Abstract
Purpose
This study aimed to assess the relationship between metabolic control factors, socio-demographic characteristics, personality traits, and self-perceived health status in diabetes.
Methods
This cross-sectional study included 318 patients with type 1 and 2 diabetes (DM). Participants completed a questionnaire-based survey, which included the NEO Personality Inventory-Revised to measure five personality dimensions and the SF-12 survey to assess self-perceived health status. Binary logistic regression was performed to analyze the data, with socio-demographic characteristics, clinical data, and nutrition status as independent variables, and self-perceived health status (categorized as poor or good condition) as the dependent variable. Unadjusted and adjusted binary logistic regression analyses were used to examine the association between personality traits (high vs. low) and metabolic control factors (good control vs. bad control) with health status scores.
Results
60.7% of the participants with diabetes in the study described their health as "good." The results indicated that female gender (OR: 0.314, 95%CI: 0.105–0.938, P = 0.038), age > 60 years (OR: 0.263, 95%CI: 0.117–0.592, P = 0.001), comorbidities (OR: 0.314, 95%CI: 0.178–0.556, P = 0.001), DM complications (OR: 0.531, 95%CI: 0.337–0.838, P = 0.007), diabetic neuropathy (OR: 0.562, 95%CI: 0.356–0.886, P = 0.013), and diabetic ulcer (OR: 0.130, 95%CI: 0.023–0.747, P = 0.022) were independent variables associated with a "poor" health status. However, regular physical activity (OR: 3.144, 95%CI: 1.209–8.175, P = 0.019) and a healthy nutritional diet (OR: 2.456, 95%CI: 1.421–4.245, P < 0.001) were associated with a higher likelihood of a "good" self-perceived health status.
Conclusion
Preventive programs and interventions aimed at improving self-perceived health among patients with diabetes should focus on increasing regular physical activity and promoting a healthy nutritional status. These actions should be particularly targeted towards female and older patients with higher neuroticism traits.
Keywords: Socio-demographic, Diabetes mellitus, Metabolic control, Personality, Self-perceived health
Introduction
Diabetes mellitus (DM) is a chronic condition with hyperglycaemia caused by impaired secretion and insulin action [1]. The high and increasing prevalence of DM associated complications and co-morbid conditions make this a significant health problem [2, 3]. Around 537 million people between the ages of 20 and 89 are affected by DM worldwide, with an estimated projection of 643 million by 2030 and 783 million by 2045 without effective prevention strategies [4, 5]. The national prevalence of diabetes in Iran was 15% and prediabetes was estimated at 25.4% between 2014 and 2020 [6]. In addition, the proportion of subjects with controlled diabetes was reported to be relatively low (41.2%) [6].
Diabetes, along with other chronic conditions such as hypertension, stroke cancer and mental illness, has a profound impact on the individuals’ general health status and quality of life (QOL) [7–9]. Individuals form a general perception and specific beliefs about their condition and its treatment when faced with a chronic or life-threatening disease [10]. Self-perceived health refers to an individual’s subjective perception of their health, even in the presence or absence of disease or infirmity [11, 12]. It is a subjective measure that reflects how individuals feel about their health status at an individual level [13, 14]. Self-perceived health is closely related to an individual’s health and well-being [15–17] and has been shown to strongly predict morbidity, mortality, and healthcare utilization [18–20].
The perception of one’s health is influenced by environmental, socio-demographic, and cultural factors [21]. Self-perceived health is not solely a reflection of objective health but also encompasses socio-demographic characteristics, clinical factors, and psychosocial variables [22, 23]. Factors influencing self-perceived health include socio-demographic variables, health/illness related factors (such as risk factors, comorbidities and complications) [24–26], and an individual’s personality, which is an important psychosocial correlates of subjective health [27, 28]. However, it is worth noting that the relationship between personality traits and self-perceived health has shown inconsistency across different studies [29–31].
By examining the influence of environmental, socio-demographic, clinical, and psychosocial variables on self-perceived health, this study seeks to gain insights into the complex nature of individuals’ perceptions of their health status. The findings will contribute valuable knowledge to the field by identifying key factors that impact self-perceived health in individuals with diabetes. Understanding the self-perceived health status of patients is vital for developing effective strategies to manage diabetes. Therefore, this study aims to evaluate the correlation between socio-demographic characteristics, metabolic control factors, personality traits, and self-perceived health status in individuals with diabetes. The results will inform the development of tailored interventions by identifying specific areas that require attention and enabling the formulation of targeted strategies to improve patients’ well-being and disease management.
Materials and methods
This cross-sectional study was conducted to assess self-perceived health status in people with diabetes and to evaluate the relationship between perceived health status and socio-demographic characteristics, metabolic control factors and personality traits for these patients. The study was conducted in accordance with the Declaration of Helsinki [32]. Informed consent was obtained from participants. The study was conducted in accordance with the STROBE statement [33].
Participants
Participants were recruited from those referred to the diabetes clinic, Baqiyatallah Hospital in Tehran, Iran, from June 2020 to January 2022. The convenience sampling method was used for data collection according to eligible criteria. Participant inclusion criteria were (a) Patients had received a physician-confirmed diagnosis of diabetes mellitus (both type 1 and type 2 diabetes) based on World Health Organization (WHO) and American Diabetes Association (ADA) guidelines at least three months previously [34], (b) patients of both sexes > 18 years of age and (c) patients who were able to complete the survey. The exclusion criteria were (a) newly diagnosed patients with DM, (b) a history of mental conditions such as severe anxiety and depression, (c) cognitive disorders such as dementia and Alzheimer (d) patients who had other chronic diseases and (e) participants with incomplete clinical data.
Data collection
The data were collected by researchers using face-to-face interviews using structured questionnaires. The first research tool was the "socio-demographic and clinical checklist"; the second was the "nutrition status questionnaire"; the third was NEO Personality Inventory-Revised (PI-R) to determine the personality traits of patients and the fourth was the SF-12 Health Survey. In addition, measuring metabolic control indicators based on laboratory tests, was recorded for each participant. Metabolic control indicators were grouped into good, borderline and poor control catergories [35]. ADA recommendation for FBS; poor control (> 140 mg/dl), Borderline control (111–140 mg/dl) and good control (80–110 mg/dl), for HbA1C; poor control (> 6.4%), borderline control (5.7–6.4%) and good control (< 6.4%), for total cholesterol; poor control (> 250 mg/dl), borderline control (201–250 mg/dl) and good control (< 200 mg/dl), for HDL, poor control (< 40 mg/dl for men and < 50 mg/dl for women), borderline control (35–40 mg/dl for men and 45–50 mg/dl for women) and good control (> 40 mg/dl for men and > 50 mg/dl for women) and for triglycerides; poor control (< 35 mg/dl), borderline control (201–250 mg/dl) and good control (< 200 mg/dl).
Research instruments
Socio-demographic and clinical checklist; The socio-demographic and clinical checklist used in this study was developed by the researchers specifically for the purpose of collecting relevant data. The checklist consisted of twelve questions encompassing various socio-demographic factors and clinical variables. These questions included inquiries about sex, age, marital status, place of residence, education levels, occupation (employed, housewife, retired or unemployed), householder status (yes or no), number of family members, religion, Body Mass Index (BMI), smoking status, and physical activity status. The development of the checklist involved careful consideration of existing measures and research in the field. The researchers reviewed relevant literature and consulted with experts to ensure that the checklist captured the necessary information to assess the socio-demographic and clinical characteristics of individuals with diabetes. The questions were designed to be comprehensive and cover a wide range of factors that could potentially influence self-perceived health status. Additionally, clinical data such as types of diabetes, duration of diabetes, mode of treatment, comorbidity diseases, and complications (neuropathy, retinopathy, or diabetic ulcer) were collected from electronic medical records. These data points were essential for understanding the clinical profile of the participants and gaining insights into their health condition.
Nutrition status; portion of fruits, vegetables and dairy products consumed (seldom, sometimes or always) in a day, the consumed fast food in a month (seldom, twice a month or more than two times) and the most type of oil intakes (solid, semi-solid or liquid vegetable oil) were asked. The consumption of dairy products, vegetables and fruits was assessed [36]. However, on the contrary, consuming fast-food and solid or semisolid oils increases the risk of many chronic diseases [37, 38]. It was accepted that a person who always consumes daily portions of fruit, vegetables and dairy product, intake liquid oil, and consumption only less than two times fast-food in a month has a healthy diet. If less than 90% of these criteria were not met, then the person was considered to have an unhealthy diet.
Personality; Personality traits were assessed using the short version of the NEO Personality Inventory-Revised (NEO-PI-R), which is based on the big five personality factors developed by Goldberg [39]. This instrument measures the hierarchical structure of personality and includes the following factors: neuroticism (N), agreeableness (A), extraversion (E), conscientiousness (C), and openness to experience (OE). The NEO-PI-R questionnaire consists of 21 items, with each item being a short self-descriptive statement. Respondents rate their agreement with each statement using a 4-point Likert scale, ranging from 1 "strongly disagree" to 4 "strongly agree." Domain scores are computed by summing up the scores of the corresponding facets. Except for extraversion, which has five questions, all domains consist of four questions. Therefore, the possible range of scores is 4 to 16 for the domains, and 5 to 20 for extraversion. To assess the reliability of the big five personality factors, test–retest and Cronbach’s alpha coefficients were calculated. The reliability coefficients ranged from 0.69 to 0.83[40]. Previous studies conducted in Iran by Haghshenas [41] and Garousie Farshi [42] reported reliability coefficients ranging from 0.53 to 0.87. Specifically, the estimated reliability coefficients for neuroticism, extraversion, openness, agreeableness, and conscientiousness were 0.86, 0.73, 0.80, 0.70, and 0.87, respectively.
Self-perceived health status; To assess self-perceived health status, the researchers utilized the SF-12 health status survey, which is a generic index instrument. This survey consists of 12 questions that are scored using a Likert scale format. Each item is rated from 0 (indicating the worst well-being) to 100 (indicating the best well-being) [43]. Summary scores, such as the Physical Component Score (PCS) and Mental Component Score (MCS), were calculated based on the responses. Higher scores on these summary scores indicate higher levels of self-perceived health. The total scores for the SF-12 range from 12 to 48. According to the standard protocol, scores between 12–24, 25–36, and 37–48 indicate poor, fair, and good health status, respectively. The SF-12 questionnaire is a validated tool, and its reliability was assessed in this study using test–retest and Cronbach’s alpha coefficients. The reliability coefficients for the Physical Component Score (PCS) and Mental Component Score (MCS) were found to be 0.86 [44, 45]. A study conducted by Rohani et al. [46] reported Cronbach’s alpha values and intra-class correlation coefficients for the Iranian version of the SF-12 ≥ 0.70 and ≥ 0.60, respectively. In addition, Cronbach α for physical and mental component summaries for the Iranian version of the SF-12were 0.89 and 0.90, respectively [47].
Statistical analysis
The patients were categorized into two groups, based on their self-perceived health status scores: poor (≤ 36) and good (≥ 37) condition of health. To examine the relationship between patients’ self-perceived health status and various factors, we conducted statistical tests. The distributions of socio-demographic data, clinical data, nutrition status, metabolic control factors, and personality traits were compared between the two health status groups. For categorical variables, we used the Chi-square test or Fisher’s exact test, while for continuous variables, we employed the t-test. These tests helped us identify any significant differences between the variables and the self-perceived health status of the patients. To further investigate the impact of socio-demographic characteristics, clinical data, and nutrition status on self-perceived health status, we conducted binary logistic regression. Here, the self-perceived health status (categorized as poor or good condition) served as the dependent variable, whereas socio-demographic characteristics, clinical data, and nutrition status were the independent variables. Additionally, we performed unadjusted and adjusted binary logistic regression analyses to explore the association between personality traits (high vs. low) and metabolic control factors (good control vs. bad control) with the health status scores. In the adjusted analysis, we employed conditional logistic regression and selected variables with a P-value < 0.05 from the unadjusted analyses. Adjustments were made for confounding factors, including gender, age, comorbidity diseases, physical activity, and nutrition status. Statistical analyses were performed using SPSS software (version 21) from SPSS Inc. (IL, Chicago, USA), and GraphPad Prism 9© from GraphPad Software Inc. (La Jolla, CA). A significance level of 0.05 was used for all analyses.
Results
Socio-demographic and clinical characteristics
The study included 318 participants with a mean age 57.65 ± 10.81 years; 139 (43.7%) were men and 179 (56.3%) were women. Type 2 DM was recorded in 226 (71.1%) patients, while type 1 DM was present in 92 (28.9%) patients. The duration of diabetes in the patients was one to four years for 28% of patients, while 38.7% had diabetes for ten years or more. The majority of the participants (99.4%) lived in rural areas. Almost all participants (99.6%) were Shia Muslims. More than half of patients (69.8%) were using oral antidiabetic (OAD) medication. Half of the participants had a diploma and upper diploma (52.9%), and 96.2% were married. The percentage of participants with comorbidity diseases was 57.5%. According to occupation, participants were often housewives (49.4%) and retired (38.4%). A total of 5.7% of the respondents were smokers and 36.2% of the participants were physically active. Nearly half of the participants had complications related to diabetes (49.7%). Diabetic neuropathy, retinopathy and diabetic ulcer were diagnosed in 43.4%, 14.8% and 3.8% of the participants, respectively (Table 1).
Table 1.
Distributions of socio-demographic and clinical characteristics according to self-perceived health status of the study population
| Socio-demographic and clinical variables | Total (n = 318) | Self-perceived health status | P-value | ||
|---|---|---|---|---|---|
| Poor (n = 125) | Good (n = 193) | ||||
| Age (years) | Mean ± SD | 57.65 ± 10.81 | 58.49 ± 10.32 | 57.11 ± 11.11 | 0.2661 |
| Age group | ≤ 59 (%) | 179 (56.3) | 60 (48) | 119 (61.7) | 0.016*2 |
| ≥ 60 (%) | 139 (43.7) | 65 (52) | 74 (38.3) | ||
| Gender | Male (%) | 139 (43.7) | 29 (23.2) | 110 (57) | < 0.001*2 |
| Female (%) | 179 (56.3) | 96 (76.8) | 83 (43) | ||
| Types of diabetes | Type I (%) | 92 (28.9) | 45 (36) | 47 (24.4) | 0.025*2 |
| Type II (%) | 226 (71.1) | 80 (64) | 146 (75.6) | ||
| Duration of diabetes | Under 1 year (%) | 32 (10.1) | 15 (12) | 17 (8.8) | 0.3122 |
| 1–4 years (%) | 89 (28) | 30 (24) | 59 (30.6) | ||
| 5–9 years (%) | 74 (23.3) | 26 (20.8) | 48 (24.9) | ||
| 10 years and over (%) | 123 (38.7) | 54 (43.2) | 69 (35.8) | ||
| Mode of treatment | Diet (%) | 6 (1.9) | 4 (3.2) | 2 (1) | 0.0622 |
| OAD (%) | 222 (69.8) | 77 (61.6) | 145 (75.1) | ||
| Insulin (%) | 22 (6.9) | 11 (8.8) | 11 (5.7) | ||
| OAD and Insulin (%) | 68 (21.4) | 33 (26.4) | 35 (18.1) | ||
| Marital Status | Married (%) | 306 (96.2) | 121 (96.8) | 185 (95.5) | 0.6663 |
| Single (%) | 12 (3.8) | 4 (3.2) | 8 (4.1) | ||
| Householder | Yes (%) | 155 (48.7) | 38 (30.4) | 117 (60.6) | < 0.001*2 |
| No (%) | 163 (51.3) | 87 (69.6) | 76 (39.4) | ||
| Education levels | Under diploma (%) | 150 (47.2) | 72 (57.6) | 78 (40.4) | 0.004*2 |
| Diploma (%) | 123 (38.7) | 43 (34.4) | 80 (41.5) | ||
| Upper diploma (%) | 45 (14.2) | 10 (8) | 35 (18.1) | ||
| Number of | ≤ 3 (%) | 208 (65.4) | 84 (67.2) | 124 (64.2) | 0.5892 |
| family member | ≥ 4 (%) | 110 (34.6) | 41 (32.8) | 69 (35.8) | |
| Occupation | Employed (%) | 36 (11.3) | 8 (6.4) | 28 (14.5) | < 0.001*2 |
| Housewife (%) | 157 (49.4) | 87 (69.6) | 70 (36.3) | ||
| Retired (%) | 122 (38.4) | 28 (22.4) | 94 (48.7) | ||
| Unemployed (%) | 3 (0.9) | 2 (1.6) | 1 (0.5) | ||
| Comorbidity diseases | No (%) | 135 (42.5) | 36 (28.8) | 99 (51.3) | < 0.001*2 |
| Yes (%) | 183 (57.5) | 89 (71.2) | 94 (48.7) | ||
| Smoking status | Never-smoker (%) | 291 (91.5) | 112 (89.6) | 179 (92.7) | 0.0512 |
| Ex-smoker (%) | 9 (2.8) | 7 (5.6) | 2 (1) | ||
| Smoker (%) | 18 (5.7) | 6 (4.8) | 12 (6.2) | ||
| Body Mass Index | Mean ± SD | 28.57 ± 4.60 | 28.94 ± 4.85 | 28.34 ± 4.42 | 0.2531 |
| Exercise | No (%) | 203 (63.8) | 89 (71.2) | 114 (59.1) | 0.028*2 |
| Yes (%) | 115 (36.2) | 36 (28.8) | 79 (40.9) | ||
| Exercise frequency | ≤ 4 (%) | 73/115 (63.5) | 29 (80.5) | 44 (55.7) | 0.005*2 |
| (hours/week) | ≥ 5 (%) | 42/115 (36.5) | 7 (19.5) | 35 (44.3) | |
| Complications | No (%) | 160 (50.3) | 51 (40.8) | 109 (56.5) | 0.006*2 |
| Yes (%) | 158 (49.7) | 74 (59.2) | 84 (43.5) | ||
| Neuropathy | Yes (%) | 138 (43.4) | 65 (52) | 73 (37.8) | 0.013*2 |
| Retinopathy | Yes (%) | 47 (14.8) | 21 (16.8) | 26 (13.5) | 0.4152 |
| Diabetic ulcer | Yes (%) | 12 (3.8) | 10 (8) | 2 (1) | 0.002*3 |
* P < 0.05 considered as significantly; OAD: Oral Antidiabetic Medication; 1 t-test; 2 Chi-square tests; 3 Fisher’s exact test
Sample characteristics according to self-perceived health status
Based on the results of the SF-12 questionnaire, 60.7% of the patients perceived their health status as "good", and 39.3% perceived their health status as "poor". The distribution of socio-demographic and clinical characteristics according to the "good" and "poor" self-perceived health status are shown in Table 1. According to the findings, the "good" self-perceived health status was significantly higher in the male participants vs. female participants (P < 0.001), patients ≤ 59 years vs. who were 60 years and upper (P = 0.016), patients with type II diabetes vs. type I diabetes (P = 0.025), householder patients vs. who was not householder (P < 0.001), patients with a higher level of education vs. patients with a lower level of education (P = 0.004), retired patients vs. employed/unemployed and housewives (P < 0.001), patients without comorbidity diseases vs. patients with comorbidity diseases (P < 0.001), patients with physical activity vs. who without physical activity (P = 0.028) and patients without complications related to diabetes vs. patients who had a complication (P = 0.006), such as diabetic neuropathy (P = 0.013) and diabetic ulcer (P = 0.002).
Correlation between sample characteristics and self-perceived health status
Table 2 presents the logistic regression analysis results for the associations between socio-demographic and clinical characteristics with "good" and "poor" self-perceived health status. In multivariate regression analysis, female gender (OR: 0.314, 95%CI: 0.105–0.938, P = 0.038), age upper 60 years (OR: 0.263, 95%CI: 0.117–0.592, P = 0.001), having comorbidities (OR: 0.314, 95%CI: 0.178–0.556, P = 0.001), having complications related diabetes (OR: 0.531, 95%CI: 0.337–0.838, P = 0.007), diabetic neuropathy (OR: 0.562, 95%CI: 0.356–0.886, P = 0.013), and diabetic ulcer (OR: 0.130, 95%CI: 0.023–0.747, P = 0.022), were found as independent variables associated with "poor" self-perceived health status. However, physical activity (OR: 3.144, 95%CI: 1.209–8.175, P = 0.019) and more than 5 h of exercise per week (OR: 2.456, 95%CI: 1.421–4.245, P = 0.001) created a risk for "good" self-perceived health status.
Table 2.
Univariate and multivariate binary logistic regression analysis to identify socio-demographic and clinical variables independently associated with self-perceived health status
| Variables | Univariate | Multivariate | ||
|---|---|---|---|---|
| OR (95% CI) | P-value | OR (95% CI) | P-value | |
| Gender (female vs. male) | 0.228 (0.138–0.377) | 0.001* | 0.314 (0.105–0.938) | 0.038* |
| Age (> 60 vs. < 60 years) | 0.574 (0.364–0.905) | 0.017* | 0.263 (0.117–0.592) | 0.001* |
| Marital status (single vs. married) | 0.764 (0.225–2.594) | 0.667 | - | - |
| Education level (under diploma vs. upper diploma) | 0.310 (0.143–0.670) | 0.003* | 0.771 (0.179–3.321) | 0.726 |
| Education level (under diploma vs. diploma) | 0.532 (0.241–1.177) | 0.119 | - | - |
| Householder (yes vs. no) | 3.525 (2.185–5.685) | 0.001* | 2.337 (0.791–6.903) | 0.125 |
| Number of family | 1.022 (0.835–1.251) | 0.836 | - | - |
| Comorbidities (yes vs. no) | 0.384 (0.238–0.621) | 0.001* | 0.314 (0.178–0.556) | 0.001* |
| Occupation (retired vs. unemployed) | 1.136 (1.033–1.248) | 0.008* | 1.028 (0.886–1.193) | 0.715 |
| Smoking status (smoker vs. non-smoker) | 0.761 (0.278–2.082) | 0.594 | - | - |
| Body Mass Index (BMI) | 0.972 (0.926–1.021) | 0.253 | - | - |
| Exercise (yes vs. no) | 1.713 (1.058–2.774) | 0.029* | 3.144 (1.209–8.175) | 0.019* |
| Exercise (> 5 vs. < 5 h/week) | 1.676 (1.189–2.361) | 0.003* | 1.376 (1.019–2.051) | 0.017* |
| Type of diabetes (II vs I) | 1.747 (1.069–2.856) | 0.026* | 0.789 (0.255–2.437) | 0.681 |
| Duration of diabetes (1–4 years vs. under 1 year) | 0.887 (0.406–1.935) | 0.763 | - | - |
| Duration of diabetes (5–9 years vs. under 1 year) | 1.539 (0.874–2.710) | 0.135 | - | - |
| Duration of diabetes (≥ 10 years vs. under 1 year) | 1.445 (0.797–2.621) | 0.226 | - | - |
| Treatment (OAD vs. diet) | 0.471 (0.081–2.748) | 0.403 | - | - |
| Treatment (OAD vs. insulin) | 1.776 (1.024–3.078) | 0.041* | 0.602 (0.328–1.106) | 0.102 |
| Treatment (OAD vs. insulin and OAD) | 0.943 (0.361–2.466) | 0.905 | - | - |
| Complications (yes vs. no) | 0.531 (0.337–0.838) | 0.007* | 0.531 (0.337–0.838) | 0.007* |
| Diabetic neuropathy (yes vs. no) | 0.562 (0.356–0.886) | 0.013* | 0.562 (0.356–0.886) | 0.013* |
| Diabetic retinopathy (yes vs. no) | 0.771 (0.413–1.441) | 0.415 | - | - |
| Diabetic ulcer (yes vs. no) | 0.120 (0.026–0.559) | 0.007* | 0.130 (0.023–0.747) | 0.022* |
*P < 0.05 considered as significant, OR: odds ratio, CI: confidence interval, OAD: Oral Antidiabetic Medication
Nutritional status
The results for the nutritional status of the participants (Table 3) show that 143 (45%) had a healthy diet. Based on this survey, 85.5%, 69.2%, and 54.7% of respondents consume fruits, vegetables, and dairy products per day, respectively. Moreover, 67.6% of the participants avoided consuming fast-food more than twice a month, and 79.2% of the patients used only liquid oils. According to the results, "good" self-perceived health status was significantly higher in the participants with healthy nutrition status compared to those with unhealthy nutrition status (53.4% vs. 46.6%, P < 0.001). In addition, univariate (OR: 2.432, 95%CI: 1.519–3.892, P < 0.001) and multivariate (OR: 2.456, 95%CI: 1.421–4.245, P < 0.001) binary logistic regression analysis showed that the probability for "good" self-perceived health status among the participants with healthy nutritional status was 2.4 times more than those who did not have a healthy nutritional status.
Table 3.
Distributions of nutritional status according to self-perceived health status of the study population
| Nutritional status | Total (n = 318) | Self-perceived health status | P-value | ||
|---|---|---|---|---|---|
| Poor (n = 125) | Good (193) | ||||
| Fruit intake | Poor (%) | 46 (14.5) | 30 (24) | 16 (8.3) | < 0.001* |
| Good (%) | 272 (85.5) | 95 (76) | 177 (91.7) | ||
| Vegetables intake | Poor (%) | 118 (37.1) | 59 (47.2) | 59 (30.6) | 0.003* |
| Good (%) | 200 (69.2) | 66 (52.8) | 134 (69.4) | ||
| Diary intake | Poor (%) | 144 (45.3) | 77 (61.6) | 67 (34.7) | < 0.001* |
| Good (%) | 174 (54.7) | 48 (38.4) | 126 (65.3) | ||
| Avoid fast-food | Poor (%) | 103 (32.4) | 30 (24) | 73 (37.8) | 0.010* |
| Good (%) | 215 (67.6) | 95 (76) | 120 (62.2) | ||
| Liquid Oil | Poor (%) | 66 (20.8) | 35 (28) | 31 (16.1) | 0.010* |
| Good (%) | 252 (79.2) | 90 (72) | 162 (83.9) | ||
| Nutrition status | Unhealthy (%) | 175 (55) | 85 (68) | 90 (46.6) | < 0.001* |
| Healthy (%) | 143 (45) | 40 (32) | 103 (53.4) | ||
* P < 0.05 considered as significantly
Personality status
Most participants reported higher agreeableness (94.7%) and extraversion (90.3%). However, most diabetic patients expressed lower levels of neuroticism (70.8%) with higher levels of conscientiousness (72.3%) and openness to experience (60.1%) (Table 4). Individuals with higher levels of neuroticism reported their self-perceived health as significantly "poor" than those with lower levels of neuroticism (22.8% vs. 77.2%, P = 0.002). However, participants with higher levels of agreeableness, extraversion and openness to experience showed significantly good their self-perceived health than those with lower levels of agreeableness (98.4% vs. 1.6%, P < 0.001), extraversion (96.4% vs. 3.6%, P < 0.001) and openness to experience (66.3% vs. 33.7%, P < 0.005). Correlations between personality traits and self-perceived health status among diabetic patients were conducted using unadjusted and adjusted binary logistic regression (Fig. 1A). For "good" self-perceived health status, after controlling confounding factors such as age, gender, comorbidities, physical activity and healthy nutritional status, neuroticism was a significant negative predictor, indicating that a higher level of neuroticism was associated with fewer reports of "good" self-perceived health (OR: 0.553, 95%CI: 0.302–0.914, P = 0.050). Whereas extraversion and openness to experience were significant positive predictors for "good" self-perceived health status, indicating that a higher level of extraversion (OR: 3.411, 95%CI: 1.17–4.947, P = 0.025) and openness to experience (OR: 1.949, 95%CI: 1.079–2.521, P = 0.027) were significantly associated with higher report “good” self-perceived health.
Table 4.
Distributions of personality traits according to self-perceived health status of participants
| Personality traits | Total (n = 318) | Self-perceived health status | P-value | |
|---|---|---|---|---|
| Poor (n = 125) | Good (n = 193) | |||
| Neuroticism | ||||
| Low ≤ 10 | 225 (70.8) | 76 (60.8) | 149 (77.2) | 0.002* |
| High > 10 | 93 (29.2) | 49 (39.2) | 44 (22.8) | |
| Agreeableness | ||||
| Low ≤ 10 | 17 (5.3) | 14 (11.2) | 3 (1.6) | < 0.001* |
| High > 10 | 301 (94.7) | 111 (88.8) | 190 (98.4) | |
| Conscientiousness | ||||
| Low ≤ 10 | 88 (27.7) | 36 (28.8) | 52 (26.9) | 0.718 |
| High > 10 | 230 (72.3) | 89 (71.2) | 141 (73.1) | |
| Extraversion | ||||
| Low ≤ 12 | 31 (9.7) | 24 (19.2) | 7 (3.6) | < 0.001* |
| High > 12 | 287 (90.3) | 101 (80.8) | 186 (96.4) | |
| Openness to experience | ||||
| Low ≤ 10 | 127 (39.9) | 62 (49.6) | 65 (33.7) | 0.005* |
| High > 10 | 191 (60.1) | 63 (50.4) | 128 (66.3) | |
* P < 0.05 considered as significantly, personality traits based on NEO Personality Inventory-Revised (PI-R)
Fig. 1.
Correlations between self-perceived health status and (A) personality traits and (B) metabolic control factors (MCF) among diabetic patients based on unadjusted and adjusted binary logistic regression (forest plots showed adjusting results, after controlling confounding factors such as age, gender, comorbidities, physical activity and healthy nutritional status)
Metabolic factors for diabetes
In the study population, only 17.9% and 21.1% of the participants had "good" control levels of FBS and HbA1C, respectively. While 62.2%, 70.1% and 48.1% of the participants had "good" control levels of total cholesterol, HDL and triglycerides (Table 5). The mean ± SD values for FBS and HbA1C were 156.51 ± 67.94 and 7.87 ± 1.93, considered a "poor" control. However, the mean ± SD value for total cholesterol, HDL and triglycerides were 168.20 ± 55.48, 43.33 ± 10.08 and 175.18 ± 93.61, respectively, which is considered a "good" control (Table 5). There were statistically significant differences in terms of the control levels of, HDL and triglycerides between patients who had a "good" perception of their health status and those who regarded their health as "poor" (P < 0.05). According to the results, 85.1% of patients who had "good" control levels of HbA1C also evaluated their health as "good", whereas 34.5% of those who had "poor" control levels of HbA1C evaluated their health as "poor" (P = 0.031). In addition, 72.2% and 80.1% of the participants who had "good" control levels of HDL and triglycerides reported their health as "good", while 11.8% and 27.8% had "poor levels of HDL and triglycerides reported their health as "poor" (P < 0.001). Unadjusted and adjusted binary logistic regression analyses were used to identify metabolic control factors (MCF) independently associated with self-perceived health status (Fig. 1B). In adjusted analysis, after controlling confounding factors such as age, gender, comorbidities, physical activity and healthy nutritional status, "good" control levels of HbA1C, HDL and triglycerides were significant positive predictors for "good" self-perceived health status, indicating that respondents with "good" control levels of HbA1C (OR:2.304, 95%CI: 1.236–4.295, P = 0.009), HDL (OR:4.155, 95%CI: 2.373–5.275, P < 0.001), and triglycerides (OR: 3.052, 95%CI: 2.115–4.763, P < 0.001) were significantly more likely to report their health "good" than those with "poor" control levels of these factors.
Table 5.
Distributions of metabolic control factors according to self-perceived health status of participants
| Metabolic control factors for diabetes | Total (n = 318) | Self-perceived health status | P-value | ||
|---|---|---|---|---|---|
| Poor (n = 125) | Good (n = 193) | ||||
| FBS (mg/dl) | Mean ± SD | 156.51 ± 67.94 | 158.80 ± 73.55 | 155.04 ± 64.20 | 0.630 |
| FBS category | Poor control (> 140) | 145 (45.6) | 57 (45.6) | 88 (45.6) | 0.314 |
| Borderline control (111–140) | 116 (36.5) | 41 (32.8) | 75 (38.9) | ||
| Good control (80–110) | 57 (17.9) | 27 (21.6) | 30 (15.5) | ||
| HBA1C (%) | Mean ± SD | 7.87 ± 1.93 | 7.88 ± 2.02 | 7.86 ± 1.88 | 0.941 |
| HBA1C category | Poor control (> 6.5%) | 209 (65.7) | 76 (36.4) | 133 (63.3) | 0.097 |
| Borderline control (5.7–6.4%) | 42 (13.2) | 15 (35.7) | 27 (64.3) | ||
| Good control (< 6.4%) | 67 (21.1) | 34 (50.7) | 33 (49.3) | ||
| Total Cholesterol (mg/dl) | Mean ± SD | 168.20 ± 55.48 | 179.46 ± 49.88 | 187.41 ± 68.47 | 0.264 |
| Total Cholesterol | Poor control (> 250) | 36 (11.3) | 14 (11.2) | 22 (11.4) | 0.904 |
| category | Borderline control (201–250) | 83 (26.1) | 31 (24.8) | 52 (26.9) | |
| Good control (< 200) | 199 (62.6) | 80 (64) | 119 (61.7) | ||
| HDL (mg/dl) | Mean ± SD | 43.33 ± 10.08 | 40.80 ± 12.44 | 44.97 ± 7.82 | < 0.001* |
| HDL category | Poor control (< 40) ** | 59 (18.6) | 52 (41.6) | 7 (3.6) | < 0.001* |
| Borderline control (35–40) | 36 (11.3) | 11 (8.8) | 25 (13) | ||
| Good control (> 40) | 223 (70.1) | 62 (49.6) | 161 (83.4) | ||
| Triglycerides | Mean ± SD | 175.18 ± 93.61 | 223.57 ± 100.94 | 143.83 ± 73.32 | < 0.001* |
| Triglycerides | Poor control (< 35) | 108 (34) | 78 (62.4) | 30 (15.5) | < 0.001* |
| category | Borderline control (201–250) | 55 (17.3) | 13 (10.4) | 42 (21.8) | |
| Good control (< 200) | 155 (48.7) | 34 (27.2) | 121 (62.7) | ||
* P < 0.05 considered as significantly; FBS: Fasting Blood Sugar; HbA1C: glycosylated hemoglobin; HDL: high-density lipoproteins, ** for HDL, poor control (< 40 mg/dl for men and < 50 mg/dl for women), borderline control (35–40 mg/dl for men and 45–50 mg/dl for women) and good control (> 40 mg/dl for men and > 50 mg/dl for women)
Discussion
This cross-sectional study aimed to examine the correlation between socio-demographic characteristics, metabolic control factors and personality traits with self-perceived health status in patients with DM. In the study, 60.7% of the patients with diabetes described their health status as “good”. The results of this research indicated that self-perceived health with male gender, younger age, more physical activity, absence of comorbidities, absence of DM complications, healthy nutritional status, high level of neuroticism traits, low level of extroversion, good control level of HbA1C, HDL and triglycerides were increased in patients with diabetes.
Consistent with previous studies, we found that women had lower levels of self-perceived health than men [20, 48]. Some studies report that women’s poorer health indicates their chronic health problems [49]. Evidence shows biological and psychosocial factors are responsible for gender differences in self-perceived health status [50]. According to this hypothesis, we compared women with men participants regarding age, comorbidities, diabetes-related complications, physical activity level, and metabolic control factors. In this regard, no significant difference was observed between them (P > 0.05). The only exception was that men were better than women in good HDL control (76.3% vs. 65.4%, P = 0.035). So, it appears that, despite differences in mortality, men tend to perceive themselves to be in better health than women, and women over-report health problems [49, 51]. This difference can be explained by the effect of psychosocial factors such as stress and anxiety, which appears to have a higher impact on women than men [52, 53].
One important socio-demographic factor affecting the self-assessed health of patients with diabetes is age. Considering the fact that self-perceived health status shows a significant inverse relationship with comorbidities and physical inactivity. Therefore, older patients may perceive their health as worse than young ones due to comorbidities and physical conditions, which are more often present in older age [21, 54]. In this study, 68.7% of participants who exercised regularly reported their health status as “good”. In addition, 72.02% of those with a healthy nutritional status also reported self-perceived health status as “good”. Our findings suggest that regular exercise and healthy nutrition are associated with better self-perceived health status [22]. Evidence suggests that a healthy diet and exercise are associated with improved glucose tolerance for patients with diabetes [55, 56]. Regular physical activity can thus enhance psychological well-being and augment the QoL for patients with diabetes [57, 58].
Our results revealed that individuals with higher levels of neuroticism report more health problems. Conversely, individuals who scored higher levels of extraversion and openness to experience were more likely to report experiencing fewer problems, which is consistent with prior studies [27, 28, 59]. It may be that individuals who report more neuroticism are more likely to display negative affect. Neuroticism reflects the tendency to frequently experience unpleasant emotions. Higher neuroticism is related to health-risk behaviors such as less physical activity and more sedentary behaviors [60], smoking [61], and excessive alcohol use [62], which may lead to worse health over time. Whereas higher extraversion and openness to experience were related to more favorable current ratings of one’s health. Extroverts usually report a higher level of mental well-being due to their high energy, positive emotions and sociability [63, 64]. Patients with a high level of openness to experience and a preference for novelty and variety are less likely to report health problems [65, 66].
Glycemic control (FBS), HbA1c, total cholesterol, HDL and triglyceride are critical indicators of diabetes. Health status, glycemic control and metabolic control factors in diabetes correlated significantly with self-perceptions of health. The results of this study also provide evidence for the significant positive association of "good" self-perceived health with "good control" levels of HbA1c, HDL and triglyceride. Several studies have reported the relationship between self-perceived health and metabolic control [22, 67]. Evidence suggested that a lower HbA1c in white patients with type 2 DM correlated significantly with better perceptions of health [68]. It has been shown that better diabetes control is associated with better health perception [69]. According to the current study findings, participants with "good" HbA1C values have good perceived health status, while participants with bad HbA1C values have poor perceived health status [67, 69] in line with the findings of previous studies.
Several limitations in this study should be considered before generalizability including small sample size, which may not have been large enough to detect potential relationships. Another limitation is that a convenience sample and a cross-sectional research design were used in this study, which will make the generalization of results difficult.
Conclusion
According to the findings, more than half of the participants reported ‘‘good’’ levels of self-perceived health. Male gender and younger age as non-modifiable risk factors, regular physical activity, and healthy nutritional status as modifiable risk factors created a higher risk for self-perceived "good" health status. It was also found that personality traits play a special role in self-perception of health. Our results suggest that lower neuroticism, higher extraversion, and openness to experience are related to more favorable self-evaluations of health. In addition, "good" control levels of HbA1C, HDL and triglycerides, as important indicators of metabolic control, were related to self-perceived "good" health status. It is important to consider metabolic control factors when assessing diabetes treatment and care. Preventive programs and interventions aimed at improving self-perceived health among individual with diabetes should concentrate on increasing regular physical activity and healthy nutritional status. Those actions should be particularly addressed to female and older patients with higher neuroticism traits.
Acknowledgements
The study was supported by Vice-chancellor of "Clinical Research Development Unit of Baqiyatallah Hospital". We are grateful to the guidance and advice from the Clinical Research Development Unit of Baqiyatallah Hospital of Medical Sciences, Tehran, Iran.
Abbreviations
- IDF
International Diabetes Federation
- QOL
Quality of life
- NEO-PI-R
NEO Personality Inventory-Revised
- HbA1C
Glycosylated hemoglobin
- BMI
Body Mass Index
- SF-12
Short Form health status survey includes 12 questions
- MCS
Mental Component Score
- PCS
Physical Component Score
- OR
Odds ratio
- CI
Confidence intervals
- MCF
Metabolic control factors
Authors’ contributions
A.VA and A.S developed the study concept. All authors contributed to the study design. Testing and data collection were performed by H.A, M.MA, MS.H, and M.F. Data analysis and interpretation were performed by S.A under the supervision of A.VA. Drafted the manuscript by S.A, T.S and H.A. Critical revisions was provided by A.VA and A.S. All authors approved the final version of the manuscript for submission.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Data availability
All data collected and analyzed during the current study can be provided by the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participation
The study protocol was reviewed and approved by the Ethics Committee of Baqiyatallah University of Medical Sciences, Tehran, Iran under code (IR.BMSU.REC.1399.201). The study was performed in accordance with the Declaration of Helsinki of the World Medical Association. Informed consent was obtained from all participants.
Consent for publication
Not applicable.
Competing interests
None to declare.
Footnotes
Publisher's note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Amir Vahedian-Azimi, Email: amirvahedian63@gmail.com.
Amirhossein Sahebkar, Email: amir_Saheb2000@yahoo.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data collected and analyzed during the current study can be provided by the corresponding author on reasonable request.