Zurita-Cruz et al.

Health and Quality of Life Outcomes (2018) 16:94

https://doi.org/10.1186/s12955-018-0906-y

RESEARCH Open Access

Health and quality of life outcomes

impairment of quality of life in type 2
diabetes mellitus: a cross-sectional study
Jessie N. Zurita-Cruz1, Leticia Manuel-Apolinar2, María Luisa Arellano-Flores2, Alejandro Gutierrez-Gonzalez3,
Alma Gloria Najera-Ahumada4 and Nelly Cisneros-González5*

Abstract
Background: Type 2 diabetes mellitus (DM2) is a chronic disease, and for treatment to succeed, it is necessary to
harmonize the mental health of the patient with the environment, which impacts quality of life and adherence to
medical regimens. The objetive of this study is describe the quality of life of patients with DM2 and the factors
relates to its modification.
Methods: This investigation was a cross-sectional study. Patients over 18 years of age with DM2 were selected. The
following variables related to quality of life were studied: age, sex, occupation, marital status, years of DM2 evolution,
comorbidities and presence of depression (Beck Depression Inventory). Perceived quality of life was measured with a
health-related quality of life (HRQoL) scale, the 36-Item Short-Form Survey (SF-36). Patients were classified according to
SF-36 HRQoL score (< 50, 51-75 and > 76 points).
Results: Among the 1394 patients included, the median age was 62 years. Global HRQoL had a median of 50.1 points.
Bivariate analysis showed that age, marital status, sex, occupation, comorbidities, duration of DM2 and comorbidities
had impacts on HRQoL. The logistic regression model identified age (odds ratio [OR] 1.04) and depression (OR 4.4) as
independent factors that influenced overall quality of life.
Conclusions: Patients with DM2 have poor HRQoL, which is associated with a high frequency of depression. Older age
and the presence of depression impair patient HRQoL.
Trial registration: R-2013-781-052. Registered 20 December 2014.
Keywords: Type 2 diabetes mellitus, Quality of life, Depression

Background prevalence of overweight and obesity compared to that

Type 2 diabetes mellitus (DM2) is a chronic noncommu- reported in 2000, from 61.8% to 71.3% [4, 5]. Conse-
nicable disease that arises when the pancreas does not quently, between 2000 and 2012, there was a reported in-
produce sufficient insulin and/or when the body cannot crease in the prevalence of DM2 from 5.7 to 9.1% in adults
effectively use the insulin it produces, resulting in 20 years of age or older, equivalent to a relative increase of
chronic hyperglycemia [1, 2]. DM2 is directly associated almost 60% [6], and an increase in morbidity and mortality
with obesity, which produces peripheral insulin resistance secondary to DM2.
and leads to the medium- or long-term development of Complications lead to increased numbers of medical
DM2 [3]. appointments and hospitalizations, which affect patient
In Mexico, according to the National Health Survey quality of life (QoL) and increase the burden of hospital
of 2012, there has been a significant increase in the care costs. Macrovascular complications include systemic
hypertension, acute myocardial infarction (AMI), congest-
* Correspondence: [email protected] ive heart failure, cerebrovascular accident (CVA), and per-
5
Epidemiological Surveillance Coordination, Instituto Mexicano del Seguro ipheral artery disease (PAD) [7]. Patients with DM2 are at a
Social (IMSS), Mexico City, Mexico
Full list of author information is available at the end of the article
2- to 4-fold increased risk of suffering from either AMI or

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Zurita-Cruz et al. Health and Quality of Life Outcomes (2018) 16:94 Page 2 of 7

CVA [8]. Microvascular complications include neuropathy, medical diagnosis of dementia, schizophrenia, depression
retinopathy and nephropathy [9], as well as diabetic foot or any other psychiatric diagnosis that modified the results
syndrome [10]. These complications have an emotional and of the questionnaires and those who did not agree to par-
physical impact on affected individuals with DM2, causing ticipate in the study were excluded.
alterations in personal and family well-being. Because of Based on the results described with Zhang et al. [19],
the chronic nature of the disease and the difficulty in con- who analyzed multiple factors associated with the QoL
trolling it, DM can affect mood and self-esteem, generating in subjects with DM2, including age, sex, marital status,
frustration and symptoms linked to depression; further- duration of the disease, comorbidities and depression, all
more, restrictions on food and comorbidities in sexual life these variables impacted the QoL; however depression
can lead to conflicts and contribute negatively to the QoL presented the smallest difference in proportions, (depres-
of the patient [11, 12]. sion being in 27.9% of subjects with adequate QoL and in
QoL has become highly emphasized in recent years as 38.4% of subjects with inadequate QoL); before this, the
an important health care outcome. Medicine should aim sample size was calculated by a difference of proportions
for the preservation and restoration of both the health with an alpha of 5% and a power of 80%, leaving a total of
and the dignity of the patient [13]. Consequently, it 334 subjects per group, i.e., with and without depression.
should influence not only the quantity of life but also its A total of 1894 subjects were eligible to participate; how-
quality. QoL can be defined as a sense of well-being that ever, only 1540 patients met the inclusion criteria, of
encompasses the physical, psychological, social and spirit- whom 146 were excluded: 13 patients had a diagnosis of
ual condition [14]. When we refer to QoL in patients with dementia; 48 patients had depression and were awaiting
chronic diseases, we can define it as the overall evalu- evaluation by a specialist for initiation of pharmacological
ation that the subject makes of his life, which depends treatment; and 85 patients did not agree to participate.
both on the characteristics of the subject and on external The 1540 patients were given the questionnaires, and
factors [15]. upon completion, they were assessed to ensure that they
Multiple factors have been shown to modify the QoL were completed. Questionnaires that lacked an answer
in patients with DM2; the most prominent factors include were returned to the patients to complete them.
the presence of diabetes distress, medication adherence, The following variables related to QoL were studied:
depression symptomatology, longer duration of diabetes, age; sex; occupation; marital status; years of DM2 evolu-
use of insulin, marital status, and comorbidities among tion; presence of other comorbidities, such as obesity,
others [16–19]. systemic arterial hypertension, dyslipidemia and cardiac
For diabetes treatment to succeed, harmony must be conditions; and presence of depressive symptoms. Per-
achieved among the patient’s mental health, the emotional ceived QoL was measured with a health-related quality
environment of the family and the control of blood glu- of life (HRQoL) scale, the 36-Item Short-Form Survey
cose concentrations [20]. (SF-36). This scale consists of 11 questions with five op-
Although there are multiple studies where QoL has tions and evaluates 8 scales: physical function, physical
been analyzed in subjects with DM2, there are few studies role, physical pain, general health, vitality, social function,
conducted in developing countries, where sociocultural emotional role and mental health. Possible scores range
conditions can modify factors related to QoL, and large from 0 (no perceived QoL) to 100 (maximum perceived
number of subjects and factors related to the quality of life QoL). This scale has been validated in the Mexican popu-
can be assessed. Given this challenge, the objectives of our lation [22, 23].
study were to describe the QoL of patients with DM2 and Depressive symptoms were identified through the Beck
related factors that modify QoL. Depression Inventory, a self-administered instrument
validated for Spanish-speaking adults. Patients with de-
Methods pressive symptoms were defined as having a score ≥ 14.
A cross-sectional study was performed from 1st January In addition to identifying patients diagnosed with de-
2014 to 20th December 2014. The cohort included all pressive symptoms, we also classified the patients as
consecutive outpatients who were over 18 years old and having mild (score 14-19), moderate (score 20-28) or se-
diagnosed with DM2, as defined by the criteria of the vere (score ≥ 29) depressive symptoms [24].
American Diabetes Association (ADA); patients were se- Patients were classified into 4 groups according to
lected from five hospitals belonging to the Mexican Insti- their HRQoL scores: those with scores from 0 to 25
tute of Social Security (IMSS) in different cities in Mexico points, from 26 to 50 points, from 51 to 75 points and
(Tampico, Ciudad Juárez, La Paz, Torreón and Ciudad from 76 to 100 points. When the results of the 1394 ques-
Lerdo) [21]. Patients who knew how to read and write, tionnaires administered to the patients were analyzed,
had no physical limitations, and could answer the self- none had a score lower than 25. Therefore, we ultimately
administered questionnaire were included. Subjects with a analyzed them in 3 groups: Group A (inadequate HRQoL
Zurita-Cruz et al. Health and Quality of Life Outcomes (2018) 16:94 Page 3 of 7

[quartile 1 and 2]), scoring 0 to 50 points; Group B (ac- (quartile 1 and 2), acceptable (quartile 3) and optimum
ceptable HRQoL [quartile 3]), scoring 51 to 75 points; (quartile 4) QoL [25].
and Group C (optimum HRQoL [quartile 4]), scoring A multivariate linear regression was performed to con-
76 to 100 points. trol for confounding variables in the HRQoL scales that
In compliance with the Declaration of Helsinki, the presented the lowest scores in the patients studied (phys-
protocol was evaluated and approved by the National Re- ical function, emotional health, body pain and mental
search and Health Ethics Committee of IMSS with regis- health). A multivariate logistic model was built to control
tration number R-2013-781-052. The patients signed an for confounding variables. The association of factors with
informed consent letter. inadequate global HRQoL [26, 27] was determined using
odds ratios (ORs) and 95% confidence intervals (95% CIs).
All analyses were performed using SPSS version 12.0
Statistical analysis (Chicago, IL, USA).
The Shapiro–Wilk test was applied to determine the dis-
tribution of the quantitative variables, and they were all
found to be non-normally distributed. The variables are Results
presented as medians, minimum (min.) values and max- Of the 1394 patients included, there was no predomin-
imum (max.) values; qualitative variables are presented ance with respect to sex (49.9% female, n = 696), and the
as absolute numbers and percentages. median age was 62 years. Eighty-two percent (n = 1143)
The chi-squared test and the Kruskal–Wallis test were were married, and 41.6% (n = 580) of all subjects were
used for comparisons among the groups with inadequate housewives by occupation (Table 1).

Table 1 Comparison of demographic factor of diabetic patients by Quality of Life

Overall sample Quality of Life p
< 50 51-74 > 75
n = 1394 n = 690 n = 682 n = 22
n (%)
Sex Female 696 (49.9) 322 (46.7) 364 (53.4) 10 (45.5) 0.042
Male 698 (41.1) 368 (53.3) 318 (46.6) 12 (54.5)
Age (year)* 62 (28-77) 63 (38-77) 62 (25-76) 54 (26-78) 0.0001
Marital status Married 1143 (82) 593 (85.9) 529 (77.6) 21 (95.5) 0.001
Widower 109 (7.8) 52 (7.5) 57 (8.4) –
Single 80 (5.8) 26 (3.8) 53 (7.8) 1 (4.5)
Divorced 42 (3) 15 (2.2) 27 (3.9) –
Other 20 (1.4) 4 (0.6) 15 (2.3) –
Occupation Housewives 580 (41.6) 298 (43.2) 275 (40.3) 7 (31.8) 0.0001
Retired 454 (32.5) 299 (43.3) 154 (22.6) 1 (4.6)
Employee 205 (14.7) 37 (5.4) 157 (23) 11 (50)
Other 147 (10.5) 53 (7.7) 91 (13.4) –
Unemployed 8 (0.5) 3 (0.4) 5 (0.7) 3 (13.6)
Duration of diabetes(months) 240 (0-300) 252 (0-300) 132 (0-300) 72 (0-204) 0.0001
Number of morbidities 0 208 (14.9) 61 (8.8) 142 (20.8) 5 (22.7) 0.0001
1 766 (54.9) 369 (53.5) 388 (56.9) 9 (40.9)
2 187 (13.4) 87 (12.6) 97 (14.2) 3 (13.7)
3 218 (15.7) 165 (23.9) 48 (7.1) 5 (22.7)
4 15 (1.1) 8 (1.2) 7 (1) –
Depression No 352 (25.2) 70 (10.1) 263 (38.6) 19 (86.4) 0.0001
Mild 223 (16) 129 (18.7) 94 (13.8) –
Moderate 723 (52.9) 428 (62.1) 292 (42.8) 3 (13.6)
Severe 96 (6.9) 63 (9.1) 33 (4.8) –
"*" median (min-max)
Zurita-Cruz et al. Health and Quality of Life Outcomes (2018) 16:94 Page 4 of 7

With regard to DM2, the median duration of the dis- which indicates a poor HRQoL, and only 1.5% (n = 22) of
ease was 240 months, and up to 85.1% (n = 1186) of the patients had a score higher than 75, which indicates
patients presented comorbidity. Of the comorbidities an optimum HRQoL.
recorded, the most frequent was systemic arterial When analyzing the factors that could influence a pa-
hypertension (SAH), which occurred in 1044 patients tient’s HRQoL group (inadequate, acceptable or optimum)
(74.9%), followed by dyslipidemia in 380 patients (27.2%), , we found that sex, age, marital status, occupation, dur-
obesity in 233 patients (16.7%) and cardiac conditions in ation of diabetes, number of comorbidities and depressive
201 patients. According to the questionnaire applied, only symptoms were statistically significant. Regarding these
25.2% (n = 352) had no depression (Table 1). characteristics, Table 1 shows that the group with inad-
Out of a possible score of 100 points, which represents equate HRQoL (score less than 50) was older and had a
the optimum QoL, the median overall HRQoL score was greater duration of DM2, number of comorbidities, pro-
50.1 points, with a maximum of 75.5 and a minimum of portion of retirees and housewives, and prevalence of de-
28.6 points. When analyzing HRQoL by scales, we found pressive symptoms than the group with an acceptable
that physical function, emotional role, body pain and HRQoL (score greater than 75).
mental health had medians below 50 points, which indi- When all these variables were included in the logistic
cates that they are the most affected scales in this group regression model, only age and depressive symptoms
of patients (Fig. 1). were identified as independent factors influencing over-
After identifying the scales with the greatest effects, all HRQoL. Notably, depression (OR 4.4, 95% CI 2.03 to
we demonstrated that for physical function, the depressive 9.9) had a greater impact than age (OR 1.04, 95% CI
symptoms, age and duration of the DM2 had negative im- 1.0008 to 1.09) on HRQoL (Table 3).
pacts, while marital status (married) improved the score;
for emotional health, the depressive symptoms, age, dur- Discussion
ation of diabetes and number of morbidities had negative Main findings of the study
impacts; for body pain, the depressive symptoms and In general, patients with DM2 had inadequate HRQoL,
number of morbidities had negative impacts; and for the of which the most affected scales were physical function,
mental health scale, the depressive symptoms, duration of emotional health, body pain and mental health. Depres-
diabetes and number of morbidities had negative effects. sion was the factor that had the greatest impact on inad-
In all the scales analyzed, the depressive symptoms had equate HRQoL.
significant negative effects on QoL and had the strongest This is one of a few recent studies investigating the
effects on the physical and emotional scales (Table 2). population with DM2 that included a large number of
When separating patients into groups according to the subjects, in which demographic factors affecting the
HRQoL score, we observed that almost half of the patients HRQoL were associated (multivariate analysis); in
(49.4%, n = 690) had a QoL score lower than 50 points, addition, it did not show that sex affected global HRQoL

Fig. 1 Median observed HRQoL (SF-36) dimension value

Zurita-Cruz et al. Health and Quality of Life Outcomes (2018) 16:94 Page 5 of 7

Table 2 Multivariate linear regression analysis of factors Table 3 Multivariate logistic regression analysis of factors
associated to health-related quality of life in the modules associated to bad quality life in patients with type 2 diabetes
physical function, emotional role, body pain and mental mellitus
health in patients with type 2 diabetes mellitus Factor OR 95% CI p
Factor β 95% CI p Depressive symptoms 4.4 2.03-9.9 0.0001
PHYSICAL FUNCTION Sex 0.75 0.29-1.94 NS
Depressive symptoms −9.3 −10.5 to −8.01 > 0.001 Age (year)* 1.04 1.0008-1.09 0.017
Sex 1.78 −0.71 to 4.2 NS Marital status 2.06 0.93-4.4 NS
Age (year)* −0.47 −0.6 to −0.33 < 0.001 Occupation 1.11 0.77-1.6 NS
Marital status 2.86 1.65 to 4.06 < 0.001 Duration of diabetes(months) 0.99 0.99-1.005 NS
Occupation 0.72 −0.23 to 1.68 NS Number of morbidities 0.82 0.54-1.26 NS
Duration of diabetes(months) − 0.1 − 0.11 to − 0.08 < 0.001 "*" median (min-max)
Number of morbidities − 0.82 −1.99 to 0.35 NS
EMOTIONAL ROLE educational level, lower income and belonging to the fe-
male sex were associated with poor QoL in people with
Depressive symptoms −11.6 −13.8 to −9.4 < 0.001
diabetes [31].
Sex −1.17 −5.4 to 3.07 NS
The identified factors impacting QoL, such as older
Age (year)* −0.72 − 0.95 to − 0.5 < 0.001 age and depression, impact glycemic control, which could
Marital status 2.13 − 0.01 to 4.17 NS be an added factor that deteriorates QoL [32]. Another
Occupation 0.43 −1.19 to 2.05 NS important factor is that patients with DM2 often feel chal-
Duration of diabetes(months) −0.04 − 0.06 to − 0.02 < 0.001 lenged by their illness and the related demands on a daily
basis, which also impacts their perception of QoL [33].
Number of morbidities −8.56 −10.5 to −6.57 < 0.001
Several studies have shown that the presence of co-
BODY PAIN
morbidities decreases the QoL of patients with diabetes;
Depressive symptoms −4.75 −3.44 to −6.05 < 0.001 for example, Wermeling et al. evaluated 2086 patients
Sex −2.47 −5.01 to 0.05 NS with DM2 in the Netherlands and found that those with
Age (year)* 0.21 −0.07 to 0.35 NS comorbidities had a significantly lower health status than
Marital status 0.57 −0.34 to 1.8 NS those without comorbidities [34]. In contrast, a study
conducted in Singapore failed to find such an association
Occupation 1.59 −0.21 to 2.56 NS
[35]. Factors such as the time course of diabetes and the
Duration of diabetes(months) −0.01 −0.03 to 0.01 NS
use of insulin have also been negatively associated with
Number of morbidities −5.62 −4.43 to −6.81 < 0.001 QoL. In the present study, 85.1% of patients with DM2
MENTAL HEALTH presented at least one non-psychiatric medical comorbid-
Depressive symptoms −0.82 − 0.17 to −1.48 0.013 ity; however, in the multivariate analysis, these comorbidi-
Sex 0.45 −0.81 to 1.71 NS ties were not found to impact QoL. Although we did not
observe an effect, it is important that health care providers
Age (year)* 0.06 −0.004 to 0.13 NS
take special care in managing the comorbidities of DM2,
Marital status 0.65 −0.04 to 1.26 NS
as other studies have shown that QoL worsens and that
Occupation −0.18 −0.67 to 0.29 NS survival drastically decreases as the number of comorbidi-
Duration of diabetes(months) −0.01 −0.02 to − 0.01 < 0.001 ties increases [36].
Number of morbidities −1.11 − 0.51 to − 1.7 < 0.001 Furthermore, the results of the present study suggest
"*" median (min-max) that depression is common among patients with DM2
and is associated with the perception of a poor QoL;
or physical function, emotional health, body pain and depression should be screened for in these patients, es-
mental health [16, 28]. pecially older patients, who face greater risks related to
The determination that patients with DM2 present the lack of motivation and emotional exhaustion [19, 37].
low HRQoL coincides with previously published results Depression and diabetes interact so closely that it is dif-
in which DM2 had a negative impact on QoL, mediated ficult to identify which pathology begins first; the diagno-
by factors such as the need for a strict dietary plan, exer- sis of DM2 causes mourning for the loss of health, which
cise and a specific treatment regimen [29, 30]. The find- favors the evolution of depression, and a depressed state
ings in the literature regarding the QoL of patients with can promote poor eating habits [38]; that is, depression in-
DM2 and its association with sociodemographic factors terferes with the ability to initiate healthy life patterns and
have been variable. Previous reports found that lower mitigate risk at the onset of DM2. Emphasis should be
Zurita-Cruz et al. Health and Quality of Life Outcomes (2018) 16:94 Page 6 of 7

placed on the need to better understand any overlap be- Conclusions

tween depression and difficulty in adhering to pharmaco- In general, patients with DM2 have inadequate QoL.
logical treatment and changes in lifestyle. The factors related to QoL include depression, and older
The psychological and pharmacological treatment of patients with depression showed a greater deterioration
depression in subjects with diabetes is associated with in HRQoL.
significant clinical improvements. Such improvements The results of this study indicate that it is essential to
occur not only in mood but also in adherence to diet support DM2 patients by implementing integral manage-
and treatment regimens for DM2, thereby impacting ment strategies with support groups.
glycemic control, reducing chronic complications and
Abbreviations
improving QoL [38]. ADA: American Diabetes Association; AMI: Acute myocardial infarction;
The high incidence of elevated depressive symptoms CHF: Congestive heart failure; CVA: Cerebrovascular accident; DM2: Type 2
in the sample may be because depressed patients have diabetes mellitus; HRQoL: Health-related quality of life; IMSS: Instituto Mexicano
del Seguro Social; PAD: Peripheral artery disease; QoL: Quality of Life
an increased risk not only for diabetes but also for meta-
bolic syndrome, which is sometimes defined as pre- Funding
diabetes [39]. Therefore, it is possible that there is a The authors would like to thank AstraZeneca for their financial support in
bidirectional association between depression and dia- professionally translating this article to English for publication.
betes, i.e., depression can increase the risk for metabolic
Availability of data and materials
risk factors that subsequently develop into DM, which The datasets used and/or analyzed during the current study are available
increases the risk for mental health status impairment from the corresponding author on reasonable request.
and poor QoL.
Authors’ contributions
Management of DM2 is complicated by psychosocial JNZC analyzed and interpreted the data and wrote the article. LMA wrote
challenges, and it is important to recognize the potential the article. MLAF wrote the article. AGG analyzed and interpreted the data.
influence of depression and the deterioration of QoL in AGNA provided critical review for important intellectual content, wrote the
discussion and approved the final version of the article. NCS designed the
the prognosis and management of the disease, as evidenced study design and acquired information. All authors read and approved the
by the results of this and other studies [38, 40–42]. Add- final manuscript.
itionally, for better control and monitoring of the disease, a
combination of effective activities should be implemented Ethics approval and consent to participate
In compliance with the Declaration of Helsinki, the protocol was evaluated
to improve self-care [40]. and approved by the National Research and Health Ethics Committee of
Consequently, identifying the epidemiological profile IMSS with registration number R-2013-781-052.
and factors associated with QoL in these patients will
Competing interests
contribute to the design of a comprehensive program
The authors declare that they have no competing interests.
that includes interventions for effective self-care, promo-
tion of the correct use of medicines and promotion of
healthy individual and collective conditions. Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
However, depression is not a DM-specific risk factor published maps and institutional affiliations.
for impaired QoL as it is reproducible across different
Author details
patient populations. Depression was documented as an 1
Unit of Research in Medical Nutrition, Pediatric Hospital “Centro Médico
important predictor of impaired QoL across non-DM Nacional Siglo XXI”, Instituto Mexicano del Seguro Social (IMSS), Mexico City,
patient populations, such as patients with brain tumors Mexico. 2Endocrine Research Unit, Centro Medico Nacional, Instituto
Mexicano del Seguro Social (IMSS), Mexico City, Mexico. 3Computer Research
and older persons [43, 44]. Center of Instituto Politecnico Nacional, Mexico City, Mexico. 4Division of
One limitation of the study was the type of design, Prenatal Care and Family Planning Instituto Mexicano del Seguro Social
which, being a transversal study, could not identify (IMSS), Mexico City, Mexico. 5Epidemiological Surveillance Coordination,
Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico.
the relationship between depression and poor per-
ceived QoL, and we could not ascertain which came Received: 23 August 2017 Accepted: 19 April 2018
first. In addition, the study did not analyze QoL ac-
cording to the presence of chronic complications
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