Printer Friendly

Depression among patients with diabetes: A community-based study in South India.

Byline: Abdullahi. Aminu, Varalakshmi. Chandrasekaran, Sreekumaran. Nair

Background: Depression is one of the more common mental health conditions found among people suffering from chronic diseases. Its presence in patients with type 2 diabetes could hinder the adherence to and effectiveness of treatment. Most studies on depression among patients with diabetes are hospital-based suggesting the need for a community-based study to assess the correlates of depression among patients with diabetes. Aim: This study aimed to estimate the prevalence and to identify the factors influencing depression among patients with type 2 diabetes in Udupi taluk situated in southern India. Subjects and Methods: This study recruited 200 patients with type 2 diabetes from both rural and urban areas. Demographic, clinical, and diabetes-related information were collected using a semi-structured questionnaire. Depression was assessed using Patient Health Questionnaire-9; a standardized questionnaire developed in the United States of America and validated in the Indian population. Results: The prevalence of depression among patients with diabetes in the community was found to be 37.5%. Most frequently, depression was mild (42, 21%) in nature with severe depression (9, 4.5%) seen the least. Several factors were found to be positively associated with depression including female gender, rural residence, unemployment, and the status of being unmarried. The presence of diabetic complications and other chronic diseases such as hypertension and obesity also were found to be associated with depression. Conclusion: Depression was found to be particularly high among the study population. Since depression could significantly hinder patient's adherence to treatment, there is an urgent need for early diagnosis and treatment. This calls for the integration of mental health care into the management of diabetes.

Introduction

Diabetes mellitus (DM) is a chronic endocrine disease resulting due to either failure of the pancreas to produce enough insulin (type 1) or inability of the body to utilize the produced insulin (type 2).[1],[2] DM represents a tremendous issue of global concern.[3],[4] According to the International Federation of Diabetes,[4] the prevalence of DM has already reached its epidemic level globally.[4] About 9 million adults in 2014 from both developed and developing countries and across gender, as well as social class, were reported to be living with DM.[2] It accounted for about 1.5 million deaths globally in 2012 with more than 80% of the deaths believed to have occurred in low- and middle-income countries.[2] India has the highest number of patients with diabetes in the world.[3]

DM is not only a public health threat as a disease by itself but also worrisome is concomitant comorbid conditions usually found in patients with diabetes.[5],[6],[7],[8],[9],[10],[11],[12] One such is depression, defined by the World Health Organization as 'a common mental disorder, characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, feelings of tiredness, and poor concentration.'[13] Depression is among the most common mental disorders affecting around 350 million people in the world.[13] Certainly, depression is paid due to attention both by researchers and clinical practitioners in developing and underdeveloped settings.

Depression has been documented in patients with DM.[12],[13],[14],[15],[16],[17],[18] This has been reported in many studies across states, regions, and continents.[5],[6],[7],[8],[9],[10],[11],[12],[18] Its presence in patients with diabetes had been pointed out to hinder the adherence to and effectiveness of treatment.[19],[20],[21],[22],[23] Although there are limited data with regards to depression among patients with diabetes, a few available studies indicated considerably high prevalence in this select group (patients with diabetes) with the common associated factors was gender, income, socioeconomic status, comorbid conditions, and complications.[24],[25],[26],[27] A proper knowledge about the extent and factors associated with depression in patients with diabetes might be of immense importance as it may pave the way for the clinicians toward an improved and effective management of the burdensome disease. It could as well as help researchers and guide policy makers in identifying the group at high risk of developing depression and accordingly implement a successful preventive program.

In this study, the aim and objectives were to estimate the prevalence of depression and identify its influencing factors in patients with type 2 diabetic in the communities of Udupi taluk in the South of India.

Subjects And Methods

This community-based, cross-sectional study was carried out in Udupi taluk located in Udupi District, Karnataka State of southern India over 6 months between January and June 2016. Ethical clearance was obtained from a tertiary healthcare center. This study population comprised adult individuals suffering from type 2 DM willing to participate following consent. Following appropriate permissions, a total of 200 participants were enrolled from the community. This sample size was statistically calculated using an anticipated prevalence (Pp) of 45% as reported by in a similar study.[1] The total sample size required for this study was estimated to be 194 after considering a design effect of 1.5 and a nonresponse rate of about 10%. This was rounded up to 200 which gave the final number of participants enrolled in this study.

The list of all the villages (rural areas) and wards (urban areas) of Udupi taluk constituted the sampling frame. The sampling was done in three stages. First, stratified sampling technique was used where the sampling frame was stratified into two strata, urban and rural strata. The strata comprised wards and villages, respectively. In the second stage, ten units each of villages and wards were selected using simple random sampling technique. Finally, the selection of study participants was done by the house-to-house search in each of the selected villages and wards. In the household visit, the first house in each village or ward was selected at random and the search continued to the adjacent house until the desired number of participants in that particular area was achieved. Individuals who were 18 years and above and were confirmed cases of type 2 DM of not less than a year were included in this study. Those diagnosed with type 2 DM but were unable to respond due to severe illness and/or diagnosed with mental illnesses (other than depression) were excluded from this study.

Study tools

Two questionnaires were employed in the data collection process. These includes a semi-structured questionnaire for the collection of sociodemographic information as well as information on clinical and diabetes-related variables. It was designed by the investigators and validated by one of the coinvestigators and a clinical psychologist, among other experts.

Patient Health Questionnaire-9, a free tool developed by Kroenke et al .[28] with an educational grant from Pfizer Inc., was used for the diagnosis of depression. Minimal (or no depression), mild, moderate, and severe depression are defined by the tool as total scores of 0-4, 5-9, 10-14, and 15 and above, respectively.[28] The instrument was previously validated in the Indian population.[3]

Study procedure

There was a rigorous house-to-house search for patients with type 2 diabetes in each of the twenty visited areas. The first house in each area was selected at random and the search continued to the next house. In each of the households visited, only one participant was found and interviewed, but one in which the couple are both patients with diabetes. Both participants were included and interviewed in total strictness to the protocol. In each visited house, the members would be asked if they had anyone diagnosed with DM after briefing them about this study. If there was an eligible participant in the family, they were asked whether they would like to participate or not. If interested, they were asked to sign the informed consent form after reading and thoroughly understanding the participant information sheet. In all cases, participation was purely voluntary.

Statistical analysis

The data were analyzed using Statistical Software for the Social Sciences version 16 (SPSS Inc., Chicago, IL, USA). Continuous variables were summarized by the mean and standard deviation for normally distributed and median and interquartile range for continuous skewed variables. Categorical variables were summarized by frequencies and percentages. Association between depression and categorical variables was computed using Chi-square test. Univariate and multivariate logistic regression analyses were performed for modeling and to find the crude and adjusted odds ratios.

Results

A total of 200 adult individuals with type 2 DM participated in this study. The mean age of the participants was 63 ([+ or -]11.478). The median duration of diabetes was found to be 8 years (interquartile range = 11.5). Of the participants, 92 (46%) and 108 (54%) were males and females, respectively. This study included urban dwellers 140 (70%) roughly twice larger than rural dwellers. This was in an effort to reflect the estimated proportions of the target population residing in the two different settlements. Majority of the participants 122 (69.3%) were married, whereas 78 (30.7%) of them were either single or widowed. This study population included participants representing various social classes including 29.1% belonging to the upper class, 61.5% belonging to the middle class, and 9.5% belonging to the lower class. The sociodemographic distribution of the study population is summarized in [Table 1].{Table 1}

More than half (118, 59%) of the participants were shown to bear extra burden of other chronic conditions with hypertension (92, 46%) being the most common comorbid condition. Other conditions included but were not limited to, asthma and obesity. Diabetic complications were also seen in some of the participants. The complications included coronary artery disease and retinopathy, which were found to be the most frequent complications among others. Almost a quarter (24.5%) of the participants had one form of complication or the other and in a few cases more than one.

The overall prevalence of depression was 37.5%. This, in the absolute figure, translates to 75 patients with depression. The most frequent level of depression was a mild depression 42 (21%), followed by moderate depression 24 (12%), and then severe depression 9 (4.5%). This is depicted in [Table 2].{Table 2}

While assessing for depressive symptoms, multiple responses were allowed to be made as depression can present with varied symptoms. Depression or hopelessness (81.3%), tiredness (80%), lack of interest or pleasure (78.7%), and sleep disturbances (67.6%) were seen to be among the most common of all the depressive symptoms reported by the total of 75 patients with depression. The least was concentration problem and suicidal thoughts.

Depression was found to be significantly associated with a number of variables. The statistically significantly associated variables include female gender ( P < 0.01), marital status ( P < 0.01), rural residence ( P < 0.05), and unemployment ( P < 0.01). Others were clinical variables including the presence of comorbid condition ( P < 0.05) and diabetic complication ( P < 0.05). On the other hand, age, educational status, socioeconomic status, and type of treatment received were among the variables not found to be significantly associated with depression. This is summarized in [Table 3] and [Table 4].{Table 3}{Table 4}

Discussion

This study aimed at estimating the prevalence of depression among patients with type 2 diabetes in a community-based setting and identifying its correlates.

The overall prevalence of depression was 37.5%. However, this figure is comparable but less than those reported in many hospital-based studies ranging from 21% to 83% with majority having a prevalence of 41% and above.[29],[30],[31],[32],[33],[34],[35] This could be due to selection bias as hospital settings attract patients with active symptomatology who are more likely to present at the health centers.

Depression was significantly more common among women than men. Similar findings were reported in many other studies.[27],[29],[31],[32],[36] A common explanation to this gender difference had been the fact that women play differing social roles as opposed to their male counterparts with attendant disadvantages including dependence and unemployment to mention but few.[36] In the current study, for instance, the majority of the women were unemployed and were homemakers. A significant association was found between depression and unemployment in this study. These findings could contribute to the relatively higher prevalence of depression among women.

Several studies have reported no significant association between age and depression.[8],[29],[30] This is consistent with the findings of the present study. The present study established a significant difference in prevalence of depression among patients with diabetes with one or more complications compared to the patients without diabetic complication. This is in similarity with the current literature.[1],[3],[29],[33],[37],[38],[39],[40],[41],[42],[43] Similarly, the presence of other chronic conditions such as hypertension, obesity, and/or asthma was seen to be associated with increased likelihood of depression in this population. This coincides with many other study findings.[3],[10],[29],[32] Complications such as nephropathy, neuropathy, and diabetic foot among others, and/or comorbid conditions may increase the cost of management or treatment of DM which may, in turn, leads to some level of economic stress and consequently depression. This is more likely to be applicable to those patients of lower socioeconomic status. Moreover, the presence of comorbidity and complications in the patients add to the morbid suffering of the patients and thereby making them vulnerable to depression. Functional limitation resulting from complications such as retinopathy and amputation may as well contribute to the development of depression.[40]

In this study, being unmarried, including singlehood and widowed status, was found to be significantly associated with depression. This is in line with the findings of Zhang et al ., TAaAaAeA@llez-Zenteno and Cardie and Collins et al .[11],[32],[42] It is widely believed that being married could confer individual with better mental health and hence, less psychiatric morbidity.[25],[26] However, Joseph et al . reported no association between the two.[1]

Although a number of studies established a significant association between educational status and depression,[3],[34],[44] it is not the case in the present study as no significant association was observed between the two. However, this finding is consistent with those of other studies.[1],[30],[45],[46],[47]

Depression was seen to be more frequent in rural residents as compared to their urban counterparts in this study. Similar findings were also reported by Raval et al . and Ciechanowski et al .[3],[20]

Individual monthly income was seen to be associated with depression status. Patients with higher monthly earnings showed a lower prevalence of depression and vice versa. This was consistent as reported in other studies.[14],[15],[17],[19] This is likely due to relatively higher level of financial stress in lower earning class compared to their higher-earning counterparts as well as crippled access to better.

There was no significant association between socioeconomic status and depression demonstrated in the present study. This disagrees with the findings from other studies.[1] A possible explanation to this inconsistency may be the fact that, the present study tried to recruit patients from both rural and urban areas and a considerable number of the participants, especially in rural areas accessed primary health care provided through the health centers were health services are provided free of cost. Due to this reason, difference in socioeconomic status may not have contributed to significant differences in depression between the different social classes in this study population.

Depression was found to be significantly more frequent among unemployed participants than in employed ones. This is consistent with the findings of Joseph et al ., Rahman et al ., and Goldney et al . in similar studies conducted in India, Bangladesh, and Australia, respectively.[1],[24],[30] Being unemployed may affect an individual's mental balance in several ways including forcing someone to stay at home with little or no company for most parts of the day and to depend on others for their day-to-day financial expenses including that of diabetes care. Similarly, unemployment may increase the burden of the cost of treatment as suggested by Joseph et al [Table 5] and [Table 6].[1]{Table 5}{Table 6}

Conclusion

The prevalence of depression among patients with diabetes was found to be high with approximately one out of every three patients with diabetes reported to suffer from one of three levels of depression. About 4.5% of the participants were suffering from severe depression which could translate into very large numbers given the huge burden of diabetes in India.

Depression was found to be significantly associated with female gender, residing in rural areas, lower monthly income, the presence of complication and/or comorbidities, and unemployment among others.

Depression could be a barrier in the effective treatment of diabetes as it could lead to nonadherence to treatment by the patients. It is important that patients with diabetes be screened, treated where necessary, for depression and other common mental disorders. This could by far improve treatment adherence and consequently better overall diabetes management.

Limitations

The fact that the current study has a number of strengths does not make it free of limitations. One of the limitations of this study is its proneness to recall bias. This is because data depended solely on the responses of the participants. The study being cross-sectional or vertical cannot give any tangible insight into temporal association or cause-effect relationship. One cannot with full certainty know whether the reported associated factors preceded depression in the patients. In the same vein, this study lacks a comparison group with which to use as a reference in accurately estimating the difference in the prevalence of depression among diabetic and normal individuals.

Have you evaluated the severity of DM? No. Not really. However as per protocol, we excluded bedridden and physically/severely very ill patients who could not be able to respond. Fortunately, we did not encounter such cases in the field.

And did you evaluate anti-DM medication in the present study, as a type of antidiabetic treatment might have different impacts on depression? Yes. Majority of the participants used oral hypoglycemic drug (metformin). Type of treatment was not found to be significantly associated with depression in the present study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1. Joseph N, Unnikrishnan B, Raghavendra Babu YP, Kotian MS, Nelliyanil M. Proportion of depression and its determinants among type 2 diabetes mellitus patients in various tertiary care hospitals in Mangalore city of South India. Indian J Endocrinol Metab 2013;17:681-8.

2. Diabetes. World Health Organization; 2016. Available from: http://www.who.int/mediacentre/factsheets/fs312/en/. [Last cited on 2016 Apr 03].

3. Raval A, Dhanaraj E, Bhansali A, Grover S, Tiwari P. Prevalence and determinants of depression in type 2 diabetes patients in a tertiary care centre. Indian J Med Res 2010;132:195-200.

4. Egede LE, Ellis C. Diabetes and depression: global perspectives. Diabetes Res Clin Pract 2010;87:302-12. doi: 10.1016/j.diabres.2010.01.024. Epub 2010.

5. Thour A, Das S, Sehrawat T, Gupta Y. Depression among patients with diabetes mellitus in North India evaluated using patient health questionnaire-9. Indian J Endocrinol Metab 2015;19:252-5.

6. Das R, Singh O, Thakurta RG, Khandakar MR, Ali SN, Mallick AK, et al. Prevalence of depression in patients with type II diabetes mellitus and its impact on quality of life. Indian J Psychol Med 2013;35:284-9.

7. Mathew CS, Dominic M, Isaac R, Jacob JJ. Prevalence of depression in consecutive patients with type 2 diabetes mellitus of 5-year duration and its impact on glycemic control. Indian J Endocrinol Metab 2012;16:764-8.

8. Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: A meta-analysis. Diabetes Care 2001;24:1069-78.

9. Roy T, Lloyd CE, Parvin M, Mohiuddin KG, Rahman M. Prevalence of co-morbid depression in out-patients with type 2 diabetes mellitus in Bangladesh. BMC Psychiatry 2012;12:123.

10. Balhara YP, Sagar R. Correlates of anxiety and depression among patients with type 2 diabetes mellitus. Indian J Endocrinol Metab 2011;15 Suppl 1:S50-4.

11. Zhang W, Xu H, Zhao S, Yin S, Wang X, Guo J, et al. Prevalence and influencing factors of co-morbid depression in patients with type 2 diabetes mellitus: A general hospital based study. Diabetol Metab Syndr 2015;7:60.

12. Thomas J, Jones G, Scarinci I, Brantley P. A descriptive and comparative study of the prevalence of depressive and anxiety disorders in low-income adults with type 2 diabetes and other chronic illnesses. Diabetes Care 2003;26:2311-7.

13. Marcus M, Yasamy MT, van Ommeren, M, Chisholm D, Saxena S. Depression: A global public health concern. Geneva, Switzerland: WHO Department of Mental Health and Substance Abuse; 2012. Available from: http://www.who.int/mental_health/management/depression/who_paper_depression_wfmh_2012.pdf. [Last cited on 2017 Jul 18].

14. World Health Organization. Depression [Fact Sheet No. 369]; 2015. Available from: http://www.who.int/mediacentre/factsheets/fs369/en/. [Last accessed on 2016 Feb 20].

15. Everson SA, Maty SC, Lynch JW, Kaplan GA. Epidemiologic evidence for the relation between socioeconomic status and depression, obesity, and diabetes. J Psychosom Res 2002;53:891-5.

16. Andreoulakis E, Hyphantis T, Kandylis D, Iacovides A. Depression in diabetes mellitus: A comprehensive review. Hippokratia 2012;16:205-14.

17. Egede LE, Zheng D, Simpson K. Comorbid depression is associated with increased health care use and expenditures in individuals with diabetes. Diabetes Care 2002;25:464-70.

18. Niraula K, Kohrt BA, Flora MS, Thapa N, Mumu SJ, Pathak R, et al. Prevalence of depression and associated risk factors among persons with type-2 diabetes mellitus without a prior psychiatric history: A cross-sectional study in clinical settings in Urban Nepal. BMC Psychiatry 2013;13:309.

19. Kalsekar ID, Madhavan SS, Amonkar MM, Makela EH, Scott VG, Douglas SM, et al. Depression in patients with type 2 diabetes: Impact on adherence to oral hypoglycemic agents. Ann Pharmacother 2006;40:605-11.

20. Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: Impact of depressive symptoms on adherence, function, and costs. Arch Intern Med 2000;160:3278-85.

21. Yesudian CA, Grepstad M, Visintin E, Ferrario A. The economic burden of diabetes in India: A review of the literature. Global Health 2014;10:80.

22. Anjana RM, Pradeepa R, Deepa M, Datta M, Sudha V, Unnikrishnan R, et al. Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and Rural India: Phase I results of the Indian Council of Medical Research-INdia DIABetes (ICMR-INDIAB) study. Diabetologia 2011;54:3022-7.

23. Joshi SR, Saboo B, Vadivale M, Dani SI, Mithal A, Kaul U, et al. Prevalence of diagnosed and undiagnosed diabetes and hypertension in India - Results from the Screening India's Twin Epidemic (SITE) study. Diabetes Technol Ther 2012;14:8-15.

24. Goldney RD, Phillips PJ, Fisher LJ, Wilson DH. Diabetes, depression, and quality of life: A population study. Diabetes Care 2004;27:1066-70.

25. St. John PD, Montgomery PR. Marital status, partner satisfaction, and depressive symptoms in older men and women. Can J Psychiatry 2009;54:487-92.

26. Stutzer A, Bruno SF. Does marriage make people happy, or do happy people get married? J Socio Econ 2006;35:326-47.

27. Siddiqui MA, Khan MF, Carline TE. Gender Differences in Living with Diabetes Mellitus. Materia Socio-Medica, 2013;25:140-2. Available from: http://doi.org/10.5455/msm.2013.25.140-142. [Last cited 2017 Aug 23].

28. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-13.

29. Nasser J, Habib F, Hasan M, Khalil N. Prevalence of depression among people with diabetes attending diabetes clinics at primary health settings. Bahrain Med Bull 2009;31:1-7.

30. Rahman M, Rahman MA, Flora MS, Rakibuz-Zaman M. Depression and associated factors in diabetic patients attending an Urban hospital of Bangladesh. Int J Collab Res Intern Med Public Health 2011;3:65-76.

31. Sotiropoulos A, Papazafiropoulou A, Apostolou O, Kokolaki A, Gikas A, Pappas S. Prevalence of depressive symptoms among non insulin treated Greek type 2 diabetic subjects. BMC Res Notes 2008;1:101.

32. TAaAaAeA@llez-Zenteno JF, Cardiel MH. Risk factors associated with depressi in patients with type 2 diabetes mellitus. Arch Med Res 2002;33:53-60.

33. Perveen S, Otho MS, Siddiqi MN, Hatcher J, Rafique G. Association of depression with newly diagnosed type 2 diabetes among adults aged between 25 to 60 years in Karachi, Pakistan. Diabetol Metab Syndr 2010;2:17.

34. Poongothai S, Anjana RM, Pradeepa R, Ganesan A, Unnikrishnan R, Rema M, et al. Association of depression with complications of type 2 diabetes - The Chennai Urban Rural Epidemiology Study (CURES- 102). J Assoc Physicians India 2011;59:644-8.

35. Singh H, Raju MS, Dubey V, Kurrey R, Bansal S, Malik M. A study of sociodemographic clinical and glycemic control factors associated with co-morbid depression in type 2 diabetes mellitus. Ind Psychiatry J 2014;23:134-42.

36. Roupa Z, Koulouri A, Sotiropoulou P, Makrinika E, Marneras X, Lahana I, et al. Anxiety and depression in patients with type 2 diabetes mellitus, depending on sex and body mass index. Health Sci J 2009;3:32-40.

37. de Groot M, Anderson R, Freedland KE, Clouse RE, Lustman PJ. Association of depression and diabetes complications: A meta-analysis. Psychosom Med 2001;63:619-30.

38. Iversen MM, Tell GS, Espehaug B, Midthjell K, Graue M, Rokne B, et al. Is depression a risk factor for diabetic foot ulcers? 11-years follow-up of the Nord-TrAaAaAeA ndelag Health Study (HUNT). J Diabetes Complicatio 2015;29:20-5.

39. Lloyd CE, Dyer PH, Barnett AH. Prevalence of symptoms of depression and anxiety in a diabetes clinic population. Diabet Med 2000;17:198-202.

40. Pouwer F, Beekman AT, Nijpels G, Dekker JM, Snoek FJ, Kostense PJ, et al. Rates and risks for co-morbid depression in patients with type 2 diabetes mellitus: Results from a community-based study. Diabetologia 2003;46:892-8.

41. Siddiqui S. Depression in type 2 diabetes mellitus - A brief review. Diabetes Metab Syndr 2014;8:62-5.

42. Collins MM, Corcoran P, Perry IJ. Anxiety and depression symptoms in patients with diabetes. Diabet Med 2009;26:153-61.

43. Katon W, Von Korff M, Lin E, Simon G, Ludman E, Bush T, et al. Improving primary care treatment of depression among patients with diabetes mellitus: The design of the pathways study. Gen Hosp Psychiatry 2003;25:158-68.

44. Agbir TM, Audu MD, Adebowale TO, Goar SG. Depression among medical outpatients with diabetes: A cross-sectional study at Jos University Teaching Hospital, Jos, Nigeria. Ann Afr Med 2010;9:5-10.

45. Al-Amer RM, Sobeh MM, Zayed AA, Al-Domi HA. Depression among adults with diabetes in Jordan: Risk factors and relationship to blood sugar control. J Diabetes Complications 2011;25:247-52.

46. Engum A, Mykletun A, Midthjell K, Holen A, Dahl AA. Depression and diabetes: A large population-based study of sociodemographic, lifestyle, and clinical factors associated with depression in type 1 and type 2 diabetes. Diabetes Care 2005;28:1904-9.

47. Fisher L, Chesla CA, Mullan JT, Skaff MM, Kanter RA. Contributors to depression in Latino and European-American patients with type 2 diabetes. Diabetes Care 2001;24:1751-7.
COPYRIGHT 2017 Medknow Publications and Media Pvt. Ltd.
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2017 Gale, Cengage Learning. All rights reserved.

 
Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:Original Article
Author:Aminu, Abdullahi; Chandrasekaran, Varalakshmi; Nair, Sreekumaran
Publication:Journal of Medical Sciences
Article Type:Clinical report
Geographic Code:9INDI
Date:Nov 1, 2017
Words:4516
Previous Article:Effects of a 12-week exercise training on insulin sensitivity, quality of life, and depression status in patients with type 2 diabetes.
Next Article:The effectiveness of the telehomecare for self-care behaviors of patients with diabetes in Taiwan: A consecutive observational study.
Topics:

Terms of use | Privacy policy | Copyright © 2018 Farlex, Inc. | Feedback | For webmasters