The Relationship between Metabolic Factors and Quality of Life Aspects in Type 2 Diabetes Patients

 

Fatemeh Haidari¹, Esmat Mansoori²*, Mehrnoosh Zakerkish³,

Mohammadhossein Haghighizadeh⁴

¹Nutrition and Metabolic Diseases Research Center, Ahvaz Jundishapur University of Medical Sciences,

Ahvaz, Iran.

²Nutrition Department, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.

³Endocrinologist, Diabetes Research Center, Ahvaz Jundishapour University of Medical Sciences, Ahvaz, Iran.

⁴Department of Biostatistics and Epidemiology, Faculty of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.

 

ABSTRACT:

Background and Objective: Quality of life (QoL) significantly influences the therapeutic outcomes in diabetic patients. The present study aimed to investigate the impacts of different aspects of QoL of patients with metabolic factors. Methods: This cross-sectional descriptive study recruited 263 patients (mean age 51.79 years) with type 2 diabetes (T2D). Data were collected using demographic information form, the Persian version of the 36-item health-related QoL and Audit of Diabetes-Dependent Quality of Life (ADDQoL) questionnaires. Clinical and laboratory tests including total cholesterol, HDL-C and LDL-C were also performed. Statistical analysis was performed with  statistical package SPSS version 22.0. Results: The mean total score of Diabetes Quality of Life (DQoL) was 53.54 ± 20.85 based on SF-36. The overall score of QoL showed a negative significant correlation with the levels of FBS, HbA1C and triglycerides (P<0.05). A statistically significant negative correlation was observed between physical health and total cholesterol levels, between mental health and QoL with FBS (P= 0.000), HbA1c (P= 0.001) and total cholesterol (P=0.024); however, no significant correlation was observed with other parameters. Conclusion: Improvements in metabolic control have a significant effect on the Quality of Life among Adult T2D patients.

 

 

 

 

INTRODUCTION:

According to World Health Organization (WHO), the prevalence of diabetes mellitus is increasingly spreading worldwide so that the number of patients is expected to increase more than two times in 2030 (1). Diabetes mellitus not only significantly influences  the patients'  physical health, but also effects emotional health that can lead to premature mortality and morbidity (2). Many factors can influence the quality of life (QoL) in diabetic patients (3). Audit of Diabetes-Dependent Quality of Life (ADDQoL) is a single-index measure planned to measure persons’ perceptions of the impact of diabetes on their QoL (4). The ADDQoL comprises thirteen-items relating to psychological well-being, social well-being, role activities, physical functioning, symptoms and personal constructs (5). Intensive treatment is shown to improve QoL which is associated with better glycemic control (6). The previous studies investigated the QoL of diabetic patients showed that different culture of each community results in different level of QoL of these patients which in turn need different approach for effective managements QoL(7). Therefore, it is necessary to obtain more information about the QoL of diabetic patients, their characteristics, disease conditions, the effect of acute and chronic complications of diabetes, healthcare system, environmental-social characteristics which lead to reduced QoL. Therefore, the present study aimed to evaluate the metabolic factors and their possible relationships with health-related QoL in patients with type 2 diabetes (T2D).

 

MATERIAL AND METHODS:

Participants:

This was a cross-sectional descriptive study conducted on 263 patients with T2D. The calculated sample size was 241 subjects using a standard sample size formula for quantitative variables and considering r= 0.23, β= 5% and α= 0.05 (8) and to compensate possible sample loss of 10%, a total of 263 patients were evaluated in this study. Patients who attended Diabetes Clinic of Ahvaz Golestan Hospital, Ahvaz, Iran and met the inclusion criteria were selected by convenience sampling. Inclusion criteria included definitive diagnosis of T2D by two subspecialists, age range of 30-65 years old, the history of diabetes for more than two years, no mental illnesses, and no chronic and high-risk diseases such as cancer, multiple sclerosis, respiratory diseases including chronic obstructive pulmonary disease (COPD), congestive heart failure, liver disease, and non-pregnant and non-lactating women. All of the study procedures and the possible benefits and risks were clearly explained to all participants and then written consent forms were filled and signed by all participants.

 

The ADDQoL Instrument:

Demographic and anthropometric data were collected using a standard questionnaire. The Persian SF-36 (short-form health survey questionnaire with 36 items) and ADDQoL  were used to evaluate health-related QoL. The SF-36 consists of two main subscales: physical health and emotional health, each of them includes four domains; thus, eight domains are assessed. Physical health domains include: physical functioning, role limitations due to physical health, pain and general health and emotional health domains include: social functioning, role limitations due to emotional problems, energy and fatigue and emotional well-being. Item 36 is also a question about the health status in patient’s own view that evaluates the overall QoL in patients. The Likert scale is used for scoring a 0-100 numerical rating scale where zero and one hundred respectively indicates  the lowest level and highest level of QoL. ADDQoL contains 19 items of 7-point scale. Two parts of the ADDQoL measure the overall QoL of diabetic patients and other parts are related to the specific QoL of diabetic patients. ADDQoL evaluates people's perception of the impact of diabetes on QoL. This questionnaire is scored from +3 to -3 (extremely bad to extremely good) and determines the degree of importance of each item, based on the scale from zero to three (not important to very important). The final score of ADDQOL measures the QoL in diabetic patients. The reliability and validity of this questionnaire were determined in previous studies (9, 10).

 

Biochemical Analysis:

Fasting blood samples (5CC) were collected from patients to evaluate the metabolic parameters. Fasting blood sugar was measured by glucose oxidase method. Total cholesterol (TC), triglycerides (TG), and HDL-C were measured by enzymatic method using Pars Azmoon Kits, Iran and LDL-C was calculated using Friedewald formula. The HbA₁C was measured with ELISA method using Nyco Card kit.

 

Statistical Analysis:

The data were analyzed by SPSS software, version 22. At first, normality of data was assessed by Kolmogorov-Smirnov test. Descriptive statistics were expressed for quantitative variables as the mean and standard deviation (mean ± SD) and for qualitative variables as percentages (%). Pearson’s correlation coefficient was used to determine the relationship between each parameter of the QoL and metabolic factors. Consequently, multiple linear regression test was used to evaluate the relationship between significant variables. For all of the statistical analyses the significance level was considered as P<0.05.

 

RESULTS:

In this study, 263 patients with T2D were evaluated. Participants’ mean age was 51.79 ±8.63 years. Participants’ demographic and anthropometric information are presented in Table 1.

 

The mean of QoL components scores based on SF-36 questionnaire and its relationship with metabolic factors are shown in Table 2. The mean score was 53.54±20.85 for overall QoL, 61.69 ± 66.88. In eight domains of QoL evaluated in this study, social functioning scored the highest (73.31 ± 26.11) and Energy/Fatigue scored the lowest (51.40±23.79) in Emotional health subscale.

 

Table 1. Participants’ demographic and anthropometric information

Qualitative data were expressed as number and percentage and quantitative data  as mean ± SD.

 

Table 2. The mean of quality of life components scores (based on SF-36 questionnaire) and its relationship with metabolic factors

Quality of life parameters	mean ± SD2		FBS	HbA1c	TC	TG	HDL-C	LDL-C
Physical functioning	69.45 ± 27.63	r	-0.059	-0.043	-0.111	-0.028	-0.053	-0.054
		p	0.371	0.510	0.094	0.673	0.431	0.428
Role limitations due to physical health	45.33 ± 61.60	r	-0.101	-0.134	-0.185	-0.134	-0.061	-0.076
		p	0.121	0.041	0.005	0.043	0.369	0.270
Pain	63.33 ± 25.92	r	-0.084	-0.097	-0.140	-0.014	-0.073	-0.077
		p	0.197	0.141	0.034	0.832	0.278	0.261
General health	52.40 ± 23.61	r	-0.074	-0.057	-0.252	-0.104	-0.122	-0.117
		p	0.259	0.384	0.000	0.115	0.069	0.086
Physical health	61.69 ± 66.88	r	-0.105	-0.115	-0.218	-0.100	-0.093	-0.100
		p	0.110	0.080	0.001	0.129	0.167	0.144
Social functioning	77.31 ± 26.11	r	-0.113	-0.174	-0.070	0.000	0.074	-0.032
		p	0.084	0.008	0.294	0.998	0.272	0.636
Role limitations due to emotional problems	60.71 ± 45.61	r	-0.195	-0.136	-0.086	-0.078	0.024	-0.004
		p	0.003	0.039	0.196	0.239	0.727	0.949
Emotional well-being	55.26 ± 19.97	r	-0.300	-0.246	-0.102	-0.027	-0.015	-0.092
		p	0.000	0.000	0.125	0.683	0.830	0.184
Energy /Fatigue	51.40 ± 23.79	r	-0.049	-0.162	-0.215	-0.049	-0.097	-0.172
		p	0.013	0.014	0.001	0.464	0.161	0.012
Emotional health	61.16 ± 22.54	r	-0.239	-0.220	-0.149	-0.061	0.001	-0.082
		p	0.000	0.001	0.024	0.361	0.990	0.237
Overall Rating	53.54 ± 20.85	r	-0.198	-0.212	-0.127	-0.225	-0.056	-0.127
		p	0.002	0.001	0.056	0.001	0.412	0.064

The relationship between variables was shown by Pearsonʼs correlation. The scores range from 0 to 100 and higher scores indicate better conditions.

FBS=fasting blood sugar

HbA1c=glycosylated hemoglobin

TC= total cholesterol

TG=triglyceride

HDL-C=high density lipoprotein-cell surface

LDL-C=low-density lipoprotein-cell

 

The results showed a significant negative correlation between the overall score of QoL and the levels of FBS, HbA1c and triglycerides (P< 0.05) as well as a marginal significant relationship with total cholesterol (P< 0.056). The mean score of the QoL components, based on ADDQOL questionnaire, and their relationship with metabolic factors are represented in Table 3. In this study, there was a significant negative correlation between FBS levels and physical appearance, People in general react and financial situation. The level of HbA₁c was also negatively correlated with people in general react. The relationship between total cholesterol and Feelings about the future, living conditions, family life, physical activity was also significant in this study.

 

Table 3. The mean of quality of life components scores (based on ADDQOL questionnaire) and its relationship with metabolic factors

Variable	mean ± SD2		FBS	HbA1c	Total Chol	TG	HDL-c	LDL-c
Leisure activities	-3.1 ± 2.59	r	-0.056	-0.072	-0.055	-0.030	-0.026	0.008
		p	0.390	0.277	0.403	0.654	0.696	0.910
Working life	-3.1 ± 3.14	r	-0.108	-0.105	-0.160	-0.088	0.011	-0.208
		p	0.409	0.418	0.227	0.502	0.932	0.117
Travelling	-2.0 ± 2.67	r	-0.041	-0.046	-0.111	-0.136	-0.015	-0.049
		p	0.531	0.486	0.093	0.039	0.826	0.474
Holidays	-3.1 ± 3.20	r	0.003	-0.220	-0.203	-0.107	0.080	-0.230
		p	0.984	0.147	0.193	0.495	0.610	0.142
Physical Activity	-3.3 ± 2.50	r	-0.091	-0.082	-0.154	-0.050	-0.025	-0.081
		p	0.166	0.216	0.020	0.450	0.715	0.241
Family life	-1.8 ± 2.77	r	-0.005	-0.036	-0.164	0.051	-0.011	-0.069
		p	0.946	0.585	0.014	0.445	0.866	0.316
Friendships and Social life	-1.7 ± 2.67	r	0.010	-0.016	-0.104	0.088	0.019	-0.060
		p	0.882	0.807	0.118	0.185	0.784	0.383
Closest Personal Relationship	-1.4 ± 2.54	r	-0.038	-0.075	-0.146	0.023	0.017	-0.128
		p	0.609	0.321	0.054	0.760	0.825	0.102
Sex Life	-2.4 ± 2.29	r	-0.060	-0.062	0.031	0.101	0.089	-0.053
		p	0.424	0.412	0.682	0.183	0.251	0.505
physical appearance	-3.5 ± 2.80	r	-0.128	-0.119	-0.077	-0.010	-0.015	-0.034
		p	0.049	0.070	0.248	0.885	0.822	0.623
Self Confidence	-2.3 ± 2.60	r	-0.075	-0.006	-0.082	-0.067	0.049	-0.057
		p	0.253	0.926	0.219	0.313	0.469	0.407
Motivation	-2.3 ± 2.65	r	-0.097	-0.028	-0.119	-0.095	0.013	-0.084
		p	0.143	0.673	0.075	0.156	0.853	0.222
People in general react	-1.4 ± 2.17	r	-0.160	-0.182	-0.068	-0.016	-0.020	-0.041
		p	0.014	0.006	0.307	0.808	0.763	0.550
Feelings about the future	-2.86 ± 2.75	r	-0.081	-0.032	-0.140	-0.011	-0.025	-0.129
		p	0.216	0.626	0.034	0.865	0.709	0.059
financial situation	-4.2 ± 3.68	r	-0.156	-0.070	-0.104	-0.108	-0.018	-0.057
		p	0.017	0.291	0.117	0.104	0.785	0.406
Depend on others	-1.8 ± 2.65	r	-0.014	0.047	-0.084	0.016	0.038	-0.073
		p	0.834	0.481	0.208	0.806	0.578	0.290
living conditions	-4.4 ± 2.82	r	-0.053	-0.079	-0.151	-0.002	-0.057	-0.100
		p	0.414	0.231	0.022	0.981	0.398	0.144
freedom to eat	-4.2 ± 2.92	r	0.071	-0.019	0.003	-0.032	0.130	0.012
		p	0.278	0.733	0.958	0.634	0.054	0.866
freedom to drink	-3.3 ± 3.00	r	0.041	-0.003	-0.122	-0.083	0.130	-0.103
		p	0.533	0.962	0.066	0.210	0.127	0.132

The relationship between variables was shown by pearsonʼs correlation. Score -9 means the most negative effect and score +9 means the most positive effect of diabetes on the study parameters.

FBS= Fasting blood sugar

HbA1c= Glycosylated hemoglobin

TC= Total cholesterol

TG= Triglyceride

HDL-C= High density lipoprotein-cell surface

LDL-C= Low-density lipoprotein-cell

 

After adjusting for confounders, the relationship between main subscales of QoL scores and significant variables in this study are shown in Table 4.

 

Table 4. Relationship between main subscales of quality of life scores and significant variables

Variables		HbA1c	FBS	TC	Weight (kg)
Physical health	β	-	-	-0.097	-
	p	-		0.004	-
Emotional health	β	-	-0.064	-	-0.431
	p	-	0/001	-	0.000
Total quality of life	β	-2.80	-		-
	p	0.000	-	-	-

The relationship between significant variables was shown by multiple linear regression after adjustment for age and gender.

HbA₁c = Glycosylated hemoglobin

FBS= Fasting blood sugar

TC= Total cholesterol

Multiple linear regression model showed a significant negative relation between HbA₁c levels and total score of QoL (P= 0.000), FBS levels and emotional health (P= 0.001), total cholesterol and physical health (P= 0.004), and Weight and emotional health (P= 0.000).

 

DISCUSSION:

The present study aimed to investigate the impacts of different aspects of QoL of patients with metabolic factors. In the present study, the participants had moderate to severe problems in doing some physical activities such as taking part in exercise program and walking more than one kilometer during a day. Most of these problems were due to lumbar disc and surgery. Moreover, participants performed daily normal activities with lower quality and accuracy because of mental problems. Timareh et al. (2012) conducted 350 diabetic patients who attended to Kermanshah Diabetes Research Center, the mean score of QoL was moderate in both subscales of Physical and Emotional health, as the lowest score was related to general health (42.53 ± 22.24) (11). Similarly, in another study that conducted by Darvishpour Kakhki et al. in 2006, the QoL and its relationship with individual characteristics of diabetic patients was evaluated. They also showed that the lowest score was for general health (46.2 ± 13.0) (12). Therefore, it seems that the general health of participants was more affected by diabetes rather than mental health. This result has been confirmed in a meta-analysis by Norris et al. (13). However, the mean of QoL scores and its component scores was different in similar studies (14). In general, the differences in the QoL score in previous studies may be due to differences in individuals’ attitudes toward their health and lifestyle. This difference can also be influenced by factors such as gender distribution of participants, and patients’ cultural, social, and economic factors in different studies. In the present study, with the reduced levels of HbA₁c, the overall score of QoL and the scores of physical role limitations, social functioning, emotional problems, mental health and vitality was inversely increased. Therefore, it is concluded that the better controlling of diabetes is related to more QoL scores in diabetic patients. Ebrahimi et al. also showed same results in this regards. They showed that several aspects of QoL were improved by better metabolic control (15). However, in another study by Arian et al, no significant relationship was observed between QoL and HbA₁c levels (16). A part of this inconsistency can be attributed to  the smaller sample size in the Arian study, furthermore, they used only SF-36 questionnaire for evaluating QoL. This study also showed a significant negative correlation among the overall score of QoL and some of its components such as physical limitations, physical pain, general health, physical health, vitality, and mental health with FBS, TG, and TC. Ebrahimi et al. reported the same results where  QoL scores were improved by lowering the values of glycemic and lipid profiles (15). However, the studies of Triefet al. (2002), Masoudi Alavi et al. and Lau et al. (2004) showed a weak relationship between QoL and metabolic factors (17-19). In another study, Pitale et al. evaluated the effects of diabetes treatment and glycemic control on the QoL in patients with T2D. They observed no significant changes in the health status of patients in standard treatment group. In addition, strict control of blood sugar among the patients with progressive T2D in our study had no effect on individuals’ health status and health-related QoL (20). Other researchers showed that only patients with T2D whose HbA₁c levels were less than 7% represented significantly better improved QoL (21). Therefore, it seems that long-term control of diabetes can improve QoL in diabetic patients.

 

CONCLUSION:

As previously mentioned ADDQOL measures patients’ perception of the effect of diabetes on their QoL. Based on the results of the present study, there was a relationship between metabolic factors and certain components of QoL in diabetic patients based on ADDQOL questionnaire; as patients who had better controlled metabolic factors had better QoL. However, the limitations of this study include its cross-sectional design and its inability to identify the cause and effect actors of parameters. According to our investigation, the present study is the first study conducted on the relationship between metabolic factors and QoL components based on ADDQOL on patients with T2D. Generally, it was concluded diabetes could reduce patients’ QoL by affecting different aspects of QoL. Considering the relationship between some components of QoL and metabolic factors, conducting further studies with large sample size and longitudinal design is necessary to determine the type of relationship and recognize the causes.

 

CONFLICT OF INTEREST:

Authors have no conflicts of interest.

 

ACKNOWLEDGMENT:

This study is issued from the Master of Science thesis of Esmat Mansouri. Special thanks to Arvand International Division of Ahvaz Jundishapur University of Medical Sciences for the financial support (NO. B-9442). The authors also thank Diabetes Research Center, Ahvaz Jundishapur University of Medical Sciences for technical assistance and all patients who participated in this study.

 

REFERENCES:

1.     Afshari M, Tol A, Taghdisi MH, Azam K. The effect of the combinational program on improving foot care in type 2 diabetic patients referred to diabetes clinic of samirom city: Application of BASNEF model. J Health Syst Res 2014; Health Education Supplement:1697-1707.

2.     Monjamad Z, Aliasqharpoor M, Mehran A, Peimani T. The quality of life in diabetic patients with chronic complications. HAYAT 2006;12(1):55-66.

3.     Polonsky WH. Understanding and assessing diabetes specific quality of life. Diabetes spectrum. 2000;13(1):36.

4.     Mikailiūkštienė A, Juozulynas A, Narkauskaitė L, Žagminas K, Sąlyga J, Stukas R. Quality of life in relation to social and disease factors in patients with type 2 diabetes in Lithuania. Med Sci Monit 2013; 19:165-174.

5.     Nicolau J, Rivera R, France´s C, Chaca´rtegui B, Masmiquel L. Treatment of depression in type 2 diabetic patients: Effects on depressive symptoms, quality of life and metabolic control. Diabetes Research and Clinical Practice 2013;101:148-152.

6.     Meng Li, Ting Li, Bing-Yin S, Cui-Xia G. Impact of motivational interviewing on the quality Of life and its related factors in type 2 diabetes mellitus patients with poor long-term glycemic control. International journal of nursing sciences 2014;1:250-254.

7.     Darvishpoor Kakhk A, Abed Saeedi J, Yaghmaie F, Alavi Majd H, Montazeri A. Quality of life of diabetic patients referred to Tehran hospitals in 2004[Article in Persian]. Iranian Journal Of Endocrinology and Metabolism. 2006; 8: 49- 56.

8.     Papelbaum M, Lemos HM, Duchesne M, Kupfer R, Moreira RO, Coutinho WF. The association between quality of life, depressive symptoms and glycemic control in a group of type 2 diabetes patients. Diabetes Research and Clinical Practice 2010;89:227-230.

9.     Montazeri A, Goshtasebi A, Vahdaninia M, Gandek B. The Short Form Health Survey (SF-36): translation and validation study of the Iranian version. Quality of Life Research 2005; 14(3):875-82.

10.  Darvishpoor Kakhaki A , Abed Saeedi ZH, Yaghmaie F, Alavi Majd H. Instrument development to measure diabetic clients quality of life (DCQOL) [Article in Persian].Iranian Journal of Endocrinology and Metabolism 2005;7(2):149-155.

11.  Timareh M, Rhimi M, Abbasi P, Rezaei M, Haiydarpoor S. Quality of life in diabetic patients referred to the diabete research center in Kermanshah[Article in Persian].Journal Of Kermanshah University Of Medical Sciences2012;16(1).63-69.

12.  DarvishpoorKakhki A, Abed Saeedi J, Yaghmaie F, AlaviMajd H, Montazeri A. Quality of life of diabetic patients referred to Tehran hospitals in 2004[Article in Persian]. Iranian Journal Of Endocrinology and Metabolism. 2006; 8: 49- 56.

13.  Norris SL, Zhang X, Chowdhury FM, Zhang P. Health related quality of life measured by SF-36 for adults with diabetes: a meta–analysis. Ottawa: Cochrane collaboration; 2004: 111

14.  Ghanbari A, Yekta P, Atrkar R. Effective factors on quality of life in diabetic patients. Journal Of Guilan University Of Medical Sciences 2001;10(37-38):82-89.

15.  Ebrahimi H, Sadeghi M, Bazghaleh M, Shaker S, Ghasemi M. Relationship between metabolic control indexes and quality of life in patients with type II diabetes mellitus. Iran Journal of Nursing(IJN)2014;27(90-91):73-82.

16.  Arian V, Farvid M, Montazeri A, Yavari P. Association between health related quality of life and glycemic control in type 2 diabetices. Iranian Journal of Endocrinology and Metabolism 2012;14(4):318-324.

17.  Trief PM, Wade MJ, Britton KD, Weinstock RS. A prospective analysis of marital relationship factors and quality of life in diabetes. Diabetes Care. 2002;25(7):1154-8.

18.  Masoudialavi N, Ghofranipor F, Ahmadi F, Rajab A, Babai GH. [Quality of life in diabetic patient refers to diabetic association of Iran (Persian)]. Behbood Journal 2004 ;( 2):47-56

19.  Lau CY, Qureshi AK, Scott SG. Association between glycaemic control and quality of life in diabetes mellitus. J Postgrad Med. 2004;50(3):189-93; discussion 194.

20.  Pitale S, Kernan-Schroeder D, Emanuele N, Sawin C, Sacks J, Abraira C. Health-related quality of life in the VA Feasibility Study on glycemic control and complications in type 2 diabetes mellitus. J Diabetes Complications 2005; 19: 207-11.

21.  Akinci F, Yildirim A, Go¨zu¨H, Sargın H, Orbay E, Sargın M. Assessment of health-related quality of life (HRQoL) of patients with type 2 diabetes in Turkey. Diabetes research and clinical practice 2008; 79:117-123.

 

 

 

 

 

Accepted on 30.5.2017             © RJPT All right reserved