Quality of Life and Metabolic Indicators of Patients with Type 2 Diabetes: A Cross-Sectional Study in Iran

Background The World Health Organization (WHO) has considered type 2 diabetes mellitus (T2DM) a major global health challenge because of its high prevalence worldwide. T2DM can affect patients' personal, social, and economic statuses. On the other hand, due to the increasing prevalence of T2DM, Quality of Life (QOL) has received more attention in recent years. Objective The present study was conducted to investigate the relationships between QOL and physical activity level, body mass index, fasting blood sugar, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglyceride, total cholesterol, HbA1c, and systolic and diastolic blood pressure among Iranian patients with uncomplicated T2DM. Methods This cross-sectional study was conducted on 135 participants selected through consecutive sampling. The study data were collected using International Physical Activity Questionnaire and Short-Form Health Survey Questionnaire. Then, the data were entered into the SPSS ver. 28 software, and Pearson's correlation was used to measure the correlation between the variables. Linear regression was also employed. The significance level was set at 0.05. Results The significant association was observed between gender (p = 0.007), HDL level (p = 0.02), and gender-adjusted physical activity (p = 0.002) with QOL. Conclusions Due to the association between physical activity and HDL level with QOL in patients with uncomplicated T2DM, they should be given the necessary training to improve their physical activity and regulate HDL level. Also, empowering them in this matter improves their QOL.


Introduction
Te World Health Organization (WHO) has considered type 2 diabetes mellitus (T2DM) a major global health challenge due to its high prevalence worldwide [1]. Tere are currently more than 423 million patients [2], the majority of whom live in developing countries [3]. Based on the World Health Report, the prevalence of T2DM in adults has been expected to increase by 64% between 1995 and 2045 (from 135 million to 628 million) [4]. Accordingly, there will be a 42% increase from 51 to 72 million in developed countries and a 170% increase from 84 to 228 million in developing countries. Tus, the proportional increase will be greater in developing countries [2,5,6]. In Iran, the prevalence of T2DM is approximately 11.9%. It has also been estimated that 9.2 million patients will sufer from T2DM by 2030 [7].
Studies performed in Iran and some other countries have indicated that T2DM negatively infuences the patients' Quality of Life (QOL) [8][9][10][11][12]. T2DM is, in fact, a costly health problem for patients and the healthcare system that is detected in all age groups and countries [2]. It can afect the personal, social, and economic statuses of patients, increase the prevalence of chronic diseases and dissatisfaction with life, and decrease the QOL. In addition, boring treatments as well as disabling and life-threatening complications of T2DM can afect patients' physical, psychological, and social health, i.e., QOL [13][14][15][16]. Since patients' QOL may boost their metabolism [17], more attention should be paid to the key determinants of Health-Related QOL (HRQOL) to identify and implement appropriate policies to achieve better T2DM management and improve the patients' QOL [8]. In this context, it is necessary to determine how T2DM afects patients' QOL since improving the QOL is among the most important goals of healthcare systems [18].
Tus, the present study aims to investigate the relationships between QOL and physical activity level, BMI, FBS, HDL, LDL, triglyceride, total cholesterol, HbA1c, and systolic and diastolic blood pressure among Iranian patients with T2DM.

Study Design, Setting, and Period.
Tis cross-sectional, comparative study was conducted on the participants selected through consecutive sampling of patients with T2DM who had active medical records in Mobarakeh Diabetes Clinic afliated with the Social Security Organization during January-March 2019.

Sample Size Determination and Study Participants.
Te sample size was estimated at a confdence interval of 95% (z 1− (∝/2) � 1.96) with an acceptable error (d) of 1.85 (3% mean: 61.90) and a standard deviation (σ) of 7.50 for the Quality of Life of Iranian patients with T2DM [23,24]. Ten, 135 were included in the study due to the probability of not completing the questionnaires. Te inclusion criteria were (1) no mental retardation and (2) writing and reading literacy, and the exclusion criteria included sufering from (1) other diseases or disorders such as cancer, multiple sclerosis, arthritis, dementia, and depression and (2) complications such as diabetes-related neuropathy and nephropathy.

Data Collection.
Te data including metabolic indices, FBS, HDL, LDL, triglyceride, total cholesterol, and HbA1c were extracted from the patients' medical records within 30 days before the survey. Other data including weight and height for estimated BMI and blood pressure were recorded by a specialist on the day the patients attended the clinic for care and treatment. Ten, the questionnaires were completed in a separate room within 30 minutes.

Data Collection Tools.
Te data were collected using the three self-administered questionnaires: the demographic characteristics questionnaire, the Persian version of the International Physical Activity Questionnaire (IPAQ), and the Persian version of the Short-Form Health Survey Questionnaire (SF-36) [25,26].

Te Demographic Characteristics
Questionnaire. It consists of four questions about age, gender, education level, duration of T2DM, and medication treatment of T2DM.

Te Persian Version of the International Physical
Activity Questionnaire (IPAQ). Tis 21-item questionnaire was used to measure the level of physical activity. Tis instrument classifes the persons in three groups with low(not meeting medium or high criteria), medium (≥ 600 < 3000 MET-minutes per week), and high (≥ 3000 MET-minutes per week) physical activity. Te ICC exceeded 0.7. In addition, the Spearman-Brown correlation coefcient was reported to be 0.9.

Te Persian Version of the Short-Form Health Survey
Questionnaire . Tis tool was used to evaluate HRQOL. Cronbach's α coefcients ranged between 0.77 and 0.90 except for the vitality scale (α � 0.65). Convergent validity showed that all correlations above 0.40 ranged between 0.58 and 0.95. Factor analysis identifed two principal components that jointly accounted for 65.9% of the variance. Te original versions of both questionnaires were used for scoring [27,28].

Data Processing and Analysis.
After completing the questionnaires, the data were extracted and analyzed using the SPSS ver. 26 software [29]. Descriptive statistics, such as frequency, mean, and standard deviation, were used to describe the variables. In addition, Pearson's and Spearman's correlation, independent samples T-test, and one-way ANOVA were used to measure the correlation and relationship between the variables. Linear regression was performed and boxplot was drawn to explore the association between the variables. Te signifcance level was set at 0.05.

Te Demographic Characteristics.
Te mean age of the 135 participants was 58.02 ± 9.4 years, and the mean duration of the disease was 8.81 ± 6.11 years. Furthermore, the majority of them were females and the minority of them had a university education and no medication treatment for diabetes (Table 1).

Te Status of Physical Activity and HRQOL.
Te mean level of physical activity of participants was 1625.68 ± 1230.30 MET-min/week, and the majority of them were engaged in moderate physical activities (Table 1). Additionally, the mean level of HRQOL was 54 ± 27.63 (Table 2).

Te Level of BMI and Metabolic Indicators.
Te mean level of BMI, FBS, HDL, LDL, triglyceride, total cholesterol, HbA1c, and systolic and diastolic blood pressure of participants was within the normal range (Table 2).

Te
Association between HDL Level, Physical Activity, Gender, and HRQOL. Te results of multiple linear regression between gender, physical activity, and HDL level with HRQOL that were signifcant in Pearson's analysis are presented in Table 5. Accordingly, gender (p � 0.007) and HDL level (p � 0.02) were associated with QOL, so that its level was higher in males and lower in the group with HDL level >60 mg/dL (p � 0.03) (Figures 1 and 2). After adjusting physical activity for gender (p � 0.002), the association between it and HRQOL was demonstrated ( Figure 3). According to Figure 4, men's physical activity was more intense than women's physical activity.

Discussion
Improving QOL is among the most important goal of the healthcare system; thus, it is important to investigate how diabetes afects patients' QOL [30,31]. In the present study, a signifcant association was observed between HDL level >60 mg/dL and lower HRQOL, which was inconsistent with the results of Xepapadaki et al. [22], while some studies have shown that higher consumption of HDL is related to improved cardiovascular function, and lower consumption is associated with mental and cognitive disorders and subsequently better QOL. [32-34b32b33b34. In other studies, the high level of HDL was not confrmed as a protective factor for cardiovascular diseases, and the quality of HDL's function may be more important than its quantity for this matter [35,36]. Hence, future research studies are needed to explore these relationships.  International Journal of Endocrinology

International Journal of Endocrinology
Te present study showed no signifcant correlation between FBS, HbA1c, blood pressure, cholesterol level, and HRQOL, while other studies showed signifcant correlations using the 5-levelEuroQoL-5 dimensions (EQ-5D-5L) questionnaire or World Health Organization Quality of Life (WHOQOL-BREF) short-form questionnaire [21,37,38]. Te diference in this correlation between the studies could be attributed to utilizing diferent questionnaires with diferent number of questions in the extent of dimensions on the relevant topic.
Another fnding of our study was the association between male gender and higher HRQOL. Similarly, Castellano-Guerrero et al. and Huebschmann et al. had shown this relationship [39,40]. It seems that the sociocultural and health behavior diferences between men and women could be a reason for it.
In addition, the fndings of the present study showed a signifcant association between the total score of HRQOL and the gender-adjusted physical activity, which was supported by Tiel et al.'s study [41]. Similarly, Xu et al. revealed a signifcant positive correlation between physical activity and QOL in patients with T2DM [42]. It should be noted that the best type of physical activity for people with T2DM is aerobic exercise, especially if it is done daily [43,44]. Tis fnding warns us to adopt appropriate supportive policies to improve education and provide environmental support for promoting physical activity in society, especially among women.
According to the fndings of the present study, similar studies are recommended to be conducted on patients with chronic diseases in diferent age groups and populationbased sampling methods. Te results of this study can be efective in improving educational methods, as an efective factor in patients' self-management of chronic diseases.
Te present study had some limitations including incomplete questionnaires, difculties in having access to patients, and patients' low literacy levels that caused difculties in completing the questionnaires. Other limitations were conducting the study in only one center, volunteer sampling, and data collection through self-report that could afect the generalizability of the results. In addition, the results might have been afected by personality diferences and the lack of a healthy control group.

Conclusion
Te results of the present study show that performing physical activity and regulating HDL levels could improve HRQOL in patients with T2DM. Terefore, according to the status of these factors in them, appropriate health programs such as self-directed group physical activity, team sports, and recreational sports, such as mountain climbing should be implemented to improve their QOL.

Data Availability
Te data used to support the fndings of this study are available from the corresponding author upon request.

Ethical Approval
Ethical approval was acquired from the Research Ethics Committee (REC) of Shiraz University of Medical Sciences (SUMS) under approval ID: IR.SUMS.REC.1397.621, in 2018. All of the methods were performed in accordance with the relevant guidelines and regulations.

Consent
Written informed consent was obtained from participants.

Conflicts of Interest
Te authors declare that they have no conficts of interest.

Authors' Contributions
MHK supervised all of the processes from registering the project proposal until fnal editing of the manuscript as a supervisor. KN collected the data. KH analyzed the data and wrote the manuscript. MN participated in correcting the title of the project, choosing the instrument, and conducting the study as an advisor. All authors read and approved the fnal version of the manuscript.   International Journal of Endocrinology