Health-related quality of life of adolescents with type 1 diabetes mellitus

Objective: To evaluate the health-related quality of life of adolescents with type 1 diabetes mellitus, associating it with socio-demographic, clinical and biochemical variables. Method: Cross-sectional study with 92 adolescents with type 1 diabetes mellitus. A form containing socio-demographic, clinical and biochemical variables was used, as well as the Diabetes Quality of Life for Youths questionnaire. Descriptive statistics and logistic regression were used for analysis. Results: Regarding socio-demographic variables, economic class showed statistically significant differences in relation to total Health Related Quality of Life (p-value =0.02) and the impact domain (p-value =0.009). However, the impact domain was more compromised. Diabetes-related complications (p-value =0.004), number of hospitalizations (p-value =0.01), number of daily insulin injections (p-value =0.02), glycated hemoglobin (p-value =0.002) and triglycerides (p-value =0.03) were associated with greater impairment of quality of life related to total health and greater dissatisfaction. Conclusion: Single male adolescents with lower level of education and high glycated hemoglobin levels were more likely to have lower health-related quality of life.


July 2014.
The universe of the study was composed of 120 adolescents with T1DM who regularly attended the service, of which 28 were no longer in regular care, due to having more than three consecutive absences.  (15) .  to the original categories "low" and "very low"; and 1 -"high", equivalent to the original categories "high" and "very high". The "low" category of the outcome variable is associated with low DQOLY scores, and therefore is associated with high HRQoL. The "high" categoryassociated with the outcome variable -is associated with the instrument's high scores, which indicates low    (Tables 4 and 5).     Postprandial glucose  High-Density Lipoprotein  to the advancement of knowledge necessary to support the educational process (4) .
The results regarding total HRQoL and its domains among adolescents living in the Northeast region was similar to the results found in a study conducted in the Southeast region (15) . This finding suggests that even in a country with continental dimensions and multicultural historical and social formation such as Brazil, HRQoL perception remains similar in different regions.
A study with Portuguese adolescents with DM found high HRQoL, in contrast to research in eastern countries, which found that HRQoL ranged from moderate to low (16) . Regarding the items with the highest scores in each domain, dissatisfaction was related to the time spent in laboratory and eye exams, the flexibility of the diet and the burden the disease places on family dynamics. In the impact domain, the highest items were related to parents' overprotective attitude and their excessive concern with their children's glycemic control. Therefore, educating family members on how to effectively solve problems and resolve conflicts can support diabetes management and optimize glycemic control, reducing diabetes distress and, consequently, improving quality of life (17) . This process must continue throughout childhood and adolescence.
In the concern domain, the item with the highest value was related to ability to complete their education.
These Positive association between HRQoL and self-perceived health was also reported in another study (15) . The results show the importance of offering support to patients with T1DM, guiding them in appropriate treatment to reduce the risk of acute and chronic complications and improve the quality of life and encouraging constant engagement in education programs (4) .

Multiple analysis indicated that HRQoL in adolescents
with T1DM is associated with gender. A review study showed that girls with the disease experience more coercive control associated with culture and family when compared to boys, which has been shown to be a negative factor in relation to adolescents' quality of life (3) . Another study also pointed out that girls reported greater impact and worries than boys (11) . The study found that female adolescents have better HRQoL in all dimensions of the DQOLY scale, except for the impact domain (16) .
The relationship between HRQoL and economic class was investigated in a study conducted in Germany, which found that low socioeconomic status was significantly associated with suboptimal T1DM management, despite of health care being freely available (18) . This may negatively affect quality of life. The present study showed statistically significant differences in total HRQoL be more susceptible to complications resulting from the disease (18) . In addition, the higher frequency of diabetes complications contributes to reduced life expectancy and lower HRQoL, as shown in the bivariate analysis conducted in this study.
The association between disease duration, treatment time and HRQoL has been addressed in national and international studies. In this study, the bivariate and multivariate analyzes with these variables did not find statistically significant differences, which is corroborated by other authors (11,16,19) . However, a similar study found significant association (12) , suggesting that these variables should be investigated in future studies.
Age at diagnosis was not significantly associated with total HRQoL and its domains, which is in agreement with another study (11) .   (16) .
A multicenter study found that the lower the glycated hemoglobin levels, the better the HRQoL, pointing to a strong association between improved quality of life and glycemic control. This study also pointed out that potentially modifiable behavioral factors related to glycemic control may contribute to the implementation of clinical interventions to improve HRQoL (21) .
Other studies should explore the sociodemographic, clinical and laboratory variables related to HRQoL among adolescents with T1DM to advance the knowledge of this topic. Limitations of the present study include the inability to generalize results and compare data due to study design and the cultural and regional differences that may affect quality of life, including the characteristics of the health service investigated.
Some findings may inspire future investigations based on new hypotheses and variables, such as: the significant number of adolescents who presented hypoglycemic and hyperglycemic episodes, low adherence to blood glucose monitoring, hospitalization rates and disease management tests outside normal range, difficulty to follow the diet plan, concern for the professional future and parental overprotection.

Conclusion
The results of this study allowed concluding that the mean HRQoL scores and the domains satisfaction,