الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Diabetes is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. Diabetes is a major lifestyle disorder, the prevalence of which is increasing globally. Its high prevalence constituted chiefly by T2DM, is a global public health threat. Studies conducted in different populations of the Eastern Mediterranean Region have reported high prevalence rates varying from 7% to 25% in the adult population. Diabetes mellitus is a chronic illness that requires continuing medical care and ongoing patient self-management education and support to prevent acute complications and to reduce the risk of long-term complications.
Quality of life has been recognized as an important health outcome in patients suffering from chronic diseases. HRQOL refers to the physical, psychological, environmental and social domains of health that are influenced by a person’s experiences, beliefs, expectations, and perceptions.
It must be emphasised that the ultimate goal of diabetes care is to pertain a good QOL for patients rather than complete treatment of the disease. Individuals with DM are known to have lower HRQOL. Therefore, efforts to improve QOL will lead to better management of the disease for a satisfactory outcome. Quality of life is an important aspect in diabetes because poor QOL leads to diminished self-care, which in turn leads to worsened glycemic control, increased risks for complications, and exacerbation of diabetes overwhelming in both the short run and the long run.
Many factors were proved to affect HRQOL of diabetic patients. The most consistent impact on HRQOL has been reported for socio-economic status, co-morbidities and disease-related complications. Although assessing QOL is methodologically complex, valid and reliable tools are available and can be used with diabetes patients. Heretofore, a limited number of studies have been conducted in the Middle East to document the HRQOL of patients with DM. More importantly, only a limited number of studies have been conducted in Kuwait to document the QOL of diabetes patients.
The objectives of the present study were to describe the socio-demographic characteristics, personal habits and practise, and clinical profile of T2DM patients attending the primary health care diabetes clinics in the State of Kuwait, assess HRQOL in T2DM patients, and identify factors that could be associated with poor QOL for diabetic patients.
To achieve these objectives, a cross-sectional descriptive epidemiological approach was carried out for description of the QOL of diabetic patients and to determine factors that could be associated with lower QOL level.
The study was carried out in the specialized diabetes clinics located in the primary health care centers in the state of Kuwait. The sample size was estimated to be 450 subjects having T2DM.
A structured questionnaire was designated for data collection that included section 1 for collection of soci-demographic, personal and clinical data and section 2 (WHOQOL-BREF) for assessing the QOL of studied diabetic patients. It contained 4 domains (physical, psychological, social, and environment). The mean score of items within each domain is used to calculate the domain score. To make domain scores comparable with the scores used in the WHOQOL-100, raw scores were converted to transformed score to enable comparisons to be made between domains composed of unequal numbers of items. The QOL score (70%) was used as the cut-off level for classification of participants into patients with poor QOL (less than 70%) and patients with good QOL (≥ 70%).
All the necessary approvals for carrying out the research were obtained. A pilot study was carried out on 20 diabetic patients to test the clarity, applicability and suitability of the used questionnaire. The process of interview was performed in the examination room in the selected centers and patients’ electronic records were reviewed.
The main results of this study could be summarized as follows:
Recruitment effort resulted in participation of 450 T2DM patients.
• Only few studied diabetic patients declared that their general QOL was very bad (0.2%) or bad (4.2%). Less than a fifth (18.8%) stated that their life was of moderate quality whereas the majority stated that they lived good (64.0%) or very good (12.8%) QOL in the last four weeks.
• Out of 450 T2DM patients attending PHC centers in Kuwait, 285 (63.3%) were classified as having poor QOL. The median of total QOL score was 65.8, physical domain score was 63.0 and that for psychological, social and environment domains was 69.0.
• Male patients constituted (53.8%) and they were significantly more encountered in the good QOL group (60.0%) than poor QOL group (50.2%).
• The age of the studied diabetic patients ranged from 37.0 to 82.0 years, with a mean age = 54.9±10.4 years. Patients with poor QOL were significantly older than patients with good QOL.
• Kuwaiti patients constituted 64.9% of the studied sample, and were significantly more represented among patients with good QOL than patients with poor QOL.
• Just more than a third of patients had primary or less level of education with higher percentage among poor QOL persons (46.3% versus 20.0%).
• Not working and worker patients were more presented among poor QOL patients whereas clerks and professional persons were more presented among good QOL group significantly.
• The majority of the studied diabetic patients were married (84.0%). This percentage was significantly higher in good QOL than patients with poor QOL (89.7% versus 80.7%).
• Higher income was significantly more encountered among patients with good QOL. Higher percentage of patients with good QOL were living in villa than patients with poor QOL (37.6% versus 20.4%).
• Overall, 80.9% of studied diabetic patients were non-smokers. Smokers/ex-smokers constituted only 19.1%. No significant difference could be detected between poor and good QOL groups.
• Overall, 39.3% of studied diabetic patients did not practise physical activity at all. The percentage of those practising activity was significantly higher among patients with good QOL (69.7%) as compared to those with poor QOL (55.4%).
• Overall, calculated BMI ranged from 18.6 to 62.1 (29.8±5.6), with a higher mean in patients with poor QOL (30.3±5.7) than in patients with good QOL (29.0±5.3). The percentage of overweight, obese or morbidly obese were significantly higher in poor QOL (84.2%) than in patients with good QOL (75.2%).
• Overall, waist to hip ratio ranged from 0.64 to 1.43 (0.91±0.10), with a higher values in patients with poor QOL (0.91±0.10) than in patients with good QOL (0.90±0.09). The percentage of studied diabetic patients with abnormal high value was significantly higher in poor QOL (57.5%) than in patients with good QOL (47.9%).
• The duration of diabetes since diagnosis was significantly higher for poor QOL (9.3±6.8) than for patients with good QOL (6.7±5.2).
• A significant higher percentage of poor QOL (38.9%) used insulin treatment, as a single or combined with oral drugs, than patients with good QOL (24.2%).
• Only 72 diabetic patients (16.0%) had history of hospital admission during the last year, with a significant higher percentage in poor QOL (20.7%) than in patients with good QOL (7.9%).
• About two thirds of diabetic patients reported a history of one or more of associated chronic co-morbid conditions (64.2%), with a significant higher percentage in patients with poor QOL (73.3%) than patients with good QOL (48.5%).
• One fifth of studied diabetic patients had history of hypoglycemic crisis with statistically higher percentage among poor QOL group than good QOL group (24.6% versus 14.6%) and (59.1%) of studied diabetic patients suffered from hyperglycemic crises with higher percentage among patients with poor QOL (66.0%) as compared to patients with good QOL (47.3%).
• Overall, (39.8%) of studied diabetic patients were complaining from chronic diabetic complications with significant higher percentage among patients with poor QOL (50.2%) as compared to those with good QOL (21.8%).
• The majority of diabetic patients (80.7%) reported regular follow-up visits to the diabetic centers, without a significant difference between the two groups.
• Overall, 58.0% of diabetic patients reported their compliance with treatment instructions with significant lesser percentage among poor QOL (49.1%) than patients with good QOL (73.3%).
• Overall, HBA1c level ranged from 4.50 to 15.90 mmol/L (8.31±1.95), with significantly higher mean value among patients with poor QOL (8.54±2.00) than among patients with good QOL (7.92±1.78). Regarding blood cholesterol, higher levels were encountered among patients with poor QOL than patients with good QOL without a significant difference between the two groups. The overall prevalence of microalbuminurea was (15.3%) that was significantly more presented among poor QOL patients (20.4%) than among patients with good QOL (6.7%).
Results of regression analysis revealed the socio-demographic characteristics, clinical and diabetes related variables affected the total QOL and accounted for 28% of variance in the total HRQOL of studied diabetic patients. Lower level of education, being single or divorced, lower income, high BMI, longer duration of diabetes, uncontrolled hyperglycemia, presence of other co-morbid diseases or chronic diabetes complications significantly lower the total HRQOL.
Comparing Beta of all co-variants shows that lower level of education and presence of chronic diabetes complications greatly influenced the total QOL of subjects with diabetes.
Based on these results, the following are recommended:
National efforts should be made to face diabetes and its complications taking into consideration patients’ QOL.
At the level of the structure
• Development of diabetes registry using computerized recording system.
• Increasing the number of diabetic centers, to cover all PHC centers.
• Improving knowledge of health care providers to up-to-date.
• Management nutritional therapy should be adequately covered by insurance.
At the level of health care providers
• A complete medical evaluation for each patient.
• Adherence and applying guidelines in the area of diabetes care.
• Medical nutrition therapy should be considered for each patient.
• Attending training programs and workshops on diabetes management.
At the patient level
• Health education should be given at a particular personalized schedule for each patient.
• Considering intensive education for patients at high risk of poor QOL.
• Health education and support should include medical nutrition therapy, losing weight, nutritious diet and carefully-planned regular exercise, adherence to prescribed medications.