Diabetes Self-care Activities and Their Relation with Glycemic Control in Patients Presenting to The Indus Hospital, Karachi

Introduction Nowadays, chronic conditions are increasing globally, stressing on self-management and patients' responsibility toward recognizing and resolving issues related to their illness. Diabetes is also a chronic illness, and diabetes-related self-care activities have been shown to be promising towards preventing its complications and achieving optimal glycemic control. Objective 1) To assess the association between glycemic control and diabetes-related self-care activities 2) To evaluate the association of patients' sociodemographic characteristics with diabetes-related self-care activities 3) To examine the impact of patients' sociodemographic characteristics on glycemic control Materials and methods This cross-sectional study was conducted at The Indus Hospital Karachi from February 2019 to July 2019. A total of 288 patients of both genders, age ≥18 years, having type 2 diabetes mellitus with glycated hemoglobin (HbA1c) done within the last three months from the interview date were enrolled in the study using a non-probability consecutive sampling technique. Whereas patients not giving consent for participation in the study, ICU admitted patients, critically ill patients, pregnant women, comatose, patients with type 1 diabetes mellitus, Alzheimer’s disease, dementia, coexisting and chronic liver disease were excluded from the study. Results Majority of the patients were female (n=209; 72.6%) and had uncontrolled glycemic control (n=235; 81.6%). Furthermore, less than half of the patients had inadequate diabetes-related self-care activities (n=140; 48.6%). The Mean ± SD of age was 51.9±10.2 years. The significantly higher proportion of patients who have had a duration of illness and treatment ≥3 years had uncontrolled diabetes but adequate diabetes-related self-care activities. Moreover, there was no association between diabetes-related self-care activities and glycemic control. Conclusion There was no significant relationship between diabetes-related self-care activities and glycemic control. Moreover, a higher proportion of patients with a longer duration of diabetes (≥3 years) had poor glycemic control but adequate diabetes-related self-care activities.


Introduction
Diabetes mellitus (DM) is one of the most common non-communicable diseases, a major public health problem, and the most important cause of premature illness and deaths worldwide [1][2]. Globally, 425 million people are suffering from this disease and Pakistan stands as second (7.028 million) amongst the Middle East and North Africa [3].
DM is known for its progressive nature, chronicity, and complexity and is known as an illness of self-management as it requires regular blood glucose monitoring [4]. There are various ways to monitor blood glucose levels amongst them Glycated hemoglobin (HbA1c) is considered as the most reliable method. Internationally, it is accepted as a gold standard biochemical indicator of average blood glucose concentrations over the preceding three months [5]. A reasonable goal for most adults is <7% according to recent American Diabetes Association (ADA) guidelines [6].
The increasing prevalence of DM depends on several factors, including a sedentary lifestyle. Good glycemic control in diabetic patients cannot only be achieved through good compliance with medication but also depends largely upon a regular routine, which includes a healthy diet, glucose monitoring, and exercise. Lack of physical activity is the major root cause of all chronic diseases. It has been observed that the elderly population does not comply with exercise leading to a high rate of diabetes-related complications [7][8].
Studies have shown that diabetes-related self-care activities improve glycemic control [4,[9][10]. Moreover, just a lifestyle modification in poorly controlled diabetic patients can lead to a reduction in HbA1c up to 1% [11]. This leads to an approximately 25% reduction in microvascular complications such as diabetic retinopathy, cataract, neuropathy, nephropathy, heart failure, and amputations [12][13][14].
Thus, this makes diabetes treatment a two-pronged approach: 1) anti-diabetic treatment and 2) the self-care management behavior of diabetic patients. Therefore, it is necessary to uncover the patients' self-care factors that are associated with good glycemic control in our population. This will help in the counseling and education of patients regarding the disease and its available management approaches; in particular, lifestyle modifications.
Hence, the present study was conducted with the aim to: 1) assess the association between glycemic control and diabetes-related self-care activities, 2) evaluate the possible association of patients' sociodemographic characteristics with diabetes-related self-care activities, and 3) examine the impact of patients' sociodemographic characteristics on glycemic control.

Materials And Methods
This cross-sectional study was conducted at The Indus Hospital Karachi, which is a free-of-cost tertiary care facility, from February 2019 to July 2019. A priori sample size was calculated through PASS software (Power and sample size version 11.0; NCSS LLC., Kaysville, Utah) using various diabetes-related self-care activities [15] (glucose management, dietary control, physical control, health-care use, sum scale) with the following assumptions: 80% power, 95% confidence interval. The highest sample size came out to be 288.
Patients of both genders, age ≥18 years, having type 2 diabetes mellitus, with glycated hemoglobin (HbA1c) done within the last three months from the interview date were enrolled in the study. Whereas for patients not giving consent for participation in the study, the intensive care unit (ICU) admitted patients, critically ill patients, pregnant women, comatose patients, patients with type 1 diabetes mellitus, Alzheimer's disease, dementia, and coexisting and chronic liver disease were excluded from the study. All the eligible patients were recruited from the outpatient and diabetic clinic using a non-probability consecutive sampling technique. Sociodemographic details included participants' age, gender, education, ethnicity, family history of diabetes and occurrence of diabetes-related complications, and clinical characteristics, including systolic and diastolic blood pressure, height (in cm), weight (in kg), and body mass index (kg/m 2 ), were recorded on a pre-designed questionnaire.
Diabetes-related self-care activities were assessed using the Diabetes Self-Management Questionnaire (DMSQ) [15]. The Patient Health Questionnaire (PHQ) was used to assess depression in study participants [16][17].
The independent sample T-test/Mann-Whitney U test was applied, as appropriate, to assess the difference in DMSQ score, PHQ score, and various sociodemographic variables between glycemic control. The independent sample T-test/Mann-Whitney U test was applied, as appropriate, to assess the difference in HbA1c, PHQ score, and various sociodemographic variables between the self-care behavior. The chi-square test/Fisher exact test was applied, as appropriate, to assess the association of various categorical variables with self-care behavior and glycemic control. P-value <0.05 was considered statistically significant.

Results
A total of 288 patients were enrolled in the study, out of which 209 (72.6%) were females. The mean ± SD of age was 51.9 ± 10.2 years ( Table 1). The median (IQR) of body mass index (BMI), education, income, duration of diabetes, duration of treatment, and DMSQ score of all the patients was 28.7 (25.5-32.7), 5 (0-10), 20k (15k-25k), 5 (2-12), 10 (6-16), and 6.0 (5.2-6.9), respectively ( Table 1), with no significant difference between patients with controlled and uncontrolled diabetes except duration of diabetes and treatment ( Table 1). The majority of the patients had uncontrolled glycemic control (n=235; 81.6%). Results showed that a significantly higher proportion of patients who have had a duration of illness and treatment ≥3 years had uncontrolled diabetes in comparison to those who had a duration of illness and treatment <3 years (76.2% vs 23.8%, p=0.009; 64.3% vs 35.7%, p=0.011, Table 1). The food I choose to eat makes it easy to achieve optimal blood sugar levels.
Does not apply to me 5 (9.4) 17 (   Also, it was observed that a higher proportion of patients on oral hypoglycemic agents had inadequate diabetes-related self-care activities in comparison to others (p=0.041, Table 2). Moreover, a larger number of patients with inadequate diabetes-related self-care activities had delayed wound healing while other complications were found to be more in patients with adequate diabetes-related self-care activities (p=0.010, Table 2).
Additionally, a U-shaped relationship was observed between the levels of depression and diabetes-related self-care activities. It was found that a significantly higher proportion of patients who have had mild to moderate depression had inadequate diabetes-related self-care activities in comparison to other groups (p=0.007, Table 2). Interestingly, a greater number of moderately severe to severely depressed patients were found to have adequate diabetes-related self-care activities ( Table 2).

Discussion
Globally, diabetes is considered a serious public health problem. The increasing occurrence of diabetes in both developed and developing states not only increases the financial burden but also accounts for morbidity and lifelong disabilities [18]. The major component of diabetes management is to prevent complications that involve various aspects of understanding disease pathogenesis and progression. Apart from the medication, patient-led diabetes-related selfcare activities (DRSCA) play a key role in diabetes management [9].
In this study, we found that two-thirds of the patients had poor glycemic control. This was comparable to findings from other parts of Pakistan reporting 60% of the patients with uncontrolled glycemia [19][20]. The high prevalence of poor glycemic control has also been observed in Middle East countries, i.e. 69% in UAE, 65.1% in Jordan, 65% in Oman, and 78.8% in Kuwait [21], indicating that uncontrolled glycemic control is emerging as an endemic condition globally.
Literature reported the association of various factors, such as gender, employment status, addiction status, treatment of diabetes, its associated complications, and diabetes-related selfcare activities with glycemic control [22][23]. However, we were unable to establish a relationship between gender, employment status, education, addiction status, income, and BMI with glycemic control.
However, an inverse relationship between the duration of diabetes and its treatment was observed with glycemic control. It was found that a higher proportion of patients with a duration of illness and treatment ≥3 years had uncontrolled sugar levels in comparison to the others. This inverse relationship is also supported by recent studies [24][25]. This may be due to the progressive loss of β-cells causing impaired insulin secretion and increasing insulin resistance [25].
Interestingly, we even didn't find an association of diabetes-related self-care activities with glycemic control. The possible reason could be the family support system. Pakistan has a strong family system and family support is valued a lot and plays a significant role in the livings of the family members [26]. It is known that diabetic patients become aggressive with the progression of the disease and lifelong treatment [27]. Family members and relatives are the ones who can tolerate and handle such a type of aggression [27]. Asian families are known for being patient, tolerant and responsible amongst the members regardless of the intensity of the hardship [27]. It might be possible that such patients are being taken care of by their family members, as we have an Asian culture of the joint family system. It has also been reported in another study done in Bangladesh that family offers emotional and economic support, safe food, ensure strict follow-up regimen, improve the battle against anxiety and even reduce deleterious effects of stress on patients [28].
Furthermore, results revealed that a higher proportion of patients who have had an illness and are getting treatment for ≥ 3 years had adequate diabetes-related self-care activities. This demonstrates that patients with a longer duration of diabetes were more compliant with selfcare activities. This result of the association between duration and better self-care activities is consistent with the study conducted in Ethiopia, which found that a longer duration leads to improved awareness of the disease, which, in turn, is linked to increased self-efficacy [29].
In our study, treatment modality was also associated with the DSMQ score. A higher proportion of patients who were on oral hypoglycemic agents had inadequate diabetes-related self-care activities. The result is similar to the study conducted in Ethiopia that also found treatment modality as a significant predictor of self-care [30]. Also, our study revealed delayed wound healing in patients with inadequate diabetes-related self-care activities in comparison to the other group. This result was expected, as wound healing requires vigilant monitoring and self-care.
Additionally, we found a U-shaped relationship of severity of depression with diabetes-related self-care activities. It was observed that mild to moderately depressed patients had a higher proportion of inadequate diabetes-related self-care activities. Again, the only reason for this Ushaped relationship could be family support. Severely depressed patients have significant behavioral changes and other psychotic symptoms due to which they might be taken care of by their families more in comparison to mild to moderately depressed patients, whereas normal patients are able to manage the disease themselves. Further studies should be done to establish the relationship between the severity of depression and diabetes-related self-care activities.

Limitations
The study didn't include any questions regarding family and social support, which could have an impact on self-care activities for diabetes management. Second, the study was crosssectional so causal inferences and temporality could not be developed. Third, this is a singlecenter, hospital-based study. Prospective community-based studies should be conducted in the future to study the phenomenon more deeply and accurately.

Conclusions
It was found that a longer duration of illness was associated with poor glycemic control but adequate diabetes-related self-care activities. Furthermore, diabetes-related self-care activities were found to have no impact on glycemic control.

Additional Information Disclosures
Human subjects: Consent was obtained by all participants in this study. Interactive Research Development Institutional Review Board issued approval IRD_IRB_2018_12_003. IRB EXPEDITED STATUS: APPROVED The IRD-IRB has reviewed the above-referenced study and determined that, as currently described, it was eligible for expedited review and has been approved, as per the following category: Category 07: Research on individual or group characteristics or behavior (including, but not limited to, research on perception, cognition, motivation, identity, language, communication, cultural beliefs or practices, and social behavior) or research employing survey, interview, oral history, focus group, program evaluation, human factors evaluation, or quality assurance methodologies. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.