Comparative Study of Quality of Life, Activities of Daily Living, and Sexual Satisfaction in Type 2 Diabetic Patients Using Insulin and Oral Medications: A Prospective Cohort Study

Comparative Study of Quality of Life, Activities of Daily Living, and Sexual Satisfaction in Type 2 Diabetic Patients Using Insulin and Oral Medications: A Prospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparative Study of Quality of Life, Activities of Daily Living, and Sexual Satisfaction in Type 2 Diabetic Patients Using Insulin and Oral Medications: A Prospective Cohort Study Arefe Fattah, Eman Al-Awabdeh, Richard Mottershead, Mohaddeseh Hosseinzadeh, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7006272/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 15 You are reading this latest preprint version Abstract Background This study aimed to determine and compare quality of life, level of daily living activities, and sexual satisfaction in two groups: insulin users and oral medications. Materials & Methods This prospective cohort study was conducted on patients attending the diabetes clinics at Baghdad Hospital in Iraq between 2021–2024. The number of patients in the study was 130 participants including two groups (using insulin vs oral medication). At First, after one year, and after three years, all participants completed four questionnaires: Quality of Life, Sexual Satisfaction, and Activities of Daily Living. The collected data were analyzed using SPSS software with descriptive and analytical statistical methods. Results According to the results, activity daily living, quality of life and sexual satisfaction in both groups decreased over time from first to the third time, and this difference was significant in the all three variables except in the oral medications group quality of life was not significant (p = 0.68), also in the insulin group sexual satisfaction was not significant (p = 0.72). In the between-group comparison showed quality of life just three years later difference was significant (0.017). In the Activities of daily living variable, no significant difference was observed between the two groups at any time. However, in the sexual satisfaction the insulin group's score was higher at one year and three years later, and the difference was significant at both mentioned times (0.049, 0.054 respectively). Discussion This study found that in both groups’ daily activities, quality of life, and sexual satisfaction reduced over time. Diabetes Quality of Life Daily Activity Living Sexual Satisfaction Insulin Oral Medications Introduction Diabetes is a common chronic disease in the world that affects all races differently (1). The prevalence and incidence of the disease are increasing in many societies, especially in developing countries (2). According to World Health Statistics, the prevalence of diabetes in adults in the world is 8.8%, of which about 90% is type 2 diabetes. In this disease, although insulin is secreted in sufficient quantities, cell receptors become resistant to it, and its function in regulating blood sugar levels is impaired (3). The cause of type 2 diabetes is usually a combination of genetic and environmental factors. The risk of developing this disease increases when a person has an unhealthy lifestyle, such as excessive calorie consumption, lack of exercise or obesity (4). These factors can increase the resistance of cells to insulin and ultimately lead to type 2 diabetes (5). Type 2 diabetes can be accompanied by common symptoms of diabetes, such as frequent thirst and frequent drinking (polydipsia), frequent urination (polyuria), or it can be completely asymptomatic (3). For this reason, it is necessary to examine and screen people who are asymptomatic but have risk factors for diabetes (6). Although drug treatments play a key role in controlling this disease, diabetes treatment is generally a set of measures that together will have a desirable effect and is not limited to drug therapy (7). Although type 2 diabetes has no definitive cure; however, the correct and regular use of medications prescribed by the treating physician, as well as lifestyle modifications, greatly helps to effectively control symptoms and improve and maintain the quality of life of people with diabetes (8). Type 2 diabetes, as a chronic disease, requires continuous management. Managing diabetes by regulating blood sugar and preventing its dangerous complications can significantly improve a person's quality of life (9). Furthermore, changes in diet, weight control, and regular physical activity can help reduce insulin resistance and increase the body's sensitivity to this hormone (10). Uncontrolled diabetes leads to blood sugar levels that are higher than normal. High blood sugar levels over time and after a few years can cause problems in our bodies and damage the eyes, kidneys, nerves, skin, heart, and blood vessels (4). Due to its long-term process and long-term complications on various body systems, type 2 diabetes causes disruption in various aspects of a person's life (6). Type 2 diabetic patients experience many problems that disrupt their quality of life. A chronic disease such as type 2 diabetes affects the lives of all family members and may cause problems such as anxiety and stress, depression, anger and financial problems for them (11). Type 2 diabetes, as a biological, psychological and social problem, affects all aspects of a person's life, including their quality of life (12). Another variable that is affected in chronic diseases such as type 2 diabetes is the individual's activities of daily living index. Activities of daily living include tasks that are necessary to complete daily work (2). The inability to perform these tasks creates problems for the individual in daily life. Activities of daily living allow the patients to maintain their independence (1). The results of the study by Daneshvar et al. showed that diabetic patients had significantly lower scores in the areas of physical functioning, role limitations due to physical problems, role limitations due to emotional problems, vitality, social functioning, physical pain, and general health compared to non-diabetic individuals (13). When diabetes is left uncontrolled, the effects of the disease on the reproductive and nervous systems become fully apparent. Diabetes can damage nerves by increasing blood sugar levels, which can affect sexual function (9). Diabetic neuropathy is a type of nerve damage associated with diabetes that is a factor in sexual problems. Sexual dysfunction in individuals with diabetes encompasses any disruption or issue in the sexual response cycle, which may include decreased libido, erectile dysfunction, pain during intercourse, difficulty achieving orgasm, or infections (14). The most important and common treatments used for diabetes are oral medications and the use of various insulins. The use of oral medications and insulin each has advantages and disadvantages (15). The use of these treatments may affect the quality of life, the level of daily activities, and sexual dysfunction (7). Therefore, given the high prevalence of diabetes and that there is also no study in this field that has fully examined these variables, and considering the different culture and context of Iraq, this study was conducted with the general aim of determining a comparative study of quality of life, daily activities, and sexual satisfaction in type 2 diabetic patients treated with insulin and oral medications as a prospective cohort study. Materials and Methods Study setting and participants The present study is a prospective cohort study conducted on 230 patients with diabetes who were referred to the Diabetes Clinic at Baghdad Hospital in 2021. The study period lasted from January 2021 to December 2024. The study units were selected on a convenience basis and then randomly assigned to two intervention and control groups using SPSS software. The inclusion criteria for patients included all patients diagnosed with diabetes by a specialist physician, complete and stable consciousness, not using other medications or supplements, use of oral antidiabetic medication or use of insulin, no chronic disease or other underlying condition, and informed consent to participate in the study. The exclusion criteria included the patient's worsening condition and the development of emergency conditions, unwillingness to continue the study for any reason, and the patient's death. Sample size The sample size was calculated based on the formula \(\:\frac{\left({{\mathbf{Z}}_{1-\frac{\varvec{\alpha\:}}{2}}+{\mathbf{Z}}_{1-\varvec{\beta\:}})}^{2}\right({\varvec{S}}_{1}^{2}+{\varvec{S}}_{2}^{2})}{{\left(\mathbf{d}\right)}^{2}}\) and the study by Alcubierre et al. (2014) (16) with a confidence level of 95% and a test power of 80%. Considering the probability of sample attrition at 10%, the sample size was 140 (intervention group: 70, control group: 70). However, ultimately, 130 patients completed the study and 10 patients were excluded from the study, of whom 5 people had emergency conditions or died, 2 people were unwilling to continue the study, and 3 people had emigrated. Finally, 64 patients in the insulin group and 66 patients in the oral medication group completed the study. Data Collection and study instruments Data-gathering instruments included personal information questionnaires, the World Health Organization quality of life questionnaire, the sexual satisfaction questionnaire, and the daily activity living questionnaire. The World Health Organization Quality of Life Short Form (WHOQOL-BREF) is a 26-item questionnaire that measures an individual's overall and general quality of life. This scale was developed in 1996 by a group of World Health Organization experts by modifying the items of the 100-item form of this questionnaire. This questionnaire has 4 subscales and an overall score. These subscales are physical health, mental health, social relationships, environmental health, and an overall score. The minimum and maximum scores are between 0 and 100. A higher score indicates a higher quality of life. The results of the study by Rasafiani et al. (2020) (17) indicate that the World Health Organization Quality of Life Questionnaire has acceptable validity and reliability in the studied sample. Its validity was obtained through facial and content validity with a content validity index (CVI) of 0.85, and its reliability was confirmed by the test-retest method with a coefficient of 0.79. The Activities of Daily Living (ADL) scale was completed to assess the level of ability to perform daily activities for the subjects. This tool has 10 questions, and the 0-1-2 method has been proposed for scoring it, which determines the status of independence or dependence in performing daily activities on a scale of 0–20, such that a higher score indicates less dependence in performing daily activities. A score of 20 is interpreted as complete independence, a score between 13 and 19 as partial dependence, a score of 9–12 as semi-independent, and a score of 0–8 as complete dependence. In the study by Taheri Tanjani et al. (2016), the content validity index of this questionnaire was 0.82, and the Cronbach's alpha coefficient of this questionnaire was 0.75 (18). The second questionnaire was the Sexual Satisfaction Questionnaire. This questionnaire was developed by Larson in 1998. The Larson Sexual Satisfaction Questionnaire assesses the level of sexual satisfaction in couples and relationships. This questionnaire has 25 questions and is in the form of 5 options and is based on a Likert scale from 1 to 5, where the option "never" receives a score of 1, the option "rarely" receives a score of 2, "sometimes" a score of 3, "most of the time" a score of 4, and "always" a score of 5. Questions 4-5-6-7-8-9-11-14-15-18-20-24 and 25 are scored in reverse. Based on this questionnaire, the scores are generally between 25 and 125, and sexual satisfaction is classified into levels of sexual dissatisfaction: (score less than 50), low satisfaction (score between 51 and 75), moderate satisfaction (score between 76 and 100), and high satisfaction (score above 101). After obtaining permission and introducing the researcher to the research environment, the participants first completed an informed consent form, and the objectives of the study were fully explained. The researcher helped complete the questionnaires in 15 to 30 minutes. The patients' characteristics were recorded in the hospital along with their medical records. After one year and three years after the first assessment, when the patients were referred to the hospital's diabetes clinic for follow-up, they completed the relevant questionnaires again. Data analysis After collecting and entering the data into the computer, data analysis was performed using SPSS software, considering a confidence level of 95% and a significance level of 0.05. Descriptive statistics and indices of mean and standard deviation and percentage and frequency distribution were used to describe demographic characteristics and variables. The Kolmogorov-Smirnov test was also used to determine the normality of the data. Repeated analysis of variance tests was used for intragroup comparison of each variable, and independent t-tests were also used for comparison between variables of groups at different times. Chi-square, ANOVA, and Mann-Whitney tests were also used to examine differences in demographic variables. Ethical consideration The study was approved by ethics committees of Council of the Nursing College/University of Baghdad. Official permissions were gained from relevant authorities before collecting the study data. Other ethical considerations in this research include obtaining informed written consent from patients to participate in the research, maintaining the respect and dignity of research participants, and upholding the independence of research participants by assuring them of their freedom to participate, not participate, or withdraw from the research. The same conditions were considered for all participants in the research. All participants were assured that their information would remain confidential. The principles of the Declaration of Helsinki have been followed throughout the research. Results Finally, 130 patients completed the study: 64 patients were in the insulin group, and 66 patients were in the oral medication group. Mean age (standard deviation) of patients was 55.22 ± 6.85; 51.4% (64) were male and 49.6% (66) were female. The majority of participants (65.38%) were married. In terms of residence, 26.93% lived in villages and 73.07% lived in cities. Regarding education level, 43 patients (33.07%) reported they have a diploma degree, and 52 patients (40%) were under the diploma level. Totally, there was no significant difference between the groups in the demographic variables in the intergroup comparison except for the level of education variable, which had a p-value of 0.024, meaning that the number of people with a college education was higher than those with a high school diploma (Table 1 ). Table 1 Demographic characteristics of the study participants Variable Oral medications group Insulin group Overall Results of the intergroup comparison test Mean ± standard deviation Mean ± standard deviation Mean ± standard deviation Age 6.9 ± 54.56 7.53 ± 56.3 6.85 ± 55.22 P = 0.86 Duration of diabetic suffering 11.85 ± 2.8 9.17 ± 3.4 10.65 ± 2.74 P = 0.15 Variable Number (percentage) Number (percentage) Number (percentage) Results of the intergroup comparison test Sex Male 30 (45.46) 34 (53.12) 64 )51.4( P = 0.34 Female 36 (54.54) 30 (46.88) 66 (49.6) Marital status Married 48 (72.72) 37 (57.82) 85 (65.38) P = 0.56 Single 18 (27.27) 27 (42.18) 45 (34.62) Level of education Under diploma 38 (57.57) 14 (21.87) 52 (40) P = 0.024 diploma 22 (33.33) 21 (32.81) 43 (33.07) above Diploma 6 (9.09) 29 (45.32) 35 (26.93) Place of residence Village 49 (74.24) 46 (71.88) 95 (73.07) P = 0.66 City 17 (25.76) 18 (28.12) 35 (26.93) The repeated measures Analysis of Variance (ANOVA) was used to test the differences among variables at three observation times in each group. According to the results summarized in Table 2 , daily activity living, quality of life, and sexual satisfaction in both groups decreased over time from the first to the third time, and this difference was significant in all three variables except in the oral medications group, where quality of life was not significant (p = 0.68). Also, in the insulin group, sexual satisfaction was not significant (p = 0.72). An independent t-test was used to compare the mean and standard deviation of variables between the two groups at any time. It showed in the variable of quality of life just three years later the difference was significant (0.017), which implies that the quality-of-life score after three years was better in the oral antidiabetic drug group. In the between-group comparison of the variable activities of daily living, no significant difference was observed between the two groups at any time. However, in the sexual satisfaction variable, the insulin group's score was higher at one year and three years later, and the difference was significant at both time points (0.049, 0.054, respectively) (Table 2 ). Table 2 Within- and between-group comparisons of mean and standard deviation of variables in the first assessment, one and three years later Variables Group First assessment One year later Three years later P value Quality of life Oral medications group 43.23 ± 11.22 41.23 ± 9.45 40.92 ± 9.22 0.68 Insulin group 43.85 ± 12.85 41 ± 9.88 35.55 ± 9.22 0.041 P value 0.58 0.82 0.017 - Daily activity living Oral medications group 14.22 ± 3.85 12.7 ± 2.98 9.58 ± 2.35 0.025 Insulin group 16.22 ± 3.98 14.7 ± 2.85 10.85 ± 2.15 0.013 P value 0.87 0.66 0.59 - Sexual satisfaction Oral medications group 76.35 ± 17.32 58.75 ± 7.45 54.75 ± 8.25 0.027 Insulin group 73.85 ± 15.83 70.33 ± 13.75 69.45 ± 88.45* 0.72 P value 0.56 0.049 0.054 - Based on Table 3 , the results of the independent t-test analysis showed that there was no significant difference between the mean score of variables of quality of life and daily activity living by gender (p > 0.05), but in sexual satisfaction it was significant. The results of the independent t-test also indicated that there was no significant difference in all of the variables (p > 0.05) according to marital status. Regarding level of education, the results of the one-way analysis of variance test also showed that there was a difference between that and just quality of life (p = 0.017). The independent t-test showed that there was a difference between the place of residence and quality of life. The Pearson correlation test also showed that there is an inverse and significant relationship between age and all of the variables, but the duration of diabetic suffering variable showed an inverse relationship just with sexual satisfaction (p = 0.000, r=-0.78). Table 3 Relationship between demographic characteristics with chest pain, arrhythmia incidence, and anxiety Variable Quality of life Daily activity living Sexual satisfaction Gender Male Female 0.56 = t p = 0.72 0.1.25 = t 0.023 = p 067 = t 0.88 = p Marital status Married Single 0.54 = t 0.74 = p 0.87 = t 0.54 = p 0.67 = t 0.17 = p Level of education Under Diploma Diploma Above Diploma 0.017 = p F = 1.25 0.63 = p F = 0.79 0.86 = p F = 0.95 Place of residence Village City 1.38 = t 0.033 = p 0.48 = t 0.92 = p 0.74 = t 0.68 = p Age 0.078 = p 0.74 -=r p = 0.024 r=-0.68 p = 0.044 r=-0.84 Duration of diabetic suffering p = 0.87 r = 0.11 p = 0.56 r = 0.23 p = 000 r=-0.78 Discussion The aim of this study was to determine and compare quality of life, level of daily living activities, and sexual satisfaction in two groups: insulin users and oral medication users. According to the results of this study quality of life in both groups decreased over time from the first to the third time, and this change was significant in the insulin group, but it was not significant in the oral medications group. This decrease in quality of life was greater in the insulin group than in the oral medication group, which may be due to the daily and frequent injections that are performed in insulin patients, which causes challenges in these patients. Quality of life is an important health outcome and is considered a major issue in the care of various patients, including patients with diabetes (19). The results of the study by Daneshvar et al. (2018) showed that diabetic patients had significantly lower scores in the areas of physical functioning, role limitations due to physical problems, role limitations due to emotional problems, vitality, social functioning, physical pain, and general health compared to non-diabetic individuals (20). Many efforts have been made in new research to address this issue (21). New-generation insulins now provide both long-acting and rapid-acting insulin in a single injection, which can significantly improve the patient's quality of life (22). Based on the results about demographic characteristics, there was a significant difference between level of education and place of residence with quality of life; however, this relationship for age was inverse, which means that as age increases, the quality of life decreases. Daneshvar et al. (2018) emphasize that changes in the dimensions of quality of life are actually affected by individual, social, and economic factors, and it can be concluded that measuring quality of life along with individual-social characteristics provides complete information for chronic patients, which can ultimately be used to plan treatment and care for chronic patients and improve their quality of life (20). In the study of 2017, there was a statistically significant difference between quality of life, especially in domains of physical performance scores, feelings of well-being, and pain, according to individuals' education (23). However, in the study by Soleimani et al. (2016), no statistically significant relationship was observed between the quality of life of diabetic patients and the demographic variables of age, gender, marital status, occupation, and education (24). Another main result of this study implied that daily activity living in both groups decreased over time from the first to the third time, and this difference was significant. Also, in this variable, no significant difference was observed between the two groups at any time. Activities of Daily Living (ADL) for people with diabetes refers to the ability to perform everyday tasks such as bathing, dressing, eating and drinking, and going to the toilet. People with diabetes can maintain or improve their ADL levels with the right help (25). Regular daily activity can help control blood sugar levels and prevent diabetes complications. For people with diabetes who face physical challenges, assistive devices such as bath chairs, bath rails, and wall grab bars can help increase ADL levels (26). In line with the results of our research, a study by Kazemi et al. also showed that using the International Classification of Functioning, Disability, and Health (ICF) as a framework for assessing the performance and determining the health status of diabetic patients, hand function and ability to perform work in patients with diabetes were not at the desired level. Their performance and ability to perform work decrease with increasing blood sugar levels (25). Moreover, there is an inverse and significant relationship between age and daily activity living. These differences between young and old elderly people were due to the reduction of muscle strength in both upper and lower limbs and changes in body-fat percentage, flexibility, agility, and endurance. Research by Zoran Milanović (2016) also confirmed that the level of daily activity is inversely related to age, and as age increases, the level of daily activity decreases (27). The last chief result of this study demonstrated that sexual satisfaction in both groups decreased over time, and this change was significant in the oral medications group, but it was not significant in the insulin group. Besides, the insulin group's score was higher at one year and three years later, and the difference was significant at both mentioned times. This indicates that sexual satisfaction was better in the insulin group than in the oral medication group. Insulin use is not directly linked to sexual satisfaction, but diabetes, which requires insulin, can affect sexual function and therefore sexual satisfaction through its side effects. In other words, uncontrolled diabetes can lead to damage to nerves and blood vessels, which affects sexual function. Controlling blood sugar through insulin can improve sexual satisfaction (28). But in general, other studies emphasize proper blood sugar management is crucial for minimizing the impact of diabetes on sexual health, regardless of the treatment approach (29). The results also indicated a significant difference in sexual satisfaction based on gender and the duration of diabetes. Besides this relationship, age was inverse, which means that as age increases, sexual satisfaction decreases. Other studies have shown that women with diabetes are also at higher risk for urinary tract infections (UTIs) and vaginal yeast infections, which in turn may lead to painful sex and decreased sexual satisfaction (30). According to another study, middle-aged women whose diabetes requires insulin are 80 percent more likely to have trouble reaching orgasm than women without diabetes (31). The length of time having diabetes can also affect sexual satisfaction. Diabetes, especially if it's not well controlled, can cause complications over time that can lead to sexual dysfunction in both men and women. These can include decreased libido, difficulty with arousal and orgasm, and pain during sex (32). Conclusion According to this study, daily activity, living, quality of life, and sexual satisfaction in both groups decreased over time from the first to the third time. This decrease in quality-of-life variables was greater in the insulin group than in the oral medication group, but sexual satisfaction was better in the insulin group than in the oral medication group. However, in the daily activity living, no significant difference was observed between the two groups at any time. It is suggested that attention to these three variables in type 2 diabetic patients should be increased by the entire treatment and care team, considering their decrease over time. However, given the role of demographic variables in some of these variables, the health care providers should select the appropriate treatment approach based on the patient's condition and characteristics such as age, education level, and gender. Declarations Acknowledgements We would like to express our deep gratitude to all the individuals and institutions that contributed to the realization of this study. We are grateful to the patients who agreed to participate in this study. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author contributions H A CH and E R. designed the study and supervised the overall project. E A participated in data collection and analyze the result.. M H, R M, and A K wrote the main manuscript text.. All authors reviewed the manuscript Data Availability The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Consent to participate Informed written consent was obtained from all participants included in the study. The principles of the Declaration of Helsinki have been followed throughout the research. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Clinical trial number not applicable. References Poretsky L. Principles of diabetes mellitus. 2nd ed. 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Age-related decrease in physical activity and functional fitness among elderly men and women. Clin Interv Aging. 2013;8:549-56. Copeland, Kelli L et al. “Diabetes mellitus and sexual function in middle-aged and older women.” Obstetrics and gynecology vol. 120,2 Pt 1 (2012): 331-40. Hoorsan R, Lamyian M, Ahmadi F, Azin SA, Rahimiforoushani A. Exploring Sexual Life Experiences and Perceptions of Women with Diabetes: A Qualitative Study. Int J Community Based Nurs Midwifery. 2022;10(3):223-233. Wallner LP, Sarma AV, Kim C. Sexual functioning among women with and without diabetes in the Boston Area Community Health Study. The Journal of Sexual Medicine. Kizilay F, Gali HE, Serefoglu EC. Diabetes and sexuality. Sexual Medicine Reviews. 2016;5:45–51. Sefa A, Nigussie T, Henok A, Mamo Y. Prevalence of sexual dysfunction and related factors among diabetes mellitus patients in Southwest Ethiopia. BMC Endocrine Disorders. 2019;19:141. Additional Declarations No competing interests reported. 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The prevalence and incidence of the disease are increasing in many societies, especially in developing countries (2). According to World Health Statistics, the prevalence of diabetes in adults in the world is 8.8%, of which about 90% is type 2 diabetes. In this disease, although insulin is secreted in sufficient quantities, cell receptors become resistant to it, and its function in regulating blood sugar levels is impaired (3).\u003c/p\u003e\u003cp\u003eThe cause of type 2 diabetes is usually a combination of genetic and environmental factors. The risk of developing this disease increases when a person has an unhealthy lifestyle, such as excessive calorie consumption, lack of exercise or obesity (4). These factors can increase the resistance of cells to insulin and ultimately lead to type 2 diabetes (5).\u003c/p\u003e\u003cp\u003eType 2 diabetes can be accompanied by common symptoms of diabetes, such as frequent thirst and frequent drinking (polydipsia), frequent urination (polyuria), or it can be completely asymptomatic (3). For this reason, it is necessary to examine and screen people who are asymptomatic but have risk factors for diabetes (6).\u003c/p\u003e\u003cp\u003eAlthough drug treatments play a key role in controlling this disease, diabetes treatment is generally a set of measures that together will have a desirable effect and is not limited to drug therapy (7). Although type 2 diabetes has no definitive cure; however, the correct and regular use of medications prescribed by the treating physician, as well as lifestyle modifications, greatly helps to effectively control symptoms and improve and maintain the quality of life of people with diabetes (8). Type 2 diabetes, as a chronic disease, requires continuous management. Managing diabetes by regulating blood sugar and preventing its dangerous complications can significantly improve a person's quality of life (9). Furthermore, changes in diet, weight control, and regular physical activity can help reduce insulin resistance and increase the body's sensitivity to this hormone (10).\u003c/p\u003e\u003cp\u003eUncontrolled diabetes leads to blood sugar levels that are higher than normal. High blood sugar levels over time and after a few years can cause problems in our bodies and damage the eyes, kidneys, nerves, skin, heart, and blood vessels (4). Due to its long-term process and long-term complications on various body systems, type 2 diabetes causes disruption in various aspects of a person's life (6).\u003c/p\u003e\u003cp\u003eType 2 diabetic patients experience many problems that disrupt their quality of life. A chronic disease such as type 2 diabetes affects the lives of all family members and may cause problems such as anxiety and stress, depression, anger and financial problems for them (11). Type 2 diabetes, as a biological, psychological and social problem, affects all aspects of a person's life, including their quality of life (12).\u003c/p\u003e\u003cp\u003eAnother variable that is affected in chronic diseases such as type 2 diabetes is the individual's activities of daily living index. Activities of daily living include tasks that are necessary to complete daily work (2). The inability to perform these tasks creates problems for the individual in daily life. Activities of daily living allow the patients to maintain their independence (1). The results of the study by Daneshvar et al. showed that diabetic patients had significantly lower scores in the areas of physical functioning, role limitations due to physical problems, role limitations due to emotional problems, vitality, social functioning, physical pain, and general health compared to non-diabetic individuals (13).\u003c/p\u003e\u003cp\u003eWhen diabetes is left uncontrolled, the effects of the disease on the reproductive and nervous systems become fully apparent. Diabetes can damage nerves by increasing blood sugar levels, which can affect sexual function (9). Diabetic neuropathy is a type of nerve damage associated with diabetes that is a factor in sexual problems. Sexual dysfunction in individuals with diabetes encompasses any disruption or issue in the sexual response cycle, which may include decreased libido, erectile dysfunction, pain during intercourse, difficulty achieving orgasm, or infections (14).\u003c/p\u003e\u003cp\u003eThe most important and common treatments used for diabetes are oral medications and the use of various insulins. The use of oral medications and insulin each has advantages and disadvantages (15). The use of these treatments may affect the quality of life, the level of daily activities, and sexual dysfunction (7).\u003c/p\u003e\u003cp\u003eTherefore, given the high prevalence of diabetes and that there is also no study in this field that has fully examined these variables, and considering the different culture and context of Iraq, this study was conducted with the general aim of determining a comparative study of quality of life, daily activities, and sexual satisfaction in type 2 diabetic patients treated with insulin and oral medications as a prospective cohort study.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cb\u003eStudy setting and participants\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe present study is a prospective cohort study conducted on 230 patients with diabetes who were referred to the Diabetes Clinic at Baghdad Hospital in 2021. The study period lasted from January 2021 to December 2024. The study units were selected on a convenience basis and then randomly assigned to two intervention and control groups using SPSS software. The inclusion criteria for patients included all patients diagnosed with diabetes by a specialist physician, complete and stable consciousness, not using other medications or supplements, use of oral antidiabetic medication or use of insulin, no chronic disease or other underlying condition, and informed consent to participate in the study. The exclusion criteria included the patient's worsening condition and the development of emergency conditions, unwillingness to continue the study for any reason, and the patient's death.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSample size\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe sample size was calculated based on the formula \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\frac{\\left({{\\mathbf{Z}}_{1-\\frac{\\varvec{\\alpha\\:}}{2}}+{\\mathbf{Z}}_{1-\\varvec{\\beta\\:}})}^{2}\\right({\\varvec{S}}_{1}^{2}+{\\varvec{S}}_{2}^{2})}{{\\left(\\mathbf{d}\\right)}^{2}}\\)\u003c/span\u003e\u003c/span\u003e and the study by Alcubierre et al. (2014) (16) with a confidence level of 95% and a test power of 80%. Considering the probability of sample attrition at 10%, the sample size was 140 (intervention group: 70, control group: 70). However, ultimately, 130 patients completed the study and 10 patients were excluded from the study, of whom 5 people had emergency conditions or died, 2 people were unwilling to continue the study, and 3 people had emigrated. Finally, 64 patients in the insulin group and 66 patients in the oral medication group completed the study.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Collection and study instruments\u003c/b\u003e\u003c/p\u003e\u003cp\u003eData-gathering instruments included personal information questionnaires, the World Health Organization quality of life questionnaire, the sexual satisfaction questionnaire, and the daily activity living questionnaire. The World Health Organization Quality of Life Short Form (WHOQOL-BREF) is a 26-item questionnaire that measures an individual's overall and general quality of life. This scale was developed in 1996 by a group of World Health Organization experts by modifying the items of the 100-item form of this questionnaire. This questionnaire has 4 subscales and an overall score. These subscales are physical health, mental health, social relationships, environmental health, and an overall score. The minimum and maximum scores are between 0 and 100. A higher score indicates a higher quality of life. The results of the study by Rasafiani et al. (2020) (17) indicate that the World Health Organization Quality of Life Questionnaire has acceptable validity and reliability in the studied sample. Its validity was obtained through facial and content validity with a content validity index (CVI) of 0.85, and its reliability was confirmed by the test-retest method with a coefficient of 0.79.\u003c/p\u003e\u003cp\u003eThe Activities of Daily Living (ADL) scale was completed to assess the level of ability to perform daily activities for the subjects. This tool has 10 questions, and the 0-1-2 method has been proposed for scoring it, which determines the status of independence or dependence in performing daily activities on a scale of 0\u0026ndash;20, such that a higher score indicates less dependence in performing daily activities. A score of 20 is interpreted as complete independence, a score between 13 and 19 as partial dependence, a score of 9\u0026ndash;12 as semi-independent, and a score of 0\u0026ndash;8 as complete dependence. In the study by Taheri Tanjani et al. (2016), the content validity index of this questionnaire was 0.82, and the Cronbach's alpha coefficient of this questionnaire was 0.75 (18).\u003c/p\u003e\u003cp\u003eThe second questionnaire was the Sexual Satisfaction Questionnaire. This questionnaire was developed by Larson in 1998. The Larson Sexual Satisfaction Questionnaire assesses the level of sexual satisfaction in couples and relationships. This questionnaire has 25 questions and is in the form of 5 options and is based on a Likert scale from 1 to 5, where the option \"never\" receives a score of 1, the option \"rarely\" receives a score of 2, \"sometimes\" a score of 3, \"most of the time\" a score of 4, and \"always\" a score of 5. Questions 4-5-6-7-8-9-11-14-15-18-20-24 and 25 are scored in reverse. Based on this questionnaire, the scores are generally between 25 and 125, and sexual satisfaction is classified into levels of sexual dissatisfaction: (score less than 50), low satisfaction (score between 51 and 75), moderate satisfaction (score between 76 and 100), and high satisfaction (score above 101).\u003c/p\u003e\u003cp\u003e After obtaining permission and introducing the researcher to the research environment, the participants first completed an informed consent form, and the objectives of the study were fully explained. The researcher helped complete the questionnaires in 15 to 30 minutes. The patients' characteristics were recorded in the hospital along with their medical records. After one year and three years after the first assessment, when the patients were referred to the hospital's diabetes clinic for follow-up, they completed the relevant questionnaires again.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eAfter collecting and entering the data into the computer, data analysis was performed using SPSS software, considering a confidence level of 95% and a significance level of 0.05. Descriptive statistics and indices of mean and standard deviation and percentage and frequency distribution were used to describe demographic characteristics and variables. The Kolmogorov-Smirnov test was also used to determine the normality of the data. Repeated analysis of variance tests was used for intragroup comparison of each variable, and independent t-tests were also used for comparison between variables of groups at different times. Chi-square, ANOVA, and Mann-Whitney tests were also used to examine differences in demographic variables.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEthical consideration\u003c/b\u003e\u003c/p\u003e\u003cp\u003e The study was approved by ethics committees of Council of the Nursing College/University of Baghdad. Official permissions were gained from relevant authorities before collecting the study data. Other ethical considerations in this research include obtaining informed written consent from patients to participate in the research, maintaining the respect and dignity of research participants, and upholding the independence of research participants by assuring them of their freedom to participate, not participate, or withdraw from the research. The same conditions were considered for all participants in the research. All participants were assured that their information would remain confidential. The principles of the Declaration of Helsinki have been followed throughout the research.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFinally, 130 patients completed the study: 64 patients were in the insulin group, and 66 patients were in the oral medication group. Mean age (standard deviation) of patients was 55.22\u0026thinsp;\u0026plusmn;\u0026thinsp;6.85; 51.4% (64) were male and 49.6% (66) were female. The majority of participants (65.38%) were married. In terms of residence, 26.93% lived in villages and 73.07% lived in cities. Regarding education level, 43 patients (33.07%) reported they have a diploma degree, and 52 patients (40%) were under the diploma level. Totally, there was no significant difference between the groups in the demographic variables in the intergroup comparison except for the level of education variable, which had a p-value of 0.024, meaning that the number of people with a college education was higher than those with a high school diploma (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic characteristics of the study participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOral medications group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInsulin group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOverall\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eResults of the intergroup comparison test\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.9\u0026thinsp;\u0026plusmn;\u0026thinsp;54.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.53\u0026thinsp;\u0026plusmn;\u0026thinsp;56.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.85\u0026thinsp;\u0026plusmn;\u0026thinsp;55.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.86\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDuration of diabetic suffering\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.85\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.17\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10.65\u0026thinsp;\u0026plusmn;\u0026thinsp;2.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eVariable\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNumber (percentage)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNumber (percentage)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNumber (percentage)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eResults of the intergroup comparison test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (45.46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e34 (53.12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e64 )51.4(\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.34\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36 (54.54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30 (46.88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e66 (49.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48 (72.72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37 (57.82)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e85 (65.38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.56\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (27.27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27 (42.18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e45 (34.62)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eLevel of education\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnder diploma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38 (57.57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (21.87)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e52 (40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.024\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ediploma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (33.33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21 (32.81)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e43 (33.07)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eabove Diploma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (9.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29 (45.32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e35 (26.93)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003ePlace of residence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVillage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (74.24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46 (71.88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95 (73.07)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eP\u0026thinsp;=\u0026thinsp;0.66\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (25.76)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18 (28.12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e35 (26.93)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe repeated measures Analysis of Variance (ANOVA) was used to test the differences among variables at three observation times in each group. According to the results summarized in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, daily activity living, quality of life, and sexual satisfaction in both groups decreased over time from the first to the third time, and this difference was significant in all three variables except in the oral medications group, where quality of life was not significant (p\u0026thinsp;=\u0026thinsp;0.68). Also, in the insulin group, sexual satisfaction was not significant (p\u0026thinsp;=\u0026thinsp;0.72).\u003c/p\u003e\u003cp\u003eAn independent t-test was used to compare the mean and standard deviation of variables between the two groups at any time. It showed in the variable of quality of life just three years later the difference was significant (0.017), which implies that the quality-of-life score after three years was better in the oral antidiabetic drug group. In the between-group comparison of the variable activities of daily living, no significant difference was observed between the two groups at any time. However, in the sexual satisfaction variable, the insulin group's score was higher at one year and three years later, and the difference was significant at both time points (0.049, 0.054, respectively) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eWithin- and between-group comparisons of mean and standard deviation of variables in the first assessment, one and three years later\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFirst assessment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOne year later\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eThree years later\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eQuality of life\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOral medications group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43.23\u0026thinsp;\u0026plusmn;\u0026thinsp;11.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e41.23\u0026thinsp;\u0026plusmn;\u0026thinsp;9.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e40.92\u0026thinsp;\u0026plusmn;\u0026thinsp;9.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.68\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInsulin group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43.85\u0026thinsp;\u0026plusmn;\u0026thinsp;12.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e41\u0026thinsp;\u0026plusmn;\u0026thinsp;9.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e35.55\u0026thinsp;\u0026plusmn;\u0026thinsp;9.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.041\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDaily activity living\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOral medications group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.22\u0026thinsp;\u0026plusmn;\u0026thinsp;3.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9.58\u0026thinsp;\u0026plusmn;\u0026thinsp;2.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.025\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInsulin group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.22\u0026thinsp;\u0026plusmn;\u0026thinsp;3.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10.85\u0026thinsp;\u0026plusmn;\u0026thinsp;2.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.013\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSexual satisfaction\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOral medications group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76.35\u0026thinsp;\u0026plusmn;\u0026thinsp;17.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e58.75\u0026thinsp;\u0026plusmn;\u0026thinsp;7.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e54.75\u0026thinsp;\u0026plusmn;\u0026thinsp;8.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.027\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInsulin group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e73.85\u0026thinsp;\u0026plusmn;\u0026thinsp;15.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70.33\u0026thinsp;\u0026plusmn;\u0026thinsp;13.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e69.45\u0026thinsp;\u0026plusmn;\u0026thinsp;88.45*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.72\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.049\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.054\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eBased on Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the results of the independent t-test analysis showed that there was no significant difference between the mean score of variables of quality of life and daily activity living by gender (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), but in sexual satisfaction it was significant. The results of the independent t-test also indicated that there was no significant difference in all of the variables (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) according to marital status. Regarding level of education, the results of the one-way analysis of variance test also showed that there was a difference between that and just quality of life (p\u0026thinsp;=\u0026thinsp;0.017). The independent t-test showed that there was a difference between the place of residence and quality of life. The Pearson correlation test also showed that there is an inverse and significant relationship between age and all of the variables, but the duration of diabetic suffering variable showed an inverse relationship just with sexual satisfaction (p\u0026thinsp;=\u0026thinsp;0.000, r=-0.78).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRelationship between demographic characteristics with chest pain, arrhythmia incidence, and anxiety\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eQuality of life\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDaily activity living\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSexual satisfaction\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.56\u0026thinsp;=\u0026thinsp;t\u003c/p\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.1.25\u0026thinsp;=\u0026thinsp;t\u003c/p\u003e\u003cp\u003e0.023\u0026thinsp;=\u0026thinsp;p\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e067\u0026thinsp;=\u0026thinsp;t\u003c/p\u003e\u003cp\u003e0.88\u0026thinsp;=\u0026thinsp;p\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.54\u0026thinsp;=\u0026thinsp;t\u003c/p\u003e\u003cp\u003e0.74\u0026thinsp;=\u0026thinsp;p\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.87\u0026thinsp;=\u0026thinsp;t\u003c/p\u003e\u003cp\u003e0.54\u0026thinsp;=\u0026thinsp;p\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.67\u0026thinsp;=\u0026thinsp;t\u003c/p\u003e\u003cp\u003e0.17\u0026thinsp;=\u0026thinsp;p\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLevel of education\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnder Diploma\u003c/p\u003e\u003cp\u003eDiploma\u003c/p\u003e\u003cp\u003eAbove Diploma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.017\u0026thinsp;=\u0026thinsp;p\u003c/p\u003e\u003cp\u003eF\u0026thinsp;=\u0026thinsp;1.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.63\u0026thinsp;=\u0026thinsp;p\u003c/p\u003e\u003cp\u003eF\u0026thinsp;=\u0026thinsp;0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.86\u0026thinsp;=\u0026thinsp;p\u003c/p\u003e\u003cp\u003eF\u0026thinsp;=\u0026thinsp;0.95\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePlace of residence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVillage\u003c/p\u003e\u003cp\u003eCity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.38\u0026thinsp;=\u0026thinsp;t\u003c/p\u003e\u003cp\u003e0.033\u0026thinsp;=\u0026thinsp;p\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.48\u0026thinsp;=\u0026thinsp;t\u003c/p\u003e\u003cp\u003e0.92\u0026thinsp;=\u0026thinsp;p\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.74\u0026thinsp;=\u0026thinsp;t\u003c/p\u003e\u003cp\u003e0.68\u0026thinsp;=\u0026thinsp;p\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.078\u0026thinsp;=\u0026thinsp;p 0.74 -=r\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.024 r=-0.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.044\u003c/p\u003e\u003cp\u003er=-0.84\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDuration of diabetic suffering\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.87 r\u0026thinsp;=\u0026thinsp;0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.56 r\u0026thinsp;=\u0026thinsp;0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;000 r=-0.78\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe aim of this study was to determine and compare quality of life, level of daily living activities, and sexual satisfaction in two groups: insulin users and oral medication users. According to the results of this study quality of life in both groups decreased over time from the first to the third time, and this change was significant in the insulin group, but it was not significant in the oral medications group. This decrease in quality of life was greater in the insulin group than in the oral medication group, which may be due to the daily and frequent injections that are performed in insulin patients, which causes challenges in these patients. Quality of life is an important health outcome and is considered a major issue in the care of various patients, including patients with diabetes (19). The results of the study by Daneshvar et al. (2018) showed that diabetic patients had significantly lower scores in the areas of physical functioning, role limitations due to physical problems, role limitations due to emotional problems, vitality, social functioning, physical pain, and general health compared to non-diabetic individuals (20). Many efforts have been made in new research to address this issue (21). New-generation insulins now provide both long-acting and rapid-acting insulin in a single injection, which can significantly improve the patient's quality of life (22). Based on the results about demographic characteristics, there was a significant difference between level of education and place of residence with quality of life; however, this relationship for age was inverse, which means that as age increases, the quality of life decreases. Daneshvar et al. (2018) emphasize that changes in the dimensions of quality of life are actually affected by individual, social, and economic factors, and it can be concluded that measuring quality of life along with individual-social characteristics provides complete information for chronic patients, which can ultimately be used to plan treatment and care for chronic patients and improve their quality of life (20). In the study of 2017, there was a statistically significant difference between quality of life, especially in domains of physical performance scores, feelings of well-being, and pain, according to individuals' education (23). However, in the study by Soleimani et al. (2016), no statistically significant relationship was observed between the quality of life of diabetic patients and the demographic variables of age, gender, marital status, occupation, and education (24).\u003c/p\u003e\u003cp\u003eAnother main result of this study implied that daily activity living in both groups decreased over time from the first to the third time, and this difference was significant. Also, in this variable, no significant difference was observed between the two groups at any time. Activities of Daily Living (ADL) for people with diabetes refers to the ability to perform everyday tasks such as bathing, dressing, eating and drinking, and going to the toilet. People with diabetes can maintain or improve their ADL levels with the right help (25). Regular daily activity can help control blood sugar levels and prevent diabetes complications. For people with diabetes who face physical challenges, assistive devices such as bath chairs, bath rails, and wall grab bars can help increase ADL levels (26). In line with the results of our research, a study by Kazemi et al. also showed that using the International Classification of Functioning, Disability, and Health (ICF) as a framework for assessing the performance and determining the health status of diabetic patients, hand function and ability to perform work in patients with diabetes were not at the desired level. Their performance and ability to perform work decrease with increasing blood sugar levels (25). Moreover, there is an inverse and significant relationship between age and daily activity living. These differences between young and old elderly people were due to the reduction of muscle strength in both upper and lower limbs and changes in body-fat percentage, flexibility, agility, and endurance. Research by Zoran Milanović (2016) also confirmed that the level of daily activity is inversely related to age, and as age increases, the level of daily activity decreases (27).\u003c/p\u003e\u003cp\u003e The last chief result of this study demonstrated that sexual satisfaction in both groups decreased over time, and this change was significant in the oral medications group, but it was not significant in the insulin group. Besides, the insulin group's score was higher at one year and three years later, and the difference was significant at both mentioned times. This indicates that sexual satisfaction was better in the insulin group than in the oral medication group. Insulin use is not directly linked to sexual satisfaction, but diabetes, which requires insulin, can affect sexual function and therefore sexual satisfaction through its side effects. In other words, uncontrolled diabetes can lead to damage to nerves and blood vessels, which affects sexual function. Controlling blood sugar through insulin can improve sexual satisfaction (28). But in general, other studies emphasize proper blood sugar management is crucial for minimizing the impact of diabetes on sexual health, regardless of the treatment approach (29). The results also indicated a significant difference in sexual satisfaction based on gender and the duration of diabetes. Besides this relationship, age was inverse, which means that as age increases, sexual satisfaction decreases. Other studies have shown that women with diabetes are also at higher risk for urinary tract infections (UTIs) and vaginal yeast infections, which in turn may lead to painful sex and decreased sexual satisfaction (30). According to another study, middle-aged women whose diabetes requires insulin are 80 percent more likely to have trouble reaching orgasm than women without diabetes (31). The length of time having diabetes can also affect sexual satisfaction. Diabetes, especially if it's not well controlled, can cause complications over time that can lead to sexual dysfunction in both men and women. These can include decreased libido, difficulty with arousal and orgasm, and pain during sex (32).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAccording to this study, daily activity, living, quality of life, and sexual satisfaction in both groups decreased over time from the first to the third time. This decrease in quality-of-life variables was greater in the insulin group than in the oral medication group, but sexual satisfaction was better in the insulin group than in the oral medication group. However, in the daily activity living, no significant difference was observed between the two groups at any time. It is suggested that attention to these three variables in type 2 diabetic patients should be increased by the entire treatment and care team, considering their decrease over time. However, given the role of demographic variables in some of these variables, the health care providers should select the appropriate treatment approach based on the patient's condition and characteristics such as age, education level, and gender.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our deep gratitude to all the individuals and institutions that contributed to the realization of this study. We are grateful to the patients who agreed to participate in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eH A CH and E R. designed the study and supervised the overall project. E A participated in data collection and analyze the result.. M H, R M, and A K wrote the main manuscript text.. All authors reviewed the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed written consent was obtained from all participants included in the study.\u0026nbsp;The principles of the\u0026nbsp;Declaration of\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eHelsinki have been followed throughout the research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003enot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePoretsky L. 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J Gerontol A Biol Sci Med Sci. 2001;56(10):B443\u0026ndash;B448.\u003c/li\u003e\n\u003cli\u003eMilanović Z, Pantelić S, Trajković N, Spori\u0026scaron; G, Kostić R, James N. Age-related decrease in physical activity and functional fitness among elderly men and women. Clin Interv Aging. 2013;8:549-56. \u003c/li\u003e\n\u003cli\u003eCopeland, Kelli L et al. \u0026ldquo;Diabetes mellitus and sexual function in middle-aged and older women.\u0026rdquo; \u003cem\u003eObstetrics and gynecology\u003c/em\u003e vol. 120,2 Pt 1 (2012): 331-40. \u003c/li\u003e\n\u003cli\u003eHoorsan R, Lamyian M, Ahmadi F, Azin SA, Rahimiforoushani A. Exploring Sexual Life Experiences and Perceptions of Women with Diabetes: A Qualitative Study. Int J Community Based Nurs Midwifery. 2022;10(3):223-233. \u003c/li\u003e\n\u003cli\u003eWallner LP, Sarma AV, Kim C. Sexual functioning among women with and without diabetes in the Boston Area Community Health Study. The Journal of Sexual Medicine.\u003c/li\u003e\n\u003cli\u003eKizilay F, Gali HE, Serefoglu EC. Diabetes and sexuality. Sexual Medicine Reviews. 2016;5:45\u0026ndash;51.\u003c/li\u003e\n\u003cli\u003eSefa A, Nigussie T, Henok A, Mamo Y. Prevalence of sexual dysfunction and related factors among diabetes mellitus patients in Southwest Ethiopia. BMC Endocrine Disorders. 2019;19:141.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Diabetes, Quality of Life, Daily Activity Living, Sexual Satisfaction, Insulin, Oral Medications","lastPublishedDoi":"10.21203/rs.3.rs-7006272/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7006272/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThis study aimed to determine and compare quality of life, level of daily living activities, and sexual satisfaction in two groups: insulin users and oral medications.\u003c/p\u003e\u003ch2\u003eMaterials \u0026amp; Methods\u003c/h2\u003e\u003cp\u003eThis prospective cohort study was conducted on patients attending the diabetes clinics at Baghdad Hospital in Iraq between 2021\u0026ndash;2024. The number of patients in the study was 130 participants including two groups (using insulin vs oral medication). At First, after one year, and after three years, all participants completed four questionnaires: Quality of Life, Sexual Satisfaction, and Activities of Daily Living. The collected data were analyzed using SPSS software with descriptive and analytical statistical methods.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003e According to the results, activity daily living, quality of life and sexual satisfaction in both groups decreased over time from first to the third time, and this difference was significant in the all three variables except in the oral medications group quality of life was not significant (p\u0026thinsp;=\u0026thinsp;0.68), also in the insulin group sexual satisfaction was not significant (p\u0026thinsp;=\u0026thinsp;0.72). In the between-group comparison showed quality of life just three years later difference was significant (0.017). In the Activities of daily living variable, no significant difference was observed between the two groups at any time. However, in the sexual satisfaction the insulin group's score was higher at one year and three years later, and the difference was significant at both mentioned times (0.049, 0.054 respectively).\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e\u003cp\u003eThis study found that in both groups\u0026rsquo; daily activities, quality of life, and sexual satisfaction reduced over time.\u003c/p\u003e","manuscriptTitle":"Comparative Study of Quality of Life, Activities of Daily Living, and Sexual Satisfaction in Type 2 Diabetic Patients Using Insulin and Oral Medications: A Prospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-05 09:02:38","doi":"10.21203/rs.3.rs-7006272/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-26T16:08:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-20T18:50:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211797002890279258875440382491758908875","date":"2025-09-11T18:15:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-02T05:00:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"69789373215250824439042568836024789673","date":"2025-09-02T04:55:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-12T15:20:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-04T05:18:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291558928417776209550433499050603607652","date":"2025-08-03T02:52:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74980658729634287190966124187312942861","date":"2025-08-02T18:55:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"336072918041742434651522979145122047284","date":"2025-07-31T15:50:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-31T15:11:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-20T09:03:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-15T11:02:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-14T18:19:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2025-07-11T07:56:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5afa4e25-d0ec-43bf-8538-7788ca129333","owner":[],"postedDate":"August 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T08:11:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-05 09:02:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7006272","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7006272","identity":"rs-7006272","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}