Diabetes Mellitus and quality of life: lower socio-economic status patients in Indian tertiary healthcare – a cross sectional study

Introduction

The World Health Organization (WHO) defines QoL as “an individual’s 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.”¹ Improved QoL is the main goal to be achieved in management of long lasting ailments, thereby making QoL an essential health consequence.² QoL consists of four categories; environmental, physical, social and psychological. Decreased QoL is observed in patients having diabetes and worsens when comorbidities or complications occur. Metabolic diseases comprising of hyperglycaemia without treatment constitute diabetes. Etiopathology of diabetes is mixed and it consists of defective action and/or secretion of insulin along with derangements in metabolism of proteins, fats and carbohydrates. Individuals having “fasting plasma glucose ≥ 7.0 mmol/L (126 mg/dl)”, “2-h post-load plasma glucose ≥ 11.1 mmol/L (200 mg/dl)”, “HbA1c ≥ 6.5% (48 mmol/mol)”; or “random blood glucose ≥ 11.1 mmol/L (200 mg/dl)” along with appropriate clinical features are regarded as diabetic patients. “Type I diabetes (T1DM)” and “Type II diabetes (T2DM)” are the “2” essential types. The difference between these two types is according factors like need for insulin treatment, insulin resistance, age at onset, involvement of diabetes-associated antibodies and β cell function loss. Neuropathy, nephropathy and retinopathy are the explicit side effects seen in diabetes in the long run. There is also presence of association with ailments involving tuberculosis, cerebrovascular disease, heart, erectile dysfunction, obesity, non-alcoholic fatty liver disease and cataract. Confirmation of diabetes comes with various consequences for patients, in respect of their health, plus the existence of several social stigmas. A diabetes diagnosis can in turn affect various aspects of their life such as their social opportunities, employment, driving status, life and health insurance and carrying out ethical and cultural customs.⁴ Patients often feel burdened by their ailment and its daily management necessities and these challenges are considerable; making innumerable decisions on a daily basis.⁴ Management of diabetes, for instance, insulin administration, can reduce symptoms of hyperglycaemia or can increase symptoms of hypoglycaemia; which therefore has a beneficial or negative affect on quality of life. A life with diabetes can be a psychosocial burden. This can in turn lead to repercussions in terms of lack of self-care and thus, can affect glycaemic control in turn leading to development of long-term complications, and finally affecting QoL.⁵ The benefits of self-care in lifestyle management of diabetes is influenced by psychosocial factors and its variables are strong determinants of end results, such as hospitalization and death as compared to physiologic and metabolic adjustments.⁶ Diabetes is one of the topmost hazards to public health worldwide and in the case of countries with low to middle-income, such as India, the situation becomes more frightful, where the disease burden has steadily increased and will continue to rise further in the future.⁷ India is experiencing a rise in incidence and a transition in prevalence of diabetes from older to younger individuals, the wealthy to the poor and from urban to rural areas.⁸ The ultimate goal of healthcare interventions is evaluation of QoL in clinical practice and research settings. From various QoL research studies, several findings of clinical use have been reported.⁵ Routine assessments of QoL in clinical practice has the ability to improve doctor-patient relationships, identify issues that are often ignored, prioritise obstacles, and assess the outcome of restorative attempts at the individual level.⁵ This study aims to understand the relation between various domains of quality of life affected among patients belonging to lower socio-economic status with Diabetes Mellitus in our setting.

Methods

Results

Data obtained from 100 participants was evaluated. Table 1 stands for the baseline characteristics namely sex, age and B. G Prasad category.¹⁰ The majority of the participants were males (63%) as compared to females (37%). The mean age of the patients was 57.2 ± 1.2 years. The highest number of participants belonged to 51-60 years old age bracket (31%), followed by 41-50 years (25%) and 61-70 years (18%). In the case of socio-economic status, there was almost equal distribution of participants with a higher number in Category 4 (52%) as compared to Category 5 (48%). Table 2 represents details about diabetes mellitus such as duration, HBA1c, medications, comorbidities and complications. In terms of the duration of the disease, the majority of the participants belonged to 1-5 years (44%), followed by 6-10 years (28%) and >20 years (9%). >6.5 HbA1c was seen among 95% participants and <6.5 among 5%. Most of the patients were on only OHA (87%), followed by Insulin (8%), followed by combination of both OHA and Insulin (5%). There was an almost equal distribution of participants among presence (51%) and absence (49%) of comorbidities. The majority of the participants had microvascular complications (43%), followed by macrovascular (29%), followed by absence of any complications (24%), followed by both macrovascular and microvascular complications (4%). Table 3 represents the distribution of the QoL scores and its various determinants. As per the cut-off set by the MDQoL-17 questionnaire, a QoL score above 70 suggests a better QoL as compared to a score of 50-70 which indicates moderate QoL and score less than 50 suggests a poor QoL.⁹ Table 4 depicts the association between various factors and the overall QoL. A p-value of <0.001 was observed when physical functioning, physical health, emotional wellbeing, emotional health, social functioning and general health were compared with overall QoL, suggestive of extreme significance. Remaining determinants showed a p-value of >0.05 when compared with overall QoL.

Discussion

In our study we assessed the quality of life and its various domains among 100 diabetic patients belonging to lower socioeconomic groups as classified by the B.G. Prasad category 4 and 5. The average age of the participants was around 57 years old, with most being male. A similar distribution with regard to age and gender was noted in a study of global prevalence of diabetes by Wild et al., as well as regional studies with the average age of diabetic patients around 45-65 years.^9,11,12 Quality of life significantly worsened with age and duration of diabetes as supported by similar studies on quality of life of diabetic patients.^9,13

In this study we note lower quality of life scores among females as compared to the male patients. A similar observation was also made in studies conducted among the general population in different parts of the world.^3,13,17 Diabetes seems to have a more severe impact on quality of life of women, irrespective of their socioeconomic status or race.

Though more than 95% participants had an HbA1C of more than 6.5% and 76% had diabetic complications, only 13% were receiving insulin therapy. Many factors may have contributed to the poor compliance of these patients to initiate or continue insulin therapy such as accessibility, cost, storage and difficulty in administering insulin.

Most patients demonstrated an overall moderate to poor quality of life with determinants such as physical health, emotional wellbeing, social functioning and general health significantly affected. Increased energy fatigue, decreased energy levels, sleep disturbances and problems in social or work life were noted in the participants further impairing quality of life.

A lack of self-care and awareness of the course of the disease may have affected the general health of the patients.

We need to conduct follow up visits of diabetic patients, especially those belonging to lower socioeconomic status and ensure compliance to treatment. Regular follow up visits with the doctor will improve the doctor patient relationship, glycaemic control and also enable early identification of factors affecting quality of life. Patients should be encouraged to maintain a healthy diet and regular exercise and self-care. Complications can be detected early and managed accordingly without causing significant morbidity. The visits may also provide an opportunity to address any problems they may be facing concerning their physical or emotional health. Screening for depression should be done routinely. These measures may improve their quality of life which is the main goal while managing chronic ailments.

Conclusion

The study demonstrates a significantly affected QoL in diabetic patients belonging to lower socioeconomic strata in terms of physical health, emotional wellbeing and social functioning. We need to address common problems faced by patients in lower socioeconomic groups; lack of patient education and the financial burden of the disease can negatively affect their compliance with treatment.

With a better interpretation of the various domains of QoL affected in diabetic patients belonging to lower socioeconomic status we can use targeted approach to improve QoL. This study highlights the need for routine evaluation of these patients to assess compliance to treatment, identify complications and timely intervention thus improve their QoL.