Prevalence of Misconceptions about Diabetes and their Association with Metabolic and Psychological Variables

Introduction

The International Diabetes Federation estimates a prevalence of 463 million people with diabetes around the world [1]. México is considered the sixth country with more diabetes, with around 17 million people between 20 and 79 years old [1]. According to the National Survey of Health and Nutrition (ENSANUT Medio Camino) 2016, México has a prevalence of 9.4% of people with diabetes previously diagnosed [2]. Considering the high prevalence of diabetes, is important to identify knowledge, perceptions, beliefs, misconceptions and actions related to this chronic condition that could have an impact in diabetes control [3].

Misconceptions have been associated with various factors such as educational level, cultural or religious beliefs which change between countries [4, 5]. Mexico has a broad cultural heritage with strong health beliefs and myths around different diseases.

There are some studies around the world describing the most frequent myths and misconceptions in people with diabetes and their families [4, 5, 6, 7]. However, there are no studies that associate these beliefs with metabolic and psychological variables in prospective assessments.

The objective of this study was to evaluate misconceptions about diabetes in participants who attend the Center for Comprehensive Care of the Patient with Diabetes (CAIPaDi) at baseline, as well as its association with metabolic and psychological variables in the first visit and in the follow up of 3 months and 1 year. The hypothesis was that participants with misconceptions about diabetes had worst metabolic and psychological parameters.

Results

The survey was answered by 902 participants who attended the first visit of the CAIPaDi program. The population was 50 ±10 years old, with 1 (0-5) years living with type 2 diabetes and 54.3% were women. Up to 52.8% of the participants had at least 1 misconception, being more frequent in women (p=0.045) and in population with lower educational level (p<0.001). In the group with misconceptions 31.1% of participants had basic, 18.7% medium and 50.1% advanced educational level. In the group of participants without misconceptions, 17.1% had basic educational level, 16.4% medium and 66.4% advanced. The most common misconceptions were “emotional stress and fright cause diabetes” (34.4%), “in the control of my diabetes only matters glucose management” (15.2%) and “women with diabetes should not get pregnant” (11.8%). The prevalence of misconceptions is shown in Table 1.

We compared the BMI, blood pressure, metabolic and psychological variables a baseline, at 3 months and 1 year between participants with and without misconceptions at the first visit, as shown in Table 2. At basal, participants with misconceptions had worst glycaemic control, higher scores in PAID questionnaire, lower quality of life and more depression and anxiety symptoms. Participants with misconceptions had lower educational level. At 3 months people with misconceptions at baseline had worst HbA1c and more problematic areas in diabetes. There were no significant differences between groups at a 1 year follow up.

Discussion

This study presents the prevalence of misconceptions about diabetes in people who attend the first visit at CAIPaDi, as well as its association with educational, metabolic and psychological variables at baseline, 3 months and 1 year of follow up. We found a high prevalence of participants with misconceptions about diabetes. At baseline, this group had worst glycaemic control, more problematic areas in diabetes, lower quality of life and more depressive and anxious symptoms. People with misconceptions had a lower educational level. At 3 months, participants who had misconceptions in the first visit had higher HbA1c and more problematic areas in diabetes. Although mean HbA1c improved in both groups, it was lower in patients who did not had misconceptions at baseline. At 1 year of follow up, triglycerides and HbA1c were in better control in the group who did not have misconceptions at baseline, but was not statistically significant.

Other studies in Mexico have found similar misconceptions. Andrade, et al. [14] explored misconceptions about diabetes in clinics in a qualitative study, where they found that 31.2% of the people with diabetes thought that “emotional stress and fright causes diabetes”, very similar to our population (34.4%). In the same study, 43.7% of the patients had the misconception that “home remedies can help in diabetes control”; in our study only 2% thought that home remedies can replace medical treatment [14]. Garza- Elizondo, et al. [15] found that 22% of the participants with type 2 diabetes had the misconception that fright causes diabetes. Recent studies have found that psychological chronic stress and depression are linked to type 2 diabetes, through various mechanisms such as inflammatory citokine expression leading to chronic low grade inflammation, release of glucose and lipids into the circulation and the modification of health behaviours such as exercise, food choice and adherence to medication [16]. However, in the Mexican population, people generally consider that a single stressful situation can lead to diabetes, without taking into account other potential risk factors as obesity, first degree relatives with diabetes, physical inactivity, dyslipidemia, hypertension, and age, among others [17].

Other study explored myths and misconceptions of 300 patients with diabetes who attend a Mexican Social Security Institute (IMSS) clinic and found that some of the most prevalent misconceptions were “if I feel well it is because my sugar levels are normal” (84%), “insulin causes blindness” (46.3%), “insulin treatment means I am on last stage of diabetes” (45%), “home remedies help in diabetes control” (31.8%), “anger causes diabetes” (41.3%), “fright causes diabetes” (40%) and “diabetes can be cured” (11.7%) [8]. The first misconception was not included in our study, but will be included in a second phase because it can have an impact on treatment abandonment. In our study, the misconceptions “diabetes can be cured” and “fright causes diabetes” were found in a similar proportion, but the other misconceptions were less common. Our population was less afraid to insulin treatment (only 6.2% thought that insulin causes blindness and 4% believe that insulin prescription means last stage of the disease) compared with Salazar et al results [10]. In a recent study, it was found that people with (i) recent diagnosis of diabetes (< 6 years), (ii) overweight or obesity, and (iii) not taking insulin, could achieve diabetes remission, defined as HbA1c <6.5% after at least 2 months without antidiabetic medications. This remission was achieved in 46% of the intervention group, being higher in persons who lost 5-10

kg (57%) and >15 kg (86%) in a follow up of 12 months. So according to this study diabetes remission can be achieved in some patients with a low calorie diet, exercise and a maintained weight loss for up to 12 months [18]. However in the Mexican population, the misconception of “diabetes can be cured” can lead the patients to take alternative therapies that have no scientific evidence of working and to abandon medical treatment.

In a study conducted in the United States of America and Europe, misconceptions about insulin were evaluated in people with type 2 diabetes with recent insulin prescription. From the 87 participants of the study, only 43.7% decided to start insulin treatment. Misconceptions founded as a barrier to insulin initiation were “insulin prescription means last stage of diabetes” (21%) and “insulin treatment causes vision loss” (6.9%). The incidence of the latter misconception was very similar to that of our study`s population (6.2%), but the incidence of the former misconception was 5 times higher than in our study [7]. In an Indian study analyzing 505 people with type 2 diabetes who refused insulin injections, it was found that the main barriers were “fear of side effects” (68.7%) and “injected insulin causes addiction” (64.7%) which were much higher than in our study`s population [19]. Although insulin is essential when patients no longer have pancreatic insulin reserve, its prescription does not imply that the patient is in the last stage of the disease or that his condition is serious. The problem of these misconceptions is the rejection or delay in its use.

In 2016, Nitsche, et al. conducted a study on a population in South America. 306 individuals (25% health professionals, 14% patients with diabetes and 15% caregivers) were asked about beliefs and myths in diabetes, feelings related to the disease, nutritional issues and medical treatment. They found that 10% of the population believed that “diabetes can be cured with natural treatments” and 15% that “there is good and bad diabetes”, both misconceptions very similar to our findings (8.9% and 11.3%, respectively] [3]. In India, a country with deep-rooted beliefs in spiritual treatment and alternative medicine, common misconceptions were “diabetes is contagious” (17.8%), “soaking feet in water helps decrease blood sugar level” (11.8%), and “diabetes occurs because of past sins and can be cured with spiritual treatment” (9.4%) [5]. We did not include these misconceptions in our survey because no one referred them in our interventions. Some interesting results of this study are that people without diabetes had more misconceptions that participants with this condition (related to causes and treatment), and there were no differences on misconceptions between religions (Muslim vs Hindu). Only the misconception “spiritual treatment can cure diabetes” (p=0.02), was higher in Muslin population. Similar to our results, women had more misconceptions than men and more common in population with less educational level [5].

Misconceptions like “women with diabetes should not get pregnant”, “if glucose levels normalize, diabetes is cured” and “for diabetes control, only matters glucose management” were not found in the reviewed literature. However, they were mentioned in our population and were found in an important proportion. It is important to mention that women in reproductive age that lives with diabetes should receive preconception counseling as part of their diabetes care routine in order to achieve a good diabetes control and an HbA1c <6.5% (before and during pregnancy) to reduce the risk of congenital anomalies, macrosomia, preeclamsia, and other maternal-fetal complications [20].

The strength of our study is the number of patients evaluated and the comparison of metabolic and psychological parameters in prospective basis. It is a fast, simple and low- cost strategy that provides an overview of the knowledge and beliefs about the disease of the population with diabetes, which facilitates the accuracy of the approach. This study has external validity in Mexican population since we considered Mexican culture and misconceptions.

The limitations of the study were that the misconceptions were not directly related to actions and were not evaluated in subsequent visits. Is important to search for misconceptions related to other diabetes areas, as nutrition, exercise, mental health or medical treatment, that could have more influence in decision making. Based on this, a second survey was developed to assess myths and misconceptions of different areas in diabetes that have more impact in self-care, and therefore the identification and eradication of these beliefs could help in diabetes control, reinforce treatment adherence and promote the prevention of complications in a long-term basis.