Regional updatePsychological health and menopause-specific quality of life of Malaysian women with type 2 diabetes
Introduction
The world prevalence of diabetes is increasing rapidly; diabetes affected 382 million people worldwide in 2013 and the number is projected to rise to 592 million by 2035 (IDF, 2013). The prevalence is expected to shift to the South East Asia Region by 2025, with an estimated prevalence of 13.5% and affecting 145 million people (IDF, 2013; IDF, 2003). In Malaysia, a middle-income, developing country located in the South East Asia Region, the prevalence of diabetes has doubled over the past decade (Hasan et al., 2013a, Hasan et al., 2013b, Hasan et al., 2013c, Zanariah et al., 2010). The National Health and Morbidity Survey I (NHMS-I) conducted in 1986, reported a 6.3% prevalence of diabetes among adults aged ≥35 years; however, the prevalence rose to 8.3% in 1996 and 15.2% in 2011 (Institute for Public Health, 2011, Zanariah et al., 2010). WHO estimates a total of 2.48 million people with diabetes in Malaysia by 2030 (Zanariah et al., 2010). In other developing countries such as China, Brazil and Egypt, diabetes is more prevalent among women, regardless of age (Hu et al., 2001, Wild et al., 2004). The prevalence of diabetes worldwide is similar among men and women although it is more prevalent in women after the age of 65 years (Wild et al., 2004).
Diabetes mellitus is one of the chronic, inherited or acquired diseases where patients experience a number of co-morbidities including physical and psychological problems (Hasan et al., 2013a). Depression and anxiety are two common, co-morbid, modifiable psychological conditions associated with diabetes (Hasan et al., 2013b, Smith et al., 2013), and recent meta-analyses have found significant and positive associations for diabetes with both depression (Hasan et al., 2013b), and anxiety (Smith et al., 2013) although, Brown et al. (2006) found no association. Co-morbid conditions of diabetes with depression and/or anxiety intensify the burden of diabetes symptoms (Katon, 1982, Konen et al., 1996), increase complications (Kaholokula et al., 2003), increase glycaemic levels (Gary et al., 2000), increase non adherence to medications (Lin et al., 2008), and reduce quality of life (Lloyd et al., 2000). Despite the high prevalence of diabetes in the general population in Malaysia (Institute for Public Health, 2011, Zanariah et al., 2010), only a few cohort or case-control studies are available on this topic. These studies support the hypotheses that people with diabetes are more likely to have depression or anxiety symptoms than people who do not have diabetes (Kaur et al., 2013, Subramaniam et al., 2009). Some authors have also suggested that depression and anxiety symptoms are significantly higher in postmenopausal women compared to premenopausal women (Saqsoz et al., 2001).
Type 2 diabetes mellitus is one of the most common chronic diseases in women after menopause (Monterrosa-Castro et al., 2013). However, whether menopausal status independently influences or increases diabetes risk remains controversial (Kim, 2012, Monterrosa-Castro et al., 2013, Szmuilowicz et al., 2009). There is a higher prevalence of diabetes among women with a history of menstrual irregularity (Roumain et al., 1998), particularly in those with long and highly irregular menstrual cycles (Solomon et al., 2001). The increase in abdominal fat caused by depletion of ovarian function (Meyer et al., 2011), may cause disturbances in insulin sensitivity and glucose metabolism in postmenopausal women (Szmuilowicz et al., 2009). The changes in hormonal levels during the menopausal transition and after menopause can trigger fluctuations in blood glucose levels (Otsuki et al., 2007). The changes in hormonal levels may also result in weight gain (Simkin-Silverman and Wing, 2000), sleep (Australian Menopause Society, 2013), and sexual problems (Dennerstein et al., 2003).
Women can experience a number of menopausal symptoms as part of a normal physiological process that often occurs in women at an average age of 50 years (Burger et al., 2002). These symptoms are often attributable to reduced hormone levels and include vasomotor, psychological, musculoskeletal or physical and urogenital or sexual symptoms (Ogbera et al., 2011). These symptoms can affect the quality of life as measured by Menopause Specific Quality of Life (MENQOL) in postmenopausal women (Williams et al., 2009). Women with diabetes generally appeared to have worse quality of life and mental well-being compared to men with diabetes; explicitly, more diabetes-related worries and less ability to cope (Unden et al., 2008). This suggests that diabetes combined with menopausal symptoms may significantly reduce quality of life.
Anxiety and depression are more common among females and those experiencing diabetes and menopause; hence women are the target population in our study (Collins et al., 2009, Grigsby et al., 2002, Khuwaja and Kadir, 2010). Menopausal symptoms experienced by women can vary tremendously from individual to individual, and population to population (Gold et al., 2000, World Health Organization, 1990, World Health Organization, 1996); therefore, there is a need to investigate these symptoms and associated risk factors in different communities. The primary objective of this study was to determine the pattern of menopausal symptomatology in Malaysian women with and without type 2 diabetes. The specific aims of this study include the following: to determine the association between symptoms of depression and anxiety and type 2 diabetes, and MENQOL domains and type 2 diabetes using case-control data; and to compare the symptomatology of menopause in postmenopausal women with and without type 2 diabetes.
Section snippets
Study design and population
This study involved women with diabetes matched to women without type 2 diabetes in the same age range. A frequency matching technique was used to match participants on cell instead of individual basis. The frequency matching was conducted using two conditions: presence or absence of diabetes and aged 35 years or more. The frequency matching was completed in two steps. In the first step, only women aged 35 and older who attended outpatient clinics for the management of T2DM and who had a known
Results
A total of 640 women (320 people with diabetes and 320 people without diabetes) were interviewed, and the socio-demographic characteristics of those with diabetes and those without diabetes are summarised in Table 1. The median age at diagnosis of diabetes was 50 years (Range: 27–70); patients with diabetes were slightly older than those without diabetes, with a mean difference in age of 9.3 ± 1.05. In the diabetes group, most of the participants were of Indian origin (37%), no income (54%), and
Discussion
This study investigated the psychological health and menopause-specific quality of life among pre and postmenopausal women with and without diabetes in Malaysia. In this study, most of the patients with diabetes were of Indian origin (36.6%), followed by Chinese (30.9%) and Malay (30.6%); these demographics are similar to those of NHMS III (Zanariah et al., 2010). Women with diabetes were slightly older than women who did not have diabetes, suggesting that the age range differs between the two
Conclusions
Despite some limitations this study has both clinical and research implications. From the clinical perspective, the results indicate that symptoms of depression and anxiety are more prevalent among women with diabetes than women without diabetes. Both diabetes and psychological issues have negative impact on MENQOL. Except for some aspects, the menopausal symptomatology in Malaysian women with type 2 diabetes is comparable to symptomology among women without type 2 diabetes. The finding that
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