The Impact of Diabetes Mellitus on the Physical Health and

Physical Activity

Zivana Gavric

1,2

, Dragana Grujic-Vujmilovic

1,2

and Miodrag Marjanovic

The Public Health Institute Republic of Srpska, Jovan Ducic 1, Banja Luka, Bosnia and Herzegovina

Department of Social Medicine, Faculty of Medicine University Banja Luka, Banja Luka, Bosnia and Herzegovina

Keywords: Diabetes Mellitus, Quality of Life, Physical Health, Physical Activity.

Abstract: Chronic diseases affect the quality of life and all components of the health, and they decrease physical

activity. The aim of the research was to assess how diabetes mellitus affects the physical health component

in relation to sex, age and level of education. For survey research at the Clinical Center of Banja Luka in the

period from October 2011 to June 2012, which included 150 patients with diabetes mellitus, we used a

questionnaire of the World Health Organization (WHOQOL-BREF). The mean score for physical domain

of health were slightly higher in male patients (57.92), but without statistically significant difference (t =

1.256; p >0.05) compared to female respondents. With a statistically significant difference (p <0.01) the

mean scores for the physical domain of health were higher among younger respondents and those with

higher education and those mean scores declines with age and with lower levels of education. Mean score

were highest in unmarried people, followed by married but without statistically significant difference

(p>0.05) compared to divorced and widower. In our patients, diabetes mellitus has an impact on the

physical health component and restrict certain physical activities, especially in patients who are older and

with lower education.

1 INTRODUCTION

Ancient scientific evidence and an increase in

epidemiological facts suggest that “healthy eating

habits and moderate exercise can reduce the

incidence of heart attacks, diabetes and non-

communicable diseases” (WHO, 2002, page 8).

„Physical inactivity is a global health problem that

causes more than two million deaths each year

making it one of the top 10 leading causes of death

and disability“(WHO, 2002, page 2). „The

increasing global problem of NCDs means that

obesity, poor diet and inactivity are increasing

problems for countries in the epidemiological

transition“(Waxman, 2004, page1). “Chronic

diseases are characterized by long duration and slow

progression and they are the leading cause of death

worldwide among which the most important are:

heart diseases, stroke, cancer, chronic respiratory

diseases and diabetes, making 63% of all deaths”

(WHO, 2012, page 6). In 2004, in the world,

diabetes mellitus, in the total burden of disease,

occupied 19 place with a share of 1.3% DALY's, and

it is anticipated that by 2030 the total burden of

disease occupy 10th place with a share of 2.3%

DALY- a " (WHO, 2008, page 22-23). Chronic

diseases affect the quality of life and all components

of the health, and they decrease physical activity.

According to Sigal et all. (2004): Adaptations to

endurance exercise enable the muscle to use O2 and

blood-borne fuels, whereas those for resistance

exercise lead to improved force generation (e.g.,

hypertrophy, contractile properties). Of specific

interest to people with diabetes are those adaptations

that directly affect the metabolism of glucose. (Page

2522) According to Sigal et all. (2004): Before

beginning a program of physical activity more

vigorous than brisk walking, people with diabetes

should be assessed for conditions that might

contraindicate certain types of exercise or predispose

to injury (e.g., severe autonomic neuropathy, severe

peripheral neuropathy, or preproliferative or

proliferative retinopathy), which require treatment

before beginning vigorous exercise, or that may be

associated with increased likelihood of CVD. The

patient’s age and previous physical activity level

should be considered (Page 2523). According to

Guelfi KJ et all. (2005): Exercise in diabetes,

particularly T1DM, can predispose patients to

150

Gavric, Z., Grujic-Vujmilovic, D. and Marjanovic, M..

The Impact of Diabetes Mellitus on the Physical Health and Physical Activity.

In Proceedings of the 3rd International Congress on Sport Sciences Research and Technology Support (icSPORTS 2015), pages 150-155

ISBN: 978-989-758-159-5

hypoglycaemia. The most rapid drop in blood

glucose usually occurs during aerobic or endurance

exercise, when circulating insulin suppresses

metabolic fuel production and increases glucose

uptake into muscles, but an attenuated drop in blood

glucose is also seen with intermittent high-intensity

exercise (which is a mixture of both aerobic and

anaerobic exercise, characteristic of team sports and

children's play) ( Page 1289). “Hypoglycaemia can

also occur after all types of exercise, often

overnight, most likely because of a combination of

increased insulin sensitivity and the need to

replenish depleted energy stores”( McMahon SK,

2007, page 260). Graveling and Frier (2010): An

extreme case is hypoglycaemia-associated

autonomic failure, where a vicious cycle of recurrent

hypoglycaemia develops. This occurs because

exercise blunts the endocrine response to

hypoglycaemia, but hypoglycaemia also blunts the

endocrine response to exercise, and in extreme cases

can result in significant morbidity (Page 587).

According to WHO (1998): Quality of life is defined

by the WHO as “individuals' perceptions of their

position in life in the context of the culture and value

systems in which they live and in relation to their

goals, expectations, standards and concerns”. This

definition reflects the view that quality of life refers to

a subjective evaluation, which is embedded in a

cultural, social and environmental context. The

physical domain of quality of life includes: the

aspect of pain and discomfort, energy and fatigue,

sleep and rest, activities of daily living, dependence

on medication or treatment and work capacity

(Pages 7, 48).

Objective: Assess how diabetes mellitus affects

the component of physical health in relation to sex,

age and level of education.

2 METHODS

With survey research at the Clinical Center of Banja

Luka in the period from October 2011 to June 2012,

we have covered 150 patients with diabetes mellitus.

For the assessment of quality of life, we used a

questionnaire of the World Health Organization

(WHOQOL-BREF). WHOQOL User Manual

(1998): Assessing the quality of life was within the

last 2 weeks. Answers were given on a Likert scale

of 1-5, with 1 being the least and 5 being the highest

agreement, and then the answers were transformed

into points, in two steps, within the 0-100 scale. A

higher score represents greater ("better"), and a

smaller number of points represent a lower

("worse") level of functioning. The questionnaire

contained a number of questions on socio-

demographic condition (age, sex, level of

education).

3 RESULTS

From a total of 150 patients with diabetes mellitus,

58.0% were male and 42.0% female, with average

age of 56 (± 12.4) years, most were aged 30 to 59

years (53.3%) and over 60 years (41.3%). In relation

to the level of education the highest percentage of

respondents had secondary (48%) and primary

(20%) level of education. According to marital

status 2/3 (66.7%) were married, and 1/5 (20%)

were divorced/widower. (Table 1)

Table 1: Sociodemographic characteristics of the sample.

Variables Respondents (N=150)

n %

Gender

Male 87 58.0

Female 63 42.0

Age

<30 8 5.3

30-59 80 53.3

≥60 62 41.3

Min- Max

Me (±SD)

21-75

55.95±12.4

Level of education

Unfinished primary 20 13.3

Primary 30 20.0

Secondary 72 48.0

High/college 28 18.7

Marital status

Single 20 13.3

Married 100 66.7

Divorced/Widowed 30 20.0

The higher percent of women but without

statistically significant difference compared to male

patients feel that physical pain prevents them from

doing what they need to do; that they need medical

treatment to function in everyday life; that they do

not have enough energy for everyday life; assessed

their ability to get around poor and very poor, and

they were very dissatisfied and dissatisfied with

sleep. Male patients were more satisfied and very

satisfied with their ability to perform daily activities

and very dissatisfied and dissatisfied with their

capacity for work, but without statistically

significant differences compared to female patients.

(Table 2)

The Impact of Diabetes Mellitus on the Physical Health and Physical Activity

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Table 2: Answers of questions* in relation to gender.

Quest

Genderº

Answers (%) Kruskal

Wallis

Test*

Not at all

A little

A moderate

amount

Very much

An extreme

amount

1 M 25.3 25.3 28.7 9.2 11.5

2496.6

P=0.34

F 19.0 27.0 27.0 11.1 15.9

T 22.6 26.0 28.0 10.0 13.3

2 M 8.0 9.2 33.3 41.4 8.0

2618.5

P=0.63

F 1.6 17.5 30.2 36.5 14.3

T 5.3 12.7 32.0 39.3 10.7

Gende

Answers (%)

2527.5

P=0.39

Not at all

A little

Moderately

Mostly

Completely

M 4.6 13.8 19.5 40.2 21.0

F 9.5 12.7 23.8 33.3 20.6

T 6.7 13.3 21.3 37.3 21.3

Gende

Answers (%)

2322.0

P=0.09

Very poor

Poor

Neither poor

nor good

Good

Very good

4 M 3.4 13.8 31.0 35.6 16.1

F 3.2 22.2 36.5 27.0 11.1

T 3.2 17.3 33.3 32.0 14.0

Gende

Answers (%)

Very dissatisfie

Dissatisfie

either satisfied

nor dissatisfie

Satisfie

Very satisfie

5 M 1.1 31.0 21.8 32.2 13.8

2390.0

P=0.17

F 9.5 27.0 27.0 28.6 7.9

T 4.7 29.3 24.0 30.6 11.3

6 M 2.2 13.8 24.1 50.6 10.3

2584.5

P=0.52

F 3.2 12.7 25.4 54.0 4.8

T 2.0 13.3 24.7 52.0 8.0

7 M 4.6 24.1 26.4 35.6 9.2

2670.0

P=0.78

F 3.2 23.8 20.6 50.8 1.6

T 4.0 24.0 24.0 42.0 6.0

ºM-men; F-females; T-total

*Questions of the physical domain of quality of life:

1. To what extent do you feel that physical pain

prevents you from doing what you need to do?

2. How much do you need any medical treatment to

function in your daily life?

3. Do you have enough energy for everyday life?

4. How well are you able to get around?

5. How satisfied are you with your sleep?

6. How satisfied are you with your ability to perform

your daily living activities?

7. How satisfied are you with your capacity for work?

Without statistically significant differences more

than half of the patients of in all age groups said they

need any medical treatment to function in everyday

life, and that they are satisfied and very satisfied

with the ability to perform daily activities. With a

statistically significant difference with the increase

of age very much and an extreme amount feel that

pain (physical) prevents them to do what they want

to do (p = 0.037); that not at all and a little have

enough energy for daily living (p = 0.005); that their

ability to get around is very poor and poor (p =

0.000); that they are very dissatisfied and

dissatisfied with their sleep (p = 0.025) and that they

were very dissatisfied and dissatisfied with their

capacity for work (p = 0.004). (Table 3)

Half of the respondents (50%) with unfinished

primary school said that physical pain prevents them

from doing what they need to do, but without

statistically significant difference in relation to

persons with secondary (19.4%) and high education

(14.2%). With the increase of the level of education

decreases dissatisfaction among patients, so with

statistically significant difference in higher

percentage patients without primary education said

they very much (20%) and an extreme amount

(30%) need medical treatment to function in

everyday life, and that they not at all (25%) have

enough energy for everyday life, that they have poor

(40%) ability to get around and that they are

dissatisfied with sleep (60%); with ability to perform

daily living activities (30%) and with a capacity for

work (60%) compared to patients with secondary

and higher education. (Table 4)

Mean score for the physical domain of health in

patients with diabetes mellitus were slightly higher

in male patients (57.92), but without statistically

significant difference (t = 1.256; p >0.05) compared

to female respondents. With a statistically significant

difference (p <0.01) the mean scores for the physical

domain of health were higher among younger

respondents and the mean score declines with age.

Mean score with a statistically significant difference

(p <0.01) decrease with decrease of the level of

education so that the highest value is for those with

higher education and the lowest in patients without

primary education. Mean score for the physical

domain of health in patients with diabetes mellitus

were highest in unmarried people followed by

married but without statistically significant

difference (p> 0.05) compared to divorced/widowed.

(Table 5)

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Table 3: Answers of questions* in relation to age.

Questions

Answers (%) Kruskal

Wallis

test

Not at all

A little

a moderate

amount

Very much

An extreme

amount

1 1 37.5 62.5 0.0 0.0 0.0

10.245

p=0.037

2 17.5 32.5 33.8 6.3 10.0

3 27.4 12.9 24.2 16.1 19.4

2 1 12.5 25.0 12.5 12.5 37.5

8.185

p=0.085

2 5.0 17.5 32.5 33.8 11.3

3 4.8 4.8 33.9 50.0 6.5

Answers (%)

14.821

p=0.005

Not at all

A little

Moderately

Mostly

Completely

1 0.0 0.0 0.0 50.0 50.0

2 3.8 13.8 21.3 40.0 21.3

3 11.3 14.5 24.2 32.3 17.7

Answers (%)

31.821

p=0.000

Very poor

Poor

Neither

poor nor

good

Good

Very good

4 1 0.0 0.0 0.0 37.5 62.5

2 3.8 10.0 32.5 36.3 17.5

3 3.2 29.0 38.7 25.8 3.2

Answers (%)

Very dissatisfied

Dissatisfied

Neither satisfied

nor dissatisfied

Satisfied

Very satisfied

5 1 12.5 0.0 12.5 50.0 25.0

11.187

p=0.025

2 1.3 25.0 27.5 32.5 13.8

3 8.1 38.7 21.0 25.8 6.5

6 1 0.0 0.0 12.5 62.5 25.0

7.873

p=0.096

2 1.3 10.0 28.8 48.8 11.3

3 3.2 19.4 21.0 54.8 1.6

7 1 0.0 0.0 0.0 100 0.0

15.099

p=0.004

2 2.5 18.8 26.3 42.5 10.0

3 6.5 33.9 24.2 33.9 1.6

**Age: 1. <30; 2. 30-59; 3. ≥60

Table 4: Answers of questions* in relation to education.

Questions

***Education

Answers (%) Kruskal

Wallis

test

Not at all

A little

A moderate

amount

Very much

An extreme

amount

1 1 20.0 10.0 20.0 20.0 30.0

5.943

p=0.114

2 30.0 26.7 20.0 6.7 16.7

3 19.4 26.4 34.7 9.7 9.7

4 25.0 35.7 25.0 7.1 7.1

2 1 5.0 5.0 0.0 90.0 0.0

12.136

p=0.007

2 0.0 10.0 30.0 40.0 20.0

3 6.9 9.7 43.1 29.2 11.1

4 7.1 28.6 28.6 28.6 7.1

Answers (%)

16.295

p=0.001

Not at all

A little

Moderately

Mostly

Completely

1 25.0 25.0 30.0 10.0 10.0

2 6.7 13.3 30.0 30.0 20.0

3 2.8 12.5 20.8 37.5 26.4

4 3.6 7.1 7.1 64.3 17.9

Answers (%)

Very poor

Poor

Neithe

r poor

nor

good

Good

Very good

25.669

p=0.000

1 15.0 40.0 30.0 15.0 0.0

2 6.7 20.0 40.0 26.7 6.7

3 0.0 12.5 38.9 31.9 16.7

4 0.0 10.7 14.3 50.0 25.0

Answers (%)

Very dissatisfie

Dissatisfie

Neither

satisfied nor

ssat

Satisfie

Very satisfie

1 5.0 60.0 10.0 25.0 0.0

13.918

p=0.003

2 10.0 36.7 23.3 26.7 3.3

3 4.2 20.8 25.0 29.2 20.8

4 0.0 21.4 32.1 42.9 3.6

6 1 10.0 30.0 25.0 35.0 0.0

10.971

p=0.012

2 0.0 13.3 26.7 60.0 0.0

3 0.0 11.1 27.8 45.8 15.3

4 3.6 7.1 14.3 71.4 3.6

7 1 10.0 60.0 0.0 30.0 0.0

14.266

p=0.003

2 6.7 30.0 23.3 36.7 3.3

3 2.8 15.3 30.6 41.7 9.7

4 0.0 14.3 25.0 57.1 3.6

***Level of education 1-unfinished primary; 2-primary;

3-secondary; 4-high/college

The Impact of Diabetes Mellitus on the Physical Health and Physical Activity

153

Table 5: Mean scores for the physical domain of health

relation to sociodemographic characteristics.

Variables Physical domain t-test

F-test

Me ±SD

Gender

Male 57.92 19.57 T=1.256

P=0.211

Female 53.85 19.59

Age

<30 75.00 11.29 F=6.306

P=0.000

30-59 62.65 17.65

≥60 49.94 19.84

Level of education

Unfinished primary 38.75 19.84 F=9.397

P=0.000

Primary 51.79 17.91

Secondary 60.02 18.09

High/college 63.63 17.25

Marital status

Single 60.89 19.65 F=0.743

P=0.477

Married 55.89 20.27

Divorced/Widowed 54.17 17.37

4 DISCUSSION

People with diabetes mellitus in our sample had a

mean score for the physical domain of quality of life

(mean score 56.21 ± 19.62) lower than patients with

diabetes mellitus in Denmark (mean score 76.6)

(Nørholm,2001, page 234.), in Iran (mean score

63.75 ± 15.59) (Aghamollaei, 2003, page 56), in

Maryland (mean score 61 ± 29) (Hill-Briggs, 2002,

page 414), in Emirates (mean score 61.8±14.3)

(Bani-Issa,2011, page 827), and higher value in

relation to the mean score (mean score

51.31±19.087) of respondents in the study in Serbia

(Bosić-Živanović, 2012, page 860).

Without statistically significant difference in our

study female had a lower mean score compared to

male patients. In a study in Tokat in Turkey mean

score were significantly lower in women for

physical health domain (Saatcioglu, 2008, page

108), as well as in a study of Bandar Abbas clinic in

Iran (Aghamollaei, 2003, page 56) in study in

Greece (Papadopoulos, 2007, page 4). Statistically

significant lower mean score in the area of physical

functioning in women were in the study conducted

in Estonia (Kalda, 2008, page 24), and in a study in

Japan, women have reported a significantly higher

percentage of problems in the dimension of mobility

than men (Sakamaki, 2006, page 50).

In our study, the mean score statistically

significant declined with age, as well as in a study in

the United States (Glasgow, 1997, page 564). As

well in Study in the Netherlands older age was

associated with statistically significantly greater

frequency of problems in dimension of mobility

(Redekop 2002, page 461). In 240 patients with type

I and type II diabetes mellitus, both groups of

patients had statistically significant worse physical

functioning with increase of age in a study in Boston

(Jacobson, 1994, page 270). People with diabetes

mellitus aged with and over 70 years in study in

Japan reported statistically significantly more

problems in the dimension of mobility and the

dimension of everyday activities than people in other

age groups (Sakamaki, 2006, Page50). There was no

association between age and assessment of quality of

life in the study in Bandar Abbas clinic

(Aghamollaei, 2003, page 56) as well as in study in

Ile -Ifa in Nigeria (Kolawole, 2009, page 163).

The association between level of education and

quality of life assessment was also found in a study

in Bandar Abbas in Iran in which educated patients

had a better quality of life at all scales. Illiterate

patients had poorer estimation of the quality of life

on all scales in relation to patients who were literate

(Aghamollaei, 2003, page 56). Contrary to the

findings of these studies are the findings in Ile-Ifa

(Kolawole, 2009, page 163) and Gaza (Eljedi, 2006,

page 5) in which there was no significant correlation

between the assessment of quality of life and level of

education. Exercise has many health benefits, and

these are important in both T1DM and T2DM.

It is important to be aware that both

hypoglycaemia and hyperglycaemia can occur

during exercise, but strategies are available to deal

with these challenges. (Lumb , 2014, pager 675)

5 CONCLUSION

In our patients, diabetes mellitus has an impact on

the physical health component and restrict certain

physical activities, especially in patients who are

older and with lower education. A more complete

picture would be if we have studied the level of

physical activity that was present before the disease

and restrictions that have resulted from these chronic

diseases, because the physical activity is essential

for the regulation of blood glucose levels as well as

for the functioning of the insulin. What is evident in

our patients is that the level of education affects the

quality of life of the patient in the physical

component of health, and that people with higher

education have better mean score for the physical

component of quality of life.

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