Health-related Quality of Life Among Patients With Type 2 Diabetes

Introduction[edit | edit source]

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Improved Quality of life (QOL) has been regarded as a key goal of healthcare interventions for Diabetes (DM) management programs.

DM is a significant and growing healthcare challenge primarily because of increased physical inactivity, consumption of unhealthy diets, obesity and sedentary lifestyles. DM is a major cause of blindness, kidney failure, heart attacks, stroke and lower limb amputation. DM and its complications have contributed tremendously to the burden of mortality and disability worldwide.[1]

Diabetes often leads to the development of physical disabilities that, in turn, can have a detrimental effect on a patient's quality of life (QOL). Literature suggests that people with diabetes have lower QOL in general, and that depression among people with type 2 diabetes (T2DM) further reduced the QOL[2]

The importance of optimizing health-related QOL (HRQOL) has increasingly been recognized, not only because it represents an important goal for health care on its own but also because of the associations between poor HRQOL and adverse outcomes in people with type 2 diabetes, including poor response to therapy, disease progression, and even mortality.[3]

The Global Burden of Type 2 Diabetes[edit | edit source]

T2DM is a global public health crisis that threatens the economies of all nations, particularly developing countries. It is estimated that about 85-95% of all people living with diabetes in developing countries suffer from T2DM[4][5]. Diabetes mellitus (DM) and related complications have reached epidemic levels. According to the International Diabetes Federation (IDF) report:

  • 1 in 11 adults aged 20–79 years (425 million adults; 451 million if the age is expanded to 18–99 years) had DM globally in 2017
  • Of the above, 90% of them were with type 2 diabetes mellitus (T2DM).
  • The prevalence and incidence of DM are increasing worldwide, and a rapid progression has been reported in middle- and low-income countries.[1]

Quality of Life[edit | edit source]

Quality of life (QOL) is a multidimensional concept that measures a person’s wellbeing. The discussion and use of QOL as a measurable outcome in health has increased in recent decades as healthcare has shifted from a disease-focused biomedical model to a more holistic, well-being focused biopsychosocial model. QOL has also become more important with improvements in medical treatments and disease management leading to longer lives of people in general and particularly those living with chronic diseases. [6]

Diabetes and HRQoL[edit | edit source]

T2DM is a complex and serious chronic disease that imposes a significant burden on patients and society in a term of morbidity and premature mortality [7]. In the long term, diabetic patients have to face many complications. HRQoL is an important outcome for persons with T2DM, and is 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 the quality of life.

QoL studies have been recognized as an important health outcome of all medical interventions and has become a core issue in diabetes care. They provide clinicians with important information to support clinical decision making, taking both biomedical and psychosocial into consideration.

Persons with T2DM report lower HRQoL than the general population[8]. The main cause of health-related quality of life (HRQoL) diminution are:

  1. Diabetes-related complications
  2. Episodes and fear of hypoglycemia
  3. Change in lifestyle[9].

Several factors have been identified as predictors of HRQoL and diabetes-related quality of life in T2DM, including

  • older age,
  • female sex,
  • depressive symptoms,
  • number of diabetic complications,
  • presence of comorbidities, and
  • insulin use [10].

Physical Health Domain[edit | edit source]

The physical health domain assesses the impact of the disease on the activity of daily living, dependence on medical substances, a lack of energy and initiative, restricted mobility and the capacity to work[11].

A study conducted in Iraq in 2010 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), aged 60 years and more, low level of education, sedentary type of work and long duration of diabetes [12].

A study on Self-Care, Foot Problems and Health in Tanzanian Diabetic Patients and Comparisons with Matched Swedish Diabetic patients it was found that: more Tanzanian than Swedish patients experienced foot problems; most frequently reported foot problem in Tanzanian patients was pain; 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[13]; those with PN also had lower HRQol [14].

Psychological Domain[edit | edit source]

The psychological domain accesses the patient’s own thoughts about body image and appearance, negative feelings, self-esteem and personal beliefs[11]. Psychological well being is the focus of intense research attention and is relevant to the experience of the individual[11]. It is a person's evaluative reaction to his or her life; either in terms 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[11]. The impact of diabetes on quality of life and general quality of life was different between males and females[15]. Similarly Miksch A et al [16] found gender-specific differences within the quality of life of patients with diabetes.

Social Health Domain[edit | edit source]

The social domain assesses personal relationship, social support and sexual activity[11].

  • Social relationships were one of the main area affected in people living with T2DM.
  • 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[17].

The study conducted at Turkey in urban primary healthcare 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[18].

Measurement of HRQoL[edit | edit source]

There are arrays of instruments (outcome measures) to assess HRQoL in type 2 diabetes. These outcome measures can be generic or diabetes-specific measures. 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[19].

  • Generic HRQoL measures: They are generic preference-based measures which provide valuable health status information of patients with diabetes and allow comparisons with the general population and chronic health diseases[19][20][1]. See table 1 below for examples of generic measures used in type 2 diabetes.
  • Psychological HRQoL measures: These assess functional status and psychological well-being (anxiety and depression) of the patient with type 2 diabetes[19]. See the table for types (Table 1).
  • Diabetes-specific HRQoL measures: These assess a specific aspect of diabetes such as the presence of diabetes symptoms, attitudes, worries, self-care, treatment satisfaction, adherence to the diabetic regimen, locus of control, and social and family support[19]. See the table 1 for types of diabetes-specific measures.

Selecting Appropriate HRQoL Measures[edit | edit source]

Finding ideal tools to measure HRQoL in routine data collection among patients 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[21][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[22].

Conclusion[edit | edit source]

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[18].

It is clear that different measures can be utilized to manage the quality of life change because of T2DM and this needs strategic health policy.

HRQoL measures used in type 2 diabetic populations[edit | edit source]

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)

References[edit | edit source]

  1. 1.0 1.1 Alshayban D, Joseph R. Health-related quality of life among patients with type 2 diabetes mellitus in Eastern Province, Saudi Arabia: a cross-sectional study. PLoS One. 2020 Jan 10;15(1):e0227573. Available: (accessed 22.9.2021)
  2. Mishra SR, Sharma A, Bhandari PM, Bhochhibhoya S, Thapa K. Depression and health-related quality of life among patients with type 2 diabetes mellitus: a cross-sectional study in Nepal. PloS one. 2015 Nov 23;10(11):e0141385.Available: 22.9.2021)
  3. Landman GW, Van Hateren KJ, Kleefstra N, Groenier KH, Gans RO, Bilo HJ. Health-related quality of life and mortality in a general and elderly population of patients with type 2 diabetes (ZODIAC-18). Diabetes care. 2010 Nov 1;33(11):2378-82. Available: (accessed 22.9.2021)
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