Khaled J. Issa 1, Yosaf Ibrahim 1, Nasir Ali 1, Abdulla Haroon 1, Mohammed Waseem 1, Noor Aldin 1, Shatha Al- Sharbatti 2, Rizwana Burhanuddin Shaikh 2, Elsheba Matthew 2 1) 4 th Year M.B.B.S. Students, College of Medicine, 2) Department of Community Medicine, Gulf Medical University, Ajman, UAE. Correspondence: Prof. Shatha Al Sharbatti Dept. of Community Medicine, Gulf Medical University, Ajman, UAE Email id: researchdivision2@gmail.com - Phone: +97167431333 - Fax: +97167431222 Abstract Background: Diabetes mellitus is an endocrine disorder with a high prevalence in the Middle East. The effect of this condition has been studied by various researchers indicating a marked effect on the quality of life of patients. Objective: To assess the effect of diabetes mellitus on quality of life (QOL). To identify the domain that shows the greatest impact of diabetes. Materials and methods: A crosssectional study was done in Ajman among diabetic and non-diabetic individuals. A standardized selfadministered questionnaire (Short Form-36) was used to assess the QOL of the participants in different domains, Physical function, Role of physical limitation due to DM, Bodily pain, General health, Vitality, Social functioning, Role of emotional limitation due to DM, Mental health, Physical Component, and Mental Component. A standardized scoring system was used to determine the QOL domains scores for each individual. Data analysis was done using SPSS version 19. Results: The study included 180 diabetic and 180 non-diabetic individuals. The median scores for QOL domains PF, RP, BP, GH, V, SF, RE, MH, PCS, and MCS were significantly lower in diabetic group compared to non-diabetics. The greatest difference between median scores of the two groups was noticed in the Role- physical domain which reflects the extent to which physical capabilities limit activity of the individual and this was followed by the Role emotional. Conclusion: Diabetes mellitus affects the quality of life of patients in all dimensions, physical, mental and social. Key words: Diabetes, Quality of life, Ajman. Introduction Diabetes mellitus is a common, costly condition associated with significant morbidity and mortality (1). The number of people with this condition is increasing due to population growth, ageing, urbanization, and increasing prevalence of obesity and physical inactivity (2). It is an increasingly important public health concern in many part of the world. In the United States, diabetes is present in 8% of the adult population, and is associated with a two-fold increase in age adjusted mortality (3). Diabetes prevalence in some Eastern Mediterranean countries is among the highest in the world (4). In the United Arab Emirates, diabetes has been identified as a growing problem, and according to statistics released by the WHO, a prevalence of 20.5% and 19.2% was reported for diabetes among adult males and females respectively (5). Diabetes has detrimental effects on a range of health outcomes 48 including health-related quality of life (HRQoL) (6-8). In the Medical Outcomes Study, diabetes was found to impair all dimensions of health except mental health and pain (9). In a more recent multinational study, diabetes was found to have a notable impact on general health, measured using the Medical Outcomes Short-Form 36 (SF-36) (10). The magnitude of the impact of diabetes on HRQoL was reported to be equivalent to that of having cardiovascular conditions, cancer and chronic respiratory disease (11). Information on the impact of diabetes on quality of life (QOL) of diabetics in the United Arab Emirates was not available. Objective To assess the effect of diabetes mellitus on quality of life (QOL). To identify the domain that shows the greatest impact of diabetes.
Materials and methods A cross-sectional study was done from 1 st October 2010 to 15 th April 2011 with participants selected from three hospitals [Gulf Medical College Hospital & Research Center (GMCHRC), Sheikh Khalifa Hospital Ajman, and Umm Al Quwain Hospital]. The presence of diabetes was assessed by asking the subjects whether a doctor had ever told them they had diabetes. Persons who responded positively and companion or relative of patients who responded negatively for the same question were invited to participate in the study. Informed consent was taken from participants after discussing the aims of the study and before enrollment in the study. A standardized self-administered questionnaire (Short Form-36) was used to assess the QOL of the participants in different domains. It also included demographical questions and some questions related to diabetes for the diabetic group. The questionnaire assessed many aspects of the patient s well-being. The results of the questionnaire were scored using a system that broke down the results into eight subunits to help us identify the area of most/least effect. Those subunits are: 1. Physical functioning (PF): ability to deal with physical requirements of life. 2. Role - physical (RP): extent to which physical capabilities limit activity. 3. Bodily pain (BP): perceived amount of pain experienced during previous four weeks and the extent to which it interfered with normal work activities. 4. General health (GH): general health in terms of personal perception. 5. Vitality (VT): feeling of pep, energy and fatigue. 6. Social functioning (SF): extent to which social activities were affected. 7. Role-emotional (RE): extent to which emotional factors affected work or other activities. 8. Mental health (MH): extent of feelings of depression and anxiety. Furthermore, two more variables, known as standardized physical component (PCS) and mental component (MCS), were used which are basically a summary of the above. PCS is composed of PF, RP, BP and GH, whereas the MCS is composed of VT, SF, RE, and MH. A standardized scoring system was used to determine the QOL domains scores for each individual, with higher scores (range 0 100) reflecting better perceived health (12). Reliability 49 and validity of the SF-36 have been demonstrated for diabetic patients (13). With regard to job, it was categorized in to: manual laborer, non-manual, unemployed, and housewife. The questionnaire was translated into Arabic for use by the Arabic speaking participants. Back translation was done and both copies were examined to ensure validity of the translated tool. The final tool for data collection was validated by two physicians and one community medicine specialist. A pilot study was done to test the questionnaire. The pilot study included a sample of 10 individuals [5 diabetics and 5 non diabetics] who were selected from GMCHRC. The questionnaire was found convenient to be used with the public and it was felt that a good amount of information could be obtained. Data taken from the pilot group was not included in the analysis. Data analysis was done using SPSS version 19. Mann Whitney U test was used to test the significance of difference between median score values of the diabetic and non diabetic groups. Ethical consideration and human subject protection The study was approved by the Ethical Research Committee in GMU, and informed consent was taken from participants after discussing the aims of the study and before enrollment in the study. The participants privacy and confidentiality of information were ensured. Results The study included 180 diabetic and 180 non diabetic individuals. The distribution of the participants by gender, nationality, occupation, marital status and insurance status is shown in Table (1) Males constituted 50.6% and 45.6%. of the diabetic and non diabetic groups respectively. Most of the participants in both groups were from the Middle East. Most diabetics had non-manual job, while most of the non diabetics were unemployed. Most of the diabetics were married, while most of the non-diabetics were single.
Table (1): Distribution of the participants by gender, nationality, occupation, marital status and insurance status Non- Diabetics Variables Diabetics Total No (%) No (%) No (%) Gender Male 91 (50.6) 82 (45.6) 173 (48.1) Female 89 (49.4) 98 (54.4) 187 (51.9) Nationality Middle Eastern 138 (76.7) 84 46.7) 222 (61.7) African 14 (7.8) 35 (19.4) 49 (13.6) Asian 26 (14.4) 56 (31.1) 82 (22.8) Caucasian (USA, Europe) 2 (1.1) 5 (2.8) 7 (1.9) Job Non-manual 89 (49.4) 41 (22.8) 130 (36.1) Manual 13 (7.2) 19 (10.6) 32 (8.9) Other 44 (24.4) 23 (12.8) 67 (18.6) Unemployed 34 (18.9) 97 (53.9) 131 (36.4) Marital status Married 143 (79.4) 69 (38.3) 212 (58.9) Single 21 (11.7) 109 (60.6) 130 (36.1) Divorced 2 (1.1) 2 (1.1) 4 (1.1) Widow 14 (7.8) -- 14 (3.9) Insurance Yes 129 (71.7) 93 (51.7) 222 (61.7) No 51 (28.3) 87 (48.3) 138 (38.3) Table (2) shows the age distribution of the participants. The highest proportion of diabetics were in the age group 50-59 years and that of nondiabetics in the age group 20-29 years. Table (2): Age distribution of the participants Age group Diabetics Non-diabetics Total No. % No. % No. (%) <19 1 0.6 20 11.1 21 5.8 20-29 14 7.8 80 44.4 94 26.1 30-39 20 11.1 33 18.3 53 14.7 40-49 32 17.8 28 15.6 60 16.7 50-59 47 26.1 15 8.3 62 17.2 60-69 44 24.4 2 1.1 46 12.8 70-79 15 8.3 1 0.6 16 4.4 80+ 7 3.9 1 0.6 8 2.2 Table (3) shows health-related characteristics of the participants. There were higher frequencies of all chronic health problems in the diabetic group compared to the non-diabetics, except for musculoskeletal problems which showed similar frequencies in both groups. 50 Table (3): Health-related characteristics of the participants Nondiabetics Presence of chronic Diabetics Total medical conditions No % No % No % Heart disease 39 21.7 0 39 10.8 Cerebrovascular disease 26 14.4 2 1.1 28 7.8 Vision problems 76 42.2 3 1.7 79 21.9 Renal problems 26 14.4 1 0.6 27 7.5 Lung problems 3 1.7 1 0.6 4 1.1 Musculoskeletal illnesses 2 1.1 2 1.1 4 1.1 Hypertension 96 53.3 13 7.2 109 30.3 Hyperlipidemia 68 37.8 1 1.1 69 19.1 Table (4) shows the median and standard deviation (SD) scores of the SF-36 components in the diabetic and the non-diabetic groups. It can be seen the diabetics have significantly lower median values in all domains. The greatest difference between median scores of the two groups was noticed in the Role - physical (RP) domain, which reflects the extent to which physical capabilities limit activity of the individual. This is followed by the Roleemotional (RE): extent to which emotional factors affected work or other activities of the individual. Table (4): Median and standard deviation (SD) scores of the SF-36 components in diabetic and nondiabetic groups SF*Components Group Median scores SD p Physical function Diabetic 60.0 33.2 Non Diabetic 95.0 19.8 Role-Physical Diabetic 25.0 43.4 Non Diabetic 100.0 22.9 Bodily Pain Diabetic 64.0 27.0 Non Diabetic 74.0 22.3 <0.05 General Health Diabetic 52.0 21.3 Non Diabetic 67.0 18.0 Vitality Diabetic 50.0 20.7 Non Diabetic 60.0 16.0 Social functioning Diabetic 62.5 26.6 Non Diabetic 75.0 21.0 Role-Emotional Diabetic 33.3 44.6 Non Diabetic 100.0 32.6 Mental Health Diabetic 56.0 20.0 Non Diabetic 64.0 18.9 Physical Diabetic 42.4 12.7 Component Score Non Diabetic 53.4 7.0 Mental Component Diabetic 41.4 10.3 Score Non Diabetic 46.3 8.7 *SF=Short Form 36, 1=Diabetic group, 2= non-diabetic group
Table (5) shows Pearson correlation coefficient (r) and p values for the relationship between age and physical (PCS) and mental (MCS) components scores of cases and controls. Significant inverse correlations were found between age and both physical (PCS) and mental (MCS) components scores for cases only. Table (5): Pearson correlation coefficient (r) and p values for the relationship between age and physical (PCS) and mental (MCS)components scores of cases and controls. Groups r for PCS p for PCS r for MCS p for MCS Diabetics -0.362 <.001-0.223 <0.01 Non-Diabetics -0.054 NS 0.140 NS Discussion Health care providers should strive to understand the physical, emotional, and social impacts of having chronic disease. Such patient-centered knowledge can be incorporated into chronic disease treatment strategies designed to improve or enhance function in everyday life and improve or enhance quality of life (12). In this study, we found that subjects with diabetes experienced higher frequencies of chronic health problems compared to non-diabetics. This is in accordance with studies done in Singapore (14) Pakistan (15) and Italy (16). In this study, we found that subjects with diabetes experienced lowering of QOL as compared to subjects without diabetes. Similar finding was reported in another study done in Singapore (14). Researchers suggested that the reason for the lower scores for diabetics is probably multifactorial. Compared with non-diabetics, diabetics tend to be older, tend to be overweight, are much more likely to have co-morbidities (e.g. hypertension, coronary artery disease, hypercholesterolemia), and are more likely to suffer complications such as painful polyneuropathy, upper gastrointestinal symptoms, impotence, retinopathy, nephropathy, amputations, symptomatic hyperglycemia, and hypoglycemia (17-19). In this study, the greatest difference between median SF-36 domain scores of the diabetic and non-diabetic groups was noticed in the Role - physical (RP) domain which reflects the extent to which physical capabilities limit activity of the individual. This was followed by the Role-emotional (RE) which reflected the extent to which emotional factors affected work or other activities of the 51 individual. A study on health-related quality of life in Mexican Americans with diabetes (20) revealed lower mean SF-36 domain scores for diabetic subjects compared to non-diabetic group, and the differences were significant in all domains except that for role limitations due to emotional problems, mental health, and standardized mental composite scale. In the previous study, greater reduction in the mean SF-36 domain scores for diabetic subjects compared to non-diabetic group was in the physical functioning and role limitations due to physical functioning. Significant inverse correlations were found between age and both physical (PCS) and mental (MCS) components scores for cases only. Similar finding was reported by other researchers (20) for the physical Component scale only. In conclusion, we found that diabetes mellitus affects the quality of life of patients in all dimensions, physical, mental and social. References: 1. Economic consequences of diabetes mellitus in the US in 1997. Diabetes care 1998; 21:296-309. 2. Wild S, Roglic G, Green A, et al. Global Prevalence of Diabetes. Diabetes Care 2004; 27:1047-1053. 3. Gu K, Cowie CC, Harris MI: Mortality in adults with and without diabetes in a national cohort of the U.S. population, 1971 1993. Diabetes Care 1998; 21:1138-1145. 4. Malik M, Bakir A, Saab,BA, et al. Glucose intolerance and associated factors in the multiethnic population of the United Arab Emirates: results of a national survey. Diabetes Research and Clinical Practice 2005; 69(2):188-95. 5. Khatib OMN. Guidelines for the prevention, management and care of diabetes mellitus. EMRO Technical Publications Series 32. WHO 2006. Available from: http://www.emro.who. int/dsaf/dsa664.pdf. 6. Reddy SS. Health outcomes in type 2 diabetes. Int J Clin Pract Suppl 2000; 113:46-53. 7. Harris MI. Health care and health status and outcomes for patients with type 2 diabetes. Diabetes Care 2000; 23:754-758. 8. Hornquist JO, Wikby A, Stenstrom U, et al. Type II diabetes and quality of life: a review of the literature. Pharmacoeconomics 1995; 8 (Suppl 1): 12-16. 9. Stewart AL, Greenfield S, Hays RD, et al. Functional status and well-being of patients
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