The Quality of Life in Relationship with Glycemic Control in People with Type2 Diabetes

1. Department of Health Education and Health Promotion, School of Public Health, Shahid Sadoughi University of Medical Science, Yazd, Iran
2. Young Researchers and Elite Club, Zahedan Branch, Islamic Azad University, Zahedan, Iran
3. Solid Tumor Research Center, Urmia University of Medical Sciences, Urmia, Iran.
4. Urmia Health Center, Urmia University, Urmia, Iran         
5. Science and Research Branch, Islamic Azad University of Tehran, Iran

ARTICLE INFO		ABSTRACT
Original Received: 24 Oct 2016 Accepted: 30 Jan 2017		Introduction: Diabetes is a complex disease that affects the quality of patient’s life. Numerous studies have shown that quality of life in the people with diabetes is less than in people without diabetes, but, less research are discussed about the relationship between the quality of life and glycemic control. This study aimed to evaluate the health-related quality of life and its relationship with glycemic control in people with type 2 diabetes. Methods: Cross-sectional research (descriptive - analysis) is used in this study, which included 250 patients with type 2 diabetes in rural health centers. Demographic variables and data were collected via a standard SF-36 questionnaire. Data were analyzed using the descriptive statistics and independent t-test, ANOVA and Pearson correlation coefficient by SPSS v.21 software. Results: Average Total score of the quality of life of the participants was 58.32±19.62 and men had higher scores than women in all aspects of quality of life. There was no significant relationship among the dimensions of physical, mental, and the quality of life with HbA1C. However, there was a significant relationship between education level and marital status, quality of life and its dimensions (p> 0.05). Conclusion: According to the results of the study, the patients had undesirable situation in the dimensions of physical, mental, and the quality of life, therefore it is recommended that authorities design special planning due to nursing measures in order to prevent or control the side effects as well as consider the programs providing consulting services, improvement of medical and health services, increased social participation and programs that promote the quality of patients’ life.   Keywords: Type 2 Diabetes, Quality of Life, Glycemic Control
Corresponding Author: Soleiman. Akbari

How to cite this paper:

Despite the development of science and technology in the modern era, societies and the health of communities are faced with the most prominent and important problem, chronic diseases (1). Diabetes is a common disease in human societies, which, unfortunately, despite advances in medical science, its outbreak is increasing daily instead of decreasing (2). The prevalence of diabetes in developing countries in the Middle East is increasing. Diabetes is the most common endocrine disease in the world and is responsible for 4 million deaths a year; as at 1985, 30 million people worldwide have been infected with the disease and statistics shows that there are about 230 million people infected with the disease as at 2008 (3,4). The prevalence of diabetes in Iran was 7.7% in 2005, an approximate of 2 million people and is projected to reach nearly 5.2 million cases in 2025 with the continuation of the current trend (5,6).
Quality of life in diabetic patients is important. Lack of care, lack of glycemic control and the increase of diabetes complications lead to reduced quality of life (7). Concept of quality of life is today greatly considered due to development of communities and improvement of life health level (8). Quality of life is a multidimensional concept defined by the World Health Organization as the individual’s perception of their position in life, values, goals, standards and the individual interests (9). The quality of life generally is one of the main goals in the treatment of chronic patients (10). The diabetic complications affect various aspects of patients' quality of life, including psychological, physical, social, economic, family life and  sexual function (11). Several studies have shown that the quality of life in diabetic patients is less than in non-diabetic patients (12). The study of Sanchez et al (2005) showed that the quality of life in insulin-dependent diabetes patients is  in low level (13). The results of Pena et al in Madrid showed that in patients who suffer from diabetes, their mental health and quality of life is significantly lower than the control group (14). Hull et al. in their study, stated that the quality of life is related to the health of diabetics 1, and concluded that the multiplicity of chronic diabetes duties will lead to the creation of negative effects on the quality of life (15).
The results of Moghaddasian et al research (1386) showed that nearly half of the diabetics did not have a good quality of life in social and physical dimensions (16).
The studies showed that one of the very important concepts in chronic diseases such as diabetes is the concept of quality of life, due to the high incidence of diabetes in the world and Iran and a long - term and short - term effects and the high cost for the treatment of its effects (17). Over the past two decades, studies have shown that the main goal of treatment is not only addressing the physical signs and symptoms of disease, but it should consider the improving of the overall quality of patient’s life (18). Therefore, studying the quality of life in these patients have special importance to provide proper planning according to the results, in order to improve the quality of life of these patients.  Although in Iran, many studies have been conducted to determine and identify the quality of life of diabetic patients, few studies have been conducted in relation to the quality of life of diabetic patients by the glycemic Index.
According to the importance of glycemic control in diabetic patients and its relation to the quality of life, as well as the lack of similar studies in the city of Urmia, this study aimed to evaluate health-related quality of life (physical, psychological, social) and its relationship with glycemic control in people with type 2 diabetes.
Methods
Cross-sectional research (descriptive - analysis) is used in this study. According to previous studies, using the formula for estimating sample size for averages with a 95% confidence level, the alpha value of 0.5, S = 35 d = 4.5, the sample size was  estimated as 250 people, which included 250 patients with type 2 diabetes from the rural health centers. Cluster random sampling was used in this study as a sampling method, which is done in rural health centers. The samples were selected randomly among the type 2 diabetes patients in
10 identified medical centers, and then patients
were invited to interview and complete the questionnaires.
Data were collected through interviews and recorded information of the patient's files. So the quality of life questions were completed after explaining the purpose of the research, and satisfaction of diabetics population and tip’s of the questioner as a self report questionnaire, and the questionnaires of illiterate patients were completed by health workers of the centers by interviewing. Questions about demographics, glycemic and body mass index will be recorded by health workers from the patient files in the questionnaire.
Inclusion criteria for the study:
1. The quality of life of patients can be affected by affliction with type 2 diabetes at least after 2 years.
2. They shouldn’t have any other diseases  except diabetes.
3. The samples should be in the age group of35-65 years. Because according to research, the most common age of onset of type 2 diabetes is 40-65 years old.
4. There should be no change in diet or medication intake and have not received specific training on diabetes 3 months prior to the research.
5. It should not exceed a month after the HbA1c test.
Demographic variables data were collected through a standard SF-36 questionnaire, which is a questionnaire to determine the quality of life while the various aspects and factors of the quality of life were taken into consideration and are scored in different ways. It consists of two parts: the first part consists of demographic information including age, gender, occupation and education,. while the second part consists of questions related to quality of life. The questionnaire have 36 words in 8 categories including: physical functioning (10 items), mental health (5 items), social functioning (4 words), physical role (4 items), bodily pain (2 items), emotional role (3 phrase), vitality (4 items), general health (4 words). Due to the validation and translation of the questionnaire by Montazeri et al,  in the past studies, there is no need to re-assess the reliability and validity (19). Cronbach's alpha correlation values (0.86) were obtained.
Data were analyzed using SPSS software version 19. Chi-square test was used to measure the relationship between demographic variables with quality of life and Pearson correlation test was used to evaluate the relationship between quality of life and its dimension with blood glucose. The level of statistical significance was considered as p.value=0.05.
Results
According to the results, demographic characteristics of the population of study are shown in Table 1. A total of 70 and 30% of patients are male and female, respectively. Almost 62% of patients were illiterate, 66.5% were housewife and 76.5% were married. Total score of the quality of life of the participants is 58.3±19.6. In terms of quality of life, physical function (69.7±25.3) and public health (44.6± 13.06) had the highest and the lowest score, respectively (Table 2).

Characteristics	Levels	Number (Percentage)
Gender	Male Female	78(30) 182(70)
Education	Illiterate Elementary Guidance school Diploma Academic	161(61.9) 55(21.2) 30(11.5) 11(4.2) 3(1.2)
Job	Poulterer Self-employment Employee Housewife Other	42(16.2) 24(9.2) 2(0.8) 173(66.5) 19(7.3)
Marital status	Single Married Divorcee Widow	12(4.6) 199(76.5) 6(2.3) 43(16.5)
The term of the identification of diabetes	Less than  2 2-5 6-9 More than 10	47(18.1) 75(28.8) 72(27.7) 66(25.4)
Ethnicity	Azeri Kurd Fars Other	146(56.2) 112(43.1) 1(0.4) 1(0.4)
Type of treatments	Insulin Pill Diet	37(14.2) 191(73.5) 32(12.3)
Smoking	Yes No	23(8.8) 237(91.2)

Mean and Standard deviation (SD)	Indexes of quality of life
44.63±13.06	General Health
69.71±25.28	Physical function
53.27+_39.47	Physical role
61.66+_41.99	Emotional role
65.14±24.79	Social function
56.53±25.39	Pain
55.03±17.69	Vitality
60.55±17.64	Mental health
58.32±19.62	Total

According to the results in Table 3, there was a significant relationship between level of education and quality of life and its dimensions (p = 0.000), such that by increasing the level of education, the quality of life will increase.
 

Variable	Levels	General health	Physical function	Physical role	Emotional role	Social function	Pain	Vitality	Mental health	Total
Education	Illiterate  Elementary Guidance school45±15 Diploma51.6±5.7 Academic  P value P=.001	42.1±12.9 48±12.4 51.5±11.1	62.7±26.3 78.2±18.8 83.3±19.4 85.9±16.4 91.6±5.7 P=.000	43.6±39.6 60.4±36.8 80.8±25.1 75±33.5 83.3±14.4 P=.000	54.4±43.2 69.1±41.5 83.3±27.3 69.6±37.8 66.6±33.3 P=.004	59.6±24.5 71.4±24.2 79.5±16.3 76.1±30.3 62.5±0 P=.000	49.6±25.1 65.4±20.2 67.1±21.8 73.8±27.1 91.6±7.2 P=.000	50.8±16.1 61.4±18.1 64.5±13.9 57.7±29.2 58.3±2.8 P=.000	57.4±16.5 67.2±17.5 64±16.8 62.5±27.1 61.3±11.5 P=.007	52.56±19.3 65.15±17.40 71.77±11.72 68.23±21.46 70.892±4.64 P=.000
Gender	Male Female P value	46.6±13.1 43.7±12.9 P=.112	78.1±23.8 66.1±25.1 P=.000	57.3±39.3 51.5±39.5 P=.272	64.9±42.9 60.25±41 P=.409	72.2±24.5 62.1±24.3 P=.002	64.5±24.6 53.1±24.9 P=.001	57.5±16.1 53.9±18.3 P=.142	62.4±16.4 59.7±18.1 P=.268	62.98±18.29 56.32±19.87 P=.012
job	Poulterer Self-employment Employee Housewife Other P value	44.8±13.2 44.3±12.4 55±0 43.9±13.1 49.7±12.7 P=.322	72.1±29.6 86.4±11.5 95±0 66.1±24.2 73.6±28.4 P=.002	56.5±39.4 62.5±38.3 75±0 50.1±39.7 60.5±39.3 P=.416	61.6±41.9 63.4±45.8 69.4±41 60.5±41.4 56.1±41.6 P=.757	69.9±25.1 70.8±23.2 62.5±0 62.1±24.1 75.6±29 P=.061	63.1±26.9 68.7±21.1 87.5±0 52.9±24.3 55.9±29.8 P=.005	56.2±11.4 54.3±20.5 60±0 53.8±17.9 63.4±22.5 P=.251	63.6±13.8 57.3±20.1 68±0 59.6±17.7 65.6±21 P=.341	61.22±19.23 64.25±17.85 73.29±2.94 56.14±19.35 62.59±23.55 P=.120
Marital status	Single Married Divorcee Widow P value	36.6±12.8 46.6±12.7 45.8±10.6 37.3±11.4 P=.000	72.5±19.9 73.3±23.4 79.1±19.1 50.6±27.2 P=.000	47.9±43.2 57.2±39.2 70.8±24.5 33.7±35.7 P=.003	36.1±36.1 66.6±41.3 77.7±27.2 43.4±41.4 P=.0001	62.5±27.6 67.7±24.1 75±28.5 52.3±23.1 P=.002	61.4±22.8 59.7±24.5 68.7±28.2 38.3±21.8 P=.000	44.5±21.5 57.1±16.3 58.3±25.8 48.1±19.2 P=.003	44±15.1 61.9±17.3 63.3±25.8 58.3±16.4 P=.005	50.71±14.39 61.32±18.79 67.37±20.43 45.28±18.97 P=.000

The relationship between quality of life and its dimensions was investigated using Pearson test. The results showed that there was no significant correlation between quality of life and its subscales based on the SF-36 questionnaire with blood sugar control which indicated that with increase of the quality of life, blood sugar control in diabetic patients did not increase.

HbA1C		Indexes of quality of life
P value	Correlation coefficient (r)
0.84	-0.024	General Health
0.81	-0.021	Physical function
0.80	-0.018	Physical role
0.55	-0.014	Emotional role
0.59	-0.017	Social function
0.73	-0.028	Pain
0.64	-0.019	Vitality
0.51	-0.011	Mental health
0.66	-0.027	Total

Discussion
Diabetes is one of the most common and important metabolic disease in the world and is one of the major causes of death in most societies. The results of the study indicate that an overall score of the quality of life of the participants is 58.3 ± 19.6. Also, in terms of quality of life dimensions, the physical function (69.7 ± 25.3) and public health (44.6± 13.06) have the highest and lowest score, respectively. This is in line with the study of Aryan et al (20), in which the lowest and highest score was the score of  general health and physical functioning, respectively. However, in the research of  Montazeri et al(19), the lowest score was related to the scale of emotional role, and the highest scores on physical performance. It seems that public health of patients has been more negatively affected. In terms of education and occupation, most of the patients were illiterate and housewives which is consistent with the study of Bagust et al (21).  The results showed that between sex and quality of life in all eight dimensions, the women obtained lower scores in comparison with men, considering the fundamental role of education in the treatment of diabetes and its effect on the quality of life. With regard to the study of Ghasemi et al., it can be concluded that low level of education among women compared to men, is the reason of low social support about diabetes, healthy diet and appropriate treatment (22). Also, low levels of quality of life in women compared to men may be due to more attention of women  to health symptoms and deficits. In addition, limited physical activity of women and their response in the face of adverse events and the arrival of menopause are also factors contributing to the differences in the quality of life between men and women (23). The results of this study showed that there is a significant relationship between marital status and all aspects of quality of life. Zareipour et al. in their research showed that successful marriage may improve compatibility with the disease conditions. The support from the patient's spouse is the most important source of support of the individuals during the disease phases (24). The results show that there is a significant relationship between educational attainment and all aspects of quality of life. It seems that, the quality of life will improve by increasing levels of education.
This can be due to the increased awareness on the importance of diet and exercise as well as proper metabolic control, proper use of drugs and control of other factors affecting the risk of
chronic diabetes. In fact, higher education levels cause increase economic, social and political participation, and subsequently quality of life, too. Education is one of the important factors affecting the quality of life which directly or indirectly affect the quality of life through social class and income. In the scrutinizing of  jobs and all eight dimensions of quality of life except the social function, employees had a higher score rather than other business groups. Considering the fact that people with specific occupation are involved in a string of job activities and are associated with participation in different social environments with various people more than those who have no job, occupation can affect their health (23).
The results showed that there is a significant correlation between identifying the disease and physical function, emotional disorders, social function, pain and quality of life. If the identification of diabetes is less, diabetic patients will have higher quality of life. Madigan et al’s results are consistent with the findings of this research (25). Ahmadi et al’s research results in the province of Chahar Mahal Bakhtiari showed that diabetes imposition and duration of the disease have greatest impact on quality of life. If a long time from the diagnosis and disposition to of diabetes has passed, it would have more effect on the quality of life (26). The findings of this study show that there is no significant correlation between quality of life (based on SF-36 questionnaire) and HbA1c. Pitale et al. indicated that there was no significant relationship between quality of life scales (SF-36) with HbA1c levels in patients with type 2 diabetes (27). However, the study of Santhanam et al., showed the inconsistent results, such that blood glucose levels were associated with quality of life and increase in the HbA1c reduced the quality of life, i.e. the quality of life among patients with type 2 diabetes increased with the control and reduction of HbA1c (10). Finally, there were no significant changes in health status on standard treatment groups, and on the other hand, there was no significant difference between two groups. Therefore, intensive glycemic controls in type 2 diabetes have no impact on people's health and also the reducing the glycemic control does not improve health-related quality of life (26). The study of Li et al (2009) showed that, there was no significant correlation between the scales of quality of life SF-36 by indicators of diabetes control (HbA1c) in patients with type 2 diabetes (28). We can say that diabetes like any other disease or chronic condition reduces quality of life by affecting different aspects of life. Obtained differences in the present study compared to the results of other studies in other countries suggest that, it is necessary to take into consideration some factors in the medical recommendations - and planning health care for diabetic patients, such as the type of diabetes, type of treatment etc., in order to improve the self-care behaviors, monitor and better control of diabetes and improve the quality of life of the patients.
Medical staff who are dealing with diabetics should pay attention to the fact that laboratory indices such as a HbA1c and blood sugar don’t necessarily have direct relationship with the quality of life and these criteria cannot represent the physical and mental tangible feeling among patients, except that they only represent the criteria to guess the quality of treatment.Sometimes, excessive stress causes extreme physical and mental burden on the patient which will reduce their quality of life.
Conclusion
The results showed that there was no significant relationship among the dimensions of physical, mental, and quality of life with HbA1C, but some of the health-related  scales of quality of life had a significant relationship with blood sugar, so it is proposed that in order to improve the quality of life among diabetic patients, some factors should be kept under observation such as social and economic support, lifestyle, attitudes, self-care program, improve medical and health services, and providing consulting services.
Acknowledgment
The authors thank all the participants, officials and staff of all health care centers in the study helped us.
Conflict of Interest
None declared by authors.

2. Baghiani Moghadam MH, Afkhami Ardekani M, Mazloumi SS, et al.Quality of life in diabetes type II patients in Yazd. Journal of  Shahid Sadoughi University of  Medical Sciences and Health Services. 2007; 14(4); 49-54.
3. Shaw J.E, Sicree P.Z, Zimmet P.Z. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Research and Clinical Practice. 2010;87(1):4-14.
4. Heshmati H,Behnampour N, Khorasani F,et al. Prevalence of chronic complications of diabete and its related factors in referred type 2 diabetes patients in Freydonkenar diabetes center. Journal of  Neyshabur University of  Medical  Sciences.2014; 1 (1) :36-43
5. Zareipour M, Khazir Z, Valizadeh R,et al. The Association between Spiritual Health and Blood Sugar Control in Elderly Patients with Type 2 Diabetes. Elderly Health Journal.2016; 2 (2) :67-72
6. Ghasemi pour M, Ghasemi V, Zamani A R. Study of life quality in the patients with diabetes referred to Khorramabad Shohada hospital in 2008. Yafteh.2009; 11 (3) :125-133.
7.Ghavami H, Ahmadi F, Entezami H,et al. Effect of continuous care model on the quality of life in diabetic patients. Urmia Medical Journal.2005; 16:22-7.(persian)
8.  Morovati Sharifabadi M A, Movahed E, Jadgal K M,et al.  Drivers' life quality, marital satisfaction, and social support in cargo terminal of Yazd city. Journal of Community Health Research. 2017; 6 (1) :53-63
9. Divanon F, Delamillieure P, Lehaguez A, et al. Comparative evaluation of quality of life in patients with schizophrenia treated with conventional versus atypical neuroleptics: results of a transversal study. L'Encephale. 2006;32(4 Pt 1):459-65.
10. Santhanam P, Gabbay RA, Saleem TF. Poor quality of life scores in persons with higher A1Cs in type 2 diabetes. Diabetes Rresearch and Clinical Practice. 2011;92(3):e53-4.
11. Smeltzer S, Bare BG. A textbook of medical – surgical nursing. 10th ed. Philadelphia: W.B. Lippincott Co; 2004.
12. Alonso J, Angermeyer MC, Bernert S,et al. Disability and quality of life impact of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disord ers (ESEMeD) project. Acta Psychiatr Scand Suppl 2004 (420): 38-46.
13. Sanchez JM, Montejo AL, Mensa I, et al. Quality of life in insulin-treated diabetic out-patients. Ineuropean Neuropsychopharmacology .2005 ; 15:  S396-S396.
 14. Pena MM, Hernandez B, V, Fernandez C, X, et al. Self-perception of health status, mental health and quality of life among adults with diabetes residing in a metropolitan area. Diabetes Metab .2010; 36(4): 305-11.
15. Hahl J, Hamalainen H, Sintonen H,et al. Health-related quality of life in type 1 diabetes without or with symptoms of long-term complications. Qual Life Res. 2002; 11(5): 427-36.
16. Moghadasian S, Mohammad pour Y, Haririan H, et al. The quality of  life and its dimensions among the type 2 diabetes  patients  referred to the diabetes center of Tabriz university of medical siences. Nursing or Midwifery Tabriz University of Medical Sciences. 2008; 38(10): 38-45.[Persian]
17. Karlsson J.Bergllin E, larsson PA. Sense of coherence: quality of life before and after coronary artery bypass surgery.a longitudinal study. Journal of Advanced Nursing .2000; 31(6): 1383 – 1392 .
18.  Jahanlou A Sh, Ghofranipour F, Sobhani A, et al. Evaluating curvilinear hypothesis in quality of life and glycemic control in diabetic patients. Journal of Arak University of Medical Sciences.2008; 11(2): 27-34.
 19.Montazeri A, Goshtasebi A, Vahdaninia M, et al. The short form health survey (SF-36): translation and validation study of the Iranian version. Qual Life Res 2005; 14(3): 875-82.
20 . Arian V, Farvid M, Montazeri A, et al. Association between health-related quality of life and glycemic control in type 2diabetics. Iranian Journal of Endocrinology and Metabolism. 2012; 14(4): 318-324.
21. Bagust A, Wilson E, Perry SA. Utility and quality of life in the CODE-2 study for type 2 diabetes. UK prospective diabetes study group. Diabetes care. 2001; 50: 1096.
22. Ghasemi V, Zamani A, Ghasemi pour M. A sociological study of the relationship between social support and quality of life in the referring diabetes patients to the Khorramabad city clinics M.A. Thesis, Faculty of Literature & Human Sciences, University of Isfahan, 2009; 11(3):  125- 133.[Persian]
23.  Zareipour MA, Movahed E, Ghelichi Ghojogh M, et al. Reviewing the relation between social support and blood sugar control in elders with diabetes type 2. International Journal of Medical Research & Health Sciences. 2016; 5 (9S) : 394-399.
24. Zareipour MA, Abdolkarimi M, Valizadeh R,et al. Perceived stress and its relationship with spiritual health in patients with diabetes in the city of Urmia,Iran. Bioscience Biotechnology Research Communications. 2016; 9(4) : 750-755.
25. Maddigan S, Feeny D, Majumdar S, et al. Understanding the determinants of health for people with type 2 diabetes. American Journal of Public Health. 2006; 96 (9) : 1649- 1655.
26. Ahmadi A, Hasanzadeh J, Rahimi M, et al. Effective factors in the quality of life of patients with type 2 diabetes in Chaharmahal & Bakhteyari province . Journal  of North  Khorasan  University of Medical  Sciences. 2011; 3 (1) :7-13.
27.Pitale S, Kernan-Schroeder D, Emanuele N, et al. Health-related quality of life in the VA Feasibility Study on glycemic control and complications in type 2 diabetes mellitus. J Diabetes Complications. 2005; 19(4): 207-11.
28. Lee HJ, Chapa D, Kao CW, et al. Depression, quality of life, and glycemic control in individuals with type 2 diabetes. Journal of the  American  Association of  Nurse Practitioners .2009; 21(4): 214-24.