Factors influencing the quality of life of young patients with diabetes

Authors


Pantelis Perdikaris, 9 Dyrou St,
GR-104 43 Athens, Greece.
Tel: +30 21 0223 5255
Fax: +30 21 0223 5255
Email: pantperdikaris@ath.forthnet.gr

Abstract

Background:  Diabetes is a significant challenge for pediatric health care professionals because it affects youths’ psychoemotional functioning and, consequently, the quality of life (QOL). The aim of the present study was to evaluate the QOL in young patients with diabetes, as well as the factors affecting it.

Methods:  The study was conducted from April to September 2008 in 98 young patients, 11–18 years of age, who were under the supervision of Diabetological Center, General Pediatric Hospital (Athens, Greece). The Diabetes Quality of Life for Youths Questionnaire was used to evaluate the QOL of youths with diabetes.

Results:  The mean QOL score was 97.5. There was a negative correlation between the QOL and age (= 0.02), the duration of diabetes (= 0.05), body mass index (BMI; = 0.04), and comorbidities (= 0.03). In contrast, there was a positive correlation between QOL and increased metabolic control (= 0.03), participating in sports activities (= 0.007), and a greater number of insulin infusions (= 0.04).

Conclusions:  The QOL of young diabetics was influenced by demographic, somatometric, and other characteristics of diabetes. Increased metabolic control, participating in sports activities, and a greater number of insulin infusions resulted in better QOL. Increased patient age, duration of diabetes, HbA1c values, BMI, and the coexistence of various health problems, as well as the use of an insulin pump, decreased QOL.

Introduction

Diabetes can impact on the physical, mental, and social functioning of children and adolescents.1 Many children and adolescents suffer from depression, adaptation problems, and nutritional disorders at the time of diabetes diagnosis. Young patients whose diabetes started before the age of 5 years and who have experienced frequent hypoglycemic episodes usually have neurological deficiencies and exhibit a lack of concentration and decreased verbal ability.2–5

The quality of life (QOL) in children and adolescents is defined as their subjective perception about life in terms of cultural characteristics, social beliefs and values, personal goals and expectations, patterns and concerns. It is well known that QOL is multidimensional and, in children and adolescents, its subjective dimension is highlighted, as expressed through positive views about life. Moreover, young patients with diabetes highlight changes in individual reactions to their disease as they experience them within their own cultural and environmental milieu.6 The Diabetes Control and Complications Trial (DCCT; 1983–1993) introduced a stricter regimen for metabolic control, including frequent glucose blood counts, more insulin injections, nutritional control, and exercise.7,8 This approach aimed to decrease the complications associated with diabetes, although increased body mass and frequent hypoglycemic episodes may, in fact, downgrade a patients’ QOL. It is of considerable importance to understand the way diabetes and its treatment can affect the QOL in young patients. When assessing the QOL in young patients, full consideration should be given to the type of diabetes treatment, the signs and symptoms of the disease, the patient’s stamina, social, and emotional development, as well as his/her academic performance.7,8

In the present study, children and adolescents were surveyed to determine their QOL within the framework of diabetes, as well as any variables that may impact upon it.

Methods

Sample

The present study not only assessed the QOL of young diabetic patients, but also gathered data regarding demographics, somatometrics, and disease characteristics, in addition to data on parental demographics and level of education.

The study was conducted from April to September 2008 in 98 children and adolescents between 11 and 18 years of age who were under the supervision of Center of Diabetes, General Pediatric Hospital (Athens, Greece). The Center of Diabetes is a separate department of the General Pediatric Hospital (one of the three pediatric hospitals in Athens). It provides care for children with diabetes in an outpatient setting. On average, 28 young patients aged between 4 and 18 years are under the supervision of the Center each week. The staff consist of three pediatric nurses and five pediatricians who have specialized in diabetes. The nursing staff are responsible for evaluating blood glucose control, HbA1c levels, weight, stature, and body mass index (BMI) in the patients. In addition, the patients are educated about diabetes, metabolic control (blood glucose control), food, exercise, sports activities, and insulin injections.

The inclusion criteria for the present study were: (i) age 11–18 years of age; (ii) at least a 6 month duration of diabetes; and (iii) no psychiatric disorders. Of the 121 young patients seen at the Center over the 6-month period, 98 met the inclusion criteria, and their parents provided informed consent for them to participate in the study (response rate: 80.99%). Data were collected by the researcher during meetings with the young patients who visited the Center of Diabetes every Tuesday, Thursday, and Friday. Demographic and somatometric data, as well as information about disease characteristics and parental demographics and level of education, were collected by the researcher, whereas the patients were required to complete the Diabetes Quality of Life for Youths (DQOLY 1991) questionnaire.9 Each meeting lasted approximately 20 min. The patients completed the questionnaire after HbA1c levels had been determined.

Instrument

The DQOLY (1991) questionnaire was used to evaluate the QOL in children and adolescents with diabetes. Initially developed by the Diabetes Control and Complications Trial (DCCT) Research Group and later modified by Ingersoll and Marrero,9 the DQOLY scale measures QOL among diabetic children and adolescents and consists of four subscales: (i) a 17-item “Diabetes Life Satisfaction” scale; (ii) a 23-item “Disease Impact” scale; (iii) an 11-item “Disease-Related Worries” scale; and (iv) a single item on health perception. Each item is measured on a five-point Likert scale ranging from 1 (“very satisfied”) to 5 (“very dissatisfied”) on the Satisfaction scale and 1 (“never”) to 5 (“all the time”) on the Impact and Worries scales, which measure specific events. The three subscales are not statistically independent. Health perception is measured using a four-point Likert scale.9,10 Overall scores are obtained by summing the score for each answer. Higher scores indicate lower life satisfaction, greater disease impact, and increased disease-related worries. Scores on the Satisfaction subscale are often reversed so that a higher score can reflect greater QOL, because the Satisfaction subscale is negatively correlated with the Impact and Worries subscales. Cronbach’s α for each scale in psychometric testing by the authors was as follows: Satisfaction 0.85, Impact 0.83, and Worries 0.82.11

The DQOLY questionnaire was translated into Greek by two independent translators. Back-translation was performed by another two translators. In the study, Cronbach’s α was 0.90 (0.78 for the Satisfaction and Worries scales and 0.80 for the Impact scale). A panel of experts, consisting of two doctors, a pediatric nurse, and two associate professors, studied the content validity of the questionnaire. Before the DQOLY questionnaire was translated into Greek, permission was obtained from Ingersoll. A specific form that included questions about demographics, somatometrics, and other disease characteristics was also used. The questionnaire responses were anonymous.

The protocol of the present study was approved by the Ethics Committee and the Scientific Council of the General Pediatric Hospital (Athens, Greece).

Although there is no agreement upon numerical definition of hypoglycemia for young patient with diabetes, blood glucose values <3.3–3.9 mmol/L (60–70 mg/dL) are generally agreed to place the individual at risk of severe hypoglycemia. According to Clarke et al.,12 for clinical use, values of <3.6 mmol/L (65 mg/dL) are most often used to define hypoglycemia in the pediatric population. In the present study, blood glucose values <3.9 mmol/L (70 mg/dL) were defined as indicating hypoglycemia. “Sports activity” was defined participation in sports such as soccer, basketball, swimming, jogging, aerobic exercise, gymnastics etc. for at least 1 h/day). The BMI is a heuristic measure of body weight based on a person’s weight and height. It is defined as an individual’s body weight (in kg) divided by the square of his or her height (in m).

Statistical analysis

The normality assumption was evaluated by using both the Kolmogorov–Smirnov criterion (> 0.05 for all variables) and normality plots. The variables appeared reasonably normally distributed and parametric methods of analysis were used. Continuous variables are presented as the mean ± SD, whereas categorical variables are presented as absolute and relative frequencies. Pearson’s correlation coefficient was used to measure associations between continuous variables, whereas contingency tables with the Chi-squared test were used to evaluate associations between categorical variables. Differences in mean scores were analyzed using independent samples t-tests and one-way analyses of variance (anova). In anova, subsequent post hoc tests were corrected with a Bonferroni procedure for multiple comparisons. Variables that were significantly different (< 0.05) on scores in bivariate analyses were entered into the backward stepwise linear regression. Criteria for the entry and removal of variables were set at < 0.05 and > 0.10, respectively. In multivariate linear regression, unstandardized β coefficients with 95% confidence intervals, P values and adjusted R2 were calculated. All statistical tests were considered to be significant at an α level of 0.05 on a two-tailed test and were performed with spss version 16.0 software (SPSS Inc., Chicago, IL, USA).

Results

The demographic characteristics of the sample are presented in Table 1. Sixty-six girls (67.3%) participated in the study. The mean age of the participants was 14.9 ± 2.4 years, with mean age at diagnosis of 7.6 ± 3.8 years. Mean BMI was 22.1 ± 3.2 kg/m2. Most patients (64.3%) mentioned that they could treat their diabetes themselves and they assessed their health status as “good” (59.2%). However, mean HbA1c levels (7.4 ± 1.2%) indicated that there was inadequate control of diabetes. However, 76.5% of patients had not experienced a hypoglycemic episode for 3 months. Furthermore, 65.3% of patients participated in sports activities, 67.3% were not using an insulin infusion pump, and 84.7% had no other health problems except for the diabetes. There appeared to be a negative effect of demographics, patients’ somatometric characteristics, and other disease characteristics on patients’ QOL, as it was assessed by a mean DQOLY score of 97.5 ± 21.2.

Table 1.   Demographic data of the sample
  1. Data are either presented as the number of patients in each group with percentages given in parentheses or as the mean ± SD.

  2. BMI, body mass index; DQOLY, Diabetes Quality of Life for Youths questionnaire.

Gender
 Male32 (32.7%)
 Female66 (67.3%)
Parental level of education
 Primary school20 (20.4%)
 High school51 (52%)
 University27 (27.6%)
Parental participation in treatment plan
 Yes63 (64.3%)
 No35 (34.7%)
Participation in sporting activities
 Yes64 (65.3%)
 No34 (34.7%)
Hypoglycemic episode in past 3 months
 Yes23 (23.5%)
 No75 (76.5%)
Using insulin pump
 Yes32 (32.7%)
 No66 (67.3%)
Other coexisting health problems
 Yes15 (15.3%)
 No83 (84.7%)
Patients’ opinion about their health status
 Perfect27 (27.6%)
 Good58 (59.2%)
 Average13 (13.3%)
 Poor 0 (0%)
Age (years)14.9 ± 2.4
Age at time of diagnosis (years) 7.6 ± 3.8
Duration of diabetes (years) 7.3 ± 4.0
BMI (kg/m2)22.1 ± 3.2
Metabolic control 5.0 ± 1.8
HbA1c (%) 7.4 ± 1.2
DQOLY score (total)97.5 ± 21.2
 Patients’ satisfaction subscale score31.0 ± 7.9
 Consequences of diabetes subscale score47.3 ± 9.9
 Concerns related to diabetes subscale score19.2 ± 6.8

Bivariate analysis of the data is presented in Table 2. Data retrieved from “Diabetes Life Satisfaction” subscale of the DQOLY questionnaire show that older patients (= 0.28, = 0.005), a longer duration of diabetes (= 0.19, = 0.05), high BMI (= 0.31, = 0.002), the number of insulin infusions (= 0.05), and the presence of other health problems (= 0.04) resulted in increased DQOLY scores (Table 2), indicating lower life satisfaction. Young patients who participated in sporting activities (= 0.009) and had frequent glucose blood counts (= −0.21, = 0.04) reported lower scores on the Satisfaction subscale of the DQOLY questionnaire (Table 2) and, consequently, a better QOL. Data retrieved from the Disease Impact subscale of the DQOLY questionnaire showed better glucose control was related to lower scores on the DQOLY (= −0.28, = 0.08; Table 2). Moreover, young patients participating in sporting activities reported lower scores on the DQOLY questionnaire (= 0.03), whereas those with other health problems in addition to diabetes reported higher scores (=0.05; Table 2). Older children (= 0.29, = 0.004) and patients with a longer duration of diabetes (= 0.29, = 0.004) also reported higher scores for the Disease-Related Worries subscale the DQOLY questionnaire (Table 2). The mean score on this subscale of the DQOLY questionnaire was higher for boys than girls (20.6 vs 16.4, respectively; = 0.004; Table 2). In addition, the mean scores on the DQOLY questionnaire were lower for young patients participating in sports activities (= 0.03) and having insulin injections (= 0.02; Table 2). Overall, older age (= 0.23, = 0.02), a longer duration of diabetes (= 0.19, = 0.05), and a higher BMI (= 0.21, = 0.04) were related to higher scores on the DQOLY questionnaire, reflecting a lower life satisfaction, whereas frequent glucose blood counts (= −0.22, = 0.03) were associated with lower scores (Table 2). Young patients who participated in sports activities reported lower scores on the Diabetes Life Satisfaction subscale (= 0.009), on the Disease Impact subscale (=0.03), on the Disease-Related Worries subscale (= 0.03) and overall compared with those not participating in any sporting activities (93.4 vs 105.3, respectively; = 0.007).

Table 2.   Results of bivariate analysis between various factors and quality of life, as determined using the Diabetes Quality of Life for Youths questionnaire
 DQOLY subscale scores
Diabetes Life SatisfactionDisease ImpactDisease-Related WorriesTotal score
Mean ± SDP valueMean ± SDP valueMean ± SDP valueMean ± SDP value
  1. *Independent samples t-test.

  2. BMI, body mass index; DQOLY, Diabetes Quality of Life for Youths questionnaire.

Gender*
 Male31.8 ± 7.90.546.8 ± 8.30.720.6 ± 7.00.00494.9 ± 18.60.4
 Female30.6 ± 7.947.6 ± 10.616.4 ± 5.798.8 ± 22.3
Age 0.005 0.4 0.004 0.02
Duration of diabetes 0.05 0.6 0.004 0.05
BMI 0.002 0.3 0.2 0.04
Parental level of education
 Primary school30.1 ± 5.50.847.5 ± 7.80.9919.1 ± 4.60.896.6 ± 14.20.9
 High school31.2 ± 8.547.2 ± 11.018.9 ± 7.497.3 ± 24.1
 University31.3 ± 8.247.3 ± 9.320.0 ± 7.398.6 ± 20.0
Parental participation in treatment plan
 Yes30.1 ± 8.20.147.0 ± 10.00.718.9 ± 7.00.696.0 ± 21.60.3
 No32.6 ± 7.247.8 ± 9.819.8 ± 6.5100.2 ± 20.3
Participation in sporting activities*
 Yes29.5 ± 7.50.00945.7 ± 8.90.0318.2 ± 7.00.0393.4 ± 19.90.007
 No33.8 ± 7.950.2 ± 11.121.2 ± 6.0105.2 ± 21.5
Metabolic control 0.04 0.08 0.07 0.03
HbA1c levels 0.1 0.2 0.7 0.2
Incidence of hypoglycemia*
 Yes31.4 ± 7.30.848.0 ± 9.10.718.7 ± 4.50.698.2 ± 19.10.9
 No30.9 ± 8.147.1 ± 10.119.4 ± 7.497.3 ± 21.9
Insulin infusions*
 Yes33.1 ± 8.20.0549.1 ± 10.90.218.1 ± 6.60.0294.5 ± 19.70.04
 No30.0 ± 7.546.4 ± 9.321.6 ± 6.8103.8 ± 23.0
Other coexisting health problems*
 Yes34.7 ± 8.70.0451.7 ± 11.10.0522.0 ± 7.40.09108.5 ± 23.20.03
 No30.3 ± 7.646.5 ± 9.518.7 ± 6.795.6 ± 20.3

Negatively correlations were found between QOL and older age, longer duration of diabetes and high BMI, whereas frequent glucose blood counts resulted in lower (total) scores on the DQOLY questionnaire. Total scores on the DQOLY questionnaire were lower for patients who participated in sports activities (= 0.007) and had insulin injections (= 0.04). In contrast, higher total scores on the DQOLY questionnaire (and, consequently, poorer QOL) were noted for patients with other health problems in addition to diabetes (= 0.03). There were significant correlations between the young patients’ opinions about their health status and both the duration of diabetes (= 0.03) and BMI (= 0.02); those patients with a shorter duration of diabetes (Table 3) and with a lower BMI (Table 4) had a better opinion of their health status.

Table 3.   Young patients’ opinions of their health status according to duration of diabetes
Perceived health statusnMean (±SD) duration of diabetes (years)95% CI for meanRange
MinimumMaximum
  1. CI, confidence interval.

Perfect276.21 ± 3.634.77–7.641.0012.50
Good587.32 ± 3.886.30–8.340.5014.00
Average139.73 ± 4.077.27–12.192.0014.50
Total987.33 ± 3.946.54–8.120.5014.50
Table 4.   Young patients’ opinions of their health status according to body mass index
Perceived health statusnMean (±SD) duration of diabetes (years)95% CI for meanRange
MinimumMaximum
Perfect2721.45 ± 2.0420.65–22.2617.0726.12
Good5821.89 ± 3.2521.04–22.7515.9729.43
Average1324.29 ± 3.8821.94–26.6320.6831.25
Total9822.09 ± 3.1621.46–22.7215.9731.25

Multivariate linear regression analysis revealed that increased BMI, reduced metabolic control and the existence of other health problems increased the score in the Satisfaction domain (Table 5), indicating a poorer QOL. These three variables explained 20% of the variance in the Satisfaction score. Multivariate linear regression analysis also revealed that children who did not participate in sports activities had higher scores on the Disease Impact subscale (Table 5) and that this variable explained 10% of the variance in the Disease Impact score. Furthermore, multivariate linear regression analysis revealed that higher age and a longer duration of diabetes increased the Disease-Related Worries subscale score, with boys having a higher score than girls (Table 5). These three variables explained 20% of the variance in the Worries subscale score. Multivariate linear regression analysis revealed that a reduction metabolic control increased the total score (Table 5). In addition, young patients who did not participate in sports activities, who had no insulin injections and those with other health problems had higher total scores (Table 5). These four variables explained 20% of the variance of the total score.

Table 5.   Multivariate analysis with scores as dependent variables
 β95% CIP
  1. CI, confidence interval; BMI, body mass index.

Diabetes Life Satisfaction subscale (R2 = 0.2)
 BMI0.670.2 to 1.20.006
 Metabolic control−1−1.8 to −0.20.02
 Other health problems  (yes = 1)4.50.5 to 8.50.03
Disease Impact subscale (R2 = 0.1)
 Participation in sports  activities (n = 1)4.70.8 to 8.70.02
Disease-Related Worries (R2 = 0.2)
 Gender (male = 1)4.31.6 to 6.90.002
 Age0.70.1 to 1.30.02
 Duration of diabetes0.3−0.01 to 0.70.05
Total score (R2 = 0.2)
 Sports activities (n = 1)10.42.2 to 18.70.02
 Metabolic control−3.3−5.5 to −1.10.005
 Insulin injections (n = 1)10.11.9 to 18.80.02
 Other health problems  (yes = 1)11.60.9 to 22.30.03

Discussion

The aim of the present study was to assess the QOL in young patients with diabetes and the effect of demographics and other variables on QOL. The results demonstrate a significant effect of demographic variables and factors related to both the disease and patient on QOL. The total mean score on the DQOLY questionnaire was found to be high, indicating a negative impact on the QOL of young patients with diabetes. Girls with diabetes reported significantly lower scores on the Disease-Related Worries subscale. This finding is inconsistent with the findings of other studies,13 which have reported that girls have more concerns related to disease, a lower level of satisfaction, and a worse view about their health status compared with boys. Personal expectations, changes in body image, patterns of beauty, self-esteem, nutritional and psychological disorders, and crises within the family may contribute to these attitudes among girls with diabetes.13 Nevertheless, there are also studies that have reported no significant difference in the QOL of life between male and female diabetics.14–17 It has been reported that worries are not related to gender, age, or the duration of diabetes.14–17

Patient age seems to have a negative impact on QOL. In the present study, children were classified as “younger” if they were 10 years of age, “older” if they were 11–12 years of age, and “adolescent” if they were ≥12 years of age. Older children noted higher scores on the Diabetes Life Satisfaction subscale, the Disease-Related Worries subscale, and overall (Table 2). However, the age at the time of diagnosis was not found to be significantly related to a patient’s QOL. The QOL of older children and adolescents tended to be worse than that for younger children. Puberty is a crucial time for adolescents with diabetes because they need to develop greater responsibility for their condition and its treatment. Adolescents tend to want to be independent and may resent perceived parental interference. Thus, any insulin-based treatment needs to be more intensive and flexible to accommodate their lifestyle. Many times, adolescents with diabetes do not follow their treatment protocols because it interferes with their lives, which can lead to poor metabolic control.18 Older children and adolescents with diabetes report no improvement in their health status. Diabetes and other coexisting health problems can have negative impacts on personal, familial, and academic areas of their lives.19,20 A review of the literature reveals some studies reporting no negative correlation between age and QOL in pediatric patients with diabetes.2,13,21 Many adolescents with diabetes feel that their health status is similar to that of their healthy peers; moreover, diabetes does not have a negative influence on their activities, although parents usually note a poorer health status for their diabetic children.2,13,21

The duration of diabetes appears to be associated with higher scores in the Satisfaction and Concerns Related to Diabetes subscales, as well as with the total score (Table 2). Patients who were younger had a better view of their own health status compared with older patients (Table 3). We note that this result is contentious, because other studies have reported no relationship between the duration of diabetes and QOL.2,17 Another factor that was found to be significantly associated with the QOL in younger patients was BMI. Increasing BMI was found to be associated with higher scores on the Diabetes Life Satisfaction and Disease Impact subscales, as well as with higher total scores. Patients with a low BMI (i.e. <25 kg/m2) reported a better health status (Table 4). In addition, scores on the Diabetes Life Satisfaction, Disease Impact, and Disease-Related Worries subscales, as well as overall, tended to be lower in children and adolescents who participated in sports activities, reflecting a better QOL in this group (Tables 2,5).

Insufficient control of diabetes may cause several potentially lethal emotional disorders, such as anxiety, distress, depression, low self-esteem, anorexia, or bulimia. Increasing BMI, not taking care of one’s physical status, and not participating in any form of exercise can result in poor metabolic control and a bad QOL. By participating in sports activities, body weight may be better controlled in young patients with diabetes, in addition to improvements in body image and better management of diabetes.22–25 It seems that increased monitoring of blood glucose levels may have a positive effect on the QOL in young patients, although the increased rate of metabolic control may mean more punctures and more pain. Children and adolescents with diabetes mentioned that increased monitoring of blood glucose levels resulted in greater flexibility with their diet and the ability to maintain normal circadian rhythms. They also noted that having low glucose blood levels increased their feelings of happiness and satisfaction.

The results of the present study indicate that there was insufficient diabetes control in the sampled population because HbA1c levels were >7%. Increased HbA1c levels were related with higher scores on the Diabetes Life Satisfaction subscale and poorer QOL, although these differences did not reach statistical significance. This finding is in agreement with the findings of other studies that have reported that adolescents with lower HbA1c levels report better QOL and fewer diabetes-related complications.17,21,26–29 However, there are studies in which no correlation was reported between QOL and metabolic control, as assessed using HbA1c levels.2,13–15,30 One possible explanation for this may be that in those studies the young patients were educated about living with diabetes as soon as the diagnosis was made.2,13–15,30

In the present study, young patients with health problems in addition to diabetes reported worse QOL compared with patients who had diabetes only. Patients with comorbidities reported higher scores on the Diabetes Life Satisfaction (= 0.04) and Disease Impact (= 0.05) subscale, as well as overall (= 0.03). In contrast, Ravens-Sieberer and Bullinger31 reported that there was no significant difference in QOL between children with asthma in addition to diabetes and young patients with diabetes only.

Statistical analysis in the present study did not demonstrate any correlation between the level of parental education and the QOL of their children. However, parental participation in their child’s treatment plan had a positive effect on QOL. Young patients whose parents were in control of their diabetes treatment reported lower scores on the Diabetes Life Satisfaction subscale, and better QOL consequently, compared with young children who were responsible for their own treatment, but this difference failed to reach statistical significance. This may be explained by the fact that strong relationships are developed within Greek families that tend to protect those who have health problems or disabilities, even though not all family members take part directly in the treatment plan. The burden placed on the family by the disease usually decreases as the patient grows up. In addition, as the children with diabetes grow up, the influence of their family decreases, whereas that of their peers and schoolmates increases.1,17,19,29

Many young individuals in the present study did not use an insulin infusion pump. Moreover, most had not experienced a hypoglycemic crisis in the 3 months prior to data collection. The incidence of hypoglycemia was not related to the QOL in young patients. Furthermore, it seems that managing diabetes with insulin injections had positive impact on QOL. Young patients who were injecting themselves with insulin reported lower scores on the Disease-Related Worries subscale (= 0.02), as well as overall (= 0.04). Adolescents with diabetes reported better QOL, better psychological status, and higher academic performance when their HbA1c levels were <8% and they were injecting insulin no more than three times per day. Many studies have reported that diabetes treatment based on insulin infusion pumps results in improved metabolic control and a decrease in the incidence of hypoglycemia.28,32–35 New devices, such as pens and machines for the continuous blood glucose monitoring, can lead to tremendous improvements in the QOL of children and adolescents with diabetes.28,32–35

According to the psychometric properties for the specific use of the instrument, there were no available data for establishing convergence validity with another QOL instrument, concurrent validity, and construct validity with factor analysis. The relatively small number of children and adolescents with diabetes limits the generalization of the findings. Moreover, the study population consisted of patients who were attending the Diabetes Center only. Increasing the number of participants, as well as including more pediatric hospitals or diabetes centers, may provide evidence to support the initial findings of the present study. The R2 is extremely low (10%–20%) because there were few independent variables that explained the variance for each subscale score. It seems that there were some variables that were not included in the present study, although they may explain an important portion of the variance of each subscale score, as well as overall. Another limitation of the present study is that we did not investigate the possible existence of a relationship between HbA1c and insulin injections, or the numbers of tests performed, or pump usage; nor was the relationship between these factors and QOL measures evaluated. Therefore, it is of considerable importance to undertake further studies to evaluate the effects of sociodemographic and other factors on the QOL of children and adolescents with diabetes. Such well-designed cross-sectional studies will obviously help identify the potential influence of different factors on the QOL of young patients with diabetes.

Conclusions

The QOL of young patients with diabetes may be affected by demographics, somatometrics, and other disease characteristics. Girls reported a better QOL than did boys. There was also a positive correlation between QOL and glucose blood counts (metabolic control), participation in sporting activities, insulin injections, and parental participation in the diabetes treatment plan. However, older children with a longer duration of diabetes and those who used insulin infusion pumps, with increased levels of HbA1c and BMI, reported a worse QOL. Furthermore, there was no correlation between QOL and the incidence of hypoglycemic crises or the level of parental education.

Disclosure

At the time of submission, no author has any involvement, financial or otherwise, that may potentially bias this work.

Ancillary