Factors affecting glycemic control among women with type 2 diabetes mellitus

Introduction

Type 2 diabetic mellitus (T2DM) is world known metabolic disorder, and its prevalence has been increasing rapidly⁽¹⁾. T2DM is characterized by hyperglycemia and late presentations of vascular and neuropathic complications. This disease has an important association with a hormonal deficiency known as insulin deficiency⁽²⁾. This is also called insulin resistance, T2DM being associated with irreversible risk factors such as age, genetic, race and ethnicity, and also with reversible factors like diet, physical activity and smoking⁽³⁾.

Dietary patterns are defined by the variety, quantity, or combination of different foods and drinks included in a diet, as well as the frequency with which these are consumed as part of habitual behavior. These patterns are influenced by various factors, including ethnicity, race, economic status, gender, educational level, and many other aspects. The dietary pattern of the individual influences many diseases, not only the type 2 diabetes mellitus^(4,5). Sociodemographic factors, such as age, gender, race and ethnicity, cultural barrios, marital status, religion, social support, economic status and educational level, have a great involvement in T2DM⁽⁶⁾.

As an endocrine disorder, type 2 diabetes mellitus has also a psychological involvement. Stress, anxiety disorder, and depressive symptoms are playing a major role⁽⁷⁾. Local studies emphasize that there is an upward trend in the prevalence of T2DM. The earliest study reveals a prevalence of 2.5% in 1990. The largest study on the diabetes prevalence in 2005 revealed a prevalence of 14.2% among males and 13.5% among females⁽⁸⁾. Women diagnosed with T2DM show higher self-control than males. However, it depends on the support from spouse, race and ethnicity, along with many other factors⁽⁹⁾.

The authors of a study performed in Southern Sri Lanka⁽¹⁰⁾ mentioned: “Even though the majority had adequate knowledge on diabetes, there is still some room for improvement as one fourth of study participants had poor knowledge on variance aspect of diabetics”. In Sri Lanka, T2DM prevalence has rapidly increased all over the years, due to a combination of genetic and environmental factors, like a sedentary life style, physical inactivity, stress and obesity⁽¹¹⁾. Our study focused on describing factors affecting the glycemic control among women with type 2 diabetes mellitus. Therefore, this study will assess the factors affecting glycemic control among women with T2DM attending the diabetic clinic of the Teaching Hospital Karapitiya (THK), Sri Lanka.

Methodology

Research approach and design

In this study, we used self-administered questionnaire as a data collecting tool to generate numerical data and statistical analysis for organizing data. Therefore, the quantitative approach is the most suitable method for this study. The benefits of quantitative research are represented by the fact that we can gather empirical evidence that is rooted in objective reality, and we can obtain a significant accuracy through measuring psychological phenomena.

Research setting

The study setting was the diabetic clinic at Teaching Hospital Karapitiya in Sri Lanka. Teaching Hospital Karapitiya is the largest government hospital in Galle district, located in Karapitiya. It is a teaching-oriented hospital that maintains a bed strength of 2500 and around 4500 staff involved in patient care. It provides treatment for about 250,000 inward patients and 800,000 outpatients per year. It covers most of the tertiary specialties and is properly equipped to treat the patients and provide the best training for students. It provides outpatient care in various clinical settings. The diabetes clinic of the THK is the research setting according to feasibility of the study team. There are about 10,500 patients registered here, and the clinic is conducted from 8.00 a.m. to 4.00 p.m. every weekday except Sunday. There are six medical officers working under specialists. Other than that, four nursing officers, nutritionists and healthcare assistants are also allocated to this unit.

Population and sample

The study sample consisted of female patients who have registered in the diabetes clinic of the Teaching Hospital Karapitiya. Patients were selected for the study using simple random sampling technique. Researchers got the list of female clinic attendees with T2DM from the clinic’s register. A total of 300 participants were selected, by one in every three patients, according to clinic’s register. Simple random sampling method was used.

Lawanga & Lame show equation (1991):
 

N = required minimal sample size

Z = 1.96; critical value of specified confidence, at 95% confidence interval

P = probable estimate of proportion of given characteristic

d = degree of accuracy desired set as 0.06.

Since no previous prevalence study on factors affecting glycemic control among women had been carried out in Sri Lanka, the anticipated population proportion was taken at 50% (N=294). Sample size (N) was rounded to 300 participants.

Inclusive and exclusive criteria

Female patients who have registered in the diabetes clinic of THK with diagnosed T2DM more than two years before, with ages between 30 and 65 years old. Critically ill patients and cognitive impaired patients were not included.

Data collection method

Data collection is a systematic process of gathering, measuring and analyzing information to address research objectives and answer specific questions. It involves selecting appropriate tools and techniques, such as surveys, interviews, observations or experiments, based on the nature of the study and the type of data required (qualitative or quantitative). A well-designed data collection method ensures accuracy, reliability and validity while minimizing biases. The process typically includes defining the research population, developing instruments, piloting tools and implementing the method while adhering to ethical standards to protect participants’ confidentiality and integrity. In this study, we used simple random sampling technique.

Data collection instrument and tool

The data were collected using both self-administered questionnaire and biochemical laboratory reports. Questionnaire consisted of three sections to be filled by patients. Sociodemographic data were included into part A. Part B included the questions referring to dietary factors, using food frequency questionnaire. Part C consisted of questions referring to psychological factors to assess depression, anxiety and diabetes-related distress. Last HbA1c levels were filled by researchers.

Validity and reliability

The questionnaire was prepared by researchers. Reliability was assessed with 10 participants, using test-retest method. For assessing reliability and consistency of the questionnaire, Cronbach’s alpha test was used.

Data collection

Prior to conducting the main research, the scholars obtained approval from the Faculty of Medicine, University of Ruhuna. All the research studies, data collections and data presentations were done purely with the university’s knowledge and administration. After personal discussions with each and every patient who wanted to be participate in the research, 300 patients were given the questionnaire to collect the data, and 297 responses were received.

Ethical consideration

For this study, ethical approval for the study was obtained from the Ethical Review Committee of the Faculty of Medicine, University of Ruhuna, and an information sheet was distributed among the subjects, containing the purpose, objectives, risks and benefits of the study. A serial number was allocated to each questionnaire distributed among each participant to assure the anonymity. The participants who wished to participate in the study were permitted to withdraw from the study at any time. Data were stored under password protected file with restricted access only to the principal investigator and other members. The data were used for research purpose only. The hard copies of data will be retained under lock and key for five years.

Data analysis

Data were introduced, managed and analyzed using MS Excel and Statistical Package of the Social Sciences Software (SPSS) version 21. Data from complete questionnaires were entered into MS Excel and SPSS. The reliability of the questionnaire was checked using the Cronbach’s alpha test. Data analysis was conducted both descriptive and inferential statistics to present the results of the study. Demographic characteristics were analyzed with the use of descriptive statistics such as mean, median, mode, standard deviation and frequencies. The results were summarized and presented by tables and charts. SPSS software and Microsoft Excel were used as tools for statistical and the graphical analysis.

Results

Data collection was done by self-administered questionnaire, with 300 participants selected from the clinic’s register of the diabetes clinic in the Teaching Hospital Karapitiya, Sri Lanka. A total of 297 participants gave their responses. All were female attendees with T2DM.

Table 1 indicates the HbA1C level of the participants. Most of the participants were suffering from diabetes (82.8%), and 11.4% of the participants were suffering from prediabetes. This shows that the larger part of our study participants were included in the age category 50-59 years old (35.7% of the total respondents). Those between 30 and 39 years old represented 11.8%.
 

Figure 1 presents the association between the HbA1C level and the age of the participants. All those aged 60-65 years old were suffering from diabetes (26%), while 37% of those aged 50-59 years old were suffering from diabetes.
 

Table 1 further reveals that, regarding religion, most of the participant were Sinhala (79.5%) followed by Muslims (11.8%). Figure 2 shows that all the Hindu and Islam participants were suffering from diabetes (6% and 12%, respectively).
 

Regarding the marital status of the participants, all the widowed participants were suffering from prediabetes or diabetes (18% and 7%, respectively), and 24% of the single participants had normal HbA1C levels.

As seen in Figure 3, regarding the association between the HbA1C level and the monthly income status of the participants, all those with a monthly income below 10,000 were suffering from diabetes (4%).

Figure 4 presents the association between the HbA1C levels and the participants’ diabetes treatment. It was found that all participants who adhered to medical nutrition therapy were suffering from diabetes (2%), while 24% of those using only insulin were affected.
 

Discussion

More than 37 million Americans have diabetes (about one in ten people), and approximately 90-95% of them have type 2 diabetes. Type 2 diabetes most often develops in people over the age of 45, but more and more children, teenagers and young adults are also developing it⁽¹²⁾.

Factors such as age, gender, marital status, experience of working and present residence affect their HbA1C level. However, there is limited research regarding type 2 diabetes mellitus (T2DM) in Sri Lanka, including the developing countries. So, this is a descriptive hospital-based study on T2DM and related factors. In this study, we used 300 patients. Our questionnaire included three parts, regarding sociodemographic data, dietary factors, and psychological factors.

Based on our findings, 26% of participants aged 60-65 were affected by T2DM, the highest among all age groups. Among ethnic groups, Tamil participants (8%), Muslim participants (14%), and Burgher participants (2%) were affected by T2DM. Hindu (6%) and Islam (12%) participants were also affected. Widowed participants had the highest rates of prediabetes (18%) and diabetes (7%), while most single participants (24%) had normal HbA1C levels.

It was revealed in this study that retired individuals represented the most common group affected by type 2 diabetes mellitus (T2DM), with 8% of this demographic group suffering from the condition. Retired individuals are considered the most stressed group, as the transition from employment to a normal lifestyle requires significant adaptation to new routines, dietary habits, and a different level of freedom. The study also highlighted the role of education level as a major factor in the prevalence of noncommunicable diseases. Among the surveyed participants, 6% of illiterate individuals and 9% of those with only primary education were found to have T2DM. Furthermore, monthly income emerged as another significant determinant, as dietary patterns often depend on financial capacity. According to the survey, 4% of participants with a monthly income below 10,000 reported having T2DM.

Conclusions

Significant evidence was observed regarding HbA1C levels and related factors among women with T2DM. The presence of more dependents was associated with variations in HbA1C levels and dietary factors. According to the respondents, HbA1C levels were categorized as normal in 5.7% of cases, prediabetic in 11.4%, and diabetic in 82.8% of cases. T2DM is a chronic medical condition that affects millions of people worldwide. Unmanaged diabetes may lead to blindness, kidney failure, heart disease, and other serious conditions.

Implication for patients

These findings can be used to reduce the HbA1C levels among women with T2DM, to identify the causes of T2DM, and to prevent unhealthy behaviors among patients. This research study findings are especially useful in further educational opportunities of patients, nurses and students. This study experience helped us to conducting further research studies.

Recommendations

This study can serve as a baseline for further studies to recognize the factors related to type 2 diabetes mellitus and reduce the HbA1C levels.

Limitation

The test group, along with the purposes and outcomes of the test, is difficult to define, and the participants are hard to identify.

Autori pentru corespondenţă: F.M.M.T. Marikar E-mail: faiz@kdu.ac.lk

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.