Association of diabetes-related distress, depression, medication adherence, and health-related quality of life with glycated hemoglobin, blood pressure, and lipids in adult patients with type 2 diabetes: a cross-sectional study

Figures & data

Figure 1 Proportion of patients according to the categories of diabetes-related distress, depressive symptoms, medication adherence, and health-related quality of life.

Abbreviations: DDS, Diabetes Distress Scale 17 items (low, no distress, mean DDS score <2; medium, moderate distress, mean DDS score 2–2.9; high, distress worthy of clinical attention, mean DDS score ≥3); PHQ, Patient Health Questionnaire 9 items (depression severity: low, no depression; PHQ score 0–4; medium, mild depression, PHQ score 5–9; high, moderate to severe depression, PHQ score 10–27); MMAS, Morisky Medication Adherence Scale 8 items (low, low adherence, MMAS score <6; medium, medium adherence, MMAS score 6–7; high, high adherence, MMAS score 8); WHOQOL-BREF, World Health Organization Quality of Life-Brief (low, 0–49.99; medium, 50.01–74.99; high, 7–100. WHOQOL-BREF categories are arbitrarily set).

Table 1 Sociodemographic characteristic according to the health clinics

		Total	HbA1c (%)		CBG (mmol/L)		SBP (mmHg)		DBP (mmHg)		LDL-C		HDL-C		TG		Total-C
			Mean (SD)	P	Mean (SD)	P	Mean (SD)	P	Mean (SD)	P	Mean (SD)	P	Mean (SD)	P	Mean (SD)	P	Mean (SD)	P
			8.5 (2.1)		9.4 (3.7)		136.9 (17.7)		79.2 (12.2)		3.0 (1.0)		1.0 (0.3)		1.9 (1.3)		4.8 (1.2)
Gender	Female	368	8.4 (2.0)	0.253	9.4 (3.6)	0.638	137.0 (17.6)	0.902	78.8 (12.0)	0.381	3.0 (1.0)	0.084	1.0 (0.3)	<0.0001	1.8 (1.0)	0.003	4.9 (1.1)	0.119
	Male	329	8.6 (2.3)		9.5 (3.8)		136.8 (17.8)		79.6 (12.3)		2.9 (1.0)		0.9 (0.3)		2.1 (1.6)		4.7 (1.2)
Ethnicity	Malay	367	8.4 (2.2)	0.138	9.5 (3.9)	0.753	138.6 (17.9)	0.020	81.0 (12.8)	<0.0001	3.1 (1.0)	0.136	0.9 (0.3)	<0.0001	2.0 (1.3)	0.214	4.9 (1.2)	0.587
	Chinese	162	8.3 (1.8)		9.3 (3.2)		136.1 (16.0)		75.6 (11.5)		2.9 (0.9)		1.1 (0.4)		1.8 (0.9)		4.8 (1.0)
	Indian	165	8.8 (2.2)		9.6 (3.7)		134.2 (18.5)		78.5 (10.6)		2.9 (1.0)		0.9 (0.3)		2.0 (1.5)		4.8 (1.1)
	Aborigine	3	7.8 (1.6)		8.3 (1.8)		125.7 (7.4)		77.7 (2.1)		1.6 (0.5)		0.7 (0.2)		2.0 (1.0)		3.2 (0.5)
	Others	3	7.1 (0.9)		5.5 (1.1)		130.7 (13.3)		77.0 (14.1)		2.3 (0.6)		0.9 (0.2)		1.4 (0.5)		3.8 (0.6)
Religion	No religion	33	8.7 (1.8)	0.494	8.6 (3.2)	0.457	133.0 (14.6)	0.053	73.5 (9.2)	<0.0001	2.8 (0.8)	0.147	1.2 (0.4)	<0.0001	1.6 (0.7)	0.066	4.7 (0.8)	0.223
	Moslem	375	8.4 (2.2)		9.5 (3.9)		138.6 (17.9)		80.9 (12.9)		3.1 (1.0)		0.9 (0.3)		2.0 (1.3)		4.9 (1.2)
	Buddhist	82	8.3 (2.0)		9.9 (3.5)		137.0 (16.4)		76.4 (12.1)		3.0 (1.0)		1.1 (0.5)		1.9 (1.1)		5.0 (1.0)
	Hindu/Sikh	149	8.7 (2.7)		9.4 (3.6)		133.6 (18.5)		78.1 (10.2)		3.0 (1.1)		0.9 (0.2)		2.1 (1.5)		4.8 (1.2)
	Christian/Catholic	22	8.8 (2.7)		9.1 (3.2)		134.5 (14.7)		80.0 (13.2)		2.5 (0.6)		1.0 (0.3)		1.3 (0.6)		4.3 (0.7)
	Others	37	8.1 (1.7)		8.7 (2.6)		136.5 (16.3)		75.2 (10.4)		2.7 (1.0)		1.1 (0.3)		1.7 (0.7)		4.6 (1.1)
Religiosity	Very agree	294	8.6 (2.2)	0.586	9.5 (3.5)	0.334	137.5 (18.5)	0.744	80.4 (12.9)	0.065	3.1 (1.1)	0.404	1.0 (0.3)	<0.0001	2.0 (1.5)	0.272	4.9 (1.3)	0.542
	Agree	301	8.3 (2.2)		9.5 (3.9)		137.1 (17.6)		78.7 (10.9)		2.9 (0.9)		0.9 (0.3)		2.0 (1.2)		4.7 (1.0)
	Not sure	25	8.6 (1.5)		10.0 (3.0)		133.4 (16.0)		78.0 (11.3)		2.8 (0.9)		1.0 (0.3)		2.1 (1.2)		4.9 (1.0)
	Disagree	73	8.4 (1.8)		8.6 (3.2)		135.4 (15.6)		75.9 (14.0)		3.0 (0.9)		1.2 (0.4)		1.6 (0.6)		4.9 (1.0)
	Very disagree	3	9.5 (0.9)		9.6 (2.0)		133.0 (2.6)		80.0 (6.1)		2.9 (1.7)		1.0 (0.2)		2.0 (1.1)		4.8 (1.4)
Marital status	Married	548	8.6 (2.2)	0.067	9.5 (3.7)	0.123	136.8 (17.7)	0.942	79.9 (12.1)	0.024	3.0 (1.0)	0.642	1.0 (0.3)	0.039	2.0 (1.3)	0.216	4.8 (1.2)	0.152
	Living with a partner	3	8.1 (2.7)		11.0 (4.3)		128.3 (14.6)		73.7 (6.7)		2.5 (0.2)		1.0 (0.1)		1.3 (0.8)		4.9 (1.3)
	Divorced	13	8.9 (2.5)		8.6 (3.1)		138.2 (16.0)		77.8 (9.5)		3.2 (1.3)		1.1 (90.3)		2.7 (2.4)		5.7 (1.7)
	Widowed	98	8.0 (1.9)		9.1 (3.6)		138.0 (18.8)		75.3 (12.3)		3.0 (0.9)		1.0 (0.4)		1.7 (0.9)		4.8 (1.0)
	Separated	8	10.2 (2.4)		11.2 (3.0)		135.5 (23.1)		79.8 (15.0)		3.0 (1.1)		1.0 (0.2)		2.2 (1.4)		5.0 (1.0)
	Single	26	7.9 (1.6)		7.9 (2.6)		137.3 (15.1)		80.5 (12.2)		2.7 (0.8)		1.1 (0.6)		1.9 (1.3)		4.5 (0.8)
Educational level	Primary	259	8.4 (2.2)	0.807	9.4 (3.4)	0.870	137.2 (19.6)	0.673	77.3 (12.4)	0.003	2.9 (1.0)	0.466	1.0 (0.3)	<0.0001	1.8 (1.2)	0.206	4.7 (1.1)	0.181
	Secondary	310	8.6 (2.2)		9.5 (4.0)		136.2 (16.9)		80.2 (11.9)		3.0 (1.0)		1.0 (0.3)		2.0 (1.4)		4.9 (1.2)
	Tertiary	75	8.5 (1.8)		9.3 (3.3)		136.8 (15.8)		82.2 (11.7)		3.1 (1.0)		0.9 (0.20)		2.2 (1.5)		4.9 (1.3)
	Others	45	8.5 (2.0)		9.8 (3.9)		139.5 (14.9)		77.1 (11.9)		2.9 (1.0)		1.2 (0.6)		1.9 (0.7)		4.9 (1.0)
Employment status	Employed	315	8.7 (2.3)	0.166	9.4 (3.7)	0.632	135.3 (17.8)	0.054	80.7 (12.9)	0.004	3.0 (1.1)	0.254	0.9 (90.3)	0.007	2.1 (1.5)	0.050	4.9 (1.3)	0.600
	Unemployed	11	8.7 (1.3)		9.7 (3.3)		130.5 (21.2)		81.5 (15.1)		3.2 (0.6)		0.8 (0.1)		2.3 (1.3)		5.0 (0.8)
	Retired	172	8.3 (1.9)		9.7 (3.7)		137.5 (18.4)		76.6 (10.6)		2.8 (1.0)		1.0 (0.4)		2.0 (1.2)		4.7 (1.1)
	Home manager	199	8.3 (2.1)		9.2 (3.6)		139.3 (16.5)		78.7 (11.8)		3.0 (1.0)		1.0 (0.3)		1.7 (0.9)		4.8 (1.1)
Income (RM)	No income	157	8.3 (2.1)	0.703	9.2 (3.2)	0.742	138.0 (17.9)	0.405	75.3 (11.3)	<0.0001	2.8 (0.9)	0.228	1.0 (0.4)	0.115	1.8 (1.0)	0.412	4.7 (1.1)	0.254
	<1,000	170	8.5 (2.1)		9.5 (4.0)		138.2 (919.4)		79.4 (12.3)		3.0 (1.0)		1.0 (0.3)		2.0 (1.5)		4.8 (1.2)
	1,000–2,999	235	8.5 (2.3)		9.3 (3.5)		135.3 (17.1)		80.2 (12.8)		3.0 (1.0)		0.9 (0.2)		2.0 (1.4)		4.9 (1.3)
	3,000–4,999	87	8.7 (2.1)		9.9 (3.8)		135.5 (14.6)		82.4 (10.4)		3.1 (1.1)		1.0 (0.3)		2.0 (1.3)		4.9 (1.2)
	≥5,000	38	8.3 (1.6)		9.6 (3.3)		136.8 (15.5)		79.6 (11.8)		3.0 (0.8)		1.0 (0.3)		1.6 (0.5)		4.7 (0.8)
Exercise	No	295	8.6 (2.2)	0.443	9.5 (3.9)	0.481	137.7 (17.8)	0.309	79.9 (12.2)	<0.0001	2.9 (1.0)	0.071	0.9 (0.3)	0.080	2.0 (1.3)	0.325	4.8 (1.1)	0.046
	≤3 times/week	232	8.4 (2.2)		9.6 (3.6)		137.2 (17.5)		80.4 (11.8)		3.1 (1.0)		1.0 (0.3)		2.0 (1.4)		5.0 (1.2)
	>3 times/week	169	8.3 (2.0)		9.1 (3.4)		135.1 (17.8)		75.8 (12.1)		2.9 (1.0)		1.0 (0.4)		1.8 (1.0)		4.7 (1.2)
Smoking	Never	532	8.4 (2.1)	0.177	9.4 (3.5)	0.983	137.0 (917.6)	0.808	79.3 (11.9)	0.804	3.0 (1.0)	0.109	1.0 (0.3)	0.163	1.9 (1.3)	0.393	4.9 (1.1)	0.375
	Stopped ≤5 years	22	9.1 (2.8)		9.3 (5.6)		139.8 (23.2)		80.5 (13.2)		2.7 (0.8)		1.0 (0.4)		2.3 (2.7)		5.0 (1.6)
	Stopped >5 years	60	8.1 (2.3)		9.5 (4.0)		136.1 (15.7)		77.9 (12.2)		2.7 (1.2)		0.9 (0.2)		2.1 (1.3)		4.6 (1.4)
	Yes	83	8.7 (2.0)		9.6 (3.7)		135.9 (18.0)		79.0 (13.7)		2.9 (1.0)		1.0 (0.4)		2.1 (1.0)		4.8 (1.1)
Alcohol consumption	Never	607	8.5 (2.2)	0.359	9.5 (3.7)	0.692	137.0 (17.9)	0.615	79.1 (12.0)	0.844	3.0 (1.0)	0.358	1.0 (0.3)	0.106	1.9 (1.3)	0.296	4.8 (1.2)	0.105
	Yes	45	8.4 (1.8)		9.3 (3.7)		134.5 (17.8)		78.7 (13.5)		3.0 (1.1)		1.1 (0.5)		2.2 (1.4)		5.0 (1.1)
	Stopped drinking	46	8.0 (1.8)		9.0 (3.5)		137.8 (15.1)		80.1 (13.9)		2.7 (0.9)		0.9 (0.2)		1.8 (0.8)		4.5 (0.9)
Hypertension	No	149	8.9 (2.1)	0.024	10.1 (4.6)	0.014	130.3 (15.4)	<0.0001	79.2 (13.2)	0.932	3.1 (0.9)	0.112	0.9 (0.3)	0.051	1.8 (1.3)	0.193	4.9 (1.2)	0.383
	Yes	539	8.4 (2.1)		9.3 (3.3)		138.9 (17.8)		79.2 (11.8)		2.9 (1.0)		1.0 (0.3)		2.0 (1.3)		4.8 (1.2)
Dyslipidemia	No	408	8.4 (2.1)	0.465	9.6 (3.9)	0.199	139.3 (18.4)	<0.0001	81.6 (12.6)	<0.0001	3.0 (0.9)	0.277	0.9 (0.3)	<0.0001	2.0 (1.4)	0.544	4.8 (1.2)	0.929
	Yes	265	8.6 (2.2)		9.2 (3.2)		133.5 (16.0)		75.6 (10.5)		2.9 (1.1)		1.0 (0.3)		1.9 (1.2)		4.8 (1.2)
Stroke/TIA	No	681	8.5 (2.1)	0.288	9.4 (3.7)	0.790	136.8 (17.7)	0.239	79.2 (12.2)	0.974	3.0 (1.0)	0.363	1.0 (0.3)	0.386	1.9 (1.3)	0.886	4.8 (1.2)	0.699
	Yes	14	7.8 (2.0)		9.2 (3.0)		142.4 (16.1)		79.1 (11.9)		2.6 (1.2)		0.9 (0.1)		2.0 (0.8)		4.7 (1.3)
Ischemic heart disease	No	662	8.5 (2.2)	0.816	9.4 (3.6)	0.488	136.8 (17.8)	0.430	79.3 (12.2)	0.202	3.0 (1.0)	0.048	1.0 (0.3)	0.509	1.9 (1.3)	0.784	4.8 (1.2)	0.042
	Yes	31	8.4 (1.6)		9.9 (5.1)		139.3 (15.7)		76.5 (11.4)		2.6 (90.9)		0.9 (0.5)		2.0 (0.7)		4.4 (1.1)
Retinopathy	No	680	8.4 (2.1)	0.013	9.4 (3.7)	0.858	136.9 (17.8)	0.986	79.3 (12.2)	0.136	3.0 (1.0)	0.191	1.0 (0.3)	0.015	1.9 (1.3)	0.589	4.8 (1.2)	0.459
	Yes	19	9.7 (2.2)		9.6 (3.5)		136.8 (14.5)		75.1 (10.5)		2.7 (1.1)		1.2 (0.8)		1.8 (0.9)		4.6 (1.2)
Nephropathy	No	670	8.5 (2.2)	0.350	9.4 (3.7)	0.689	136.8 (17.7)	0.807	79.2 (12.2)	0.655	3.0 (1.0)	0.404	1.0 (0.3)	0.566	1.9 (1.3)	0.997	4.8 (1.2)	0.569
	Yes	23	8.9 (1.7)		9.7 (3.5)		137.7 (17.3)		78.0 (9.6)		2.8 (1.1)		1.0 (0.7)		1.9 (1.2)		4.7 (1.1)
Diabetic foot problems	No	672	8.5 (2.1)	0.994	9.5 (3.7)	0.065	137.1 (17.7)	0.071	79.4 (12.3)	0.019	3.0 (1.0)	0.146	1.0 (0.3)	0.047	1.9 (1.2)	0.148	4.8 (1.2)	0.107
	Yes	22	8.5 (2.0)		8.0 (3.1)		130.2 (15.3)		73.2 (7.3)		2.6 (0.9)		0.8 (0.1)		2.4 (2.2)		4.4 (1.1)
OHA	No	61	9.0 (2.5)	0.041	10.1 (4.3)	0.128	144.1 (20.2)	0.001	78.2 (11.4)	0.504	3.2 (1.2)	0.064	0.9 (0.2)	0.257	2.3 (1.4)	0.040	5.2 (1.3)	0.009
	Yes	634	8.4 (2.1)		9.4 (3.6)		136.2 (17.3)		79.3 (12.3)		2.9 (1.0)		1.0 (0.3)		1.9 (1.3)		4.8 (1.2)
Insulin	Nil	423	7.7 (1.7)	<0.0001	8.6 (3.0)	<0.0001	136.1 (16.9)	0.075	80.1 (12.6)	<0.0001	3.0 (0.9)	0.015	1.0 (0.3)	0.433	1.7 (0.9)	<0.0001	4.7 (1.0)	0.004
	1 type	191	9.6 (2.1)		10.5 (3.4)		136.6 (19.0)		77.1 (10.6)		2.9 (1.1)		1.0 (0.4)		2.3 (1.6)		4.9 (1.3)
	2 types	69	10.2 (2.3)		11.7 (5.5)		141.1 (18.5)		77.6 (12.6)		3.3 (1.0)		0.9 (0.2)		2.3 (2.0)		5.3 (1.4)
	≥3 types	11	8.8 (1.7)		10.8 (5.6)		144.8 (10.6)		90.8 (10.1)		3.5 (1.3)		0.8 (0.2)		1.9 (0.8)		5.1 (1.5)
Number of AHA agents	Nil	82	8.7 (2.1)	0.530	10.1 (4.6)	0.038	125.7 (14.0)	<0.0001	78.0 (14.5)	0.192	3.2 (1.0)	0.209	1.0 (0.3)	0.154	1.7 (1.4)	0.057	4.9 (1.1)	0.630
	1 type	206	8.6 (2.1)		9.3 (3.5)		132.8 (14.5)		77.8 (10.6)		3.0 (1.0)		1.0 (0.3)		1.8 (1.0)		4.8 (1.1)
	2 types	204	8.3 (2.1)		8.9 (93.3)		137.3 (16.4)		79.7 (11.7)		2.9 (1.0)		1.0 (0.3)		1.9 (91.1)		4.7 (1.1)
	3 types	144	8.3 (2.3)		9.8 (3.5)		143.8 (18.5)		80.6 (12.8)		2.9 (1.0)		1.0 (0.4)		2.2 (1.7)		4.9 (1.3)
	≥4 types	58	8.5 (2.0)		9.9 (4.0)		148.2 (21.5)		80.2 (13.4)		3.1 (1.1)		0.9 (0.2)		2.1 (91.3)		4.9 (1.1)
Number of LLA agents	Nil	156	8.5 (2.1)	0.773	9.7 (4.1)	0.417	137.4 (17.8)	0.125	81.2 (13.8)	0.051	3.1 (0.8)	0.111	1.0 (0.3)	0.608	1.7 (0.8)	0.035	4.8 (0.9)	0.981
	1 type	534	8.5 (2.1)		9.3 (3.5)		136.6 (17.6)		78.6 (11.7)		2.9 (1.0)		1.0 (90.3)		2.0 (1.4)		4.8 (1.2)
	2 types	4	9.3 (1.0)		11.2 (93.9)		154.3 (15.5)		76.3 (7.9)		2.3 (0.7)		0.8 (0.4)		2.1 (1.3)		4.9 (1.8)
Number of APA agents	Nil	616	8.4 (2.1)	0.656	9.5 (93.7)	0.686	137.1 (17.8)	0.644	79.8 (12.2)	<0.0001	3.0 (1.0)	0.900	1.0 (0.3)	0.560	1.9 (1.3)	0.866	4.9 (1.2)	0.291
	1 type	74	8.7 (2.3)		9.2 (93.6)		135.1 (16.6)		74.1 (10.7)		2.7 (0.9)		1.0 (0.3)		2.0 (1.4)		4.6 (1.2)
	2 types	2	8.0 (0.6)		7.9 (3.2)		140.5 (20.5)		69.0 (1.4)		2.6 (0.5)		0.8 (0.1)		2.0 (0.9)		4.4 (0.8)

Note: P-values were for the independent t-test and analysis of variance. The bold P-values signify those that were below the significant cut-off value of <0.05.

Abbreviations: CBG, casual blood glucose; SBP, systolic blood pressure; DBP, diastolic blood pressure; LDL-C, low-density lipoprotein cholesterol; HDL-C, high-density lipoprotein cholesterol; OHA, oral hypoglycemic agent; AHA, antihypertensive agent; LLA, lipid-lowering agent; APA, antiplatelet agent; SD, standard deviation; TG, triglycerides; TIA, transient ischemic attack.

Table 2 Clinical variables according to the health clinics

	Health clinic, mean (SD) [valid n]				F	P-value
	Total	Seri Kembangan	Dengkil	Salak
Age (years)	56.9 (10.18) [698]	58.8 (10.21) [222]	57.7 (11.08) [123]	55.5 (9.64) [353]	7.81	<0.0001
Diabetes duration (years)	6.5 (5.71) [677]	9.1 (7.05) [220]	6.3 (4.34) [123]	4.9 (4.43) [334]	39.94	<0.0001
HPT duration (years)	6.8 (5.80) [515]	8.4 (6.25) [171]	7.0 (4.59) [108]	5.6 (5.67) [236]	12.60	<0.0001
Dyslipidemia duration (years)	4.2 (3.01) [250]	4.9 (3.33) [124]	3.4 (2.28) [113]	5.1 (3.68) [13]	8.87	<0.0001
HbA1c (%)	8.5 (2.14) [621]	8.5 (2.05) [190]	8.6 (2.21) [121]	8.4 (2.16) [310]	0.13	0.878
CBG (mmol/L)	9.4 (3.66) [687]	9.1 (3.12) [219]	9.3 (3.37) [123]	9.7 (4.05) [345]	2.00	0.137
SBP (mmHg)	136.9 (17.7) [695]	134.5 (15.1) [219]	131.1 (17.0) [123]	140.5 (18.6) [353]	16.71	<0.0001
DBP (mmHg)	79.2 (12.2) [695]	76.6 (11.0) [219]	76.4 (9.3) [123]	81.7 (13.2) [353]	16.57	<0.0001
LDL-C (mmol/L)	3.0 (1.00) [566]	3.0 (1.04) [201]	2.8 (1.11) [121]	3.0 (0.90) [244]	1.70	0.184
HDL-C in mmol/L	1.0 (0.32) [569]	1.2 (0.32) [202]	0.9 (0.32) [122]	0.9 (0.26) [245]	59.24	<0.0001
Triglycerides (mmol/L)	1.9 (1.39) [569]	1.8 (1.07) [201]	2.0 (1.01) [123]	2.0 (1.54) [245]	2.53	0.081
Total cholesterol (mmol/L)	4.8 (1.17) [619]	5.0 (1.09) [203]	4.7 (1.21) [123]	4.8 (1.20) [293]	2.51	0.082
DDS-17	37.1 (15.98) [663]	40.6 (17.34) [206]	40.3 (18.46) [118]	33.8 (13.35) [339]	14.93	<0.0001
Emotional burden	11.9 (5.33) [685]	11.9 (5.65) [219]	12.6 (6.03) [120]	11.6 (4.84) [346]	1.30	0.274
Physician distress	7.9 (4.67) [683]	9.6 (5.67) [216]	9.1 (4.68) [121]	6.4 (3.29) [346]	40.49	<0.0001
Regimen distress	11.3 (5.20) [690]	12.0 (5.36) [218]	12.2 (6.06) [121]	10.6 (4.65) [351]	7.88	<0.0001
Interpersonal distress	6.3 (3.65) [689]	7.2 (4.40) [217]	7.0 (3.95) [121]	5.6 (2.77) [351]	16.15	<0.0001
PHQ-9	4.6 (4.31) [684]	5.5 (4.91) [218]	4.2 (4.01) [121]	4.2 (3.90) [345]	7.69	<0.0001
MMAS-8	5.6 (1.42) [668]	5.6 (1.45) [216]	5.8 (1.31) [121]	5.6 (1.45) [331]	0.76	0.469
WHOQOL-BREF	55.5 (6.31) [694]	54.9 (6.66) [218]	55.0 (6.11) [123]	56.0 (6.12) [353]	2.70	0.068
Physical health	13.1 (1.70) [700]	12.8 (1.80) [224]	13.1 (1.65) [123]	13.3 (1.64) [353]	5.22	0.006
Psychological health	13.3 (1.88) [697]	13.0 (1.91) [221]	12.7 (2.03) [123]	13.6 (1.73) [353]	12.94	<0.0001
Social relationship	14.7 (2.40) [698]	14.7 (2.50) [222]	15.3 (2.45) [123]	14.5 (2.29) [353]	5.82	0.003
Environmental	14.4 (2.08) [697]	14.3 (2.47) [221]	13.9 (1.89) [123]	14.7 (1.83) [353]	8.19	<0.0001

Note: P-values are for the analysis of variance.

Abbreviations: DDS-17, Diabetes Distress Scale 17 items; PHQ-9, Patient Health Questionnaire 9 items; MMAS-8, 8-item Morisky Medication Adherence Scale; WHOQOL-BREF, World Health Organization Quality of Life-Brief 26 items; CBG, casual blood glucose; SBP, systolic blood pressure; DBP, diastolic blood pressure; LDL-C, low-density lipoprotein cholesterol; HDL-C, high-density lipoprotein cholesterol; HPT, hypertension; SD, standard deviation; HbA_1c, glycated hemoglobin.

Table 3 Determinants of disease biomarkers

Model	Crude B (95.0% CI)	Adjusted B (95.0% CI)	Adjusted B (95.0% CI)	Significance	Adjusted R^2
HbA1c		n=441*	n=441**
Intercept	–	–	9.77 (8.488, 11.053)	<0.0001	0.308
MMAS-8	−0.21 (−0.329, −0.085)	−0.10 (−0.224, 0.018)	−0.11 (−0.224, 0.014)	0.082
CBG		n=613†	n=613^††
Intercept	–	–	14.83 (11.526, 18.128)	<0.0001	0.110
PHQ-9	0.07 (0.010, 0.139)	0.01 (−0.067, 0.077)	0.01 (−0.068, 0.077)	0.900
MMAS-8	−0.22 (−0.419, −0.029)	−0.11 (−0.311, 0.085)	−0.10 (−0.295, 0.100)	0.332
WHOQoL-BREF	−0.06 (−0.107, −0.021)	−0.05 (−0.103, −0.005)	−0.06 (−0.105, −0.007)	0.024
SBP		n=623‡	n=623^‡‡
Intercept	–	–	146.97 (136.544, 157.397)	<0.0001	0.166
DDS-17	−0.17 (−0.255, −0.089)	−0.09 (−0.174, −0.008)	−0.08 (−0.161, 0.005)	0.066
LDL-C		n=401§	n=401^§§
Intercept	–	–	3.87 (3.018, 4.719)	<0.0001	0.052
PHQ-9	0.03 (0.007, 0.044)	0.02 (0.000, 0.044)	0.02 (−0.001, 0.043)	0.061
MMAS-8	−0.07 (−0.133, −0.015)	−0.04 (−0.110, 0.030)	−0.03 (−0.103, 0.037)	0.356
Triglycerides		n=551‖	n=551^‖‖
Intercept	–	–	2.74 (1.809, 3.660)	<0.0001	0.073
Physician distress	−0.03 (−0.049, −0.003)	−0.02 (−0.046, −0.001)	−0.02 (−0.046, 0.002)	0.072
Total cholesterol		n=569¶	n=569^¶¶
Intercept	–	–	7.06 (5.816, 8.311)	<0.0001	0.082
PHQ-9	0.04 (0.014, 0.056)	0.02 (−0.006, 0.043)	0.01 (−0.011, 0.039)	0.265
MMAS-8	−0.11 (−0.177, −0.046)	−0.07 (−0.139, 0.001)	−0.06 (−0.131, 0.009)	0.086
WHOQoL-BREF	−0.02 (−0.030, −0.001)	−0.02 (−0.033, 0.001)	−0.02 (−0.032, 0.001)	0.070

Notes: Variables in the model include:

* age, diabetes duration, HPT duration, retinopathy, OHA, insulin;

† diabetes duration, HPT, insulin, AHA agents;

‡ age, ethnic, HPT, dyslipidemia, OHA, AHA agents

§ age, diabetes duration, HPT duration, ischemic heart disease, insulin;

‖ age, gender, employment, OHA, insulin, LLA;

¶ age, OHA, insulin, exercise, ischemic heart disease;

^{**, ††, ‡‡, §§, ‖‖ and ¶¶}In these models, health clinic is added.

Abbreviations: DDS-17, 17-item Diabetes Distress Scale; PHQ-9, 9-item Patient Health Questionnaire; MMAS-8, 8-item Morisky Medication Adherence Scale; WHOQoL-BREF, World Health Organization Quality of Life-Brief 26 items; HPT, hypertension; OHA, oral hypoglycemic agent; AHA, antihypertensive agent; LLA, lipid-lowering agent; APA, anti-platelet agent; CI, confidence interval; HbA_1c, glycated hemoglobin.