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

Introduction

• 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 [4] .
• 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 [20] .

Participants

• 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.

Procedures

• 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.

Measures

• Perceived level of social support The Multidimensional Scale of Perceived Social Support developed by Zimet and colleagues [21] 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 [27] .
• 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).

Self-management behavior

• 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 [36] 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.

FPG level

• 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 [41] .

Data analysis

• 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 [43] .
• 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 [59] .
• It might be dangerous to multi-vulnerable patients because it might result in hypoglycemia, causing dysfunctional osmolality and a range of consequences [62], including death [63] .

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 [65] .

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 [12] .
• 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.

Conclusion

• 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.

Full text

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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
Harbin Medical University School of Health Management
Guiying Chen
Harbin Medical University First Aliated Hospital Department of Cardiology
Huan Liu
Harbin Medical University School of Health Management
Jingjing Liu
Harbin Medical University School of Health Management
Jiahui Wang
Harbin Medical University School of Health Management
Xin Zhang
Harbin Medical University School of Public Health
Yanhua Hao
Harbin Medical University School of Health Management
Qunhong Wu (  wuqunhong@163.com )
Harbin Medical University https://orcid.org/0000-0002-2873-5266
Mingli Jiao
Harbin Medical University School of Health Management
Research
Keywords: Elderly, Hypoglycemia, Quality of Life, Patient Self-Management, Social Support
Posted Date: October 9th, 2020
DOI: https://doi.org/10.21203/rs.3.rs-87544/v1
License:   This work is licensed under a Creative Commons Attribution 4.0 International License. 
Read Full License

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Version of Record: A version of this preprint was published at Health and Quality of Life Outcomes on
November 12th, 2021. See the published version at https://doi.org/10.1186/s12955-021-01881-y.

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Abstract
Objective:
Elderly patients with type 2 diabetes mellitus are highly vulnerable due to serious
complications. Thus far, there is little research on the relationship between social support and quality of
life, which warrants further exploration of the internal mechanism. This study assessed 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. Signicant correlations among social support, self-management behavior, FPG level,
and quality of life were noted. A multiple mediator model revealed that social support inuenced quality
of life in three ways: (i) directly (c´ = 0.6549); (ii) indirectly through self-management behavior (a1*b1 =
0.2596); and (iii) indirectly through FPG control (a2*b2 = 0.2825). Self-management behavior inuenced
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 elderly patients with type 2 diabetes mellitus regarding medication, blood glucose monitoring,
and physical exercise.
Introduction
The incidence of type 2 diabetes mellitus has been growing rapidly as a consequence of lifestyle
changes, urbanization, and aging. Type 2 diabetes mellitus accounts for 90% of diabetes cases
worldwide [1], and the global prevalence of adult diabetes has increased dramatically from 4.7% in 1980
to 9.0% in 2014 [2]. Sixty percent of the increment was expected to occur in developing countries [3]. The
global prevalence of type 2 diabetes mellitus among the elderly is approximately 40%, indicating that it a
serious public health issue [4]. In China, the number of adult patients with diabetes has increased from
0.67% in 1979 to 2.7% in 2002 and to 11.6% in 2010 [5, 6]. Similar to the global trends, the proportion of
elderly patients with type 2 diabetes mellitus in China has increased from 10.2% in 2000 to 13.6% in
2006, 20.4% in 2007, and 22.86% in 2010 [5–7]. Diabetes is characterized by severe chronic
complications that can impose a heavy economic burden on patients and decrease their quality of life[8].
With a gradually declining physical condition and increasingly poor economic status, the elderly may
have diculty in self-managing their health, thus becoming a vulnerable population [9]. Therefore, the

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quality of life of elderly patients with type 2 diabetes mellitus should receive more attention from medical
staff and the society.
Previous researchers have studied the relationship between social support and quality of life in diabetes
[10, 11]. Social support refers to spiritual or material support from people such as family, friends, and
colleagues. 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. Given the complexity of diabetes and its various complications,
burdensome self-management activities such as daily diet, physical activity, blood glucose monitoring,
and medication adherence are essential. The purpose of self-management is to control the disease and
improve the quality of life. Health care professionals should provide advice and guidance on self-
management. However, the ability and willingness of patients to manage their own health are the main
determinants of successful metabolic control [12]. In recent years, the Chinese government has paid close
attention to the management of diabetes, including diabetes screening and healthy lifestyle promotion,
but little progress has been made. More than a quarter of patients with diabetes have poor self-
management, and only 32–49% of patients have adequately controlled blood glucose levels [5, 13]. Poor
social support to the elderly may lead to unrecognized complications, irregular treatment, and poor self-
management behavior. In turn, poor self-management behavior may cause persistent
hyperglycemia/hypoglycemia or glucose level uctuation. Consequently, there is growing interest in
nding effective ways to enhance self-management in elderly patients with type 2 diabetes mellitus.
The treatment of diabetes is complex and multidisciplinary [14]. Its three main goals are as follows: (i) to
control complications; (ii) to prevent hyperglycemia/hypoglycemia; and (iii) to maintain a patient’s quality
of life. Adequate blood glucose control can not only prevent and reduce the complications of diabetes but
also decrease the probability and risk of hypoglycemia. However, it is worth noting that there is a general
lack of attention to hypoglycemia in the treatment of diabetes. Patients with diabetes often feel nervous
or embarrassed if faced with hyperglycemia, but hypoglycemia is usually ignored [15]. The incidence of
hypoglycemia in patients with diabetes over 65years old is 50% greater than that in patients with
diabetes under 65years old [16]. Elderly patients have diculty in perceiving hypoglycemia due to
functional impairment of the nervous system, which lowers the blood glucose threshold sensitivity and
increases the occurrence of severe hypoglycemia [17]. Therefore, avoiding hypoglycemia in elderly
patients with type 2 diabetes should be the priority.
Furthermore, some studies in elderly patients with type 2 diabetes mellitus have shown that close
attention to postprandial blood glucose (PBG) may also help achieve adequate blood glucose control
without increasing the risk of fasting hypoglycemia [18]. However, in middle-aged patients, FPG and PBG
increase simultaneously; therefore, treatment should take both indicators into account [19]. In China, the
rate of blood glucose self-monitoring in elderly patients with type 2 diabetes mellitus is only 21.4%, and
hypoglycemia occurs in 30% of patients. 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 [20].

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Most previous studies have focused on single variables. However, there is little research on the
relationship between social support and quality of life, and further exploration of the internal mechanism
of multiple variables has seldom been conducted. This study aimed to assess the relationships between
social support, self-management behavior, FPG level, and quality of life in elderly patients with type 2
diabetes mellitus. The results of this study provide scientic evidence to develop more targeted
intervention programs as well as a valuable reference for other countries to deal with the challenges of
type 2 diabetes mellitus in the elderly.
Methods
Participants
Patients with type 2 diabetes mellitus were recruited from the Jianhua community, Qiqihar city, China
between June and December 2012. The inclusion criteria were as follows: a) a diagnosis of type 2
diabetes mellitus made by a physician at least 1year before the study; b) self-manage their health ; and
c) age > 60years old. The exclusion criteria were as follows: a) acute or chronic inammatory disease; b)
cancer; and c) type 1 diabetes mellitus. All participants signed a formal consent form before enrolment
into this study.
Procedures
Survey and standard investigation procedures were carried out to ensure the uniformity of data collection.
First, chronic illness records of type 2 diabetes mellitus patients were reviewed and their eligibility was
evaluated. Second, elderly patients with type 2 diabetes mellitus were encouraged to participate in the
program after having been explained the purpose of the study. 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.
Measures
Perceived level of social support
The Multidimensional Scale of Perceived Social Support (MSPSS) developed by Zimet and colleagues
[21] was used to measure patient perception of social support. The scale contains 12 items evaluating
three dimensions of support: family (including parents, children, and spouse [items 3, 4, 8, and 11]);
friends (items 6, 7, 9, and 12); and others (including neighbors and doctors [items 1, 2, 5, and 10]). Each
item was scored on a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree), with the total
score ranging from 12 to 60 [22]. A higher score indicates better overall social support. Previous studies
have demonstrated the reliability of MSPSS, with Cronbach’s α ranging from 0.85 to 0.94 [21, 23–25].
Test–retest reliability was evaluated over a 2–3-month interval (r = 0.72–0.85) [26]. In this study,

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Xinye Qi Harbin Medical University School of Health Management Jiao Xu this paper, Guiying Chen, Guo et al.