because of accessibility issues, they limit their follow-up to the local primary health care centre and may not visit a specialised diabetes clinic or centre until the disease has progressed and they acquire complications. To improve the control among this susceptible group, the healthcare system should provide special diabetes education programs for healthcare providers working at remote places, and motivate them to use the online continuous education programs that are currently available and accredited by the Saudi Health System. General physicians working on remote sittings should also be provided with timely hotline or email access to specialists including endocrinologists, ophthalmologist and podiatrist. Patients, on the other hand, should have frequent teleconference or phone calls by diabetes educators, dietitians and other allied health professionals if these healthcare professionals are not assigned to the remote place where patients live.
Similar to other previous studies [18, 49, 50], our results showed that the use of injectable medications was a strong predictor for inadequate control. It is of concern that even after management with insulin, which is highly effective modality of treatment [59], a large proportion of people continued to have high blood glucose level. Low adherence to injectable medication regimen because of social stigmata, interference with daily activity, and fear of hypoglycaemia, have been suggested to increase the risk of poor control among people using injectable medications [60]. In Addition, the progression of the disease, weight gain related to insulin use, and polypharmacy can also contribute to poor glycaemic control among people with T2DM who are on injectable medications [61].
Our findings support the previous study that showed an association between inadequate glycaemic control and low income as well as low adherence to medications [18, 52, 62]. Low income decreases the likelihood of adherence to lifestyle modifications and treatment regimen [62], and low adherence to management plan is a known risk factors for poor glycaemic control [18, 52].
The association between hypoglycaemia and glycaemic control is of interest. Our findings showed that people with infrequent symptoms of hypoglycaemia were at higher risk of poor glycaemic control compared to those who had frequent symptoms of hypoglycaemic. This may indicate that while an intensive treatment regimen improve glycaemic control, it may come at the cost of frequent hypoglycaemia symptoms. Severe hypoglycaemia is associated with lower productivity, reduced quality of life, and a higher risk of anxiety, depression and mortality [63, 64]. Therefore, hypoglycaemia should be prevented, and the treatment should aim at achieving the lowest HbA1c level without severe hypoglycaemia episodes and a minimum number of mild hypoglycaemia symptoms [65].
The strength of this study lays on the relatively large sample size that was recruited from multiple centres from different regions of Saudi Arabia. The consideration of several potential risk factors and the use of a validated electronic questionnaire, which reduce data errors, also add strength to this study. This study, however, has some limitations. Cross-sectional study design lack temporality and causality cannot be inferred. Another limitation is that information regarding individualised glycaemic control targets could not be collected because it was not documented in participants' medical records. Therefore, a HbA1c cut off point of 7% was selected to categorise adequate control which is too strict for old people with longer duration of the disease and those who have advanced cardiovascular disease [4]. In addition, we could not investigate the effect of new anti-hyperglycaemic agents such as the glucagon-like peptide-1 (GLP-1) receptor agonists on glycaemic control because only a very small number of participants in our database were using them. Nonetheless, this study clearly revealed the burden of inadequate glycaemic control among people with T2DM in Saudi Arabia and its associated risk factors.
Inadequate glycaemic control is a common and widespread problem among people with T2DM in Saudi Arabia. Healthcare providers should undertake a patient-centred approach and individualise management strategies with consideration to all identified risk factors for inadequate control. Continuous education programs should also be implemented to raise the awareness of the disease and the importance of lifestyle modification. The healthcare system should prioritise diabetes prevention strategies through active screening and intensive management of people at risk. The health system should also take special measures to improve glycaemic control for people with diabetes living at remote locations. Future research should investigate the effectiveness of education programs targeting people with diabetes and barriers to adhering to lifestyle modifications.
eGFR:
Estimated glomerular filtration rate
HbA1c:
Glycated haemoglobin A1c
HDL:
High density lipoprotein
LDL:
Low density lipoprotein
T2DM:
El Bcheraoui C, Basulaiman M, Tuffaha M, Daoud F, Robinson M, Jaber S, et al. Status of the diabetes epidemic in the Kingdom of Saudi Arabia, 2013. Int J Pub Health. 2014;59(6):1011–21.
Cho NH, Kirigia J, Mbanya JC, Ogurstova K, Guariguata L, Rathmann W, et al. IDF DIABETES ATLAS eighth edition 2017. Int Diabet Fed. 2017:1–147.
Al-Quwaidhi AJ, Pearce MS, Sobngwi E, Critchley JA, O'Flaherty M. Comparison of type 2 diabetes prevalence estimates in Saudi Arabia from a validated Markov model against the international diabetes federation and other modelling studies. Diabetes Res Clin Pract. 2014;103(3):496–503.
American Diabetes Association. American Diabetes Association Standards of Medical Care in Diabetes-2017. The Journal of Clinical and Applied Research and Education. 2017;40.
Collaboration ERF. Diabetes mellitus, fasting glucose, and risk of cause-specific death. N Engl J Med. 2011;2011(364):829–41.
Klein R, Klein BE, Moss SE. Relation of glycemic control to diabetic microvascular complications in diabetes mellitus. Ann Intern Med. 1996;124(1_Part_2):90–6.
Ismail-Beigi F, Craven T, Banerji MA, Basile J, Calles J, Cohen RM, et al. Effect of intensive treatment of hyperglycaemia on microvascular outcomes in type 2 diabetes: an analysis of the ACCORD randomised trial. Lancet. 2010;376(9739):419–30.
Duckworth W, Abraira C, Moritz T, Reda D, Emanuele N, Reaven PD, et al. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med. 2009;360(2):129–39.
Al-Nuaim AR, Mirdad S, Al-Rubeaan K, Al-Mazrou Y, Al-Attas O, Al-Daghari N. Pattern and factors associated with glycemic control of Saudi diabetic patients. Ann Saudi Med. 1998;18(2):109–12.
Al-Hayek AA, Robert AA, Alzaid AA, Nusair HM, Zbaidi NS, Al-Eithan MH, et al. Association between diabetes self-care, medication adherence, anxiety, depression, and glycemic control in type 2 diabetes. Saudi Med J. 2012;33(6):681–3.
Alsulaiman TA, Al-Ajmi HA, Al-Qahtani SM, Fadlallah IM, Nawar NE, Shukerallah RE, et al. Control of type 2 diabetes in king Abdulaziz Housing City (Iskan) population, Saudi Arabia. J Family Community Med. 2016;23(1):1.
Almutairi MA, Said SM, Zainuddin H. Predictors of poor glycemic control among type two diabetic patients. Am J Med Medical Sci. 2013;3(2):17–21.
Alzaheb RA, Altemani AH. The prevalence and determinants of poor glycemic control among adults with type 2 diabetes mellitus in Saudi Arabia. Diabetes Metab Syndr Obes. 2018;11:15.
Alwakeel J, Sulimani R, Al-Asaad H, Al-Harbi A, Tarif N, Al-Suwaida A, et al. Diabetes complications in 1952 type 2 diabetes mellitus patients managed in a single institution. Ann Saudi Med. 2008;28(4):260.
Al Ghamdi AH, Rabiu M, Hajar S, Yorston D, Kuper H, Polack S. Rapid assessment of avoidable blindness and diabetic retinopathy in Taif, Saudi Arabia. Br J Ophthalmol. 2012;96(9):1168–72.
Halawa MR, Karawagh A, Zeidan A, Mahmoud A-E-DH, Sakr M, Hegazy A. Prevalence of painful diabetic peripheral neuropathy among patients suffering from diabetes mellitus in Saudi Arabia. Curr Med Res Opin. 2010;26(2):337–43.
Binhemd TA. Diabetes mellitus: knowledge, attitude, practice and their relation to diabetes control in female diabetics. Ann Saudi Med. 1992;12(3):247–51.
Sanal T, Nair N, Adhikari P. Factors associated with poor control of type 2 diabetes mellitus: a systematic review and meta-analysis. J Diabetol. 2011;3(1):1–10.
Alramadan MJ, Afroz A, Batais MA, Almigbal TH, Alhamrani HA, Albaloshi A, et al. A study protocol to assess the determinants of Glycaemic control, complications and health related quality of life for people with type 2 diabetes in Saudi Arabia. J Health Edu Res Develop. 2017;5(2):1–6.
Al-Turki YA. Blood sugar control, ophthalmology referral and creatinine level among adult diabetic patients in primary health care, Riyadh, Saudi Arabia. Saudi Med J. 2002;23(11):1332–4.
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81.
Armstrong T, Bull F. Development of the world health organization global physical activity questionnaire (GPAQ). J Public Health. 2006;14(2):66–70.
England CY, Thompson JL, Jago R, Cooper AR, Andrews RC. Development of a brief, reliable and valid diet assessment tool for impaired glucose tolerance and diabetes: the UK diabetes and diet questionnaire. Public Health Nutr. 2017;20(2):191–9.
Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care. 1986;24(1):67–74.
Moghtaderi A, Bakhshipour A, Rashidi H. Validation of Michigan neuropathy screening instrument for diabetic peripheral neuropathy. Clin Neurol Neurosurg. 2006;108(5):477–81.
Skapinakis P. The 2-item Generalized Anxiety Disorder scale had high sensitivity and specificity for detecting GAD in primary care. Evid Based Med. 2007;12(5):149.
Kroenke K, Spitzer RL, Williams JB. The patient health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41(11):1284–92.
Storey JE, Rowland JT, Conforti DA, Dickson HG. The Rowland universal dementia assessment scale (RUDAS): a multicultural cognitive assessment scale. Int Psychogeriatr. 2004;16(01):13–31.
Oglesby AK, Secnik K, Barron J, Al-Zakwani I, Lage MJ. The association between diabetes related medical costs and glycemic control: a retrospective analysis. Cost Eff Resour Alloc. 2006;4(1):1.
Al-Lawati JA, Barakat NM, Al-Lawati AM, Mohammed AJ. Optimal cut-points for body mass index, waist circumference and waist-to-hip ratio using the Framingham coronary heart disease risk score in an Arab population of the Middle East. Diab Vasc Dis Res. 2008;5(4):304–9.
Deed G, Ackermann E, Newman R, Audehm R, Arthur I, Barlow J, et al. General Practice Management of Type 2 Diabetes: 2014–15: Royal Australian College of General Practitioners (RACGP); 2014.
Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF, Feldman HI, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150(9):604–12.
Grams ME, Rebholz CM, McMahon B, Whelton S, Ballew SH, Selvin E, et al. Identification of incident CKD stage 3 in research studies. Am J Kidney Dis. 2014;64(2):214–21.
Billah B, Huq MM, Smith JA, Sufi F, Tran L, Shardey GC, et al. AusSCORE II in predicting 30-day mortality after isolated coronary artery bypass grafting in Australia and New Zealand. J Thorac Cardiovasc Surg. 2014;148(5):1850–5. e2
Al Baghli N, Al Turki K, Al Ghamdi A, El Zubaier A, Al Ameer M, Al Baghli F. Control of diabetes mellitus in the eastern province of Saudi Arabia: results of screening campaign. 2010.
Al-Rasheedi AAS. The role of educational level in glycemic control among patients with type II diabetes mellitus. Int J Health Sci. 2014;8(2):177.
Al Balushi KA, Al-Haddabi M, Al-Zakwani I, Al Z'a M. Glycemic control among patients with type 2 diabetes at a primary health care center in Oman. Prim Care Diabetes. 2014;8(3):239–43.
Al-Ibrahim AAH. Factors associated with compliance to diabetes self-care behaviors and glycemic control among Kuwaiti people with type 2 diabetes 2012.
Al-Kaabi J, Al-Maskari F, Saadi H, Afandi B, Parkar H, Nagelkerke N. Assessment of dietary practice among diabetic patients in the United Arab Emirates. Rev Diabet Stud. 2008;5(2):110–5.
Al-Hamdan N, Kutbi A, Choudhry A, Nooh R, Shoukri M, Mujib S. WHO stepwise approach to NCD surveillance country-specific standard report Saudi Arabia. In: Organization WH, editor. WHO Stepwise Approach. Geneva: WHO; 2005.
Al-Nozha MM, Al-Hazzaa HM, Arafah MR, Al-Khadra A, Al-Mazrou YY, Al-Maatouq MA, et al. Prevalence of physical activity and inactivity among Saudis aged 30-70 years. A population-based cross-sectional study. Saudi Med J. 2007;28(4):559–68.
Al Othaimeen A, Al Nozha M, Osman A. Obesity: an emerging problem in Saudi Arabia. Analysis of data from the National Nutrition Survey. East Mediterr Health J. 2007;13(2):441–8.
Al-Nozha MM, Al-Maatouq MA, Al-Mazrou YY, Al-Harthi SS, Arafah MR, Khalil MZ, et al. Diabetes mellitus in Saudi Arabia. Saudi Med J. 2004;25(11):1603–10.
Alqurashi K, Aljabri K, Bokhari S. Prevalence of diabetes mellitus in a Saudi community. Ann Saudi Med. 2011;31(1):19.
Shamsi N, Shehab Z, AlNahash Z, AlMuhanadi S, Al-Nasir F. Factors influencing dietary practice among type 2 diabetics. Bahrain Med Bull. 2013;35:3.
Tang YH, Pang S, Chan MF, Yeung GS, Yeung VT. Health literacy, complication awareness, and diabetic control in patients with type 2 diabetes mellitus. J Adv Nurs. 2008;62(1):74–83.
Cagliero E, Levina EV, Nathan DM. Immediate feedback of HbA1c levels improves glycemic control in type 1 and insulin-treated type 2 diabetic patients. Diabetes Care. 1999;22(11):1785–9.
Levetan CS, Dawn KR, Robbins DC, Ratner RE. Impact of computer-generated personalized goals on HbA1c. Diabetes Care. 2002;25(1):2–8.
Al-Lawati JA, Barakat MN, Al-Maskari M, Elsayed MK, Al-Lawati AM, Mohammed AJ. HbA1c levels among primary healthcare patients with type 2 diabetes mellitus in Oman. Oman Med J. 2012;27(6):465–70.
D'Souza MS, Karkada SN, Hanrahan NP, Venkatesaperumal R, Amirtharaj A. Do perceptions of empowerment affect glycemic control and self-care among adults with type 2 diabetes? Glob J Health Sci. 2015;7(5):80–90.
McBrien K, Manns B, Hemmelgarn B, Weaver R, Edwards A, Ivers N, et al. The association between sociodemographic and clinical characteristics and poor glycaemic control: a longitudinal cohort study. Diabet Med. 2016;33(11):1499–507.
Alramadan MJ, Afroz A, Hussain SM, Batais MA, Almigbal TH, Al-Humrani HA, et al. Patient-related determinants of Glycaemic control in people with type 2 diabetes in the Gulf cooperation council countries: a systematic review. J Diabet Res. 2018;2018:9389265.
Drewelow E, Wollny A, Pentzek M, Immecke J, Lambrecht S, Wilm S, et al. Improvement of primary health care of patients with poorly regulated diabetes mellitus type 2 using shared decision-making–the DEBATE trial. BMC Fam Pract. 2012;13(1):88.
Chuang L-M, Soegondo S, Soewondo P, Young-Seol K, Mohamed M, Dalisay E, et al. Comparisons of the outcomes on control, type of management and complications status in early onset and late onset type 2 diabetes in Asia. Diabetes Res Clin Pract. 2006;71(2):146–55.
Hsieh S, Yoshinaga H. Abdominal fat distribution and coronary heart disease risk factors in men-waist/height ratio as a simple and useful predictor. Int J Obes Relat Metab Disord. 1995;19(8):585–9.
Eberhardt MS, Lackland DT, Wheeler FC, German RR, Teutsch SM. Is race related to glycemic control? An assessment of glycosylated hemoglobin in two South Carolina communities. J Clin Epidemiol. 1994;47(10):1181–9.
Czernichow S, Kengne A-P, Huxley RR, Batty GD, De Galan B, Grobbee D, et al. Comparison of waist-to-hip ratio and other obesity indices as predictors of cardiovascular disease risk in people with type-2 diabetes: a prospective cohort study from ADVANCE. Eur J Cardiovasc Prev Rehabil. 2011;18(2):312–9.
Astrup A, Finer N. Redefining type 2 diabetes:'diabesity'or 'obesity dependent diabetes mellitus'? Obes Rev. 2000;1(2):57–9.
Nathan DM, Buse JB, Davidson MB, Ferrannini E, Holman RR, Sherwin R, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of diabetes. Diabetes Care. 2009;32(1):193–203.
Peyrot M, Barnett A, Meneghini L, Schumm-Draeger PM. Insulin adherence behaviours and barriers in the multinational global attitudes of patients and physicians in insulin therapy study. Diabet Med. 2012;29(5):682–9.
Davies M. The reality of glycaemic control in insulin treated diabetes: defining the clinical challenges. Int J Obes. 2004;28:S14–22.
Brown AF, Ettner SL, Piette J, Weinberger M, Gregg E, Shapiro MF, et al. Socioeconomic position and health among persons with diabetes mellitus: a conceptual framework and review of the literature. Epidemiol Rev. 2004;26(1):63–77.
Davis RE, Morrissey M, Peters JR, Wittrup-Jensen K, Kennedy-Martin T, Currie CJ. Impact of hypoglycaemia on quality of life and productivity in type 1 and type 2 diabetes. Curr Med Res Opin. 2005;21(9):1477–83.
Bonds DE, Miller ME, Bergenstal RM, Buse JB, Byington RP, Cutler JA, et al. The association between symptomatic, severe hypoglycaemia and mortality in type 2 diabetes: retrospective epidemiological analysis of the ACCORD study. BMJ. 2010;340:b4909.
Seaquist ER, Anderson J, Childs B, Cryer P, Dagogo-Jack S, Fish L, et al. Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society. J Clin Endocrinol Metabol. 2013;98(5):1845–59.
We would like to acknowledge the contribution of Fatema A. AlRamadan, Basmah J. Al Ramadhan, Ameera J. Alramadan, Ahmed J. Alramadhan, Talal A. Alzahrani, Hawra H. Alramadhan, Ayat S. Alabdullah, Noor A. Alabdullah, Husam M. Almaramhi, Nawaf F. Almukaibil, Nouf A. Alzaid, Nour A. Bayaseh, Sara M. Alameer, Wed A. Alkharras, Ghada M Amin, and Ahmad Alhammad in the data collection for this study.
All authors were involved in the conception and design of the study. MJA, HJA, WFM, and AMA contributed to the acquisition of data. MJA, DJM, AA, BB, THA and MAB contributed to data analysis and interpretation of results. MJA and BB drafted the manuscript. All authors critically reviewed the manuscript and approved the final version.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
The datasets generated during and analysed during the current study are available from the corresponding author on reasonable request.
Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
Mohammed J. Alramadan
, Dianna J. Magliano
, Afsana Afroz
& Baki Billah
Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
Dianna J. Magliano
College of Medicine, King Saud University, Riyadh, Saudi Arabia
Turky H. Almigbal
& Mohammed Ali Batais
College of Medicine, King Faisal University, Al-Ahsa, Saudi Arabia
Hesham J. Alramadhan
Ibn Sina National College, Jeddah, Saudi Arabia
Waad Faozi Mahfoud
Medical City - King Saud University, Riyadh, Saudi Arabia
Adel Mehmas Alragas
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Correspondence to Baki Billah.
Ethical approval was obtained from the Monash University Human Research Ethics Committee in Australia and the Research Ethics Committee of the Ministry of Health in Saudi Arabia. Written informed consent was obtained from all the study participants.
Alramadan, M.J., Magliano, D.J., Almigbal, T.H. et al. Glycaemic control for people with type 2 diabetes in Saudi Arabia – an urgent need for a review of management plan. BMC Endocr Disord 18, 62 (2018). https://doi.org/10.1186/s12902-018-0292-9
Glycaemic control

redpajama_set_name: RedPajamaCommonCrawl


Barnswallow Quilt Guild members invite you to their annual quilt show taking place on May 3 – 5, 2019 at the Access Event Centre in Morden (2nd and Gilmour Streets). Come join us for a lovely day in Morden!
How can we match last year's very successful bed turning? By focussing on smaller, with an "easel flip" of course! Throughout the weekend, members will "flip" a sampling of their small quilts, providing a brief explanation of techniques and fabrics. These presentations are scheduled for 11:00am and 2:00pm on Friday and Saturday and 2:00pm on Sunday.
If you wish to enter a quilt in the show, it must be dropped off at the Quilters' Den (11th and Stephen Streets, Morden) on April 30 or May 1 between 10am to 5pm, with a registration form. 2019 Barnswallow Show Entry Registration Please submit this computer-generated registration form. This is a fillable PDF file. Please fill it in before printing it.
All entries must be picked up at 5:30pm at the Access Event Centre on Sunday, May 5.


You are here: Home / Crafts / Pretty Fall Banner With Wood Letters Make This In No Time Flat!
You know I love fall. If not, now you know. I enjoy diy crafts projects and crafting. But, somehow I don't always have time to create projects. I've been looking for a few more fall craft ideas to put together. If your like me, right now I'm into making quick, and easy fall projects that I can hang up right away. I hope that you enjoy making this seasonal fall project; Fall banner With Wood Letters. Today I'm sharing a fall banner DIY craft project that I designed, and that anyone can do!
You don't need a lot of supplies. Some you may have around your craft room. You can make this or put your own spin on today's project. But, I have have a full tutorial to show you how. I have included a supply list which can be helpful if your new to crafting or just want to grab everything you need quickly and get to crafting.
For your supplies you just need two colors of paint, large twine / rope, wood letters, a flower pack and pine cones and a glue gun along with glue sticks….
I purchased some of my supplies on Amazon and some at Michael'sCrafts. With Prime you can't beat free shipping.
Most wood letters come almost ready to paint. If needed sand and wipe clean prior to painting. Dampen your brush, squeezing out excess water. Dip in paint and paint all your letters the color you picked. I picked a deep orange color.
Next while your paint is semi wet. Take your gold and paint sides and over parts of the top. This will give you two tones and hints occasional streaks of gold.
You will cover this up with the orange again so it's just peaking through. If you look closely at the front of the letter you can see the gold that has been covered. Then wait for it to dry before touching up any on the inside edges.
Do this to each letter one by one. Remember let dry and touch up as needed. Using an angle brush for this part is helpful. It allows you to get close to edges while not getting onto other surface area.
When completely dried; measure your rope to where you want to hang it. Give yourself at least a few inches extra on each side +3 to 4. Measure from the middle and place letters down equally spaced. Set into place then hot glue them down one by one. Use a good amount of hot glue, be careful when gluing. You can see the pin that I marked the middle with.
Now, take leaves and pine cones making mini arrangements in between your letters. Then glue them into place. I use tweezers as not to burn my fingers! You can easily pull the glue off your tweezers when dry but, dedicate that pair to crafting.
On each end I create one leaf, flower and pine cone. I didn't keep the flowers the same colors. You can create yours any way you like!
It's all about creating interest and balance. You can't go wrong with fall colors!
Then hang yours any where you like! I hung it on my curio at my entry area for the photo. But, I just might hang it on my mantel with my fall home decor.
Here's a few other craft supplies that would be great in a fall craft banner or other crafts projects. Just click on images and head over to Amazon to see these or other craft supplies.
Want more craft projects like today's? Be sure to subscribe and never miss out! Don't forget if you can't make it now you can pin it for later. Happy Fall Crafting!
What a pretty banner! Something like this would look great hanging from my mantle. I will have to see if I can find wood letters at my local craft shop. Pinned.
Hi Jen, Thanks for the compliment and pin! Share it with me when you make one. I look forward to seeing yours!!
This is cute for Fall and really looks easy enough to do with my gbaby. I think Fall is one of her favorite times of year.
Stacie recently posted & would love you to read..Macy's Front Row Shopping Party at Southdale!
Be sure to share yours with us if you make a fall banner!
Oh my word, how cute is this?!? I need to take a trip to Hobby Lobby to make this happen!
Hi Julie, If you do I hope you share it with us! Thanks for stopping by.


So I never thought I'd even consider getting a tattoo, unless it was Harry Potter related or something else that I love just as much.
I want "I solemnly swear that I am up to no good" (how it looks in the movies), maybe "Mischief Managed" somewhere else, and a beautiful coloured tattoo of Fawkes. No idea where on my body but somewhere a little bit hidden, not on my arm or leg or anything.
What do you think would make cool HP tattoos? Do you want any?
i love the idea but im such a wimp lol.
I would love the Dealthy Hallows symbol on my wrist or something.
I have seen loads of HP tattoos, everything you can imagine, quotes, symbols, spells, characters/creatures, etc. I personally don't think I'll be getting one. I love tattoos and there is one that I want, but it's not HP related, I mean I guess I could tie into HP somehow. But I'm so indecisive about it and I don't want to get it and then regret it later... no regrets is what tattoos are about.
I wouldn't worry so much about the pain, I've went with friends when they got their tattoos and they've said it's not as bad as everyone makes it out to be, it also depends where on the body you get it, your wrist, tailbone, and ankle are the most painful because there isn't much muscle there. My friends have said it's like a burning feeling, also depending on the size and detail of the tat has a lot to do with the pain factor, it's part of the reason it takes some tattoos a few months to get finished (these are usually huge tattoos though).
What all this blah blah blah is about is, if you really want a tattoo (HP or not) and you're fully committed to getting one, don't let the fear of pain stop you.
But will you be just as proud of it and still agree with your decision when your 50 years old and you're walking around with I Solemnly Swear That I'm Up To No Good on your body?
I have been thinking about getting an Emma-Watson-themed tattoo for two or three years now, even did the design work...but actually going out and have it done is a much bigger step than I thought at first.
While the sense of permanence with a tattoo can be part of the appeal for many, the intrinsic quality of its' permanence is certainly worthy of consideration when making the final decision. That said, in fairness, how many of us can truthfully say how we'll feel about any of the decisions we make 50 years from now as oppossed to today?
If you have a strong desire to get a tattoo, and you take your time in deciding what that tattoo should be and where you want to get it, that's the best I think you can hope for in making a decision you won't regret down the road. Decide if you want the tattoo for public display, or for private, personal reasons. Decide whether or not you want the tattoo somewhere you can see it regularly, or somewhere it is displayed for others when you go out (if you want it for public display, decide if it is something that you can display with pride and without fear of judgement or consequence). Find out if your getting the tattoo in a place that is likely to change shape and alter the tattoo in any way as you get older. Take all those things into account and make sure you go to a respected tattoo artist if you choose to get the tattoo. Others can add anything they think would also be relevant in making the decision... but those are the things I think you should consider most as you weigh the benefits/drawbacks to getting something that is going to be representative of you in a very real way, likely for the rest of your life.
In 2 months i'm getting the deathly hallows sign on my wrist. (Wand, stone and cloak) Not too big, just about 1-2 inches at the most. Just decideing what way to get it. Faceing me or outwards?
I also want the bird from the Emma Watson old side or the dangling converse. I just need to find the image on my other arm, identical place as the deathly hallows sign.
oh that's awesome do post picture when you get it done.
^I will! Thank you, I might get it facing me.
I wouldn't have any tattoos personally, it is just not me, but I think that they look great on some people and I have seen some brilliant HP tattoos before.
I agree with 'The Dude' though, although you can never be 100%, you need to be as certain as you can be that it's not something you are going to regret 30-40 years down the line, if you have any doubts, you should really think about it before going for it and make sure it is what you really want.
Apart from that, good luck to those who are thinking about it and try not to let the fear of pain put you off as it is only temporary (if at all), you should go for it.
If anyone gets one or already has one, you should post up pictures, they would be good to see.
Would recommend against this. Eat Me has sexual connotations and you don't want to be sending guys a signal you didn't intend to send. Because really, guys don't need much encouragement when it comes to that department.
As far as the permanency is concerned, think about how cool the guy that got May The Force Be With You tatooed on himself in 1980 feels today.
It's from Alice in Wonderland. I only intend on having my boyfriend through my life.
I know what it's from. I'm just saying, expect guys to give you a rash of crap about it.
This is true. But if you're ever out at a bar or even a restaurant or something and there's a bunch of guys around and someone sees this tattoo, expect crude comments.
I'm not saying don't get it. And I'm not trying to be mean here. I was just trying to let you in on how guys think. They'll take any opportunity they can to mess with a girl like that. Especially if they don't realize it's from Alice In Wonderland.
I wouldn`t have known where it`s from. And I might have gotten funny ideas about what they mean. Although coming from a non-english speaking country, I`d have had some serious doubts and you`d be safe from me.
I'm sure i'll be fine as i don't drink >.< Or know any jerks.


The first Boiler Room was established in a derelict pub in Reading, England in 2001. The idea caught on and today there are 34 Boiler Rooms of varying sizes on 4 continents, all centred on a rhythm of prayer whilst seeking to make a measurable difference amongst the poor and the lost.
This growing Boiler Room network is supported by an international team of experienced leaders.


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York County senator grabs protester outside $1K-per-plate fundraiser in Harrisburg
Groundhog Day tradition has long history
Bob Marchio
For The Evening Sun
"Punxsutawney Phil," the weather prognosticating groundhog, makes his prediction Thursday morning. Whatever the animal's shadow may forecast, it is based on a tradition that the Punxsutawney Groundhog Club says was founded by the Romans.
As the story goes, the myth became part of German lore during the Roman invasions centuries ago.
Early German settlers in Pennsylvania's Jefferson County carried the traditional of celebrating Candlemas Day to this country in the 1800s.
Puxsutawney Groundhog Club members say Candlemas Day is celebrated on Feb. 2. The tradition states that is "any animal came out from its underground hibernation on that day, and if the sun was out, there would be six more weeks of winter. This was born the tradition of 'two winters' or the 'second winter.'"
The German legend of Candlemas Day is based on the legend: "For as the sun shine on Candlemas day, so far will the snow swirl in May."
In 1886 a group of Punxsutawney residents started searching for a groundhog. The town's newspaper editor called them the "Punxsutawney Groundhog Club." A hilltop near the town where the animal made its prediction in 1887 was called "Gobblers Knot."
Thus began an annual celebration that has received widespread news coverage. Annual predictions are entered in the Library of Congress, and the day has attracted interest from presidents and was the basis of hit movie in 1992.
The groundhog was a likely candidate for prognostic fame as one of the few mammals that are true hibernators. Instead of going into a deep sleep, the groundhog will actually go into a deep coma when its body temperatures drop, heart beats and blood flow slows and breathing nearly stops.
Also called "whistle pigs" for their high-pitched whistle that they use as a warning and a courting signal in the spring, a groundhog's life span ranges from six to eight years. The PGC claims "Phil" drinks "a magical punch every summer during the Annual Groundhog Picnic, which gives him seven more years of life."
Gifford Pinchot State Park in Warrington Township is conducting winter walks led by a park naturalist. The free program is 1-2:30 p.m. Friday, and participants will explore the trails in the park's Conewago Day Use Area, off Alpine Road, near Rossville, north of York.
Participants are advised the walks will begin promptly at 1 p.m. Be sure to dress for the weather for comfort and warmth. Bring a water bottle and snacks as desired. For information concerning weather conditions call the park office.
Walks are also scheduled for Saturday, Feb. 25, Saturday, March 4 and Friday, March 10. All walks are 1-2:30 p.m.
Drug take-back
The Pennsylvania Fish Commission and the Geisinger Health System have teamed up to establish medication take-back boxes across the state to dispose of unused medications. To date some 500 boxes have been placed, mainly in local police stations.
PFBC Executive Director John Arway said that in addition to providing a way for citizens to properly and safely dispose of unused medications, the effort will also help improve the health of the Susquehanna River and its smallmouth bass population.
"Research shows that chemicals found in medications are being absorbed by fish and are contributing factors to various problems, including lesions on young-of-year smallmouth bass and intersex fish, in which male fish develop female egg cells," he said. "When we reduce the amount of medications entering our waterways, we help protect the environment and the aquatic life in the waterways."
These chemical contaminants – called endocrine disrupting compounds – can enter waterways from people illegally dumping trash or from flushing medications down the toilet.
Bob Marchio is outdoor writer for The (Hanover) Evening Sun. He can be reached at bmarchio@embarqmail.com.


Over the years, I certainly have found myriad manners in which to change negative energies into positive. They range from the four-step smudging (offering tobacco, cedar smudge, sweet grass smudge and finally sage smudge including prayers that I may discuss at a later time) to the detailed oriental art of feng shui. All of which are admirable and productive ways to clear a space. I use them all.
But today I want to share a quick and easy, instant ~if you will~ method for clearing energy from an object. This can be used at inconvenient times when the other, more organized methods are out of the question.
Suppose you are at an event and find that your crystal or pendulum have collected negative energy, or at least energy that is not harmonious to yours. You certainly don't have time to go through the four-step smudging. I have a quick and effective method for you.
Simply hold the pendulum in your left hand. Clear your mind. Ground yourself. Focus your intent on clear, positive, heart-love flowing vibrations. As soon as you are ready, place your right hand about two inches above your item. With your focused intent, start moving your right hand in a clock-wise circle, moving up into a spiral. This should take four or five circles. Finish by closing your right hand to your left, with the item inside.
Yeah, some people will say this sounds like hocus-pocus. Well, I guess it really is. Hocus-pocus is a magickal method of changing vibrations. It is similar to alchemy. And these things cannot take place without focused intent. You have effectively changed the vibrations of your crystal's energy.
Another quick tip: To change a room's energy, that has stale or heavy vibrations, simply clap your hands! Start by the doorway and clap your hands four or five times. Then turning left, go to the first corner. Clap your hands up high, near the ceiling. Move on to each corner until you reach the doorway again. Finish by clapping one time at the doorway. This chases the heavy energies out the door.
…more metaphysical tips on the way…meanwhile go to http://www.PsychicIntegrity.com to get more information about the spirit and psychic worlds.
What Is The Spirit World, Anyway?
As you grow up from a small child into adulthood, you are always introduced to the term, heaven. Normally, it is when a close loved one dies and your parents try to explain to you about the passing of life. They really don't know what it is or how to describe it. It usually ends up being a lovely place we all go when our bodies die. And Grandma is now an angel.
But over the years, we begin to believe heaven or the spiritual world is the only higher level of vibration separate from the physical world: all spirits in the spirit world are highly evolved beings. Quite often, while discussing this work, generalities are made. Psychic readers talk about "the material world" or "the spirit world". This is very limiting. It completely leaves out the majority of layers that represent the vibrations of spirit.
The world of spirit is used to convey all frequencies including that of loved ones who have died. But we tend to only think of our grandparents in the spirit world. The world of spirit is very vast and includes lower as well as, higher entities. You may be aware of angels and spirit guides in the reachable spirit realm of existence.
There are also expanded levels (or other heavens) with archangels and other highly evolved entities unreachable to mere mortals, such as in the Un-Manifest, Expressive, Causal, Mental, and Emotional Planes.
These planes do not need what we know as the laws of physics. Space and time do not exist outside of the physical world. Those of us in the body are the only ones who maneuver in the third dimension, and have no concept of what it would be like not to live here.
We are all part of one huge, dimensionless object made of things not of this world. Yet they are manifested in the elements of solid, liquid, gas and the ethers so we may live and understand them with physical recognition.
Our bodies are alive because they are temporarily inspirited within a time and space window. Our souls are eternally alive because they are eternally inspirited, part of the infinite existence of all.
As our awareness expands in life with the experiences we are having, we begin to see life as a whole: The wholeness of all of creation and interconnection with All. This symbolizes our idea of total consciousness.
To be able to understand how Spirit Communication works, it is first important to understand the different levels of spirit. This is something that is rarely spoken of or taught. A large number of readers, whether they are psychics or mediums, may not have any concept of where they are getting their information. To them, especially if there was no instruction, spirit is spirit and it must all be good. Nothing could be further from the truth.
To me, it could be risky not understanding the chain of command. As explained earlier, there are many trickster spirits in other realms and astral energies representing them selves as well known Biblical personalities, historical figures and even entertainers. These impersonators actually get their kicks by making you think they are who they say they are.
Near Death Experience or After Life Experience?
Tell me, if you will, why is it that when someone's heart has stopped for an extended period of time, there is no breathing, no sign of life, and they are brought "back to life" that it is called a near death experience?
My understanding is that breath is life. Breath is what gives the human body life. So, if there is no breath, the must be no life. So whatever…what ever…happens after life is over should reasonably be called after life experience. Don't you think?
In his book, Gupta mentions topics like: life after death and miracles. So it should be interesting to see if he addresses the spiritual concept of the spirit living on after the physical body dies.
Of course, you all know where I stand on that topic. If I am a spiritual medium, then it stands to reason I side with the non-scientific views of miracles and life after death.
He says the bright light so many people claim to see is the activation of the visual system normally caused by REM that creates the bright lights. He also says the tunnel so often recognized by those who are in the "near-death" experience is lack of blood flow to the eye.
But not all physicians agree with Nelson. Dr. Bill O'Callahan, is the emergency room doctor who brought Anna Bagenhold (another doctor) back to life after being clinically dead (no breath) for over two hours.
There have been too many people (800) each day who experience life after death (or after life experiences) to be completely confused by REM and lack of blood flow. There are also those who move out of their bodies and watch everything going on in the room. There are some who can tell surgeons and nurses exactly –word for word—what was said while they were "out" There are also some who "traveled" into other rooms or out of buildings and shared those experiences.
To me, science just has to explain everything away. But when it comes down to it, just because a scientist or doctor says it isn't so doesn't mean they are right. Just ask someone who has died and and come back to life!
As promised, here is the second excerpt from Psychic Integrity. It comes from Chapter 2, Intuition, Psychics, and Mediumship.
Mediumship is being aware of the vibrations of spirit beings, and receiving messages from them. It is the communication of a deceased loved one through an intermediary. The information is then given to those who are grieving the loss.
The main purpose is to provide recognition of continuing life after the physical death, and to send love and encouragement.
Connecting with the crown chakra (or seventh energy system) at the top of the head, a bridge is built to the higher levels or planes of existence.
By building this bridge, an association is made with visions, imagination, and spiritual awakening. It enables you to empower your spiritual path. This opens you to integrity in becoming responsible in your communication dealings.
Association with the higher realms also plants a firm foundation for the connection with finer vibratory entities and spirit teachers. Lower level energies will not be attracted to you, since you have established your connection with higher vibrations.
Other reasons spirit beings open communication with the living are to give evidential information only acknowledged by those still in the body. They create outward activities perceived by humans in a physical manner. These activities are often recognized as paranormal activity. They manifest in physical form to be identified.
Mediumship involves cooperation between a living person and a person in the spirit realm. This entails either communication of some kind or physical manipulation of energies.
Mediumship is divided into two categories: mental (communication) or physical (energy manipulation).
Physical mediumship is done with the use of physical energy. It is done under control as in the mental mediumship, but usually much deeper. The spirit manages the transformation of energy into physical objects, movement or sounds. A paranormal event occurs in the physical, and can be felt, heard or seen by humans.
This form of mediumship has to be the most unusual demonstration of what a spirit entity can do through medium control.
There have been far too many contrived and deceitful examples of the séance event. Because of that, many people discredit the entire concept of mediumship.
The spirit entity operating for the evidential séance uses both mental and physical energies of the medium to create a physical manifestation. This is something all sitters in the experience can witness physically.
The physical medium is one who has an over-abundance of a magnetic and etheric energy emanating as part of the aura/energy field of the individual. Usually, while the medium is in a deep trance state, the spirit being uses this etheric energy and creates ectoplasm.
If you have ever seen the movie "Ghost Busters" or any ghost-laden, scary program, you have seen a filmy or cloudy emanation coming from or around an entity, spirit being or ghost. This is the best representation of ectoplasm available.
Although the medium's etheric energy is the main source for the event, usually more is gathered from the sitters. If the energies are good, a large amount of ectoplasm is formed to work with. It takes full attention of everyone in the séance.
The use of personal, auric energy (full of emotional and feeling experience of the each person) is a main ingredient for this operation to be successful.
This is why the sitters in the séance not only experience the event, but actually become part of the event. It can be a very dramatic demonstration of spirit manipulation.
The medium gives consent to be used by the spirit being, by going into the trance state. The spirit is now in control of the work being done and can manipulate the ectoplasm to create phenomena.
A medium can produce physical phenomena because she has an abundance of this etheric energy (ectoplasm). It is a part of the subtle energy body that allows us to emanate as humans.
There is no limit to what can be done through physical mediumship, as long as the proper conditions are held in the séance room. These physical phenomena can range from rapping, levitation of objects or people, lights, independent writing/painting, direct voice (spirit speaks without the medium), and partial or full materialization of the spirit people.
…oops…can' reveal it all right here! You'll have to buy the book to read everything.


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ASBPE Announces 2005 Lifetime Achievement Award Winner: Don Ranly
By ASBPE Staff	/ January 3, 2012
He is a teacher — a most noble profession. His message is compelling and is the essential mission of business, trade, and association publications, whether in print or on the Internet.
Don Ranly's work is a testament to the lasting influence and savvy judgment he has for the practical concerns of business publishers.
It is a testament to the valuable objective of university faculty to provide community service and continuing education for working professionals.
It is a testament to every corporate executive, manger, engineer, or chemist who reads a business or trade publication to learn what useful ideas they can incorporate into their work.
As a professor at the University of Missouri School of Journalism, Dr. Ranly helped pioneer the concept of "service journalism." For 28 years as head of Missouri's magazine sequence, Dr. Ranly taught hundreds of students and advised many publications — especially those in the business-to-business market — to develop service journalism as their foundation.
The Lifetime Achievement Award from ASBPE reflects his enormous influence and success in the area.
Dr. Ranly defines service journalism with three words: useful, usable, and used — distinctions based on his conviction that efforts to benefit readers are illusive, and won't work unless information is easy to access and, ultimately, helps lead readers to significant action.
Beyond college, Dr. Ranly has promulgated his vision through hundreds of professional seminars and workshops, where he is recognized for his stimulating presentations, which themselves are designed to be useful, usable, and used.
Soon after, he became editorial manager of the Messenger Press in Celina, Ohio, 1967-1969, while also working as an instructor at St. Charles Seminary.
Dr. Ranly came to Missouri in 1973 to pursue his doctoral degree after earning a certificate in film, radio, and television from New York University. He immediately began teaching classes and the next year became head of the Columbia Missourian's Sunday magazine, Vibrations, and continued to teach.
He received the doctorate in journalism in 1976 and became the head of the magazine sequence. Three years later he was tenured.
Over the years, Dr. Ranly taught 15 different courses at the journalism school, including every class in the magazine sequence except design (although he probably could, given his expertise in service and visual journalism). His classes have included magazine editing, philosophy, and ethics of journalism, general semantics, magazine article writing, reporting, and mass media and society.
In 1995, Dr. Ranly received a University of Missouri-Columbia Faculty-Alumni Award and was named the O.O. McIntyre Distinguished Professor of Journalism for 1995-1996. In 1998, he won a University of Missouri Golden Chalk award for excellence in teaching.
The journalism faculty nominated Dr. Ranly three times for the Presidential Award for Outstanding Teaching. He's also been nominated for the Byler Distinguished Professor Award, the Thomas Jefferson Award, and The Kemper Teaching Award. The latter award, which he won in 2003, is the most special to him.
"There are people who say you should not identify yourself with your work," Dr. Ranly has said, "but I am a teacher. WHen that is my identity, to receive the highest award at the university for teaching — well, that is tremendous."
Publishing Public Service
Dr. Ranly has given more than 900 seminars and workshops for a wide variety of publishing conferences, including ASBPE (three times), City and Regional Magazine Association, Folio:Show (45 times), International Association of Business Communication (18 times), and the Florida Magazine Association (four times).
His work for publishing companies and magazines has included Advanstar, Argus, Automotive News, Meredith Corp., Southern Living,Times-Mirror, and Vance Publishing.
Dr. Ranly has judged awards competitions for Advanstar, Associated Church Press, City and Regional Magazine Association, Investigative Reporters and Editors, Missouri Scholastic Press Association, National Association of Agricultural Journalism, Neal Awards, and the Society of American Travel Writers.
He is coauthor of News Reporting and Writing (7th ed.); Telling the story: Writing for Print, Broadcast and Online; and Beyond the Inverted Pyramid and author of Publication Editing.
He has also compiled a reader, The Principles of American Journalism, and written a number of book chapters and articles for professional and scholarly publications.
Presently, he is on the advisory board of Academe, the bimonthly magazine of the American Association of University Professors, and is executive director of the Missouri Association of Publications.
About the Lifetime Achievement Award
Our Lifetime Achievement Award was established in 2000 to recognize editors who have made significant and lasting contributions to our editorial profession and to the industries their magazines serve. Previous recipients were Patrick McGovern of International Data Group, Dana Chase of Dana Chase Publications, editorial consultant Howard Rauch of Editorial Solutions, Vernon Henry of Advanstar Communications and Bernie Knill of Penton Media.
To receive the Lifetime Achievement award, a candidate must meet four requirements:
Significant tenure (20 years or more) on business publications. Nominees need not currently hold editorial positions, and may be retired, but they must have spent the bulk of their careers in senior editorial positions. Nominees need not be members of ASBPE.
A commitment to editorial excellence. This may be demonstrated by general reputation of their publications(s); industry-related awards (e.g., ASBPE, Neal Awards, Folio:); internal company awards; other forms of recognition or other valid measures of editorial success.
A commitment to the business and professional press. Nominees should be or have been involved in lending their experience and time to benefit others in the business press. Examples might be participation in local or national business press or related organizations, corporate or university teaching, mentoring programs, or significant research or publication of articles on business press issues.
A commitment to the industries their publications serve. Examples include committee work with trade or professional associations or standards groups; frequent speaking engagements at industry events; significant research or publication of articles on industry issues; or significant advocacy work with government agencies.


Give us a call at 813.333.1709, or submit the form below!
Sealing your pavers will protect them from the elements or anything foreign, such as oil, that may stain them. It will also preserve the natural beauty of the pavers. Sealing pavers is not an easy undertaking. Proper sealing requires the right products and the right technique. A botched paver sealing job will leave your pavers looking white, yellow, cloudy, or plastic. A paver sealing job gone wrong is no fun and costly. It will likely require some form of paver restoration in Lutz, FL.
At Pressure Points, we recommend calling in a professional to seal your pavers to avoid the following paver sealer mishaps.
Anything sitting on your pavers will become trapped if you seal them before cleaning. Using an efflorescence cleaner will ensure that dirt, debris, and any preexisting stains are removed. Skipping this step will only cause the sealer to emphasize these things more.
The most common issue people experience when sealing is over applying the sealer. Sealers are designed to perform well with just one or two coats. More than this and you can end up with unstable sealer. Over applying a sealer can cause all kinds of issues, including bubbles, a white haze, or blisters in the sealer.
Choose a sealer and stick with it. Do not mix a solvent-based sealer with a water-based sealer. If you've already sealed your pavers with a water-based sealer previously, reseal them again with the same.
Sealer problems are easier to prevent than to repair. If you're wondering why your pavers look blotchy, uneven, yellow, milky, brown, or cloudy, the sealer was applied improperly and you'll benefit from a paver restoration in Lutz, FL. Don't hesitate to call us to restore the beauty of your pavers.
To schedule a paver restoration in Lutz, FL please fill out our contact form or give us a call at 813-333-1709.


During the board meeting april 2016 we took the opportunity to visit the renomated Floralies at Ghent. For the first time in 35 years, this historic event returns to the centre of Ghent, and in no less than four stunning locations. With its captivating inspirational gardens, breathtaking floral arrangements and cradle workshops. We could admire the beautifull creations of leading National en International florists, ornamental growers and landscape artists. The edition of 2016 Ghent Floralies was an unforgettable experience for the EIlO member board.


LeapFrog Scout's Build And Discover Tool Set Just $11.24 Down From $20!
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LeapFrog Scout's Build And Discover Tool Set Just $11.24 Down From $20!
Check out this fun Amazon deal. LeapFrog Scout's Build And Discover Tool Set is just $11.24 down from $20! Get yours now while it lasts!
Measure, tighten and hammer to build Scout a doghouse. Take it apart and do it again!
Tool set includes 5 tools: a hammer, ruler, saw, screwdriver and wrench.
Match colors to find the right tool for each job, count nails with Scout and more: the learning is built in!
Teaches Building & Tinkering, Counting and Colors.


Before Muharram there is a thing going on called ohbat no Majlis in every household, Similarly we had the Majlis in our house. My aunt wears a scarf under her rida so that her hair don't show(like ppl do during hajj) so the bhensaab called her n asked why do u wear this? She very simply replied that after I came from my umrah I have never worn rida without my scarf. The bhensaab said ki 'tame alag dekhao cho' My aunt was angry bcoz bhensaab being at a very high post in molas family should know that a lady should not show her hair. After that they all quickly prayed farz ni namaz and left.
My aunt prayed the full namaz and was astonished that they left so quickly.
1)shouldn't you appreciate someone who is trying to cover their hair as Allah likes ? Being a bhensaab are you not aware that women should actually cover their hair?
2) aren't you supposed to pray the whole namaz being a bhensaab ? Are you setting this type of example?
The bhensaab asked how do you pray tahhajud?
She said she refers to Ihya ul Layl.
The bhensaab quickly responded Pani ma nakhavi do. Apna si Gujarati ma ilteja na karai.
My aunt said ok but she still prays from the book.
1) what is wrong in the book?
2) why can't someone do ilteja in Gujarati?
3) how does a book prayed by everyone become inappropriate to pray suddenly?
1. If your aunty was told that she looks different, she should take it as a compliment.
2. I have not heard about this book.. is the font in gujrati but the phonetics and vocals in Arabic or is the actual dua'a in gujrati language?


Adopting a rescue animal from a shelter or rescue provides many benefits. Not only for you, but for the animal shelter or rescue, by allowing them to be able to save more animals. For every dog or cat a shelter or rescue adopts out, they have room for the next animal that needs their help. Adoption fees help to pay for the medical bills for the next animal that needs rescuing too, instead of lining the pockets of puppy mill owners, or backyard breeders.
1. Adopting a rescue animal saves lives.
As mentioned above, adopting an animal from a shelter or rescue gives them the resources to continue helping more animals in need. It opens up space in their shelter or foster homes. Adoption fees help pay for shelter upkeep costs, medical bills for the next rescue animals. And you're helping to keep animal shelters and rescues alive and growing. This country needs more of them, especially No Kill rescues and shelters.
2. Adopting a rescue animal helps end puppy mills, and unethical backyard breeding.
But not supporting the people who breed animals for their own greed, you help to put these practices out of business. Turning their potential customers into adopters instead gives them less profits, and thus less reasons to keep up their horrible business practices.
3. Adopting rescue animals helps stop pet overpopulation.
Almost all animals adopted from shelters and rescues are already spayed and neutered. Preventing unwanted litters helps control the pet population. Thus helping to stop the needless killing of healthy animals each year.
4. Adopting a rescue pet gives second chances.
Most animals end up in the shelters through no fault of their own. A lot of times due to families moving, divorces, new babies, etc. Adopting gives them a second, or sometimes third, chance at having a loving forever home. The dream of all shelter animals.
5. Adoption saves you money.
Adopting a rescue pet is by far less expensive than purchasing one fro a breeder or pet store.
Most rescue pets are already spayed and neutered upon adoption. Not to mention up to date on all their vaccines.
A lot of the adult dogs are even already housebroken and know basic commands and manners. Saving you money, not only on training, but on the possible destruction that untrained dogs are prone too.
And the money you're spending is going to support a charity, instead of lining the pockets of those who breed animals for monetary gain.
6. You know the animal you're adopting has already been vetted, and received good care.
As mentioned above, rescue and shelter animals have already been fully vetted. Most rescues and shelters fully disclose any medical problems that have been diagnosed.
7. Adoption gives you more choices.
Puppies and kittens are adorable, and everyone loves them. But not everyone can handle the training it takes to make a puppy or kitten into the perfect companion animal. Rescue animals come in all ages, sizes breeds and temperaments. You have a lot more options to choose from when searching for the perfect pet for you.
Looking for a purebred? Over 25% of all animals in the shelters and rescues across the United States are purebred animals.
The choices are unlimited when you turn to animal rescues and shelters when looking for your new best friend.
8. Adopting a rescue animal gives you valuable backup resources.
Animal rescues and shelters want to help you to provide a loving forever home. Most are more than willing to impart their knowledge and resources to keep their adopted animals in their new homes. Don't be afraid to ask!
9. Rescue animal bragging rights.
Nothing makes you feel better than telling people you saved a life by adopting a rescue animal. It also encourages others to adopt too!
What other reason did you have for adopting a rescue animal?