|Year : 2019 | Volume
| Issue : 4 | Page : 195-199
Quality of life in diabetics with different complications: A cross-sectional study with patients visiting a hospital on an outpatient basis
Paul Simon1, Datson Marian Pereiera1, Rashmi Theresa Mathai2, Thomas George1, Soniya Abraham1, Ovine Loyster DíSouza3, Manjeshwar Shrinath Baliga4
1 Father Muller Medical College Hospital, College Hospital, Mangalore, Karnataka, India
2 Department of General Medicine, Father Muller Medical College Hospital, College Hospital, Mangalore, Karnataka, India
3 Department of Psychiatric Nursing, Father Muller Medical College Hospital, College Hospital, Mangalore, Karnataka, India
4 Muller Research Centre, College Hospital, Mangalore, Karnataka, India
|Date of Submission||14-Feb-2019|
|Date of Acceptance||17-Jun-2019|
|Date of Web Publication||11-Nov-2019|
Manjeshwar Shrinath Baliga
In Charge of Research, Mangalore Institute of Oncology, Pumpwell, Mangalore - 575 002, Karnataka
Source of Support: None, Conflict of Interest: None
Objective: Recent data suggest that the incidence of Type II diabetes mellitus (DM2) is on a rise and is a major cause for health-care costs, morbidity and mortality. The major problem with DM II is the secondary complications such as retinopathy, nephropathy, diabetic foot disease, cardiovascular complications and neuropathy which severely hamper the afflicted individual's resources and quality of life (QOL). In the present study, we have attempted at understanding the QOL using the QOL instrument for Indian diabetic patients (QOLID). Aim: The principal objective of the study is to ascertain the QOL is DM II with and without complications in patients visiting a hospital on an outpatient basis. The QOLID is of advantage herewith as the eight domains address all relevant aspects afflicting the QOL of the patients. Materials and Methods: Depending on the complications and prevalence, we included six groups; diabetics without complications (Group I, n = 89), retinopathy (Group II, n = 72), nephropathy (Group III, n = 53), diabetic foot disease (Group IV, n = 86), cardiovascular complications (Group V, n = 25) and neuropathy (Group VI, n = 57). The demographic information, diabetes history, medication and QOLID were collected using a structured questionnaire. The collected data were analysed using the analysis of variance followed by Bonferroni post-multiple comparison test. A value of P < 0.05 was considered statistically significant. Results: In this study, 238 (62.3%) males and 144 (37.7%) females with a mean age of 58.5 years. The overall QOLID score was the highest (126.60 ± 18.54) in Group I and least (59.67 ± 13.4) in Group III. Role limitation due to physical health, physical endurance, financial worries, diet satisfaction and the overall score were lower among the groups with diabetic complications (Groups II–VI) compared to Group I and this was statistically significant. General health, treatment satisfaction, symptom botherness and emotional/mental health scored lower in the groups with diabetic complications (Groups II–VI) compared to Group I and this was statistically significant in all except with diabetic retinopathy. Conclusion: When compared to people without any complications, patients with complications had reduced QOL. Individuals with diabetic neuropathy and nephropathy had very reduced QOL compared to other diabetic complications. Prevention or delay of onset of complications through better management of diabetes may help improve the QOL.
Keywords: Cardiovascular complications and diabetic neuropathy, diabetes mellitus, diabetic foot disease, diabetic nephropathy, diabetic retinopathy, quality of life
|How to cite this article:|
Simon P, Pereiera DM, Mathai RT, George T, Abraham S, DíSouza OL, Baliga MS. Quality of life in diabetics with different complications: A cross-sectional study with patients visiting a hospital on an outpatient basis. Hamdan Med J 2019;12:195-9
|How to cite this URL:|
Simon P, Pereiera DM, Mathai RT, George T, Abraham S, DíSouza OL, Baliga MS. Quality of life in diabetics with different complications: A cross-sectional study with patients visiting a hospital on an outpatient basis. Hamdan Med J [serial online] 2019 [cited 2020 Apr 6];12:195-9. Available from: http://www.hamdanjournal.org/text.asp?2019/12/4/195/270670
| Introduction|| |
Globally, diabetes mellitus (DM) is a major non-communicable disease as old as mankind today is a major ailment and its incidence continues to be on the rise. Recent reports from the World Health Organization (WHO) suggest that in adults the global prevalence of diabetes has risen from 4.7% in 1980 to 8.5% in 2014 and that it is a major cause of blindness, kidney failure, heart attacks, stroke and lower limb amputation. From a global perspective, reports suggest that India has the second highest number of diabetics in the world after China and that the numbers are projected to increase in the coming decades. When considering the aspect from a health economics perspective, the number is staggering as the health-care facility required to cater to this humongous numbers of patients is very less and imposes a gigantic pressure on the already stretched health-care facility. The development of microvascular and macrovascular complications in the absence of regular adherence to medication and lifestyle modification increases the morbidity and mortality and further complicates the situation.,,,, To substantiate this, reports suggest that India has a high rate of complications due to poor glycaemic control and the problem can be severe.
From a psychological perspective, reports worldwide have conclusively shown that diabetes afflicts the QOL of the individual and the need to be on regular medication affects the family resources. The WHO defines 'quality of life (QOL) as individuals' perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns' and is an important by neglected aspect in India. In the present study, we used the QOL instrument for Indian diabetic patients (QOLID) developed by Nagpal et al., principally because it is India specific, has high internal consistency, discriminant validity and good concordance with Diabetes QOL Clinical Trial Questionnaire. As our objective was to ascertain the QOL in people from the society, we made a conscious attempt to ascertain it in patients visiting the hospital on an outpatient basis.
| Materials and Methods|| |
Research participants and data collection
The study was conducted at Father Muller Research Centre, Mangalore, Karnataka, India, from January 2012 to December 2012. All study procedures adhered to the principles outlined in the Declaration of Helsinki of 1975 that was revised in 2000 for research involving human subjects and clearance was obtained from the Institution Ethics Committee. Informed consent was obtained from all willing participants, either in writing or if required by the participant, the interviewer directly read and explained the purpose and procedures, and then recorded the participants' consent to participate.
The inclusion criteria consisted of patients >18 years with Type 1 and Type 2 DM. Patients with cognitive impairment or inability to communicate due to physical/mental disability and visiting the hospital on an outpatient basis were excluded from the study. Patients with kidney disease due to other causes, cataract, ocular ischaemic syndrome, central retinal artery/vein occlusion, optic neuritis or any other chronic illness which required the patient to be admitted in the hospital were also excluded from the study.
Random blood sugar and glycosylated haemoglobin were measured for the purposes of identifying diabetes. A participant was considered to have DM if any of the following criteria were met:
- History of DM and was being treated with oral hypoglycaemic medications, insulin or diet alone
- Fasting glucose level of ≥126 mg/dl
- Glycosylated haemoglobin measured at ≥6.5%
- Random blood glucose of ≥200 mg/dl with clinical symptoms of diabetes
- 2-h plasma glucose level of ≥200 mg/dl after 75 g oral glucose tolerance test.
Participants who were diagnosed with diabetes before the age of 30 years and were dependent in insulin were diagnosed with Type 1 DM and the rest were diagnosed with Type 2 DM. They were divided into six groups.
- Group I – Participants with diabetes without complications
- Group II – Participants with retinopathy
- Group III – Participants with nephropathy
- Group IV – Participants with diabetic foot disease
- Group V – Participants with cardiovascular complications
- Group VI – Participants with neuropathy.
Participants for Groups I and II were obtained from the medicine/endocrine and ophthalmology Outpatient Department, respectively. Retinopathy was defined by the presence of at least one definite microaneurysm by retinal photography. Group III were patients undergoing dialysis due to diabetic nephropathy defined as urinary albumin excretion ≥30 μg/mg of creatinine. Group IV included patients admitted in the surgery ward with diabetic ulcer, gangrene or history of amputation. Wagner ulcer classification system was used to classify diabetic foot disease. It is based on the depth of the ulcer, presence of abscess, osteomyelitis and gangrene. Group V had patients admitted to the cardiac with ischaemic heart disease (IHD) determined by a history of myocardial infarction or coronary revascularisation or Q waves on electrocardiogram or on drug treatment for IHD. Participants in Group VI were obtained from the Neurology Outpatient Department. Neuropathy was defined as loss of pressure sensation assessed using 10 g monofilament over metatarsal heads or vibration sensation assessed using 128 Hz tuning fork on lower limbs. Participants who satisfied the criteria for more than one group were excluded from the study to prevent confounding bias.
Demographic information including age, sex, smoking history and alcohol intake were recorded. A detailed history of diabetes, which included time since diagnosis, treatment modality and the presence of diabetic complications such as retinopathy, nephropathy and diabetic foot was obtained.
Quality of life instrument for Indian diabetic patients
The final version of QOLID with eight domains and 34 items was used in this study. It consists of questions related to role limitation due to physical health, physical endurance, general health, treatment satisfaction, symptom botherness, financial worries, emotional/mental health and diet advice tolerance. It was administered in a face-to-face setting by one of the investigators in the patients' native language in a standardised manner. It took approximately 7 min to complete.
The collected data were processed and analysed using the IBM SPSS Statistics version 23.0 (Chicago, IL, USA). Overall QOLID scores and subscale scores were compared between diabetics without complications and those with diabetic complications using analysis of variance followed by Bonferroni post-multiple comparison test. Values of P < 0.05 were considered statistically significant.
| Results|| |
General and disease-related characteristics
The study consisted of 382 consenting participants. They were divided into six groups based on the presence of diabetic complications. The details such as demographics, smoking and alcohol history, diabetes duration and treatment, blood pressure and fasting blood glucose level are included in [Table 1]. Overall there were 238 (62.3%) males and 144 (37.7%) females, with a mean age of 58.5 years. The percentage treated with oral hypoglycaemics in Groups I–VI was 67.4%, 88.9%, 90.6%, 87.2%, 44% and 82.45%, respectively, and insulin 33.7%, 18.1%, 52.8%, 53.5%, 48% and 68.42%, respectively. Fasting blood glucose level was higher among the groups with diabetic complications (Groups II–VI) when compared with those without diabetic complications (Group I). Mean systolic blood pressure was also higher among the groups with diabetic complications (Groups II–VI) when compared with those without diabetic complications (Group I).
Quality of life instrument for Indian diabetic patients characteristics
The distribution of QOLID scores is given in [Table 2]. The overall score was the highest (126.60 ± 18.54) among diabetics without complications (Group I). It was the least (59.67 ± 13.4) among diabetics with nephropathy (Group III). The score for each of the eight domains was also the least in Group III when compared with the other groups. The scores for each of the eight domains were compared between Group I and Groups II–VI. The P value for each of the comparisons is given in [Table 2]. Role limitation due to physical health, physical endurance, financial worries, diet satisfaction and the overall score were lower among the groups with diabetic complications (Groups II–VI) compared to Group I and this was statistically significant. General health, treatment satisfaction, symptom botherness and emotional/mental health scored lower in the groups with diabetic complications (Groups II–VI) compared to Group I and this was statistically significant in all except with diabetic retinopathy. Thus, the presence of diabetic complications was associated with a lower QOL. Analysis for association between the demographic details such as age, gender, duration of diabetes, smoking and alcohol intake status with the QOLID did not show any significance.
|Table 2: Quality of life in people with diabetes alone and various complications|
Click here to view
| Discussion|| |
In the present study, an attempt was made to identify the effect of various diabetic complications on the QOL as well as the extent of the effect of the eight domains of QOLID on that QOL. QOLID is a valid and reliable questionnaire to assess the QOL in Indian diabetic patients. This study showed that the presence of diabetic complications was associated with a reduced QOL.
Previous studies have shown that the QOL is affected in people with DM II and that the prevalence and intensity of fatigue, sleep, and pain were dependent on the consequence of glycaemic variability and diabetes-related complications. In this regard, the episodes of nocturia, polyuria, neuropathic pain and obstructive sleep apnoea increased fatigue and ultimately affecting the overall QOL. To further substantiate, cross-sectional surveys from China have also shown that low QOL were significantly higher for patients with microvascular complications, diabetic neuropathy and peripheral vascular disease.
In this study, individuals afflicted by neuropathy and nephropathy were associated with lower QOL compared to other diabetic complications and to people with only hyperglycaemia without any complications [Table 2]. These observations are in agreement with the study by Venkataraman et al. who have also reported that the QOL was reduced in people with diabetic complications rather than diabetes itself with the greatest reduction being in people afflicted with neuropathy.
The other important observation was that when compared to the cohort without foot complaints, patients who have had diabetic foot and had recurrent issues and infections had significantly reduced QOL., Diabetic foot issues compromises an individual's mobility and this will consequentially impact their day-to-day routine and activities, thereby aggravating the morbidity and decrease in QOL and recent reports from Saudi Arabia, Ethiopia, Greece  and Thailand  have confirmed these observation. To further substantiate this, seminal report from the observations by Wukich and Raspovic  affirm that people afflicted with diabetic foot issues, have low self-reported physical QOL, low QOL and have higher rates of hospital admission and mortality.
Although our study has identified the effects of diabetic complications on the QOL, it has certain limitations. The biggest drawback of our study is that this is a single centre urban-based study. Further studies with people from different geographical locations and populations in India, as well as including subjects with single and multiple complications of diabetes with profession and job status will help in establishing an accurate QOL scale applicable for clinical practice. Attempts should also be at ascertaining QOL in patients having multiple complications as in this study we excluded them in the inclusion criteria. However, this study has certain strengths, including adequate same size, a verified questionnaire adapted for the study population and standardised protocol to assess various parameters.
| Conclusion|| |
The presence of diabetic complications was associated with a reduced QOL. Neuropathy and nephropathy were associated with lower QOL compared to other diabetic complications. Prevention or delay of onset of complications through better management of diabetes may help improve the QOL.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ogurtsova K, da Rocha Fernandes JD, Huang Y, Linnenkamp U, Guariguata L, Cho NH, et al.
IDF diabetes atlas: Global estimates for the prevalence of diabetes for 2015 and 2040. Diabetes Res Clin Pract 2017;128:40-50.
Al-Rubeaan K, Youssef AM, Ibrahim HM, Al-Sharqawi AH, AlQumaidi H, AlNaqeb D, et al.
All-cause mortality and its risk factors among type 1 and type 2 diabetes mellitus in a country facing diabetes epidemic. Diabetes Res Clin Pract 2016;118:130-9.
Misra A, Gopalan H, Jayawardena R, Hills AP, Soares M, Reza-Albarrán AA, Ramaiya KL. Diabetes in developing countries. J Diabetes 2019;11:522-39.
Win Tin ST, Kenilorea G, Gadabu E, Tasserei J, Colagiuri R. The prevalence of diabetes complications and associated risk factors in Pacific Islands countries. Diabetes Res Clin Pract 2014;103:114-8.
ADVANCE Collaborative Group, Patel A, MacMahon S, Chalmers J, Neal B, Billot L, et al.
Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008;358:2560-72.
Tunner R, Holman R, Stratton I, Cull C, Frighi V, Manley S; UK Prospective Diabetes Study Group, et al
. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes (UKPDS 38). Br Med J 1998;317:703-13.
Mohan V, Shah S, Saboo B. Current glycemic status and diabetes related complications among type 2 diabetes patients in India: Data from the A1chieve study. J Assoc Physicians India 2013;61:12-5.
What quality of life? The WHOQOL group. World health organization quality of life assessment. World Health Forum 1996;17:354-6.
Nagpal J, Kumar A, Kakar S, Bhartia A. The development of 'quality of life instrument for Indian diabetes patients (QOLID): A validation and reliability study in middle and higher income groups. J Assoc Physicians India 2010;58:295-304.
Singh R, Teel C, Sabus C, McGinnis P, Kluding P. Fatigue in type 2 diabetes: Impact on quality of life and predictors. PLoS One 2016;11:e0165652.
Cong JY, Zhao Y, Xu QY, Zhong CD, Xing QL. Health-related quality of life among Tianjin Chinese patients with type 2 diabetes: A cross-sectional survey. Nurs Health Sci 2012;14:528-34.
Venkataraman K, Wee HL, Leow MK, Tai ES, Lee J, Lim SC, et al.
Associations between complications and health-related quality of life in individuals with diabetes. Clin Endocrinol (Oxf) 2013;78:865-73.
Wagner FW Jr. The diabetic foot. Orthopedics 1987;10:163-72.
Raspovic KM, Wukich DK. Self-reported quality of life and diabetic foot infections. J Foot Ankle Surg 2014;53:716-9.
AlSadrah SA. Impaired quality of life and diabetic foot disease in Saudi patients with type 2 diabetes: A cross-sectional analysis. SAGE Open Med 2019;7:2050312119832092.
Degu H, Wondimagegnehu A, Yifru YM, Belachew A. Is health related quality of life influenced by diabetic neuropathic pain among type II diabetes mellitus patients in Ethiopia? PLoS One 2019;14:e0211449.
Tzeravini E, Tentolouris A, Tentolouris N, Jude EB. Advancements in improving health-related quality of life in patients living with diabetic foot ulcers. Expert Rev Endocrinol Metab 2018;13:307-16.
Sothornwit J, Srisawasdi G, Suwannakin A, Sriwijitkamol A. Decreased health-related quality of life in patients with diabetic foot problems. Diabetes Metab Syndr Obes 2018;11:35-43.
Wukich DK, Raspovic KM. Assessing health-related quality of life in patients with diabetic foot disease: Why is it important and how can we improve? The 2017 roger E. Pecoraro award lecture. Diabetes Care 2018;41:391-7.
[Table 1], [Table 2]