Current status of comprehensive metabolic control and predictive model of blood glucose control in low- income patients with type 2 diabetes

Fuhua Huang The Second A liated Hospital of Shantou University Medical College Jing Su Shantou University Medical College Xiaoxu Weng Shantou Central Hospital Lili Dong The Second A liated Hospital of Shantou University Medical College Yanzhu Chen The Second A liated Hospital of Shantou University Medical College Xinyi Lin Shantou University Medical College Lvrong Hong Shantou University Medical College Wenzhuan Chen (  wzchen517@163.com ) The Second A liated Hospital of Shantou University Medical College


Introduction
The rising prevalence of diabetes and its multiple complications seriously affect people's quality of life, resulting in a heavy economic burden [1]. It has become important to actively carry out scienti c research, seek effective three-level prevention strategies and prevent the impact of national economic development. The comprehensive metabolic control of diabetes is the key to the prevention of complications [2,3]. In recent years, a series of new drugs have been developed in the eld of diabetes treatment. High-tech equipment has been used, such as instantaneous dynamic blood glucose meters. A large number of scholars have developed management models such as "authorization, peers" [3,4]. Although the model has yielded achieved good results, the current situation of comprehensive control of diabetes is still not ideal, which suggests that the comprehensive control of patients is affected by multiple factors. Exploring the in uencing factors in managing the chronic course of type 2 diabetes and the relationship between them is the basis of accurate individualized nursing for patients with diabetes. Some studies have shown that the economic level of patients with T2DM affects blood glucose control, and the blood glucose level of patients with high economic levels is well controlled [5,6]. China is a country that faces unbalanced economic development with a large number of diabetes patients, and as the current prevalence rate is high at 11.2% [7], the prevalence rate of chronic and severe diseases among lowincome people in China is also at a high level. Therefore, we focused on the current situation of comprehensive metabolic control and all-cause analysis of the in uencing factors of blood glucose control in type 2 diabetes with a large proportion of low-income people in China. Achieving effective management of this population is important not only for promoting the standard rate of this population but also for preventing complications. It is also important for the promotion of socialist harmony and the prosperity of the country. This study takes the seven dimensions of the comprehensive management of diabetes in 2016 as the framework and uses the Chinese version of the Diabetes Distress Scale (DDS) and the Diabetes Knowledge and Self-Management Behavior Scale to examine the current situation of comprehensive metabolic control among low-income people with type 2 diabetes on the following dimensions: body, mind and diabetes management. Comprehensive related research was also conducted in order to develop a model to predict blood glucose control and to identify all-cause factors that in uence blood glucose control. this study aims to determine the in uencing factors of patients' daily blood glucose control and the relationship between them to provide a basis for proper nursing care for low-income patients with type 2 diabetes.

Subjects of study
Four hundred and sixty-two outpatients and inpatients with type 2 diabetes were recruited by random sampling.
The inclusion criteria were as follows: patients with type 2 diabetes who meet the diagnostic criteria for diabetes set forth by the WHO in 1999; patients with type 2 diabetes whose per capital monthly income is less than RMB 2000; provided informed consent and voluntary participated; clear awareness and accurately expressed their will; no previous history of mental illness, no history of alcohol and drug dependence; age over 55 years old; score > = 7 on a short intelligence test.
The exclusion criteria were as follows: consciousness is unclear or does not cooperate; language expression is unclear; patients with malignant tumors or other serious diseases; patients with mental illness, hearing impairment or visual impairment.

Survey methods
In the form of the questionnaire, a survey was administered to outpatients and inpatients with type 2 diabetes who met the criteria of nanoplatoon. Before the survey, the purpose and signi cance of this study were explained, and after obtaining consent, the subjects lled out the questionnaire by themselves. For the patients who could not ll out the questionnaire for various reasons, the researchers read the questionnaire to them and lled it out according to the subjects' answers. A total of 480 questionnaires were sent out; 480 were recovered, and 462 were valid, yielding an effective recovery rate of 96.3%.
The following clinical biochemical indicators were collected: height, weight, BMI, blood pressure, blood lipids, glycosylated hemoglobin and others.

Research tools
The research group Diabetes General data questionnaire was used and was designed based on an extensive reading of relevant literature, guidelines and the opinions of clinical and scienti c experts. The contents included the general data of the subjects, the disease data and the knowledge of self-management. The questionnaire also assess glycosylated hemoglobin, blood pressure, blood lipids, BMI and other indexes in patients with type 2 diabetes.
The psychological status of patients with diabetes was evaluated by the Chinese version of the Diabetes Distress Scale (DDS), which was developed by Polonsky [8,9]  to 6, where no problem is scored as 1, minor problem is scored as 2, moderate problem is scored as 3, slightly serious problem is scored as 4, serious problem is scored as 5, severe problem is scored as 6. The maximum total score was112. Higher scores indicated more severe psychological pain associated with diabetes. An average DDS score ≥ 3 is considered to indicate more than moderate pain and needs clinical attention.
Regarding the Diabetes Knowledge and Self-Management Behavior Scale, which was developed by Chen Wenzheng et al., the Cronbach's α of internal consistency of the total scale was 0.975, and the Cronbach's α of the knowledge subscale and behavior subscale were 0.967 and 0.929, respectively. The test-retest reliability coe cient of the total scale was 0.906, and the test-retest reliability coe cients of the knowledge and behavior subscales were 0.896 and 0.879, respectively. There were 35 items on the total scale, including 20 items on the knowledge scale, containing three dimensions: daily nursing knowledge related to diabetes, nursing knowledge related to hyperglycemia and hypoglycemia, and comprehensive nursing knowledge related to diabetes. There were fteen items on the behavior scale contained three dimensions: behaviors related to diabetic treatment compliance, behaviors related to diabetic falls, and behaviors related to diabetic medication compliance. Each item was scored on a scale ranging from 1 to 5, where a score of 1 represented no knowledge, a score of 2 represented knowing one, a score of 3 represented knowing two, a score of 4 represented knowing three, and a score of 5 represented knowing four. The maximum total score was 175. Higher scores indicate a higher level of knowledge and behavioral ability related to diabetes. The score must reach 60 percent, or 105 to pass.

Statistical Analysis
The database was managed using Epidata3.1. All data were recorded by two individuals: one person recorded the data, and the other person double-checked. SPSS22.0 was used for statistical analysis. The quantitative data were expressed as mean ± standard deviation, and the qualitative data were expressed as frequency and percentage (%). The correlation analysis was carried out by Pearson correlation analysis, and the regression analysis was carried out by multiple linear regression analysis. A P value < 0.05 was considered statistically signi cant.

Results
General data and disease data of low-income patients with type 2 diabetes The general and disease data of patients with type 2 diabetes mellitus showed that low-income people with type 2 diabetes also had low levels of educational: the vast majority of patients' educational level was below the senior high school level. Their awareness of participating in health education was not so high, and only 30% of the patients participated in the survey. The survey also revealed that most of the patients' personal income came from their children and that they worked independently; the proportion of patients with pensions was less than 18%. The subjects had a long course of diabetes and were older. Among the 229 patients who had been diagnosed for more than 10 years, most experienced complications, the most common of which was peripheral vascular diseases. The speci c results are shown in Table 1.
Control status of blood glucose, blood pressure, blood lipids and BMI The results of the study for the control status of blood glucose, blood pressure, blood lipids and BMI in patients with type 2 diabetes showed that the success rate of glycosylated hemoglobin in low-income patients with type 2 diabetes was 26.41%, which was slightly lower than that of NEW2D [10]. The proportion of patients with a blood pressure that met the standard was only 20.39%; the prevalence of dyslipidemia was as high as 82%, and only 18% of the patients reached the standard levels of TC, TG, HDL and LDL. The standard of comprehensive metabolism was even lower; only 5 patients had blood sugar, blood pressure and blood lipid levels that all reached the standard, accounting for 1.1% of the total sample. The speci c results are shown in Table 2.

Current status of self-management knowledge and behavior
The study of the status of self-management knowledge behavior in patients with type 2 diabetes showed that the self-management knowledge and self-management behavior of low-income patients with type 2 diabetes were not high, and the average score of the behavior scale was higher than that of the knowledge scale. On the knowledge scale, the dimension with the lowest average score was daily nursing knowledge related to diabetes, and the dimension with the highest score was comprehensive nursing knowledge related to diabetes. On the behavior scale, the dimension with the lowest average score was the behavior related to treatment compliance, and the dimension with the highest average score was the behavior related to medication compliance. The speci c results are shown in Table 3.
Total score and scores for each dimension of the DDS Regarding the total score and the scores for each dimension the Chinese version of the Diabetes Distress Scale (DDS), the results showed that the proportion of low-income patients with type 2 diabetes who had psychological pain was as high as 50.43%. Emotional burden and pain related to the life law had the highest scores and were the main source of psychological pain. The speci c results are shown in Table 4.  Table 5.
Multiple linear regression analysis of blood glucose control Stepwise multiple linear regression was used to analyze the factors affecting blood glucose control. For multiclassi cation variables, dummy variables were rst set and then included in the regression model, α in = 0.05, α out = 0.10.30. The following factors were included in the model: gender, age, complications, comprehensive management, the total score and scores on each dimension of the DDS, the total score of Diabetes Knowledge and Self-Management Behavior Scale and scores for each subscale. The results showed that self-management ability, interpersonal-related pain, time to diabetes diagnosis, age, diabetic nephropathy, emotional burden, sex and smoking were statistically signi cant factors affecting HbA1c in low-income patients with type 2 diabetes, which jointly explained 47.2% of the changes in HbA1c. The speci c results are shown in Table 6.

Discussion
The study results regarding comprehensive metabolic control among low-income patients with type 2 diabetes mellitus in this speci c study area were similar to those of the NEW2D, 3B study [10,11]. Patients with type 2 diabetes are at high risk of cardiovascular disease because they have multiple cardiovascular independence risk factors. The results of this study are shown in Table 2. The blood glucose reaching rate was low, and the comprehensive reaching rate was even lower. Among the 462 patients, only 5 patients reached the standard of blood glucose, blood pressure and blood lipids, accounting for 1.1%, which was much lower than 5.6% of the 3B study [11]. The comprehensive metabolic out-of-control state is a high-risk factor for diabetic complications [12,13], and diabetic complications affect the quality of life of patients and lead to a sharp increase in economic burden. Compared with the economic burden brought to this population by standardized treatment to the early stage of diabetic complications, the economic burden of diabetic complications is more di cult for this population to bear [14]. Therefore, it is important to work together to promote comprehensive metabolic control among these patients at the policy level, medical and health level, and family and personal level. This would contribute to the tertiary prevention of diabetes and prevent or delay the progress of complications, thus reducing the economic burden of medical insurance and families.
To analyze the current situation of self-management knowledge and behavior in low-income patients with type 2 diabetes, previous research shows that the level of self-management knowledge and behavior of low-income patients with type 2 diabetes is low, and the current survey results are similar [15]. Some investigations have found that [16]there is a strong association between low income and low education level. This is similar to the baseline data investigated in this study: patients had low levels of education, poor health awareness, and a lack of access to health information. This study suggests that the success rate of the Diabetes Knowledge and Self-Management Behavior Scale is 22.5%, and the overall average level is not up to standard. The patient's behavior scale score is higher than that of the knowledge scale, which suggests that the patient can actively face diabetes, but the lack of diabetes self-management knowledge directly affects their behavior, and the patient's treatment-related compliance behavior still needs to be improved. The scale used in this study covers all the knowledge points of the self-management prescription for type 2 diabetes in China, and the purpose of the accurate evaluation is to enter the natural environment of patients with different backgrounds, help them overcome di culties in daily life, improve self-management ability, and achieve effective management. This concept is consistent with the method advocated by the "Chinese expert consensus on self-Management of Type 2 Diabetes Mellitus". According to the evaluation scale, we should carry out proper individual education to promote their self-management ability. Dynamic and continuous management of patients is a management model that can be further used by both nurses and patients in the future.
Regarding the study of psychological pain related to diabetes in low-income patients with type 2 diabetes, the results show that the vast majority of diabetic patients have diabetes-related pain: 50.43% of diabetic patients have slight pain, and 23.38% of diabetic patients have moderate or above pain, mainly related to the emotional burden and pain related to the law of life. Studies have shown that [17][18][19]health education and selfmanagement support can effectively improve diabetes-related pain in patients with diabetes. The latest research from Harvard Medical School in the United States shows that impaired insulin signals in the brain may have adverse effects on cognition, emotion and metabolism, which suggests that actively carrying out targeted and effective health education and self-management support and promoting the metabolic standards of patients is not only a necessary way to prevent and delay the complications of diabetes but also an effective way to improve their psychological pain.
The results of this study for the relationship among blood glucose control and Diabetes Knowledge and Self-Management Behavior Scale and Chinese version of Diabetes Distress scale ((DDS) (such as Tables 5 ) show that glycosylated hemoglobin is negatively correlated with the Diabetes Knowledge and Self-Management Behavior Scale score, and the differences are statistically signi cant, which suggests that the better the knowledge of diabetes, the higher the self-management behavior and the better the blood glucose control. The results are consistent with other previous ndings [20,21]. HbA1c was signi cantly positively correlated with the score of the Chinese version of the Diabetes Distress scale, suggesting that worse blood glucose control is associated with a higher the degree of diabetes-related psychological pain. There was a signi cant negative correlation between the Chinese version of the Diabetes Distress Scale and the Diabetes Knowledge and Self-Management Behavior Scale scores, suggesting that when patients have self-management knowledge and behavior levels, their blood glucose control may be better, and the corresponding degree of psychological pain may be lower.
The multiple linear regression analysis of glycosylated hemoglobin in low-income patients with type 2 diabetes examined the scores of the Diabetes Knowledge and Self-Management Behavior Scale, the scores of the Chinese version of Diabetes Distress scale, and the demographic data of patients, including comprehensive treatment measures and complications of patients with diabetes. The results show that the scores of the Diabetes Knowledge and Self-Management Behavior Scale, the pain related to interpersonal relationships in the Chinese version of Diabetes Distress scale, age, diabetic nephropathy, smoking and gender are the main factors that affect the control of blood glucose in this group of patients with type 2 diabetes. Among these factors, the most important are the scores on the Diabetes Knowledge and Self-Management Behavior Scale and the pain related to interpersonal relationship in the Chinese version of Diabetes Distress scale, which is consistent with the results of related studies [21,22]. In patients with diabetic nephropathy, glycosylated hemoglobin is lower because the glomerular ltration rate is lower, which affects drug metabolism. HbA1c is positively correlated with the course of disease and "emotion burden" on the Chinese version of the Diabetes Distress scale, suggesting that the control of blood sugar in patients with chronic disease is not better managed with the increase in the course of the disease but worsens further. The loss of control of blood sugar may cause diabetes-related pain emotion, which may be related to the lack of management knowledge. Whether the active construction of the comanagement model of nurses and patients in chronic management can improve the above situation can be further discussed in the following study. Smoking is an independent risk factor for cardiovascular disease and increases the risk of complications [23,24]. The study suggests that the control of glycosylated hemoglobin will bene t at the same time when actively doing an excellent job in smoking cessation education for low-income patients with type 2 diabetes, which may explain how previous smokers who have quit have more substantial health management knowledge and compliance with diabetes. The results also showed that the control of HbA1c in females was better than that in males, which suggests that further analysis of male and female patients should be conducted with special consideration of the control of blood glucose in male patients. The above results suggest that it is important to integrate medical and information resources, develop appropriate individualized education and management modes for this group, and encourage patients and their caregivers to actively learn diabetes management knowledge. These steps will not only reduce the degree of pain related to diabetes but also delay and prevent the complications of diabetes.

Conclusions
Low-income patients with type 2 diabetes have a low comprehensive metabolic compliance rate, a lack of knowledge of diabetes self-management and low levels of self-management. Diabetes Knowledge and Self-Management Behavior Scale scores are the main factors that in uence glycosylated hemoglobin control, which suggests that medical staff at all levels should implement effective and precise treatment and education to make effective intervention plans according to the local situation and the actual situation of patients. This will realize the transformation research of effective management and thus promote comprehensive metabolic control among low-income patients with type 2 diabetes to enable them to reach standard levels and prevent the occurrence of diabetes complications. Note: * * when the confidence level (both sides) is 0.01, the correlation is significant.