ISSN- 0301-1216 Indian J. Prev. Soc. Med. Vol. 45 No. 1-2, 2014 EFFECT OF SOCIAL FACTORS ON GLYCEMIC CONTROL OF PATIENT WITH DIABETES MELLITUS Mousumi Bhattacharya, 1 Shashi Rani Agrawal, 2 Saurabh Singh, 3 CP Mishra, 4 SK Singh 5 ABSTRACT Background: Transition in life style and economic growth are considered responsible for the rising trend of diabetes mellitus. Psychological factors might be playing important role in the genesis of type-2 diabetes mellitus. Objective : (a) To find out socio-economic background of patients with diabetes and their level of awareness about the disease, (b) to assess psychosocial stress of patients with diabetes mellitus, and (c) to retrieve information regarding cultural resources and life style. Methods: A total of 350 patients with type 2 diabetes mellitus attending tertiary referral hospital for treatment and living in urban area of Varanasi since the previous generation constituted the material of the study. After informed consent they were interviewed with the help of pre-designed and pretested interview schedule. Conclusion: The study adds to the knowledge about population susceptibility for development of diabetes, which of significance in planning any activity to prevent diabetes. The mean age of type 2 diabetes mellitus patient years was 50.97±9.74 years, mean age SD was 53.50 ±9.51 years in males and 47.50 ±8.97 years in females, the difference was highly significant (t=6.16, p<0.001). Diabetes was maximum (43.99%) in people with higher education. Maximum (35.43%) patients considered stress or hypertension as the main cause of the disease followed by the heredity. It was observed that 46% of male patients had reduction in the blood glucose while 36.67% of female patients had lowering of the blood glucose. Stress factors like death of spouse/close relatives/children is 2.53 times more in the patients with uncontrolled glycemia. The striking observation is the occurrence of diabetes mellitus in females earlier than males. Key words: Glycemic control, Life style, Psychosocial stress. INTRODUCTION Diabetes mellitus is a heterogonous disorder characterized by hyperglycemia due to insulin deficiency or defect in its action. Heterogeneity of presentation led to classification of the disease from time to time. The most common type is type 2 DM in the adult population and its prevalence is on rise over the last decade. Though this disease is in epidemic proportion globally but developing world have unique distinction of increase in the prevalence of the disease. 1 Transition in life style and economic growth are considered responsible for the rising trend of diabetic mellitus. 1. Research Scholar, Department of Sociology, Women s College, Banaras Hindu University 2. Professor, Department of Sociology, Women s College, Banaras Hindu University 3. Ex-Resident, Department of Community Medicine, IMS, BHU. 4. Professor, Department of Community Medicine, IMS, BHU. 5. Professor, Department of Endocrinology & Metabolism, IMS, BHU Corresponding Author: Dr Mousumi Bhattacharya, D-35 / 240, Jangambari, Varanasi 221 001 Indexed in : Index Medicus (IMSEAR), INSDOC, NCI Current Content, Database of Alcohol and Drug Abuse, National Database in TB and Allied Diseases, IndMED, Entered in WHO CD ROM for South East Asia.
It is projected that by year 2030, 354 million people will suffer from diabetes all over the world 2. This has been recognized that food habit, physical inactivity and irregular sleep pattern, (insomnia) favor development of diseases, like diabetes, hypertension and obesity. The impact of psycho-social stress on various diseases has been identified but data on its impact on diabetes are very scant. 3 The psychological factors might be playing important role in the genesis of type 2 DM but its direct and indirect impact is difficult to quantify in individual patient with diabetes mellitus. 4 The present study has been designed with the objectives of: (a) Finding the socio-economic background of the patients with diabetes, (b) Awareness of diabetes in subjects towards their disease, (c) Assessment of psycho-social stress of the patients with diabetes mellitus, (d) Retrieve information regarding cultural resources and life style. MATERIAL & METHODS A total of 350 patients with type-2 diabetes mellitus attending tertiary referral hospital for treatment were selected for the study. Patients living in the urban area of Varanasi District since their previous generation were included' after informed consent. The patients were interviewed and the findings were noted on the proforma. The interview schedule included items conforming to the requirements of the objectives of the study. OBSERVATION The total number of patients with type 2, DM included in the present study was 350 (200 males and 150 females). The maximum patients were in the age range of 51-60 years followed by 41-50 years (Table 1). Maximum male patients were in the age range of 51-60 years followed by more than 60 years where as female patients (42.00 %) were in the age range of 41-50 years followed by the age range of 51-60 years. The mean age of type 2DM patient was 50.97 years (±9.74 SD), mean age was 53.50 (±9.51SD) years in males and 47.50 (±8.97 SD) years in females. The difference was highly significant (t=6.16, P< 0.001). Table -1 : Age and Sex distribution of patients with diabetes mellitus Age in years No. % No. 0-10 No. 0-10 <40 20 10.00 32 21.33 52 14.86 41-50 46 23.00 63 42.00 109 31.14 51-60 76 38.00 41 27.33 117 33.43 > 60 58 29.00 14 9.33 72 20.57 Total 200 100.0 150 100.0 350 100.0 Mean + SD 53.60 9.51 47.50 8.97 50.97 9.74 Male Vs. Female t=6.16; df=348; p<0.001 (highly significant) Diabetes was maximum (43.99%) in people with higher education followed by the people with secondary education (table 2). The lowest proportion of patients was from illiterate group. The prevalence of diabetes according to educational status was statistically significant ( 2 = 34.35, P< 0.001). Educational status Table-2: Educational levels in male and female with diabetes Illiterate 4 2.00 21 14.00 25 7.14 Primary 28 14.00 41 27.33 69 19.71 Secondary 54 25.00 48 32.00 102 29.13 Higher Education 114 56.55 40 26.66 154 43.99 Total 200 100.0 150 100.0 350 100.0 2= 34.35; df=3; p<0.001 Indian J. Prev. Soc. Med Vol. 45 No. 1-2 116
Maximum (35.43%) patients considered stress or hypertension as the main cause of the disease followed by the heredity (table 3). The response in male and female patients was different. According to the male patients the tension or stress was reported as main cause (42.00%)" followed by the excess food consumption (24.50%) where as in female patients the main cause was heredity (39.33%) followed by the tension or stress (26.67%) (Table-3). Table-3: Patients views as regard to the cause of diabetes in male and female patients with diabetes. Cause of Diabetes Hereditary 39 19.50 59 39.33 98 28.00 Food 49 24.50 20 13.33 69 19.71 Tension 84 42.00 40 26.67 124 35.43 Job 28 14.00 31 20.67 59 16.86 2= 25.41; df=3; p<0.001 Maximum number of diabetic patients (38.00%) had annual income of 51-100 thousand (table 4). Similar pattern was also observed in both the sexes i.e. 34.50% male patients and 42.67% female patients were from above income group. The mean of annual income was rupees 115.429 ( 319.506 SD) thousand. It was 120.790 ± 2988.295 thousand per annum in males andl08.333 C± 303.319 SD) thousand per annum in females. The difference of income between male and female patients was not significant (t = 0.386, P > 0.05). Table-4: Distribution of patients with diabetes in different income groups Income groups (Rs. in thousand/ annum) <50 26 13.00 26 17.33 52 14.88 51-100 69 34.50 64 42.67 133 38.00 101-150 38 19.00 22 14.67 60 17.14 151-200 30 15.00 10 6.67 40 11.43 >200 37 18.50 28 18.66 65 18.57 Mean average income SD (in thousands) 120.79 ± 293.30 108.33 ±303.34 115.43 ±319.53 Male Vs. Female t = 0.386, df = 348, p> 0.05 Blood glucose decreased in two fifth (42.00%) of the total patients whereas in 38.29% of the patient's blood glucose increased during the treatment (table 5). It was observed that 46% of male patients had reduction in the blood glucose while 36.67% of female patients had lowering of the blood glucose. Table-5: Sex distribution of patients with diabetes and change in blood glucose during treatment Change in the plasma glucose Normal 40 20.00 29 19.33 69 19.71 Decrease 92 46.00 55 36.67 147 42.00 Increase 68 34.00 66 44.00 134 38.29 Total 200 100.00 150 100.00 350 100.00 2 = 4.05; df=2; p<0.05 Interestingly 44% of female patients had increase in blood glucose during treatment and only 34% of male patients had increase in the blood glucose. The difference in the response of blood glucose during treatment was not significant (p <0.05). Indian J. Prev. Soc. Med Vol. 45 No. 1-2 117
Stress factors like death of spouse/close relatives/children is 2.53 times more in the patients with uncontrolled glycemia (table 6). Similarly excessive responsibility is 1.82 times higher in the patient with uncontrolled blood glucose. Distrust is 1.68 times more in uncontrolled group. Prolonged illness of spouse/ children/ family members/themselves is affecting the uncontrolled group of patients 2.15 times more than the controlled groups. The stress of paying dowry for the marriage of their daughter is 2-20 times more in the patients of uncontrolled group. The relationships with these stress factors and the blood glucose level of the patients was statistically significant. Table- 6 : Effect of social factors on glycemic control of patients with diabetes Odds Social Factors Uncontrolled Controlled 950% of CI Significant Ratio Unprecedented happening in the family 54 49 1.35 0.83-2.20 Non- significant Death 35 18 2.53 1.35-4.76 Significant Responsibility 91 79 1.82 1.12-2.97 Significant Property dispute 48 23 3.01 1.69-5.31 Significant Use of Leisure time 20 39 0.49 0.27-0.89 Significant Distrust 69 57 1.68 1.05-2.69 Significant Disrespect & Ignorance 19 46 0.36 0.21-0.66 Significant Diseases 95 08 2.15 1.32-3.53 Significant Unemployment 36 60 0.53 0.32-0.88 Significant Habituation 10 15 0.71 0.31-1.65 Non- Significant Dowry 33 19 2.20 1.19-4.09 Significant Strained in Laws relations 16 12 1.53 0.69-3.39 Not Significant DISCUSSION The prevalence of diabetes mellitus is rising fast all over the world and more so in the developing countries. The change in the food' habit, physical inactivity, and stressful life style are contributory factors for rise in the prevalence of diabetes mellitus The effect of psychosocial stress on the development of this disease has also been identified but actual impact has not been well studied. 5 The psychosocial factors are valuable for different population with different culture. In our study, patients with diabetes were in age range 40-60 years. The striking observation is the occurrence of diabetes mellitus in females earlier than males. Most of the female patients developed diabetes at 40 years of age and males after 50 years of age. Our results are similar to the report of W.H.O.(6) and Patel & Srivastava from our own country (7-8). After interrogation most respondents agreed that it was heredity that causes diabetes but most male Effect of Social factors on Glycemic Control of Patient with Diabetes Mellitus patients considered stress and anxiety as main cause of the disease. Our results are similar to the report of World Health Organization In urban Indians with diabetes (male 44 and female AO years). The other study conducted on patients with diabetes in Australia, Diabetics were in age range of 50-79 years. Majority of male patients had higher education while the females' educational levels were up to intermediate in most of them. This reflects educational status of the population in general and not of diabetic subjects only. 6 Maximum number of patients belonged to middle income group. This might be because the data was collected from a referral hospital, and patients from lower and middle class income attend such hospital. The upper income group patients prefer to go to private doctors and clinics. Another interesting observation was that male patients with diabetes had better control of plasma glucose than female patients. Female patients were less compliant to treatment than male patients. Indian J. Prev. Soc. Med Vol. 45 No. 1-2 118
Approximately 35.43% of the respondents accepted that the stressor of modem life style is the main reason for developing diabetes. Ramesh Kumar (1991) 8 also opined that stress is the first and foremost reason in the occurrence of diabetes. Similarly while describing the contribution and environmental factors of the diabetes Park (1994) 9 also stated that internal and external tensions were the main causes of diabetes. association. 10 Most of the patients with diabetes in our study alleged their stress full life style as apparently it was an Stress was considered to be the important factor to cause diabetes in the text book of social preventive medicine by Park (1994). 9 The various factors responsible for psychological stress were death, property dispute, distrust, unemployment, dowry, social responsibility. Some of the factors like stressed in-laws relations, unprecedented happening in the family and habituation were not statistically significant in diabetic patients. In the present paper an attempt has been made for drawing the information related to the stress factors responsible for the status of diabetes mellitus With the help of interview schedule it was tried to explore stressors. The stress due to sudden death in the family, excessive family responsibility, property dispute, facing distrust, disrespect and ignorance of family members, unemployment and dowry were found to be the significant factors. Thus it can be concluded that unhealthy family environment, relationship and excessive family responsibility like paying dowry or bearing the expenses of prolonged illness of spouse/patients/children are the main source of stress among diabetes mellitus patients. In conclusion, this study suggested that diabetes is more prevalent in the middle income group related to the education status of the patients and not to income. Knowledge and awareness towards the diseases were more among the male than females. Males were more compliant to treatment than females. The stress in the life appeared more associated with increase prevalence of diabetes. The common significant stresses were death, responsibility and property dispute. Use of leisure time, distrust and disrespect, diseases in the family unemployment and dowry strained in-law relations; unprecedented happening in family and habituation did show significant relationship with occurrence of diabetes mellitus. This adds to the knowledge about population susceptibility for development of diabetes and which may be given importance while planning any activity to prevent diabetes. REFERENCES 1. King H. Rewers M. WHO Ad Hoe Diabetes Reporting Group, Global estimates for prevalence of diabetes mellitus and impaired glucose tolerance in adults. Diabetes care 1993; 6:157-177. 2. King H. Aubert RE, Herman WH. Global burden of diabetes, 1995-2025: Prevalence, numerical estimates and projections. Diabetes care 1998; 21: 1414-31 3. Gupta R, Misra A. type 2 Diabetes in India: Regional Disparities. Br J Diabetes Vasc Dis. 2007:7(1): 12-16. 4. Houson CL, Pichert JW. Perceived stress and diabetes control ill adolescent health. Psychology 1986; 5 : 439-452. 5. Surwit RS Sneider MS, Feinglos MN. Stress and diabetes mellitus. Diabetes care 1992; 15: 1413-1422. 6. World Health Organization, diabetes Mellitus. Report of WHO study group Technical report series 727. Geneva; World Health Organization, 1985. 7. Patel HS, Srivastava BN. NIDDM- Patterns of mortality and morbidity, J Assoc Phys India 1990; 38: No.1. 8. Ram chandran A, Snehlata C, Kapoor A et al. High prevalence of diabetes and impaired glucose tolerance in India: National Urban diabetes Survey. Diabetologia 2001; 44:1094-101 9. Text book of Preventive and Social Medicine Park J E.(Ed) 18 th edition Ms. Banarsidas Bhanot Pub., 2007. pp. 271. 10. Lehman CD, Rodin Mc Ewen B, Brinton R. Impact of environmental stress on the expression of insulin dependent diabetes mellitus. Behavioral Neuroscience 1991; 105:241-245. ---- Indian J. Prev. Soc. Med Vol. 45 No. 1-2 119