The stigma among diabetic patients has significant negative consequences on both their metabolic compensation and quality of life [21, 25]. It is significantly associated with higher HbA1C levels, higher body mass index, and poorly controlled blood glucose. Additionally, it affects the emotional aspects of life, which is related to the increased intensity of therapy [19]. This study addressed a research gap as there is limited data about the stigma surrounding type 2 diabetes in Iraq and other Middle East countries.

Current results demonstrated that the mean (SD) for all items' stigma score is 51.72 (16.82), and about a quarter (24.71%) of patients are potentially suffering from a relevant stigma. The means for treated differently, blame, and self-stigma subscales were 15.5, 20.2, and 16.1 respectively. A recent study conducted in Colombia showed that the mean (SD) of DSAS-2 was 49.79 (7.11), and 16.4% of participants are suffering from stigma [22]. An Australian survey of more than a thousand patients reported that the mean (SD) of DSAS-2 was 41.0 (15.9), and more than 19.3% of responders experienced diabetic stigma [27]. Another Australian online survey found that the mean (SD) of total DSAS-2 was 43.5 (16.2), and for those treated differently, blame, and self-stigma subscales were 12.0, 19.2, and 12.3 respectively [30]. Higher stigmatization among our responders could be attributed to the difference in Iraqi culture, as there are multiple factors such as socioeconomic status, educational level, and quality of health services that could play a role in their view of illness in society. Iraqi cultural beliefs such as the perception of people with diabetes were responsible for developing their condition due to misconceptions about the causes of diabetes, such as believing that it is caused by eating sweets or drinking sweetened beverages [31]. Furthermore, Iraqi diabetic patients lack proper knowledge and awareness about diabetes, which could lead to poor self-management practice that is mainly associated with poor glycemic control and diabetic complications which are attributed to higher levels of stigmatization [32].

Social background can influence the stigmatization of diabetes or other chronic diseases as cultural and social contexts mainly shape identities, behaviors, and appearances that are considered appropriate or normal [33]. A similar discrepancy was reported by the World Mental Health Surveys of the perceived stigma associated with mental and chronic physical illnesses in 16 countries, as a higher prevalence of stigma was found in developing in comparison to developed countries (22.1% vs 11.7%) [34].

Nearly half of the patients have been told that they brought diabetes to themselves (49.7%), and they have DM because of their overweight (49.9%), which is higher than previously reported rates (25.7%), and (13.1%) [27], whereas its lower than others (64.1%), and (58.8%), respectively [22].

The highest rate for a single question in the current research with more than half of the participants (53%) agreed and strongly agreed that some people judge them for their food choices because they are having DM. This is greatly higher than the reported rate (9.5%) [30], while it is lower than another (80.1%) [22].

The most commonly described theme of type 2 DM associated with stigma in this study was blaming and judgment mean score percentage equals 57.57%. This is consistent with other studies that found patients always described feeling judged and blamed by others for causing their diabetes through being overweight or obese, or due to inactivity, laziness, poor diet, or overeating [19, 35]. Several studies demonstrated that type 2 DM is a preventable disease [1, 35], emphasizing the role of behavior and personal responsibility in the development of the disease. The increased prevalence of type 2 DM is associated with the development of social stigma. In fact, the role of an individual in the development of type 2 DM may not be obvious immediately, certain risk factors like obesity and the need for daily self-management (e.g. blood glucose checking, modifying diet, and medication taking) may be conspicuous by others and lead to adverse consequences such as stigmatization [36].

Multiple regression analyses of current results demonstrated that older age (> 50 years), lower educational attainment, unemployment, and being widowed or divorced are significantly related to a higher level of stigma (P < 0.05). Other researchers also found that sociodemographic variables were related to diabetic stigma; they reported higher stigmatization with younger age [16, 21, 25], and lower educational attainment [25]. In contrast, Pedro et al. reported that age was not associated with diabetic stigma [22]. Whereas Kato et al. reported that patients who had not announced their diabetes status tended to be older, have lower educational levels, and be employed part-time [37]. These contradictories in the findings could be attributed to differences in the sample size, culture, and the distribution of sociodemographic characteristics of studied populations. Age is linked to a greater increase in stigma in the situation of increased limitation and greater functional limitation. Older people often experience stigma related to aging. They might suffer from double stigma if they are having other health problems, in addition to negative behavior and attitudes against the elderly [38, 39].

A lower educational status was strongly associated with negative physical and mental outcomes [40]. Low-educated people are less knowledgeable about their illness, and this may lead to the expression of a higher level of stigma. It is also possible that those of lower education have lower access to healthcare services. Thus, they would probably have been associated with poor outcomes such as amputations or retinopathy which affect functioning and may lead to stigma.

In fact, in diabetic patient care, there is a need for continuous medical review and financial support, especially in patients with multiple chronic illnesses [19]. Unemployed and housewives usually suffer from higher stigmatization as they are economically dependent on others.

Additionally, diabetic patients suffer from a higher level of stigma due to lower social support which reduces their ability to disease management [41]. Therefore, divorced, and single person has suffered from a higher level of diabetic stigma probably due to a lack of spousal support in the management of their illness.

A limitation of this study is that clinical data regarding diabetes control, complications, and commitment to the lifestyle were self-reported by the responders which is subjective, the same issue applied to economic status. However, to our knowledge, this is the first study in Iraq that investigated the stigma of type 2 DM.