Impact of diabetes screening on quality of life

The psychological impact of screening for type 2 diabetes

Until recently, there was little empirical data regarding the psychological impact of screening for type 2 diabetes. There is now some progress in this area, as evidenced by emerging population based studies reporting on the effects of screening for type 2 diabetes on perceived health status and well-being. Recent studies from our own and other groups show that the diagnosis type 2 diabetes has no substantial adverse or positive effect on the participants' perceived health status and well-being after notification of the test result. Importantly, screening-detected type 2 diabetes patients beforehand perceive their risk for type 2 diabetes to be low, despite the presence of risk factors, such as obesity, hypertension and a family history, and overall report low levels of diabetes-related symptom distress. Yet, screening-detected type 2 diabetes patients were bothered more by symptoms of hyperglycaemia and fatigue in the first year following diagnosis type 2 diabetes than non-diabetics. On the basis of research to date, we conclude that screening for type 2 diabetes in the general population has no serious psychological side effects. Whether lack of emotional response to screening, is because of unawareness or indifference, needs further investigation. Future studies should be aiming towards a better understanding of how to raise the awareness and understanding of type 2 diabetes and its risk factors in high-risk individuals, while avoiding or minimizing negative effects, such as emotional distress and denial. The growing number of younger people developing type 2 diabetes warrants further research into labeling effects of an early diagnosis.

Health-related quality of life of diabetic foot ulcer patients and their caregivers

AIMS/HYPOTHESIS

The effect of a foot ulcer on health-related quality of life (HRQoL) of patients with diabetes mellitus and their caregivers is unclear, and was therefore evaluated prospectively in this multicentre study.

METHODS

HRQoL according to the 36-item health-related quality of life questionnaire (SF-36) of 294 patients (ulcer duration > or = 4 weeks) and 153 caregivers was analysed at baseline (time-point zero [T0]), once the ulcer was healed or after 20 weeks (time-point 1 [T1]), and 3 months later (time-point 2 [T2]). Patients with severe ischaemia were excluded.

RESULTS

The mean age of the patients was 60 years, 72% were male, and time since diagnosis of diabetes was 17 years. Patients reported a low HRQoL on all SF-36 subscales. At T1, HRQoL scores in physical and social functioning were higher in patients with a healed vs a non-healed ulcer (p<0.05). At T2, these differences were larger, with higher scores for physical and social functioning, role physical and the physical summary score (all p<0.05). Within-group analysis revealed that HRQoL improved in different subscales in patients with a healed ulcer and worsened in patients with a persistent ulcer from T0 to T2 (all p<0.05). The caregivers of patients with a persisting ulcer had more emotional difficulties at T2.

CONCLUSIONS/INTERPRETATION

Diabetic patients with a healed foot ulcer had a higher HRQoL than patients with a persisting ulcer. Healing of a foot ulcer resulted in a marked improvement of several SF-36 subscales 3 months after healing (from T0 to T2). HRQoL declined progressively when the ulcer did not heal. A diabetic foot ulcer appeared to be a large emotional burden on the patients' caregivers, as well.

Assessment of Long-term Complications due to Type 2 Diabetes Using Patient Self-report

This study aims to develop a patient-based measure of the complications of type 2 diabetes that can be used in examining its relationship with health-related quality of life (HRQOL) and utilization of health services. Using questions analogous to those typically employed by clinicians, we developed a 17-item questionnaire to identify prior diagnoses and current symptoms of 6 common complications of type 2 diabetes. We administered it to 419 patients with type 2 diabetes who were part of the Veterans Health Study, a larger prospective investigation of veterans receiving ambulatory care. From the responses, we calculated a simple sum of the 6 complications. We examined the correlation of this Diabetes Complications Index (DCI) with use of diabetes-related medical resources, outpatient doctor visits, HRQOL, duration of diabetes, and the degree to which patients perceived their health to be diminished by diabetes. The DCI was significantly correlated with the degree to which patients perceived their health to be diminished by diabetes (r = 0.35, P = .0001), utilization of diabetes-related resources (model R = 0.15, P = .0001), outpatient doctor visits (model R = .08, P = .001), and duration of diabetes (r = 0.11, P = .04). It had a good correlation with aspects of HRQOL that reflect physical function when controlling for age and comorbid conditions (model R = 0.23, P = .0001). The DCI shows promise as an efficient method for assessing the effects of type 2 diabetes on HRQOL and predicting utilization of medical resources.

Measurement properties of the UK-English version of the Pediatric Quality of Life Inventory 4.0 (PedsQL) generic core scales

BACKGROUND

Health related quality of life (HRQL) has been recognised as an important paediatric outcome measurement. One of the more promising measures to emerge in recent years is the Pediatric Quality Of Life Inventory (PedsQL), developed in the US. Advantages of the PedsQL include brevity, availability of age appropriate versions and parallel forms for child and parent. This study developed a UK-English version of PedsQL generic module and assessed its performance in a group of UK children and their parents.

METHODS

PedsQL was translated to UK-English. The psychometric properties of the UK version were then tested following administration to 1399 children and 970 of their parents. The sample included healthy children, children diagnosed with asthma, diabetes or inflammatory bowel disease and children in remission from cancer.

RESULTS

Psychometric properties were similar to those reported for the original PedsQL. Internal reliability exceeded 0.70 for all proxy and self-report sub-scales. Discriminant validity was established for proxy and self-report with higher HRQL being reported for healthy children than those with health problems. Sex differences were noted on the emotional functioning subscale, with females reporting lower HRQL than males. Proxy and self-report correlation was higher for children with health problems than for healthy children.

CONCLUSION

The UK-English version of PedsQL performed as well as the original PedsQL and is recommended for assessment of paediatric HRQL in the UK.

TRAF4 functions as an intermediate of GITR-induced NF-kappaB activation

Members of the tumor necrosis factor receptor (TNFR) family regulate the activation, differentiation, and function of many cell types, including cells of the immune system. TNFR-associated factors (TRAFs) function as adapter molecules controlling signaling pathways triggered by TNFR family members, such as activation of nuclear factor kappaB (NF-kappaB). Despite intensive research, the function of TRAF4 in signaling pathways triggered by TNFR-related proteins remains enigmatic. Intriguingly, our functional studies indicated that TRAF4 augments NF-kappaB activation triggered by glucocorticoid-induced TNFR (GITR), a receptor expressed on T cells, B cells, and macrophages. Further analyses revealed that TRAF4-mediated NF-kappaB activation downstream of GITR depends on a previously mapped TRAF-binding site in the cytoplasmic domain of the receptor and is inhibited by the cytoplasmic protein A20. GITR is thought to inhibit the suppressive function of regulatory T cells (Treg cells) and to promote activation of T cells. Taken together, our studies provide the first indications that TRAF4 elaborates GITR signaling and suggest that TRAF4 can modulate the suppressive functions of Treg cells.

Health-related quality of life in the first year following diagnosis of Type 2 diabetes: newly diagnosed patients in general practice compared with screening-detected patients. The Hoorn Screening Study

AIMS

To determine health-related quality of life (HRQoL) in the first year following diagnosis of Type 2 diabetes among newly diagnosed patients in general practice compared with patients detected by targeted population screening.

METHODS

The study population consisted of 49 newly diagnosed patients in general practice and 116 screening-detected patients. HRQoL was operationalized as symptom distress, perceived health status and emotional well-being, that were assessed prospectively approximately 2 weeks, 6 months and 12 months after the diagnosis of Type 2 diabetes, with the Type 2 Diabetes Symptom Checklist (DSC-type 2), the Short Form 36 (SF-36) and the Well-Being Questionnaire (W-BQ12), respectively.

RESULTS

The DSC-type 2 total score (range 0-4) improved significantly within newly diagnosed patients in general practice (median at approximately 2 weeks, 6 months and 12 months; 0.56, 0.21, 0.26; P = 0.000) and not within screening-detected patients (0.24, 0.24, 0.29; P = 0.093). Descriptives showed that newly diagnosed patients in general practice compared with screening-detected patients had consistently worse mean scores on all SF-36 mental health subscales Social Functioning, Role Emotional, Mental Health, Vitality, and all W-BQ12 scales at each time point. The differences were statistically significant for Role Emotional, Mental Health, Vitality (SF-36), and General well-being (W-BQ12). The SF-36 General Health (F = 3.7, P = 0.028) and Vitality (F = 4.5, P = 0.012) scores of newly diagnosed patients in general practice improved significantly over time, compared with screening-detected patients.

CONCLUSIONS

Newly diagnosed patients in general practice compared with screening-detected patients reported more diabetes-related symptom distress shortly after the diagnosis, and a consistently worse mental health status at each time point. Improved Vitality scores in newly diagnosed patients in general practice in the first year following diagnosis of Type 2 diabetes suggest a positive effect of diabetes treatment on HRQoL.

No substantial psychological impact of the diagnosis of Type 2 diabetes following targeted population screening: The Hoorn Screening Study

AIMS

To examine the impact of the diagnosis of Type 2 diabetes on psychological well-being and perceived health status in subjects who participated in a targeted population-screening programme.

METHODS

This study was conducted within the framework of a screening project in the general (aged 50-75 years) Dutch population. The final study population consisted of 259 subjects with a high-risk score on the Symptom Risk Questionnaire; 116 of whom were subsequently detected with Type 2 diabetes and 143 who were non-diabetic. The impact was assessed approximately 2 weeks (shortly) and 6 and 12 months after the diagnosis, using the 12-item Well-Being Questionnaire (W-BQ12) and the Medical Outcomes Study Short Form 36 (SF-36), respectively. Analyses of co-variance (ancova) were used.

RESULTS

Approximately 2 weeks after the diagnosis, no significant mean differences were found on either the W-BQ12 or the SF-36, between the screening-detected Type 2 diabetes subjects and the non-diabetic subjects. Six months after the diagnosis, we found lower scores in the screening-detected Type 2 diabetes subjects compared with the non-diabetic subjects on the SF-36 dimensions Role Physical (mean difference (95% CI); -8.2 (-16.2; -0.1); P = 0.046) and Role Emotional (mean difference (95% CI); -7.9 (-15.3; -0.5); P = 0.038). One year after the test results, no significant mean differences were found between both groups on either instrument (W-BQ12; SF-36).

CONCLUSIONS

The diagnosis of Type 2 diabetes has no substantial adverse or positive effect on psychological well-being and perceived health status, shortly, and 6 and 12 months after the diagnosis.

Functional status before and after diagnosis of Type 2 diabetes

AIMS

We examined functional health status prior to the diagnosis of Type 2 diabetes, and measured the effect on functional health status of receiving the diagnosis.

METHODS

After the ADA reduced its fasting plasma glucose level for diagnosing diabetes from > 7.8 to > 7.0 mmol/l, we identified 1014 members of a large HMO who met the new criteria, and an age- and gender-matched comparison group who did not. We mailed questionnaires to these subjects in 1998, and again in 1999 to 623 who met the new criteria, after some had been notified of their diabetes, while others had not. We used the SF-12(R) Health Survey to measure physical and mental subjective health status.

RESULTS

Mean age of respondents meeting new diagnostic criteria (n = 498) was 67.3 + 10.4 years, 43.6% were women. Comparison group respondents (n = 589) were 66.7 + 10.6 years, 45.2% women. The groups were not statistically different on either characteristic. Prior to the diagnosis of Type 2 diabetes, physical functioning was already lower in subjects who met the new criteria than in the comparison group (39.5 vs. 42.1, P < 0.001), mental functioning was similar (51.4 vs. 51.9, P = 0.406). Among those who newly met diagnostic criteria for diabetes, there was no difference in the change in health status (mental or physical) in those who reported receiving a diagnosis (n = 105) compared with those who did not (n = 168).

CONCLUSIONS

Physical health status is already reduced prior to diabetes diagnosis, perhaps because of obesity or other aspects of the insulin resistance syndrome. Receiving a diabetes diagnosis after adjusting the diagnostic criteria does not adversely affect either mental or physical health status.

Assessing weight-related quality of life in obese persons with type 2 diabetes

Because approximately 80% of individuals with type 2 diabetes are obese, we examined weight-related QOL in obese persons with diabetes using the Impact of Weight on Quality of Life-Lite (IWQOL-Lite) questionnaire. Study participants were enrolled in a clinical trial for an obesity medication or a clinical study of gastric bypass surgery. Psychometric properties of the IWQOL-Lite were evaluated separately for obese persons with (n = 225) and without (n = 972) type 2 diabetes. Internal consistency reliabilities were similar for persons with and without diabetes (0.981 versus 0.980). Correlations between IWQOL-Lite scores and body mass index were significant and comparable for persons with and without diabetes. The IWQOL-Lite factor structure was similar for both the diabetic and non-diabetic subjects and consistent with earlier studies. There was no difference between diabetic and non-diabetic subjects on weight-related QOL as measured by the IWQOL-Lite; however, subjects in this study had more impaired weight-related QOL relative to a reference sample of overweight/obese community persons. We recommend the use of weight-related QOL measures in addition to generic and diabetes-specific measures when assessing quality of life in type 2 diabetes, particularly when patients are overweight or obese.