|Year : 2019 | Volume
| Issue : 2 | Page : 88-92
Anxiety prevalence in type 2 diabetes patients in Taif Saudi Arabia
Mohammed K Alharithy1, Omar R Abdalgader1, Mohammed M Alobaylan1, Ziyad O Alsugair1, Khaled A Alswat2
1 Department of Medicine, College of Medicine, Taif University, Taif, Saudi Arabia
2 Department of Medicine, Taif University School of Medicine, Taif, Saudi Arabia
|Date of Web Publication||13-Sep-2019|
Dr. Mohammed K Alharithy
College of Medicine, Taif University, AlHawiyah, Taif 26571 - 2228
Source of Support: None, Conflict of Interest: None
Background: Type 2 diabetes (T2D) is a major health problem worldwide, and anxiety is a serious psychiatric problem that can lead to serious consequences such as substance abuse. The prevalence of anxiety has been found to be high in T2D patients in several studies; data in Saudi Arabia are scarce; however, our primary goal was to identify the prevalence of anxiety among T2D patients and to examine the impact of anxiety on glycemic control, measured cardiovascular markers, and T2D-related complications. Methods: This cross-sectional, interview-based study was conducted from October 2015 to July 2016 in Taif City, Saudi Arabia. Researchers took anthropometric measures, and the laboratory results were taken from the patients' electronic files using medical record numbers. For anxiety screening, we used the Generalized Anxiety Disorder-7 (GAD-7) scale. Results: The prevalence of anxiety was 45.45%, and it was not significantly associated with socioeconomic factors. Neither hemoglobin A1c level nor lipid profile levels were affected by anxiety. After adjusting for multiple variables, retinopathy and neuropathy were negatively correlated with GAD-7 score. Conclusion: Anxiety was highly prevalent among the screened T2D patients. Although the anxiety diagnosis did not correlate with worse glycemic control or cardiovascular markers, it was negatively associated with T2D-related microvascular complications.
Keywords: Anxiety, Saudi Arabia, Taif, type 2 diabetes
|How to cite this article:|
Alharithy MK, Abdalgader OR, Alobaylan MM, Alsugair ZO, Alswat KA. Anxiety prevalence in type 2 diabetes patients in Taif Saudi Arabia. Saudi J Health Sci 2019;8:88-92
|How to cite this URL:|
Alharithy MK, Abdalgader OR, Alobaylan MM, Alsugair ZO, Alswat KA. Anxiety prevalence in type 2 diabetes patients in Taif Saudi Arabia. Saudi J Health Sci [serial online] 2019 [cited 2020 Sep 24];8:88-92. Available from: http://www.saudijhealthsci.org/text.asp?2019/8/2/88/261538
| Introduction|| |
In 2013, there were a total of 382 million patients with diabetes mellitus (DM) worldwide. Two years later, this number had increased to 415 million patients. In the Middle East and North Africa, there were 35.4 million (9.1%) DM patients aged 20–79 years. Of this population, approximately 3.49 million were located in Saudi Arabia. Therefore, the prevalence of diabetes in this country is (17.6%) one of the highest worldwide. As a result, DM one of the largest health issues in Saudi Arabia, and it is associated with major social and economic burdens.
Anxiety is one of the most prevalent psychiatric problems, particularly among females and low-socioeconomic individuals. The lifetime rate of anxiety disorders in the United States was 28.8% in a recent study. Untreated anxiety can lead to other psychiatric conditions such as depression, substance abuse (including nicotine and alcohol), and even suicide.,, Anxiety also increases the risk of heart diseases, obesity, and irritable bowel syndrome.,, A systemic review found a strong association between anxiety and depression and heart diseases, stroke, DM, asthma, cancer, arthritis, and osteoporosis, which highlights the evidence of increased morbidity and mortality associated with anxiety.
Diabetes is a chronic disease that affects people physically and mentally. It requires strict management and the engagement of both a health-care provider and a patient; poor control and compliance due to anxiety can lead to an increased risk of complications. Studies have shown that in people with type 2 diabetes (T2D) stress has the ability to worsen the condition directly by causing hyperglycemia and indirectly by reducing compliance. Anxiety disorders are believed to be more prevalent in people who have chronic illnesses compared with healthy people. A study carried out in South Africa with a total of 401 participants revealed that 32% of people had an anxiety disorder. A small study of patients with T2D showed, using the Generalized Anxiety Disorder-7 (GAD-7) questionnaire, that 34% of individuals screened positive for anxiety and that the majority of participants had mild anxiety.
In light of these findings, we conducted this study to explore the prevalence of anxiety in T2D Saudi patients and also to examine the possible risk factors associated with such a diagnosis such as gender, age, financial status, educational level, exercise status, and smoking status. We also examined the impact of anxiety on glycemic control, measured cardiovascular markers, and T2D-related complications.
| Methods|| |
We conducted this cross-sectional study from October 2015 to July 2016 in Taif City, Saudi Arabia. T2D patients above the age of 18 years who had a routine follow-up visit were allowed to participate. If these individuals verbally consented to participate, they were included. We excluded patients with T1D and individuals with known psychiatric illnesses, untreated hypothyroidism, or gestational diabetes.
This study was approved by the Committee of Ethics of Scientific Research at Taif University as well as the general administration of medical services of armed forces after meeting all the ethical requirement.
Researchers interviewed the participants and inquired about personal data, current DM management, comorbidities, T2D-related complications, and social habits. Anthropometric measurements were taken, and the most recent laboratory test results were obtained from participants' files using universal medical record numbers. We considered those who reported monthly incomes <$1335 USD as being low income.
For anxiety screening, we used the GAD-7 scale, which has 89% sensitivity and 82% specificity for a GAD diagnosis.,, This scale consists of seven statements regarding anxiety symptoms; each statement can be scored from 0 to 3 according to the frequency of occurrence within the previous 2 weeks. As a result, the total possible score on the GAD-7 ranges from 0 to 21. Scores of 5, 10, and 15 represent cutoff points for mild, moderate, and severe anxiety, respectively.
The data were analyzed using Statistical Package for the Social Sciences (SPSS) version 20 IBM based on (Armonk, New York, United States). The Chi-squared test was used to study the relationship between variables, and the t-test was used to compare between means. Two-tailed partial correlation was conducted between GAD-7 score and both glycemic control and T2D-related complications.
| Results|| |
A total of 231 patients with T2D participated in the study. The cohort had a mean age of 59.7 ± 11.0 years. The majority of them were male with long-standing diabetes; their mean body mass index (BMI) was in the obese range. The patients' mean waist circumference was 110.1 ± 13.6 cm, and their mean systolic blood pressure and diastolic blood pressure were within the normal range of T2D patients.
The majority of the patients were married, and more than half of them were characterized as low income. Only 12.1% of the patients had a bachelor's degree or higher. Approximately half of our patients (42.9%) lived a sedentary lifestyle; only one-fifth of the patients exercised >150 min/week. About 13% of the patients were active smokers.
The most prevalent complication was neuropathy followed by retinopathy, hypoglycemia, and renal failure. More than half of the patients were on a combination of oral hypoglycemic agents and insulin. The most commonly used oral hypoglycemic agent was metformin, and 75.3% of the patients were taking a statin.
The laboratory data revealed uncontrolled hemoglobin A1c (HbA1c), a mean total cholesterol of 4.6 ± 2.6 mmol/L, a mean low-density lipoprotein of 2.7 ± 0.9 mmol/L, a mean high-density lipoprotein of 1.0 ± 0.3 mmol/L, mean triglycerides of 1.7 ± 0.9 mmol/L, and a mean albumin-creatinine ratio of 25.5 ± 112.1 mg/mmol [Table 1].
About 45% of our sample was found to be anxious. Compared to individuals who were anxious, people without anxiety were more likely to be low income (P = 0.045).
Individuals who are anxious were insignificantly more likely to be younger females and have higher levels of education [Table 2].
A partial correlation adjusting for age, gender, duration of T2D, income, educational level, BMI, waist circumference, and medication showed a significant negative correlation between GAD-7 score and retinopathy (r = −0.181; P = 0.007), a significant negative correlation between GAD-7 score and neuropathy (r = −0.145; P = 0.031), and a nonsignificant positive correlation between GAD-7 score and HbA1c (r = 0.016; P = 0.811).
| Discussion|| |
Numerous studies have noted a high prevalence of anxiety among T2D patients.,,,,,,,,,,, Anxiety has also been linked to increased mortality in T2D patients. In our study, the prevalence of anxiety was 45.45%; another study in Saudi Arabia demonstrated a prevalence of 38.4%. We note that the prevalence of T2D varies across the globe and even within the same country in different studies.,,, However, the highest prevalence has been noted in Iran and Guiana., These fluctuations may be due to various factors such as the use of different screening tools, culture and/or ethnicity. Other factors may also play a role in the observed high prevalence of anxiety in Saudi Arabia such as low levels of health education and the high prevalence of T2D, which may lead to incorrect perceptions of the disease because its complications are common.
There is a wide discrepancy in the results concerning associated sociodemographic factors. The only significant correlation we found was the association between low income and a prevalence of anxiety. However, other studies have suggested contradictory results for unknown reasons.,,, While most other studies have suggested a high prevalence of anxiety among female participants,,,,,,, a few other investigations, including our own, found no link between gender and anxiety.,, Older individuals exhibited a higher prevalence of anxiety in some of the studies we reviewed.,, Other investigations failed to note an association between age and anxiety;, younger participants were more susceptible to anxiety in a couple of other studies., We also did not find an association between age and anxiety. There was no association among the duration of T2D, marital status, and anxiety; this finding is in agreement with almost all of the studies we reviewed.,,,,,,,
Neither BMI nor HbA1c influenced the prevalence of anxiety in our results. However, the data we reviewed were scarce, and all of them were consistent with our findings,,, except for two studies from Tunisia and Guinea. These studies both found an association between anxiety and elevated HbA1c., Rajput et al. found that insulin use was a significant predictor of anxiety. Our study, among others, showed no such association.,,, Furthermore, we noted that smoking and physical activity were not associated with anxiety, which has been suggested by other investigations as well.,,
After adjusting for multiple variables, we found a negative correlation between anxiety and both retinopathy and neuropathy. This finding can be explained by viewing anxiety as a motivation for patients to be alert to new symptoms and for them to visit their health-care provider regularly. We note that high-quality health care is available and free in Taif City, Saudi Arabia. Naicker et al. found that anxious women were more likely to avoid high-fat food and to consume more vegetables; they provided a similar explanation. However, several studies found an association between anxiety and retinopathy., Others found no association between T2D complications and anxiety.,,
| Conclusion|| |
Anxiety was strongly prevalent among the screened T2D patients. Although the anxiety diagnosis did not correlate with worse glycemic control or cardiovascular markers, it was negatively associated with T2D-related microvascular complications.
We are grateful to the general administration of medical services of armed forces and to the staff of The Diabetes and Endocrine Center at Prince Mansour Military Hospital for their cooperation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract 2014;103:137-49.
International Diabetes Federation. IDF Diabetes Atlas International Diabetes Federation. 7th
ed. Brussels, Belgium: International Diabetes Federation; 2015.
Huang CJ, Chiu HC, Lee MH, Wang SY. Prevalence and incidence of anxiety disorders in diabetic patients: A national population-based cohort study. Gen Hosp Psychiatry 2011;33:8-15.
Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry 2005;62:593-602.
Moylan S, Jacka FN, Pasco JA, Berk M. Cigarette smoking, nicotine dependence and anxiety disorders: A systematic review of population-based, epidemiological studies. BMC Med 2012;10:123.
Smith JP, Randall CL. Anxiety and alcohol use disorders: Comorbidity and treatment considerations. Alcohol Res 2012;34:414-31.
Nepon J, Belik SL, Bolton J, Sareen J. The relationship between anxiety disorders and suicide attempts: Findings from the national epidemiologic survey on alcohol and related conditions. Depress Anxiety 2010;27:791-8.
Allgulander C. Anxiety as a risk factor in cardiovascular disease. Curr Opin Psychiatry 2016;29:13-7.
Jorm AF, Korten AE, Christensen H, Jacomb PA, Rodgers B, Parslow RA, et al.
Association of obesity with anxiety, depression and emotional well-being: A community survey. Aust N
Z J Public Health 2003;27:434-40.
Kabra N, Nadkarni A. Prevalence of depression and anxiety in irritable bowel syndrome: A clinic based study from India. Indian J Psychiatry 2013;55:77-80.
] [Full text]
Clarke DM, Currie KC. Depression, anxiety and their relationship with chronic diseases: A review of the epidemiology, risk and treatment evidence. Med J Aust 2009;190:S54-60.
Shamsi A, Khodaifar F, Arzaghi SM, Sarvghadi F, Ghazi A. Is there any relationship between medication compliance and affective temperaments in patients with type 2 diabetes? J Diabetes Metab Disord 2014;13:96.
Kazdin AE. Encyclopedia of Psychology. 1st
ed., Vol. 8. Washington, D.C.: American Psychological Association; 2000.
Ramkisson S, Pillay BJ, Sartorius B. Anxiety, depression and psychological well-being in a cohort of South African adults with type 2 diabetes mellitus. S Afr J Psychiatr 2016;22:935.
Thour A, Nagra R, Gosal A, Sehrawat T, Das S, Gupta Y. Anxiety among patients with diabetes mellitus evaluated using generalized anxiety disorder 7-item scale. J Soc Health Diabetes 2016;4:133. [Full text]
Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med 2006;166:1092-7.
Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: Prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007;146:317-25.
Löwe B, Decker O, Müller S, Brähler E, Schellberg D, Herzog W, et al.
Validation and standardization of the generalized anxiety disorder screener (GAD-7) in the general population. Med Care 2008;46:266-74.
AlKhathami AD, Alamin MA, Alqahtani AM, Alsaeed WY, AlKhathami MA, Al-Dhafeeri AH. Depression and anxiety among hypertensive and diabetic primary health care patients. Could patients' perception of their diseases control be used as a screening tool? Saudi Med J 2017;38:621-8.
Palizgir M, Bakhtiari M, Esteghamati A. Association of depression and anxiety with diabetes mellitus type 2 concerning some sociological factors. Iran Red Crescent Med J 2013;15:644-8.
Mikaliūkštienė A, Žagminas K, Juozulynas A, Narkauskaitė L, Sąlyga J, Jankauskienė K, et al.
Prevalence and determinants of anxiety and depression symptoms in patients with type 2 diabetes in Lithuania. Med Sci Monit 2014;20:182-90.
Rajput R, Gehlawat P, Gehlan D, Gupta R, Rajput M. Prevalence and predictors of depression and anxiety in patients of diabetes mellitus in a tertiary care center. Indian J Endocrinol Metab 2016;20:746-51.
Collins MM, Corcoran P, Perry IJ. Anxiety and depression symptoms in patients with diabetes. Diabet Med 2009;26:153-61.
Smith KJ, Béland M, Clyde M, Gariépy G, Pagé V, Badawi G, et al.
Association of diabetes with anxiety: A systematic review and meta-analysis. J Psychosom Res 2013;74:89-99.
Ganasegeran K, Renganathan P, Manaf RA, Al-Dubai SA. Factors associated with anxiety and depression among type 2 diabetes outpatients in Malaysia: A descriptive cross-sectional single-centre study. BMJ Open 2014;4:e004794.
Tan KC, Chan GC, Eric H, Maria AI, Norliza MJ, Oun BH, et al.
Depression, anxiety and stress among patients with diabetes in primary care: A cross-sectional study. Malays Fam Physician 2015;10:9-21.
Masmoudi J, Damak R, Zouari H, Ouali U, Mechri A, Zouari N, et al.
Prevalence and impact of anxiety and depression on type 2 diabetes in Tunisian patients over sixty years old. Depress Res Treat 2013;2013:341782.
Camara A, Baldé NM, Enoru S, Bangoura JS, Sobngwi E, Bonnet F, et al.
Prevalence of anxiety and depression among diabetic African patients in Guinea: Association with hbA1c levels. Diabetes Metab 2015;41:62-8.
Sun N, Lou P, Shang Y, Zhang P, Wang J, Chang G, et al.
Prevalence and determinants of depressive and anxiety symptoms in adults with type 2 diabetes in China: A cross-sectional study. BMJ Open 2016;6:e012540.
Naicker K, Johnson JA, Skogen JC, Manuel D, Øverland S, Sivertsen B, et al.
Type 2 diabetes and comorbid symptoms of depression and anxiety: Longitudinal associations with mortality risk. Diabetes Care 2017;40:352-8.
Naicker K, Øverland S, Johnson JA, Manuel D, Skogen JC, Sivertsen B, et al.
Symptoms of anxiety and depression in type 2 diabetes: Associations with clinical diabetes measures and self-management outcomes in the Norwegian HUNT study. Psychoneuroendocrinology 2017;84:116-23.
[Table 1], [Table 2]