Self-management behavior and fasting plasma glucose control in patients with type 2 diabetes mellitus over 60 years old: multiple effects of social support on quality of life.
TL;DR: Doctors should provide substantial and individualized support to elderly patients with type 2 diabetes mellitus regarding medication, blood glucose monitoring, and physical exercise and Scheduled social support to self-management projects should be put into the standardized management procedure.
Abstract: OBJECTIVE Elderly patients with type 2 diabetes mellitus are highly vulnerable due to severe complications. However, there is a contradiction in the relationship between social support and quality of life, which warrants further exploration of the internal mechanism. This study assessed the quality of life and its interfering factors in this patient population. METHODS In total, 571 patients with type 2 diabetes mellitus over 60 years old were recruited from two community clinics in Heilongjiang Province, China. We collected data on health status, quality of life, self-management behavior, fasting plasma glucose (FPG) level, and social support. Structural equation modeling and the bootstrap method were used to analyze the data. RESULTS The average quality of life score was - 29.25 ± 24.41. Poorly scored domains of quality of life were "Psychological feeling" (- 8.67), "Activity" (- 6.36), and "Emotion" (- 6.12). Of the 571 patients, 65.32% had normal FPG, 9.8% had high-risk FPG, 15.94% had good self-management behavior, and 22.07% had poor social support. Significant correlations among social support, self-management behavior, FPG level, and quality of life were noted. A multiple mediator model revealed that social support influenced quality of life in three ways: (1) directly (c' = 0.6831); (2) indirectly through self-management behavior (a1*b1 = 0.1773); and (3) indirectly through FPG control (a2*b2 = 0.1929). Self-management behavior influenced the quality of life directly and indirectly through FPG control. CONCLUSION Improving self-management behavior and monitoring hypoglycemia should become priority targets for future intervention. Scheduled social support to self-management projects should be put into the standardized management procedure. Physicians should provide substantial and individualized support to the elderly patients with type 2 diabetes mellitus regarding medication, blood glucose monitoring, and physical exercise.
Summary (3 min read)
- The incidence of type 2 diabetes mellitus has been growing rapidly as a consequence of lifestyle changes, urbanization, and aging.
- The global prevalence of type 2 diabetes mellitus among the elderly is approximately 40%, indicating that it a serious public health issue  .
- Excellent social support is the basis for improving the quality of life, as it plays an essential role in relieving mental pressure, eliminating psychological obstacles, enhancing the effects of therapy, and optimizing the prognosis.
- More than a quarter of patients with diabetes have poor selfmanagement, and only 32-49% of patients have adequately controlled blood glucose levels [5, 13] .
- The occasional occurrence of hypoglycemia or abnormal uctuation of blood glucose in elderly patients with type 2 diabetes mellitus might have substantial, negative, and even serious clinical effects  .
- Patients with type 2 diabetes mellitus were recruited from the Jianhua community, Qiqihar city, China between June and December 2012.
- All participants signed a formal consent form before enrolment into this study.
- Survey and standard investigation procedures were carried out to ensure the uniformity of data collection.
- Third, appointments were scheduled for the participants to complete the questionnaire.
- At this point, the researchers elaborated on the purpose of the study and con rmed the eligibility of the patients.
- Patients who agreed to participate in the study signed a formal consent form.
- Data of the following variables were also collected: age, sex, race, education, income level, marital status, age at disease onset, duration of diabetes, FPG level, social support, self-management behavior, and quality of life.
- Perceived level of social support The Multidimensional Scale of Perceived Social Support developed by Zimet and colleagues  was used to measure patient perception of social support.
- A higher score indicates better overall social support.
Quality of life
- The Adjusted Diabetes-speci c Quality of Life Scale (CN-ADDQOL), Chinese version, was used after cultural adaptation and revision of the original scale  .
- For the importance of "my physical appearance," options were very important (3 points), important (2 points), somewhat important (1 point), and not important at all (0 points).
- A modi ed version of the Type 2 Diabetes Self-care Scale (2-DSCS) developed by Toobert et al. and Wang et al. to measure diabetes self-management behavior  was used in this study.
- The modi ed scale comprises 26 items encompassing six dimensions: diet (6 items), exercise (4 items), medication (3 items), blood glucose monitoring (4 items), foot care (5 items), and hypo/hyperglycemia (4 items).
- The total score ranged from 26 to 130, with a higher score indicating a higher level of self-management.
- To facilitate the comparison of data, the score index (score index = actual total score/possible highest score*100%) and the standard score (standard score = actual score/possible highest score*100) of each dimension were also calculated.
- Values > 3.1 mmol/L are considered relatively safe (the occurrence of hypoglycemia is improbable).
- Chinese guidelines for diabetes prevention do not recommend strict blood glucose control in elderly patients with type 2 diabetes mellitus [14, 40, 41] .
- The Chinese guidelines for Diabetes Prevention and Control (2017 edition) speci cally recommends the following FPG levels: 5.0-7.2 mmol/L for healthy elderly patients with type 2 diabetes mellitus, 5.0-8.3 mmol/L for elderly patients with type 2 diabetes mellitus and a complicated health status, and 5.6-10.0 mmol/L for elderly patients with type 2 diabetes mellitus and an extremely complicated health status.
- In the morning of the scheduled appointment, a blood sample was obtained from each patient.
- Twelve-hour FPG levels were assessed according to World Health Organization (WHO) standardized ngertip prock test procedures using calibrated blood glucose meters and reagent strips  .
- Statistical analyses were performed using SPSS, version 17.0, and structural equation modeling (SEM) was conducted using AMOS 17.0.
- Chi-square difference tests and the Akaike information criterion (AIC) were used to compare the alternate model and the theoretical model  .
- Path analysis was conducted to evaluate all indirect pathways from social support to quality of life by inspecting the direction and magnitude of path coe cients.
- All the one-way paths were considered .
- The bootstrap method was used to test the multiple mediating effects of the hypothesized model [44, 45] .
Importance of FPG monitoring
- Glycated hemoglobin (HbA1c), FPG, and PBG are the main clinical monitoring indicators for diabetes mellitus.
- Moreover, it has been con rmed that blood glucose uctuations in elderly patients with diabetes are extremely harmful.
- Carlene et al. found that each 1-mmol/l decrease of FPG was associated with a 21% lower risk of stroke and a 23% lower risk of ischemic heart disease  .
- It might be dangerous to multi-vulnerable patients because it might result in hypoglycemia, causing dysfunctional osmolality and a range of consequences , including death  .
Mechanism of attention to FPG control
- The inverse association between FPG level and quality of life indicated that better FPG control level was associated with a higher quality of life and better social support.
- The indirect effect of social support on quality of life through monitoring of FPG was signi cant.
- This might be explained by the path SS→FPG→QOL.
- Their average scores were particularly poor in the psychological, activity, and emotional domains.
- Therefore, mobilizing both external support (resources for regular monitoring) and subjective support (actions for regular monitoring) to achieve the target of monitoring FPG, preventing hypoglycemia, and improving the quality of life should be emphasized  .
Mechanism of emphasis self-management activity
- This is consistent with previous ndings that better self-management activity is associated with a higher quality of life and better social support  .
- The indirect effect of social support on quality of life through self-management behavior was signi cant.
- Hence, to improve the quality of life in elderly patients with type 2 diabetes mellitus, doctors are required to educate their patients about self-management.
- A relationship between FPG level, self-management, and quality of life was also observed.
Limitations of research
- First, as a cross-sectional study, the relationships between variables were only correlative, and causal relationships could not be established.
- Second, this study was performed at Heilongjiang province, and patients were recruited from city communities.
- Third, the MSPSS and 2-DSCS were revised in this study.
- Hence, the reliability of the scales requires further validation, despite good internal consistency.
- Fourth, this study focused on perceived social support by elderly patients.
- Elderly patients with type 2 diabetes mellitus had poor quality of life, fasting blood glucose control, and self-management.
- The authors study identi ed four important pathways constituting a complicated, interwoven network contributing to poor quality of life in elderly patients with type 2 diabetes mellitus.
- The following key interconnected paths were identi ed: SS→SM→QOL, SS→FPG→QOL, SS→SM→FPG→QOL, and SS→QOL.
- Particular attention should be paid to the quality of life and hypoglycemia in elderly patients with type 2.
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Q1. What have the authors contributed in "Self-management behavior and fasting plasma glucose control in patients with type 2 diabetes mellitus over 60 years old: multiple effects of social support on quality of life" ?
Xinye Qi Harbin Medical University School of Health Management Jiao Xu this paper, Guiying Chen, Guo et al.