Health related quality of life among patients with type 2 diabetes

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Health Related Quality of Life among Type 2 Diabetes

1. Type 2 Diabetes

Diabetes is a chronic disease with considerable impact on health status and quality of life and it is considered an urgent public health issue because it has a pandemic potential[1]. The World Health Organization (WHO) suggested a subdivision into four main groups of diabetes; Type I diabetes, Type II diabetes , gestational diabetes and other specific types (heterogenic group) [2]. Type 2 diabetes is a global public health crisis that threatens the economies of all nations, particularly developing countries. Fueled by rapid urbanization, nutrition, and increasingly sedentary life style, the epidemic has grown in parallel with the worldwide rise in obesity[3].

1.2. The Global Burden of Type 2 Diabetes

Once a disease of the west, type 2 diabetes has now spread to every country in the world. Once “a disease of affluence” it is now increasingly common among the poor. Once an adult-onset disease almost unheard of in children, rising rate of childhood obesity rendered it more common in the pediatric population.Diabetes is increasing most rapidly in developing countries, where industrialization and urbanization have led to the adoption of a western lifestyle. The world prevalence of diabetes in 2010 among adults (aged 20-79 years) was estimated to 6.4% affecting 285 million adults. By 2030 it is expected to increase to 7.7% and affecting 438 million adults with two-third of all diabetes cases occurring in low-to middle-income countries[3].

1.3. Etiology and Pathogenesis of Type 2 Diabetes

Type II diabetes is characterized by insulin resistance in peripheral tissues, but may range from predominantly insulin resistance with relative insulin deficiency, to a predominantly secretory defect with or without insulin deficiency. Insulin resistance is an impaired response to the physiologic effects of insulin, and diabetes is only one of the manifestations of the insulin resistance syndrome commonly associated with type II diabetes. Other manifestations of this syndrome include obesity, nephropathy, hypertension, dyslipidemia, ovarian hyperandrogenism and non-alcoholic fatty liver disease[4].

1.4. Contributing Factors of Type 2 Diabetes

Type 2 diabetes is increasing most quickly in developing countries where: rapid uncontrolled urbanization and major changes in lifestyle towards western diets, increased food quantity with reduced quality, low levels of exercise, smoking and increased alcohol availability as well as increased life expectancy could be driving this epidemic [5]. Risk factors for type 2 diabetes mellitus include old age, increased body mass index (BMI) and a certain body fat distribution, weight gain in adulthood, ethnicity, family history of diabetes, low birth weight, sedentary lifestyle, higher systolic blood pressure, impaired glucose tolerance, impaired fasting glucose, and history of gestational diabetes. It is estimated that about 85-95% of all people living with diabetes in developing countries suffer from type 2 diabetes[6].

2. Quality of Life Dimensions

Quality of life is a complex and multidimensional concept that is difficult to define and measure[7]. The subjective dimension of quality of life has been defined as the individual’s ability to perform and enjoy social roles, work roles, family roles, and community roles and shows how good a life each individual feels he or she has, incorporated also personal satisfaction with life, meaning of life, well- being and happiness. In the objective dimension means how one’s life is perceived by the outside world, their described quality of life in material terms” related to income, possessions and career success[8].

2.1. Diabetes and Health Related Quality of Life

Diabetes is not a single disease but a heterogeneous group of syndromes characterized by an elevation of blood glucose which may affect the patient physically, mentally and emotionally. The patients’ perception of how diabetes may affect their physical, psychological and social functioning is related to diabetes-specific health-related quality of life.Type II diabetes mellitus is a complex and a serious chronic disease that impose a significant burden on patients and society in a term of morbidity and premature mortality [9]. In the long term, diabetic patients have to face many complications. In addition to diabetes-related complications, episodes and fear of hypoglycemia and change in life style are the main cause of health-related quality of life (HRQoL) diminution[10].

In recent years QoL has been recognized as an important health outcome of all medical interventions and has become a core issue in diabetes care. QoL studies may provide clinicians with important information to Support clinical decision making, taking both biomedical and psychosocial into Consideration. However, persons with type 2 diabetes report lower HRQoL than the general population[11].

HRQoL is an important outcome for persons with type II diabetes, as it has been used to evaluate the impact of the disease and its treatment on individuals and health care costs. The disease itself can have a negative impact on quality of life. Several factors have been identified as predictors of HRQoL and diabetes-related quality of life in type 2 diabetes, including older age, female sex, depressive symptoms, number of diabetic complications, presence of comorbidities, and insulin use [12] . HRQoL provides a multidimensional perspective that encompasses a patient's physical, emotional, and social functioning[13] . Generally, patients with more than one co-morbid condition report the poorest level of HRQoL, but some chronic conditions, like cancer, cardiovascular and pulmonary diseases and diabetes mellitus, are more strongly associated with poor HRQoL than others [14]. However, less is known as regards differences in HRQoL in different regions of the world.

2.1.1. Physical health domain

The physical health domain assess the impact of disease on the activity of daily living, dependence on medical substances, a lack of energy and initiative, restricted mobility and the capacity to work[15] .Physical health gives an individual the ability to perform and adapt to the environment. Physical health is estimated by an individual’s perceptions of energy and fatigue, pain and discomfort, and sleep and rest. The physical health domain has shown a positive relationship with overall quality of life when one’s physical status was reported as high, perceptions were physical health and quality of life were more positive [16]. Based on the study conducted in Iraq in 2010 which reported that Diabetes had a greater impact on the QoL of females and older patients (50 years and more) than on the QoL of males and the young. Older diabetics (50 years and more) were affected more physically than psychologically. Factors that decrease physical and psychological domains of QoL were gender (being female), age 60 years and more, low level of education, sedentary type of work and long duration of diabetes. Therefore, changes in HRQoL should be considered in the management of all people with diabetes in all health care settings [17].

In follow-up study on Self-Care, Foot Problems and Health in Tanzanian Diabetic Patients and Comparisons with Matched Swedish Diabetic patients it was founded that more Tanzanian than Swedish patients experienced foot problems. The most frequently reported foot problem in Tanzanian patients was pain, whereas Swedish patients mostly experienced problems due to badly fitting footwear. Tanzanians with peripheral neuropathy (PN) reported significantly poorer health than those free from late foot complications, whereas those with peripheral vascular disease (PVD) had health scorings equal to those without any late foot complications[18]. Relation between PN, peripheral vascular disease (PVD) and self-perceived health in Tanzanian patients Tanzanians with PN had lower scores, indicating a poorer health, in all eight health domains in comparison with those free from foot complications. Significantly lower scores were found in the health domains of physical functioning, and role functioning. Thus, PN could be an influencing factor on patients’ perceived health [19].

2.1.2.Psychological domain

The psychological domain accesses the patient’s own thoughts about body image and appearance,negative feelings, self-esteem and personal beliefs[15]. Psychological well being is the focus of intense research attention and is relevant to the experience of the individual[15]. It is a person evaluative reaction to his or her life; either in term of life satisfaction (cognitive evaluations) or effects (ongoing emotional reaction). Psychological well being has been found to be a source of resilience against stress and becoming ill[15]. The impact of diabetes on quality of life, and general quality of life were different between males and females[20]. Similarly Miksch A et al [21] found gender-specific differences within the quality of life of patients with diabetes.

2.1.3.Social health domain

According to Skevington[15]. social domain assesses personal relationship, social support and sexual activity. Social relationships were one of the main area affected in people living with type 2 diabetes. People value their relationship with self and with others. When an individual is no longer able to physically, emotionally, or sexually relate to self and others, quality of life is often negatively affected[22]. The study conducted at Turkey in urban primary health care in 2012 has concluded that female participants reported a better sex life than did males; younger participants’ social life was better than that of older participants (≥ 51 years); divorced, widowed and single participants’ social life was better than that of those who were married; and participants without complication had better family relationships, sex life, sport/ leisure, and travel opportunities than those with complications[23].

2.2 Measurement of HRQoL

There are array of instruments (outcome measures) to assess HRQoL in type 2 diabetes. These outcome measures can be generic or diabetes-specific measure. Most of these outcome measures are patient- reported outcomes. Outcome measures that assessed functional status and psychological well-being have been identified in the literature as a sub-set of generic outcome measures in type 2 diabetes[24].

  • Generic HRQoL measures: They are generic preference based measures which provide valuable health status information of patients with diabetes and allow comparisons with general population and chronic health diseases[24][25][1]. See the table 1 below for examples of generic measures used in type 2 diabetes.
  • Psychological HRQoL measures: These assessed functional status and psychological well-being (anxiety and depression) of patient with type 2 diabetes[24]. See the table for types (Table 1).
  • Diabetes-specific HRQoL measures: These assessed specific aspect of diabetes such as the presence of diabetes symptoms, attitudes, worries, self-care, treatment satisfaction, adherence to diabetic regimen, locus of control, and social and family support[24]. See the table 1 for types of diabetes-specific measures.
2.2.1 Selecting appropriate HRQoL measures

Finding ideal tools to measure HRQoL in routine data collection among patient with diabetes could be tasking due to numerous types of such measures. Selection of suitable outcome measure is based on several factors which had been stated in the literature. However, it has been recommended the use of Appraisal of Diabetes Scale in combination with the SF-12 in clinical settings[26][2]. Also, Audit of Diabetes-Dependent Quality of Life (ADDQoL), Diabetes Care Profile (DCP) and WBQ were promising diabetes-specific tools because of its good internal reliability, external and construct validity[27].


In a review of quality of life and diabetes, Rubin and Peyrot conclude that people with diabetes have worse quality of life than do those without diabetes, specifically in the areas of physical functioning and well-being. Better glucose control generally improves quality of life, and some psychosocial factors (health-related beliefs, social support, coping style, and personality) have a powerful effect on quality of life either directly or through their capacity to buffer the negative effects of diabetes[23]. It is clear that different measures can be utilized to manage the quality of life change because of Diabetes type 2 and this need strategic health policy.

Table 1: HRQoL measures used in type 2 diabetic populations[24][28][3][4]
Generic quality of life questionnaires Psychological measures Diabetes-specific scales
Short Form 6D (SF-6D) Affect Balance Scale (ABS) Diabetes Quality of Life (DQOL)
Short Form 12 (SF-12) Center for Epidemiologic Studies-Depression (CES-D) Scale Diabetes-39 (D-39)
Short Form 20 (SF-20) Zung Self-Rating Depression Scale (ZSDS) ATT39 Scale
Short Form 36 (SF-36) Symptom Check-List 90-Revised (SCL-90-R) Problem Areas in Diabetes Survey (PAID)
Sickness Impact Profile (SIP) Hospital Anxiety and Depression Scale (HADS) Diabetes Care Profile (DCP)
Dartmouth COOP/WONCA Chart Beck Depression Inventory (BDI) Diabetes Health Profile (DHP)
Nottingham Health Profile (NHP) Profile of Mood State (POMS) Diabetes Impact Measurement Scales (DIMS)
Quality of Well-Being Scale (QWB)   Diabetes Health Status Questionnaire (DHS)
EuroQol (EQ-5D)   Perceived Control scales
Well-Being Questionnaire (WBQ)   Diabetes Treatment Satisfaction Questionnaire (DTSQ)
World Health Organization Quality of Life Questionnaire (WHOQOL)   Diabetes Quality of Life Clinical Trial Questionnaire (DQLCTQ)
WHO-5 Index for QoL   The Diabetes Activities Questionnaire (TDAQ)
  Diabetes Fear of Injecting and Self-testing Questionnaire (D-FISQ)
  DSC-Type 2
  Audit of Diabetes-Dependent Quality of Life (ADDQoL)
  Appraisal of Diabetes Scale (ADS)
  Diabetes Distress Scale (DDS)
  Diabetes-Specific Quality of Life Scale (DSQoLS)
  Elderly Diabetes Burden Scale (EDBS)
  Insulin Delivery System Rating Questionnaire (IDSRQ)
  Quality of Life with Diabetes questionnaire (LQD)
  Questionnaire on Stress in Diabetic patients-Revised (QSD-R)
  Well-being Enquiry for Diabetics (WED)



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