Abstract
Aims/introduction
In patients with diabetes, obesity is an aggravating factor for glycemic control and its vascular complications. However, the psychological and behavioral characteristics of those patients with obesity have not been fully clarified. This study investigated eating and coping behavior, personality traits, quality of life (QOL), and depression status in patients with diabetes with or without obesity.
Materials and methods
Questionnaires obtained from 567 patients with diabetes at Dokkyo Medical University were analyzed. Eating behavior, coping behavior, personality traits, QOL, and depression status were evaluated by the Eating Behavior Questionnaire, Brief COPE, Japanese Ten-Item Personality Inventory, EuroQol 5 Dimensions-5 Level, and Patient Health Questionnaire-9, respectively. Participants were divided according to body mass index (BMI) into a non-obese group (BMI < 25), obese group (BMI 25–35), and high-degree obese group (BMI ≥ 35), and results were compared between groups.
Results
On all items of the Eating Behavior Questionnaire, scores were higher in the obese and high-degree obese groups than non-obese group, indicating worse eating behavior. In coping behavior, significant intergroup differences were found in self-distraction, substance use, using emotional support, using instrumental support, and venting. As for personality traits, the obese group had significantly lower conscientiousness and higher emotional instability than the non-obese group. There was no significant difference in QOL or depression status.
Conclusions
These results suggest that there are some characteristics in eating and coping behaviors and some personality traits between obese and non-obese patients with diabetes. Treatment based on such characteristics may be useful for patients with diabetes and obesity.
Supplementary Information
The online version contains supplementary material available at 10.1007/s13340-024-00721-w.
Keywords: Diabetes, Obesity, Coping, Eating behavior, Personality trait
Introduction
In patients with diabetes, obesity worsens glycemic control [1]. In addition, it increases the frequency of other metabolic disorders such as dyslipidemia and hypertension, which synergistically exacerbate vascular complications of diabetes, such as atherosclerotic diseases and microangiopathies [2, 3]. Conversely, weight loss in patients with diabetes has significant ameliorating effects on these metabolic abnormalities and obesity-related complications [4–9]. The Japan Society for the Study of Obesity (JASSO) defines a body mass index (BMI) of 25–29.9 as obesity of the first degree [10]. The mean BMI of Japanese patients with type 2 diabetes is approximately 25, indicating that about half of them have obesity. Therefore, guidelines state that body weight of patients with diabetes should be maintained at an appropriate level [4].
There are various therapeutic strategies which can help obese patients lose body weight, such as diet therapy, exercise therapy, and behavioral therapy. In addition, patients with diabetes are often prescribed drugs that can potentially reduce body weight, such as sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide 1 (GLP-1) receptor agonists [5, 11]. As an effective weight loss strategy, guidelines recommend the combined use of some or all of the above-mentioned therapeutic strategies and drugs [4]. However, for many patients with diabetes, weight loss is not always easy and depends on the ability of the patients to manage their daily life. Diet and exercise therapies sometimes cause psychological and physical stress, and they require behavioral changes and a strong will. But patients differ in many characteristics, such as personality traits, psychological reactions, coping behavior, recognition of eating, and eating habits. Therefore, health care providers may be able to better help patients successfully lose weight if they understand and appropriately approach characteristics related to psychological and behavioral factors.
In general, patients with obesity are reported to have problems with their recognition of eating and abnormal eating behavior [12]. However, it is not clear whether the same can be said for patients with diabetes and obesity, and how such patients perceive and cope with the stress related to body weight control in diabetes care. Therefore, in this study, we conducted a questionnaire survey of eating behavior, stress coping behavior, personality traits, quality of life (QOL), and depression status in patients with diabetes, and compared the results between the patients with and without obesity.
Patients and methods
Patients
Participants (n = 692) were in- and outpatients aged 15 or older who had diabetes mellitus and were being treated at the Department of Endocrinology and Metabolism at Dokkyo Medical University Hospital, Mibu, Japan. Patients with gestational diabetes mellitus, pregnancy with diabetes mellitus, and high-degree obesity who had undergone bariatric surgery were excluded from the study. The study comprised a questionnaire survey administered by continuous sampling between December 2021 and January 2022; 125 of the 692 patients were excluded because their identity could not be verified (n = 77) or no weight or height data were available (n = 48). The remaining 567 patients were divided into 3 groups according to the degree of obesity: non-obese group (BMI < 25), n = 262; obese group (BMI 25–35), n = 271; and high-degree obese group (BMI ≥ 35), n = 34. Data were then compared between groups (Suppl. Fig.). Treatment contents are shown in Suppl. Table. A total of 88 patients (15.5%) were treated by diet and exercise therapy only and took no medication. Anti-diabetic drugs included drugs with weight-gaining effects, such as thiazolidinediones, sulfonylurea, glinides, and insulin injections, and drugs with weight-loss effects, such as GLP-1 receptor agonists and SGLT2 inhibitors. All participants were included in the analysis, regardless of the type of drugs they were taking (Suppl. Table).
Questionnaire survey
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A.
Eating behavior questionnaire
Participants’ eating behavior was analyzed with the Eating Behavior Questionnaire, which has been officially approved by the Japan Society for the Study of Obesity [12]. In this questionnaire, participants respond to 55 questions about eating behavior on a scale of 1–4; the questionnaire includes 8 dummy questions. The questions are grouped into 7 sub-items and a total score, as follows: (1) recognition of weight and constitution, (2) external eating behavior, (3) emotional eating behavior, (4) sense of hunger or satiety, (5) eating style, (6) food preference, (7) regularity of eating habit, and (8) total of the 7 sub-items. Each of the scores in the groups (1)–(8) is calculated as a percentage of the total score. The closer the score is to 100%, the more problematic the eating behavior is [12, 13].
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B.
Brief COPE
Coping behavior was evaluated with Brief COPE, a scale based on a psychological stress model and a behavioral self-regulation model. The scale assesses coping behavior with 14 subscales, each of which includes 2 questions (making a total 28 questions); the 14 subscales are as follows: (1) active coping, (2) planning, (3) positive reframing, (4) acceptance, (5) humor, (6) religion, (7) using emotional support, (8) using instrumental support, (9) self-distraction, (10) denial, (11) venting, (12) substance use, (13) behavioral disengagement, and (14) self-blame. Each question is answered on a scale of 1–4 (1, not at all; 2, rarely; 3, mostly; 4, always), and 2–8 points are assigned to items (1)–(14), where a score of 8 indicates a coping strategy that the patient frequently uses [14, 15].
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C.
Japanese version of the Ten-Item Personality Inventory
Personality traits were evaluated with the Japanese Ten-Item Personality Inventory (TIPI-J), which consists of 10 personality-related questions classified into the following 5 subscales: (1) extraversion, (2) agreeableness, (3) conscientiousness, (4) emotional instability, and (5) openness to experience. Each subscale consists of 2 questions, and each question is answered on a scale of 1–7 (1, totally disagree; 7, strongly agree), with 7 indicating that the patient most likely has the personality trait [16, 17].-
D.EuroQol 5 dimensions 5 level
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D.
QOL was evaluated with the EuroQol 5 Dimensions 5 Level (EQ-5D-5L), a questionnaire consisting of 5 items: (1) degree of mobility, (2) self-care, (3) usual activities, (4) pain/discomfort, and (5) anxiety/depression. Each item has 5 options, and the participant selects the option closest to their current situation. A value from 0.025 to 1.000 is calculated from the results of the questionnaire, and the closer the value of each item is to 1.000, the higher the QOL [18, 19].
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E.
Japanese version of the Patient Health Questionnaire-9
The Japanese version of the Patient Health Questionnaire-9 (J-PHQ-9) consists of 9 questions related to symptoms of depression. Each question is answered on a scale of 0–3, depending on how often the symptom has bothered the participants in the last 2 weeks (0, never; 1, on a few days; 2, more than half the time; 3, almost every day). The highest possible score is 27 (3 points × 9 questions) and indicates the highest degree of depression [20].
If fewer than half of the total of 55 questions were answered in the Eating Behavior Questionnaire and if 1 or more answers were missing in TIPI-J, Brief COPE, EQ-5D-5L, or J-PHQ-9, the respective questionnaire was excluded from the analysis.
Statistical analysis
Descriptive analyses were performed with demographic and clinical variables. An analysis of variance (ANOVA) and Tukey post hoc tests were used to compare the primary continuous demographic and clinical characteristics between groups, and a chi-square test was used to analyze categorical variables. Data are presented as the mean ± SD. A p value of <0.05 was considered statistically significant. Data were analyzed with IBM SPSS Statistics for Windows, version 28.0.0.0.
Results
In this study, the answers to questionnaire from 567 participants were analyzed. The clinical characteristics of the participants are shown in Table 1. The mean age of all participants was 60.1 ± 14.0 years, mean BMI was 25.9 ± 5.2, and mean HbA1c was 7.3 ± 1.1%. The numbers in the non-obese group (BMI < 25), obese group (BMI 25–35), and high-degree obese group (BMI > 35) were 262, 271, and 34, respectively (Table 1).
Table 1.
Characteristics of the subjects
| Total | BMI < 25 | 25 ≤ BMI < 35 | 35 ≤ BMI | p | |
|---|---|---|---|---|---|
| Number | 567 | 262 | 271 | 34 | |
| Male, n (%) | 331 (58.4) | 145 (55.3) | 166 (61.2) | 20 (58.8) | 0.33 |
| Female, n (%) | 236 (41.6) | 117 (44.7) | 105 (38.8) | 14 (41.2) | 0.33 |
| Age (years) | 60.1 ± 14.0 | 64.3 ± 13.5 | 57.8 ± 13.5 | 47.0 ± 11.3 | < 0.001 |
| Duration of diabetes (years) | 13.8 ± 10.9 | 15.0 ± 13.1 | 13.0 ± 8.7 | 10.9 ± 6.1 | 0.051 |
| BMI (average) | 25.9 ± 5.2 | 21.8 ± 2.2 | 28.3 ± 2.5 | 39.0 ± 3.5 | < 0.001 |
| HbA1c (%) | 7.3 ± 1.1 | 7.4 ± 0.9 | 7.4 ± 1.2 | 6.9 ± 1.0 | 0.005 |
| Urinary protein positive rate (%) | 19.0 | 16.3 | 20.9 | 18.2 | 0.379 |
Values are shown as mean ± SD
The results of the Eating Behavior Questionnaire are shown in Table 2. The scores of the individual 7 items and the total score were all higher in the obese and high-degree obese groups than in the non-obese group, indicating that the patients with diabetes with obesity or high-degree obesity have unfavorable eating behavior. There was no significant difference between the obese and high-degree obese groups (Table 2).
Table 2.
Questionnaire for eating behaviors
| BMI < 25 | 25 ≤ BMI < 35 | 35 ≤ BMI | p | Post hoc | |
|---|---|---|---|---|---|
| Total score | 42.7 ± 10.9 | 49.2 ± 12.0 | 51.9 ± 12.1 | <0.001* |
A–B < 0.001* A–C < 0.001* |
| Recognition of weight and constitution | 46.7 ± 14.2 | 58.6 ± 14.7 | 61.5 ± 11.4 | <0.001* |
A–B < 0.001* A–C < 0.001* |
| External eating behavior | 42.0 ± 13.5 | 47.5 ± 15.0 | 47.7 ± 14.9 | <0.001* | A–B < 0.001* |
| Emotional eating behavior | 37.4 ± 13.6 | 41.2 ± 15.1 | 44.9 ± 17.2 | 0.001* |
A–B 0.007* A–C 0.015* |
| Sense of hunger | 40.2 ± 12.1 | 45.4 ± 14.2 | 48.6 ± 15.2 | <0.001* |
A–B < 0.001* A–C < 0.001* |
| Eating style | 42.0 ± 19.1 | 48.7 ± 18.3 | 51.6 ± 17.5 | <0.001* |
A–B < 0.001* A–C 0.03* |
| Food preference | 43.8 ± 12.6 | 50.0 ± 14.1 | 54.2 ± 18.1 | <0.001* |
A–B < 0.001* A–C < 0.001* |
| Regularity of eating habit | 41.3 ± 13.2 | 47.6 ± 15.0 | 51.0 ± 15.0 | <0.001* |
A–B < 0.001* A-C < 0.001* |
Statistical analysis was performed by ANOVA. Data are shown as mean ± SD
A: BMI < 25, B: 25 ≤ BMI < 35, C: 35 ≤ BMI
*Statistically significant
The results of the Brief COPE are shown in Table 3. ANOVA analysis of the scores for the 14 coping behaviors revealed significant differences between groups in using emotional support, using instrumental support, self-distraction, venting, and substance use. In the post hoc analysis, the scores for using emotional support and using instrumental support were significantly higher in the obese group than in the non-obese group and the scores for venting were significantly higher in the high-degree obese group than in the non-obese group. In addition, the high-degree obese group had a significantly lower score for substance use (not using alcohol/drug as a coping behavior) than the non-obese and obese groups (Table 3).
Table 3.
Brief COPE
| BMI < 25 | 25 ≤ BMI < 35 | 35 ≤ BMI | p | Post hoc | |
|---|---|---|---|---|---|
| Active coping | 5.3 ± 1.3 | 5.5 ± 1.3 | 5.7 ± 0.6 | 0.27 | |
| Planning | 5.3 ± 1.5 | 5.4 ± 1.5 | 5.5 ± 1.0 | 0.61 | |
| Positive reframing | 5.1 ± 1.4 | 5.0 ± 1.5 | 4.8 ± 1.2 | 0.74 | |
| Acceptance | 5.3 ± 1.4 | 5.5 ± 1.3 | 5.8 ± 1.1 | 0.09 | |
| Humor | 3.9 ± 1.4 | 4.2 ± 1.6 | 3.8 ± 1.2 | 0.15 | |
| Religion | 2.9 ± 1.2 | 2.9 ± 1.3 | 2.8 ± 0.8 | 0.63 | |
| Using emotional support | 4.1 ± 1.3 | 4.4 ± 1.6 | 3.9 ± 1.4 | 0.03* | A–B 0.04* |
| Using instrumental support | 4.4 ± 1.4 | 4.8 ± 1.7 | 4.7 ± 1.5 | < 0.001* | A–B < 0.001* |
| Self-distraction | 4.6 ± 1.3 | 4.9 ± 1.4 | 5.2 ± 1.3 | 0.03 | |
| Denial | 3.5 ± 1.3 | 3.3 ± 1.2 | 2.9 ± 0.9 | 0.21 | |
| Venting | 4.0 ± 1.3 | 4.2 ± 1.4 | 4.9 ± 1.7 | 0.01* | A–C 0.04* |
| Substance use | 2.7 ± 1.2 | 2.7 ± 1.3 | 2.2 ± 0.6 | 0.03* |
A–C 0.04* B–C 0.02* |
| Behavioral disengagement | 3.8 ± 1.2 | 3.7 ± 1.2 | 3.6 ± 0.9 | 0.62 | |
| Self-blame | 4.2 ± 1.3 | 4.2 ± 1.5 | 4.2 ± 1.2 | 0.80 |
Statistical analysis was performed by ANOVA. Data are shown as mean ± SD
A: BMI < 25, B: 25 ≤ BMI < 35, C: 35 ≤ BMI
*Statistically significant
The results of the TIPI-J are shown in Table 4. ANOVA analysis of the 5 subscales showed significant differences between the groups in conscientiousness and emotional instability. Post hoc analysis also showed that the obese group had significantly lower conscientiousness and higher emotional instability than the non-obese group (Table 4). The QOL and depression status scores assessed with the EQ-5D-5L and J-PHQ-9, respectively, were not significantly different between the 3 groups (Table 5).
Table 4.
TIPI-J
| BMI < 25 | 25 ≤ BMI < 35 | 35 ≤ BMI | p | Post hoc | |
|---|---|---|---|---|---|
| Extraversion | 4.2 ± 1.3 | 4.1 ± 1.4 | 4.0 ± 1.5 | 0.37 | |
| Agreeableness | 5.3 ± 1.0 | 5.2 ± 1.1 | 5.3 ± 0.7 | 0.067 | |
| Conscientiousness | 4.2 ± 1.2 | 3.7 ± 1.1 | 3.9 ± 1.0 | < 0.001* | A–B < 0.001* |
| Emotional instability | 3.6 ± 1.1 | 3.8 ± 1.4 | 3.6 ± 1.1 | 0.02* | A–B 0.02* |
| Openness to experience | 3.8 ± 1.2 | 3.9 ± 1.1 | 3.5 ± 1.1 | 0.20 |
Statistical analysis was performed by ANOVA. Data are shown as mean ± SD
A: BMI < 25, B: 25 ≤ BMI < 35, C: 35 ≤ BMI
*Statistically significant
Table 5.
EQ-5D-5L and PHQ-9
| BMI < 25 | 25 ≤ BMI < 35 | BMI ≤ 35 | p | |
|---|---|---|---|---|
| EQ-5D-5L | 0.9 ± 0.1 | 0.9 ± 0.1 | 0.9 ± 0.1 | 0.99 |
| PHQ-9 | 3.6 ± 3.5 | 4.3 ± 4.4 | 4.5 ± 4.6 | 0.10 |
Statistical analysis was performed by ANOVA. Data are shown as mean ± SD
Among all participants, 34 patients were consulting psychiatrists at the time of questionnaire collection. When the questionnaire was reanalyzed after excluding those 34 patients with psychiatric diseases, statistical significance disappeared only in conscientiousness of personality traits. There was no obvious change in the presence or absence of significant difference in other analyses after excluding those patients (data not shown).
Discussion
The psychological and behavioral differences patients with diabetes between non-obese and obese individuals has not been fully understood. In this study, we conducted a questionnaire survey on eating behavior, coping behavior, personality traits, QOL, and depression status in patients with diabetes with and without obesity, including high-degree obesity. Scores on all items of the Eating Behavior Questionnaire were significantly higher in the obese and high-degree obese groups than in the non-obese group; the Brief COPE scale showed a significant difference in the using emotional support, using instrumental support, self-distraction, venting, and substance use among the 3 groups; and the TIPI-J revealed that the obese group had significantly lower conscientiousness and higher emotional instability than the non-obese group. No significant differences were found in QOL or depression status as assessed by EQ-5D-5L and J-PHQ-9, respectively. As far as we know, few studies have demonstrated such differences in psychological and behavioral characteristics in patients with diabetes with obesity.
Obese patients are generally said to have a gap in their recognition of eating and habits in their eating behavior [12]. For example, Morita et al. reported that although they found no difference in dietary intake in patients with and without metabolic syndrome (Mets), the scores in all items of the Eating Behavior Questionnaire were significantly higher in patients with Mets (i.e., those patients showed unfavorable eating behavior) [13]. In the present study, the obese and high-degree obese groups also had significantly higher scores in all items of the Eating Behavior Questionnaire compared with the non-obese group, suggesting that also among the patients with diabetes, obese patients have a gap in their recognition of eating and habits in eating behaviors compared with non-obese patients (Table 2). In diet therapy for diabetes, it is important to restrict total calorie intake and to balance each nutrient, and stricter restriction of total calorie intake is required in individuals with obesity. The gap and habits of eating shown in the Eating Behavior Questionnaire are potential obstacles in implementing diet therapy. This study was cross-sectional, and the causal relationship between these abnormal behaviors and the presence of obesity is unknown, but the correction of the gap and habits of eating may be beneficial for weight control.
ANOVA and post hoc analyses revealed significant differences in some items of the Brief COPE (Table 3). We speculate that the high scores for self-distraction and venting in the high-degree obese group may have been related to using snacking and overeating as a distraction or as an expression of the pain associated with hunger. The high-degree obese group had lower scores for substance use, i.e., drug or alcohol use. These results may indicate a tendency for this group to prefer foods to alcohol to avoid the stress associated with hunger. The scores for use of emotional and instrumental support were higher in the obese group: A high score on these items generally means that the individual seeks emotional support, such as comfort and empathy, and behavioral advice from others and tries to act on that advice. Diet and exercise therapy for diabetes and obesity can be stressful because of the desire to eat and skip exercise, and patients need to overcome that stress by controlling their own psychology and behavior. Coping styles in which patients try to get support from others may sometimes mean that they have a positive attitude towards listening to and following advice from medical professionals such as doctors and nutritionists. However, diet and exercise therapy may not be successful if patients cannot avoid stress on their own and tend to seek support from others and if they show abnormal eating behavior, such as snacking or overeating, or discontinue exercise therapy because they lack self-discipline.
To our knowledge, no study has evaluated the characteristics of coping in patients with diabetes with obesity. Two authors of this paper, NY-F and NS, recently investigated the relationship between glycemic control and lifestyle and psychological factors, including coping, in patients with type 2 diabetes. They found that in non-insulin users, habitual alcohol consumption and single status were positively associated with HbA1c and adaptive emotion-focused coping dimension, changing mood, and changing one’s point of view were negatively associated with it; they did not observe these associations in insulin users [15]. Although obesity greatly influences the glycemic control in patients with type 2 diabetes, it is interesting that the psychological and behavioral characteristics related to the glycemic control [15] does not necessarily match those related to obesity observed in the present study (Table 3). Different coping behaviors may be required for glycemic control and weight control.
In our analysis of personality traits with the TIPI-J, the obese group had significantly lower conscientiousness and higher emotional instability than the non-obese group (Table 4). The lower conscientiousness in the obese group may be related to their poor ability to maintain strict dietary control. In addition, the conflict resulting from their inability to improve their lifestyle habits despite receiving guidance may be the cause of their anxiety and stress. A previous study on the personality traits of patients with diabetes and obesity showed a negative correlation between BMI and conscientiousness in Western countries [21]. On the other hand, a study in Japanese patients reported that BMI was positively associated with extraversion in males and negatively associated with emotional instability in females [22]. Our study found a negative correlation of conscientiousness with BMI but no positive correlation with extraversion or negative correlation with emotional instability. However, because of the small number of participants in our study, we could not conduct analyses separately by sex.
In this study, we found no significant differences between the 3 groups in QOL as assessed by EQ-5D-5L or in depression status as assessed by J-PHQ-9 (Table 5), although the mean J-PHQ-9 scores tended to be higher in the obese and high-degree obese groups than in the non-obese group (p = 0.10). The scales may have had sensitivity issues in our study population. We believe that further studies are necessary with a higher number of participants or a different evaluation scale.
All the participants in this study had diabetes. Regardless of whether patients have diabetes or not, obese people are asked to lose weight. However, comorbid diabetes may affect weight management differently. That is, patients with diabetes are asked not to gain weight, even if they are mildly obese. Also, certain antidiabetic drugs, such as sulfonyl urea or insulin injection, can make the patients more likely to gain weight. During the regular hospital visits, these patients with diabetes often receive instructions regarding weight management from medical practitioners. It is easy to imagine that these patients face greater external stress related to weight management than obese patients without diabetes. This study did not reveal how these external factors affect the psychological and/or behavioral characteristics of obese patients with diabetes. It is necessary to conduct a survey on obese patients without diabetes using the same questionnaire and to compare the results in the future.
In addition, the number of cases in high-degree obesity group was quite small. HbA1c and the mean age was lowest and the duration of diabetes was shortest in this group. Therefore, it is necessary to consider the possibility that age, duration of diabetes, control status of diabetes, etc. may influence psychological and behavioral characteristics.
The limitations of this study are as follows: (1) The study was conducted at a single institution, and the number of participants was limited. (2) It was a cross-sectional study, and we were unable to clarify the causal relationship between the obtained psychological or behavioral characteristics and obesity. (3) The most common type of diabetes mellitus in patients in this study was type 2, but cases of type 1 diabetes and diabetes associated with other specific mechanisms and diseases were also included; it was not possible to clarify the characteristics of each type of diabetes mellitus. (4) Anti-diabetic drugs included weight-increasing drugs, such as thiazolidinediones, sulfonylureas, and insulin injections, and weight-reducing drugs, such as SGLT2 inhibitors and GLP-1 receptor agonists; the study was unable to examine the effects of such drugs.
In this study, we showed that there were some different characteristics in eating and coping behavior and some personality traits in patients with diabetes with obesity or high-degree obesity from those in non-obese patients. Especially, few studies have evaluated the characteristics of coping behavior in Japanese patients with diabetes and obesity. Knowledge about these psychological and behavioral characteristics may be useful for correcting them and thus for achieving appropriate weight control in patients with diabetes.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
We thank Mr. Kazuyoshi Kawai in department of psychiatry and Miss Ryoko Sugamata in department of endocrinology and metabolism in Dokkyo Medical University for their excellent technical supports. We also thank Dr. Masato Kase, Dr. Kanako Kato, Dr. Yuiko Inoue, Dr. Toshimitsu Shinzawa, Dr. Soichiro Hosonuma, Dr. Takafumi Niitani, Dr. Syo Wakamatsu, Dr. Eitaku Kurai, Dr. Eriko Ohira, Dr. Tomohisa Kunii, Dr. Yasutake Shinohara, Dr. Nanako Hirao, Dr. Dai Tanuma, Dr. Kanako Suda, Dr. Yusuke Kamiga, Dr. Tsubasa Nakamura and Dr. Chiaki Saito in department of endocrinology and metabolism in Dokkyo Medical University for collecting the data of questionnaire. This research did not receive any specific grant from funding agencies.
Data availability
The data that support the findings of this study are available from the corresponding author, [I.U.], upon reasonable request.
Declarations
Conflict of interest
Yoshimasa Aso received honoraria from Daiichi Sankyo, Tanabe Mitsubishi, Sumitomo Pharma, and Novo Nordisk, and Isao Usui from Daiichi Sankyo as lecture fees. Masahiro Saito, Norio Sugawara, Teruo Jojima, Shintaro Sakurai, Haruka Kishi, Masaaki Sagara, Takuya Tomaru, Toshie Iijima, Kazutaka Shimoda, Norio Yasui-Furukori declare that they have no conflict of interest.
Human participants
The protocol for this research project has been approved by a suitably constituted Ethics Committee of Dokkyo Medical University Hospital (approval number R4-023), and it conforms to the provision of the Declaration of Helsinki (as revised in Fortaleza, Brazil, October 2013) and the Japanese Ethical Guidelines for Medical and Biological Research Involving Human Subjects.
Informed consent
Informed consent for study participation was obtained by an opt-out approach and patient anonymity was preserved.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data that support the findings of this study are available from the corresponding author, [I.U.], upon reasonable request.