The association between ethnicity and diabetes
specific and diabetes aspecific emotional distress
Characteristics of different ethnical subgroups in patients with diabetes mellitus
Charlotte B. Schmidt, BSC1 Bert Jan Potter van Loon, MD, PHD 1 Inge de Vlieger, MSC1 Frank J. Snoek, PHD2 Adriaan Honig, MD, PHD1,2
1
Sint Lucas Andreas Ziekenhuis (SLAZ), Jan Tooropstraat 164, 1061 AE Amsterdam. 2
Vrije Universiteit medisch centrum (VUmc), de Boelelaan 1117, 1081 HV Amsterdam
13-06-2015
Universiteit van Amsterdam, Faculteit der Maatschappij- en Gedragswetenschappen Charlotte Schmidt, 6000401
Table of contents
Abstract 2
Introduction 3
Research design and methods 4
Results 7
Discussion 14
References 16
Abstract
Background: Patients with diabetes are affected more than twice as often by aspecific
emotional distress compared to the general population. Data on diabetes aspecific and diabetes specific emotional distress in relation to ethnicity vary in the population of patients with diabetes. Since diabetes specific and aspecific emotional distress has been found associated with poor glycemic control and with a decrease in quality of life, it is of use to determine which factors contribute to these two types of emotional distress. The purpose of this study is to determine the association between ethnicity, socioeconomic status, glycated
hemoglobin (HbA1c) and both diabetes specific and diabetes aspecific emotional distress.
Methods: The observational cohort study was conducted in a diabetes outpatient clinic of a
teaching hospital in Amsterdam. About 30% of this hospital population is of non-Dutch ethnic background. Diabetes specific and diabetes aspecific emotional distress was measured by use of the following questionnaires, respectively: Problem Areas in Diabetes Scale, (PAID5) and Extended-Kessler 10, (EK10). Ethnicity (according to CBS-criteria) was determined by use of a 9-item questionnaire. HbA1c and socioeconomic status were derived from the medical charts and residence postal area code. Logistic regression analyses were performed on 570 patients (55% male) with a mean age of 58.5 +/- 14 years. Both PAID5- and EK10-scores were used dichotomous (below and above cut-off) in these logistic regression analyses.
Results: The combined ethnic minorities of Surinamese, Turkish and Moroccan origin, on
average, had higher scores on EK10 and PAID5 than indigenous. Logistic regression analysis revealed a significant association between PAID5 and Moroccan origin (OR = 4.09; 95% CI = 1.60 to 10.49; p < .01), indicating that people of Moroccan ancestry report more diabetes specific emotional distress. Furthermore, EK10-depression and Turkish origin were
significantly associated (OR = 5.62; 95% CI = 1.34 to 23.62; p = .02), indicating that Turkish minorities report more diabetes aspecific emotional distress.
Conclusion: Compared to Dutch patients with diabetes, Moroccan patients with diabetes
report more diabetes specific emotional distress, whilst Turkish patients with diabetes report more diabetes aspecific emotional distress. To our knowledge, this is the first study to describe these results. Physicians should take these findings into account when consulting these ethnic minorities.
Introduction
Patients with diabetes are found twice as likely to report elevated depressive symptoms, defined as diabetes aspecific emotional distress, compared to the general population. Diabetes aspecific emotional distress is defined as depressive and anxiety symptoms, that are not specifically related to diabetes mellitus. By estimate 1 in 6 patients with diabetes experiences diabetes aspecific emotional distress (1), whereas in the general population this figure is 6%. In addition, aspecific emotional distress is associated with a greater decrease of quality of life as to having diabetes-related complications (2) and with higher mortality rates (3). These studies indicate that it is of clinical significance to diagnose and to treat aspecific emotional distress in patients with diabetes. For accurate diagnosis it is helpful to investigate which factors are associated with diabetes aspecific emotional distress in patients with diabetes. Diabetes specific emotional distress seems to be one of these factors.
Besides aspecific emotional distress, about 15% of patients with diabetes report diabetes specific emotional distress (16). Diabetes specific emotional distress is defined as emotional distress directly associated with diabetes mellitus; such as fear of complications, worrying about the disease and mood complaints directly associated with diabetes mellitus. Both diabetes aspecific and diabetes specific emotional distress seem related to ethnic minority. Data on the role of ethnicity and diabetes aspecific and diabetes specific emotional distress in the population of patients with diabetes vary. Previous findings demonstrate, that ethnic minority is related to poor glycemic control in patients with diabetes (4,5). Furthermore, an association has been found between emotional distress and high glycemic blood levels (6, 24). Moreover there are indications that ethnic minorities (i.e. migrants from Turkey, Morocco and Mexican-Americans) report more aspecific emotional distress in general, American, population (7,8). However, data on the role of ethnicity and diabetes aspecific and diabetes specific emotional distress in the population of patients with diabetes vary. Some studies report the combination of belonging to an ethnic minority and having diabetes has been found a predictor for diabetes aspecific emotional distress (9,10), whilst other studies were unable to demonstrate such a relation (11). A recent study evaluated the association between ethnicity and diabetes aspecific emotional distress in patients with diabetes. In this study, one third of all patients with diabetes experienced elevated diabetes aspecific
emotional distress, unrelated to ethnicity (12).However, these findings are based on a relative small sample. As the authors pointed out, the study should be replicated using a larger sample of ethnic minorities. In the present study we sought to do so by using the same questionnaire to measure diabetes aspecific emotional distress (13) in a larger sample of ethnic minorities. Little is known about ethnic minorities and diabetes specific emotional distress in patients with diabetes. Previous findings demonstrate that ethnic minority is a risk factor for disease- specific emotional distress for both cancer patients and patients with other chronic health conditions (18). In this study, disease specific emotional distress was higher in Hispanics and Blacks in comparison to Whites. The results of a study from the Netherlands implicate that ethnic minority is related to diabetes specific emotional distress (29). In this study, Turkish
An additional subtopic regarding diabetes specific emotional distress is the use of the
Problem Areas in Diabetes Scale 5 (PAID5). This is a short version of a questionnaire that is developed to indicate diabetes-specific emotional distress in patients with diabetes (14). Although the psychometric quality of this instrument has been well examined (15) as well as the practical use (16), little is known about the PAID in relation to specific groups. As previously mentioned, diabetes specific emotional distress is associated with poor glycemic control (24). Therefore it is worthwhile to consider the association between ethnicity and diabetes specific emotional distress, measured by means of the PAID5.
In the present study we will explore to what degree ethnicity is related to diabetes specific emotional distress, measured by means of the PAID5 and diabetes aspecific emotional distress, measured by means of the EK10. The question, therefore, is to what extent ethnicity is a predicting variable to diabetes specific emotional distress and diabetes aspecific
emotional distress, independently from quality of life, socioeconomic status, glycated
hemoglobin (HbA1c), body mass index (BMI), sex, age, and type of diabetes. The aim of this cross-sectional study is first, to investigate whether ethnicity is a predicting variable to diabetes specific emotional distress and second, whether ethnicity is a predicting variable to diabetes aspecific emotional distress.
Research Design and Methods
The observational cohort study was executed in the Sint Lucas Andreas Hospital, which is particularly suitable because of its ethnic diversity of its patient population. The study is part of a larger study on patients experiencing diabetes specific emotional distress. Baseline measurements were collected from patients with diabetes (both T1DM and T2DM) visiting the diabetes outpatient clinic. Informed consent was signed by all patients for use of
anonymized data for research purposes. Ethical approval of the study was obtained from the Sint Lucas Andreas Hospital.
Patients
All adult (≥18 years) patients with T1DM or T2DM were requested to complete the
questionnaires. Exclusion criteria were gestational diabetes, or insufficient knowledge of the Dutch, determined as being unable to give informed consent.
Questionnaires
Above mentioned patients of the diabetes clinic were requested by the physician assistants to fill in paper forms as specified below, prior to consultation with the diabetes nurse or
physician. Filling in these forms took 5-10 minutes on average. After giving informed consent, patients were requested to fill in the following forms:
Diabetes-aspecific emotional distress
1. Diabetes-aspecific emotional distress, defined as mood- and anxiety symptoms, was measured by means of the EK10 (Extended 10), an extended version of the Kessler-10 (13). The reason we choose this questionnaire is because it is well examined amongst ethnic minorities. The EK10 contains 10 items about mood on a 5-point Likert scale (scored from 0-4, in which 0 stands for ‘never’ and 4 stands for ‘all the time’), and 5 items about
applicable). All questions evolve around mood and anxiety symptoms during the past month, for example: ‘During the last month, how often were you tired without a clear cause?’ and ‘During the last month, were you anxious or worried most of the time?’. A cutoff score of 20, out of a maximum of 40, was used to indicate mood symptoms. To indicate anxiety
symptoms, a cutoff score of 1 was used (one or more ‘yes’-scores on 5 yes/no– items for anxiety symptoms). Cronbach’s α for the EK10 is 0.94.
Diabetes-specific emotional distress
2. Diabetes-specific emotional distress, defined as emotional distress directly associated with diabetes mellitus; such as fear of complications, worrying about the disease and mood
complaints directly associated with diabetes mellitus, was measured by means of the PAID5 (Problem Areas in Diabetes Short Form) (15). The PAID5 consists of 5 items (only items 3, 6, 12, 16 and 19) derived from a larger questionnaire, the PAID20. These 5 items are
measured on a 5-point Likert scale, scored from 0-4 in which 0 stands for ‘no problem’ and 4 stands for ‘a big problem’. The questions are about problems that are experienced at the moment. For example, participants are asked how much of a problem the following statements cause at the moment: ‘Feeling anxious about my diabetes,’ ‘the feeling that diabetes costs a lot of energy during the day’. A cutoff score of 8, out of a maximum of 20, was used to indicate diabetes-specific emotional distress. A higher score indicates more diabetes-specific emotional distress. Cronbach’s α of the PAID5 ranges from 0.84 to 0.88. Quality of life
3. Quality of life and wellbeing as experienced by the patient was measured by means of the SF12 (Health Survey Short Version) (21). The SF12 contains 12 items derived from a larger questionnaire (the SF-36), that consists of questions about mental and physical health regarding the past 4 weeks. For example: ‘The past 4 weeks, did you achieve less than you would have wanted due to you physical health?’ and ‘How often did you feel calm and peacefully during the past 4 weeks?’. The questionnaire consists of 2 items that are scored from 0-2, 4 items that are scored from 0-1 and 6 items that are scored from 0-4. A description of precise scoring of the SF12 is given by Ware et al., 1995 (21). The SF-12 is used to
measure different concepts of functioning including physical functioning, bodily pain, general health, vitality, social functioning, role functioning emotional, and mental health. Results are expressed in terms of two meta-scores: the Physical Component Summary (PCS) and the Mental Component Summary (MCS). A meta-score ≥50 indicates good health according to the patient, and a score ≤ 49 indicates less good health according to the patient. In our study, the cut-off score was set to 49 for both subscales, indicating less good health according to the patient (21). Cronbach’s α of the SF12 ranges from 0.91 to 0.94.
Ethnicity
Data on ethnicity and nationality were collected by a 9-item questionnaire following CBS-criteria (22). One was considered to be of foreign descent if one or both parents were born abroad. If both parents were born in a different country, we used the descent of the mother. For additional analyses, ethnicity was operationalized in five groups: Dutch, Moroccan, Turkish, Surinamese and Other.
Socioeconomic status
Biological and other parameters (HbA1c, BMI, age, type of diabetes, sex) were obtained from the medical charts, no additional blood samples were derived within the context of this study. Socioeconomic status was estimated based on postal area code in a dichotomous way (0 = high/normal socioeconomic status, 1 = low socioeconomic status). These measurements are based on the postal area codes listed (23). Postal area codes are linked in a national registry which is regularly updated to income, population density, mean % of non-employment (excluding students), and mean education level.
Statistical analyses
SPSS 21.0 was used for statistical analyses. Predictor-outcome ratio was calculated by use of the following formula: N = 10k / p, in which k stands for the number of, possible, predictors, and p stands for the proportion of high (≥ 8) PAID-scores in the population of diabetes patients (20). In this case p is 0.15 (16) and k is 9: Ethnicity, depression, anxiety, quality of life, socioeconomic status, HbA1c, sex, age, and BMI. This results in a sample size of around 600 patients to register an effect of sufficient power.
In advance, an equal distribution comprising all parameters was checked for every group (by means of χ²-tests). The same was done for the group of patients that were excluded prior to analyses, to check whether the results would apply to the general Dutch population of patients with diabetes.
Furthermore, a logistic multivariate regression analysis was performed to investigate to what degree ethnicity is an independent predictor to the PAID5. Unadjusted logistic regression analysis was used to identify predictors. This analysis was executed for 9 variables, to consider whether they were associated with PAID5 (<8 or ≥ 8) or not. These variables were ethnicity, depression (EK10 < 20 or ≥ 20), anxiety (EK10-anxiety < 1 or ≥ 1), quality of life (SF12 < 49 or ≥ 49), socioeconomic status (0 or 1), HbA1c, sex (0 or 1), age and BMI. Subsequently, all variables that were associated (p < 0.05) with PAID5 were included in the logistic multivariate regression analysis.
Logistic multivariate regression analysis was performed in the same manner on EK10 (depression) and EK10 (anxiety). All statistical analyses were performed at an α of 0.05, this indicates that results were considered significant in case p ≤ .05.
Results
Our study population consisted of 1007 patients, of which 203 were excluded due to language problems and 229 were excluded because they refused to participate. A total of 575 patients were analyzed, as shown in Figure 1.
The demographic characteristics of these included patients are shown in Table 1. Mean HbA1c-levels were 62 mmol/l and mean body mass index was 30.1 +/- 6.5, mean age was 58.5 +/- 14 years. No significant differences occurred between the excluded patients, and the included patients in HbA1c-levels, body mass index, gender, age and socioeconomic status. We did not have data on ethnicity for the excluded group of patients.
Table 1, Demographic Characteristics of Included Patients
Characteristic Number Percentage
Gender Male 315 54.7% Female 254 44.1% Missing 6 1.2% Ethnicity Moroccan 73 12.7% Turkish 32 5.6% Surinamese 63 10.9% Dutch 284 49.3% Other 108 18.8% Missing 15 2.7% Socioeconomic status High 360 62.5% Low 205 35.6% Missing 10 1.9% Type of diabetes Type 1 diabetes 140 24.3% Type 2 diabetes 422 73.3% LADA 4 0.7% Missing 9 1.7%
To begin with, we checked the multicollinearity of our variables; all VIF’s (Variance Inflation Factor’s) were < 1.5. This indicates that no multicollinearity was detected (26). In Table 2, the mean EK10 and PAID5-scores are shown, divided by ethnicity.
Table 2, Mean EK10 and PAID5-scores Divided by Ethnicity.
EK10(depression) EK10(anxiety) PAID5
n Mean (SD) ≥20 (%) n Mean (SD) ≥1 (%) n Mean (SD) ≥8 (%)
Total 498 10.1 (8.3) 13.5% 538 0.7 (1.1) 37.8% 543 4.1 (4.7) 19.3% Ethnicity Dutch Moroccan Turkish Surinamese Other 256 55 29 54 95 8.4 (7.1) 14.9 (10.3) 15.4 (10.1) 12.0 (9.0) 9.1 (7.6) 9.4% 27.3% 34.5% 20.4% 6.3% 272 0.5 (0.9) 66 1.3 (1.4) 30 1.2 (1.4) 56 0.9 (1.2) 103 0.5 (1.0) 32.1% 57.6% 51.6% 50.8% 29.1% 273 3.1 (3.7) 68 7.2 (5.3) 29 6.0 (4.9) 59 4.7 (4.6) 104 3.9 (4.5) 12.5% 42.6% 34.5% 22.0% 15.4%
To investigate whether these mean scores differed from each other, we used Mann Whitney tests. These analyses showed that, on average, 1. Ethnic minorities had higher scores on EK10depression than the ethnic majority (Dutch), p <.01. 2. Ethnic minorities had higher
scores on EK10anxiety than the ethnic majority, p <.01 3. Ethnic minorities had higher scores on PAID5 than the ethnic majority, p <.0001.
To investigate whether these higher scores were explained by other factors than ethnicity, we used logistic regression analyses to adjust for possible confounders. Unadjusted logistic regression analysis was used to identify predictors to the outcome variable, and thus which variables should be incorporated in the multivariate logistic regression analysis as possible confounders. We included the mental aspect of quality of life (MCS from the SF12), the physical aspect of quality of life (PCS from the SF12), socioeconomic status, glycated hemoglobin (HbA1c), body mass index (BMI), sex, age, ethnicity, diabetes specific emotional distress and diabetes aspecific emotional distress as independent variables. The variables that were significantly associated with the outcome variable, were then put into multiple logistic regression analyses as possible predictors. The results of the three multiple logistic regression analyses are shown in Table 3b, Table 4b and Table 5b. We used Dutch ethnicity as reference category in all analyses.
Diabetes specific emotional distress
Table 3a shows the results of unadjusted logistic regression analyses, to identify possible predictors to diabetes specific emotional distress (PAID5).
Table 3a, Unadjusted Logistic Regression Analyses of Variables Possibly Associated With Diabetes Specific Emotional Distress (PAID5)
Predictor p eB 95% C.I. Ethnicity Moroccan Turkish Surinamese Other Socioeconomic status Age PCS (SF12) MCS (SF12) EK10depression EK10anxiety HbA1c BMI Sex *p<.05 <.001* <.001* .01* .06 .45 .03* <.001* ..01* .39 <.001* <.001* .08 .36 .44 5.10 3.70 1.99 1.28 1.62 .97 2.38 1.24 10.43 6.56 1.01 1.02 1.18 Lower 2.80 1.59 0.97 0.67 1.05 0.96 1.44 0.76 5.91 4.05 1.00 0.98 0.77 Upper 9.27 8.62 4.05 2.43 2.50 0.99 3.94 2.01 18.40 10.62 1.03 1.05 1.81
All parameters that were significantly associated with PAID5 (p<.05) were included in the multivariate logistic regression analysis. The results of this analysis are shown in Table 3b.
Table 3b, Multiple Logistic Regression Analysis of Predictors Associated With Diabetes Specific Emotional Distress (PAID5)
Predictor β S.E. Wald χ ² p eB 95% C.I.
Ethnicity Moroccan Turkish Surinamese Other Socioeconomic status Age PCS (SF12) EK10depression EK10anxiety Constant 1.41 .43 .43 .32 .42 .03 -.02 -1.81 .92 1.66 .48 .63 .51 .43 .36 .01 .01 .41 .34 1.17 8.70 8.60 .45 .72 .56 1.35 7.65 2.47 19.90 7.17 2.02 .07 <.01* .50 .40 .45 .25 .01* .12 <.001* .01* .16 4.09 1.53 1.54 1.38 1.53 .97 .98 6.08 2.50 5.26 Lower 1.60 0.44 0.57 0.60 0.32 0.95 0.98 2.75 1.28 Upper 10.49 5.30 4.20 3.18 1.34 0.99 1.01 13.46 4.89
Note R² = .35 (Nagelkerke), Hosmer & Lemeshow Goodness of Fit χ ² (8) = 6,79 , p = .56 *p<.05
Table 3b shows a significant association between both PAID5 and EK10-depression (OR = 6.08; 95% CI = 2.75 to 13.46; p <.0001) and EK10anxiety (OR = 2.50; 95% CI = 1.28 to 4.89; p <.01). In addition, PAID5 and Moroccan origin were significantly associated (OR = 4.09; 95% CI = 1.60 to 10.49; p < .01). This indicates that the odds of having diabetes
specific emotional distress increase by 4.09 for patients of Moroccan origin, in comparison to indigenous. Other ethnicities and PAID5 were not associated.
Furthermore, PAID5 and lower age were associated, indicating that lower age increases the odds of diabetes specific emotional distress (OR = 0.97; 95% CI = 0.95 to 0.99; p < .01). PAID5, socioeconomic status and quality of life were not associated.
Diabetes aspecific emotional distress (depression)
Table 4a shows the results of unadjusted logistic regression analyses, to identify possible predictors to diabetes aspecific emotional distress (EK10-depression).
Table 4a, Unadjusted Logistic Regression Analysis of Variables Possibly Associated With Diabetes Aspecific Emotional Distress (EK10-depression)
Predictor p eB 95% C.I. Ethnicity Moroccan Turkish Surinamese Other Socioeconomic status Age PCS (SF12) MCS (SF12) PAID5 EK10anxiety HbA1c BMI Sex *p<.05 <.001* <.01* <.001* .02* .37 <.01* .04* <.001* .17 <.001* <.001* .02* .11 .74 3.54 5.09 2.47 0.65 2.10 0.98 0.95 0.98 10.43 18.68 1.02 1.03 1.09 Lower 1.71 2.12 1.13 0.26 1.24 0.97 0.92 0.95 5.91 8.67 1.00 0.99 0.65 Upper 7.31 12.19 5.42 1.65 3.55 1.00 0.97 1.01 18.40 40.25 1.04 1.07 1.84
All parameters that were significantly associated with EK10-depression (p<.05) were
included in the multivariate logistic regression analysis. The results of this analysis are shown in Table 4b.
Table 4b, Multiple Logistic Regression Analysis of Predictors Associated With Aspecific Emotional Distress (EK10-depression)
Predictor β S.E. Wald χ ² p eB 95% C.I.
Ethnicity Moroccan Turkish Surinamese Other Socioeconomic status Age PCS (SF12) EK10anxiety PAID5 HbA1c Constant .48 1.73 .65 -.22 -.27 -.00 1.64 2.59 1.86 .00 -5.24 .62 .73 .61 .63 .45 .02 .43 .53 .43 .01 1.41 6.77 .60 5.57 1.14 .12 .38 .01 14.75 23.93 18.62 .00 .01 .15 .44 .02* .29 .73 .55 .94 <.001* <.001* <.001* .99 <.001* 1.62 5.62 1.92 .80 .76 1.00 5.17 13.27 6.45 1.00 13.04 Lower .48 1.34 .58 .23 .32 .97 2.24 4.71 2.77 .97 .01 Upper 5.49 23.62 6.40 2.77 1.85 1.03 11.97 37.38 15.05 1.03
Note R² = .52 (Nagelkerke), Hosmer & Lemeshow Goodness of Fit χ ² (8) = 3.82 , p = .87 *p<.05
___________________________________________________________________________
Table 4b shows a significant association between EK10depression and PAID5 (OR = 6.45; 95% CI = 2.77 to 15.05; p <.0001) and between EK10depression and EK10anxiety (OR = 13.27; 95% CI = 4.71 to 37.38; p <.0001). In addition, EK10depression and Turkish origin were significantly associated (OR = 5.62; 95% CI = 1.34 to 23.62; p = .02). This indicates that the odds of aspecific emotional distress increase by 5.62 for Turkish patients, in comparison to indigenous. There was no association between other ethnicities and EK10depression.
Furthermore, there was a significant association between EK10depression and the physical aspect of quality of life (PCS) indicating that lower experienced physical quality of life is associated with increased odds of aspecific emotional distress (OR = 5.17; 95% CI = 2.24 to 11.97; p <.0001). EK10depression, socioeconomic status and age were not associated. Diabetes aspecific emotional distress (anxiety)
Table 5a, Unadjusted Logistic Regression Analysis of Variables Possibly Associated With Diabetes Aspecific Emotional Distress (EK10-anxiety)
Predictor p eB 95% C.I. Ethnicity Moroccan Turkish Surinamese Other Socioeconomic status Age PCS (SF12) MCS (SF12) PAID5 EK10depression HbA1c BMI Sex *p<.05 <.001* <.001* .03* <.01* .79 <.001* .25 <.001* .41 <.001* <.001* <.01* .11 .06 3.54 2.22 2.30 .94 1.98 .99 .97 .99 6.55 18.68 1.02 1.02 1.38 Lower 2.97 1.06 1.32 .59 1.40 .98 .95 .97 4.05 8.67 1.01 1.00 .98 Upper 5.05 4.64 3.99 1.51 2.82 1.01 .98 1.01 10.62 40.25 1.03 1.05 1.93
All parameters that were significantly associated with EK10-anxiety (p<.05) were included in the multivariate logistic regression analysis. The results of this analysis are shown in Table 5b.
Table 5b, Multiple Logistic Regression Analysis of Predictors Associated With Aspecific Emotional Distress (EK10anxiety)
Predictor β S.E. Wald χ ² p eB
95% C.I. Ethnicity Moroccan Turkish Surinamese Other Socioeconomic status PCS (SF12) EK10depression PAID5 HbA1c Constant .03 -.45 .41 -.12 .68 -.01 2.28 .96 .02 -1.83 .45 .60 .42 .33 .28 .01 .49 .35 .01 .84 2.09 .00 .55 .96 .12 6.11 1.69 21.68 7.76 4.36 4.69 .72 .95 .46 .33 .66 .01* .19 <.001* .01* .04* .03* 1.03 .64 1.51 .73 1.97 .99 9.81 2.61 1.02 .16 Lower .43 .20 .66 .47 1.15 0.97 3.75 1.33 1.00 Upper 2.48 2.08 3.45 1.70 3.38 1.01 25.63 5.14 1.04
Note R² = .30 (Nagelkerke), Hosmer & Lemeshow Goodness of Fit χ ² (8) = 4.43, p = .82 *p<.05
_______________________________________________________________________ Table 5b shows a significant association between EK10anxiety and EK10depression (OR = 9.81; 95% CI = 3.75 to 25.63; p <.0001) and between EK10anxiety and PAID5 (OR = 2.61; 95% CI = 1.33 to 5.14; p < .01). Furthermore, EK10anxiety and socioeconomic status were significantly associated (OR = 1.97; 95% CI = 1.15 to 3.38; p = .01) as well as EK10anxiety and HbA1c (OR = 1.02; 95% CI = 1.00 to 1.04; p = 0.04). There were no associations between EK10anxiety and ethnicity and quality of life.
Discussion
The purpose of this study was to investigate whether ethnicity is associated with diabetes specific emotional distress, and with diabetes aspecific emotional distress.
The results revealed that diabetes specific emotional distress is associated with the ethnic subgroup of Moroccan minorities in the Netherlands. These findings demonstrate that Moroccans with diabetes report more diabetes specific emotional distress, in comparison to other ethnicities. In addition, diabetes specific emotional distress is associated with lower age, which is in consonance with previous findings on this topic (24).
Furthermore, according to the results diabetes aspecific emotional distress is associated with Turkish minorities in the current cohort. This indicates that this subgroup reports more diabetes aspecific emotional distress, in comparison to other ethnicities; a finding which is in line with previous studies in general Dutch population (8). In addition, diabetes aspecific emotional distress is associated with the physical aspect of quality of life. This means that patients who consider their physical quality of life to be low, report more diabetes aspecific emotional distress.
In terms of the anxiety part of diabetes aspecific emotional distress, our results revealed no independent association with ethnicity. Factors that were associated with the anxiety part of diabetes aspecific emotional distress were socioeconomic status and HbA1c. This indicates that the anxiety part of diabetes aspecific emotional distress is both associated with lower socioeconomic status, and with higher HbA1c. Whilst Santos et al. (2013) found the
depression part of diabetes aspecific emotional distress to be associated with HbA1c (6), we found an association with the anxiety part of diabetes aspecific emotional distress. One thing that could explain these different findings, is that we found an association with HbA1c and depression in our unadjusted analysis, but not in the analysis that was adjusted for ethnicity, quality of life and anxiety. It could be that one of these confounding factors explain the association between depression and HbA1c. Furthermore, our population consisted of mostly (75%) T2DM patients, whilst their population consisted of T1DM patients only. It could be that the effect of emotional distress on glycemic control differs between these two types of diabetes. In addition, the mean age in our population was higher than the mean age in the population of Santos et al., who studied young adolescents.
To our knowledge this is the first study to describe the associations between ethnic subgroups and diabetes specific and diabetes aspecific emotional distress, a part from other contributing factors. What is particularly interesting about our findings, is that the independent
associations between diabetes specific and diabetes aspecific emotional distress differ between different types of ethnicity. Whilst diabetes specific emotional distress is more associated with Moroccan ethnical minorities, diabetes aspecific emotional distress is more associated with Turkish ethnical minorities. We do not have a clear explanation for this finding. It could be that Moroccans are more concerned about their diabetes (resulting in diabetes specific emotional distress), due to poor psycho-education on this topic. We did not include how often patients consulted their physician or diabetes nurse, but during follow-up we noticed that a lot of elderly Moroccan patients visited Morocco on a regular basis for months at a time. This could result in the fact that they do not meet with their caregiver as often as patients from other ethnicities, and that they are therefore less educated in their disease. A recent systematic review and meta-analysis showed that adequate education about diabetes reduces diabetes specific emotional distress in patients with diabetes (27).
Since diabetes specific distress concerns around 19% of our patient population, it is important to stress methods to reduce this type of distress. As education appears to be effective in reducing diabetes specific emotional distress (25), more attention to different forms of diabetes education is required. In clinical practice, it is important to incorporate diabetes education that is accessible for all patient groups, including ethnic minorities. Considering our findings that Moroccans report diabetes specific emotional distress more often,
language problems (20%). This means that 42% of the initial patient group was excluded. It is plausible that selection bias has occurred; it could be that the subgroup of patients with worse diabetes regulation, more diabetes specific or diabetes aspecific emotional distress, or numerous comorbid diseases did not fill in the questionnaires. Previous findings demonstrate that no-show is high amongst patients with a current depressive episode (28). Therefore these specific types of patients might be under represented in our sample. Furthermore, we did not take into account the number of comorbid chronic diseases, which is a component of diabetes aspecific emotional distress (12). We tried to overcome this limitation with deriving
information from the medical charts, but since this information was insufficient for most patients we decided not to incorporate these findings. Therefore it could be that not ethnicity, but the number of comorbid chronic diseases is an important predictor for diabetes aspecific and diabetes specific emotional distress.
Further study should focus on replicating our findings, whilst taking into account the number of comorbid chronic diseases. Furthermore, future research should focus on diabetes
education programs for different ethnical subgroups. By example, a qualitative study with patient interviews would help to address the aspects different ethnical subgroups would look for in diabetes education (what form of education, how often, given by whom and in what manner).
To our knowledge, this is the first study to discover that Moroccan patients with diabetes report more diabetes specific emotional distress, whilst Turkish patients with diabetes report more diabetes aspecific emotional distress. Physicians should take these findings into account when consulting these ethnic minorities.
References
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Appendix
Informed consent
Onderzoek naar depressie bij mensen met diabetes mellitus (suikerziekte)
Geachte heer/ mevrouw,
Hierbij zouden wij uw medewerking willen vragen aan een onderzoek dat wij doen op de polikliniek Interne geneeskunde bij mensen met diabetes mellitus (suikerziekte).
De Nederlandse Diabetes Federatie, waarin ook de Diabetes Patiënten Vereniging (DVN) vertegenwoordigd is, heeft een richtlijn geschreven met daarin het advies alle mensen met suikerziekte te onderzoeken op een mogelijke depressie. Depressie komt veel voor in de algehele bevolking, ongeveer 6-8 % van de ogenschijnlijk gezonde mensen is depressief. Bij mensen met suikerziekte is dit getal veel hoger, ongeveer 18 %. Mensen met depressie voelen zich vaak ongelukkig en dat heeft een grote invloed op hun kwaliteit van leven. Daarnaast tast een depressie ook de gezondheid aan. Vaak hebben mensen zelf niet door dat ze een depressie hebben. Juist daarom is het advies gekomen om te screenen op een depressies via vragenlijsten. Op deze manier kan een depressie vroegtijdig ontdekt worden en kan in een vroege fase een behandeling aangeboden worden voor de depressie.
Wanneer er bij u uit de vragenlijst aanwijzingen komen voor een depressie, dan zullen we dat in een team bespreken en u daarvoor een voorstel doen voor extra begeleiding. Het is een voorstel, dat de diabetesverpleegkundige met u zal bespreken. U bent niet verplicht deze extra begeleiding aan te nemen.
Bij mensen met suikerziekte is bovendien het hebben van suikerziekte een extra belasting en de mate van belasting van de suikerziekte kan een rol spelen bij het al dan niet ontwikkelen van een depressie en ook de behandeling ervan. Daarom hebben wij ook een diabetes specifieke vragenlijst aan het onderzoek toegevoegd. Deze vragenlijst wordt elders al uitgebreid toegepast.
Om vragenlijsten goed te kunnen beoordelen is er altijd extra informatie nodig over hoe u dagelijks in het leven staat en daarvoor is de derde vragenlijst die we u aanbieden om in te vullen. Dit betreft vragen over hoe u uw gezondheidstoestand ervaart.
Het invullen van bovengenoemde lijsten kost ongeveer 20 minuten en kan gedaan worden in de wachtkamer voor arts of diabetesverpleegkundige en kan anoniem worden ingeleverd in een postbus. De lijsten zullen 3x in een jaar worden afgenomen.
We vragen u toestemming deze vragenlijsten bij u af te nemen, de uitslagen van deze vragenlijsten anoniem te verwerken tezamen met gegevens uit uw medisch dossier. De gegevens zullen niet herleidbaar zijn tot uw persoon. Onze bedoeling is deze gegevens uiteindelijk in een artikel in een wetenschappelijk tijdschrift te publiceren.
Uw deelname is geheel vrijwillig, als u niet wilt meedoen met het onderzoek zal dat op geen enkele wijze uw reguliere behandeling beïnvloeden. Ook als u uw toestemming heeft
gegeven en later besluit uw toestemming terugtrekt, zal dat op geen enkele wijze uw reguliere behandeling beïnvloeden. Uw gegevens zullen dan niet gebruikt worden voor het verdere onderzoek.
Onderzoek naar depressie bij mensen met diabetes mellitus (suikerziekte)
Ik verklaar dat ik voldoende uitleg heb gekregen over de aard, uitvoering en gevolgen van het onderzoek “Onderzoek naar Depressie bij mensen met diabetes mellitus (suikerziekte)” , en voldoende tijd heb gehad om hierover na te denken en hierover vragen te stellen. De vragen zijn voldoende beantwoord.
Ik besef dat mijn deelname aan deze studie vrijwillig is en dat ik te allen tijde mijn medewerking aan deze studie kan opzeggen.
Naam:……….. Geboortedatum:………... Handtekening:………. Datum:……….
Ik verklaar dat ik bovengenoemde patient voorgelicht heb over aard, uitvoering en gevolgen van het onderzoek “Onderzoek naar Depressie bij mensen met diabetes mellitus
(suikerziekte)” , en de daaruit voortvloeiende vragen heb beantwoord. Naam:………..
Functie:………... Handtekening:………. Datum:……….
Nationaliteit
De volgende vragen gaan over uw nationaliteit.
1.Welke nationaliteit(en) heeft u? (Meerdere antwoorden mogelijk)
………
2.Tot welke etnische groep rekent u zichzelf? (Kruis aub één hokje aan)
□ Nederlanders □ Turken □ Marokkanen □ Hindoestaanse Surinamers □ Creoolse Surinamers □ Antillianen □ Overig: ………..
3.In welk land bent u geboren?
□ Nederland
□ Anders: ………..
4.In welk land zijn de volgende personen geboren?
a.Uw biologische vader:
□ Nederland
□ Anders: ……….
b.Uw biologische moeder:
□ Nederland
□ Anders: ……….
c.De biologische vader van uw vader (uw grootvader van vaders kant):
□ Nederland
□ Anders: ……….
e.De biologische moeder van uw vader (uw grootmoeder van vaders kant):
□ Nederland
□ Anders: ………
f.De biologische moeder van uw moeder (uw grootmoeder van moeders kant):
□ Nederland
EK10
De volgende vragen gaan over de afgelopen maand. Wilt u alle vragen beantwoorden door het juiste vakje aan te kruisen?
altijd meestal soms af en
toe
nooit
1 Hoe vaak voelde u zich erg vermoeid zonder duidelijke reden?
2 Hoe vaak voelde u zich zenuwachtig?
3 Hoe vaak was u zo zenuwachtig dat u niet tot rust kon komen?
4 Hoe vaak voelde u zich hopeloos?
5 Hoe vaak voelde u zich rusteloos of ongedurig?
6 Hoe vaak voelde u zich zo rusteloos dat u niet meer stil kon zitten?
7 Hoe vaak voelde u zich somber of depressief?
8 Hoe vaak had u het gevoel dat alles veel moeite kostte?
9 Hoe vaak voelde u zich zo somber dat niets hielp om u op te vrolijken?
10 Hoe vaak vond u zichzelf afkeurenswaardig, minderwaardig of waardeloos?
ja nee
11 Heeft u in de afgelopen maand een paniekaanval gehad, waarbij u zich plotseling bang of angstig voelde of plotseling veel lichamelijke verschijnselen kreeg?
12 Heeft u in de afgelopen maand een sterke angst gehad om alleen uit huis te gaan, in een menigte te zijn, in een rij te staan of om met de bus of trein te reizen?
13 Heeft u in de afgelopen maand een sterke angst gehad om iets te doen in het bijzijn van andere mensen, zoals praten, eten of schrijven?
15 Gebruikt u momenteel medicijnen voor angst, depressie, spanning of stress?
Omcirkel het antwoord dat op u van toepassing is:
Krijgt u momenteel psychologische of psychiatrische hulp?
Ja / Nee
Krijgt u momenteel medicatie voor psychische klachten?
Ja / Nee
PAID 5
Geef bij elk van de volgende onderwerpen aan in hoeverre dit voor u op dit moment een probleem vormt. Kruis daarvoor het best passende antwoord aan.
Geen probleem Een beetje een probleem Enigszins een probleem Behoorlijk een probleem Een groot probleem 1 U angstig voelen als u denkt aan diabetes? 2 U somber voelen bij de gedachte aan diabetes? 3 U zorgen maken over de toekomst en de kans op complicaties?
4 Het gevoel dat uw diabetes
dagelijks teveel energie kost?
5 Het gevoel dat u bij uw diabetes niet door uw vrienden en familie wordt gesteund?
SF-12
1. Zou u, in het algemeen, zeggen dat uw gezondheid uitstekend, zeer goed, goed, matig of slecht is?
Uitstekend Zeer goed Goed Matig Slecht
De volgende vragen gaan over activiteiten die u tijdens een doorsnee dag zou
kunnen verrichten. Beperkt uw gezondheid u tijdens deze activiteiten? Zo ja, hoeveel?
2. Matige activiteiten zoals het verplaatsen van een tafel, stofzuigen, bowlen of golfen. Beperkt uw gezondheid u hierbij:
Veel Een beetje Helemaal niet
3. Meerdere trappen oplopen. Beperkt uw gezondheid u hierbij:
Veel Een beetje Helemaal niet
4. Heeft u in de afgelopen 4 weken minder bereikt dan u zou willen door uw lichamelijke gezondheid?
Nee Ja
5. Was u in de afgelopen 4 weken beperkt door uw lichamelijke gezondheid in uw werk of andere veelvoorkomende activiteiten?
Nee Ja
6. Heeft u in de afgelopen 4 weken minder bereikt dan u zou willen door emotionele problemen, zoals gevoelens van somberheid of angst?
Nee Ja
UW ALGEHEEL WELBEVINDEN
7. Heeft u in de afgelopen 4 weken uw werk of andere veelvoorkomende
activiteiten minder zorgvuldig dan gewoonlijk gedaan door emotionele problemen, zoals gevoelens van somberheid of angst?
Nee Ja
buitenshuis als uw huishoudelijke activiteiten?
Helemaal niet Enigszins Matig Vrij veel Enorm
De volgende vragen gaan over hoe u zich voelt en hoe het met u is gegaan de afgelopen 4 weken. Geef svp voor iedere vraag, het antwoord dat het dichtst in de buurt komt van hoe u zich heeft gevoeld.
9. Hoeveel tijd gedurende de afgelopen 4 weken voelde u zich kalm en vredig?
De hele tijd Meestal Vrij vaak Zelden Helemaal nooit
10. Hoeveel tijd gedurende de afgelopen 4 weken had u veel energie?
De hele tijd Meestal Vrij vaak Zelden Helemaal nooit
11. Hoeveel tijd gedurende de afgelopen 4 weken voelde u zich somber?
De hele tijd Meestal Vrij vaak Zelden Helemaal nooit
12. In de afgelopen 4 weken, hoeveel verstoorde uw lichamelijke gezondheid of emotionele problemen uw sociale activiteiten, zoals bezoeken van vrienden, familie etc.?
Socio-economische status
Lijst met achterstandswijken, volgens het Achterstandswijk Ondersteuningsfonds Amsterdam (2014) 1021 B, C, E, G, H, L, N, P, R, T, V. 1022 A, B, C, W, X. 1024 A, B, C, D, E, G, H, J, K, L, M, N, P, R, S, T, V, W, X. 1027 E 1031 A, B, C, D, E, G, J, T, V, X 1032 A, B, C, E, G, H, J, V, X, Z. 1053 D, H, J, K, M, N, P, R. 1055 A, D, E, G, H, J, K, L, M, N, P, R, S, T, V, W, X, Z. 1056 H, X. 1057 A, K, N, P. 1058 E 1061 A, B, C, D, E, G, H, J,M, S, T, V, W, X. 1062 A, B, C, D, J. 1063 A, B, C, E, G, H, J, K, M, N, P, S, T, V, X, Z. 1064 A, B, C, D, E, G, H, J, K, L, M, N, P, R, S, T, V, X, Z. 1067 A, C, D, E, G, J, K, L, N, P, R, X, Z. 1068 C, P, V. 1069 A, B, D, G, H, J, K, R, S, X, Z. 1073 G, H, J, K, L, N, P, R, S. 1074 G, H, J, S, T, V. 1091 L, N, P, W, X, Z. 1092 G, H, J, K, S, V, X. 1093 A, B, C, D, E, G, H, J, K, L, M, N, R, S, T, V, W, X, Z. 1094 A, B, C, E, G, H, J, K, L, M, N, P, R, S, T, V, X, Z. 1095 A, B, C, D, E, G, H, J, L, R, S, T, V, W, X, Z. 1097 G, H, S, T, V, W, X, Z. 1102 A, B, C, D, E, G, H, J, K, L, M, N, P, R, S, T, V, W, X, Z. 1111 LZ, PD, PE, PG, PH, PJ, PK, PL, RA, RB. 1112 C, T, X. 1312 A, B.
1314 N, R, T, V. 1503 A, B, C, E, G, T, V. 1504 A, B, C, D, E, G, H, J, K, L, N. 1622 B, N, Z. 1628 N. 1782 A, L, M. 1784 C, D, G, K, L. 1787 R. 1813 D, E, J, L. 1824 X 2033 S, T, V, W, X, Z. 2035 A, B, C, E, L, R, S, T, V, W, X. 2316 C, E, G, H, K, N, P, R, S, T.
