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ORIGINAL ARTICLE  
Year : 2020  |  Volume : 45  |  Issue : 4  |  Page : 497-500
 

Identifying the burden and predictors of diabetes distress among adult Type 2 diabetes mellitus patients


1 Department of Community Medicine, Dumka Medical College, Dumka, Jharkhand, India
2 Department of Endocrinology, Diabetes & Metabolism, Narayana Health City, Bangalore, Karnataka, India

Date of Submission24-Dec-2019
Date of Acceptance05-Aug-2020
Date of Web Publication28-Oct-2020

Correspondence Address:
Dr. K S Shivaprasad
Departments of Endocrinology, Diabetes and Metabolism, Narayana Health City, 258/A, Bommasandra Industrial Area, Hosur Road, Bengaluru - 560 099, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcm.IJCM_533_19

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   Abstract 


Background: Diabetes is a psychologically challenging medical condition. Diabetes distress (DD) refers to the unique, often hidden emotional burdens and worries that the patient experiences when managing diabetes. Objective: The objective of the study was to find the burden and identify the predictors of DD in adult Type 2 diabetes mellitus (T2DM) patients. Materials and Methods: Two hundred and fifty T2DM patients were recruited for this study from the endocrine outpatient department from February to April 2019. DD was measured using the Diabetic Distress Scale. Results: The prevalence of DD was 19.6%. The risk of DD was 4.25 times more in those aged ≤45 years as compared to those aged >45 years. Patients with hemoglobin A1c (HbA1c) >8% had 8.8 times more DD. Patients on insulin had more DD (5.4 times) as compared to patients who were on oral antidiabetic drugs. Patients with a history of treatment interruption had 11 times more risk of DD as compared to patients who did not. Conclusions: DD was found to be high among patients aged ≤45 years, illiterates, patients on insulin, patients with a history of treatment interruption, and those with HbA1c >8%. Patients with high DD were found to have higher HbA1c levels.


Keywords: Cross-sectional study, diabetic distress, hemoglobin A1c level, Type 2 diabetes


How to cite this article:
Ratnesh, Shivaprasad K S, Kannan S, Khadilkar KS, Sravani G V, Raju R. Identifying the burden and predictors of diabetes distress among adult Type 2 diabetes mellitus patients. Indian J Community Med 2020;45:497-500

How to cite this URL:
Ratnesh, Shivaprasad K S, Kannan S, Khadilkar KS, Sravani G V, Raju R. Identifying the burden and predictors of diabetes distress among adult Type 2 diabetes mellitus patients. Indian J Community Med [serial online] 2020 [cited 2020 Dec 1];45:497-500. Available from: https://www.ijcm.org.in/text.asp?2020/45/4/497/299448





   Introduction Top


Diabetes mellitus (DM) is one of the most common metabolic diseases with a complex, multifactorial etiology and has varied clinical and biochemical manifestations.[1]

DM is a psychologically challenging medical condition for the patients as well as for their caregivers. Living successfully with DM requires lifelong discipline and commitment, which could be very demanding, stressful, and depressing.[2],[3]

Diabetes distress (DD) refers to psychological distress specific to people living with diabetes. It can encompass a wide range of emotions such as feeling overwhelmed by the demands of self-management required through adherence to diet, exercise, and medications. They may worry about existing or future complications, be fearful of hypoglycemia, and harbor feelings of guilt or shame, notably in relation to obesity or lifestyle.[4]

DD lowers the motivation for self-care, often leading to lowered physical and emotional well-being, poor diabetes control, poor adherence to medication, and increased mortality among individuals with diabetes.[2],[3]

The objective of the study was to find the burden and identify the predictors of DD in adult Type 2 diabetes mellitus (T2DM) patients.


   Materials and Methods Top


This cross-sectional study was conducted on T2DM patients attending Endocrine Outpatient Department (OPD) of Mazumdar Shaw Medical Centre, Narayana Hrudayalaya, Bengaluru, over a period of 3 months from February to April 2019. The study protocol was approved by the ethics committee of the institute.

A total of 250 DM patients were included in the study. This sample size was calculated using EpI Info 7 software (Details: Epi Info™, Division of Health Informatics & Surveillance (DHIS), Center for Surveillance, Epidemiology and Laboratory Services (CSELS) Other details of software: NH City, Bangalore, Karnataka, India). The prevalence was taken as 18% based on estimates in previous studies,[5],[6],[7],[8] with 5% absolute error, and considering nonresponse rate of 10% patients to be nonrespondents.

Inclusion criteria

T2DM patients ≥18 years visiting the endocrinology OPD who were on treatment for at least 6 months were included in the study.

Exclusion criteria

(1) Inpatients, (2) patients on dietary modification and/or exercise alone, (3) patients on corticosteroids therapy, (4) patients who were having any psychiatric illness or on any psychotropic medications, (5) patients with cancer and/or on treatment (chemo or radiotherapy), and (6) patients who were on dialysis or awaiting for any major surgery or procedure (coronary artery bypass grafting and amputation) were excluded from the study.

Informed consent was obtained from all the study participants. They were interviewed using a predesigned, semi-structured questionnaire with variables related to their sociodemographic profiles, literacy, body mass index (BMI), the family history of diabetes, the duration of diabetes, their occupation and relevant past medical history. DD levels among the study participants were measured by using the Diabetes Distress Scale (DDS),[9] which was in English language, however questions were asked in the local language at the time of interview, which they can understand easily. The patients were also assessed for their glycemic control (hemoglobin A1c [HbA1c]).

DDS is a 17-item rating scale and gives a total DD score plus 4 subscores, each addressing a different kind of distress, namely, emotional burden, physician-related distress, regimen-related distress, and interpersonal distress. To score, simply sum the patient's responses to the appropriate items and divide by the number of items in that scale. Each item is rated on a 6-point scale considering the degree to which respective items may have distressed or bothered the diabetic patients during the past month.

Operational definition

The mean item score in DDS ≥3 is taken as a level of distress worthy of clinical attention and defining DD in the study.

The data collected were entered in Microsoft Excel and were analyzed usingSPS S software version 23 (NH City, Bangalore, Karnantaka, India). Logistic regression (LR) was used to study the associations between selected variables and the DD. P < 0.05 was considered statistically significant.


   Results Top


The baseline characteristics of the study participants are shown in [Table 1].
Table 1: Profile of the study participants

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[Figure 1] shows the burden of different types of DD. The prevalence of DD (total), i.e., mean DDS score ≥3 for the current study, came out to be 19.6%. The highest level of DD was seen in emotional type (34.8%).
Figure 1: Burden of different types of diabetic distress in the study population

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[Table 2] shows the LR analysis of predictors of DD. Odds for DD were significantly higher among those who were young, illiterate, not going for an annual consult, on insulin, non adherant, smokers, consuming alcohol and with uncontrolled diabetes.
Table 2: Logistic regression analysis for predictors of diabetic distress* (n=250)

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A positive moderate correlation (using Pearson's correlation coefficient) was found (r = 0.707, P < 0.001) between the participants' mean DDS score and HbA1c levels, indicating a significant linear relationship between the two variables.


   Discussion Top


The current study was conducted to find the burden and identify the predictors of DD in adult T2DM patients. The prevalence of DD (mean DDS score ≥3) was found to be 19.6% as compared to other studies, which was in the range of 18%–25%.[5],[6],[8]

This study also revealed that emotional DD was high as compared to regimen-, interpersonal-, and physician-related DD. There were two important emotions which contributed to high emotional DD. The first emotion was feeling that the diabetes is taking up too much mental and physical energy every day and the second emotion was a feeling that he/she will end up with serious long-term complications.

The risk of DD was 4.25 times higher in the study participants aged ≤45 years as compared to those aged >45 years. Prior studies by Islam et al. and Wardian and Sun also showed similar findings of a significant association between age and DD.[6],[10]

The study participants who were illiterates had 2.3 times more risk as compared to literates. In a study conducted by Gahlan et al., low education level was one of the major predictors for high DD,[5] which was in support of our study findings. Probably, illiteracy leads to poor knowledge about DM, its management, and complications, which in turn leads to poor compliance to medication and nonadherence to follow-up visits. This study also revealed that patients who visited doctor less frequently (once in 12 months) had higher risk of DD by four times (approx.) as compared to people who visited a doctor once in 3 months.

Patients on insulin had more distress (5.4 times) as compared to patients who were on OADs, which was similar to the findings reported in the study conducted by Islam et al.[6],[11] This could be possibly because of the complex regimen which includes multiple injections, frequent glucose monitoring, and the fear of hypoglycemia.

Patients with a history of treatment interruption had 11 times more risk of distress as compared to patients who did not have any treatment interruption. Smokers and alcoholics had 3.9 and 3.5 times the risk of having DD, respectively. Patients with HbA1c >8% had 8.8 times more DD.

DD was 2.5 times more in patients with 1–5 years' duration of diabetes as compared to patients having a long duration of diabetes (>10 years). In a study conducted by Islam et al.,[6] smoking, duration of diabetes, and poor HbA1c had an influence on DD, which was statistically significant.


   Conclusions Top


The burden of DD was 19.6%, and the major determinants were young age, illiteracy, insulin treatment, short duration of diabetes, history of treatment interruption, and poor glycemic control. Emotional DD was found to be more common than regimen-, interpersonal-, and physician-related DD. Patients with high DD were found to have higher HbA1c levels.

The limitation of our study is a lack of follow-up of study participants with any intervention. DD still needs further research in the Indian scenario, and a validated tool should be developed which can be used with ease for diagnosing DD.

Financial support and sponsorship

Nil.

Conflicts of interest

The principal author Dr. Ratnesh was present in the Department of Endocrine and Diabetes, Narayana Health City, Bengaluru, during the study period and after its completion left the department. He joined Dumka Medical College, Dumka, Jharkhand.



 
   References Top

1.
Holt RI, Cockram CS, Flyvbjerg A, Goldstein BJ. Classifiaction and diagnosis of diabetes. In: Textbook of Diabetes. 5th ed. Publisher location Chichester, West Sussex, UK: John Wiley & Sons, Ltd.; 2017. p. 23.  Back to cited text no. 1
    
2.
Thakur M. Diabetes and depression: A review with special focus on India. Glob J Med Public Health 2015;4:1-5.  Back to cited text no. 2
    
3.
Natesan S, Aravamuthan A, Venkatraman V. Impact of patient education on diabetic distress and clinical outcomes in type II diabetes mellitus patients. Int J Pharm Sci Rev Res 2016;37:194-9.  Back to cited text no. 3
    
4.
Adriaanse MC, Pouwer F, Dekker JM, Nijpels G, Stehouwer CD, Heine RJ, et al. Diabetes-related symptom distress in association with glucose metabolism and comorbidity: The Hoorn Study. Diabetes Care 2008;31:2268-70.  Back to cited text no. 4
    
5.
Gahlan D, Rajput R, Gehlawat P, Gupta R. Prevalence and determinants of diabetes distress in patients of diabetes mellitus in a tertiary care centre. Diabetes Metab Syndr 2018;12:333-6.  Back to cited text no. 5
    
6.
Islam MR, Islam MS, Karim MR, Alam UK, Yesmin K. Predictors of diabetes distress in patients with type 2 diabetes mellitus. Int J Res Med Sci 2014;2:631.  Back to cited text no. 6
    
7.
Dogra P, Prasad SR, Subhashchandra BJ. Assessment of depression and diabetes distress in type 2 diabetes mellitus patients in a tertiary care hospital of South India. Int J Res Med Sci 2017;5:3880.  Back to cited text no. 7
    
8.
Vidya KR, Jayanthkumar K. Assessment of diabetes distress and disease related factors in patients with type 2 diabetes attending a tertiary care hospital, Bangalore. Int J Public Ment Health Neurosci2015;2:60-2.  Back to cited text no. 8
    
9.
Polonsky WH, Fisher L, Earles J, Dudl RJ, Lees J, Mullan J, et al. Assessing psychosocial distress in diabetes: Development of the diabetes distress scale. Diabetes Care 2005;28:626-31.  Back to cited text no. 9
    
10.
Wardian J, Sun F. Factors associated with diabetes-related distress: Implications for diabetes self-management. Soc Work Health Care 2014;53:364-81.  Back to cited text no. 10
    
11.
Delahanty LM, Grant RW, Wittenberg E, Bosch JL, Wexler DJ, Cagliero E, et al. Association of diabetes-related emotional distress with diabetes treatment in primary care patients with Type 2 diabetes. Diabet Med 2007;24:48-54.  Back to cited text no. 11
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]



 

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