Article:General health status in Iranian diabetic patients assessed by short-form-36 questionnaire: a systematic review and meta-analysis. (5984362)

From ScienceSource
Jump to: navigation, search

This page is the ScienceSource HTML version of the scholarly article described at https://www.wikidata.org/wiki/Q55259249. Its title is General health status in Iranian diabetic patients assessed by short-form-36 questionnaire: a systematic review and meta-analysis. and the publication date was 2018-05-31. The initial author is Masoud Behzadifar.

Fuller metadata can be found in the Wikidata link, which lists all authors, and may have detailed items for some or all of them. There is further information on the article in the footer below. This page is a reference version, and is protected against editing.



Converted JATS paper:

Journal Information

Title: BMC Endocrine Disorders

General health status in Iranian diabetic patients assessed by short-form-36 questionnaire: a systematic review and meta-analysis

  • Masoud Behzadifar
  • Rahim Sohrabi
  • Roghayeh Mohammadibakhsh
  • Morteza Salemi
  • Sharare Taheri Moghadam
  • Masood Taheri Mirghaedm
  • Meysam Behzadifar
  • Hamid Reza Baradaran
  • Nicola Luigi Bragazzi

Publication date (epub): 5/2018

Publication date (pmc-release): 5/2018

Publication date (collection): /2018

Abstract

Background

Diabetes mellitus is one of the most prevalent diseases worldwide. Diabetes is a chronic disease associated with micro- and macro-vascular complications and deterioration in general health status. Therefore, the aim of this study was to estimate general health status among Iranian diabetic patients through a systematic review and meta-analysis of study utilizing the Short-Form-36 questionnaire.

Methods

Searching the EMBASE, PubMed, ISI/Web of Sciences (WOS), MEDLINE via Ovid, PsycoINFO, as well as Iranian databases (MagIran, Iranmedex, and SID) from January 2000 to December 2017. The methodological quality of the studies was evaluated using the “A Cochrane Risk of Bias Assessment Tool: for Non-Randomized Studies of Interventions” (ACROBAT-NRSI). Random-effect model was used and the means were reported with their 95% confidence interval (CI). To evaluate the heterogeneity between studies, I2 test was used. Egger’s regression test was used to assess the publication bias.

Results

Fourteen studies were retained in the final analysis. The mean general health status using SF-36 in diabetic patients of Iran was 51.9 (95% CI: 48.64 to 53.54). The mean physical component summary was 52.92 [95% CI: 49.46–56.38], while the mean mental component summary was 51.02 [95% CI: 46.87–55.16].

Conclusion

The findings of this study showed that general health status in Iranian diabetic patients is low. Health policymakers should work to improve the health status in these patients and take appropriate interventions.

Electronic supplementary material

The online version of this article (10.1186/s12902-018-0262-2) contains supplementary material, which is available to authorized users.

Paper

Background

Diabetes mellitus is one of the most prevalent diseases worldwide, imposing a relevant epidemiological and clinical burden, both in terms of deaths and morbidities. The prevalence of diabetes is increasing both in developed and developing countries, and has doubled over the past three decades, with almost 80% of diabetic patients living in less developed countries [[1], [2]]. Population aging, lifestyle changes, lack of mobility, and many other factors characterizing modern life have contributed to such an increase [[3]]. In 2014, the prevalence of diabetes in people aged greater than 18 years in the world was about 8.5%. It is anticipated that diabetes will be the seventh cause of death by 2030, and, despite all efforts to control the disease, it still remains one of the major public health challenges [[4]]. The number of people with diabetes is expected to rise up to about 592 million by 2035 [[5]]. The prevalence of diabetes in the Middle East and North Africa is about 10.9%. In these areas, about 35 million people are affected by diabetes, with Iran having the highest prevalence (9.94%) among the countries of the Middle East [[6]].

Such concerns necessitate adequate health policies in order to control and prevent diabetes [[7]]. This disorder represents a chronic disease associated with micro- and macro-vascular complications, which dramatically impact on general health status [[8]]. Studies have shown that such complications can affect physical, mental and social life of people, modifying and interfering with their usual every day functioning [[9]]. Hence, treatments of diabetes are usually evaluated based on their effect on health status [[10]], which, as a key factor in effectiveness studies, refers, indeed, to the mental, physical and social status of the patient [[11]]. Considering the general health status among diabetic patients can provide care givers with a better understanding of patients’ conditions, indicating which health provisions are necessary for a proper management of the disease [[12]].

To assess general health status among diabetes patients, a variety of questionnaires have been developed that can measure different dimensions of the patients’ life. The Short-Form 36 (SF-36) questionnaire is one of the most commonly used instruments [[13]]. It includes 36 questions distributed across eight domains (namely, vitality, physical function, body pain, health perception, physical role, emotional role, social role and mental health) [[14], [15]].

Various studies have been conducted to assess Iranian diabetic population’s quality of life. Such information can be helpful for measuring the severity of complications and designing and implementing appropriate healthcare policies. In 2013, a review study was conducted in Iran on health status in diabetic patients. In this study, the assessment of health status of diabetics was based on all questionnaires used in Iran. Authors suggested that a meta-analysis study could better provide information about health status in diabetic patients [[16]]. Therefore, the aim of this study was to estimate general health status among Iranian diabetic patients through a systematic review and meta-analysis of studies utilizing a specific instrument, namely the SF-36 questionnaire.

Methods

The current study has been performed according to the “The Meta-analysis of Observational Studies in Epidemiology” (MOOSE) guidelines [[17]]. (Additional file 1).

Two authors independently searched different scholarly electronic databases: namely, EMBASE, PubMed, ISI/Web of Sciences (WOS), MEDLINE via Ovid, PsycoINFO, as well as Iranian databases (MagIran, Iranmedex, and SID). These databases were systematically searched from January 2000 to December 2017 using the following search strategies: (“general health status”) AND (“Short form 36” OR “SF-36” OR “SF-36 health survey questionnaire” OR “Short form-36 health survey questionnaire”) AND (“Diabetes” OR “Diabetic”) AND “Iran”. Studies were searched both in English and Persian (no language filter applied). Reference lists of each included study were also scanned and hand-searched for possible related studies.

Inclusion/ criteria

Studies with the following criteria were included if: i) utilizing the SF-36 questionnaire for investigating general health status among Iranian populations, ii) reporting an average score for the eight domains of the questionnaire, iii) reporting both Physical Component Summary (PCS) and Mental Components Summary (MCS) indicators, and iv) reporting means with standard errors (SE) or standard deviations (SD). Both cross-sectional or case-control studies were considered.

Exclusion criteria

Studies were excluded if: i) designed as reviews, letters to the editor, editorials, expert opinions, commentaries, clinical trials, case-reports, case-series, or ii) not reporting quantitative details of the SF-36 questionnaire.

Quality assessment

The methodological quality of the studies was evaluated using the “A Cochrane Risk of Bias Assessment Tool: for Non-Randomized Studies of Interventions” (ACROBAT-NRSI) [[18]].

Data extraction

Two authors (MB and NLB) extracted the data from the studies, and if there was a controversy between them, another author (AA) resolved the issue. The name of first authors of the studies, the year of publication, the place where the studies were conducted, the number of participants, the duration of diabetes, the design, and the mean scores of SF-36 domains were extracted.

Statistical analysis

The pooled value of the mean of overall scores, as well the scores of the eight domains of the questionnaire and the PCS and MCS scores were calculated as the mean and SE. Random-effect model was used and the means were reported with their 95% confidence interval (CI). To evaluate the heterogeneity among studies, I2 test was used [[19]]. For evaluating the potential sources of heterogeneity, subgroup analyses based on the study design, sample size and type of diabetes (type 1 and type 2 diabetes) were conducted. Sensitivity analysis was performed to ensure that the results were stable. This analysis was also performed based on the year of publication. Egger’s regression test was used to assess the publication bias [[20]].

Finally, case-control studies were pooled together, computing the standardized mean difference (SMD).

Figures with a p-value < 0.05 were considered statistically significant. All data were analyzed using Stata 12.0 software (Stata Corp LP, College Station, TX).

Results

After the initial electronic database search, 378 studies were found. Eighty-three duplicate studies were deleted. The titles of the retrieved studies were reviewed and 258 studies were excluded due to lack of relevance to the topic. Then, the title and abstract of 37 remaining studies were reviewed by two authors independently and 21 studies were excluded with reason. Finally, the full texts of the remaining 16 studies were examined and, based on the inclusion/exclusion criteria, 14 studies were retained in the final analysis [[21][34]]. Figure 1 summarizes the stages of the retrieval and selection of the studies.Fig. 1

Flowchart of the study retrieval and selection

The included studies were conducted between 2011 and 2017. The total number of participants in the studies was 4492, ranging from 60 to 1847 people. The study designs varied across studies and were cross-sectional for 10 studies and case-control for 4 studies). Table 1 shows the main characteristics of the studies retained in the present systematic review and meta-analysis.Table 1

The main characteristics of the included studies about general health status in Iranian patients with diabetes

First author Year of publication Mean score of general health status Sample size Female Male Age (Mean ± SD) Type of diabetes Design of study Duration of diabetes (Year ± SD) Married (%) Setting (City) Setting (Province)
Borzou 2011 55.53 165 111 54 NA Type 2 Cross- Sectional NA NA Hamedan Hamedan
Khaledi 2011 45.23 198 166 32 NA Type 2 Cross- Sectional 1–5 80.8 Sannadaj Kurdistan
Saadatjoo 2012 28.52 100 54 46 42.82 ± 16.57 Type 2 Case-Control NA 82 Birjand South Khorasan
Timareh 2012 52.97 350 204 146 52.91 ± 11.7 Both type Cross- Sectional NA 86.9 Kermanshah Kermanshah
Sadabadi 2013 44.72 60 NA NA NA Type 2 Case-Control NA NA Tabriz East Azerbaijan
Darvishpoor Kakhki 2013 46.2 131 79 52 NA Type 2 Case-Control NA 80.2 Tehran Tehran
Hadi 2013 54.11 300 222 78 50.98 Both type Cross- Sectional NA 84 Shiraz Fars
Darvishpoor Kakhki 2013 52.11 140 NA NA 47.3 ± 12.7 Both type Cross- Sectional 8.83 ± 6.10 NA Tehran Tehran
Mohammadshahi 2015 51.81 110 51 59 53.4 ± 8.12 Type 2 Cross- Sectional NA NA Ahvaz Khuzestan
Kashfi 2015 61.33 124 89 35 59.65 ± 12.3 Type 2 Case-Control 7.68 ± 6.93 83.9 Larestan Fars
Borhaninejad 2016 46.48 120 69 51 71.32 ± 5.13 Type 2 Cross- Sectional NA 73.4 Kerman Kerman
Hajian-Tailaki 2016 56.27 747 372 375 68 ± 7.6 in male and 67.7 ± 7.9 in female Type 2 Cross- Sectional NA NA Babol Mazandaran
Mazloomy Mahmood Abad 2017 59.27 100 59 41 51.92 ± 11.53 Type 2 Cross- Sectional NA 94 Sirjan Kerman
Gholami 2017 51.11 1847 1289 558 59.65 ± 12.3 Type 2 Cross- Sectional NA 19.9 Nishabur Razavi Khorasan

The quality assessment of the risk of bias of the included studies is shown in Table 2 and Fig. 2.Table 2

Risk of Bias Assessment of included studies based on the ACROBAT-NRSI instrument

Study Domains of bias
Bias due to confounding Bias in selection of participants Bias in measurement of interventions Bias due to departures from intended interventions Bias due to missing data Bias in measurement of outcomes Bias in selection of reported results
Borzou Moderate risk Low risk Low risk Low risk Low risk Low risk Low risk
Khaledi Low risk Low risk Low risk Moderate risk Low risk Low risk Moderate risk
Saadatjoo Serious risk Low risk Serious risk Moderate risk Serious risk Moderate risk Serious risk
Timareh Serious risk Moderate risk Low risk Moderate risk Moderate risk Low risk Moderate risk
Sadabadi Moderate risk Low risk Moderate risk Serious risk Moderate risk Moderate risk Low risk
Darvishpoor Kakhki Serious risk Low risk Low risk Moderate risk Low risk Moderate risk Low risk
Hadi Low risk Low risk Moderate risk Low risk Low risk Low risk Low risk
Darvishpoor Kakhki Moderate risk Low risk Low risk Low risk Low risk Moderate risk Low risk
Mohammadshahi Low risk Moderate risk Low risk Low risk Low risk Moderate risk Low risk
Kashfi Low risk Low risk Low risk Low risk Low risk Low risk Moderate risk
Borhaninejad Moderate risk Low risk Moderate risk Moderate risk Low risk Low risk Low risk
Hajian-Tailaki Low risk Low risk Low risk Moderate risk Moderate risk Low risk Low risk
Mazloomy Mahmood Abad Low risk Moderate risk Low risk Low risk Low risk Low risk Low risk
Gholami Moderate risk Low risk Low risk Moderate risk Low risk Low risk Low risk
Fig. 2

The result of quality assessment of risk of bias of included studies

The mean general health status using SF-36 based on the random-effect model in diabetic patients of Iran was 51.9 (95% CI: 48.64 to 53.54). The lowest health status was observed in the study of Saadatjoo with a score of 28.52 and the highest in Kashifi’s study, with a value of 61.33. Figure 3 shows the overall general health status among the included studies.Fig. 3

The Mean health status in Iranian diabetic patients (2011–2017), based on the random-effects model

Using the Egger’s test, no publication bias could be detected (p = 0.859, see Fig. 4).Fig. 4

Probability of publication bias in the included studies

To investigate the possible sources of heterogeneity between studies, subgroup analysis was conducted based on study design, sample size and study quality. Table 3 shows the results of subgroup analysis.Table 3

The results of subgroup analysis

Variables Number of studies Number of participants Mean score of general health status (95% CI) I2 P-value
Design of studies
 Cross-sectional 10 4077 52.32 (50.02–54.62) 86.8% 0.001
 Case-control 4 415 46.47 (38.87–54.08) 93.3% 0.001
Sample size
 ≤120 6 614 49.58 (43.11–56.05) 92% 0.001
 > 120 8 3878 51.60 (48.95–54.24) 90.7% 0.001
Type of diabetes
 Type 2 11 3702 50.46 (47.43–53.49) 92.46% 0.001
 Both type (type 1 and 2) 3 790 53.22 (51.37–55.07) 0% 0.001

For further evaluation of sources of heterogeneity, the results of meta-regression were analyzed based on the year of publication and the sample size of studies, as presented in Table 4. The results showed that the quality of life of diabetic patients has increased on a yearly basis and has decreased based on the sample size. However, none of the results were statistically significant.Table 4

The results of meta-regression

Variables Coefficient S.E. t P-value Lower 95% Upper 95%
Year 1.36 1.07 1.27 0.22 −0.99 3.73
Sample size −0.00 0.00 −0.22 0.82 −0.01 0.00

The results based on the eight domains of the SF-36 questionnaire are presented in Table 5. The mean scores of PCS and MCS are shown in Figs. 5 and 6. The mean of PCS was 52.92 [95% CI: 49.46–56.38], while the mean of MCS was 51.02 [95% CI: 46.87–55.16].Table 5

The health status based on the 8 domains of the SF-36 questionnaire

Variables Mean (95% CI) Heterogeneity P-value of publication bias
I2 P-value
Physical function 61.62 (55.70–67.53) 98.6% 0.001 0.78
Role physical 49.96 (44.50–55.41) 95.6% 0.001 0.83
Body pain 52.26 (48.47–56.04) 95.8% 0.001 0.57
General health 47.34 (44.15–50.53) 96.5% 0.001 0.01
Vitality 46.99 (43.28–50.69) 97.4% 0.001 0.64
Social function 57.86 (46.87–68.85) 99.7% 0.001 0.15
Role emotional 50.38 (45.29–55.47) 97.4% 0.001 0.28
Mental health 47.79 (40.06–55.52) 99.6% 0.001 0.32
Fig. 5

The Physical component summaries (PCS)

Fig. 6

The mental component summaries (MCS)

Finally, case-control studies were pooled together (Fig. 7). The general health status of diabetic patients compared to healthy controls was lower with a SMD of − 0.84 [95% CI: -1.83 to 0.51] and compared to the group of patients with tuberculosis with a SMD of 0.44 [95% CI: 0.21- 0.67].Fig. 7

The results of pooling together case-control studies

Discussion

In the 14 studies included in this systematic review and meta-analysis, numerous complications and co-morbidities were reported in people with diabetes. Health policy- and decision-makers should pay attention to the implications of the reduced general health status in diabetic patients in Iran. Various studies have, indeed, shown that health status is an independent prognostic predictor of survival and hospitalization rate in patients with peripheral arterial and renal patients, and of mortality in patients with coronary heart disease [[35][38]].

General health status is decreased in diabetic patients [[39]], when compared to the health status of general population, which, in a recent study, reported an average score of 67.69 ± 14.78 [[40]]. Healthcare providers should be aware of the patients’ perspective and their perceived health. Preventing further diabetes complications and providing better conditions for patients’ lives is fundamental. Physical and mental interventions can improve the health status of diabetic patients and avoid, or at least delay, further deterioration [[41]].

Our findings showed that the dimensions of physical and social function had the highest score whereas the lowest score was related to vitality and general health. The results of our study are consistent with the study done in Brazil [[42]], whereas other studies reported higher values [[43][45]]. The level of access to health services, the economic and social conditions of people, the physical and mental conditions of individuals can, at least partially, explain these differences [[46], [47]]. Some studies point to the existence of health inequalities in that people with a higher socioeconomic status have more incentive and energy to change their livelihood and are more involved in their own health care processes [[48]]. An important cross-sectional survey of 13 national samples from Asia, Australia, Europe and North America of 5104 patients with diabetes from the multinational study of Diabetes Attitudes, Wishes and Needs (DAWN) has shown that the reported levels of well-being, self-management, and diabetes control correlate with country, respondent demographic and disease characteristics, as well as with healthcare features [[49]]. These findings have been replicated by a follow-up study [[50]].

The findings of the present study indicate that diabetes dramatically affects vitality and general health domains; hence these areas should be given more attention when treating diabetic patients. In our study, MCS was less than PCS, which was consistent with the results of the Al-Shehri study [[51]]. Various studies have been conducted to show that mental disorders such as depression in patients with diabetes can be remarkably observed. In a review, results showed that depression in diabetic patients had a negative effect on the treatment process and increased complications of the disease [[52]].

It seems that the chronic and severe nature of diabetes mellitus in the long run leads to a decrease in the general health status [[53]]. It should be noted that the core of the concept of reported/perceived health status is a feeling/perception of one’s own health and, in fact, other aspects of the health status form a sense of health that is low in patients with diabetes. Affecting the emotional aspects impacts on energy and vitality of patients with diabetes. Other studies have also shown a decrease in vitality, with an increase of fatigue, depression, anxiety and stress problems, among patients with diabetes. Therefore, diabetes has a long-term negative effect on the health of patients. The decrease in the health status in patients with diabetes has also been replicated in other studies [[54]].

These observations can be confirmed if we compare health status of Iranian subjects with diabetes with the health status of people with chronic-degenerative disorders, such as rheumatoid arthritis with an average score of 52.47 [[55]], or cardiovascular disorders with a mean of 53.19 [[56]], among others. Similarly, low scores have been found for asthma [[57]] or chronic kidney disease [[58]]. Scores even lower (40.43 ± 12.7) were reported for individuals with drug addiction [[59]].

In meta-analysis studies, taking into account potential sources of heterogeneity is crucial [[60]]. To investigate this aspect, we performed subgroup-analysis based on each SF-36 scale domain. The results of meta-regression were also studied for further evaluation of heterogeneity sources, which showed an increased average health status of diabetic patients based on the year of publication, even though not statistically significant. In recent years the status of services provided to diabetics is on the rise, but it seems that many of the services provided to them are not of sufficient standards, and the quality of care for these patients should be monitored more closely by healthcare providers in Iran.

However, this study has some limitations that should be properly mentioned. First, the primary studies missed to give some complementary information about patients, such as sex, other illnesses/co-morbidities, education level and income. Second, a high level of heterogeneity was observed, which can be attributed to methodological differences. Third, the health status in diabetic patients has not been studied in many Iranian provinces, which can challenge the generalizability of our estimation to all Iranian diabetic population.

Conclusion

The findings of this study showed that general health status in Iranian diabetic patients is low. Health policy- and decision-makers should work to improve the health status in these patients and take appropriate interventions. Therefore, it is recommended to look at important factors such as patients’ attitudes in changing and improving their lifestyle. A combination of both clinical and non-clinical interventions should be targeted at increasing the standard of living of these patients.

Additional file

Additional file 1:

MOOSE Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies. (DOCX 22 kb)

Acknowledgements

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Availability of data and materials

Not applicable. This study is a systematic review and we used primary data, which are already publicly available.

References

  1. P ZimmetKG AlbertiDJ MaglianoPH BennettDiabetes mellitus statistics on prevalence and mortality: facts and fallaciesNat Rev Endocrinol2016121061662210.1038/nrendo.2016.10527388988
  2. NCD Risk Factor Collaboration (NCD-RisC)Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4.4 million participantsLancet2016387100271513153010.1016/S0140-6736(16)00618-827061677
  3. J SpeightMD ReaneyKD BarnardNot all roads lead to Rome-a review of quality of life measurement in adults with diabetesDiabet Med200926431532710.1111/j.1464-5491.2009.02682.x19388959
  4. CD MathersD LoncarProjections of global mortality and burden of disease from 2002 to 2030PLoS Med2006311e44210.1371/journal.pmed.003044217132052
  5. L GuariguataDR WhitingI HambletonJ BeagleyU LinnenkampJE ShawGlobal estimates of diabetes prevalence for 2013 and projections for 2035Diabetes Res Clin Pract2014103213714910.1016/j.diabres.2013.11.00224630390
  6. M JavanbakhtA MashayekhiHR BaradaranA HaghdoostA AfshinProjection of diabetes population size and associated economic burden through 2030 in Iran: evidence from micro-simulation Markov model and Bayesian meta-analysisPLoS One2015107e013250510.1371/journal.pone.013250526200913
  7. S WildG RoglicA GreenR SicreeH KingGlobal prevalence of diabetes: estimates for the year 2000 and projections for 2030Diabetes Care20042751047105310.2337/diacare.27.5.104715111519
  8. AA PapadopoulosN KontodimopoulosA FrydasE IkonomakisD NiakasPredictors of health-related quality of life in type II diabetic patients in GreeceBMC Public Health2007718610.1186/1471-2458-7-18617663782
  9. SR ColbergRJ SigalB FernhallJG RegensteinerBJ BlissmerRR RubinExercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statementDiabetes Care20103312e147e16710.2337/dc10-999021115758
  10. F Gusmai LdeS Novato TdeS Nogueira LdeThe influence of quality of life in treatment adherence of diabetic patients: a systematic reviewRev Esc Enferm USP201549583984610.1590/S0080-62342015000050001926516756
  11. American Diabetes AssociationStandards of medical care in diabetes-2016 abridged for primary care providersClin Diabetes201634132110.2337/diaclin.34.1.326807004
  12. International Diabetes Federation Guideline Development GroupGlobal guideline for type 2 diabetesDiabetes Res Clin Pract2014104115210.1016/j.diabres.2012.10.00124508150
  13. JE Ware JrCD SherbourneThe MOS 36-item short-form health survey (SF-36)Med Care199230647348310.1097/00005650-199206000-000021593914
  14. AA Al HayekAA RobertA Al SaeedAA AlzaidFS Al SabaanFactors associated with health-related quality of life among Saudi patients with type 2 diabetes mellitus: a cross-sectional surveyDiabetes Metab J201438322022910.4093/dmj.2014.38.3.22025003076
  15. RA LyonsHM PerryBN LittlepageEvidence for the validity of the short-form 36 questionnaire (SF-36) in an elderly populationAge Ageing199423318218410.1093/ageing/23.3.1828085500
  16. AA KiadaliriB NajafiM Mirmalek-SaniQuality of life in people with diabetes: a systematic review of studies in IranJ Diabetes Metab Disord2013125410.1186/2251-6581-12-5424354933
  17. DF StroupJA BerlinSC MortonI OlkinGD WilliamsonD RennieMeta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of observational studies in epidemiology (MOOSE) groupJAMA2000283152008201210.1001/jama.283.15.200810789670
  18. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919.
  19. JP HigginsSG ThompsonJJ DeeksDG AltmanMeasuring inconsistency in meta-analysesBMJ2003327741455756010.1136/bmj.327.7414.55712958120
  20. M EggerG Davey SmithM SchneiderC MinderBias in meta-analysis detected by a simple, graphical testBMJ1997315710962963410.1136/bmj.315.7109.6299310563
  21. SR BorzouM SalavatiM SafariS HadadinejadM ZandiehB TorkamanQuality of life in type II diabetic patients referred to Sina hospital, HamadanZJRMS20111344346
  22. S KhalediG MoridiF GharibiSurvey of eight dimensions quality of life for patients with diabetes type II, referred to Sanandaj diabetes center in 2009J Fasa Univ Med Sci2011112937
  23. S SaadatjooM RezvaneeS TabyeeD OudiLife quality comparison in type 2 diabetic patients and none diabetic personsMod Care J2012912431
  24. M TimarehM RhimiP AbbasiM RezaeiS HyaidarpoorQuality of life in diabetic patients referred to the Diabete research Center in KermanshahJ Kermanshah Univ Med Sci20121616369
  25. A Darvishpoor KakhkiJ Abed SaeediMR MasjediH AskariComparison of life quality of diabetic patients with TB patientsJ Knowledge Health2013827175
  26. A Darvishpoor KakhkiZ Abed saeediHealth-related quality of life of diabetic patients in TehranInt J Endocrinol Metab2013114e794510.5812/ijem.794524719629
  27. N HadiS GhahramaniA MontazeriHealth related quality of life in both types of diabetes in Shiraz, IranShiraz E-Med J2013142112122
  28. M Hatamloo SadabadiKJ BabapourComparison of Quality of Life and Coping Strategies in Diabetic and Non Diabetic PeopleJSSU2013205581592
  29. SM KashfiA NasriA DehghanM YazdankhahComparison of quality of life of patients with type II diabetes referring to diabetes Association of Larestan with healthy people in 2013J Neyshabur Univ Med Sci2015323238
  30. M MohammadshahiF ShiraniS ElahiS GhasemiM Alayi ShahniF HaidariEvaluation of relationship between dietary patterns and quality of life in patients with type 2 diabetesDaneshvarmed201522114112
  31. V BorhaninejadL KazaziM HaghiN ChehrehnegarQuality of life and its related factors among elderly with diabetesSalmand201611116217310.21859/sija-1101162
  32. K Hajian-TilakiB HeidariA Hajian-TilakiSolitary and combined negative influences of diabetes, obesity and hypertension on health-related quality of life of elderly individuals: a population-based cross-sectional studyDiabetes Metab Syndr2016102 Suppl 1S37S4210.1016/j.dsx.2016.01.01826934907
  33. A GholamiM Khazaee-PoolN RezaeeB AmirkalaliA Abbasi GhahremanloF MoradpourHousehold food insecurity is associated with health-related quality of life in rural type 2 diabetic patientsArch Iran Med201720635035528646843
  34. S MazloomyM RezaeianA Naghibzadeh TahamiR SadeghiAssociation between Health–Related Quality of Life and Glycemic Control in Type 2 Diabetics of Sirjan City in 2015JRUMS20171617382
  35. SM IssaSE HoeksWJ Scholte op ReimerYR Van GestelMJ LenzenHJ VerhagenHealth-related quality of life predicts long-term survival in patients with peripheral artery diseaseVasc Med201015316316910.1177/1358863X1036420820483986
  36. AA LopesJL Bragg-GreshamS SatayathumK McCulloughT PiferDA GoodkinHealth-related quality of life and associated outcomes among hemodialysis patients of different ethnicities in the United States: the Dialysis outcomes and practice patterns study (DOPPS)Am J Kidney Dis200341360561510.1053/ajkd.2003.5012212612984
  37. PM MommersteegJ DenolletJA SpertusSS PedersenHealth status as a risk factor in cardiovascular disease: a systematic review of current evidenceAm Heart J2009157220821810.1016/j.ahj.2008.09.02019185627
  38. GR Parkerson JrRA GutmanHealth-related quality of life predictors of survival and hospital utilizationHealth Care Financ Rev200021317118411481754
  39. MT SchramCA BaanF PouwerDepression and quality of life in patients with diabetes: a systematic review from the European depression in diabetes (EDID) research consortiumCurr Diabetes Rev20095211211910.2174/15733990978816682819442096
  40. R GhafariM RafieiMR Taheri NejadAssessment of health related quality of life by SF-36 version 2 in general population of Qom cityAMUJ201416116372
  41. LC BaptistaG DiasNR SouzaMT VeríssimoRA MartinsEffects of long-term multicomponent exercise on health-related quality of life in older adults with type 2 diabetes: evidence from a cohort studyQual Life Res20172682117212710.1007/s11136-017-1543-328303367
  42. JG Nunes-SilvaVS NunesRP SchwartzS Mlss TreccoD EvazianML Correa-GiannellaImpact of type 1 diabetes mellitus and celiac disease on nutrition and quality of lifeNutr Diabetes201471e23910.1038/nutd.2016.43
  43. A HervásA ZabaletaG De MiguelO BeldarráinJ DíezHealth related quality of life in patients with diabetes mellitus type 2An Sist Sanit Navar2007301455210.4321/S1137-6627200700010000517491607
  44. G LindsayK InverarityJR McDowellQuality of life in people with type 2 diabetes in relation to deprivation, gender, and age in a new community-based model of careNurs Res Pract2011201161358921994835
  45. VC VázquezLM GonzálezEM RuizJM IsidoroMS OrdóñezCS GarcíaAssessment of health outcomes in the type 2 diabetes processAten Primaria201143312713310.1016/j.aprim.2010.03.01420542600
  46. A EljediRT MikolajczykA KraemerU LaaserHealth-related quality of life in diabetic patients and controls without diabetes in refugee camps in the Gaza strip: a cross-sectional studyBMC Public Health2006626810.1186/1471-2458-6-26817074088
  47. DP WubbenD PorterfieldHealth-related quality of life among North Carolina adults with diabetes mellitusN C Med J200566317918516130940
  48. R De VogliD GimenoM KivimakiSocioeconomic inequalities in health in 22 European countriesN Engl J Med200835912129010.1056/NEJMc08141418799564
  49. RR RubinM PeyrotLM SiminerioHealth care and patient-reported outcomes: results of the cross-national diabetes attitudes, wishes and needs (DAWN) studyDiabetes Care20062961249125510.2337/dc05-249416732004
  50. FJ SnoekNY KerschE EldrupI Harman-BoehmN HermannsA KokoszkaMonitoring of individual needs in diabetes (MIND)-2: follow-up data from the cross-national diabetes attitudes, wishes, and needs (DAWN) MIND studyDiabetes Care201235112128213210.2337/dc11-132622837364
  51. AH Al-ShehriAZ TahaAA BahnassyM SalahHealth-related quality of life in type 2 diabetic patientsAnn Saudi Med200828535236010.4103/0256-4947.5168718779640
  52. S AliM StoneTC SkinnerN RobertsonM DaviesK KhuntiThe association between depression and health-related quality of life in people with type 2 diabetes: a systematic literature reviewDiabetes Metab Res Rev2010262758910.1002/dmrr.106520186998
  53. IM KingQuality of life and goal attainmentNurs Sci Q199471293210.1177/0894318494007001108139813
  54. I SvenningssonB MarklundS AttvallB GeddaType 2 diabetes: perceptions of quality of life and attitudes towards diabetes from a gender perspectiveScand J Caring Sci201125468869510.1111/j.1471-6712.2011.00879.x21362008
  55. S KarimiMH YarmohammadianA ShokriP MottaghiK QolipourA KordiPredictors and effective factors on quality of life among Iranian patients with rheumatoid arthritisMater Sociomed201325315816210.5455/msm.2013.25.158-16224167426
  56. A YaghoubiJS TabriziMM MirinazhadS AzamiM Naghavi-BehzadM GhojazadehQuality of life in cardiovascular patients in Iran and factors affecting it: a systematic reviewJ Cardiovasc Thorac Res2012449510124250995
  57. NS KiaF MalekE GhodsM FathiHealth-related quality of life of patients with asthma: a cross-sectional study in Semnan, Islamic Republic of IranEast Mediterr Health J201723750050610.26719/2017.23.7.50028853134
  58. B GhiasiD SarokhaniAH DehkordiK SayehmiriMH HeidariQuality of life of patients with chronic kidney disease in Iran: systematic review and meta-analysisIndian J Palliat Care201824110411129440817
  59. M HeidariM GhodusiRelationship of assess self-esteem and locus of control with quality of life during treatment stages in patients referring to drug addiction rehabilitation centersMater Sociomed.201628426326710.5455/msm.2016.28.263-26727698598
  60. DB PetittiApproaches to heterogeneity in meta-analysisStat Med200120233625363310.1002/sim.109111746342
The underlying source XML for this text is taken from https://www.ebi.ac.uk/europepmc/webservices/rest/PMC5984362/fullTextXML. The license for the article is Creative Commons Attribution 4.0 International. The main subject has been identified as diabetes mellitus.