ReviewSocial support and glycemic control in type 2 diabetes: A systematic review of observational studies
Introduction
Social support is an important explanatory variable with prognostic significance for health outcomes [1], [2], [3]. The self-management of type 2 diabetes mellitus (T2DM) is cornerstone to achieving good glycemic control and reducing the risk of developing microvascular (retinopathy, nephropathy and neuropathy) and macrovascular (cardiovascular and cerebrovascular disease) complications. The management of diabetes necessitates an active role of the patient. This involves lifestyle modifications such as improving diet, increasing physical activity, self monitoring of health status (blood glucose and examination of feet), acquisition of diabetes knowledge as well as adherence to professional advice.
Recently, there has been an increase in research into the supportive role of healthcare professionals, diabetes education and patient participation groups in the management of T2DM; support that can be classified as ‘formal’. The role of more informal interpersonal relations in diabetes care, that is, the presence or support provided by social networks or family members, has been less studied. Social support comprises of structural and functional elements [4]. These elements vary in their characteristics and in their effects on health [5], [6]. The structural aspects of support refer to webs of social relationships and linkages which are best measured through quantitative scoring of the size of networks or existence of support resources (marital status, social networks and community ties). Functional components (social support) are elicited from the structural basis of social relations [4]. The existence and quantity of social relationships do not necessarily provide social support, however they certainly increase the likelihood of receiving help when needed. Social support functions are more consistently associated with health outcomes than structural aspects of support [5]. However, not all support is helpful. The term ‘social support’ carries positive connotations. Social support may often be wanted, but can result in misconstrued social pressure, such as nagging or criticism, or unwanted (negative) outcomes [7].
In health, social support is purported to exert its influence in two main ways: (1) directly: providing necessary support to cope with health problems, adhere to self care-regimen and avoid potentially negative situations (for example, economic problems) or (2) indirectly: acting as a buffer (protection) against the impact of stressful events [8].
In diabetes, both mechanistic routes of action may lead to improved glycemic control. Social support is associated with increased adherence to diabetes self care [9], [10], [11], [12], [13], [14], [15], however there is a lack of consensus as to whether this translates into improved biomedical outcomes. A recent meta analysis of six randomized controlled trials (RCT) of formal supportive interventions (group visits to clinician, telephone and internet support, spouse involvement and family and friend support in interventions) for patients with T2DM (pooled n = 712) tentatively reported favorable results in diabetes self-management and biomedical outcomes [14]. Biomedical outcomes were assessed in four of the trials and improved in two, although effects were seen in different bio-markers. HbA1c and lipids improved following group visits to the clinician [16] and BMI improved following spouse involvement in diabetes weight-management education in women only [17]. Across trials, improvements were also seen in diabetes self care, quality of life and diabetes knowledge [16], [17], [18], [19].
There is some evidence to suggest that formal social support is effective in improving glycemic control. However, RCTs artificially introduce social support. There is rich data available from observational studies which may allude to the, as yet unidentified, active ingredients of support. By using observational data to understand the active ingredient this can then be translated into RCTs. Furthermore with increasing pressure on healthcare systems, formalized support interventions are expensive to provide, rigid and risk not engaging some individuals. On the other hand, informal support, such as that provided by significant others, friends and family, is ‘free’, readily available and specific to the individual. Investigating these constructs in the context of long term conditions such as T2DM may be important in the support of self-management. Evidence from observational studies is the main method by which to study such associations.
The social determinants of biomedical outcomes in T2DM is an understudied area. Due to the epidemic of T2DM and its increasing societal and economic burden, the need to identify non pharmacological, cheap and modifiable targets for intervention is increasing. Our aim is to systematically review published and unpublished literature investigating the association between INFORMAL social support and glycemic control in adults with T2DM.
Section snippets
Methods
Eligible studies were those meeting the following inclusion criteria: observational studies (case control, cohort and cross-sectional studies) of adults (≥18 years of age) with T2DM or non insulin dependent diabetes, that investigated the relationship between social support and glycemic control; studies with a primary or secondary emphasis on the association between social support and glycemic control; studies utilizing measures assessing structural and functional components of (informal)
Results
The search strategy yielded 874 studies. Reference searching, conference proceedings and expert advice identified a further 17 studies and 90 studies were selected for full text review (Fig. 1). Data extraction from the full texts identified 23 studies from the electronic database search, 4 manuscripts from the reference search and 2 abstracts from conference proceedings for inclusion. Reasons for exclusion from the review are shown in Fig. 1.
The studies included in the systematic review are
Discussion
We conducted a systematic review of published and unpublished observational studies examining the association between social support and HbA1c in adults with T2DM. There is some evidence for a beneficial effect of social support (family support and multi dimensional assessments of social support) on glycemic control. There was limited evidence that being married or living with a partner was associated with worse glycemic control. The majority of statistical associations in the review were not
Conclusion
The findings of this systematic review indicate tentative evidence for a potentially important role for informal support sources in glycemic control in individuals with T2DM. There is need for consensus and standardization of social support measures to build an evidence base from the literature.
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