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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 Aliated 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.
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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. Signicant correlations among social support, self-management behavior, FPG level,
and quality of life were noted. A multiple mediator model revealed that social support inuenced 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 inuenced
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 diculty 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 65years old is 50% greater than that in patients with
diabetes under 65years old [16]. Elderly patients have diculty 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 scientic 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 1year before the study; b) self-manage their health ; and
c) age > 60years old. The exclusion criteria were as follows: a) acute or chronic inammatory 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 conrmed 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,