Volume 37 Issue 6 Article 10
2023
An Audit of Diabetes-Dependent Quality of Life and Glycemic An Audit of Diabetes-Dependent Quality of Life and Glycemic Control Among Type 2 Diabetes Patients in a Tertiary Hospital in Control Among Type 2 Diabetes Patients in a Tertiary Hospital in Bangkok: A Hospital-based Cross-sectional Study
Bangkok: A Hospital-based Cross-sectional Study
Nattaya Tungsirikoon
Faculty of Public Health, Mahidol University, Bangkok, Thailand Nopporn Howteerakul
Faculty of Public Health, Mahidol University, Bangkok, Thailand Nawarat Suwannapong
Faculty of Public Health, Mahidol University, Bangkok, Thailand Petch Rawdaree
Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
Follow this and additional works at: https://digital.car.chula.ac.th/jhr
Part of the Epidemiology Commons, and the Social and Behavioral Sciences Commons
2586-940X/© 2023 The Authors. Published by College of Public Health Sciences, Chulalongkorn University. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
An Audit of Diabetes-Dependent Quality of Life and Glycemic Control Among Type 2 Diabetes Patients in a Tertiary Hospital in Bangkok: A Hospital-Based Cross-Sectional Study
Nattaya Tungsirikoon
a, Nopporn Howteerakul
a,*, Nawarat Suwannapong
a, Petch Rawdaree
baFaculty of Public Health, Mahidol University, Bangkok, Thailand
bFaculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
Abstract
Background: This hospital-based cross-sectional study aimed to examine the association between diabetes-specific quality of life (QoL), diabetes-related clinical characteristics and glycemic control among type 2 diabetes (T2DM) patients.
Methods:335 T2DM patients receiving treatment at the diabetes clinic of a tertiary hospital in Bangkok, Thailand, were recruited into the study. The Audit of Diabetes-Dependent Quality of Life (ADDQoL19) was used to assess QoL. The ADDQoL scores were split into two groups using quartiles. The group in the lower quartile was considered as“having low QoL.”Hemoglobin A1c (A1C) was used as an index of glycemic control.
Results:67.8% of participants were female. The mean age was 62.5 (SD 11.8) years and mean diabetes duration was 11.3 (SD 7.8) years. 53.7% of participants had lower QoL and 74.0% had poor glycemic control (A1C≥7%). The life domains of the ADDQoL with the highest negative impacts were“freedom to eat,” “freedom to drink”and“feelings about the future.”Multiple logistic regression analysis indicated that lower QoL and a combination of oral medication with in- sulin were independently associated with poor glycemic control.
Conclusion:Lower diabetes-specific QoL and combination of oral medication with insulin were associated with poor glycemic control. Health personnel should encourage patients to continue to receive treatment and monitoring from their physicians. Screening T2DM patients with ADDQoL is beneficial to identifying and implementing the appropriate diabetes self-management interventions to improve patients’QoL and better glycemic control.
Keywords:Depression, Diabetes-specific quality of life, Glycemic control, Type 2 diabetes, Thailand
1. Introduction
D
iabetes mellitus is a non-communicable dis- ease and major public health problem with serious complications. In 2021, the International Diabetes Federation reported that 537 million (10.5%) adults aged 20e79 years were living with diabetes worldwide and this number is predicted to increase to 783 million (12.2%) by 2045 [1]. Over 90%of all diabetes patients worldwide have Type 2
Diabetes Mellitus (T2DM). In 2018, the prevalence of diabetes among Thais aged 20 years and over was reported to be 9.9% [2]. The Diabetes Association of Thailand adopted the goal of T2DM patients having hemoglobin A1c (A1C) of <7% in order to prevent complications [3]. However, studies from 2018 showed only around 25%e35% of patients achieved A1C<7% [4].
Evidence indicates that poor glycemic control in- creases the risk of macro- and micro-vascular
Received 3 November 2022; revised 14 January 2023; accepted 3 February 2023.
Available online 6 June 2023
*Corresponding author.
E-mail address:[email protected](N. Howteerakul).
https://doi.org/10.56808/2586-940X.1053
2586-940X/©2023 The Authors. Published by College of Public Health Sciences, Chulalongkorn University. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
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diabetes complications that can increase healthcare costs [5]. Previous studies have shown that poor glycemic control in T2DM patients is affected by several factors. Increased age [6e8], being female [6], higher body mass index [6], high blood pressure [7], poor diet and nutrition [8], longer duration of diabetes [7,9], low physical exercise [7,8,10e12], alcohol drinking [6], smoking [7,8], depression [8], drug use pattern [10,11,13,14], and poor medication adherence [10,14] have been associated with poor glycemic control. Previous studies [15,16] also re- ported that the relationship between QoL and gly- cemic control was reciprocal or bidirectional: QoL may affect diabetes self-efficacy, selfcare behaviors, glycemic control and complications, just as each of these variables may affect each other and QoL. In addition, two studies [13,17] using QoL as explana- tory variables of glycemic control found that QoL was inversely associated with A1C.
T2DM is a progressive disorder. The longer the duration of diabetes, the more difficult it is for the patient to achieve the target A1C level <7%. Most patients will eventually require insulin therapy to maintain glycemic control despite being on other diabetes medication [18]. The long-term treatment of diabetes may reduce T2DM patients' QoL even though they improve their health. In assessing outcomes of diabetes care, it is important to mea- sure the impact of diabetes on patients’QoL. Clin- ical assessments of diabetes-specific QoL can be used to improve the lives of T2DM patients [19].
The Audit of Diabetes-Dependent QoL (ADD- QoL) is a diabetes-specific instrument for assessing QoL. It has been validated and adopted in many countries [9,15,20e24] as it has advantages in terms of international comparative research. However, in spite of the high diabetes prevalence in Thailand and the importance of diabetes-specific QoL in the management of diabetes, there has been little pub- lished literature using ADDQoL19 to assess patient- reported QoL and glycemic control in Thailand. The published literature includes a conference research abstract that reported the Thai ADDQoL19 was culturally appropriate and had high reliability.
However, more evidence is needed on its construct validity [25]. Another study used ADDQoL19 to compare QoL among T2DM patients who attended and did not attend a “diabetes self-management education and support program” launched by a regional hospital in central Thailand [26]. This study aimed to examine the association between diabetes- specific QoL, diabetes-related clinical characteristics and glycemic control among a cohort of T2DM pa- tients seeking care at a diabetes clinic of a tertiary hospital in Bangkok, Thailand.
2. Methodology
2.1. Study design, setting and study samples
This hospital-based cross-sectional study was performed in October and November 2018, at a diabetes outpatient service of the endocrinology and metabolism clinic at a tertiary hospital in Bangkok, Thailand. The clinic provides the service every Tuesday and Thursday morning between 8.30 and 12.00 h. The study population was T2DM patients seeking care at the outpatient service. During the study period, the number of DM patients in the study clinic was 3583 [27]. The sample size was calculated using the Yamane formula [28]. The pre- cision was set at 5.5%. The sample size was calcu- lated to be at least 303. Totally, 335 T2DM patients were recruited into the study. Inclusion criteria were T2DM patients with a clinical diagnosis for at least one year; aged 35 years and over; treated with dia- betes drugs or diabetes drugs and insulin; had a record of A1C at the hospital during the study period and willing to participate in the study. Patients with other chronic diseases, such as renal failure; patients with blindness or disability, and pregnant or breastfeeding patients, as well as patients who could not communicate verbally with the principal inves- tigator were excluded. Convenience sampling was used to recruit study samples at the study site.
2.2. Research instruments
The questionnaire included general and clinical characteristics, a diabetes-specific quality of life (ADDQoL) [13,20] and depression (PHQ-9) [29]. The questionnaire wasfirst translated from English into Thai language by the first author. Two co-authors reviewed and revised the wording of the translated questionnaire for correctness of the translation. The third co-author who is an endocrinologist reviewed the latest version to confirm that it was appropriate and understandable by T2DM patients. The Thai version of the questionnaire was pre-tested with 30 T2DM patients at the study hospital for internal consistency. The Cronbach’ alpha was 0.87 for ADDQoL19 and 0.83 for PHQ-9.
2.3. Diabetes-specific quality of life measurement All participants were interviewed using the Thai version of the Audit of Diabetes Dependent Quality of Life (ADDQoL). The ADDQoL was designed and developed by Bradley et al. [20]. This instrument consists of 21 items dealing with 19 life domains.
The 19 life domains are: leisure activities, working
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life, local or long-distance journeys, holidays, physical health, family life, friendships and social life, close personal relationships, sex life, physical appearance, self-confidence, motivation to achieve things, people's reactions, feelings about the future, financial situation, living conditions, dependence on others, freedom to eat, and freedom to drink.
ADDQoL starts with two overview items measuring the patient's present global QoL. The first is “In general, my present QoL is …,” rated on a 7-point scale (3, excellent; 2, very good; 1, good; 0, neither good nor bad; 1, bad, 2; very bad and 3, extremely bad). The second is a diabetes-specific overview item“If I did not have diabetes, my quality of life would be …,” rated on a 5-point scale (3, very much better;2, much better;1, a little better;
0, the same and 1, worse). For both items, lower scores indicate lower QoL. The individual life domain items are formulated in the format of“If I did not have diabetes my (life domain) would be…”
Each life domain item is scored on a 7-point scale (3 toþ3, corresponding to very much better/much better/a little better/the same/worse/much worse).
For each item, the respondent indicates whether the life domain is very important, important, quite important, or not at all important to him or her (3e0). Five life domains have ‘not applicable op- tions’(N/A) allowing respondents to indicate those aspects of life that are not applicable to them, including working life, sex life, close personal re- lationships, holidays and family life.
Scoring and importance are multiplied to generate the weighted impact (WI) score (range9 to þ3). An average WI (AWI) score is derived by adding the weighted impact scores and dividing by the number of applicable domains. The AWI score can range from9 toþ3. A cut-point of-3 was defined as “higher quality of life” and <-3 as
“lower quality of life”[21].
2.4. Glycemic measurement
A1C is a common laboratory test used by the study endocrinology and metabolism clinic. An A1C level of <7% was considered “good glycemic con- trol”, and7% as“poor glycemic control”[3].
2.5. Other associated factors measurement
General characteristics were gathered using a nine-question questionnaire covering age, sex, marital status, education level, occupation, income, smoking, alcohol and exercise.
Clinical characteristics consisted of seven clinical factors and were retrieved from patient electronic
records held at the study clinic: BMI, duration of diabetes, family history of diabetes, A1C levels, co- morbidities, complications and drug use pattern.
Depression was assessed using the Thai version of the Patient Health Questionnaire-9 (PHQ-9) which comprises nine questions to screen for depression during the past two weeks. Each question is rated on a scale of 0e3 points (leading to a total score of up to 27 points). A score of 7 points is defined as “no depression symptoms”, 7e12 points as “mild depression”, 13e18 points as “moderate depres- sion”, and 19e27 as“severe depression”[29].
2.6. Data collection
Data were collected by the principal investigator through a structured interview with participants in a private room. Clinical characteristics were collected by reviewing medical records with the assistance of the Medical Record Unit staff. The principal inves- tigator explained the objectives of the study to all potential participants and written informed consent was gained from all participating participants before collecting data.
2.7. Data analysis
The collected data were analyzed using SPSS Version 18.0 (Chicago: SPSS Inc). Descriptive sta- tistics, such as percentage, frequency, mean, me- dian, and standard deviation were used to describe all study and outcome factors. The patients’ADD- QoL scores were split into two groups using quar- tiles. Thefirst group, in the lower quartile (score<- 3), was considered as having a “lower QoL” [21].
Binary logistic regression was used to obtain the odds ratio and a 95% CI was used to examine the association between the study variables and poor glycemic control among T2DM patients. The sig- nificance level was set at p-value<0.05.
2.8. Ethical consideration
The research protocol was approved by the Human Research Ethical Review Committee of the Faculty of Public Health, Mahidol University (COA. No. MUPH 2018e110) and the Human Research Ethical Review Committee, Faculty of Medicine Vajira Hospital, Navamindradhiraj University (COA130/2561).
3. Results
Of the 335 participants, 67.8% were female. The patient's age ranged from 35 to 89 years with a mean age of 62.5 years (SD 11.8). 56.1% were married.
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27.2% had finished a bachelor degree or higher.
43.3% were working. 51.6% had an average monthly income of less than 15,000 baht. 22.1% were current smokers, 28.4% were current drinkers and 76.1% did regular physical exercise (Table 1). 63.9% of partic- ipants were obese (BMI 25 kg/m2). 74.3% had diabetes >5 years. The mean duration of diabetes was 11.3 (SD 7.8) years. 51.3% of the participants had a sibling with diabetes, 74.0% had poor glycemic control, and 10.5% had no comorbidity. Hyperten- sion was the most common comorbidity (73.8%).
76.7% reported they had no diabetes complications.
The most common complications were retinopathy (9.0%), followed by nephropathy (8.4%), heart dis- ease (7.5%) and neuropathy (1.5%). In relation to diabetic drugs, 66.0% of participants were taking oral medication only and 34.0% reported using a combination of oral medication and insulin (34.0%), Table 2.
3.1. Depression and quality of life
Of the 335 participants, 10.4% had mild and 3.0%
had moderate depression and 53.7% had a lower quality of life (Table 3). The life domains of the
ADDQoL with the highest negative impact were freedom to eat (5.0 ± 2.3), freedom to drink (4.9 ± 2.4) and feelings about the future (4.7 ± 2.9). The life domains with the lowest negative impact were sex life (0.0±0.4), working life (1.3±2.8) and dependence on others (1.5±2.6), Table 4.
3.2. Association between diabetes-specific QoL, diabetes-related clinical characteristics and glycemic control
In multivariate analysis, age, sex andfive variables associated poor glycemic control at p-value<0.05 in univariate analysis and with no multicollinearity problems were simultaneously entered for multiple logistic regression analysis. As depicted in Table 5, two variables remained significantly associated with poor glycemic control: having lower QoL (OR, 2.21;
Table 1. General characteristics among 335 T2DM patients.
Variable n (%)
Sex
Male 108 (32.2)
Female 227 (67.8)
Age (yr.)
65 191 (57.0)
>65 144 (43.0)
Mean±SD¼62.5±11.8; Range¼35-89 Marital status
Married 188 (56.1)
Single/widowed/divorced/separated 147 (43.9) Education level
No schooling/primary school/secondary school 244 (72.8)
Bachelor degree or higher 91 (27.2)
Occupation
Not working 190 (56.7)
Working 145 (43.3)
Monthly income (baht)a
<15,000 173 (51.6)
15,000 162 (48.4)
Median¼16,864.6; Range¼600e100,000 Smoking
Never or ex-smoker 261 (77.9)
Current smoker 74 (22.1)
Alcohol consumption
Never or ex-drinker 240 (71.6)
Current drinker 95 (28.4)
Regular exercise
Yes (3 times/week) 80 (23.9)
No (<3 times/week) 255 (76.1)
SD¼standard deviation.
a 1 USD¼31.83 baht.
Table 2. Clinical characteristics among 335 T2DM patients.
Variable n (%)
Body Mass Index (BMI)a
18.5e22.9 kg/m2(Normal) 67 (20.0)
23.0e24.9 kg/m2(Overweight) 54 (16.1)
25.0 kg/m2(Obese) 214 (63.9)
Mean±SD¼27.2±5.5; Range¼14.9e58.7 Duration of diabetes (yr.)
5 86 (25.7)
>5 249 (74.3)
Mean±SD¼11.3±7.8 Family history of diabetesb
None 68 (20.3)
Father/mother 164 (49.0)
Siblings 172 (51.3)
Uncle/aunt/grandparents 103 (30.8)
Spouse 44 (13.1)
A1C (%)
Controlled (<7) 87 (26.0)
Uncontrolled (7) 248 (74.0)
Comorbidityb
None 35 (10.5)
Hypertension 245 (73.8)
Dyslipidemia 227 (68.4)
Heart disease 48 (14.5)
Renal disease 39 (11.7)
Others (anemia, osteoporosis, migraine, etc.) 51 (15.4) Complicationsb
None 257 (76.7)
Heart disease 25 (7.5)
Retinopathy 30 (9.0)
Nephropathy 28 (8.4)
Neuropathy 5 (1.5)
Drug use pattern
Oral medication only 221 (66.0)
Oral medication and insulin 114 (34.0)
aBodyweight in kilograms divided by the square of the height in meters, the Asian cut-off point for overweight is23 kg/m2 [37]; SD, standard deviation.
b Multiple responses.
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95% CI, 1.30 to 3.76) and taking a combination of oral medication with insulin (OR, 3.20; 95% CI, 1.78 to 5.63).
4. Discussion
The findings of this study indicate that all 19 life domains the ADDQoL tested were impaired by
diabetes to some extent. The two components that had the highest negative impact on diabetes-specific QoL in this study were“freedom to eat”(5.0±2.3) and “freedom to drink” (4.9 ± 2.4), which aligns with previous studies that used ADDQoL-19 to assess patients'QoL in Asia [9,22] and Europe [30]. It is likely that the impact of dietary restrictions on QoL is considerable because the restricted diabetic diet is probably quite different from the patients’
previous or preferred diet. In addition to the dietary restrictions, the patients felt required to continu- ously monitor and record their dietary consump- tion, physical exercise and blood sugar levels to help reduce the risk of development of complications.
This constant tracking resulted in feelings of stress and anxiety around eating and drinking. Diabetes self-management interventions are needed to alle- viate the negative impacts of food and drink
Table 3. Depression and quality of life among 335 T2DM patients.
Variable n (%)
Depression (PHQ-9 score)
No (<7) 288 (86.0)
Mild (7e12) 33 (10.4)
Moderate (13e18) 10 (3.0)
Severe (19) 2 (0.6)
Audit of Diabetes-Dependent Quality of Life (ADDQoL) score
Good (-3.0) 155 (46.3)
Poor (<-3.0) 180 (53.7)
Table 4. Quality of life domains among 335 T2DM patients.
Domain Not applicablean (%) Mean±SD
Impact ratingb Importance ratingc Weighted impact scored Rank
Freedom to eat 2.1±1.0 2.4±1.0 5.0±2.3 1
Freedom to drink 2.0±1.0 2.4±1.0 4.9±2.4 2
Feelings about the future 2.0±1.0 2.0±1.0 4.7±2.9 3
Self-confidence 1.9±1.0 2.4±1.0 4.6±2.6 4
Leisure activities 1.8±1.0 2.3±0.6 4.3±2.6 5
Financial situation 1.6±1.2 2.4±1.0 4.3±3.6 6
Living conditions 1.9±1.0 2.1±1.0 4.2±2.7 7
Journeys 1.8±1.1 2.0±1.0 4.2±3.0 8
People's reaction 1.8±1.0 1.8±1.0 3.9±2.7 9
Physical health 1.6±1.1 2.2±1.0 3.7±2.8 10
Motivation 1.1±1.1 2.3±1.0 2.7±3.0 11
Holidays 52 (15.5) 1.0±1.1 1.9±1.1 2.7±3.2 12
Physical appearance 1.1±1.1 2.0±1.0 2.6±2.9 13
Friendship and social life 0.9±1.1 1.9±1.0 2.3±2.8 14
Family life 61(18.2) 0.7±1.0 2.1±1.1 1.8±2.9 15
Personal relationship 34 (10.1) 0.7±1.0 1.9±1.0 1.7±2.8 16
Dependence on others 0.6±1.1 1.3±1.1 1.5±2.6 17
Working life 190 (56.7) 0.5±1.0 1.1±1.3 1.3±2.8 18
Sex life 298 (89.0) 0.0±0.2 0.2±0.7 0.0±0.4 19
a T2DM patients are able to not respond to those aspects of life that are not applicable to them or sensitive items.
b Impact rating:3, very much better;2, much better;1, a little better; 0, the same;þ1, worse.
c Importance rating: 0, not at all important; 1, somewhat important; 2, important; 3 very important.
d Weighted impact score: weighted impact score for each domain/the number of applicable domains. The AWI score ranges from9 (maximum negative impact) toþ3 (minimum negative impact).
Table 5. Association between diabetes-specific QoL, diabetes-related clinical characteristics and poor glycemic control among 335 T2DM patients.
Variable Crude OR (95% CI) Adjusted OR (95% CI) p-value
Audit of Diabetes-Dependent Quality of Life (ADDQoL) score
Higher (-3.0) 1.00 1.00 <0.01
Lower (<-3.0) 2.38(1.44e3.93) 2.21(1.30e3.76)
Drug use pattern
Oral medication only 1.00 1.00
Oral medication and insulin 3.13 (1.88e5.19) 3.20 (1.78e5.63) <0.001
Adjusted for: age, sex, income, duration of diabetes (continuous data), depression, diabetes drugs, and ADDQoL
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restrictions and other diabetes-related selfcare ac- tivities [23]. Successful diabetes care needs good communication, support and empathy from health personnel.
The third component that most negatively affected QoL was “feelings about the future”
(4.7 ± 2.9), which is similar to the results of pre- vious studies [13,22,31]. This result is likely due to diabetes being a chronic disease that requires adherence to medications and performing regular diabetes self-management, all of which carry time and money expenses and burdens. These expenses and burdens may cause patients to worry about their future health, income and independence. A high proportion of“not applicable’responses were found in the life domains of sex life and working life which was in line with the previous studies in Asia [24,31] and Europe [32].
The multiple logistic regression analysis results revealed that the predictors of poor glycemic control among T2DM patients were poor QoL (OR, 2.21;
95% CI, 1.30 to 3.76) and a combined of oral medi- cation and insulin (OR, 3.20; 95% CI, 1.78 to 5.63).
QoL is a multidimensional construct composed of psychological, physical and social issues of health that are influenced by a person's beliefs, experiences and perceptions [33], therefore, the association be- tween QoL and glycemic control is complex [13].
Several personal and diabetes-related clinical fac- tors, including depression, that reduce QoL can also affect glycemic control [33]. QoL may impact an individual's priorities and actions, such as their di- etary behavior, medication adherence and diabetes selfcare which in turn might affect A1C levels [33].
The result of this study is consistent with a previous study in Europe that found diabetes-specific QoL was associated with glycemic control [13,17].
The pattern of drug use influences T2DM patients' glycemic control. In this study, patients who received only oral medications had a better glycemic control than those receiving a combination of oral medication and insulin. Due to the progressive impairment of insulin secretion over time as a result of b-cell failure, the addition of insulin to sulpho- nomides taken at maximum doses significantly improved glycemic control without an increase in hypoglycemic event [34]. This was consistent with thefindings of Weiss et al. [35] that the addition of insulin to oral medication was associated with a significant decrease in A1C levels in T2DM patients inadequately controlled by oral medication. The effectiveness of drug treatment also depends on the efficacy of the prescribed medications and patient's adherence to the treatment [36]. Lower QoL may impact an individual's reluctance to take prescribed
medications and follow other aspects of diabetes self-management such as consuming balanced meals and appropriate portion sizes which in turn might affect A1C levels [33]. Ourfinding are in line with previous studies [10,11,14].
4.1. Limitations
There are four limitations in this study which should be considered in any further studies: 1) Data were collected from a tertiary hospital in Bangkok.
The hospital-based nature of the study might not infer for other mild diabetic patients since cases referred to tertiary hospital are likely severe compared to those treated in primary care; 2) Some clinical characteristics such as patients’ chronic diseases, comorbidity and complications were ob- tained from medical records. It is possible that the collected data was incomplete; 3) The association between QoL and glycemic control is a chicken and egg issue. The better design allows one to definitely clarify the causal direction of the association be- tween QoL and glycemic control in a randomized controlled trial. The cross-sectional design limited investigation of the causal association between study factors and the outcome factor; 4) The PHQ-9 screening test for depressive symptoms was used without confirmation by a standard tool or a psychiatrist.
5. Conclusion
The ADDQoL questionnaire is a multidimen- sional construct tool used to examine the impacts of diabetes on a specific domain of life and its impor- tance for each patient which could approach more accurate individualized QoL assessment in diabetes patients. It is culturally appropriate with high reli- ability. However, more evidence is needed on its construct validity. The length of the ADDQoL could cause a substantial response burden on diabetes patients. Analysis of item response of three domains (sex life, working life and family life) accounted for a large majority of incomplete data. It is not missing data as these domains are Not Applicable to each individual patient. Lower diabetes-specific QoL and combination of oral medication with insulin were independently associated with poor glycemic con- trol. Health personnel should encourage patients to continue to receive treatment and monitoring from physicians. Diabetes self-management and support interventions are needed to alleviate the negative impacts of food and drink restrictions and other diabetes-related selfcare activities. Screening T2DM patients with ADDQoL is beneficial to identifying
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and implementing appropriate diabetes self-man- agement and support interventions to improve pa- tients’QoL and better glycemic control.
5.1. Recommendations
ADDQoL is culturally appropriate with high reli- ability. However, more evidence is needed on its construct validity. Future study and latent class analysis will be used to address the factors and identify the tendency of people falling into poor glycemic control or falling into to lower QoL. This analysis will help inform interventions focusing on glycemic profile and ADDQoL.
Funding None.
Conflict of interest None.
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