Differences in Disease Demographics and Associated Co- Morbidities in Working Men and Women with Type 2 Diabetes Mellitus

Study Tool

QOLID (Quality of Life Instrument for Indian Diabetes Patients) is a reliable, valid and sensitive tool for the assessment of diabetes specific quality of life in Indian subjects developed by Nagpal, et al. [16] with an overall Cronbach's Alpha value of 0.894 (subscale- 0.55 to 0.85) showing high internal consistency, good concordance (product moment correlation 0.724; p = 0.001; subscale correlation - 0.457 to 0.779) and DQL-CTQ. The QOLID questionnaire was selected for the present study as it was already subjected to expert panel review, item analysis, reliability analysis, concordant validity and discriminant validity by Nagpal, et al. [16] and is aptly suitable for studying Indian T2DM subjects with overall standardized questionnaire score and good responsiveness to metabolic control and co-morbidities establishing discriminant validity. The same questionnaire was used by the present study group to validate the data obtained on 384 T2DM subjects as a pilot work [17].

Self-administered questionnaires were provided and data was collected after willingness to participate was sought, and written consent was taken from all the Copyright© Kuna A, et al.

working men and women. Data entry was done using Epidata software. Double data entry was done to ensure accuracy and validate the process of data entry. Statistical analysis software SPSS for Windows 10.0 was used for the analysis of data. Demographic characters of the population was expressed as percentages.

Demographic Profile of Participants (N=292)

A study on Health related quality of life among working men and women with T2DM subjects was carried out on 292 subjects in Bellary & Davangere districts of Karnataka state. The demographic characteristics of participants of the study are presented in Table 1. Out of

Kuna A, et al. Differences in Disease Demographics and Associated Co- Morbidities in Working Men and Women with Type 2 Diabetes Mellitus. Med J Clin Trials Case Stud 2019, 3(1): 000207.

Copyright© Kuna A, et al.

Results on level of education among the study respondents showed that 40.12% (n = 63) of working men completed college or higher education and 43.31% (n = 68) completed secondary education. Working women were better educated than working men with 59.25% (n = 80) of them who completed college or higher education and 25.2% (n = 34) completing secondary education. Kapur [20] reported that general education level seems very important and that diagnosis can be delayed by 3-7 years in the less and uneducated sections of the population. Actively working people are diagnosed almost a decade earlier, either because of better affordability of care or the need to remain fit to earn a livelihood for the family. Majority of respondents participated in the present study were all newly diagnosed with diabetes (between 6 months to 5 years).

Results on type of occupation showed that, 59.23% of men (n = 93) and 64.44% of women (n = 87) were involved in moderate work and most them were working for 6 to7 hours / day. Majority of working men (40.12%; n = 63) were involved in both field and desktop type of work compared to women who were involved in desktop type of work (60%; n = 81). Majority of the subjects i.e., 32.5% of working men (n=51) and 40% of working women (n=54) had monthly income between 11,000 to 19,000 income per month; 38.9% of men (n=61) and 38.5% of women (n=52) had income between 20,000 to 29,000 per month, which is reasonably good earning and could help the subjects with proper treatment for diabetes. Kapur [21] reported that many socio-economic factors and health care delivery related issues impact the outcome of diabetes and consequently the costs and vice- versa. Occupation carries the specific environmental exposures, and it may be of limited value in measuring socioeconomic status for women who have not been in the paid workforce for much of their adult lives. Socioeconomic status is associated with type 2 diabetes prevalence among women, but not consistently among Kuna A, et al. Differences in Disease Demographics and Associated Co- Morbidities in Working Men and Women with Type 2 Diabetes Mellitus. Med J Clin Trials Case Stud 2019, 3(1): 000207.

men. Diabetes prevalence is more strongly associated with psychological insulin resistance (PIR) than with education or occupational status [22]. It is well established fact that patient contributions are very important for better management of diabetes [23]. Lack of knowledge of diabetes care among patients can have adverse effects on their capabilities to control diabetes and in turn, on the quality of life. As most of the study respondents of present study were educated and working, they were all diagnosed with diabetes early and also have capability to control diabetes with their level of education and earning capacity.

Demographic Profile on Disease Related Parameters

Information on disease related parameters were collected from all the 292 subjects. Information on disease related parameters (duration of diabetes, family history, health status, treatment, diabetes related hospitalization, visit to physician, associated co-morbidities, following a special diet, visit to dietician & complying with given diet & regularity in blood tests/biochemical parameters) are given in Table 2.

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1= < 6 months, 2= 6 - 12 months, 3= 1 – 5 years and 4= > 5 years duration of diabetes Figure 1: Duration of diabetes mellitus among working men and women.

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Responses about duration of diabetes (Fig.1) indicated that, 46.5% of working men (n=73) and 22.22% of working women (n=30) respondents reported duration of diabetes between 6 to12 months; 28.7% of men (n=45) and 42.22% of women (n=57) reported that the duration of diabetes was between 1 to 5 years. Majority of the respondents had a family history of diabetes (Fig.2) with either of the parent (father or mother) being diabetic. 36.3% of working men (n=57) and 37.8% of working women (n=51) subjects reported no family history of diabetes.

Kuna A, et al. Differences in Disease Demographics and Associated Co- Morbidities in Working Men and Women with Type 2 Diabetes Mellitus. Med J Clin Trials Case Stud 2019, 3(1): 000207.

Results on type of treatment among the study respondents showed that majority of them i.e., 82.2% of working men (n=129) and 93.3% of working women (n=126) were on oral pills. Results on visit to physician showed that, majority of the subjects i.e., 58% of working men (n=91) and 48.9% of working women (n=66) visit physician once in a month. 11.5% of working men (n=18) and 35.6% of working women (n=48) reported diabetes related hospitalization in the past one year indicating that diabetes related hospitalization were high in working women when compared to working men.

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Results on T2DM associated problems among the subjects showed that 73.9% of working men (n = 116) and 54.8% of working women (n = 74) had hypertension; 26.1% of working men (n = 41) and 27.4% of working women (n = 37) had high cholesterol; 15.3% of working men (n = 24) and 20.7% of working women (n = 28) had vision related problems. None of the working men or women reported brain stroke. 4.45% of working men (n = 7) and 8.2% of working women (n = 11) had heart attack. 1.5% of women (n = 2) had foot amputation and 12.6% of women (n = 17) were undergoing kidney dialysis, while none of the working men reported any foot amputation or kidney dialysis indicating that women were more prone to nephropathy and neuropathy.

Liu, et al. [24] in their cross sectional hospital based survey in urban China on prevalence of chronic complications of type 2 diabetes mellitus in outpatients reported that, chronic complication is the outcome of type 2 diabetes and that at least one chronic complication was diagnosed in 52% of diabetic respondents, which increased with age. The present study findings are in correlation with the findings of Liu, et al. [24], where more than half of the respondents reported a chronic complication, which was an outcome of type 2 diabetes.

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Co-morbidity is defined as the occurrence of one or more chronic conditions in the same person with an index-disease, which occurs frequently among patients with diabetes. Currently, integrated diabetes care programs focus on diabetes related co-morbidities like cardiovascular diseases, retinopathy, nephropathy and neuropathy [25]. However, patients with diabetes do not only have diabetes related co-morbidity, but also have non diabetes related co-morbidity, such as depression, job related stress and other problems. With the on-going population aging in most of the societies, not only the number of patients with diabetes is expected to increase, but also the number of patients with diabetes and associated co-morbidities will increase. This implies that the current single disease management approach is not applicable to a large part of the patients with diabetes in the future [26].

Results on associated co-morbidities (Figure 3) showed that majority of the respondents had hypertension followed by hyper-lipidemia, cardiac disease, visual problems, nerve related problems, sexual dysfunction, peripheral vascular disease, renal problems, erectile dysfunction (working men) and vaginal problem (working women) indicating that co-morbidities are definitely a course of concern in the management of diabetes. Working women had higher prevalence of co- morbidities than men. Women may experience more or less of the same symptoms as men, however, there are several factors that are unique to the female body (physical make up, diabetes affects them differently due to hormones, menstruation and stress of job and household activities etc) which that could be responsible for higher prevalence of T2DM associated co-morbidities.

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Note: HTN: Hypertension; HL: Hyper lipidemia; CD: Cardiac disease; Vp: Visual problems; Np: Nerve problems; Sd: Sexual dysfunction; PVD: Peripheral vascular disease; RP: Renal problems; ED: Erectile dysfunction and VGP: Vaginal problem.

Kuna A, et al. Differences in Disease Demographics and Associated Co- Morbidities in Working Men and Women with Type 2 Diabetes Mellitus. Med J Clin Trials Case Stud 2019, 3(1): 000207.

A study by Agarwal, et al. [27] reported that, among 11,157 subjects, retinopathy was diagnosed in 32.5%, nephropathy was present in 30.2%, peripheral neuropathy was present in 26.8%, coronary heart disease (CHD) was present in 25.8% and peripheral vascular disease (PVD) was present in 28% of the subjects. Microvascular complications from type 2 diabetes are common and include retinopathy and neuropathy as leading complications associated with increasing duration of T2DM [28, 29, 30].

Most adults with diabetes have at least 1 coexisting chronic condition [31], and approximately 40% have 3 or more [32]. As the number of co-morbidities increases, the risks of poor patient outcomes (eg, unnecessary hospitalizations, adverse drug events, mortality) and healthcare costs also increase [33]. Further, the types of co-morbidities have an impact on diabetes care [34]. Although previous studies have shown that the type and severity of co-morbidities matter, not just the number of conditions [35, 36], less attention has been paid to multiple chronic co-morbidities (MCCs) and how they impact diabetes care especially in working men and working women. Patients with MCCs constitute a majority of the diabetes population, and are known to require high levels of healthcare and to account for a significant proportion of healthcare costs [37]. However, it is unclear which MCC clusters in diabetes are most prevalent, or how MCC patterns vary by age and type of work in men and women separately. MCCs are an issue of growing significance not only because of their prevalence, but because they can complicate treatment and increase disease burden and costs [38, 39, 40].

Results on subjects following a special diet indicated that, 36.3% of working women (n = 49) respondents follow a special diet when compared to 24.2% of working men (n = 38). Results on subjects visit to dietician & complying with the given diet showed that, 9.55% of working men (n = 15) and 4.44% of working women (n = 6) visited dietician. Results of present study are similar to the findings of a study conducted on dietary practices by Badreldin, et al. [41] who reported 78.8% not complying with dietician visits in 222 type 2 diabetic Saudi population. Results on subjects regularity in blood tests/ biochemical parameters indicated that, 91.1% of working men (n = 143) and 94.8% of working women (n = 128) had regular blood tests.

Studies have analyzed the relationship between gender and quality of life among diabetes patients. Higher Copyright© Kuna A, et al.

quality of life was found among diabetic male patients than among diabetic female patients [42, 43] due to less physical activity, high obesity and poor socioeconomic condition of women than men [44]. It is evident from the results of the study that, working women had higher prevalence of T2DM associated co-morbidities compared to working men, indicating the multiple vulnerability of job stress, T2DM and management among working women.