Diabetes and Health-Related Quality of Life

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] Researches have further established that depression in type I diabetes patient was more than 3 times higher than normal range and 2 times higher in type 2 diabetes patients. [3]

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.[4]

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. In 2019, it was estimated that about 85-95% of all people living with diabetes in developing countries suffer from T2DM[5][6]. Diabetes mellitus (DM) and related complications have reached epidemic levels. According to the International Diabetes Federation (IDF) 2021 report:

  • 10.5 percent of adults aged 20–79 years (537 million adults) had DM globally in 2021
  • 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]
  • The IDF predicts a 46 percent increase of the DM population between 2022 and 2045 on a world level. The highest tendency is reported on the African continent with a 134 percent increase. [7]
  • Furthermore, estimates have established that 240 million people are currently living with undiagnosed diabetes worldwide.[7]

Quality of Life[edit | edit source]

Quality of life (QOL) is a multidimensional concept that measures a person’s wellbeing. As stated by the World Health organisation (WHO), QOL can be defined as the "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."[8] 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. Examples of QOL assessments are the WHOQOL-BREF and WHOQOL-100.


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 [10]. 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[11]. 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[12].

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 [13].

Physical Health Domain[edit | edit source]

The physical health domain assesses the impact of the disease on the

Diabetic foot.jpg

Research findings: Diabetes had a greater impact on the HRQoL of

  • Females and older patients (50 years and more)[15]
  • Those with low level of education, sedentary type of work and long duration of diabetes [16].
  • Foot problems, most frequently reported foot problems were pain and problems due to badly fitting footwear[17]
  • Those with peripheral neuropathy also had lower HRQol [18].

Impact on Cognitive Function[edit | edit source]


Both type 1 and type 2 diabetes are associated with mild to moderate decrements in cognitive function.

  • T2DM is usually diagnosed at an older age and is commonly associated with obesity, insulin resistance, hypertension and dyslipidemia, all of which can have negative impact on brain.
  • The underlying mechanism and the risk factors that may lead to the development of more severe cognitive dysfunction like dementia in some but not all people with diabetes are not well understood.

More studies are needed to understand the impact of mild to moderate decrements in cognitive function in the daily lives people with diabetes.

  • Mild to moderate degree of cognitive impairment likely does cause not clinically significant problems in the day to day activities of most people with diabetes. However it may present problems during more stressful and challenging situations.
  • People at the extremes of age are more likely to be at increased risk of developing clinically significant decline in cognitive function[19].

Social Health Domain[edit | edit source]

The social domain assesses personal relationship, social support and sexual activity[14].

  • 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[20].

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[21].

  • 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[21][22][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[21]. 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[21]. 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[23][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[24]. The outcome measures are summarized in the table below.

Table: 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)

Role of Physiotherapy[edit | edit source]

The ultimate aim of diabetes care is to improve the quality of life of the individuals [26]. Physical complications of diabetes can be in form of muscle weakness, pain, loss or balance and lower limb dysfunction, all which can ultimately influence the HRQoL of individuals [27]. Physiotherapists play a crucial role in the management of the physical symptoms of diabetes. By incorporating individualized physical activity and patient education in the management of diabetes, complications can be prevented.

Likewise, for individuals with physical complications of diabetes, physiotherapists employ techniques such as:

  • Exercise therapy: Exercise therapy through physical activity plays a substantial role in the management of diabetes. By developing a structured and individualized regimen, exercise can help improve the strength of weak muscles, gait pattern and balance. Hence, engaging in physical activities has a positive effect on the physical aspect of HRQoL of individuals with diabetes [28].
  • Motivation Interviewing : With motivation interviewing, the physiotherapist aims to create long term changes to the patient's lifestyle. More then just exercises, the physiotherapist tries to engage the patient's own motivation in the therapeutic process in order to create a therapeutic alliance and enhance greater daily behavior changes. [29]

Conclusion[edit | edit source]

People with diabetes have worse quality of life than 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[30]. Also, physiotherapists play a significant role in the management of the physical complications of diabetes to improve quality of life.

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.

References[edit | edit source]

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