Qi et al.

Health and Quality of Life Outcomes (2021) 19:254

[Link]

RESEARCH Open Access

Self‑management behavior and fasting

plasma glucose control in patients with type
2 diabetes mellitus over 60 years old: multiple
effects of social support on quality of life
Xinye Qi1,2, Jiao Xu1,2, Guiying Chen3, Huan Liu1,2, Jingjing Liu1,2, Jiahui Wang1,2, Xin Zhang1,2, Yanhua Hao1,2,
Qunhong Wu1,2* and Mingli Jiao1,2*

Abstract
Objective: Elderly patients with type 2 diabetes mellitus are highly vulnerable due to severe complications. How-
ever, there is a contradiction in the relationship between social support and quality of life, which warrants further
exploration of the internal mechanism. This study assessed the quality of life and its interfering factors in this patient
population.
Methods: In total, 571 patients with type 2 diabetes mellitus over 60 years old were recruited from two community
clinics in Heilongjiang Province, China. We collected data on health status, quality of life, self-management behavior,
fasting plasma glucose (FPG) level, and social support. Structural equation modeling and the bootstrap method were
used to analyze the data.
Results: The average quality of life score was − 29.25 ± 24.41. Poorly scored domains of quality of life were “Psycho-
logical feeling” (− 8.67), “Activity” (− 6.36), and “Emotion” (− 6.12). Of the 571 patients, 65.32% had normal FPG, 9.8%
had high-risk FPG, 15.94% had good self-management behavior, and 22.07% had poor social support. Significant
correlations among social support, self-management behavior, FPG level, and quality of life were noted. A multiple
mediator model revealed that social support influenced quality of life in three ways: (1) directly (c′ = 0.6831); (2) indi-
rectly through self-management behavior (a1*b1 = 0.1773); and (3) indirectly through FPG control (a2*b2 = 0.1929).
Self-management behavior influenced the quality of life directly and indirectly through FPG control.
Conclusion: Improving self-management behavior and monitoring hypoglycemia should become priority targets
for future intervention. Scheduled social support to self-management projects should be put into the standardized
management procedure. Physicians should provide substantial and individualized support to the elderly patients with
type 2 diabetes mellitus regarding medication, blood glucose monitoring, and physical exercise.
Keywords: Elderly, Hypoglycemia, Quality of life, Patient self-management, Social support

Introduction
The incidence of type 2 diabetes mellitus has been over-
growing due to lifestyle changes, urbanization, and aging.
*Correspondence: wuqunhong@[Link]; minglijiao@[Link]
1
Department of Health Policy, Health Management College, Harbin Between 2000 and 2016, there was a 5% increase in pre-
Medical University, 157 Baojian Road, Nangang District, Harbin, mature mortality from diabetes [1]. Type 2 diabetes melli-
Heilongjiang, China
tus accounts for 90% of diabetes cases worldwide [2], and
Full list of author information is available at the end of the article

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Qi et al. Health and Quality of Life Outcomes (2021) 19:254 Page 2 of 15

the global prevalence of adult diabetes has increased dra- psychological well-being of patients with diabetes [25].
matically from 4.7% in 1980 to 9.0% in 2014 [3] and 9.5% Given the complexity of diabetes and its various com-
in 2019 [4]. In China, the percentages of adult patients plications, burdensome self-management activities such
with diabetes has increased from 0.67% in 1979, to 2.7% as daily diet, physical activity, blood glucose monitor-
in 2002, to 11.6% in 2010 [5, 6], to 10.9% in 2013 [7], to ing, and medication adherence, are essential [26] abili-
11.2–12.8% in 2017 [8, 9], and 10.9% in 2019 [10]. Sixty to ties of successful metabolic control to diabetes patients
eighty percent of the increment occurred in developing [27]. In recent years, the Chinese government has paid
countries [11, 12], and 40% of patients with type 2 dia- close attention to the management of diabetes, includ-
betes mellitus worldwide were the elderly [13]. The pro- ing diabetes screening and healthy lifestyle promotion,
portion of elderly patients with type 2 diabetes mellitus but little progress has been achieved. More than a quar-
in China has increased dramatically from 10.2% in 2000 ter of patients with diabetes have poor self-management,
to 13.6% in 2006, 20.4% in 2007, 22.86% in 2010 [5, 6, 14], and only 32–49% of patients have adequately controlled
34.1% in 2017 [15], and 35.5% in 2019 [10], which indi- blood glucose levels [5, 28]. A meta-review of quantita-
cates a severe public health issue. Diabetes with severe tive systematic reviews revealed that self-management
chronic complications imposed a heavy economic burden did not improve other physiological targets of diabetes
on patients and decreased their quality of life [16]. With care rather than glycemic control, which may be caused
a gradually declining physical condition and increasingly by the narrow focus on glycemic control [29]. Thus, the
poor income status, elderly diabetes patients may have long-term balance of blood glucose in patients with dia-
difficulty self-managing their health, thus becoming a betes is clinically emphasized [30], which may lead to
vulnerable population [17]. As important as biomedical misinterpretation and hypoglycemia events during the
markers, the quality of life of elderly patients with type 2 treatment, resulting in the loss of quality of life.
diabetes mellitus should receive more attention and pri- Adequate blood glucose control does not only pre-
oritized care from medical staff and society [18]. vent and reduce the complications of diabetes but also
Social support refers to an individual’s perception of decreases the probability and risk of hypoglycemia.
spiritual or material support from family, friends, and Severe hypoglycemic events can cause unconsciousness,
other important relations. Excellent social support is myocardial ischemia, hemiplegia, arrhythmias, myocar-
the basis for improving the quality of life and played an dial infarction, cardiac failure, or even death [31] and
essential role in relieving mental pressure, eliminating are usually ignored [32]. Bramlage et al. found that the
psychological obstacles, enhancing the effects of therapy, incidence of hypoglycemia increased with age [12.8%
and optimizing the prognosis. Higher social support (e.g., (> 75 years), 9.0% (< 60 years)] [33]. Additionally, a longi-
family, friends, community) is linked to better outcomes tudinal study conducted by Lee et al. inferred that 28.3%
in patients with diabetes [19]. The stress-buffering model of elderly with diabetes who had experienced a severe low
[20] suggests that social support is related to outcomes blood sugar episode (Hypoglycemia) died within three
due to its possible role in regulating stress function, and years of the incident [34]. Elderly patients have difficulty
is a practical psychological resource in reducing stress perceiving hypoglycemia due to functional impairment
and promoting health and well-being [21]. Also, the of the nervous system, which lowers the blood glucose
main-effect model of social support proposes that irre- threshold sensitivity and increases severe hypoglycemia
spective of whether individuals are under stress or not, [35]. Therefore, avoiding hypoglycemia in elderly patients
social support resources encourage health-supporting with type 2 diabetes should be a top priority.
behaviors and directly benefit health outcomes or well- The guideline for the management of diabetes melli-
ness because it boosts overall well-being [22]. tus in elderly in China (2021) recommended the need
Self-management of chronic illness refers to indi- to carry out blood sugar self-monitoring to capture
viduals’ daily activities to keep their disease under con- the occurrence of hypoglycemia events timely [36].
trol and minimize its impact on physical health status. The occasional occurrence of hypoglycemia or abnor-
World Health Organization proposed that anyone with mal blood glucose fluctuation in elderly patients with
a long-term health problem can address a challenging type 2 diabetes mellitus might have substantial, nega-
health-related situation by setting goals or guidelines tive, and even severe clinical effects [37]. Despite the
for self-management [23]. The treatment of diabetes is evolution of diabetes management technologies, blood
complex and multidisciplinary [24]. Its three main goals glucose monitoring still plays an irreplaceable role in
are as follows: (1) to control complications; (2) to pre- diabetes management [38]. Besides, an all-cause mor-
vent hyperglycemia/hypoglycemia; and (3) to maintain tality analysis of the effect of abnormal fasting plasma
a patient’s quality of life. A review claiming successful glucose (FPG) control level on the Acute Myocardial
self-management is a crucial factor in the physical and Infarction revealed that increased and decreased FPG
Qi et al. Health and Quality of Life Outcomes (2021) 19:254 Page 3 of 15

level at admission was a predictor factor to higher mor- self-management behavioral activities and psychosocial
tality rates [39]. In China, the rate of blood glucose self- factors (e.g., social support) affected the patients’ clinical
monitoring is only 21.4%, and hypoglycemia occurs in outcomes.
30% of elderly patients with type 2 diabetes mellitus. So far, most previous studies have focused on all age
Carlene et al. found that each 1-mmol/l decrease of groups and not elderly diabetes patients, and the rela-
FPG was associated with a 21% lower risk of stroke and tionship between social support and quality of life is con-
a 23% lower risk of ischemic heart disease [40]. Fang troversial, including the complex internal mechanism of
et al. carried out continuous glucose monitoring in multiple variables among elderly diabetes. Social sup-
elderly male patients with type 2 diabetes and revealed port (e.g., family, peer support, caretakers) is considered
the significant relationship between FPG and nocturnal as one of the psychosocial factors for self-management
hypoglycemia [41]. Despite a large number of elderly behavior, clinical outcomes [52, 53], and quality of life
population with diabetes, the association of self-man- [51]. The American psychologist Baumeister et al. pro-
agement behavior and glycemic control is controversial posed the mechanism of Ego Depletion addressing
[42, 43], and limited research in China investigating self-control and active activities relay on the limited psy-
psychological and behavioral factors and their collec- chosocial resources [54], which varies from individuals
tive impacts on glycemic control. Therefore, FPG con- [55]. Tang et al. considered social support as a psycho-
trol is an important issue among elderly patients with social factor and indicated that perceived social support
diabetes, and self-management behavior may mediate plays a vital role in the diabetes-specific quality of life and
the relationship between social support and glycemic self-care behavior practices. Social support encompasses
control among type 2 diabetes patients. multiple dimensions that influence specific diabetes
While social support is usually conceptualized and health-related outcomes and behaviors [56]. Therefore,
perceived as a positive resource in chronic disease, it perceived social support may be a remarkable predic-
sometimes turns into a negative experience and may tor of self-care behavior and disease control in diabetes
deteriorate health. Thus, disputes and inconsistent find- patients.
ings relate to the relationship between social support to There is an urgent need to explore the psychological
quality of life of patients with diabetes [44]. According impact of self-management behavior and its impact on
to Bandura’s social theory, factors such as social sup- diabetes-specific quality of life and well-being, and the
port are practical aspects in the incidence of the behavior affection of self-management behavior on hypoglycemia
[45]. Walker et al. explored the relationship of psycho- or blood glucose indicators [46, 57]. Different theoreti-
logical and socioeconomic factors on diabetes self-care, cal perspectives provide clues for identifying the relevant
and considered social support as one psychosocial factor psychosocial determinants of improving the quality of life
associated with self-care behaviors [46]. Previous stud- in elderly diabetes patients (Additional file 1: eFigure1).
ies have documented that high social support can con- According to the chronic care model, mobilize resources
tribute to successful diabetes self-management [49, 50]. (e.g., social support, financial adequacy) provided by
For example, a meta-analysis of 122 studies conducted healthcare providers are needed to improve health out-

[58, 59]. Meanwhile, the AADE7 Self-Care Behaviors ®

by DiMatteo showed that self-management with medical comes and process parameters for elder diabetes patients
regimens in patients with social support increases by 27%
[47]. Poor social support to the elderly may lead to unrec- (AADE7) framework also addressed learning, behavio-
ognized complications, irregular treatment, and poor ral, clinical, and technology use effectively, improving
self-management behavior (e.g., diet, exercise, medica- the quality of life outcomes for diabetes, and achieving
tion, blood glucose monitoring). In turn, poor self-man- behavior change for better self-management behavior

and the AADE7 Self-Care Behaviors ® (AADE7) frame-

agement behavior may cause persistent hyperglycemia/ [60]. Based on the theory of the Chronic Care Model
hypoglycemia or glucose level fluctuation. A systematic
review concluded that higher levels of social support work, we hypothesized that the relationship between
are associated with improved clinical outcomes and the social support and quality of life would be explained, in
adaptation of beneficial lifestyle activities [48]; however, part, by an indirect effect via diabetes self-management
the role of social support in diabetes self-management behavior and FPG control. The hypothesis was put for-
and outcomes is not well understood [49, 50]. Young ward that with control of these indirect paths, the direct
et al. argued that inadequate family and/or social sup- relationship between social support and quality would
port might cause suboptimal self-management behavior, be substantially reduced. Path analysis was conducted
indicating the need to consider monitoring the patients’ to evaluate all indirect pathways from social support to
self-management behaviors and psychosocial factors quality of life by inspecting the direction and magni-
[51]. Thus, we assumed that patient performance of tude of path coefficients. All the one-way paths were
Qi et al. Health and Quality of Life Outcomes (2021) 19:254 Page 4 of 15

considered (Additional file 1: eFigure2). We examined (items 6, 7, 9, and 12); and other important relations
the direct pathway from social support to quality of life (including neighbors and doctors [items 1, 2, 5, and 10]).
(Arrow A). And we also investigated whether this rela- Each item was scored on a 5-point scale ranging from 1
tionship could be explained partially by indirect effects (strongly disagree) to 5 (strongly agree), with the total
through diabetes self-management (Arrows B and C) or score ranging from 12 to 60 [63]. A higher score indicates
FPG level (Arrows D and E). Additionally, a double-medi- better overall social support. In this study, scores >  = 12
ator pathway from social support to quality of life by both but <  = 36 mean a low to moderate perceived social sup-
self-management (primary mediator) and FPG level (sec- port, while scores > 36 but <  = 60 mean a high perceived
ondary mediator; Arrows B, F, and E) was investigated. social support [64, 65].
Previous studies have demonstrated the reliability of
Methods MSPSS, with Cronbach’s α ranging from 0.85 to 0.94
Participants [61, 66, 67]. Test–retest reliability was evaluated over a
Elderly patients with type 2 diabetes mellitus were 2–3-month interval (r = 0.72–0.85) [68]. In this study,
recruited from the Jianhua community, Qiqihar City, Cronbach’s α was 0.855, 0.835, 0.841, and 0.929 for each
China, between June and December 2012. The inclusion subscale and the overall scale, respectively.
criteria were as follows: (a) a diagnosis of type 2 diabe-
tes mellitus made by a physician at least one year before Quality of life
the study; (b) able to self-manage their health and (c) The Chinese version of the Adjusted Diabetes-specific
age > 60 years old. The exclusion criteria were patients Quality of Life Scale (CN-ADDQOL), was used after cul-
with: (a) acute or chronic inflammatory disease; (b) can- tural adaptation and revision of the original scale [69].
cer; and (c) type 1 diabetes mellitus. All participants The scale consists of 19 items and five dimensions: lei-
signed a formal consent form before enrolment into this sure activities (1 to 5), emotional feelings (6 to 9), psy-
study. chological feelings (10 to 14), family living conditions (15
to 17), and diet (18, 19). The participants were requested
Procedures to evaluate their actual situation and the importance of
Survey and standard investigation procedures were car- each item. For example, the question-for item 10 is, “If I
ried out to ensure the uniformity of data collection. would not have diabetes, what would my physical appear-
First, chronic illness records of type 2 diabetes mellitus ance be like?”; options were very good (− 3 points), good
patients were reviewed, and their eligibility was evalu- (− 2 points), satisfactory (− 1 point), the same as now (0
ated. Second, elderly patients with type 2 diabetes mel- points), and worse than now (l point). For the importance
litus were encouraged to participate in the program after of “my physical appearance,” options were very important
explaining the purpose of the study. Third, appointments (3 points), important (2 points), somewhat important (1
were scheduled for the participants to complete the ques- point), and not important at all (0 points). If the partici-
tionnaire. At this point, the researchers elaborated on the pant chose very good and very important, respectively,
purpose of the study and confirmed the patients’ eligibil- the score of this item was − 3*3 = − 9 [70, 71]. The total
ity. Patients who agreed to participate in the study signed score ranged from − 171 to 57, with a higher score indi-
a formal consent form. The following variables were also cating a better quality of life [72, 73]. Cronbach’s α for
collected: age, sex, race, education, income level, mari- the original scale was 0.81–0.941 [69, 74], and the com-
tal status, age at disease onset, duration of diabetes, FPG parative fitting index (CFI) of the structural equation
level, social support, self-management behavior, and model was 0.96 [75]. In this study, Cronbach’s α for CN-
quality of life. ADDQOL was 0.885.

Measures Self‑management behavior

Perceived level of social support A modified version of the Type 2 Diabetes Self-care Scale
The Multidimensional Scale of Perceived Social Sup- (2-DSCS), developed by Toobert et al. and Wang et al. to
port (MSPSS) developed by Zimet et al. [61] was used to measure diabetes self-management behavior [76], was
measure the patients’ perception of the perceived availa- used in this study. The modified scale comprises 26 items
bility and adequacy of emotional and instrumental social encompassing six dimensions: diet (6 items), exercise (4
support (helping to make decisions, taking action, and items), medication (3 items), blood glucose monitoring
so on) [62]. The overall psychometric properties of the (4 items), foot care (5 items), and hypo/hyperglycemia (4
MSPSS are strong. The scale contains 12 items evaluat- items). Items were scored from 1 (never) to 5 (always) [66,
ing three dimensions of support: family (including par- 77]. The total score ranged from 26 to 130, with a higher
ents, children, and spouse [items 3, 4, 8, and 11]); friends score indicating a higher level of self-management. The
Qi et al. Health and Quality of Life Outcomes (2021) 19:254 Page 5 of 15

score index (score index = actual total score/possible on the variance/covariance matrix using maximum likeli-
highest score*100%) and the standard score (standard hood estimation. The hypothesized model was evaluated
score = actual score/possible highest score*100) of each using the following multiple criteria of goodness-of-fit:
dimension were calculated to facilitate the comparison a) χ2/df ≤ 2; b) CFI > 0.95 [78]; c) goodness-of-fit index
of data. A score index or standard score < 60% was con- (GFI) > 0.90; d) normed-fit index (NFI) > 0.90; and e) root
sidered poor, 60–80% was considered medium, and > 80% mean square error of approximation (RMSEA) < 0.06.
was considered good [77]. Cronbach’s α for 2-DSCS was This analytical approach allows for sequential examina-
0.82–0.88, and test–retest reliability was good, at 0.92– tion of two mediators while simultaneously testing the
0.96 [78, 79]. In this study, Cronbach’s α for each of the indirect effects of each mediator independently [82].
six dimensions was 0.919, 0.891, 0.863, 0.836, 0.783, and Variables with non-significant factor loadings were
0.844, respectively; the total scale had good internal con- deleted from the structural equation model. Chi-square
sistency (Cronbach’s α = 0.880). difference tests and the Akaike information criterion
were used to compare the alternate and theoretical mod-
FPG level els [83]. A two-tailed p-value of 0.05 indicates statistical
FPG is an essential indicator of hypoglycemia and hyper- significance. The bootstrap method was used to test the
glycemia. Values > 3.1 mmol/L are considered relatively multiple mediating effects of the hypothesized model [84,
safe (the occurrence of hypoglycemia is improbable). 85]. All specific and conditional indirect effects were sub-
While the control of FPG should not be too strict to avoid jected to follow-up bootstrap analyses [85].
the possibility of a hypoglycemia crisis. When hypoglyce-
mia occurs and remains unnoticed for a certain period, Results
irreversible body injury may occur [80]. Chinese guide- Patient characteristics
lines for diabetes prevention do not recommend strict A total of 571 elderly patients with a mean duration of
blood glucose control in elderly patients with type 2 dia- type 2 diabetes mellitus of 8.23 ± 6.85 years were enrolled
betes mellitus [24]. The Chinese guidelines for Diabetes in this study. Their general characteristics and scores of
Prevention and Control (2017 edition) recommends the the quality of life are shown in Table 1. Among the 571
following FPG levels explicitly: > 5.0 and <  = 7.2 mmol/L patients, 48.3% feared hypoglycemia occurrence; 22.07%
for elderly patients with type 2 diabetes mellitus living had poor-to-moderate social support; 33.62% had poor
with more minor chronic disease, and complete cogni- self-management behavior while 15.94% had good self-
tive and functional status; > 5.0 and <  = 8.3 mmol/L for management, and 30.99% had poorly controlled FPG lev-
elderly patients with type 2 diabetes mellitus living with els (≥ 8.3 mmol/L), 9.98% had high-risk FPG level, while
complicated health status. Besides, an FPG level above 65.32% had successful FPG control (5.0–8.3 mmol/L).
16.7 mmol/L is defined as severe hyperglycemia [24, 36]. Patients with low to moderate social support and poor
On the morning of the scheduled appointment, a blood self-management behavior had the lowest quality of life
sample was obtained from each patient. Twelve-hour scores, followed by those with FPG > 16.7 mmol/L and
FPG levels were assessed according to World Health those who never engaged in physical exercise. The con-
Organization (WHO) standardized fingertip pricked test stituent ratios for each item of the MSPSS and 2-DSCS
procedures using calibrated blood glucose meters and are shown in Additional file 1: eFigure3 and eFigure4,
reagent strips [81]. In this study, an FPG level of 5.0– respectively. The specific scores for each dimension of
8.3 mmol/L was defined as successful FPG control. self-management behavior and social support are shown
in Additional file 1: eTable1. Among the patients with
Data analysis poor self-management behavior, 60.8% had poor exercise
Statistical analyses were performed using SPSS, version management, 50.1% had poor blood glucose monitor-
17.0 (IBM, Armonk, NY, USA) and structural equation ing ability, and 40.8% had poor FPG control over hypo/
modeling (SEM) was conducted using AMOS 17.0 (IBM). hyperglycemia. More than 20% of those patients reported
Missing data were imputed by expectation maximization poor social support. Quality of life, social support, and
(EM) using SPSS missing value analysis. Missing data self-management behavior data are summarized in Addi-
for quality of life, social support, and self-management tional file 1: eTable2.
behavior were 0–4.2, 0–2.5, and 0–3.5%, respectively.
Descriptive statistics were used to summarize patient Preliminary analysis: bivariate analysis
characteristics and measured variables. The results of the bivariate analysis are shown in Addi-
The SEM was deemed suitable for developing a model tional file 1: eTable 2. All correlations were significant.
to explain relationships among the study variables based Tolerance values ranged from 0.693 to 0.804, and vari-
ance inflation factor (VIF) values changed from 1.244
Qi et al. Health and Quality of Life Outcomes (2021) 19:254 Page 6 of 15

Table 1 Descriptive statistics for the total sample and scores Table 1 (continued)
of the quality of life in the elderly patients with type 2 diabetes
Variable n (%) Quality of
mellitus with different demographic characteristics (n = 571) life score
(mean ± SD)
Variable n (%) Quality of
life score
> 1, <  = 3 92 (16.11) − 25.80 ± 21.85
(mean ± SD)
> 3, <  = 5 65 (11.38) − 29.17 ± 21.29
Age, years > 5, <  = 10 149 (26.10) − 32.12 ± 25.42
>  = 60, < 65 147 (25.74) − 33.16 ± 26.11 > 10 170 (29.77) − 32.76 ± 25.88
>  = 65, < 70 129 (22.59) − 28.06 ± 22.84 Mean ± SD 8.23 ± 6.85 − 29.25 ± 24.41
>  = 70, < 75 159 (27.85) − 29.27 ± 25.49 Complications
>  = 75, < 80 89 (15.59) − 26.15 ± 21.47 Yes 472 (82.66) − 31.07 ± 25.47
>  = 80 47 (8.23) − 26.05 ± 19.81 No 99 (17.34) − 20.23 ± 12.35
Sex #
The bold font indicates poor quality of life; based on the score index and the
Men 191 (33.45) − 28.50 ± 23.23 standard score
Women 380 (66.55) − 29.62 ± 24.56 FPG = fasting plasma glucose; PBG = postprandial blood glucose; SD = standard
deviation
Education
< High school 309 (54.12) − 27.60 ± 21.41
High school 207 (36.25) − 32.36 ± 26.27
to 1.443. Further, case analysis revealed no evidence of
> High school 55 (9.63) − 26.74 ± 28.83
outliers. The results of correlation analysis provided the
Marital status
basis for testing the mediation effect.
Single 6 (1.05) − 29.22 ± 18.13
Married 465 (81.44) − 29.70 ± 25.06
Multiple mediation analysis
Divorced 18 (3.15) − 26.89 ± 19.13
Baron and Kenny’s mediation effect testing procedure
Widowed 82 (14.36) − 27.19 ± 19.72
was used to verify the hypothesis model. Model 1 was
Income group
a theoretical model depicting each path between social
< 1000RMB 127(22.2) − 30.33 ± 23.66
support and quality of life with mediators (self-man-
>  = 1000, < 3000RMB 406(71.1) − 28.89 ± 23.57
agement behavior and FPG). Three competitive models
>  = 3000RMB 38(6.7) − 29.73 ± 29.08
(Models 2, 3, and 4) and one alternative model (Model 5)
Frequency of physical exercise were also analyzed.
Never 23 (4.03) − 34.77 ± 37.13 The fit indices of Models 1, 2, 3, 4, and 5 are shown in
Occasionally 44 (7.71) − 32.69 ± 27.12 Table 2. Models 2, 3, 4, 5 were compared against Mod-
Irregular 183 (32.05) − 30.52 ± 23.91 els 1, and the comparisons indicated that Δχ2 was signifi-
Frequently 203 (35.54) − 28.64 ± 25.16 cantly difference of Model 2, 3, 4, 5 with Model 1 (all p
All the time 118 (20.67) − 25.95 ± 19.17 value < 0.001). Additionally, Model 1 showed a better fit
Level of social support than other models and all paths were significant (Addi-
Low to moderate 126 (22.07) − 44.66 ± 26.03 tional file 1: eTable3). Therefore, Model 1 was considered
High 445 (77.93) − 24.88 ± 22.09 the best model to match the observation data (Fig. 1,
Self-management ­behavior# The final mediation model). Paths from social support
Bad 192 (33.62) − 40.71 ± 26.35 to self-management (a1 = 0.329, p < 0.001), FPG level
Medium 288 (50.44) − 25.39 ± 21.72 (a2 = − 0.186, p < 0.001), and quality of life (c′ = 0.496,
Good 91 (15.94) − 16.38 ± 17.31 p < 0.001) were significant. The path coefficients from
FPG, mmol/L self-management activity to FPG level (a3 = − 0.260,
> 3.9, <  = 5.0 57 (9.98) − 24.66 ± 19.69 p < 0.001) and quality of life (b1 = 0.422, p < 0.001) were
> 5.0, <  = 8.3 373 (65.32) − 28.14 ± 24.31 significant. The path coefficient from FPG level to quality
> 8.3, <  = 16.7 137 (23.99) − 33.94 ± 24.40 of life (b2 = 0.697, p < 0.001) was also significant.
> 16.7 4 (0.70) − 36.83 ± 36.51
PBG, mmol/L
≤ 7.8 76 (13.31) − 28.66 ± 25.96 Significance test of the mediation effect
> 7.8, <  = 11.1 213 (37.30) − 25.42 ± 20.59 The estimates and bootstrapped 95% confidence inter-
> 11.1 282 (49.39) − 32.29 ± 25.67 vals (CIs) of the indirect effects were the paths verified
Duration of diabetes, years for mediation (Table 3). The finalized structural model
≤1 95 (16.64) − 21.84 ± 20.76 (Fig. 1) revealed that the paths from social support to
Qi et al. Health and Quality of Life Outcomes (2021) 19:254 Page 7 of 15

Table 2 Comparison of different structural equation models

Model Description χ2 DF GFI NFI CFI IFI RMSEA Δχ2

Model1: Hypothetical mediation model 238.01 85 0.948 0.956 0.971 0.971 0.056
Model2: Deletion of path from SM to QOL 259.05 86 0.943 0.952 0.968 0.968 0.059 21.04***
Model3: Deletion of path from SM to QOL and from SM to FPG 280.17 87 0.939 0.948 0.964 0.964 0.062 42.16***
Model4: Deletion of path from SM to FPG 273.97 86 0.940 0.950 0.965 0.965 0.062 35.96***
Model5: Alternative model: SS, SM, and FPG directly affect QOL 384.57 88 0.914 0.929 0.944 0.945 0.077 146.56***
DF = degrees of freedom; GFI = goodness-of-fit index; NFI = normed-fit index; CFI = comparative fit index; IFI = incremental fit index; RMSEA = root mean square error
of approximation; SM = self-management behavior; SS = social support; QOL = quality of life; FPG = fasting plasma glucose
***p < 0.001

Fig. 1 Multiple mediation models of social support and quality of life. SM_A = diet control management; SM_B = exercise management;
SM_C = medication management; SM_D = blood glucose monitoring management; SM_E = foot care; SM_F = hypoglycemic/hyperglycemia
management; QOL_A = quality of life, activity domain; QOL_B = quality of life, emotion domain; QOL_C = quality of life, psychological feeling
domain; QOL_D = quality of life, family burden domain; QOL_E = quality of life, diet domain; SS_A = family support; SS_B = friends support;
SS_C = support from others

Table 3 Bootstrap test results (indirect effects of X on Y)

Mediation path Effect Boot SE p 95% CI, lower limit 95% CI,
upper
limit

SS → SM → QOL (a1*b1) 0.1773 0.0410 < 0.0001 0.1044 0.2688

SS → SM → FPG → QOL (a1*a3*b2) 0.0770 0.0187 < 0.0001 0.0464 0.1236
SS → FPG → QOL (a2*b2) 0.1929 0.0430 < 0.0001 0.1165 0.2831
SS → QOL (c—c′) 0.4473 0.0555 < 0.0001 0.3425 0.5645
SS → QOL (c’) 0.6831 0.1096 < 0.0001 0.4679 0.8982
c 1.1304
SS was the independent variable (X), SM (M1) and FPG (M2) were the mediators, and QOL (Y) was the outcome. a1*b1 and a2*b2 = indirect effects of X on Y through
M1 and M2; a1*a3*b2 = indirect effect of X on Y through M1 and M2; and c′ = direct effect of X on Y; c = the total effect of X on Y (a1*b1 + a1*a3*b2 + a2*b2 + c′). The
95% CIs for indirect effects were obtained by bootstrapping with 5,000 resamples. 95% CI, lower limit = lower bound of a 95% CI; 95% CI, upper limit = upper bound of
a 95% CI. →  = “affects.”
CI = confidence interval; FPG = fasting plasma glucose; SE = standardized estimate; SM = self-management behavior; SS = social support; QOL = quality of life
Qi et al. Health and Quality of Life Outcomes (2021) 19:254 Page 8 of 15

quality of life through self-management and FPG levels the eventual improvement of the quality of life of elderly
were significant. The results showed that the 95% CIs of diabetes.
the indirect effects differed significantly from zero, and Elderly patients with type 2 diabetes mellitus had a
the mediating effects had statistical significance (p < 0.05). moderate quality of life (− 29.25 ± 24.41), which was
Point estimates for indirect effects and 95% bias-cor- lower than reported by Kan et al. (− 13.57 ± 7.68 to
rected CIs for multiple mediation analyses revealed that − 11.25 ± 7.18) [86]; poorly scored dimensions of qual-
self-management and FPG level were mediators in the ity of life were “Psychological feeling” (− 8.67), “Activ-
path between social support and quality of life. ity (− 6.36),” and “Emotion” (− 6.12). At the same time,
The indirect effect on SS → SM → QOL path (a1*b1) 82.66% of patients reported complications, indicat-
was 0.1773 (95% CI [0.1044, 0.2688], p < 0.0001), tak- ing that the quality of life in elderly patients with type 2
ing up 15.69% of the total effect (a1*b1/c) and 39.64% diabetes mellitus in China is poor [74], which was con-
of the total indirect effect (a1*b1/c–c′). The indirect sistent with the findings of previous studies [24]. Inter-
effect on SS → FPG → QOL path (a2*b2) was 0.1929 estingly, we found that the group with low social support
(95% CI [0.1165, 0.2831], p < 0.0001), taking up 17.07% (score = − 44.66) and that with poor self-management
of the total effect (a2*b2/c) and 43.13% of the total behavior (score = − 40.71) had scores that were 43.66%
indirect effect (a2*b2/c–c′). The indirect effect on and 39.71% lower than the average (score = − 29.25),
SS → SM → FPG → QOL path (a1*a3*b2) was 0.0770 respectively. Mohebi et al. inferred that social support
(95% CI [0.0464, 0.1236], p < 0.0001), taking up 6.81% of significantly reduced with increased age and duration
the total effect (a1*a3*b2/c) and 17.21% of the total indi- of diabetes [26]. With persistent and disease fluctua-
rect effect (a1*a3*b2/c–c′). tions and complications (82.66%), this could lead to poor
In the relationship of social support to quality, the quality of life. Their average scores were notably inferior
direct effect of social support on quality of life was 0.6831 in the psychological, activity, and emotional domains.
(95% CI [0.4679, 0.8982], p < 0.0001); the indirect effect of Patients felt boresome, psychological and emotional
social support on quality of life (controlling for the medi- fatigue, and more easily troublesome to talk to or seek
ators) was 0.4473 (95% CI [0.3425, 0.5645], p < 0.0001), help from their family members or friends, resulting in
which accounted for 39.57% (c–c′/c) of the total effect of their poor use of support. Elderly patients with type 2
social support on quality of life (1.1304). diabetes mellitus may experience inadequate social sup-
port and poor self-management, affecting the quality of
Discussion life. Therefore, it is necessary to focus on the support of
This study underscores the critical roles of social sup- elderly diabetes patients.
port, self-management behaviors, and FPG control in the
quality of life among elderly patients with diabetes. The Mediating effect of self‑management behavior
results revealed that social support directly influences Mediation analysis results indicate that self-management
the quality of life and indirectly predicted quality of life behavior played a mediation role in the influence of social
through self-management behaviors and FPG control support on quality of life (SS → SM → QOL). Al-Dwaikat
level. It is also shown that self-management behaviors, et al. claimed that self-management did not mediate the
directly and indirectly, influenced the horizontal qual- relationships between social support dimensions and
ity of life through the FPG control level. Furthermore, their health outcomes [87], which is not consistent with
a novel chain-mediation model revealed that self-man- the results in this study. The findings in this study sug-
agement behaviors and FPG control level mediated the gested that self-management behaviors were a signifi-
relationship between elderly diabetes patients’ social sup- cant mediator in the association between social support
port and quality of life. This study elucidated a complex and quality of life, which highlight the importance of
internal relationship among social support, FPG level, implementing necessary social support to promote effec-
self-management behavior, and quality of life in elderly tive diabetes self-management behavior to achieve bet-
patients with diabetes and provided a detailed and in- ter health outcomes among elderly patients with type 2
depth explanation of the processes and mechanism of diabetes.
how perceived social support affects quality of life among Diabetes is a disease requiring long-term treatment,
elderly diabetes patients. Based on these findings, gen- requiring patients to control their diet and self-mon-
eral practitioners and physicians highly recommended itor their blood glucose. Therefore, self-management
finding ways to accomplish and facilitate social support of diabetes is of vital importance. Lee et al. used the
intervention protocol involving optimum FPG control theory of planned behavior, confirming that diabetes
by strengthening self-management behavior targeting patients engaged in self-management education incor-
porate behavioral and psychosocial strategies (e.g., social
Qi et al. Health and Quality of Life Outcomes (2021) 19:254 Page 9 of 15

support) with better diabetes outcomes [88]. Stopford nervous system), which contributes to insulin resist-
et al. indicated that good diabetic health may not be sus- ance and poorer diabetes-related health [96]. Perceived
tainable because psychosocial factors hinder the best social support was positively related to the release of
practice of self-management of diabetes [50]. Thus, the oxytocin (a neuropeptide that relaxes individuals) [97].
main support sources are important in the health care A longitudinal study has revealed a positive association
process [89]. In this study, the standard score of self- between baseline overall decline slope of cortisol (a stress
management behavior was 66.32 ± 13.47, lower than Lei hormone) and FPG change, which indicates that corti-
et al. (78.94 ± 17.76 ~ 80.62 ± 17.77) [90]. The proportion sol plays a detrimental role in the contribution to blood
of patients with reasonable diet control, regular exercise, glycemia among diabetes patients [98]. Hooker et al. also
medication management, blood glucose monitoring, foot highlighted that supportive relationships were essen-
care, and hyperglycemia/hypoglycemia management was tial protective factors to decrease high cortisol when the
16.1%, 5.8%, 38.2%, 19.4%, 20.8%, and 31.3%, respectively. individual’s subjective socioeconomic status is low [99].
These results indicated that physical exercise and blood Research suggests that high social support has buffering
glucose monitoring engagement was weak in elderly effects that may be mediated through increased oxytocin
patients with type 2 diabetes mellitus [69]. A systematic concentrations, suggesting that oxytocin may be impli-
review evidenced that family support improved self-man- cated in reducing free cortisol levels that increase during
agement behaviors and health outcomes in uncontrolled stressful events [97]. Therefore, chronic stress (e.g., poor
glycemia diabetes, Which indicating family engagement perceived social support) and endocrine stress response
self-management education helps improve diabetes care (e.g., high cortisol, low oxytocin) are significantly related
activity [91]. It is necessary to highlight that failing to to insulin resistance and diabetes mellitus [100]. Thus,
initiate personal actions and actions involving the fam- the relationship between perceived social support and
ily and the health care system will make the individual FPG control level exists.
attempt to manage the disease the leading risk factor for This study found that 65.32% of elderly diabetes
experimenting with poor quality of life [92]. This study patients’ FPG was under control, which was consist-
suggests that physicians should pay attention to improv- ent with the findings of previous studies [101]. Many
ing the quality of life of elderly diabetes patients and pay patients measure only their blood glucose when they
attention to the self-management behaviors achieve- are not feeling well. However, the recurrent fluctuation
ment of elderly diabetes patients. Practices (eg., educa- and variability of FPG will cause an abnormal increase
tion, information) can promote social support and guide in sympathetic nerve excitability and the increase of all-
elderly diabetes patients to the aspects and standards or cause mortality and cardiovascular disease mortality
methods they need for disease management. [102, 103]. Notably, strict FPG control might be danger-
ous to multi-vulnerable patients due to hypoglycemia,
Mediating effect of FPG control dysfunctional osmolality, and consequences including
The indirect effect of perceived social support on QOL death [104, 105]. Thus, FPG control should be listed as
through FPG control suggesting that FPG control within a priority target for intervention. Additionally, Zhang
the guidance range can play a critical mediation role et al. also evidenced that hypoglycemia influenced
in affecting the relationship between perceived social patients >  = 65 years in diverse treatment pattern models
support and QOL. A systematic review of controlled [106]. A continuous blood monitoring study pointed that
intervention studies argued that prior studies on social 93% of hypoglycemia events were not discovered among
support are not associated with better glycemic control elder patients >  = 75 years [107]. Therefore, given the
[62], consistent with Chew et al., [49]. On the contrary, knowledge of the significant association between FPG
with previous reports [93, 94], this finding indicates that and mortality/complications, special attention should
good perceived social support enables elderly diabe- be paid to fasting glucose monitoring. As Seaquist et al.
tes patients to control FPG at an ideal level, which will suggested, it is necessary to emphasize individual man-
benefit the quality of life of elderly diabetes patients agement (e.g., education, diet, exercise, medicine adjust-
(SS → FPG → QOL). Therefore, psychosocial factors are ment, blood monitoring) to avoid excessive blood glucose
essential for FPG control. control [108].
The main-effect model of social support proposes that Lee et al. addressed the buffer effect of social sup-
social resources have a beneficial effect irrespective of port and revealed that adults with low autonomy sup-
being under stress or not [22]. As a chronic distress expo- port from family health supporters might be at risk for
sure and stress [95], low perceived social support was poor glycemic control [109]. Insufficient social support
associated with physiological alterations (e.g., activate the might, in turn, exert additional impact on FPG, and caus-
hypothalamic–pituitary–adrenal axis and sympathetic ing elderly diabetes patients more difficulty in keeping
Qi et al. Health and Quality of Life Outcomes (2021) 19:254 Page 10 of 15

regular monitoring of blood glucose. However, the long- with type 2 diabetes mellitus. Pilcher et al. defined social
term cost of regularly self-monitoring blood glucose support as a self-control resource [113]. As posited in the
may also be very high for elderly diabetes patients. Yao Ego Depletion theory, poor self-management behavior is
et al. revealed a low frequency of blood glucose moni- due to the lack of self-control resources of patients them-
toring among patients with type 2 diabetes mellitus in selves, which is the root cause of management failure
China and recommending that educational and financial [114]. This study showed that only 15.94% of patients had
support increase blood glucose monitoring frequency high-quality self-management, while 84.06% had moder-
in diabetes patients, especially patients with low socio- ate or poor self-management; moreover, more than 20%
economic status [110]. In this study, 22.2% of partici- of patients reported inadequate social support. The study
pants self-reported income were lower than RMB 1000. found that elderly patients with type 2 diabetes mellitus
Therefore, nurses and physicians should address social could not self-manage their health, including physical
support-based intervention protocols by mobilizing both exercise and diet, which contributed to poor quality of
external support (resources for regular monitoring) and life. Therefore, it is necessary to strengthen the self-man-
subjective support (actions for regular monitoring) to agement behaviors and social support of elderly diabetes
achieve the monitoring target of FPG [111]. patients.
Reviews evidenced that the significant relationship
Chain‑mediating effect of self‑management behaviors of interventions (eg., exercise, diet) reduces poor FPG
and FPG control level and improves the quality of life [115, 116]. In line
A notable finding of this study was the chain-medi- with the Guidance of the International Diabetes Federa-
ating effect of self-management and FPG level in the tion (2014), individual blood sugar monitoring plans are
relationship between social support and quality of life urged to self-management arrangement [117]. Wang
(SS → SM → FPG → QOL). This model illustrated that et al. found that 27.5% reported performing self-moni-
self-management behaviors acted as a mediator between toring of blood glucose with the guidance of the Chinese
social support and FPG control. FPG control mediated Diabetes Society (2007) [118]. A nationally representative
the relationship between self-management behavior and cross-sectional study of individual-level data in 680,102
quality of life, indicating that the indirect effect of self- adults from 55 low-income and middle-income countries
management behavior on quality of life through FPG revealed that only 4.6% of individuals with diabetes self-
was significant. Elderly diabetes patients in the present reported meeting the recommendation, diet counseling
study who reported receiving more excellent support (32.2%), and exercise counseling (28.2%); and fewer than
resources for disease management reported better self- 10% of diabetes in developing countries received com-
management behaviors, which, in turn, affected the qual- prehensive diabetes treatment with guideline [119]. In
ity of life indirectly through the FPG control level. This this study, the top three self-management dimensions
finding demonstrated that self-management is essential with poor score index were exercise (60.8%), blood glu-
to maintain ideal FPG levels, and poor FPG control can cose monitoring (50.1%), and hyperglycemia/hypoglyce-
negatively impact their QOL. This finding was consist- mia management (40.8%). To elderly diabetes patients,
ent with previously reported conclusions [112] and con- more self-management behavior will generate better-
firmed our hypothesis. One possible explanation is that performed, goal-oriented effectiveness of FPG control.
self-monitoring of blood glucose is an integral part of Therefore, health professionals and therapists should
diabetes treatment. Physicians need to formulate a hypo- attempt to use self-care training methods and other
glycemic program for patients and a necessary reference training and therapeutic approaches to improve quality
for patients to observe blood glucose changes (hypergly- of life and self-care and reduce blood sugar, especially in
cemia/hypoglycemia). Poor self-management behavior the elderly with no self-care behaviors [120].
might result in non-timely monitoring of the FPG level, Lack of social support regarding diet, exercise, blood
which, in turn, might reduce the quality of life. monitoring, et al., are significant barriers to self-
Glycemic control is partly dependent upon the regu- management [51]. In this study, the total social sup-
lar completion of several self-management behaviors, port score in elderly patients with type 2 diabetes
including exercise, dietary modification, foot care, self- mellitus was 43.40 ± 8.41; family support scored the high-
monitoring of blood glucose, and medication adherence. est (14.75 ± 2.99) in the three dimensions of perceived
A one-point score increase on the diabetes self-manage- social support, indicating that the main source of support
ment scale leads to a 5% drop in the risk for suboptimal was the patient’s family. According to the weak tie and
glycemic control [43], meaning that self-management strong tie theories [121], supports supplied by family or
plays an essential role in controlling glycemic. And it is friends were regarded as strong ties [89], which is con-
necessary to enhance self-management in elderly patients sistent with this study. Further analysis revealed that only
Qi et al. Health and Quality of Life Outcomes (2021) 19:254 Page 11 of 15

58.4% to 67.1% of patients received specific social sup- sensitive information referring to psychological such as
port. Moreover, in this study, the proportion of patients depression or psychological distress was not considered
who could not obtain sufficient support from family, in the investigation. Thus, further research regarding psy-
friends, and essential others was 21.4%, 24.0%, and 25.4%, chological (e.g., depression or psychological distress) of
respectively; it indicated that community nurses and phy- health need to be addressed. Lastly, this study focused on
sicians might not be providing social support to elderly perceived social support by elderly patients. Actual social
diabetes patients. Given the particularity of medical support was not analyzed. With the development and
service demand of diabetes, despite physicians, nurses, abundance of social support resources, a specific social
communities, etc., were considered as weak ties in pop- support scale for elderly patients with type 2 diabetes
ulations facing a threat [122], and other important sup- mellitus should be developed. In this study, some patients
port subjects (e.g., physicians, nurses) urgently needed to had difficulty in understanding some questions from the
elder diabetes. Mohebi et al. emphasized the importance CN-ADDQOL, for the scale needs further modification.
of patient-family communication [26]. The above study Further studies with larger, more diverse samples and
demonstrated that social support available from doctors, more variables such as actual social support and specific
family, and friends was a significant potential resource self-management are needed.
for diabetes interventions, prioritizing attention. There is
an urgent need to explore how to mobilize more actively,
timely, persistent, and more substantial social support Conclusion
from families and society. In conclusion, this study explored the underlying mecha-

Behaviors ® (AADE7) framework addressed social sup-

The Chronic Care Model and the AADE7 Self-Care nisms between social support and quality of life among
Chinese elderly patients with diabetes, which contributed
port and other factors that facilitate behavior modi- to deepening the theoretical research on the quality of life
fication [46, 123]. And it indicated that health care by extending social support/self-management application
practitioners and future interventions are needed to to the quality of life. Elderly patients with type 2 diabe-
improve individuals’ diabetes management behaviors tes mellitus had poor quality of life, fasting blood glucose
(e.g., nutrition, exercise) [124, 125], with the ultimate goal control, and self-management. Our study identified four
of promoting glycemic control. Therefore, a fundamental critical pathways constituting a complicated, interwoven
translation of a collaborative-feedback partnership (e.g., network contributing to poor quality of life in elderly
family, friends, communities, nurses, and physician) of patients with type 2 diabetes mellitus. It also revealed
social support [126, 127] and regularly assessment [51] the internal mechanism between critical variables of
is critically needed, to comprehensively guidance target social support, self-management behavior, FPG level, and
at the weakest areas of self-management. Theory-guided quality of life. The following vital interconnected paths
practice models [60, 128] practices including medication were identified: SS → SM → QOL, SS → FPG → QOL,
(dosing, frequency, and titration), self-monitoring blood SS → SM → FPG → QOL, and SS → QOL.
glucose; food intake/eating patterns; and regular physical Both social support and self-management behavior
activity provided by the collaborative-feedback partner- should be priority targets for future intervention. Par-
ship are also needed to facilitate self-management behav- ticular attention should be paid to the quality of life and
ior during routine appointments [51, 129]. hypoglycemia in elderly patients with type 2 diabetes
mellitus. These factors should be taken into considera-
Limitations of research tion when developing personalized treatment and stand-
This study had a few limitations. First, as a cross-sec- ardized management procedures.
tional study, the relationships between variables were
only correlative, and causal relationships could not Supplementary Information
The online version contains supplementary material available at [Link]
be established. It’s also a pity that we didn’t measure org/​10.​1186/​s12955-​021-​01881-y.
the glycemia variability. Second, this study was per-
formed in Heilongjiang Province, and the patients were
Additional file 1. Supplementary data of the conceptual and theoretical
recruited from city communities. Therefore, the find- explanation and details of social support, self-management in this study.
ings of this study might differ from those of rural areas.
Third, the MSPSS and 2-DSCS were revised in this study. Acknowledgements
Hence, the reliability of the scales requires further vali- The authors are very grateful to Li Yang for providing the suggestion to draft
dation, despite good internal consistency. Fourth, this the manuscript. We thank all the participating organizations and participants;
without their cooperation and suggestions, the authors won’t be able to
study has focused on the relationship between perceived complete this academic research.
social support and quality of life in elder diabetes, while
Qi et al. Health and Quality of Life Outcomes (2021) 19:254 Page 12 of 15

Authors’ contributions [Internet]. Rochester, NY: Social Science Research Network; 2019 Jun.
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No. 19AZD013), the National Natural Science Foundation of China (Grant Nos. 2021.
71804036, 71333003). 13. Zuo H, Shi Z, Hussain A. Prevalence, trends and risk factors for the
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University, 157 Baojian Road, Nangang District, Harbin, Heilongjiang, China. exger.​2013.​02.​017
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University, 157 Baojian Road, Nangang District, Harbin, Heilongjiang, China. Assessing the impact of diabetes on quality of life: what have the past
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