Community Medicine

ME213 – Group 1
Research Team

Advisor: Prof. Hematram Yadav

 GROUP 1 – RESEARCH TEAM
• Goh Kah Man
• Lim Qi Xun
• Mayure Devi A/P Selvathevan
• Ng Chang Ern
• Ng Yen Wing
• Prithvi Aditya Peddinti
• Stephen Gan Chuen Fen
• Tan Chung Hoong
• Vinoshini Devi A/P Kailaivasan
Type 2 Diabetes Mellitus and Sleep
Quality among outpatients in
Health Centres in Seremban.
 CONTENTS
1. Objectives
2. Methodology
3. Results
4. Discussion
5. Conclusion
6. Limitations
7. Acknowledgement
8. References
 1. OBJECTIVES
• To establish an association between sleep quality
and subjects with Type 2 Diabetes Mellitus.

• To compare the sleep quality among diabetic and

non-diabetic subjects.

• To compare the sleep quality in Type 2 Diabetes

Mellitus subjects with different comorbidities.
2. METHODOLOGY
 2. METHODOLOGY (1)

Study Design : Cross-sectional Study

Study Period : 2nd – 3rd July 2015

Study Area : Seremban Health Clinic 1 & 2

 2. METHODOLOGY (2)
• Phase 1: Data Collection
– Sampling:
• Convenience sampling (Response Rate: 90.1%)
• Sample size: 247 subjects
– Sampling frame:
• All patients in outpatient and diabetic clinics in
Seremban Health Clinic 1 & 2
– Study instrument:
• Self-prepared Questionnaire
• Pittsburgh Sleep Quality Index (PSQI)[1]
Pittsburgh Sleep Quality Index (PSQI)[1]
 2. METHODOLOGY (3)
• Phase 2: Data Analysis
– Statistical Package for the Social Sciences (SPSS)
vs. 20
– Chi-square test
– Confidence Level = 95%
– p-value = 0.05
– Odds Ratio
 2. METHODOLOGY (4)
Inclusion Criteria Exclusion Criteria
• ≥ 18 years old • < 18 years old

• Malaysians and • Type 1 Diabetes Mellitus

Non-Malaysians

• Subjects with comorbidities

(hypertension and smoking)
 2. METHODOLOGY (5)
Abbreviation
• DM: Diabetes Mellitus
– T1DM: Type 1 Diabetes Mellitus
– T2DM: Type 2 Diabetes Mellitus

• PSQI: Pittsburgh Sleep Quality Index

3. RESULTS
 3. RESULTS
3.1 Sociodemographics
a. Age
b. Gender
c. Ethnicity
d. Family history of T2DM
e. Education
f. Income
3.2 Sleep Quality in subjects with:
a. DM
b. DM + Hypertension
c. DM + Smoking
d. DM + Smoking + Hypertension
3.3 Reasons Contributing to Poor Sleep Quality
 3. RESULTS
• Total number of subjects = 247

Ethnicity Frequency

Gender Frequency Malay 61 (24.7%)

Male 120 (48.6%) Chinese 98 (39.7%)

Female 127 (51.4%) Indians 78 (31.6%)

Others 10 (4.0%)
 3. RESULTS
• Total number of subjects = 247
Age
Frequency
Group
< 30 25 (10.1%)

30 – 39 17 (6.9%) T2DM
Frequency
Status
40 – 49 30 (12.1%)
+ 124 (50.2%)
50 – 59 65 (26.3%)
– 123 (49.8%)
60 – 69 60 (24.3%)

70 – 79 40 (16.2%)

≥ 80 10 (4.1%)
 Graph 1: Distribution of DM and Non-DM Subjects
according to Age Group and Gender
30
24 (19.4%)
19 (15.3%)
25

20
Frequency

15
Non-diabetic
10 Diabetic

0
M F M F M F M F M F M F M F Gender

< 30 30 - 39 40 - 49 50 - 59 60 - 69 70 - 79 ≥ 80 Age Group

Chi-square value 39.421

Age
P-value < 0.001
 3. RESULTS
3.1 Sociodemographics
a. Age
b. Gender
c. Ethnicity
d. Family history of T2DM
e. Education
f. Income
3.2 Sleep Quality in subjects with:
a. DM
b. DM + Hypertension
c. DM + Smoking
d. DM + Smoking + Hypertension
3.3 Reasons Contributing to Poor Sleep Quality
 Table 1: Frequency of T2DM among
Subjects of Different Ethnicity and Family History Status
Family T2DM
Ethnicity history Total
Yes No
of T2DM
+ 20 20 61
Malay
– 5 16 (24.7%)
+ 32 24 98
Chinese
– 16 26 (39.7%)
+ 32 14 78
Indian
– 13 19 (31.6%)
+ 5 3 10
Other
– 1 1 (4.0%)
Total 124 123 247
Chi-square value 12.809
Family
Chi-square value 4.267 P-value 0.002
Ethnicity History
P-value 0.23 Odds ratio 2.59
 3. RESULTS
3.1 Sociodemographics
a. Age
b. Gender
c. Ethnicity
d. Family history of T2DM
e. Education
f. Income
3.2 Sleep Quality in subjects with:
a. DM
b. DM + Hypertension
c. DM + Smoking
d. DM + Smoking + Hypertension
3.3 Reasons Contributing to Poor Sleep Quality
 Graph 2: Distribution of DM and Non-DM Subjects
100% against Education Level
90%

80%

70%
Percentage (%)

60%

50%

40% Diabetic
30% Non- Diabetic

20%

10%

0%
No education Primary Secondary Tertiary
Education Level

Education Chi-square value 18.028

Level P-value 0.001
 3. RESULTS
3.1 Sociodemographics
a. Age
b. Gender
c. Ethnicity
d. Family history of T2DM
e. Education
f. Income
3.2 Sleep Quality in subjects with:
a. DM
b. DM + Hypertension
c. DM + Smoking
d. DM + Smoking + Hypertension
3.3 Reasons Contributing to Poor Sleep Quality
 Graph 3: Frequency of DM and Non-DM Subjects
against Monthly Income
100

90

80

70

60
Frequency

50
Diabetes
Positive
40
Negative
Non-diabetes
30

20

10

0
< 1000 1000-1999 2000-2999 3000-3999 3999-4000 > 5000
Monthly Income (RM)
 3. RESULTS
3.1 Sociodemographics
a. Age
b. Gender
c. Ethnicity
d. Family history of T2DM
e. Education
f. Income
3.2 Sleep Quality in subjects with:
a. DM
b. DM + Hypertension
c. DM + Smoking
d. DM + Smoking + Hypertension
3.3 Reasons Contributing to Poor Sleep Quality
 3. RESULTS
Sleep Quality
• Global Pittsburgh Sleep Quality Index[1]
Score of ≥ 5
= POOR SLEEP QUALITY

Score of < 5
= GOOD SLEEP QUALITY
 Table 2: Comparison of Sleep Quality among
DM and Non-DM Subjects

Sleep Quality
Diabetic Status Total
Poor Good

95 29
Diabetic 124
(76.6%) (23.4%)
80 43
Non-Diabetic 123
(65.0%) (35.0%)

Total 175 72 247

Chi-square value 4.004

Sleep
P-value < 0.04
Quality
Odds Ratio 1.76
 3. RESULTS
3.1 Sociodemographics
a. Age
b. Gender
c. Ethnicity
d. Family history of T2DM
e. Education
f. Income
3.2 Sleep Quality in subjects with:
a. DM
b. DM + Hypertension
c. DM + Smoking
d. DM + Smoking + Hypertension
3.3 Reasons Contributing to Poor Sleep Quality
 Table 3: Comparison of Sleep Quality among
Subjects with T2DM and Additional Comorbidities

Sleep Quality
Variables Odds Ratio
Poor Good

Diabetic 76.6% 23.4% 1.00

Diabetic
74.2% 25.8% 0.88
+ Hypertensive
Diabetic
90.0% 10.0% 2.75
+ Smoker
Diabetic
+ Hypertensive 100% 0% ∞
+ Smoker
*Odds Ratio for first variable used as reference
 3. RESULTS
3.1 Sociodemographics
a. Age
b. Gender
c. Ethnicity
d. Family history of T2DM
e. Education
f. Income
3.2 Sleep Quality in subjects with:
a. DM
b. DM + Hypertension
c. DM + Smoking
d. DM + Smoking + Hypertension
3.3 Reasons Contributing to Poor Sleep Quality
Pittsburgh Sleep Quality Index (PSQI)[1]
 3.3 REASONS CONTRIBUTING TO
POOR SLEEP QUALITY
3.3a Bathroom usage
3.3b Nocturnal awakening
 3.3a BATHROOM USAGE
Graph 4: Bathroom Usage at night
(>3 per week) over a Month among
Diabetic and Non-Diabetic Subjects
Type 2 Diabetes Mellitus

Yes 71.2%

No 36.9%

0 10 20 30 40 50 60 70 80 90 100
Percentage (%)

Bathroom Chi-square value 13.547

Usage P-value 0.004
 3.3b NOCTURNAL AWAKENING
Graph 5: Nocturnal Awakening
(>3 per week) over a Month among
Diabetic and Non-Diabetic Subjects
Type 2 Diabetes Mellitus

Yes 65.0%

No 35.0%

0 10 20 30 40 50 60 70 80 90 100
Percentage (%)

Nocturnal Chi-square value 17.726

Awakening P-value 0.001
4. DISCUSSION
 4. DISCUSSION (1)
Family History
• Our results:
– There is a 163% higher prevalence of T2DM in
subjects with positive family history of T2DM.

• Similar results in previous study by:

– Annis et al., 1999-2002, in US:
44% higher prevalence of T2DM in subjects with
positive family history of T2DM.[2]
 4. DISCUSSION (2)
Diabetes Mellitus and Sleep Quality
• Our results:
– Poor sleep quality is 76% more prevalent amongst T2DM
subjects.

• Similar results in previous studies by:

– Lou et al., 2008, in China:
Poor sleep quality in T2DM patients with
Odds Ratio = 1.76.[3]

– Shim et al., 2011, in Korea:

Up to 33.3% of patients with DM suffered from
concomitant sleep disorders, as compared with 8.2% of
controls without DM.[4]
 4. DISCUSSION (3)
Diabetes Mellitus and Hypertension
• Our results:
– Subjects with T2DM are 5.2 times more likely to be
hypertensive.

• Similar results in previous study by:

– Abougalambou et al., 2013, in Malaysia:
Study done on diabetic patients in Universiti Sains
Malaysia found that 92.7% of diabetic patients have
hypertension.[5]
 4. DISCUSSION (4)
Diabetes Mellitus and Smoking
• Our results:
– Subjects with T2DM are 0.86 times likely to be
smokers.

• Different results in previous study by:

– Radzevičienė et al., 2009, in Lithuania:
Suggested a 2.41 times increased risk of T2DM,
determined for current smokers vs. non-smokers.[6]
– Schipf et al., 2009, in Pomerania and Germany:
SHIP (17.3% vs 38.0%) and
GNHIES (24.7% vs 32.1%).[7]
 4. DISCUSSION (5)
Table 4: Individual variables associated with DM

Variables Odds Ratio

Sleep Quality 1.76

Hypertension 5.2

Smoking 0.86
5. CONCLUSION
 5. CONCLUSION
5.1 Summary
5.2 Recommendation
5.3 Objectives – Recap
 5.1 SUMMARY (1)
• Prevalence of T2DM increases with age.
• There is no statistical difference in prevalence of
T2DM between male and female subjects.

• There is a strong association between prevalence

of T2DM and a positive family history of T2DM.

• T2DM is most prevalent among populations with

lower education qualification.
 5.1 SUMMARY (2)
• Subjects with T2DM are more likely to have
poor sleep quality.

• Subjects with T2DM are more likely to have

hypertension.
• Subjects with T2DM and other comorbidities
have increased likelihood of having poor sleep
quality.
 5.2 RECOMMENDATION
• Sleep quality should be emphasized as an
important component in the management of
patients with diabetes mellitus.

• Early recognition of poor sleep quality among

patients with T2DM helps to slow down
diabetic complications.[8]
 5.3 OBJECTIVES – RECAP
• To establish an association between sleep quality
and subjects with Type 2 Diabetes Mellitus.

• To compare the sleep quality among diabetic and

non-diabetic subjects.

• To compare the sleep quality in Type 2 Diabetes

Mellitus subjects with different comorbidities.
 CONCLUSION

Poor sleep quality is significantly

more prevalent in subjects with
Type 2 Diabetes Mellitus.
 6. LIMITATIONS
• Interviewer bias
• Interviewee bias (Recall bias)

• Difficulty in obtaining data on other contributing

factors (BMI etc.)

• Non-ideal timing of visit (working hours)

• Results under-represent the entire population of

Malaysia
 7. ACKNOWLEDGEMENT
• Prof. Hematram Yadav
• Dr. Adnan Ananth bin Abdullah
(Director of Seremban Health Clinic 1)
• Director and administrators of
Seremban Health Clinic 2
• Outpatients of Seremban Health Clinic 1 & 2
8. REFERENCES
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 THE END

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