© Borgis - New Medicine 4/2003, s. 90-93
Maria Polocka-Molinska1, Jadwiga Kuczma-Napierala2, Kornelia Kedziora-Kornatowska3
The impact of social and economic factors on selected parameters of metabolic control of diabetes in elderly type 2 diabetics
1 Institute of Paediatric Nursing Medical University of Bydgoszcz, Bydgoszcz, Poland
Head: dr n. biol. Maria Polocka-Molinska
2 Institute of Internal Nursing Medical University of Bydgoszcz, Bydgoszcz, Poland
Head: dr n. biol. Jadwiga Kuczma-Napierala
3 Department and Clinic of Geriatrics Medical University of Bydgoszcz, Poland
Head: dr hab. Kornelia Kedziora-Kornatowska
Summary
Introduction: Diabetes is a systemic disease, the risk of being affected increasing with age. Considering the social character of the disease, we may distinguish two important influences, which help us to prevent chronic complications, and also influence good metabolic control. These are social and economic influences.
Materials and methods: The aim of our work was to analyse selected social and economic factors which have an impact on the course of diabetes in elderly people. In order to collect the necessary information for research, a "home-made” questionnaire was used as well as standard tools (assessment of means of treatment and self-evaluation sheet – WHO). Research was done on a group of 172 diabeties, diagnosed as type 2 diabeties, aged between 63 and 84. Patients were hospitalised at a Geriatric Clinic, or at the Endocrinology and Diabetology Clinic in Bydgoszcz. Clinical tests were also made, in subjective and objective research, and in laboratory tests of parameters of metabolic control. The examination of diabetes control parameters was established on the basis of the amount of glycosylated haemoglobin (HbA1c), the level of glucose on an empty stomach, the level of total cholesterol and its fractions (LDL-C, HDL-C), triglycerides in serum, and also arterial blood pressure and body mass index. From many factors that may influence the course of diabetes, analysis was made of age, education, and other social and economic.
Results: It has been proved that elderly type 2 diabetics can´t assess metabolic parameters properly, in most cases these very often exceeding limiting values.
Conclusion: Incorrect metabolic control was the result of a low level of education, little information about the disease, and lack of patients´ possibilities to control it. Insufficient knowledge about diabetes caused the patient and for their family to fail to cope with difficult life situations.
INTRODUCTION
Diabetes is one of the most common endocrine diseases among the elderly. It is a progressive disease. Metabolic disorders are caused by a lack of biological insulin activity, which leads to systemic complications. These are often connected with changes in the circulatory system (macro and microangiopathy), neurological disorders (diabetic neurophaty), and a tendency to artherosclerosis (1, 2, 3).
A factor which plays a significant role in preventing chronic complications, which naturally have a strong impact on the quality of the patients´ life, is maintaining metabolic compensation at a natural level. The ability to live with diabetes as an active member of a family, and of society, is influenced by an understanding of the course of the disease, knowledge about, financial and social conditions, changing lifestyle, and a positive attitude towards the disease.
MATERIALS AND METHODS
The main aim of this study was evaluation of the impact that social and economic factors have on elderly type 2 diabetics, and on their parameters of metabolic compensation.
Research was carried out on a group of 272 diabetics, in the 63 to 84 age group, all being diagnosed as having type 2 diabetes. The duration of the disease was from 1 to 21 years. The main object was to discover the subject´s social situation and living conditions, and the influence of these factors on the parameters of diabetes compensation.
The degree of diabetes metabolic control was established on the basis of analysis of medical documentation and the results of laboratory tests.
Social and demographic information, the disease itself, insulinotherapy and diet was collected by using a specially-prepared questionnaire. It contained three groups of data:
1)personal details – age, place of living, profession and vocational activity, social and living conditions,
2)course of diabetes, kind of treatment – including insulinotherapy,
3)treatment and diet to date.
Research was carried out in the Geriatric Clinic and Endocrynology and Diabetology Clinic of the Medical Academy in Bydgoszcz. Every respondent was informed about the aims of the research and the use of the collected information. The interview began with a casual conversation and explanation of how to fill in the questionnaire properly.
RESULTS
In the examined group 212 (77.9%) lived in a city, and the rest 60 persons (22.1%) lived in the country. From 272 respondents, nearly half (46.0%) had a technical education. Only 8.4% of respondents had had higher education and lived mainly in cities. An elementary education affected 24.3% of respondents (Table 1).
Analysing economic status and living conditions of respondents – only 6.6% of respondents stated that their economic and living conditions were very good. A significant percentage (40 persons, 14.7%) described their conditions as insufficient. Most of these were single people living in urban areas, aged over 70. Over half of the respondents (59.2%) stated that their economic and living conditions were sufficient.
The analysis of insulin treatment, showed that a simmilar number of women and men took an insulin injection once a day, on an empty stomach. In addition, 116 (42,6%) women and 114 (41,9%) men took an injection twice a day (morning and evening) (Table 2).
The degree of metabolic diabetes control was assessed on the basis of several criteria (level of glucose, glycosylated haemoglobin (HbA1), total cholesterol, and its fractions (HDL-C, LDL-C and triglycerides). Analysis of the parameters of metabolic control of diabetes showed that in both men and women all limiting values were exceeded (Table 3).
The analysis revealed that only 13% of women had a normal BMI (between 20 and 25) The rest, 87% of women were significantly overweight, or suffered from obesity or significant obesity (4.6% of respondents).
In male respondents, 16.7% had normal BMI. The 83,3% remaining were overweight or suffered from obesity (Table 4).
An important element of metabolic diabetes control the patients knowledge about the disease. This knowledge influences not only an attitude towards the disease, but also the frequency of reporting to an outpatient clinic (to examine the general state of health, to carry out laboratory tests and to prevent possible complications). Most of both male and female (62.1%) subjects said that they had inadequate knowledge of the disease. The majority of these lived in small towns or in the country (Table 5).
DISCUSSION
The fundamental cause of diabetes is a lack of physical activity and excessive eating. This disease has a strong impact on people´s lifestyle, mostly changing it by imposing systematic control of the parameters of metabolic compensation, and insulin – dependence.
The last few decades have brought a breakthrough in diabetes treatment. New "purified” insulin has appeared – it prolongs the patients´ lives, but also causes serious complications such as medium and severe arteriosclerosis.
Diabetes causes not only somatic disorders but also psychological disturbances, and sociological problems. Therefore, special emphasis should be put on providing professional education about the disease, and diabetes treatment.
Many authors emphasise the fact that the level of diabetics´ education has the biggest impact on the quality of diabetic control (5, 6).
This has been confirmed by research carried out by our Medical Academy. Similar results were found by Badurska-Stankiewicz et al., revealing a link between the patients´ inadequate knowledge and their loss of vision (7).
Poorly educated patients are also commonly badly-off, which influences the amount of money spent on treatment, and hence the quality of metabolic control. Poor patients have a tendency not to follow diet restrictions, and have an increased body mass index. They also limit their expenditure, and rarely buy a blood glucose meter.
Regular monitoring of the parameters of metabolic diabetes compensation and regular follow-up examinations are the most important factors in diabetes treatment and the patients´ well-being.
The European Diabetes Policy Group, IDF, recommends assessment of diabetics´ physical, mental and psychological conditions. Polish reality differs from European standards (8). Recently reforms, instead of improving diabetic´s situation, decreased their access to outpatient clinics. As a results, the incidence of complications related to type 2 diabetes has increased. In 1998 Griffin S. and Vaaler S., on the basis of world-wide literature, checked the impact of improving blood glucose level control on the course of type 2 diabetes (9, 10). Their research proved that only a well-organised health care system and regular follow-up examinations can lead to proper metabolic compensation. Improvement in compensation decreases the risk of possible complications.
The results of research carried out by our Medical Academy show, that the medical care system in Poland is inadequate. During the first few examinations, on a group of 272 diabetics (treated in outpatient clinics), it showed that the metabolic control system is insufficient. The average haemoglobin level (HbA1C) was 9.8% for women and 10.2% for men. Patients also had a significantly increased blood sugar level in the fasting state, and an increased concentration of total cholesterol and its fractions – total cholesterol (490 mg/dl), LDL (246 mg/dl), HDL (205 mg/dl) in women, and more adequately, 313,271 and 108 mg/dl in men.
The results of research have also indicated the urgent necessity of improvements in the care system for elderly patients suffering from type 2 diabetes.
Table 1. Place of living and education of examined diabetics.
| Community | Women | | Men | | Together |
| N | % | N | % | N | % |
| City | 111 | 40.8 | 101 | 37.1 | 212 | 77.9 |
| Country | 31 | 11.4 | 29 | 10.7 | 60 | 22.1 |
| Together | 142 | 52.2 | 130 | 47.8 | 272 | 100.0 |
| Education | Women | | Men | | Together |
| N | % | N | % | N | % |
| Elementary | 23 | 8.5 | 43 | 15.8 | 66 | 24.3 |
| Technical | 68 | 25.0 | 57 | 21.0 | 125 | 46.0 |
| Secondary | 39 | 14.3 | 19 | 7.0 | 58 | 21.3 |
| Higher | 12 | 4.4 | 11 | 4.0 | 23 | 8.4 |
| Together | 142 | 52.2 | 130 | 47.8 | 272 | 100 |
Table 2. Economic status and living conditions of respondents and insulinotherapy.
| Conditions | Women
| Men
| Together |
| N | % | N | % | N | % |
| Very good | 7 | 2.6% | 11 | 4.0 | 18 | 6.6 |
| Good | 22 | 8.1 | 31 | 11.4 | 53 | 19.5 |
| Sufficient | 102 | 37.5 | 59 | 21.7 | 161 | 59.2 |
| Insufficient | 11 | 4.0 | 29 | 10.7 | 40 | 14.7 |
| Together | 142 | 52.2 | 130 | 47.8 | 272 | 100.0 |
| Frequency
of injections | Women | | Men | | Together |
| N | % | N | % | N | % |
| 1 x day | 73 | 26.8 | 43 | 15.8 | 116 | 42.6 |
| 2 x day | 53 | 19.5 | 61 | 22.4 | 114 | 41.9 |
| 3 x day | 16 | 5.9 | 26 | 9.5 | 42 | 15.4 |
| Together | 142 | 52.2 | 130 | 47.8 | 272 | 100.0 |
Table 3. Profile of examined parameters of metabolic diabetes control by sex of subjects.
| Female parameters | Average | Minimum | Maximum | Standard deviation (? SD) |
| Glucose (mg/dl) | 191.0 | 120.0 | 405.0 | 49.5 |
| Nb A1c (%) | 9.8 | 5.8 | 13.6 | 1.8 |
| Total cholesterol | 232.4 | 159.8 | 490.0 | 65.8 |
| LDL (mg/dl) | 129.7 | 23.3 | 246.0 | 40.0 |
| HDL (mgl/dl) | 60.1 | 12.8 | 205.0 | 31.4 |
| Triglyceride (mg/dl) | 167.4 | 75.9 | 402.0 | 75.2 |
| Male parameters | Average | Minimum | Maximum | Standard deviation (? SD) |
| Glucose (mg/dl) | 201.1 | 123.0 | 362.0 | 66.0 |
| Nb A1c (%) | 10.2 | 7.2 | 23.1 | 1.9 |
| Total cholesterol | 229.7 | 135.0 | 313.0 | 43.0 |
| LDL (mg/dl) | 141.1 | 62.5 | 271.0 | 41.6 |
| HDL (mgl/dl) | 48.7 | 10.1 | 108 | 17.2 |
| Triglycerides (mg/dl) | 184.5 | 37.7 | 371.0 | 77.1 |
Table 4. Weight, height and BMI of subjects by sex.
| Female parameters | Average | Minimum | Maximum | Standard deviation (? SD) |
| Weight (kg) | 77.5 | 59.0 | 112 | 12.1 |
| Height (cm) | 161.5 | 148 | 178 | 6.2 |
| BMI (kg/m2) | 29.1 | 19.0 | 42 | 5.7 |
| Male parameters | Average | Minimum | Maximum | Standard deviation (? SD) |
| Weight (kg) | 81.5 | 67.0 | 118 | 12.7 |
| Height (cm) | 163.5 | 159 | 184 | 11.6 |
| BMI (kg/m2) | 27.6 | 20.9 | 34.1 | 4.4 |
Body Mass Index (BMI) estimated by using formula: body mass/height2
Table 5. Diabetics´ knowledge of diabetes.
| Sex | Sufficient | Insufficient | Together |
| | N | % | N | % | N | % |
| Women | 48 | 17.6 | 94 | 34.6 | 142 | 52.2 |
| Men | 55 | 20.2 | 75 | 27.6 | 130 | 47.8 |
| Together | 103 | 37.9 | 169 | 62.1 | 272 | 100.0 |
CONCLUSIONS
– Poorly educated diabetics show an insufficient level of metabolic control.
– Diabetics who assess their knowledge of diabetes as inadequate, show a significantly decreased quality of diabetic control.
– Poor financial conditions leads to bad eating habits, which leads to an increased of BMI and development of complications.
– Special attention should be paid to improvement of the diabetic health care system, especially for elderly type 2 diabetics.
Piśmiennictwo
1.Eltzwiler D.D.: Cele leczenia cukrzycy w Pediatric Diabetology Meeting. Kraków 15-17.09.1990; 1-4. 2. Finucane P., Sinclair A.: Cukrzyca u osób w podeszłym wieku. Via Medica, 1997; 69-93:268-278. 3. Drzewoski J. i wsp.: Występowanie cukrzycy typu 2 i wybranych zaburzeń metabolicznych cukrzycy w populacji miejskiej osób dorosłych powyżej 35 roku życia. P.A.M.W., 2001; 106:787-792. 4.Berger M. et al.: Health care for persons with non-insulin-dependent diabetes mellitus. The German experience. Ann. Intern. Med. 1996; 124:153-155. 5. Wamala S.P. et al.: Education and the metabolic syndrome in women. Diabetes Care 1999; 22, 1999-2003. 6. Karter A.J. et al.: Self-monitoring of blood glucose. Language and financial barriers in a managed care population with diabetes. Diabetes Care, 2000; 23:477-483. 7. Badurska-Stankiewicz E. i wsp.: Analiza efektywności programu ciągłej edukacji i rehabilitacji chorych na cukrzycę z inwalidztwem wzroku. Diabetologia Polska, 2002; 9:9-14. 8. European Diabetes POLICY Group 1998/1999. Guidelines for Diabetes Care. A desktop guide to type 2 diabetes mellitus. International Diabetes Federation, European region 1999. 9. Griffin S.: Diabetes care in general practice; meta-analysis of randomized control trials. BMJ, 1998; 317:390-395. 10. Vaaler S.: Optimal glycaemic control in type 2 diabetic patients. Does including insulin treatment mean a better outcome? Diabetes Care 2000; 23:B30-B34.
