International Journal of Clinical Medicine, 2013, 4, 556-560
Published Online December 2013 (http://www.scirp.org/journal/ijcm)
http://dx.doi.org/10.4236/ijcm.2013.412096
Open Access IJCM
The Role of Helicobacter pylori Infection, and Malnutrition
among Type 2 Diabetic Medical Services Patients in the
Gaza Strip
Mazen A. El-Sakka1, Ektemal M. Abu Jabal2, Luay M. Nasser3
1Pharmacognosy Department, Faculty of Pharmacy, Al Azhar University-Gaza, Gaza, Palestine; 2Nutrition Department, Ministry of
National Economy, Gaza, Palestine; 3Medical Service, Gaza, Palestine.
Received October 12th, 2013; revised November 10th, 2013; accepted December 3rd, 2013
Copyright © 2013 Mazen A. El-Sakka et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: Diabetes means the blood glucose, which is too high or too low. With Type 2 DM, the more common
type, the body does not make o r use insulin well. In patients with DM, Helicobacter pylori is one of the most common
infections worldwide. Available data on the possible association between H. pylori infection and DM are contradictory.
There are a few studies in the Middle East, and this study is the pioneer study, in the Medical Services Clinics in Gaza
strip. Aims: This study was conducted to reveal the prevalence of H. pylori infection, malnutrition, insulin resistance
among T2DM patients, to describe the dietary requirements of T2DM patients, finally to evaluate the current informa-
tion about diet, and lifestyle in the prevention of H. pylori, and malnutrition. Methodology: A cross-sectional study was
conducted in the Medical Services Clinics in Gaza Strip, and there were 129 patients included in this study. Data were
collected through hematological information and structured interview questionnaire. Results: Highly significant per-
centage of H. pylori (70%) among the DM patients includes in the study, but not indicates any significant association
between gender and H. pylori status. Conclusion: H. pylori patients should update their sugar level valu es in the record,
and should get exercise and diet plan for every meal.
Keywords: Type 2 Diabetes Mellitus (T2DM); Helicobacter pylori (H. pylori); Insulin Resistance (IR); Malnutrition
1. Introduction
In recent years, a significant association has been re-
ported between cardiovascular diseases, d iabetes mellitus,
and dyslipidemia and Helicobacter pylori (H. pylori)
infection. However, there are conflicting reports, and
lack of data from the Middle East should prompt local
studies for establishing the relationship between H. py-
lori and such chronic diseases [1].
In patients with diabetes mellitus (DM), chronic infec-
tions are frequent and severe, due to the impairment of
their immune status. However, data on the prevalence of
Helicobacter pylori infection in diabetics are scanty and
contradictory. Patients with insulin-dependent diabetes
mellitus (IDDM) are often affected by chronic infections
[1].
Diabetes Mellitus means the blood glucose, or blood
sugar are too high. With Type 2 diabetes mellitus, the
more comm on type, the body does not make or use insulin
well. Insulin is a hormone that h elps gluco se gets in to the
cells to give them energy. Without insulin, too much
glucose stays in the blood. Over time, high blood glucose
can lead to serious problems with heart, eyes, kidneys,
nerves, gums and teeth [2].
Helicobacter pylori are one of the most common in-
fections worldwide. Available data on the possible asso-
ciation between H. pylori infection and diabetes mellitus
(DM) are contradictory [3].
That is clearly indicated there is a considerable nutri-
tional public problem. The intention of the study is to
assess the nutritional status of the diabetic patients,
whom have H. pylori bacteria in their stomach, and to
determine the nutritional factors contributing in devel-
opment of nutritional diabetic patients [4].
Since there are only a few studies in the Middle East,
on the association of Helicobacter pylori and diabetes
mellitus, we conducted this study and focus on the fre-
quency of Helicobacter pylori infection, Insulin resis-

The Role of Helicobacter pylori Infection, and Malnutrition among Type 2
Diabetic Medical Services Patients in the Gaza Strip 557
tance and malnutrition, in patients with type 2 diabetes
mellitus, and help in providing data that is useful in the
field of medicine as well as epidemiology.
1.1. The Relationship between T2DM and
H. pylori
Many authors have extensively explored the relationship
between H. pyl ori and diabetes mellitus.
Robert P study in 2012 show there may be a link be-
tween H. pylori bacteria and type 2 diabetes mellitus in
adults, the researchers analyzed data from people who
took part in two US National Health and Nutrition Sur-
veys and found that the presence of H. pylori bacteria
was consistently associated with elevated levels of gly-
cosylated hemoglobin (HbA1c), an indicator of blood
glucose levels and diabetes mellitus, the association was
strongest in obese people [5].
According to Albaker study from Saudi Arabia, it
shows that the association of Metabolic Syndrome (MS)
and H. pylori is still controversial with emphasis on the
possible linkage between them. However, the high
prevalence of both MS and H. pylori infection might
explain the coincidence [6].
Ramazan Gen in 2010, studied the relationship be-
tween Helicobacter pylori infection and insulin resis-
tance, in a prospective, open-label, single-center study
which consisted of 159 patients. The study show ed bene-
ficial effects of H. pylori eradication on insulin resistance,
atherogenic lipid abno rmalities and low-grade inflamma-
tion. The results suggest that H. pylori eradication may
prevent coronary artery disease and metabolic syndrome
[7].
2. Subjects and Methods
2.1. Study Design
The current cross sectional study was conducted to de-
termine the prevalence of H. pylori infection in type 2
DM patients.
2.2. Study Setting
This study was carried out in the Medical Services Clin-
ics in the Gaza Strip [8].
2.3. Target Population
The study population consisted of 138 diabetic patient’s
type 2, male & female patients’ presents in Medical Ser-
vices clinics in the Gaza Strip, the sample number was
calculated by Decision Analyst State 2.0 programs.
2.4. Study Period
The proposed study was conducted from October 2011 to
May 2012.
2.5. Sampling
A Cross-Sectional Study was done randomly selected on
129 Diabetic patients with Type 2, from the Medical Ser-
vices Patients in the Gaza Strip.
2.6. Data Collection & Health Records
Health records of each type 2 diabetic patients were re-
viewed through the Medical Services Clinics in the Gaza
strip conform A, B, C and D methods.
1) Anthropometric Measurements
 Weight in kg measured by a seca scale
 Height in cm measured by a stadiometer
 Body Mass Index (BMI)
 Waist circumference
2) Biochemical Assessment
 FBS
 HbA1c
 C-Peptide
 H. pylori (IgG)
3) Clinical findings
It includes a complete physical examination, to inves-
tigate signs of malnutrition, medical history e.g. includ-
ing acute and chronic illness, diagnostic procedures,
therapies, treatments that may increase nutrient needs or
induce malabsorption, current medications.
4) Dietary assessment
It involves estimating food intake. This can be
achieved by interview techniques (usually retrospective)
and recording of intake.
3. Results
The frequency and percentage of H. pylori are given in
Table 1, and around 70.5 % of the sample found has posi-
tive H. pylori.
3.1. Correlation between Gender and H. pylori
It is found there is no significant difference between the
means of chemical variables due to the gender, and there
is insignificant association between H. pylori and the
gender as seen in Table 2.
Table 1. Distribution of H. pylori.
H. pylori No. (%)
Positive 91 (70.5%)
Negative 38 (29.5%)
Total 129 (100.0%)
Open Access IJCM

The Role of Helicobacter pylori Infection, and Malnutrition among Type 2
Diabetic Medical Services Patients in the Gaza Strip
558
Table 2. Test of association betw ee n gender and H. pylori.
Gender
H. pylori Male Female
Chi squareP-value
Positive No. (%) 49 (53.9%) 42 (46.1%)
Negative No. (%) 16 (42.1%) 22 (57.9%) 1.478 0.224
3.2. Diabetes History
Results in Table 3 shows that there are significant dif-
ferences between the means of the C-peptide and HbA1c
categories at 0.05 level of significant where there is a
significant difference between the means of the FBS
categories at 0.1 level of significant.
3.3. Physical Activity
The results showed that the most popular physical activ-
ity of sample practice is walking (46.51%) of sample
practice it, followed by house work (38.76%). The pre-
sent study observed a statistically significant association
between the means of the C-pe ptide for different activity
classes. On the other hand, almost half of the samples
sleep less than 8 hours, where the other half of the sam-
ples sleeps more than 8 hours.
3.4. Dietary Assessment
The results of this study highlights Grains, starches, bran
and mixed bread, fruit and vegetables, desserts, animal
fat, fried food, olive oil, fish, vegetables, fruits, proteins,
legumes, nuts, cold drinks, soda beverages and hot drinks,
tea, coffee, and nuts which considered as the main die-
tary factors that may associated positively or negatively
with type 2 DM.
4. Discussion
4.1. Distribution of H. pylori
The results of this study showed a highly significant per-
centage of H. pylori (70.5%) among the diabetic patients
including in the study, this resu lt is consistent with some
literature and inconsistent with others.
The results are supported by the study of Bener, and
Simon’s their results found that Helicobacter pylori in-
fection was significantly higher in diabetic patients than
non-diabetic subjects [9,10].
4.2. Correlation between Gender and Chemical
Variables
The current study revealed no significant association
between the means of chemical variables (FBS, C-pep-
tide, and HbA1c) according to the gender.
Table 3. The chemical variables based on the diabetes mel-
litus history.
FBS C-peptide HbA1c
How long
have you
diabetes? NMeanSD Mean SD MeanSD
Less than or
1 year 25127.6458.19 1.01 0.20 6.261.14
1 - 5 years32148.0656.37 1.70 0.30 6.531.0
5 - 10 years26131.2325.81 1.08 0.21 6.531.14
More than
10 years 46154.3541.03 0.88 0.13 7.401.19
Total 129142.9547.47 1.23 0.11 6.791.21
F-value 2.487 3.554 7.408
P-value 0.064** 0.016* 0.000*
*Significant at 0.05 level of significant. **Significant at 0.1 level of signifi-
cant.
No statistically significant difference found between
the socioeconomic variables according to the gender.
This does not indicate any significant association be-
tween gender and H. pylori status.
4.3. Diabetes History
This study identifies significant differences between the
presence of H. pylori and diabetes mellitus history.
This result similar to Robert P study, the findings
show there may be a link between H. pylori bacteria and
type 2 diabetes mellitus in adults, and found that the
presence of H. pylori bacteria was consistently associated
with elevated levels of glycosylated hemoglobin (HbA1c)
[5].
4.4. Dietary Habits
In general the current study shows that there are insig-
nificant correlation between food groups and Chemical
variables, but there are significant correlation between
vegetables and C-peptide, legumes and C-peptide. And
there is a statistically significant correlation detected be-
tween vegetables, hot drink and H bA1c.
The results also reported that there is no significant
difference between the means of the food groups with
respect to the H. pylori status.
4.5. Grains, Starches
The result of the present stu dy showed that slightly more
than two thirds (84.5%) of patients which is the high
percentage of white brea ds int a ke of grains, st arches once
or more weekly, 15% eating saj breads once or more
weekly, and more than a half of patients about 68.2%
didn’t eat brown breads with bran at all, and 56.6%
Open Access IJCM

The Role of Helicobacter pylori Infection, and Malnutrition among Type 2
Diabetic Medical Services Patients in the Gaza Strip 559
didn’t eat brown breads without bran at all. The present
study results show that 11.6% from the samples eating
macaroni/spaghetti once per day or more, and 47.3% of
patient didn’t intake it at all.
In general terms, most of the studies revealed th at con-
sumption of refined sugars is directly associated with
diabetes mellitus disea se [ 11].
4.6. Fruit
The current study shows that more than two thirds
(79.1%) of patients eating and drinking citrus as orange
grapefruits and lemons, once per day or more, and only
1.6% percentage didn’t intake it at all.
The results show that 60.5% of patients eating the ap-
ples once or more per day, then 34.9% patients eaten
watermelon once or more per day, in the end of the fruits
list comes the pineapple (fresh/canned) which taken by
17.8% of the diabeti c pati ent s.
4.7. Vegetables
Some studied shows that the regular consumption of fruit
and vegetables is associated with reduced risks of chro-
nic diseases, where they contain significant amounts of
bioactive components and fibers that may provide desir-
able health benefits beyond basic nutrition [12]. The cur-
rent study shows that (34% - 44%) of patients eating a
cooked vegetables as okra, molokhia, zucchini, potato
(cooked/boiled/or mashed), green beans, spinach, once or
more per day, and the results shows that about 67.4%
from patients are eating vegetable salad daily, and in
other patients taken once or more per day.
4.8. Proteins
The study results show that more than 40% from diabetic
patient intake milks, yo gurts, cheeses, eggs, and between
18% - 30% from the samples didn’t eat them at all.
And about 69.8% from chickens, that’s because the
diabetic patients inclu ding in the study prefer the ch icken
more than other meats and intake it once or more per
weeks, where 1.6% from patients don’t eat it at all.
4.9. Legumes
The results show that diabetic patients often eating leg-
ume as lentil, pea, chickpeas, bean with sesame paste,
green beans, about 50% - 55% of patients eating legumes
one or more per day, and 10% from patients didn’t eat
legumes at all.
4.10. Nuts
The results show that 20% - 24% from patients eats nuts
as (peanuts, walnuts, sunflower, watermelon, almonds),
once or more per weeks, and the higher percentage of
patients didn’t eat it at all.
4.11. Desert
The results show that 11.6% only from the diabetic pa-
tients eat keck (others), and 30.6% from samples eat
home sweats, but the higher percentage of diabetic pa-
tients didn’t eats keck or oriented sweats at all, because
of their effects of elevated the blood sugar.
4.12. Cold & Hot Drinks
The results found that 57.4% drinks the fresh fruits juice,
and 31% from patients didn’t drink it at all, about 21.7%
drink soda, and 57.4% from the samples didn’t drinks it
at all, about 76.7% from patients drinks tea, 55% drinks
coffee, and 20% - 24 % from them drinking cinnamon,
ginger, and herbal tea.
4.13. Fried Food
The study showed consumption of fried foods and exces-
sive oil about 52.7% eats (flafel, potato, eg gplants, cauli-
flower), and 18.6% only didn’t eat it at all.
4.14. Fast Food
The results showed little consumption of fast foods (as
pizza, shawerma, borger, thailandy) only about 3.9% -
9.3% eats fast foods, and 85% didn’t eat it at all.
4.15. Spices
The results found that all the samples takes spices as
red/green pepper black pepper, curcuma, other spices
with in the foods, 79.8% - 82% eat it once or more per
day.
4.16. Pickles
The results show that 43.4% intake the pickles as home-
made olives once or more per day, and 37.2% didn’t eat
the homemade, an d 70.0 % fr om the patient didn’t eat any
pickles from market at all.
5. Conclusions & Recommendation
In the present study, H. pylori infection, insulin resis-
tance and malnutrition in type 2 DM patients, were done
for all subjects.
1) An adequate lifestyle, socioeconomic factors, and
some biochem ical altera tions coul d play an import ant role
in the etiology of type 2 DM pat i e nt s.
2) This study d emonstrates t he strong relati onship of H.
pylori infection a s a risk factor fo r insulin resi stance, more
than 70.5% of the samples found to have positive H. py-
Open Access IJCM

The Role of Helicobacter pylori Infection, and Malnutrition among Type 2
Diabetic Medical Services Patients in the Gaza Strip
Open Access IJCM
560
lori.
3) Greater attention of the eradication of H. pylori has
been shown to play important roles in the etiology of
other chronic diseases.
4) We can conclude that there is insignificant associa-
tion between the H. pylori and diabetes mellitus history
(the duration of diabetes). H. pylori infection is not asso-
ciated with duration of diabetes,
5) The study exhibited a positive significant difference
between the means of weight for persons with positive
and negative H. pylori status. Consequently, the mean of
BMI of positive groups is significantly higher than the
mean BMI for the negative group.
6) The results suggest that data seem to indicate a po-
tential association between H. pylori infection, malnutri-
tion and IR, and further studies are needed to strengthen
this association and to clarify whether there is a causative
link between t hem.
Serum H. pylori should be integrated into routinely
para-clinical investigations in all patients with type 2
DM.
REFERENCES
[1] A. Baradaran and H. Nasri, “Helicobacter pylori Specific
IgG Antibody and Serum Magnesium in Type-2 Diabetes
Mellitus Chronic Kidney Disease Patients,” Saudi Jour-
nal of Kidney Diseases and Transplantation, Vol. 22, No.
2, 2011, pp. 282-285.
[2] National Institutes of Health (NIH), “A Service of the U.S.
National Library of Medicine. Annual Report,” 2012,
[3] S. A. Polyzos, J. Kountouras, C. Zavos and G. Deretzi,
“The Association between Helicobacter pylori Infection
and Insulin Resistance; Part 1,” Heicobacter Journal, Vol.
16, No. 1, 2010, pp. 76-88.
[4] M. D. Goutham Rao, “Insulin Resistance Syndrome,”
American Family Physician, Vol. 63, No. 6, 2001, pp.
1159-1164.
[5] R. Preidt, “Type of Bacteria May Be Linked to Diabetes,
The Association between H. pylori Infection, Type 2 Dis-
ease,” A Service of the US National Library of Medicine,
2012.
[6] W. I. Albaker, “Helicobacter pylori Infection and Its Re-
lationship to Metabolic Syndrome: Is It a Myth or Fact?”
Saudi Journal of Gastroenterology, Vol. 17, No. 3, 2011,
pp. 165-169. http://dx.doi.org/10.4103/1319-3767.80377
[7] R. Gen, M. Demir and H. Ataseven, “Effect of Helico-
bacter pylori Eradication on Insulin Resistance, Serum
Lipids and Low-Grade Inflammation,” Southern Medical
Journal, Vol. 103, No. 3, 2010, pp. 190-196.
http://dx.doi.org/10.1097/SMJ.0b013e3181cf373f
[8] Medical Services Commission, Annual Report 2010/
2011.
[9] A. Bener, S. A. Uduman, A. Ameen, et al., “Prevalence
of Helicobacter pylori Infection among Low Socio-Eco-
nomic Workers,” Journal of Communicable Diseases,
Vol. 34, No. 3, 2002, pp. 179-184.
[10] L. Simon’s, J. Tornoczky, M. Toth, M. Jambor and Z.
Sudar, “The Significance of Campylobacter pylori Infec-
tion in Gastroenterologic and Diabetic Practice,” Orvosi
Hetilap, Vol. 130, No. 25, 1989, pp. 1325-1329.
[11] A. Cuevas, J. Miquel, M. Reyes and F. Nervi, “Diet as a
Risk Factor for Cholesterol Gallstone Disease,” Journal
of the American College of Nutrition, Vol. 23, No. 3,
2004, pp. 187-196.
[12] R. Liu, “Health Benefits of Fruit and Vegetables Are
from Additive and Synergistic Combinations of Phyto-
chemicals,” American Journal of Clinical Nutrition, Vol.
78, No. 3, 2003, pp. 517-520.