Prevalence of Gastrointestinal Symptoms and Its Effect on Quality of Life among Patients with Diabet...

Ozden DEDELI, Sezgi CINAR PAKYUZ, Ummu KACER DABAN, Seda KIPCAK, Deniz SARI, Emel SENOL, Zeliha HEKIMSOY

American Journal of Nursing Research

Prevalence of Gastrointestinal Symptoms and Its Effect on Quality of Life among Patients with Diabetes Mellitus

Ozden DEDELI1,, Sezgi CINAR PAKYUZ1, Ummu KACER DABAN2, Seda KIPCAK2, Deniz SARI2, Emel SENOL2, Zeliha HEKIMSOY2

1Department of Internal Medicine, Celal Bayar University School of Health, Manisa, Turkey

2Department of Internal Medicine, Celal Bayar University, Hafsa Sultan Hospital, Manisa, Turkey

Abstract

Aim: The aim of this study was to determine the prevalence of gastrointestinal symptoms and its effect on quality of life among patients with diabetes mellitus. Methods: This descriptive, cross-sectional study was conducted a university hospital in Manisa, Turkey. Among the diabetic patients who reffered to two internal medicine policlinics, 138 patients were selected randomly. A questionnare has been designed including socio-demographic, medical history about diabetes mellitus (DM), Gastrointestinal Symptom Grading Scale (GSGS) and Gastrointestinal Quality of Life Index (GIQLI). Data were expressed as mean±standart deviation (SD). Comparisons between means were carried out using the Mann-Withney U, Kruskal-Wallis H, correlations. p<0.05 was considered statistically significant. Results: The mean±SD age of the patients was 49.5±12.9 years (range 18-65 years). The proportion of men in the patients was slightly higher compared with that of women (53.6% vs 46.4%). Of the 138 diabetic patients interviewed, 85.2 percent of patients had type II diabetes. The most common GI symptoms were abdominal distension (71.6%), feeling of incomplete evacuation (70.3%), reflux (60.1%), and constipation (58.7%). GIQLI score was found to be 76.1±25.1 (range 30-127) in the patients with diabetes who participated in this study. There were statistically significant negative correlation between GIQLI score and frequency of GI symptoms (p<0.01). Conclusion: The results of this study indicated that patients with diabetes mellitus hold commonly complaint of gastrointestinal symptoms, and gastrointestinal problems can impair well-being and quality of life in diabetes.

Cite this article:

  • Ozden DEDELI, Sezgi CINAR PAKYUZ, Ummu KACER DABAN, Seda KIPCAK, Deniz SARI, Emel SENOL, Zeliha HEKIMSOY. Prevalence of Gastrointestinal Symptoms and Its Effect on Quality of Life among Patients with Diabetes Mellitus. American Journal of Nursing Research. Vol. 3, No. 3, 2015, pp 48-53. http://pubs.sciepub.com/ajnr/3/3/1
  • DEDELI, Ozden, et al. "Prevalence of Gastrointestinal Symptoms and Its Effect on Quality of Life among Patients with Diabetes Mellitus." American Journal of Nursing Research 3.3 (2015): 48-53.
  • DEDELI, O. , PAKYUZ, S. C. , DABAN, U. K. , KIPCAK, S. , SARI, D. , SENOL, E. , & HEKIMSOY, Z. (2015). Prevalence of Gastrointestinal Symptoms and Its Effect on Quality of Life among Patients with Diabetes Mellitus. American Journal of Nursing Research, 3(3), 48-53.
  • DEDELI, Ozden, Sezgi CINAR PAKYUZ, Ummu KACER DABAN, Seda KIPCAK, Deniz SARI, Emel SENOL, and Zeliha HEKIMSOY. "Prevalence of Gastrointestinal Symptoms and Its Effect on Quality of Life among Patients with Diabetes Mellitus." American Journal of Nursing Research 3, no. 3 (2015): 48-53.

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1. Introduction

Diabetes Mellitus (DM) refers to a group of disorders in which hyperglycaemia is the common denominator and is associated with insulin deficiency which may be total or relative due to insulin resistance. In general gastrointestinal (GI) symptoms and dysfunction caused by DM have been under recognised [1]. As mentioned, GI symptoms are increased prevalence in patients with diabetes mellitus. Many patients with diabetes mellitus suffer from upper and lower GI symptoms. The reported prevalence of these symptoms varies among different ethnic groups/populations [1, 2]. As many as 75% of patients visiting diabetes clinics will report significant GI. The entire GI tract can be affected by diabetes from the oral cavity and esophagus to the large bowel and anorectal region. Thus, the symptoms complex that may be experienced can vary widely. Common complaints may include dysphagia, early satiety, reflux, constipation, abdominal pain, nause, vomiting, and diarrhea [3]. The natural history of GI sypmtoms as well as their pathogenesis in patients with diabetes remains poory understood. Many patients go undiagnosed and untreated because the GI tract has not been traditionally associated with diabetes and its complications [3, 4]. In recent years, studies have found that GI symptoms affect quality of life adversely and represent a substantial cause of morbidity in patients with diabetes [5, 6]. The aim of this study was to determine the prevalence of GI symptoms and it effect on quality of life among patients with diabetes mellitus.

2. Methods

This descriptive, cross-sectional study was conducted between March and September during 2015 in Manisa, Turkey. Among the diabetic patients who reffered to two internal medicine policlinics in the university hospital, 138 patients were selected according to the following criteria; who had been Type I DM or Type II DM, HBV and HCV negative, non-malignancy, between 18 and 65 years of age, and had more than one year of diabetes, able to speak and read Turkish, to be willing participant. The study purpose, procedural details, the participant’s rights and potential benefits and risks of the study were explained and written consent forms were obtained from them. Data were collected by using a socio-demographic questionnare, Gastrointestinal Symptom Grading Scale (GSGS) and Gastrointestinal Quality of Life Index (GQLI) by the researchers, which took a range from 20 to 30 minutes.

2.1. A Socio-demographic Questionnare

A socio-demographic questionnaire was developed by the authors to capture personal information on age, gender, past medical history, type of diabetes mellitus, duration and complication of diabetes mellitus.

2.2. Gastrointestinal Symptom Grading Scale

The GSGS is a disease-specific instrument of 15 items combined into five symptom clusters depicting Reflux, Abdominal pain, Indigestion, Diarrhoea and Constipation. The GSGS has a seven-point graded Likert-type scale where 1 represents absence of troublesome symptoms and 7 represents very troublesome symptoms. The reliability and validity of Turkish version of the GSGS are well-documented, and norm values for a general population are available [7].

2.3. Gastrointestinal Quality of Life Index

The questionnaire contains up to 36 items, scored on a five point Likert scale (range 0–144, higher score=better quality of life), in which additional modules, specified by the particular gastrointestinal disorders, supplement a set of core questions. The reliability and validity of Turkish version of the GQLI are well-documented, and norm values for a general population are available [8, 9, 10].

2.4. Ethical Consent

This study was endorsed by the Research Ethics Committee of the Celal Bayar University Faculty of Medicine at Manisa, Turkey.

2.5. Data Analysis

Data analyses (descriptive statistics, Mann-Withney, Kruskal-Wallis, and Pearson correlation analyses) were conducted using the SPSS 16.0 statistical packet. Descriptive statistics are expressed as mean ± Standard deviation (SD). p<0.05 was considered statistically significant. Grouping of the patients according to parameters associating with diabetes, was conducted regarding recommendations of Guideline Diagnosis and Treatment of Diabetes Mellitus, 2013 [11].

3. Results

The mean±SD age of the patients was 49.5±12.9 (range 18 to 65) years. The proportion of men in the patients was slightly higher compared with that of women (53.6% vs 46.4%). Table 1 summarizes sociodemographic characteristics of the patients with diabetes. Of the 138 diabetic patients interviewed, 85.2 percent of patients had type II diabetes. 18 diabetic patients had the history of hypertension, 13 patients had the history of heart failure, 12 patients had the history of hyperlipidemia, 10 patients had both hypertension and hyperlipidemia, 7 patients had either hypothyroidism or hyperthyroidism, 3 patients had chronic obstructive pulmonary disease (COPD), 3 patients had asthma. 48.6% of the patients described moderate level of treatment adherence. HbA1c levels were respectively normal <7% (3.6%), acceptable <8% (14.5%), high ≥8% (81.9%). Fasting glucose were respectively high ≥ 120 mg/dl (66.6%), acceptable 70-120 mg/dl (33.3%). Postprandial glucose were respectively high > 140 mg/dl (64.4%), acceptable ≤ 140 mg/dl (35.5%). 16.7% of diabetic patients had nephropathy, 70.4% of them had peripheral neuropathy, 50.7% of them had retinopathy. Table 2 summarizes diabet characteristics of the patients with diabetes.

Table 1. Sociodemographic characteristics of patients with diabetes mellitus (n=138)

The most common GI symptoms were abdominal distension (71.6%), feeling of incomplete evacuation (70.3%), gastroesophagial reflux (60.1%), and constipation (58.7%). Table 3 summarizes frequency of GI symptoms in the patients with diabetes. GQLI score was found to be 76.1±25.1 (range 30 to 127) in the patients with diabetes who participated in this study. There were statistically negative correlation between GQLI score and frequency of GI symptoms (p<0.05) (Table 4). There was statistically significant difference among patients’ GSGS score and GQLI score regarding type of diabet, peripheral neuropathy, and retinopathy (p<0.05). It was found that no statistically significant difference among patients’ GSGS score and GQLI score regarding nephropathy (Table 5).

Table 2. Diabet characteristics of the patients with diabetes (n=138)

Table 3. Frequency of gastrointestinal symptoms in the patients with diabetes

Table 4. Correlations between Gastrointestinal Symptom Grading Scale scores and Gastrointestinal Quality of Life Index scores in the patients with diabetes (n=138)

Table 5. Gastrointestinal Symptom Grading Scale scores and Gastrointestinal Quality of Life Index scores regarding type of diabet, nephropathy, peripheral neuropathy and retinopathy in the patients with diabetes (n=138)

There was statistically significant difference among patients’ GSGS score and GQLI score regarding duration of diabet, and HbA1c levels (p<0.05), but no statistically significant difference among patients’ GSGS score and GQLI score regarding treatment and treatment adherence (Table 6). In addition, it was found that statistically positive correlation between patients’ GSGS score and duration of diabet (r=0.64 p<0.05), HbA1c levels (r=0.56 p<0.05). However, it was found that statistically negative correlation between patients’ GQLI score and duration of diabet (r=-0.54 p<0.05), HbA1c levels (r=-0.46 p<0.05).

Table 6. Gastrointestinal Symptom Grading Scale scores and Gastrointestinal Quality of Life Index scores regarding duration of diabet, HbA1c levels, treatment and treatment adherence in the patients with diabetes (n=138)

4. Discussion

Prevalence of gastrointestinal symptoms has been reported to be higher in patients with diabeters than in the general population. Although there is controversy, these symptoms are not considered important causes of mortality in patients with diabetes, but they can also have a negative influence on health status and quality of life [12]. In the current study, we aimed to assess GI symptoms and its effects on quality of life in patients with diabetes mellitus. The results of this study indicated that patients with diabetes mellitus hold commonly complaint of gastrointestinal symptoms.

The pathophysiological changes observed in the diabetic patient include the effects of acute and long-term hyperglycemia on neuronal function and gastrointestinal motility [13]. Dysfunction of the gastrointestinal tract related to diabetes mellitus results from diabetic autonomous neuropathy, impaired sensory innervation and a direct effect of chronic hyperglycaemia [14]. Impaired motility and delayed gastric emptying can be affected by diabetic neuropathy in patients with longstanding diabetes. For that reason, diabetic patients commonly suffer from abdominal distansion, esophageal dysmotility and gastroparesis [13]. The prevalence of gastroesophageal reflux symptoms in diabetes could be as high as 41% [15]. Delayed gastric emptying can be demonstrated in 27%-65% of patients with type 1 diabetes and about 30% of patients with type 2 diabetes [16]. We found that the most common GI symptoms were abdominal distension, and gastroesophageal reflux in the patients with diabetes. This could indicate that GI symptoms such as abdominal discomfort and gastroesophageal reflux may be influenced long-term hyperglycemia, longstanding diabetes, and neuropathy. Similar to reference [17] demonstrated that patients with diabetes mellitus had abdominal pain, bowel-related pain, reflux, constipation frequently. Neuropathy may affect the nerves innervating the colon, leading to a decrease in colon motility and constipation [14, 18]. Constipation is a common problem affecting up to 60% of patients with long-standing diabetes mellitus [19]. We demonstrated that the most common GI symptoms were feeling of incomplete evacuation and constipation in the patients with diabetes. Similar to reference [5] stated that the most commonly symptoms were constipation followed by bloating, mass protruding through anus, abdominal pain. Contrary to Chinese patients with type 2 diabetes had GI symptoms, most commonly diarrhea, constipation, and epigastric fullness [20]. Among 68 patients with type 2 diabetes followed up at the German diabetes research institute in Duesseldorf, 22% reported constipation and 11.8% had nausea [21]. On the other hand, GI symptoms including abdominal pain, diarrhea, and constipation were similar in 89 randomly selected Finnish patients with insulin-dependent diabetes, 481 Finnish patients with noninsulin-dependent diabetes [22]. An ethnic predisposition may also exist for experiencing GI symptoms in patients with diabetes mellitus.

The results of this study indicated that gastrointestinal problems can impair well-being and quality of life in patients with diabetes mellitus. It has been reported in the literature that GI symptoms impact negatively on health related quality of life in diabetes mellitus [16, 23]. In addition, several studies have shown that type II DM with patients hold an increased prevelance rate of GI symptoms and negative impact on quality of life [6, 17, 21, 23]. We found that frequence of GI symptoms increased, and quality of life impaired among patients with Type II DM. This result could be explained that patients with type II DM was more than type I DM in our study group.

It is known that diabetes affects virtually every organ system in the body and the duration and severity of the disease may be had a direct impact on organ involvement in diabetics. Though GI complications are common in longstanding diabetes. Elevated glycated hemoglobin level, duration of diabetes in excess of 10 years and the presence of macro- and microvascular complications are all accepted risk factors for the development of GI symptoms [18]. We found that the presence of diabetic neuropathy, retinopathy, duration of diabet more than 10 years, and HbA1c of ≥8% were association between increasing GI symptoms and declining quality of life. Similar to reference [24] reported that the presence of diabetic neuropathy, retinopathy, and HbA1c of >7% were significantly related to GI symptoms in 250 patients with diabetes. Certainly, poor glycemic control will lead to early manifestation of diabetic late complications including nephropathy, neuropathy and retinopathy [19]. It has been shown that GI symptoms were significantly related to poor controlled glucose levels in patients with diabetes (n=136). [25]. In our study group, it was shown that poor controlled glucose levels. Although autonomic test was not performed in the patients with diabetes, the results of this study demonstrated that the presence of diabetic neuropathy and retinopathy were statistically significant relationships between increased GI symptoms and impaired quality of life.

5. Conclusions

In summary, our results provide evidence that GI symptoms are more prevalent in patients with diabetes mellitus and are associated with duration of diabetes, poor glycemic control, the presence of diabetic neuropathy and retinopathy. Our findings suggest that patients with diabetes mellitus hold commonly complaint of gastrointestinal symptoms, and gastrointestinal problems can impair health related quality of life in diabetes.

6. Recommendations

The limitation of this study is investigated the single clinic population and no control group recruiting from a general non-diabetic population. Therefore, we suggest that in further studies, matching with control group of this group may be of interest. In addition, we recommend that in further studies, each GI symptoms and its effects quality of life should be assessed in patients with diabetes mellitus.

Conflict of Interest

The authors declare that they have no conflict of interests.

Acknowledgment

We would like to thank all the patients for kindly participating in this study.

References

[1]  Onyekwere C, Ogbera A. Prevalence of gastrointestinal symptoms in diabetics in an Urban Hospital In Nigeria. The Internet Journal of Endocrinology. 2006;4(1):1-4.
In article      
 
[2]  Koch CA, Uwaifo GI. Are gastrointestinal symptoms related to diabetes mellitus and glycemic control? European Journal of Gastroenterology & Hepatology. 2008;20:822-25.
In article      View Article  PubMed
 
[3]  Wolosin JD, Edelman SV. Diabetes and the gastrointestinal tract. Clinical Diabets. 2000;18(4):1-7.
In article      
 
[4]  Koch CA, Uwaifo GI. Are gastrointestinal symptoms related to diabetes mellitus and glycemic control? Eur J Gastroenterol Hepatol. 2008;20:822-5.
In article      View Article  PubMed
 
[5]  Khoshbaten M, Madad L, Baladast M Mohammadi M, Aliasgarzadeh A. Gastrointestinal signs and symptoms among persons with diabetes mellitus. Gastrtoenterology and Hepatology. 2011;4(4):219-23.
In article      
 
[6]  Bytzer P, Talley NJ, Leemon M, Young JL, Jones PM, Horowitz M. Prevalence of gastrointestinal symptoms sssociated with Diabetes Mellitus. Arc Intern Med. 2001; 161:1989-96.
In article      View Article
 
[7]  Karaman Turan N, Aştı T. Validity and reliability of Turkish version of the Gastrointestinal Symptom Rating Scale. MedicReS IC2011 International Conference on Good Medical Research, Istanbul, Turkey, 25-27 Mart 2011, pp.54-54.
In article      PubMed
 
[8]  Oğuz M, Leventoğlu S. Kolorektal cerrahide yaşam kalitesinin değerlendirilmesi. In: Baykan A, Zorluoğlu A, Geçim E, Terzi C (Eds). Kolon rektum kanserleri. 1. Baskı. İstanbul: Seçil Ofset Matbaacılık ve Ambalaj Sanayi Ltd Şti, 2010. pp 721-32.
In article      
 
[9]  Çetinkünar S, Tokgöz S, Tokaç M, Bilgen K, Celep B, Hasdemir O, Atlı M. Asemptomatik safra kesesi taşı olan hastalarda laparoskopik kolesistektominin gastrointestinal hayat kalitesine üzerine etkisi. Adanan Menderes Üniversitesi Tıp Fakültesi Dergisi. 2011;12(2):2-10.
In article      
 
[10]  Celep B, Çetinkünar S, Çağlar B, Tokgöz S, Atlı MY. Safra kesesi polibi olan hastalarda kolesistektominin hayat kalitesine etkisi. Bakırköy Tıp Dergisi. 2011;7:147-52.
In article      View Article
 
[11]  Türk Diyabet Vakfı. Diyabet tanı ve tedavi rehberi. 2013. http://www.turkdiab.org/i/2013/D%C4%B0YABET%20REHBER%C4%B0%202013.pdf.
In article      
 
[12]  Rodrigues ML, Motta ME. Mechanisms and factors associated with gastrointestinal symptoms in patients with diabetes mellitus. J Pediatr (Rio J). 2012 Jan-Feb;88(1):17-24.
In article      View Article
 
[13]  Punjabi P, Hira A, Prasad S, Wang X, Chokhavatia S. Review of gastroesophageal reflux disease (GERD) in the diabetic patient. Journal of Diabetes. 2015 September; 7: 599-609.
In article      View Article  PubMed
 
[14]  Perusicová J. Gastrointestinal complications in diabetes mellitus. Vnitr Lek. 2004 May;50(5):338-43.
In article      PubMed
 
[15]  Wang X, Pitchumoni CS, Chandrarana K, Shah N. Increased prevalence of symptoms of gastroesophageal reflux diseases in type 2 diabetics with neuropathy. World J Gastroenterol. 2008; 14: 709-12.
In article      View Article  PubMed
 
[16]  Parkman HP, Yates K, Hasler WL, Nguyen L, Pasricha PJ, Snape WJ, Farrugia G, Koch KL, Calles J, Abell TL, Mc- Callum RW, Lee L, Unalp-Arida A, Tonascia J, Hamilton F. Similarities and differences between diabetic and idiopathic gastroparesis. Clin Gastroenterol Hepatol. 2011; 9: 1056-64.
In article      View Article  PubMed
 
[17]  Talley NJ, Young L, Bytzer P, Hammer J, Leemon M, Jones M, Horowitz M. Impact of chronic gastrointestinal symptoms in diabetes mellitus on health-related quality of life. Am J Gastroenterol. 2001; 96(1): 71-6.
In article      View Article  PubMed
 
[18]  Krishnan B, Babu S, Walker J, Walker AB, Pappachan MJ. Gastrointestinal complications of diabetes mellitus. WJD. 2013 ;4(3): 51-63.
In article      View Article  PubMed
 
[19]  Ohlsson B, Melander O, Thorsson O, Olsson R, Ekberg O, Sundkvist G. Oesophageal dysmotility, delayed gastric emptying and autonomic neuropathy correlate to disturbed glucose homeostasis. Diabetologia. 2006; 49: 2010-14.
In article      View Article  PubMed
 
[20]  Ko GT, Chan WB, Chan JC, Tsang LW, Cockram CS. Gastrointestinal symptoms in Chinese patients with type 2 diabetes mellitus. Diabet Med 1999; 16:670-674.
In article      View Article
 
[21]  Enck P, Rathmann W, Spiekermann M, Czerner D, Tschoepe D, Ziegler D, et al. Prevalence of gastrointestinal symptoms in diabetic patients and non-diabetic subjects. Z Gastroenterol 1994; 32:637-641.
In article      PubMed
 
[22]  Janatuinen E, Pikkarainen P, Laakso M, Pyorala K. Gastrointestinal symptoms in middle-aged diabetic patients. Scand J Gastroenterol 1993; 28: 427-437.
In article      View Article  PubMed
 
[23]  Zetina–Lopez A, Custodio–Vazquez A, Hinojosa C, Juarez–Paiz L, Schmulson M. Impact of gastrointestinal symptoms on health related quality of life in patients with type 2 diabetes mellitus. Rev Invest Clin 2003; 55(6):594-9.
In article      PubMed
 
[24]  Abid S, Rizvi A, Jahan F, Rabbani F, Islam N, Khan MH, et al. Poor glycemic control is the major factor associated with increased frequency of gastrointestinal symptoms in patients with diabetes mellitus. J Pak Med Assoc. 2007; 57:345-349.
In article      PubMed
 
[25]  Quan C, Talley NJ, Jones MP, Howell S, Horowitz M. Gastrointestinal symptoms and glycemic control in diabetes mellitus: a longitudinal population study. Eur J Gastroenterol Hepatol 2008; 20:888-897.
In article      View Article  PubMed
 
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