title: The association between patient-reported self-management behavior, intermediate clinical outcomes, and mortality in patients with type 2 diabetes: results from the KORA-A study.
abstract: OBJECTIVE
  Little is known about the impact of diabetes self-management behavior (SMB) on long-term outcomes. We aimed to examine the association among patient-reported SMB, intermediate clinical outcomes, and mortality in patients with type 2 diabetes.
  
  
  METHODS
  Data were collected from 340 patients with type 2 diabetes of the KORA-A study (1997/1998) who were recruited from two previous population-based surveys (n = 161) and a myocardial infarction registry (n = 179) in southern Germany. Based on previous methodological work, a high level of SMB was defined as being compliant with at least four of six different self-care dimensions, comprising physical exercise, foot care, blood glucose self-monitoring, weight monitoring, having a diet plan, and keeping a diabetes diary. The vital status of the participants was observed until 2009. Multivariable linear, logistic, and Cox regression models were applied to assess the association with intermediate clinical outcomes at baseline and to predict mortality over the follow-up period, adjusted for sociodemographic, behavioral, and disease-related factors.
  
  
  RESULTS
  In the cross-sectional perspective, a high level of SMB was weakly associated with a lower glycated hemoglobin A1c level (-0.44% [-4.8 mmol/mol] [95% CI -0.88 to 0.00]), but not with low-density lipoprotein cholesterol, systolic blood pressure, or the presence of microalbuminuria, peripheral arterial disease, or polyneuropathy. During a mean follow-up time of 11.6 years, 189 patients died. SMB was a preventive factor for all-cause (hazard ratio 0.61 [95% CI 0.40-0.91]) and cardiovascular mortality (0.65 [95% CI 0.41-1.03]).
  
  
  CONCLUSIONS
  Although measuring SMB is difficult and the used operationalization might be limited, our results give some indication that a high level of SMB is associated with prolonged life expectancy in patients with type 2 diabetes and highlight the potential impact of the patients' active contribution on the long-term trajectory of the disease. We assume that the used proxy for SMB is associated with unmeasured, but important, dimensions of health behavior.
authors.affiliation: Helmholtz Zentrum München, German Research Center for Environmental Health, Institute of Health Economics and Health Care Management, Neuherberg, GermanyGerman Center for Diabetes Research (DZD), Germany michael.laxy@helmholtz-muenchen.de.
authors.forename: Michael
authors.initials: M
authors.lastname: Laxy
authors.affiliation: Helmholtz Zentrum München, German Research Center for Environmental Health, Institute of Health Economics and Health Care Management, Neuherberg, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Mielck
authors.affiliation: Helmholtz Zentrum München, German Research Center for Environmental Health, Institute of Health Economics and Health Care Management, Neuherberg, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Hunger
authors.affiliation: Helmholtz Zentrum München, German Research Center for Environmental Health, Institute of Health Economics and Health Care Management, Neuherberg, Germany.
authors.forename: Michaela
authors.initials: M
authors.lastname: Schunk
authors.affiliation: Helmholtz Zentrum München, German Research Center for Environmental Health, Institute of Epidemiology II, Neuherberg, Germany.
authors.forename: Christa
authors.initials: C
authors.lastname: Meisinger
authors.affiliation: Helmholtz Zentrum München, German Research Center for Environmental Health, Institute of Epidemiology II, Neuherberg, Germany.
authors.forename: Ina-Maria
authors.initials: IM
authors.lastname: Rückert
authors.affiliation: German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University, Institute of Biometrics and Epidemiology, Düsseldorf, Germany.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Rathmann
authors.affiliation: Helmholtz Zentrum München, German Research Center for Environmental Health, Institute of Health Economics and Health Care Management, Neuherberg, GermanyGerman Center for Diabetes Research (DZD), Germany.
authors.forename: Rolf
authors.initials: R
authors.lastname: Holle
mesh_terms: D000328:Adult; D000368:Aged; D001786:Blood Glucose / Q000032:analysis*; D015190:Blood Glucose Self-Monitoring / Q000706:statistics & numerical data*; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000401:mortality; D003430:Cross-Sectional Studies; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000523:psychology / Q000628:therapy*; D019468:Disease Management; D005260:Female; D005500:Follow-Up Studies; D005858:Germany / Q000453:epidemiology; D006442:Glycated Hemoglobin / Q000032:analysis; D015438:Health Behavior; D006801:Humans; D015994:Incidence; D008017:Life Expectancy; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010349:Patient Compliance; D019984:Quality Indicators, Health Care; D012648:Self Care / Q000379:methods / Q000523:psychology*; D057566:Self Report; D015996:Survival Rate
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin