*3.1.2.4 Quality of life*

Living with diabetes negatively impacts the quality of life (QoL) of patients, which is worsened in the presence of complications [42]. The negative way that diabetes impacts the patient's QoL includes the psychological impact of being chronically ill, dietary restrictions, changes in social life, symptoms of inadequate metabolic control, chronic complications, and ultimately lifelong disabilities [43, 44]. Diabetes patients from low-income countries can maintain a high QoL when treated with insulin [45]. An Argentinian study reported that the scores of QoL did not differ from those of patients in high-income countries where there is access to a high level of diabetes care [42]. An Indian observational study reported that nearly half of the diabetes patients (48.6%) had a good QoL [44]. An Iranian study reported that men living with diabetes compared to females, non-insulin-treated patients compared with insulin-treated patients had better QoL [46]. Further findings show that patients with Hemoglobin A1c (HbA1c) less than 7% had a better quality of life compared with those with a higher HbA1c [46].

Variables such as age, gender, socio-economic status, obesity, type of diabetes, treatment, chronic complications, health insurance, quality of care, and patient education have been associated with diabetes patients' Health-Related Quality of Life (HRQoL) [42]. Studies have shown that HRQoL is associated with the duration of diabetes, age, gender, diabetic complications, comorbid diseases, and the severity of the disease itself [42, 43]. A South African study that assessed the HRQoL using a Diabetes 39 (D-39) questionnaire reported an association between HbA1c and HRQoL, and no association was found between HRQoL and other clinical parameters such as the number of insulin units used per day, exercise, body mass index (BMI), lipogram and the use of oral hypoglycemic agents (OHAs) [43]. An Indian observational study reported that diabetes had significantly affected HRQoL, especially in the social relationship domain [44].

#### *3.1.2.5 Anthropometric assessment*

Anthropometric measurements estimate risk factors of different diseases [47], including diabetes and obesity. Body Mass Index is used to assess obesity, which reflects total body fat but does not reflect patterns of fat distribution [48]. Being overweight is only linked with T2DM morbidity, while obesity is linked with increased morbidity and mortality from diabetes and its complications [48]. The BMI characterization is similar across genders and ethnic groups [47]. The cut-offs for anthropometric indexes of abdominal adiposity, called waist circumference, vary by gender [45]. A high waist circumference is associated with cardiovascular risk,

#### *Baseline Analysis for Effective Diabetes Intervention DOI: http://dx.doi.org/10.5772/intechopen.108170*

prevalence of diabetes, and incidences of hypertension [49]. High waist circumference and high body mass index (BMI) are considered risk factors for T2DM, though the relationship may differ with populations [47]. Several studies have reported that central obesity, which is measured through waist circumference, is an important and superior risk factor for developing diabetes, compared to the general obesity which is measured through BMI [47, 48].

Other anthropometric measurements for central obesity are Waist-to-Hip Ratio (WHR) and Waist-to Height Ratio (WtHR). According to Awasthi et al*.* [48], a Chinese population-based study reported that WtHR was the best anthropometric index for predicting diabetes mellitus. The WHR considers that waist circumference might over- or under-assess the dangers of different heights of individuals with the same waist circumference, while WtHR corrects waist circumference for height and can be used in different ethnic, age, and gender for central obesity [48].

#### *3.1.2.6 Social determinants of health*

Social determinants of health are non-medical factors that have an impact on health outcomes, well-being, and quality of life. These include conditions in which people are born, grow, live, work, and age [50]. Social determinants of health contribute significantly to health disparities and inequalities. For instance, a South African family of 5 adults and 4 children, depending only on an R1 890 old-age pension grant provided by the government may not have access to healthy food or good nutrition. Good nutrition is central to the development and progression of diabetes, including its management [12]. In addition, persons with less income and education were found to be 2–4 times more likely to develop diabetes compared to those with higher income and education [51, 52]. Within and outside the health sector, there are initiatives to mitigate the impact of social determinants of health through the adoption of health promotion and equity policies. For example, the introduction of social grants in South Africa is aimed at addressing social determinants of health. It is important for governments to prioritize the introduction of policies to address the social determinants of health in diabetes care, considering the increasing prevalence, complications, and management costs [53].

#### *3.1.2.7 Examples of social determinants of health impacting diabetes*

Housing: Access to proper housing is crucial in diabetes management. Improper housing creates a lack of the control and consistency needed for the daily management of diabetes, including diet, which is essential in glycemic control [54]. A lack of proper housing has been linked with increased blood glucose levels and the use of healthcare resources due to hospitalization. In addition, it impacts cholesterol and blood pressure levels, as well as the quality of life of patients with diabetes [55]. It was reported that persons in unstable housing are at a greater risk of developing diabetes, compared to those in stable housing [54]. Improved or stable housing may reduce disparities in diabetes outcomes while also helping with the initiation and maintenance of preventative care, minimizing the risk of diabetes, and improving outcomes overall [54].

Social and economic factors: Social and economic factors include income, education, employment, community safety, and social support; all of which affect the health and quality of life of persons and their life expectancy. These social and economic factors impact patients' ability to make healthy choices such as appropriate eating and active lifestyle, which are important in diabetes care. Employment or income could help in acquiring better houses, education, food, and medical treatment required in diabetes care. Unemployment or lack of income limits these options, leading to unhealthy eating and poor medical diabetes treatment [56]. Social support which includes family members is fundamental in diabetes care because most of the care happens at home [30]. Family members help with daily living activities including meal preparation and consumption, physical activity, collection of medication, bathing and clothing, distribution of household chores, and honoring of medical appointments. Family members may help patients with diabetes to cope with the disease and help with the finances needed for patients to perform their daily diabetes care activities [33]. Living alone is linked with increased depression, poor diabetes outcomes, and increased mortality [57].
