Sleep Quality and Quality of Life in Adults with Type 2 Diabetes

Dr. Dr. S. M. Niaz MowlaS. M. Niaz MowlaID NOID NO: : 14-98060-314-98060-3

Department of Public HealthDepartment of Public HealthAmerican International University- Bangladesh (AIUB)American International University- Bangladesh (AIUB)

Banani, Dhaka- 1213Banani, Dhaka- 1213

Sleep Quality and Quality of Life in Adults with Sleep Quality and Quality of Life in Adults with Type 2 DiabetesType 2 Diabetes

2014 2035

Diabetes is a huge and growing problem…

Intersects with all dimensions of development

BACKGROUND

Among these, type 2 diabetes constitutes about 85-95% of all diabetes.

BACKGROUNDPrevalence and rate ratios of self-reported health as "fair" or "poor" among individuals aged 20 years and older, by age group and diabetes status, Canada, 2009-2010

How people perceive their general health provides a good

indication of their quality of life.

In 2009-2010, nearly two-fifths (39.1%) of Canadians aged 20 years and older who reported

having diabetes rated their health as "fair" or "poor", compared to a tenth of the adult population without

diabetes (10.3%).

Source: Public Health Agency of Canada (2011)

BACKGROUNDHRQOL is an important outcome- To evaluate the impact of the disease and its

treatment on individuals and health care costs.People with type 2 diabetes have a worse quality of life than people with no

diabetes.

Poor sleep is prevalent in T2DM and inversely associated with quality of life. Sleep quality is an important clinical consideration for two major reasons. 1.Complaints about sleep quality are common.2.Poor sleep quality can be an important symptom of many sleep and medical chronic

disorders.

BACKGROUNDThis study was a baseline survey which will-

Initiate further specific study and explore new idea for the policy makers and service providers and diabetes educators,

--- to play a key role in assessing sleep and providing easy to improve sleep hygiene and quality of life,

---to emphasize of screening new patients for sleep problems, making a suggesting sleep hygiene strategies as part of diabetes management.

JUSTIFICATION OF THE STUDYStudies showed- T2DM adversely affect both well being and physical functioning, contributing to

decrease HRQOL as well as sleep quality. These studies were carried out in Europe, the USA and Japan. Do not represent population across the globe. Particularly those from Indian subcontinent. Not clear whether the results are applicable to the Bangladeshi population.About 80% of T2DM occur in developing world.9th leading cause of death in Bangladesh. (CDC in Bangladesh factsheet, 2014)

In 2030- BD will hold the 8th position according to the total cases of DM in adult population. Time to determine the sleep quality and quality of life in adults with T2DM patients in BD for a more

comprehensive and intensive approach to diabetic care as diabetes depends on ethnicity.

RESEARCH QUESTIONS

How is the sleep quality in adults with type 2 diabetes? How is the quality of life in adults with type 2 diabetes?

OBJECTIVES General ObjectivesGeneral ObjectivesTo find out the sleep quality and quality of life in adults with Type 2 Diabetes. Specific ObjectivesSpecific ObjectivesTo assess the sleep quality in adults with type 2 diabetes using Pittsburg

Sleep Quality Index.To assess quality of life of the respondents using SF-36 v2TM. To determine the association between sleep quality and quality of life among

the respondents.

Independent VariablesIndependent Variables Dependent VariablesDependent Variables

• Age • Sex• Religion• Marital status• Educational qualification• Occupation• Monthly family income

• Duration of diabetes • Present treatment

profile • Number of diabetic

complication • Presence of co-

morbidities

DemographicDemographic Diabetes MellitusDiabetes Mellitus

• Sleep latency• Sleep duration• Habitual sleep

efficiency• Sleep disturbances• Use of sleeping

medication• Day time dysfunction

Physical functioning

Role physical

Bodily pain

General health

Mental health

Vitality

Social functioning

Role emotional

Sleep QualitySleep Quality Quality of LifeQuality of Life

STUDY VARIABLES

Diabetes related variableDuration of diabetes, Treatment status (Insulin), Complications of diabetes, Presence of co-morbidities

Patient’s characteristicsAge, Sex, Marital status, Education, Occupation, Family income

Sleep qualitySleep latency, Sleep duration, Habitual sleep efficiency, Sleep disturbance, Use of sleeping medication, Day time dysfunction

Quality of lifePhysical functioning, Role physical, Bodily pain, General health, Mental health, Vitality, Social functioning, Role emotional

CONCEPTUAL FRAMEWORK

METHODOLOGY Study DesignStudy DesignA cross sectional study. Study TimeStudy TimeThe total study period was six months, commencing from July, 2015.

Study Place Study Place Out Patient Department (OPD) of National Health Care Network, Mirpur.

- Branch of BIRDEM- Easy approachability.- Availability of the patients.

METHODOLOGY

Inclusion CriteriaInclusion Criteria Age – (25 - 60 years). Duration of Diabetes more than 1 years.Attending the National Healthcare Network, Mirpur hospital. Exclusion CriteriaExclusion CriteriaType 1 diabetes. Diagnosed sleep disorder prior to diabetes. Diabetes with pregnancy. Inability to communicate due to physical and mental health.

METHODOLOGY

Sampling Method and Sampling SizeSampling Method and Sampling Size

Due to time and resource constrains, my study participants were 180. Convenient sampling was followed for selection of study sample due to scarcity of cases.

METHODOLOGY

Data Collection InstrumentsData Collection Instruments A semi- structured questionnaire and checklist was used to collect data. The questionnaire was prepared by following SF-36 version 2 to assess the

HRQOL and PSQI to assess the sleep quality.It was prepared in English and then translated to Bangla.

Data Collection ProcedureData Collection ProcedureFace to face interview.Record review.

METHODOLOGY

Data Processing and Analysis PlanData Processing and Analysis Plan

At the end of each day of data collection each questionnaire was checked to see whether the questionnaire is filled completely and consistently.

Then they were stored after giving appropriate identification number. The data were analyzed in computer with SPSS 20.0 version. After meticulous cleaning and editing of the data, an analysis plan was

structured with relevance to study objective.

METHODOLOGY

Data Processing and Analysis Plan (Cont…)Data Processing and Analysis Plan (Cont…)

For descriptive statistics- means, medians, standard deviations, ranges for continuous data and frequencies and proportion for categorical data were calculated.

For inferential statistics- one way ANOVA, t test, χ2 test and Pearson’s correlation were calculated.

Linear regression analysis was used to examine the relationships between PSQI and HRQOL.

In all the tests, p˂0.05 was considered to be statistically significant.

METHODOLOGY

Data Quality ManagementData Quality ManagementPre testing of questionnaire was made to assess the validity in out of the study area. On spot-check & review of the filled up questionnaires on daily bases to ensure completeness

and consistency. Ethical IssuesEthical IssuesEthical Approval was obtained from Research Committee of AIUB.Verbal consent of the study participants was obtained. Study has done through collection of data using questionnaire and neither any intervention nor

any invasive procedures has undertaken. Privacy and highest confidentiality of the participant was maintained strictly.All other ethical issues were handled properly.

METHODOLOGY

Limitation of the StudyLimitation of the Study

Limited number of research works on sleep quality in adults with T2DM of BD.

Sampling technique- convenient method- result might not be generalized for other population.

Possibility of recall bias of the respondents. Did not include a control group. Sample size limited to 180.

METHODOLOGY

Highest proportion of the respondent (48.9%) was ≥ 50 years age group followed by 40-49 years age group (30%). Mean (SD) age of the respondents were 48.31 (±9.02) years.

SOCIO-DEMOGRAPHIC CHARACTER-AGE

35%

65%

Gender distribution of the respondents

Male Female

SOCIO-DEMOGRAPHIC CHARACTER-GENDER

Secondary16%

Higher secondary

27%

Graduate15%

Post graduate

17%

Illiterate1%

Can sign only7%

Primary17%Upto

primary[25%]

Major proportion of respondents (43.3%) were in the educational level of S.S.C and H.S.C, up to primary level there were 25% patients, the rest were graduates and above.

SOCIO-DEMOGRAPHIC CHARACTER-EDUCATIONAL QUALIFICATION

SOCIO-DEMOGRAPHIC CHARACTER-RELIGION AND MARITAL STATUS

SOCIO-DEMOGRAPHIC CHARACTER-OCCUPATION

Characteristics Frequency PercentMonthly family income<2000020000 to 2900030000 to 3900040000 to 4900050000 to 59000≥60000

621333142236

34.47.2

18.37.8

12.320.0

Family size <55 – 67 – 8>8

121212414

67.211.713.37.8

Ownership of houseNoYes

9684

53.346.7

Type of housePacca buildingSemi- pacca building

15525

86.113.9

Area of residenceUrbanRural

15327

85.015.0

SOCIO-DEMOGRAPHIC CHARACTER-OTHERS

PERCENT DISTRIBUTION OF RESPONDENTS BY DURATION OF DIABETES

PERCENT DISTRIBUTION OF RESPONDENTS BY VARIOUS COMPLICATIONS DUE TO DIABETES

PERCENT DISTRIBUTION OF RESPONDENTS BY SELF REPORTED HEALTH STATUS

PERCENT DISTRIBUTION OF RESPONDENTS BY PHYSICALACTIVITIES

PERCENT DISTRIBUTION OF RESPONDENTS BY PHYSICAL EMOTIONAL PROBLEMS DURING PAST 4 WEEKS

PERCENT DISTRIBUTION OF RESPONDENTS BY CAUSES OF TROUBLE SLEEPING

Characteristics Possible maximum score

Mean (SD) Median Range

Overall sleep quality 21 7.28(±3.06) 7 3-15Subjective sleep quality 3 1.60(±0.68) 2 0-3Sleep latency 3 1.66(±0.87) 2 0-3Sleep duration 3 1.42(±0.89) 1 0-3Habitual sleep efficiency 3 1.00(±1.07) 1 0-3

Sleep disturbance 3 1.02(±0.14) 1 1-2Use of sleep medication 3 0.93(±1.01) 1 0-3Day time dysfunction 3 1.06(±0.46) 1 0-3

SLEEP QUALITY

Characteristics Categories N Mean score SD F p r©

P-value

Age in years <30 30-39 40-49 ≥50

5335488

4.206.157.008.00

1.302.692.783.19

5.671

0.001

0.345

<0.001

Occupation ServiceBusinessHousewifeRetiredDay laborer

442387206

6.508.396.898.6510.00

2.453.712.942.813.89

4.77

0.003

Diabetes duration (Years)

<5 5 – 9 10 – 14 ≥15

63593325

6.207.328.308.60

2.753.102.733.11

5.774

0.001

BMI Normal weightOver weightObese

488646

6.547.208.21

2.733.03 3.27

3.669

0.027

Diabetic complications YesNo

11169

8.096.00

3.262.19

t = 5.135 <0.001

Hypertension YesNo

9684

7.796.71

3.092.94

t = 2.382 0.018

Coronary heart disease YesNo

27153

9.216.93

3.162.92

t = 3.745 <0.001

OVERALL SLEEP QUALITY


P-value

Age in years <30 30-39 40-49 ≥50

5335488

1.201.421.531.73

0.440.560.600.75

2.752

0.044

0.291

<0.001

Marital status MarriedOthers

143 37

1.521.91

0.620.79

t = -3.222 0.002

Glycemic control level

r = 0.759 <0.001

Diabetic complications

YesNo

11169

1.781.31

0.700.52

t = 5.033 <0.001

Hypertension YesNo

9684

1.701.48

0.690.64

t = 2.188 0.030

Coronary heart disease

YesNo

27153

2.141.50

0.750.61

t = 4.817 0.018

SUBJECTIVE SLEEP QUALITY


P-value

Age in years <30 30-39 40-49 ≥50

5335488

1.201.401.501.80

0.440.860.740.93

2.871

0.038

0.274

<0.001

Diabetes duration (years)

<5 5 – 9 10 – 14 ≥15

63593325

1.391.721.841.92

0.810.800.930.95

3.418

0.019

Diabetic complications

YesNo

11169

1.841.36

0.900.72

t = 3.752 <0.001

Hypertension YesNo

9684

1.781.52

0.870.85

t = 1.991 0.048

SLEEP LATENCY

SOCIO-DEMOGRAPHICAL CHARACTERISTICS AND SLEEP QUALITY

Characteristics Sleep quality Total n(%) χ2 P-valuePoor sleeper Good sleepern(%) n(%)

SexMaleFemale

46(73.0)71(60.7)

17(27.0)46(39.3)

63117

0.098 0.105

Marital statusMarriedOthers

87(60.8)30(81.1)

56(39.2)7(18.9)

14337

0.021 0.022

Educational statusUp to primaryS.S.C to H.S.CGraduates and above

30(66.7)52(66.7)35(61.4)

15(33.3)26(33.3)22(38.6)

457857

0.427 0.789

Area of residenceUrbanRural

103(67.3)14(51.9)

50(32.7)13(48.1)

15327

2.414 0.120

Type of housePaccaSemi-pacca

104(67.1)13(52.0)

51(32.9)12(48.0)

15525

2.157 0.142

DIABETES PROFILE OF THE RESPONDENTS AND SLEEP QUALITY

Characteristics Sleep quality Totaln(%)

χ2 P-value OR with 95% CIPoor sleeper Good sleepern(%) n (%)

Use of oral hypoglycemic agentYesNo

72(60.0) 45 (75.0)

48(40.0) 15(25.0)

120 60

3.956 0.049 2.00(1.0043.984)

Use of insulinYesNo

75(77.3)42(50.6)

22(22.7)41(49.4)

9783

14.034 <0.001 0.30(0.158-0.570)

Presence of complicationsYesNo

80(72.1)37(56.6)

31(27.9)32(46.2)

11169

6.366 0.016 2.23(1.190-4.187)

HypertensionYesNo

68(70.8)49(58.3)

28(29.2)35(41.7)

9684

3.077 0.087 -

Coronary heart diseaseYesNo

24(85.7)93(61.2)

4(14.3)59(38.8)

28152

6.254 0.016 3.80(1.257-11.52)

Characteristics Possible maximum score

Mean (SD) Median Range

Overall quality of life

3600 2044.80 (±512.75) 2220 914-2910

Physical health 2100 1261.19 (±334.14) 1370 415-1975

Mental health 1500 283.60 (±204.50) 829 325-1200

QUALITY OF LIFE


P-value

Age in years <30 30 – 39 40 – 49 ≥50

5335488

2542.002378.002222.611782.14

230.500241.500368.990536.790

21.678 <0.001

-0.599

<0.001

Occupation ServiceBusinessHousewifeRetiredDay laborer

442387206

2337.502114.652010.361687.051322.33

320.14488.58518.14468.42306.14

11.324

<0.001


<5 5 – 9 10 – 14 ≥15

63593325

2252.302177.921801.731528.60

383.54401.67528.46534.40

20.917 <0.001

Insulin use YesNo

9783

2168.981938.53

554.55430.03

t = 3.137 0.002

Hypertension YesNo

9684

1899.302211.08

498.57479.61

t = -4.271 <0.001


27153

1481.282148.60

508.52442.38

t = -7.163 <0.001

OVERALL QUALITY OF LIFE


P-value

Age in years <30 30 – 39 40 – 49 ≥50

5335488

1588.001489.241371.671089.32

143.248187.517241.496342.048

22.324 <0.001

-0.603

<0.001


<5 5 – 9 10 – 14 ≥15

63593325

1415.241329.661097.42927.60

267.43258.21347.24315.40

21.934 <0.001


488646

1414.891235.461148.91

239.12324.01383.08

8.604

<0.001

-0.316

<0.001

Insulin use YesNo

9783

1348.121186.80

286.70354.75

t = 3.373 0.001

Hypertension YesNo

9684

1171.871363.27

314.49328.35

t = -3.979 <0.001


27153

877.851331.80

326.05282.74

t = -7.575 <0.001

PHYSICAL HEALTH


P-value

Age in years <30 30 – 39 40 – 49 ≥50

5335488

954.00889.67850.94692.83

97.301103.460161.773220.554

14.536 <0.001

-0.516

<0.001


<5 5 – 9 10 – 14 ≥15

63593325

837.06848.25707.30601.00

145.55182.38215.03232.35

14.308 <0.001


488646

896.29765.02700.76

138.88195.70229.44

12.945

<0.001

-0.352

<0.001

Insulin use YesNo

9783

820.85751.73

174.41223.87

t = 2.331 0.021

Hypertension YesNo

9684

727.42847.80

210.22178.29

t = -4.111 <0.001


27153

603.42816.79

208.78186.15

t = -5.469 <0.001

MENTAL HEALTH

Sleep quality Quality of lifeOverall Physical health Mental health

r© P-value r© P-value r© P-valueOverall quality of sleep -0.530 <0.001 -0.540 <0.001 -0.447 <0.001Subjective sleep quality -0.539 <0.001 -0.535 <0.001 -0.474 <0.001Sleep latency -0.462 <0.001 -0.472 <0.001 -0.387 <0.001Sleep duration -0.322 <0.001 -0.329 <0.001 -0.270 <0.001Habitual sleep efficiency -0.281 <0.001 -0.288 <0.001 -0.234 0.002Sleep disturbance -0.180 0.015 -0.186 0.012 -0.148 0.048Use of sleep medication -0.284 <0.001 -0.312 <0.001 -0.201 0.007Day time dysfunction -0.529 <0.001 -0.499 <0.001 -0.511 <0.001

Sleep quality score in overall sleep quality and all domains were inversely correlated with overall quality of life, physical and mental health score. There were strong significant correlation of overall sleep quality (r= -0.530, p<0.001), subjective sleep quality(r= -0.539, p< 0.001) and day time dysfunction (r= -0.529, p<0.001) with overall quality of life.

CORRELATION BETWEEN SLEEP QUALITY SCORE AND QUALITY OF LIFE

Overall sleep quality was categorized into two groups good sleepers (score ≤5) and poor sleepers (score >5). Relationship between the sleep quality with the overall quality of life, physical health and mental health was significant (p>0.001). Average score in overall quality of life, physical and mental health domains were lower in poor sleeper than good sleeper.

Characteristics Sleep quality N Mean score SD t P-value

Overall quality of life

Poor sleeperGood sleeper

11763

1905.482303.52

541.17326.29

6.147 <0.001

Physical health Poor sleeperGood sleeper

11763

1169.311431.82

351.58213.46

6.222 <0.001

Mental health Poor sleeperGood sleeper

11763

136.17871.69

213.33153.15

4.912 <0.001

OVERALL SLEEP QUALITY AND QUALITY OF LIFE

Linear regression analysis showed that duration of diabetes explains 26.1%, 15.3% and 8.6% of the variability of physical and mental health components of SF-36 and PSQI respectively.

Duration of Diabetes

R R Square Adjusted R Square Std. Error of the Estimate

Physical health(PCS) 0.511 0.261 0.257 288.06804

Mental health(MCS) 0.397 0.157 0.153 188.23365

Sleep quality(PSQI) 0.293 0.086 0.081 2.94011

CRRELATION BETWEEN DURATION OF DIABETES WITH PCS,MCS AND PSQI

On the other hand, linear regression analysis also showed that sleep quality explains 29.2% and 20.0% of the variability of physical health and mental health of the health related quality of life.

Sleep Quality R R Square Adjusted R Square Std. Error of the Estimate

Physical health(PCS) 0.540 0.292 0.288 282.00904

Mental health (MCS) 0.447 0.200 0.196 183.40262

CORRELATION BETWEEN SLEEP QUALITY WITH PCS AND MCS

The purpose of this study was to examine the relationship between sleep quality and health-related of life in adults with type 2 diabetes.

To our knowledge, this is the first systematic investigation to find out the association between poor sleep and quality of life in T2DM in Bangladesh.

For this purpose, we interviewed one eighty individuals with type 2 diabetes through a semi-structured questionnaires and check list assessing sleep quality, health-related quality of life, comorbidities.

CONCLUSION

117 participants (65%) were poor sleepers (global PSQI >5). (Comparatively, previous studies have identified between 45% and 67% of persons with type 2 diabetes to have poor sleep quality and/or difficulty initiating or maintaining sleep.)

Poor sleeper had significantly poorer SF-36 PCS and MCS and poorer functioning on each of the 8 domains of the SF-36 (all p<0.001).

Poor sleeper tended to be aged, to be female, and to have more comorbidities.

CONCLUSION

Overall quality of life is better in females than male but they are mentally compromised.

Both sleep quality and quality of life were better in married persons than others.

HRQOL was associated with age, years since diabetes diagnosis, number of comorbidities, number of diabetic complications, insulin use.

On an average, the respondents who were suffering from diabetes ≥15 years had lower score in overall quality of life, physical and mental health.

Overall quality of life was highest in younger (15-29 years) and lowest in elderly subjects (over 50 years). Life quality decreased with increasing age.

CONCLUSION

These results suggest that poor sleep is common among persons with type 2 diabetes and that poor sleep quality is associated with HRQOL and diabetes-related quality of life, in particular satisfaction with and impact of treatment.

This study suggested that adequate sleep quality and quantity should be considered a fundamental component of a healthy lifestyle, like weight control and physical activity.

CONCLUSION

Ensure sleep hygiene strategies as part of diabetes management.

Ensure control blood sugar level with appropriate treatment for every type 2 diabetes patients.

Strategies should be designed to early diagnosis of diabetes and aggressive management of blood pressure, hyperlipidaemia and albuminuria should be ensured.

A comprehensive nationwide study about sleep quality and quality of life of type 2 diabetes patients should be conducted.

RECOMMENDATION

My SupervisorAll respected faculties of MPH, AIUB

All my wonderful batch-mates of MPHNHN, MIRPUR

ICDDR,BMy lovely family

&

Finally, American International University- Bangladesh (AIUB)

ACKNOWLEDGEMENT

Sleep Quality and Quality of Life in Adults with Type 2 Diabetes

Healthcare

Transcript of Sleep Quality and Quality of Life in Adults with Type 2 Diabetes