CC BY
56
Hanmehmet Kh. R., Ismailov S. I., Alimova N. U.
Tashkent Pediatric Medical Institute Republican Specialized Scientific-Practical Medical Center of Endocrinology of the Ministry of Health of the Republic of Uzbekistan
E-mail: [email protected]
QUALITY OF LIFE ASSESSMENT IN CHILDREN AND ADOLESCENTS WITH TYPE1 DIABETES MELLITUS ON INSULIN PUMP THERAPY IN UZBEKISTAN
Abstract.
Background: Worldwide, 5-10% of diabetes cases are type 1 diabetes mellitus (T1DM). Despite intensive research, T1DM is presently incurable. Over the past three decades, diabetes management has increasingly benefited from innovations in technologies aimed at diabetes care.
Purpose: The purpose of this study was to assess the quality of life in children and adolescents with type 1 diabetes mellitus on insulin pump therapy in Uzbekistan
Materials and methods: Twenty children with type 1 diabetes who were on insulin pump therapy participated in the study 12 boys and 8 girls (mean age 12.3 ± 0.7 years). Russian version of the Diabetes Quality of Life for Youth Pediatric Quality of Life (DQOLY-SF) questionnaire was used in our study.
Results of the study: impact of diabetes symptoms decreased by 5%, impact of treatment by 8.2%, impact on daily activities improved by 7.7%, relationship with parents became better by 14.3%. Worries associated with diabetes decreased almost twice. Perceptions of health changed for the better side by 2.3%.Overall quality of life assessment showed an improvement in QOL by 7%.
Conclusion: the results of the conducted study demonstrate that the use of modern technologies is accompanied by the improvement of not only of glycemic control, but also the quality of life of children and adolescents with type 1 diabetes.
Keywords: quality of life, insulin pump therapy, diabetes mellitus in children and adolescents.
Introduction
According to IDF, 542,000 children (0-14 years) with type 1 diabetes mellitus (T1DM) were registered in the world in 2015, of which 86.000 were newly diagnosed. [1] The prevalence of type 1 diabetes varies considerably in different countries, within one country and in various ethnic groups. Most often it occurs in Finland [2], in Nordic countries [3; 4] and Canada [5]. Among Europeans living in Europe, the frequency of occurrence is 20-fold scatter [6] and correlates with the incidence of HLA genes in the population[7]. Of the approximately 500,000 children with T1DM which constituted about 26% from Europe and 22% from North America and the Caribbean. In Asia, the incidence of T1DM is very low: South-East Asia recorded 149,300 children and adolescents with type 1 diabetes. In 2017, according to the International Diabetes Federation, approximately 19,500 newly identified children and adolescents were registered. India is on the second place in the world with type 1 diabetes after the United States, the number of incidents is 128.500 [8; 12; 17]. In Republic of Uzbekistan by the period 01.01.2017, 2532 patients with type 1 diabetes
mellitus were registered and added to dispensary record. Children with type 1 diabetes mellitus compromise 1791 and adolescents 741. On the period of 10 years, the prevalence of type 1 diabetes among children in the Republic increased from 10.6 to 19.8 per 100,000 children for the period 2006-2016. As for adolescents, this indicator has doubled from 22.2 to 41.2 per 100,000 adolescents. The incidence in 2016 was 2.3 per 100000 children, at the same time it should be noted that the incidence among adolescents for 10 years increased by 3 times. In 2006, the 100000 adolescent population had a morbidity rate of 2.6, in 2016 this figure was 6.9 [18].
In accordance with the "St. Vincent Declaration", the main directions of the medical and social policy regarding diabetes should be aimed at minimizing its growth, development of complications and improving the quality of life (QoL) in patients of all age groups [15]. From the moment of manifestation of type 1 Diabetes mellitus patients should be introduced with insulin therapy in the basal-bolus regimen (ISPAD2017).
Insulin pumps fundamentally new and progressive step in the treatment of diabetes [16]. Insulin pumps provide better
glycemic control compared to the multiple daily injections of insulin (MDI) regime and significantly reduce the incidence of hypoglycemia, which is one of an important aspects in the compensation of diabetes. Worldwide Insulin pump therapy is used quite often not only in type 1 diabetes, but also up to 34% of adult patients with DM 2 in the US and up to 25% in Europe use pumps to administer insulin. In Russia the number ofpump users is progressively increasing and by 2014 it has been about 10.000 people [9]. Researchers from European countries have shown that QOL depends on many factors - age, gender, duration of the disease, family relationships, treatment methods and others. It is quite obvious that long-term maintenance of glycemic targets with low QOL or at the cost of its reduction, for example, the need to increase the frequency of self-monitoring and the number of daily injections often sharply reduces QOL. For a patient it may be more important to evaluate a happy family life, an opportunity to enj oy a hobby, personal finances rather than wellbeing. Patient-oriented questionnaires for assessment of quality of life, where a person with diabetes determines and evaluates important things for the patient and gives higher QOL score to those using continuous subcutaneous insulin infusion (CSII) compared to MDI [14]. Only one large multicenter prospective study was published that evaluated satisfaction with treatment and QOL in patients using the integrated continuous blood glucose monitoring system and continuous subcutaneous insulin infusion (RT-CGM / CSII) systems [10]. Along
with the improvement of QOL, CSII is an effective and safe diabetes treatment method in children and adolescents, of which only a small part of patients continue insulin therapy in MDI regime after 6-12 months of using CSII) [11]. It is also important to emphasize that CSII provides better glycemic control compared with the MDI together with significant reduction in the incidence of hypoglycemia [13].
In order to extensive the use of intensive care methods such as MDI and insulin pumps in Uzbekistan, tables for assessing the carbohydrate value in Uzbek and Eastern cuisine in Bread Units (BU) were developed. An electronic base for integration into specialized computer programs for better calculation of type of bolus depending on food was prepared.
Thus assessment of QOL is very important when transferring patients with type 1 diabetes from MDI to insulin pump therapy.
Purpose: The purpose of this study was to assess the quality of life in children and adolescents with type 1 diabetes mellitus on insulin pump therapy, with consideration the carbohydrate value in Uzbek national food.
Methods and materials of the research.
Twenty children with type 1 diabetes who were on pump insulin therapy participated in the study. A group of patients with type 1 diabetes was formed from the number of patients at the city Endocrinology dispensary in Tashkent and the Region Endocrinology dispensary of the Tashkent.
Table 1. - Clinical characteristic of the patients
The indicators of the groups
The number of the patients N = 20
Average age 12.3 ± 0.7
Sex Boys 12
Girls 8
Duration of the disease 4.5 ± 0.7
complications no
Duration of control 12 months
General clinical observation of the patients included: Weight, height SDS, blood glucose and glycated hemoglobin
All patients have been investigated by standardized clinical-laboratory observation, which included collection of anamnesis, the physical observation of the patients, laboratory and instrumental investigation, and assessment of the quality of the life with the questionnaire.
General clinical observational methods consisted of:
a) questionnaire, constructed protocol of research;
b) anthropometric methods of assessment of physical development, which is the measurement of the weight, height SDS by percentiles(WHO 2007);
c) functional methods of investigation (ECG);
d) Biochemical investigations (urine assay, creatinine);
e) Consultation of the oculist whit the direct ophthalmoscopy of the eyeground.
Clinical methods of the investigation.
Indicators of the compensation of the carbohydrate metabolism have been assessed by the recommendations of ISPAD (International Society for Pediatric and Adolescent Diabetes) published in 2014.
For the assessment of QOL of the patients with type 1 diabetes mellitus Russian version of the questionnaire of Diabetes Quality of Life for Youth Pediatric Quality of Life (DQOLY-SF) was used. This questionnaire is distinguished by high reliability, validity and sensitivity and allows to ob-
jectively assess the quality of life of children and adolescents with type 1 diabetes.
In the present study, blocks for the age groups 8-12 and 13-18 years were used. The DQOLY-SF questionnaire includes 22 questions relating to scales assessing quality of life factors: the impact of diabetes symptoms, the impact of treatment, the impact on daily activities, relationships with parents, experiences related to diabetes, health perception. In addition, during the survey, it is possible to count the total scores of various scales of the questionnaire.
Each question has five possible options for assessing the degree of one or another concern from 0 to 4, with 0 - never, and 4 - constantly. A higher score indicates a more negative impact of diabetes and a worse quality of life, lower scores are associated with good QOL. The evaluation of each subsection is made separately by summing up the scores for each sub-item question. The emphasis on the sum of points in each subsection, in contrast to the total score, makes it possible to assess the problem in more detail in a separate area.
The total number of points after recoding (transfer of raw data to life quality scores) was calculated on a 100-point scale; The lower the value, the higher the quality of life of the child.
The following formulas were used in the explanation to the questionnaire:
This questionnaire was provided to patients for completion before group training on a structured program and after the completion of the annual follow-up period. All patients signed informed consent to participate in the study.
Results:
The use of insulin pump therapy has a positive impact on all aspects of the quality of life detected by the questionnaire DQOLY-SF. The greatest improvements were noted in such aspects of quality of life as the impact of diabetes symptoms, the impact of treatment, the impact on daily activities, relationships with parents. Moreover, worries associated with diabetes decreased by almost twice. Against background of investigation and modified therapy according improvement of carbohydrate metabolism there were registered positive dynamic of the main aspects of the QOL. For the children under 12 year and for the parents of the children younger 12 have been suggested to fill up the questionnaire of QOL before and after using 1 year of pump insulin therapy.
By evaluating of quality of life we got following results (table. 2).
Table 2.- Comparative assessment of quality of life of patients with type 1 diabetes mellitus before and after using CSII for 1 year
Quality of life parameters Score before CSII (%) Score after 1 year of using CSII (%) Score % P value
Influence of symptoms of diabetes mellitus 23 18 45 < 0.05
Effect of treatment 27.8 19.6 48.2 < 0.05
Impact on daily activities 13.6 5.9 47.7 < 0.05
Relations with parents 62 47.7 |14.3 < 0.05
Anxiety associated with diabetes 40 22.4 417.6 < 0.05
Perception of health 50 47.7 42.3 < 0.05
Overall assessment of QOL 29.5 22.3 47.2 < 0.05
Table 2 shows statistically significant differences in the quality of life indicators obtained when the questionnaire was filled by children and parents before the initiation of CSII and after 1 year. After transferring to pump insulin therapy, parents and children evaluated all the indicators higher:
- impact of diabetes symptoms decreased by 5%;
- impact of treatment by 8.2%;
- impact on daily activities improved by 7.7%;
- relationships with parents became better by 14.3%;
- Worries associated with diabetes decreased almost twice;
- Perceptions of health changed for the better side by 2.3%, while after transferring to CSII more patients and parents began to assess the health of children good and excellent;
- Overall quality of life assessment showed an improvement in QOL by 7%.
When comparing questionnaires filled with parents and children, parents were more concerned about the development of complications of diabetes than children.
Thus, the results of the conducted study reliably demonstrate that the use of modern technologies is accompanied by the improvement of not only glycemic control but also QOL.
Discussion.
The latest published meta-analysis of studies comparing CSII and MDI (multiple daily injection) [19; 20] demonstrated improvement in glycemic control using pump therapy in patients with T1DM. At the current time, there are
only a few reviews on the use of CSII in adults, adolescents and small children with T1DM.
In this study quality of life was assessed in children and adolescents with type 1 diabetes mellitus on insulin pump therapy, taking into account the carbohydrate value in dishes of Uzbek national cuisine. It was shown that the method of insulin administration plays a huge role in achieving compensation of type 1 diabetes, thereby improving the glycemic control and QOL parameters of the subjects. Attention is drawn to the more pronounced dynamics of a statistically significant improvement in QOL for a larger number of patient outcomes after transferring to the PIT regime after a year. Thus, the results of the conducted study demonstrate reliably that the use of modern technologies, such as CSII, is accompanied by an improvement not only in glycemic control, but also in QOL. Taking into account the data of earlier studies and the accumulated clinical experience, it can be assumed that pump insulin therapy has an ambiguous effect on patients: the repeatedly increasing amount of information on glycemia, its dynamic changes depending on various events and the possibility of flexible control of food intake by patients provides a great opportunity for them to look at diabetes with other eyes. QOL
is an important result both in itself and because it can affect the patient's activity with regard to self-management of the disease. If the requirements for adherence to the treatment scheme do not coincide with how patients want to live, they can choose less strict glycemic control in order to maintain their QOL. Thus, patients on pump therapy in conventional clinical practice admitted improving thinking, mood and well-being after a transfer from MDI, and these and other psychosocial factors are increasingly being evaluated in scientific studies on CSII. Knight et al. showed that the improvement in HbA1c in children with type 1 DM after transition to CSII was accompanied by an improvement in a number of cognitive indicators, such as sensory perception, selective attention and short-term memory, relationship with parents, etc.
Conclusions:
1. The use of CSII has a positive impact on all aspects of QOLs on the DQOLY-SF questionnaire.
2. The greatest improvements were noted in relation to such aspects of QOL as the impact of the symptoms of diabetes mellitus, the impact of treatment, the impact on daily activities, relationships with parents. Worries associated with diabetes decreased in almost twice.
References:
1. Dedov I. I., Shestakova M. V., Maiorov A. Iu. Algorithms of specialized medical care for patients with diabetes.Sakharnyi-diabet.- 8-i vypusk.- 2017.
2. Dedov I. I., Peterkova V. A., Kuraeva T. L. Russian consensus on treatment of diabetes in children and adolescents.Farmate-ka. 2010.- No. 3.- P. 7-14.
3. Ibragimova L. I., Filippov Iu. I., Maiorov A. Iu. The efficiency of learning and quality of life in patients with diabetes mellitus type 1 on insulin pump therapy. Sakharnyidiabet. 2012.- No. 1.- P. 35-40.
4. Kompaniets O. V. Quality of life and optimization of tactics of treatment of children with diabetes type 1,- Saratov, 2010.- 23 p.
5. Peterkova V. A., Kuraeva T. L., Emel'ianov A. O. Pump insulin therapy in pediatricians practice. Pediatriia. 2008.- T. 87.-No. 5.- P. 46-50.
6. Rybochkina A. V., Romanova T. A., Petrova L. M. Diabetes as a health and social problem in childhood. Nauchnyevedo-mosti. SeriiaMeditsina. Farmatsiia. 2014.- No. 11 (182).- Vypusk 26.- P. 191-194.
7. SamoilovaIu G., Oleinik O. A. Anintegral indicators of the quality of life of children and adolescents with diabetes type 1 diabetes.Pediatriia. 2010.- T. 89.- No. 5.- P. 57-63.
8. Sabirova A. V., Nefedova A. A., Volosnikov D. K., Iusupova A. R. Assessment of quality of life of children with diabetes type 1 that in pump insulin therapy.vestnikIuUrGU, 2010.- No. 6.- P. 66-68.
9. Filippov Iu. I., Ibragimova L. I., Pekareva E. V. Calculation of doses of insulin through an insulin pump: optimization settings calculator "boluses". Sakharnyidiabet. 2012.- No. 3.- P. 74-80. DOI: 10.14341/2072-0351-6089.
10. Bergenstal R. M., Tamborlane W. V., Ahmann A., et.al, for the STAR3 Study Group*. Effectiveness of Sensor-Augmented Insulin-Pump Therapy in Type 1 Diabetes. N Engl J Med. 2010.- Jul 22; 363 (4): 311-20.
11. Hofer S. E., Heidtmann B., Raile K. et al. Discontinuation of insulin pump treatment in children, adolescents, and young adults. A multicenter analysis based on the DPV database in Germany and Austria. Pediatric Diabetes. 2010; 11(2): 116121. DOI: http://dx.doi.org/10.1111/j.1399-5448.2009. 00546.x
12. IDF Diabetes Atlas 8th edition. 2017.
13. Pankowska E., Blazik M., Dziechciarz P., Szypowska A., Szajewska H. Continuous subcutaneous insulin infusion vs.multiple daily injections in children with type 1 diabetes: a systematic review and meta-analysis of randomized controltrials. Pediatric Diabetes. 2009; 10(1): 52-58.
14. Pickup J. C., Harris A. Assessing quality of life for new diabetes treatments and technologies: a simple patient-centered score // J Diabetes Sci Technol. 2007.- Vol. 1.- No. 3.- P. 394-399.
15. Rawshani A., Landin-Olsson M., Svensson A. M. et al. The incidence of diabetes among 0-34 year olds in Sweden: new data and better methods. Diabetologia 2014: 57: 1375-1381.
16. Urakami T., Suzuki J., Yoshida A., Saito H., Mugishima H. Incidence of children with slowly progressive form of type 1 diabetes detected by the urine glucose screening at schools in the Tokyo metropolitan area. Diabetes Res ClinPract 2008: 80: 473-476.
17. World Bank national accounts data, and OECD National Accounts data files. The World Bank, 2017. [cited 2017 July 31] Available at: URL: http://data.worldbank.org.
18. Rakhimova G. N., Akbarov Z. S., IsmailovS. I., Alimova N. U., Sadykov A. S., Aliev A. V., Gulyamova Kh. R. Pump insulin therapy as a treatment of DM 1 type of children and adolescences. Methodical textbook. - Tashkent, 2017.
19. Pickup J., Mattock M., Kerry S. Glycaemic control with continuous subcutaneous insulin infusion compared with intensiv insulin injections in patients with type 1 diabetes: meta analysis c randomised controlled trials // BMJ. 2002.- P. 324-705.
20. Retnakaran R., Hochman J., DeVries J. H. et al. Continuous subcutaneous insulin infusion versus multiple daily injections: impact of baseline Ale // Diabetes Care. 2004.- 27.- P. 2590-2596.
