This study is the first to assess the quality of life of patients with T1D in the State of Maranhão, an admixed population of the Northeast region of Brazil. In our evaluation, the variables that positively influenced the HRQoL of these patients included the following: being male, age under 18 years old, single status, elementary school education, having health insurance, having less than FIVE years of diagnosis, and practicing certain types of physical activity. In addition, non-occurrence of hypoglycemia in the last 30 days, lack of chronic complications (retinopathy and nephropathy), participation in any group educational activity, using analogous insulin, monitoring blood glucose, maximum adherence to treatment, and coming from secondary service showed statistical significance. Autosomal ancestry and self-reported color/race did not show influence on HRQoL indexes.
In a multicenter national study conducted in 2015, the average score attributed to general health (EQ-VAS) was lower than that obtained in the present study (72.5 ± 22 versus 76.24 ± 21.30). The differences found in the literature in relation to the quality of life are related to urbanization, poverty, and organization of health services. However, despite this structure, the study mentioned above showed better quality of life reported in the EQ-VAS (74.6 ± 30), lower depression rate, and lower anxiety frequency in the northeast region, which characteristically features a lower urbanization rate, wealth, and structuring in health services. These findings were like those observed in our study, suggesting additional factors, such as lifestyle, in this assessment (17)
When we associated the socio-demographic criteria with the quality of life through HRQoL, the male patients showed better HRQoL. Other studies have already observed the lower quality of life among female patients (3)(18)(19). Women generally present higher disease-related concerns, lower level of satisfaction, and worse perception of their health compared with men (19).
We observed significant improvement in the HRQoL in the group with supplementary health insurance. The American Diabetes Association observed that patients with public and private health insurance have more access to health care and thus achieve better glycemic indexes and quality of life (9). A recent study evaluating a significant sample of the Brazilian population corroborates our findings of fewer diabetes-related chronic complications, especially in retinopathy, when patients have access to public and private health services(20).
We also observed better HRQoL in the patients who participated in group education in secondary care. A study in the United Kingdom evaluated the HRQoL before and after a three-day educational course offered to adolescents with T1D to help manage diabetes. The results showed that the group's pre-course yearnings were met, and the educational assessment was solid. The A1c indices and BMI were unchanged, and no episodes of hypoglycemia were observed; both parents and patients reported an improved HRQoL after training (21). In a Greek study, patients with T1D participated for 1 year in groups, in which knowledge about the disease was transmitted in a simple and understandable manner. At the end of this program, reduced A1c levels, fewer blood glucose fluctuations, and lower incidence of hypoglycemia were observed, improving the HRQoL of these patients (22).
The use of analog insulin also demonstrated a positive impact on the HRQoL of our population. In the literature, this finding is controversial. A 2018 meta-analysis showed no overall difference in HRQoL compared with the use of the recombinant human insulin (NPH) (23). A Brazilian meta-analysis in 2019 failed to reach a consensus on the superiority of using fast acting analogs over regular insulin due to the scarcity of well-designed studies in the literature (24). However, reductions in severe hypoglycemia, postprandial blood glucose, and HBA1c, factors that impact the quality of life, were observed.
HBA1c is an indirect measure of mean blood glucose levels, reflecting blood glucose levels over the past three months; despite its known limitations, it remains the primary tool for ensuring glycemic control and predicting the risk of complications (25). The mean HBA1c in this study was slightly lower than that observed in a multicenter Brazilian study in 2015, specifically in terms of the overall average of Brazil (9.05 ± 2.27 versus 9.4 ± 2.4) and in the evaluation of the northeast region of Brazil (9.05 ± 2.27 versus 9.6 ± 2.6). No significant difference in HRQoL was observed between the patients with or without good metabolic control as evaluated by this tool. We attribute this finding to the large number of patients without good metabolic control, that is, 82.39% of our population. In a cohort from the diabetes outpatient clinic of the Hospital das Clinicas of the Federal University of Paraná with T1D adolescents, the patients with the best HRQoL included those with lower HBA1c levels; the higher the HBA1c, the greater the likelihood of lower levels of satisfaction (26). A previous study assessing adolescents with T1D observed that those with A1c in their goal may realize that diabetes results in an unfavorable effect on their lives, resulting in depression and difficulty in coping with the disease (27).
Physical activity is related to patients' lifestyle and is an impact variable in diabetes care. Every patient should be encouraged to allot leisure periods of physical activity and balanced exercise (9). In this study, sedentary lifestyle exhibited a significant negative impact on the HRQoL, in line with other studies conducted on patients with T1D and HRQoL (18)(26). Physical activity is strongly associated with psychological well-being and therefore, should be encouraged in this population (28).
Hypoglycemia, another important factor in the evaluation of this group, is described as the main limiting factor in the management of T1D (9). The data obtained in our research regarding the frequency hypoglycemia episodes and the fear of these episodes are in line with other studies demonstrating impairment in HRQoL (29). Hypoglycemia has been associated with cognitive dysfunction in children with T1D, and the fear of hypoglycemia may add to the difficulty faced by patients in adhering to the proposed treatment and therefore glycemic control (30)(31).
According to the literature, insufficient diabetes control and increased BMI negatively influence HRQoL, because they generate emotional disorders, such as anxiety, anguish, depression, low self-esteem, anorexia, or bulimia, whereas adequate capillary blood glucose monitoring and dietary flexibility are related to higher levels of HRQoL (19). We observed no difference in the HRQoL between the patients with different BMI levels. However, capillary blood glucose monitoring showed improvement in the HRQoL of patients.
A survey of young Germans comparing the HRQoL of T1D adolescents aged 11 to 17 years old and their healthy peers showed that the diagnosis of the disease in early childhood caused no impairment in the HRQoL compared with that of the peers without diabetes. This finding is probably due to the process of adaptation common in individuals with chronic diseases, with those who experienced such process from an early age becoming accustomed to their condition, considering their disease as normal and as a part of their daily life; as a result, and individuals with chronic diseases feel no different from their healthy peers (32). A Brazilian study showed by linear regression that complications and time of diabetes had low impact on EQ-VAS and failed to clarify the causes (16). Our study failed to show a better HRQoL of patients when considering the same variables. With earlier diagnosis of T1D, a better EQ-VAS was observed in patients with less disease time, and this finding is related to the absence of complications.
The presence of microvascular complications (retinopathy and nephropathy) was associated with a lower HRQoL in our study. The 23-year study of DCCT/DTIS also showed that the presence of microvascular complications significantly decreased the HRQoL in patients with T1D (33). Retinopathy and nephropathy impair the autonomy, self-care, and HRQoL of patients with T1D (34).
Our study has shown a better HRQoL in patients coming from the secondary public service, which can be attributed to the higher number of patients using insulin analogs and presenting less hypoglycemia, which are important factors affecting the HRQoL of our patients. In addition, these patients had health insurance and received various services in private services, which may also influence their perception of HRQoL. These patients also had more access to educational programs, which have been shown by several studies to positively impact HRQoL (21)(22).
We found a negative correlation between European ancestry and glycemic control, the higher the degree of European ancestry the worse HBA1C. Evidence suggests that minority populations tend to have poorer self- management and diabetes outcomes, for example African and Hispanic children and adolescents have worse control when compared to their white peers (10)(35). We hypothesize that the difference in our study is due to the large percentage of European ancestry found in our highly mixed population.
Our population is composed by the miscegenation between European, African, and Native American populations (36). This fact was noted in our study through the analysis of genomic ancestry. Through our analyses we found that, as in all Brazilian regions, European ancestry was the largest contributor, but in our population, it approached 50% differing from the weighted average of 68.1% found in the Brazilian population in a systematic review study conducted in 2019. We also obtained a similar percentage between African and Native American ancestry (around 25% each), which again differs from the Brazilian average of 19.6% African and 11.6% Native American. The distribution of ancestral groups did not occur homogeneously in the Brazilian territory, differing depending on the geographic region, and reflecting the history of colonization with different levels of miscegenation (37). In general, this occurred with an asymmetrical mating pattern, preferably between European men and Native American or African women. In Afro-descendant communities such as the Amazon and Maranhão, another pattern between African men and Native American women was also observed (36). Also, in Maranhão, Native Americans maintained contact with the Brazilian population of mixed race and with African slaves, in the pattern of the mating of Native American men with African or mixed women (38). These patterns may justify our observed ancestry panel.
Surveys have shown a low correlation between color report and ancestry, however, in our analysis we found that in self-reported whites had higher European ancestry, and self-reported blacks had higher African ancestry, suggesting adequate perception by our patients (39).
Quality of life questionnaires are barely explored in Brazil, particularly in the State of Maranhão, the northeast region of the country. Our study is the first to measure HRQoL and recognize the impact of T1D through the analysis of multiple factors related to the quality of life and autosomal ancestry in patients with from Maranhão, a state formed by a population highly admixed. The results validate the need to provide T1D patients with continuous training on self-management and self-monitoring, seeking better results in metabolic control and consequently, in the prevention of acute and chronic complications to generate positive impacts on the quality of life of this population. In addition, reinforcing physical activity at each appointment should be part of the health team’s routine.