Beyond Glycaemia
Socioeconomic Factors and Diabetes Distress are Associated with Health-Related Quality of Life in People with Type 2 Diabetes
DOI:
https://doi.org/10.15605/jafes.040.01.19Keywords:
type 2 diabetes, health-related quality of life, diabetes distressAbstract
Background. Diabetes is a complex multifactorial disease. Therapy focused only on managing glycaemia does not yield optimal health outcomes. Health-related Quality of Life (HRQOL) is a broad, subjective, and multidimensional concept gaining significance in diabetes care. The complex interplay of HRQOL and other factors must be addressed to achieve optimal health outcomes.
Objective. We aim to describe the factors associated with HRQOL in type 2 diabetes.
Methodology. A single-center cross-sectional short messaging service (SMS) survey invited adults with type 2 diabetes (T2D) with ≥1 clinic attendance in the past year. Participants completed the Problem Areas in Diabetes-5 (PAID5), Diabetes Distress Scale-17 (DDS17), and European Quality of Life Score (EQ5D5L). Demographic and diabetes-related data were retrieved from electronic medical records. Multiple regression models were created with EQ5D5L Index score (HRQOL) as the dependent variable.
Result. A total of 1406 people with T2D participated, 46.4% women, mean (SD) age 61.1 (13.4) years, BMI 27.1(5.4) kg/m2, and HbA1c 8.0 (1.4)%. Of these, 60.9% had ≥1 microvascular and 23.8% had ≥1 macrovascular complication. Mean (SD) of EQ5D5L Index score was 0.81 (0.27), EQ5D Visual Analog Score (VAS) was 77.4 (23.8), Total mean DDS17 score was 1.87 (0.93) and PAID5 score was 5.04 (4.5). 26.9% and 11.3% had significant diabetes distress (DD) based on PAID5 ≥8 and DDS17 ≥3. Multiple regression models revealed diabetes distress, a lower class of housing type, presence of macrovascular complication, higher BMI, older age, and female sex to be associated with a poorer EQ5D5L Index Score.
Conclusion. Multiple non-glycemic factors like sociodemographic, socioeconomic, and diabetes distress impact health-related QoL in people with type 2 diabetes.
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References
1. Karimi M, Brazier J. Health, health-related quality of life, and quality of life: What is the difference? Pharmacoeconomics. 2016;34(7):645–9. https://pubmed.ncbi.nlm.nih.gov/26892973 https://doi.org/10.1007/s40273-016-0389-9
2. Burckhardt CS, Anderson KL, Archenholtz B, Hägg O. The Flanagan Quality of life scale: Evidence of construct validity. Health Qual Life Outcomes. 2003;1:59. https://pubmed.ncbi.nlm.nih.gov/14613563 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC269996 https://doi.org/10.1186/1477-7525-1-59
3. McHorney CA. Health status assessment methods for adults: Past accomplishments and future challenges. Annu Rev Public Health. 1999;20:309–35. https://pubmed.ncbi.nlm.nih.gov/10352861 https://doi.org/10.1146/annurev.publhealth.20.1.309
4. ElSayed NA, Aleppo G, Aroda VR, et al. 1. Improving care and promoting health in populations: Standards of Care in Diabetes—2023. Diabetes Care. 2023;46(Supplement_1):S10–8. https://pubmed.ncbi.nlm.nih.gov/36507639 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9810463 https://doi.org/10.2337/dc23-S001
5. Polonsky WH, Fisher L, Earles J, et al. Assessing psychosocial distress in diabetes: Development of the diabetes distress scale. Diabetes Care. 2005;28(3):626–31. https://pubmed.ncbi.nlm.nih.gov/15735199 https://doi.org/10.2337/diacare.28.3.626
6. Perrin NE, Davies MJ, Robertson N, Snoek FJ, Khunti K. The prevalence of diabetes-specific emotional distress in people with Type 2 diabetes: A systematic review and meta-analysis. Diabet Med. 2017;34(11):1508–20. https://pubmed.ncbi.nlm.nih.gov/28799294 https://doi.org/10.1111/dme.13448
7. Devarajooh C, Chinna K. Depression, distress and self-efficacy: The impact on diabetes self-care practices. PLOS ONE. 2017;12(3):e0175096. https://pubmed.ncbi.nlm.nih.gov/28362861 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5376339 https://doi.org/10.1371/journal.pone.0175096
8. Zhu L, Chandran SR, Tan WB, Xin X, Goh SY, Gardner DSL. Persistent anxiety is associated with higher glycemia post-transition to adult services in Asian young adults with diabetes. Diabetes Metab J. 2021;45(1):67–76. https://pubmed.ncbi.nlm.nih.gov/32602276 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7850875 https://doi.org/10.4093/dmj.2019.0226
9. Pintaudi B, Lucisano G, Gentile S, et al. Correlates of diabetes-related distress in type 2 diabetes: Findings from the benchmarking network for clinical and humanistic outcomes in diabetes (BENCH-D) study. J Psychosom Res. 2015;79(5):348–54. https://pubmed.ncbi.nlm.nih.gov/26526307 https://doi.org/10.1016/j.jpsychores.2015.08.010
10. Hayashino Y, Okamura S, Tsujii S, Ishii H. Diabetes distress and care registry at Tenri study group. association between diabetes distress and all-cause mortality in Japanese individuals with type 2 diabetes: a prospective cohort study (Diabetes Distress and Care Registry in Tenri [DDCRT 18]). Diabetologia. 2018;61(9):1978–84. https://pubmed.ncbi.nlm.nih.gov/29947921 https://doi.org/10.1007/s00125-018-4657-4
11. Xu Y, Tong GYY, Lee JYC. Investigation on the association between diabetes distress and productivity among patients with uncontrolled type 2 diabetes mellitus in the primary healthcare institutions. Prim Care Diabetes. 2020;14(5):538–44. https://pubmed.ncbi.nlm.nih.gov/32354680 https://doi.org/10.1016/j.pcd.2020.04.004
12. Friis AM, Johnson MH, Cutfield RG, Consedine NS. Kindness matters: A randomized controlled trial of a mindful self-compassion intervention improves depression, distress, and HbA1c among patients with diabetes. Diabetes Care. 2016;39(11):1963–71. https://pubmed.ncbi.nlm.nih.gov/27335319 https://doi.org/10.2337/dc16-0416
13. Lutes LD, Cummings DM, Littlewood K, et al. A tailored cognitive-behavioural intervention produces comparable reductions in regimen-related distress in adults with type 2 diabetes regardless of insulin use: 12-month outcomes from the COMRADE trial. Can J Diabetes. 2020;44(6):530–6. https://pubmed.ncbi.nlm.nih.gov/32792107 https://doi.org/10.1016/j.jcjd.2020.05.016
14. World Health Organization. Closing the gap in a generation: Health equity through action on the social determinants of health - Final report of the commission on social determinants of health. Accessed November 29, 2023. https://www.who.int/publications-detail-redirect/WHO-IER-CSDH-08.1
15. Hill-Briggs F, Adler NE, Berkowitz SA, Chin MH, et al. Social determinants of health and diabetes: A scientific review. Diabetes Care. 2021;44(1):258–79. https://pubmed.ncbi.nlm.nih.gov/33139407 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783927 https://doi.org/10.2337/dci20-0053
16. (DOS) | SingStat Table Builder – Average Monthly Household Income from Work Per Household Member (Excluding Employer CPF Contributions) among resident employed households. December 5, 2023. https://tablebuilder.singstat.gov.sg/table/CT/17817
17. McGuire BE, Morrison TG, Hermanns N, et al. Short-form measures of diabetes-related emotional distress: The Problem Areas in Diabetes Scale (PAID)-5 and PAID-1. Diabetologia. 2010;53(1):66–9. https://pubmed.ncbi.nlm.nih.gov/19841892 https://doi.org/10.1007/s00125-009-1559-5
18. Lee EH, Lee YW, Lee KW, Kim YS, Nam MS. Measurement of diabetes-related emotional distress using the Problem Areas in Diabetes scale: Psychometric evaluations show that the short form is better than the full form. Health Qual Life Outcomes. 2014;12:142. https://pubmed.ncbi.nlm.nih.gov/25358396 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4215007 https://doi.org/10.1186/s12955-014-0142-z
19. EQ-5D-5L. Accessed November 29, 2023. https://euroqol.org/information-and-support/euroqol-instruments/eq-5d-5l/
20. Valuation – EQ-5D. November 28, 2023. https://euroqol.org/information-and-support/resources/value-sets/
21. Luo N, Wang P, Thumboo J, Lim YW, Vrijhoef HJM. Valuation of EQ-5D-3L health states in Singapore: Modeling of time trade-off values for 80 empirically observed health states. Pharmacoeconomics. 2014;32(5):495–507. https://pubmed.ncbi.nlm.nih.gov/24519603 https://doi.org/10.1007/s40273-014-0142-1
22. Redenz G, Ibaceta MC, Aceituno D, Balmaceda C, Espinoza MA. Health state utility values of type 2 diabetes mellitus and related complications: A systematic review and meta-analysis. Value Health Reg Issues. 2023;34:14–22. https://pubmed.ncbi.nlm.nih.gov/36371899 https://doi.org/10.1016/j.vhri.2022.09.005
23. Mok CH, Kwok HHY, Ng CS, Leung GM, Quan J. Health state utility values for type 2 diabetes and related complications in East and Southeast Asia: A systematic review and meta-analysis. Value Health. 2021;24(7):1059–67. https://pubmed.ncbi.nlm.nih.gov/34243830 https://doi.org/10.1016/j.jval.2020.12.019
24. Teli M, Thato R, Rias YA. Predicting factors of health-related quality of life among adults with type 2 diabetes: A systematic review. SAGE Open Nurs. 2023;9:23779608231185921. https://pubmed.ncbi.nlm.nih.gov/37448972 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10336768 https://doi.org/10.1177/23779608231185921
25. Tran Kien N, Phuong Hoa N, Minh Duc D, Wens J. Health-related quality of life and associated factors among patients with type II diabetes mellitus: A study in the family medicine center (FMC) of Agricultural General Hospital in Hanoi, Vietnam. Health Psychol Open. 2021;8(1):2055102921996172. https://pubmed.ncbi.nlm.nih.gov/33747536 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7905732 https://doi.org/10.1177/2055102921996172
26. Shamshirgaran SM, Ataei J, Iranparvar Alamdari M, Safaeian A, Aminisani N. Predictors of health-related quality of life among people with type II diabetes Mellitus in Ardabil, Northwest of Iran, 2014. Prim Care Diabetes. 2016;10(4):244–50. https://pubmed.ncbi.nlm.nih.gov/26654733 https://doi.org/10.1016/j.pcd.2015.11.004
27. Al Hayek AA, Robert AA, Al Saeed A, Alzaid AA, Al Sabaan FS. Factors Associated with health-related quality of life among Saudi patients with type 2 diabetes mellitus: A cross-sectional survey. Diabetes Metab J. 2014;38(3):220–9. https://pubmed.ncbi.nlm.nih.gov/25003076 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4083029 https://doi.org/10.4093/dmj.2014.38.3.220
28. Olsson M, Björkelund AJ, Sandberg J, et al. Factors important for health-related quality of life in men and women: The population based SCAPIS study. PLOS ONE. 2023;18(11):e0294030. Phttps://pubmed.ncbi.nlm.nih.gov/37922283 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10624288 https://doi.org/10.1371/journal.pone.0294030
29. Sari Y, Isworo A, Upoyo AS, et al. The differences in health-related quality of life between younger and older adults and its associated factors in patients with type 2 diabetes mellitus in Indonesia. Health Qual Life Outcomes. 2021;19(1):124. https://pubmed.ncbi.nlm.nih.gov/33863354 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8052736 https://doi.org/10.1186/s12955-021-01756-2
30. Jannoo Z, Wah YB, Lazim AM, Hassali MA. Examining diabetes distress, medication adherence, diabetes self-care activities, diabetes-specific quality of life and health-related quality of life among type 2 diabetes mellitus patients. J Clin Transl Endocrinol. 2017;9:48–54. https://pubmed.ncbi.nlm.nih.gov/29067270 Phttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC5651286 https://doi.org/10.1016/j.jcte.2017.07.003
31. Chew BH, Mohd-Sidik S, Shariff-Ghazali S. Negative effects of diabetes–related distress on health-related quality of life: an evaluation among the adult patients with type 2 diabetes mellitus in three primary healthcare clinics in Malaysia. Health Qual Life Outcomes. 2015;13:187. https://pubmed.ncbi.nlm.nih.gov/26596372 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4657278 https://doi.org/10.1186/s12955-015-0384-4
32. Eckert K. Impact of physical activity and bodyweight on health-related quality of life in people with type 2 diabetes. Diabetes Metab Syndr Obes. 2012;5:303–11. https://pubmed.ncbi.nlm.nih.gov/22952412 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3430085 https://doi.org/10.2147/DMSO.S34835
33. Shim YT, Lee J, Toh MPHS, Tang WE, Ko Y. Health-related quality of life and glycaemic control in patients with Type 2 diabetes mellitus in Singapore. Diabet Med. 2012;29(8):e241-8. https://pubmed.ncbi.nlm.nih.gov/22507291 https://doi.org/10.1111/j.1464-5491.2012.03689.x
34. Lim SM, Siaw MYL, Tsou KYK, Kng KK, Lee JYC. Risk factors and quality of life of patients with high diabetes-related distress in primary care: A cross-sectional, multicenter study. Qual Life Res. 2019;28(2):491–501. https://pubmed.ncbi.nlm.nih.gov/30194625 https://doi.org/10.1007/s11136-018-1994-1
35. Lim DYZ, Chia SY, Abdul Kadir H, Mohamed Salim NN, Bee YM. Establishment of the SingHealth diabetes registry. Clin Epidemiol. 2021;13:215–23. https://pubmed.ncbi.nlm.nih.gov/33762850 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7982443 https://doi.org/10.2147/CLEP.S300663
36. Alzoubi A, Abunaser R, Khassawneh A, Alfaqih M, Khasawneh A, Abdo N. The bidirectional relationship between diabetes and depression: A literature review. Korean J Fam Med. 2018;39(3):137–46. https://pubmed.ncbi.nlm.nih.gov/29788701 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5975983 https://doi.org/10.4082/kjfm.2018.39.3.137
37. Tan CWY, Xu Y, Lee JYC. Severe distress & denial among Asian patients with Type 2 Diabetes Mellitus in the primary care: A prospective, multicentre study. Diabetes Res Clin Pract. 2023;197:110574. https://pubmed.ncbi.nlm.nih.gov/36773673 https://doi.org/10.1016/j.diabres.2023.110574
38. Schmitt A, Reimer A, Kulzer B, Haak T, Ehrmann D, Hermanns N. How to assess diabetes distress: comparison of the Problem Areas in Diabetes Scale (PAID) and the Diabetes Distress Scale (DDS). Diabet Med. 2016;33(6):835–43. https://pubmed.ncbi.nlm.nih.gov/26287511 https://doi.org/10.1111/dme.12887
39. Asher MG, Nandy A. Singapore’s policy responses to ageing, inequality and poverty: An assessment. Int Soc Secur Rev. 2008;61(1):41-60. https://doi.org/10.1111/j.1468-246X.2007.00302.x
40. Means testing. Agency for integrated care. Accessed December 5, 2023. Available from: https://www.aic.sg/care-services/means-testing/
41. Who we are. ACE. Accessed January 30, 2024. https://www.ace-hta.gov.sg/about-us
42. ACE Clinical Guidances (ACGs) [Internet]. ACE. Accessed January 30, 2024. https://www.ace-hta.gov.sg/healthcare-professionals/ace-clinical-guidances-(acgs)
43. Lin LK, Sun Y, Heng BH, Chew DEK, Chong PN. Medication adherence and glycemic control among newly diagnosed diabetes patients. BMJ Open Diabetes Res Care. 2017;5(1):e000429. https://pubmed.ncbi.nlm.nih.gov/28878942 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5574459 https://doi.org/10.1136/bmjdrc-2017-000429
44. Patel MR, Piette JD, Resnicow K, Kowalski-Dobson T, Heisler M. Social determinants of health, cost-related non-adherence, and cost-reducing behaviors among adults with diabetes: Findings from the National Health Interview Survey. Med Care. 2016;54(8):796–803. https://pubmed.ncbi.nlm.nih.gov/27219636 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4945373 https://doi.org/10.1097/MLR.0000000000000565
45. Hood CM, Gennuso KP, Swain GR, Catlin BB. County health rankings: Relationships between determinant factors and health outcomes. Am J Prev Med. 2016;50(2):129–35. https://pubmed.ncbi.nlm.nih.gov/26526164 https://doi.org/10.1016/j.amepre.2015.08.024
46. Fisher L, Glasgow RE, Mullan JT, Skaff MM, Polonsky WH. Development of a Brief Diabetes Distress Screening Instrument. The Annals of Family Medicine. 2008;6(3):246–52. https://pubmed.ncbi.nlm.nih.gov/18474888 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2384991 https://doi.org/10.1370/afm.842
47. ElSayed NA, Aleppo G, Aroda VR, et al. 5. Facilitating positive health behaviors and well-being to improve health outcomes: Standards of care in diabetes—2023. Diabetes Care. 20231;46(Supplement_1):S68–96. https://pubmed.ncbi.nlm.nih.gov/36507648 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9810478 https://doi.org/10.2337/dc23-S005
48. Lee KH, Low LL, Lu SY, Lee CE. Implementation of social prescribing: lessons learnt from contextualising an intervention in a community hospital in Singapore. Lancet Reg Health West Pac. 2023;35:100561. https://pubmed.ncbi.nlm.nih.gov/37424685 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10326684 https://doi.org/10.1016/j.lanwpc.2022.100561
49. Morse DF, Sandhu S, Mulligan K, et al. Global developments in social prescribing. BMJ Glob Health. 2022;7(5):e008524. https://pubmed.ncbi.nlm.nih.gov/35577392 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9115027 https://doi.org/10.1136/bmjgh-2022-008524
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