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© Borgis - Postępy Nauk Medycznych 2/2017, s. 60-65
*Anna Duda-Sobczak, Dorota Zozulińska-Ziółkiewicz, Bogna Wierusz-Wysocka
Socioeconomic, psychological and health-related correlates of fatigue in adults with longstanding type 1 diabetes**
Socjoekonomiczne, psychologiczne oraz związane ze zdrowiem wykładniki zmęczenia u osób dorosłych z długim wywiadem cukrzycy typu 1
Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences
Head of Department: Professor Dorota Zozulińska-Ziółkiewicz, MD, PhD
Wstęp. Cukrzyca typu 1 jest chorobą przewlekłą wymagającą stałej insulinoterapii. Konieczność dopasowania zasad leczenia do aktualnego stylu życia może stanowić źródło napięcia emocjonalnego i zmęczenia.
Cel pracy. Celem badania była ocena czynników warunkujących zmęczenie u osób z długim wywiadem cukrzycy typu 1.
Materiał i metody. Do badania włączono 285 osób (151 kobiet); mediana wieku 43 lata [rozstęp międzykwartylowy (IQR): 34-52], czas trwania cukrzycy ponad 20 lat, HbA1c 7,8% (IQR: 7,1-8,9). Wykluczono osoby z rozpoznanymi przewlekłymi powikłaniami powodującymi niesprawność. Pacjenci wypełniali kwestionariusz zawierający pytanie: „Czy jest Pani/Pan zmęczona/y życiem z cukrzycą?” oraz Kwestionariusz Obszarów Problemowych w Cukrzycy (PAID), Kwestionariusz Depresji Becka (BDI), Inwentarz Osobowości NEO-FFI, Skalę Poczucia Zmęczenia (MFSI-SF). Oceniono status socjoekonomiczny pacjentów oraz wyrównanie metaboliczne cukrzycy.
Wyniki. 55,8% osób deklarowało zmęczenie związane z życiem z cukrzycą. Wykazano zależność pomiędzy oceną zmęczenia opartą o jedno pytanie a wynikami uzyskanymi w skali MFSI-SF (r = 0,38; p < 0,001). Osoby posiadające zatrudnienie oraz pozostające w stałym związku partnerskim rzadziej deklarowały zmęczenie (p < 0,05). Lęk przed niedocukrzeniem oraz przed wstrzyknięciami insuliny występował częściej w grupie deklarującej zmęczenie (p < 0,05). Wykazano związek zmęczenia z wynikami uzyskanymi w skalach BDI, PAID oraz z osobowością neurotyczną. Nie obserwowano związku zmęczenia z HbA1c. W analizie regresji wieloczynnikowej wykazano, że lęk przed niedocukrzeniem, lęk przed wstrzyknięciami insuliny, poziom wykształcenia, mała aktywność fizyczna oraz przewlekłe powikłania mikronaczyniowe były niezależnie związane ze zmęczeniem.
Wnioski. Zmęczenie w cukrzycy typu 1 jest związane ze współistniejącymi zaburzeniami depresyjnymi, stopniem radzenia sobie z chorobą, neurotyczną osobowością oraz szczególnymi czynnikami socjoekonomicznymi.
Introduction. Type 1 diabetes is a chronic disease requiring continuous insulin therapy. Adjusting the rules of treatment to the existing lifestyle can be a source of emotional distress and fatigue.
Aim. The aim of this study was to assess factors determining fatigue in subjects with long history of type 1 diabetes.
Material and methods. 285 subjects (151 women), median age 43 years [interquartile range (IQR): 34-52], type 1 diabetes duration over 20 years, HbA1c 7.8% (IQR: 7.1-8.9) were included. Subjects diagnosed with chronic complications causing disability were excluded. Patients completed questionnaire comprising the question: Do you feel fatigue due to living with diabetes? Additionally, Problem Areas in Diabetes Questionnaire (PAID), Beck Depression Inventory (BDI), Neuroticism Extraversion Openness Five-Factor Inventory (NEO-FFI), Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF) were completed. Socioeconomic status and parameters of metabolic control were assessed.
Results. 55.8% of subjects declared fatigue due to diabetes. There was a relationship between fatigue assessment based on single question and scores exhibited in MFSI-SF Total (r = 0.38; p < 0.001). Employed and married participants less frequently declared fatigue (p < 0.05). The fear of hypoglycemia and insulin injections was more frequent in group declaring fatigue (p < 0.05). Fatigue was strongly associated with scores exhibited in BDI, PAID questionnaire as well as with neurotic personality. No relation of HbA1c with fatigue was found. Multivariate regression analysis showed that the fear of hypoglycaemia, fear of insulin injections, degree of education, physical activity and microangiopathy were associated with fatigue.
Conclusions. Fatigue in type 1 diabetes is determined by comorbid depressive disorder, coping with diabetes, neurotic personality and particular socioeconomic factors.
Type 1 diabetes is a chronic disease requiring complex and demanding treatment based on insulin therapy. Patient is obliged to perform daily diabetes self-management tasks, as performing regular glucose checks, exercising, following proper diet to maintain good metabolic control. The treatment goals include appropriate glycated hemoglobin (HbA1c) < 7% due to low, not high blood glucose variability, prevention of acute and chronic complications such as microvascular retinopathy, chronic kidney disease, neuropathy or macrovascular myocardial infarction or stroke (1). The treatment regimen is usually individualized, with respect to patient’s behaviours, needs, mental skills as well as social and economic status. Different educational approaches are used to implement therapeutic regimens, most of them comprising issues of patient empowerment (2, 3). Since the results of The Diabetes Control and Complications Trial have been published in 1993, a need for good metabolic control in terms of prevention of chronic complications was emphasized in diabetes management guidelines (4). Then, intensive functional insulin therapy has been recommended as a method for well-educated patients, when an insulin dose is calculated on a basis of actual glucose level, amount of carbohydrate in a meal and planned physical activity. However, adjusting the rules of treatment to the existing lifestyle may be a source of emotional distress and fatigue, that in turn may affect motivation and ability to perform necessary self-management tasks, resulting in poorer metabolic control. High levels of diabetes-related stress are also likely to reduce the patient’s quality of life. As a result, the risk of disease complications may be increased. Moreover, widely understood non-diabetes-related stress, i.e. due to social or economic status may influence treatment compliance and metabolic control in diabetic patients. Therefore it is important to early diagnose diabetes- and non-diabetes-related distress and to understand factors determining the feeling of fatigue. Still, not every subject diagnosed with chronic disease, such as diabetes, declares fatigue and decreased quality of life. Fatigue as a complaint is common among general population. According to Eurobarometer Mental Health, 27% of responders from 27 European countries reported to be “tired most of the time” (5). However, the term fatigue is multidimensional, includes physiological, psychological and environmental aspects and origins (6).
The aim of this study was to assess fatigue in subjects with longstanding type 1 diabetes.
Material and methods
A total of 312 patients were identified as eligible from our outpatient clinic to participate in the study. Of these, 1 refused participation because of lack of interest, 26 failed to complete baseline data. Finally, 285 subjects were included, 53% of women. The median age was 43 years [interquartile range (IQR): 34-52], type 1 diabetes duration over 20 years [median duration time 26 years (IQR: 22-31)], median age at onset 14 years (IQR: 9-23), HbA1c 7.8% (IQR: 7.1-8.9). We excluded patients diagnosed with chronic complications causing disability, such as blindness, end stage renal disease, manifested by estimated glomerular filtration rate (eGFR) < 15 ml/min/1.72 m2 [eGFR was calculated using Modification of Diet in Renal Disease (MDRD) study equation], history of limb amputation or painful peripheral neuropathy as irreversible disability or chronic pain are recognized factors of chronic distress and fatigue themselves. We also established the upper age border at 60 years, as older patients are more often retired which can affect their questionnaire answers concerning lifestyle. 191 subjects had a positive history of using reusable needles requiring sterilization for insulin injections, 225 subjects a history of using bovine or porcine insulin.
To assess fatigue participants were asked to complete the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF) and to answer the question: “Do you feel fatigue due to living with diabetes?”. MFSI-SF is a 30-item self-report measure designed to assess multidimensional aspects of fatigue that include general, physical, emotional, mental fatigue and vigor. The vigor subscale score is subtracted from the sum of the 4 fatigue subscales to yield a total fatigue score. Subscale scores range from 0 to 24, and MFSI-SF total scores range from -24 to 96, with higher scores indicating more fatigue (7). The scale has no established cut-off scores, although Stein et al. showed that MFSI-SF Total scores above 0.85 represented significant fatigue (8). While the validity and reliability of MFSI-SF was shown on cancer patients, it is not a disease-specific fatigue scale and may be used in other chronic diseases (9, 10). Participants of our study fulfilled some additional questionnaires assessing their personality, depressive symptoms, coping with diabetes. We based the assessment of personality on Neuroticism Extraversion Openness Five-Factor Inventory (NEO-FFI) by Costa and McCrae (11, 12), a 60-item psychological personality inventory measuring The Big Five personality traits: Extraversion, Agreeableness, Conscientiousness, Neuroticism, and Openness to Experience. The Beck Depression Inventory, a 21-question multiple-choice tool was used for screening for emotional and physical symptoms of depression. We also used The Problem Areas in Diabetes Questionnaire (PAID), a 20-item scale measuring and classifying diabetes-related emotional distress into subgroups of: emotional burden, physician-related distress, regimen distress and interpersonal distress (13, 14). Body mass index (BMI) was obtained in all participants. We collected blood samples in fasting state defined as no caloric intake for at least 8 hours. Serum concentration of total cholesterol (T-Chol), high density lipoproteins (HDL) cholesterol, low density lipoproteins (LDL) cholesterol, triglicerides (TG), creatinine, thyroid-stimulating hormone (TSH) and high-sensitivity C-reactive protein (hsCRP) were measured using standard methods. The glycemic control was expressed by measuring HbA1c with the use of high-performance liquid chromatography (HPLC). The information on participants’ social and economic status, educational degree, lifestyle habits and diabetes-related issues was collected based on survey prepared for the purpose of this study. Chronic complications were assessed via medical chart review. We assumed the presence of microangiopathy when either retinopathy or nephropathy or neuropathy was diagnosed.
All participants provided written informed consent after reading the description of the study. The study was conducted in accordance with the Declaration of Helsinki and the protocol was approved by the local Ethics Committee.
Statistical analysis

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otrzymano: 2017-01-04
zaakceptowano do druku: 2017-01-25

Adres do korespondencji:
*Anna Duda-Sobczak
Department of Internal Medicine and Diabetology Poznan University of Medical Sciences Raszeja's City Hospital
Mickiewicza 2, 60-834 Poznań
tel./fax +48 618-474-579

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