The effects of Social Determinants of Health on Type 2 Diabetes Outcomes (A1C)

Abstract

Background: Diabetes Mellitus is one of the most prevalent chronic diseases in Lebanon and understanding its underlying risk factors beyond the scope of diet and lifestyle is imperative for proper diabetes management. Objective: The aim of this study is to assess the social and psychological determinants of diabetes control in Lebanese patients with type 2 diabetes. Design: A convenience sample of 300 Lebanese patients with type 2 diabetes (56±11 years; 48% Females; Median A1C: 7%) were recruited from several primary health care centers in Lebanon (Beirut, Mount Lebanon and North Lebanon) and surveyed. Data concerning their demographics, social determinants of health (subjective diabetes self-care activities, quality of life, depression, fatalism, food security, health literacy, diabetes knowledge, and adverse childhood experience), as well as anthropometric and other measures (weight, height, waist circumference, blood pressure, and A1C) were collected. Results: The primary outcome A1C was dichotomized into controlled (A1C< 7%) (n=131) and uncontrolled (A1C≥7%) (n=164) groups. Results of bivariate analyses showed significant differences between the controlled and uncontrolled groups for the independent risk factors: availability of certain house facilities (p<0.05), diabetes duration (p=0.00), diabetes complications (p<0.05), quality of life score (p=0.002), and self-monitoring of blood glucose (p=0.003).After multivariate analysis, only diabetes duration of 5-10 years remained significant in explaining the variability in HbA1C (OR=3.79; CI: 1.5-9.57; p=0.005, R2=0.342). To explore possible mediators in this relationship, a path analysis was conducted based on a hypothetical model derived from the literature. Significant direct and indirect relationships were obtained between several risk factors (socioeconomic factors, depression, fatalism emotional distress, diabetes duration of 5-10 years, diabetes self- care activities, self-monitoring of blood glucose, diabetes medication and/or insulin therapy, quality of life, and diabetes complications) and A1C. Discussion: Patients with controlled A1C had better household and living conditions, took higher doses of medication, and were surrounded with a supportive environment that enhances diabetes management. Diabetes duration of 5-10 years increased the odds of having uncontrolled A1C by more than 3 folds. Moreover, results of the path analysis showed a significant interrelation between independent risk factors, mediators, and A1C. Conclusion: Better understanding interlinked causal pathways and upstream factors underlying diabetes is imperative to drive novel and effective approaches for effective diabetes management and prevention of its debilitating health and psychological consequences.