Comorbidities Decrease Health Related Quality of Life in Youth with Type 1 Diabetes

Lori M. Laffel, MD, MPH

A recent cross-sectional study examined the association of comorbid conditions on health-related quality of life (HRQOL) in youth with type 1 diabetes (T1D).

Investigators, led by Lori M. Laffel, MD, MPH, Joslin Diabetes Center, found that HRQOL was preserved in youth with T1D, unless the youth were met with multiple comorbidities reported by youth and parents.

The team determined the association between number of comorbid conditions (0,1, ≥2), as well as particular comorbid conditions and youth HRQOL across a wide age range (5 – 18 years).

Study

The team included 601 youth with T1D and parents/guardians in the study.

Eligibility criteria included duration of type 1 diabetes, ≥6 months, and daily insulin dose ≥0.5 units/kg, as well as fluency in English.

Exclusions included youth with developmental disabilities, cognitive disorders, or recent psychiatric hospitalization, as investigators assumed there would be challenges with diabetes self-care.

For data collection, the youth and parents completed the Pediatric Quality of Life Inventory (PedsQL) Generic Core Scales, a 23-item survey that measures youth HRQOL.

Responses were calculated on a 5-point Likert scale from 0 (never) to 4 (almost always). The PedsQL assessed total, physical (8 items), and psychosocial (15 items – emotional, school, social functioning) HRQOL.

As a result, the total score is calculated from an average of the total, from 0 – 100 with the higher score representing better HRQOL.

Patients also reported comorbid conditions using a checklist of medical and mental health conditions, with 34 individual conditions including autoimmune, gastrointestinal, cardiovascular, neurological/eye, mental health, respiratory, and other conditions.

Investigators also conducted linear regression models to test the relationship between number of comorbid conditions as well as specific comorbid conditions with reported HRQOL.

Results

The data show that 56% of youth with T1D had no comorbid conditions (n = 338), while 26% (n = 157) had 1 condition, 11% (n = 65) had 2 conditions, 3% (n = 19) had 3 conditions, 3% (n = 16) had 4 conditions, and 1% (n = 6) had 5 or 6 conditions.

An important note the investigators made was youth with ≥2 comorbid conditions had significantly lower HRQOL by youth self-report (0: 85±12, 1: 85±13, 2+: 78±16, P =<.0001) and parent-proxy report (0: 83±12, 1: 81±13, 2+: 74±15, P <.0001).

They found the most frequent comorbid conditions included seasonal allergies (n = 66), asthma (n = 61), hypothyroidism (n = 45), ADHD (n = 29), skin problems (n = 29), and celiac disease (n = 26), while 10% of youth (n = 60) had a mental health condition.

As well, youth with mental health condition were more likely to have more medical conditions, with 20% having 1 medical comorbidity and 27% having 2 or more medical comorbidities.

Of the 511 youth who self-reported HRQOL, the average score was 83.9±13.3 and patient proxy-report was 81.1±13.3.

In analysis, youth with ≥2 comorbidities had significantly lower self-reported HRQOL than youth with 0 or 1 comorbidity.

However, the team did note that autoimmune, gastrointestinal, cardiovascular, neurological/eye, and respiratory conditions did not have significant associations with youth or parent proxy-reports for HRQOL.

An important measure in the study, data show a presence of a mental health condition was significantly associated with lower HRQOL (β=-8.9, P <.0001).

With multivariable models predicting youth self-report HRQOL, the presence of a mental health condition (β=-6.7, P =.001) and ≥2 comorbid conditions (β=-5.6, P =.0005) had a significant association with lower HRQOL.

Conclusion

The team concluded that the results suggest T1D coupled with multiple comorbid conditions is a contributing factor to the decline in self-reported and parent proxy reported HRQOL.

They noted it was found especially prevalent in the presence of a mental health condition in youth.

“Clinical implications of this study highlight the opportunity to track comorbid conditions, possibly by reviewing problem and medication lists in the medical record, as well as assessing for mental health conditions to allow timely interventions to preserve HRQOL in youth with type 1 diabetes,” investigators wrote.

The study, “Health-Related Quality of Life (HRQOL) in Youth with Type 1 Diabetes: Associations with Multiple Comorbidities and Mental Health Conditions,” was published online in Diabetic Medicine.