Title: Association of Intermediate Health Determinants with Gestational Diabetes Self-care: A
Structural Equation Modeling Approach
Version: 4 Date: 26 Apr 2024
Reviewer's report:
1) The researchers have provided references such as the impact of "quality of life" on "self-care"
as the basis of the model. I read the papers and summarized them below and highlighted them in
yellow. Kim et al. (2017) investigated the factors affecting the quality of life of elderly diabetics.
They mentioned that the quality of life was related to some scores of the questionnaires, such
as the self-care questionnaire. The important question is whether it can be concluded from the
correlation between the scores of two questionnaires that one is effective on the other or the
causal model is one-sided. ? This conclusion is not correct. These two concepts are closely
related because some of their sub-components overlap, but we cannot draw a one-way arrow for
them with this article by Kim et al.
6. Kim H, Kim K. Health-Related Quality-of-Life and Diabetes Self-Care Activity in Elderly
Patients with Diabetes in Korea. J Community Health. 2017;42(5):998-1007.
Abstract:
A critical goal in the management of elderly patients with diabetes is to improve their health-
related quality of life (HRQOL). This study aimed to identify the factors affecting HRQOL
in elderly Korean patients with diabetes. Participants were 365 elderly patients with diabetes
who were treated in a general hospital in Korea. The data were analysed using independent
t-tests, Pearson correlations, and stepwise multiple regression. The mean total HRQOL score
was 74.77, and HRQOL showed positive correlations with activities of daily living (ADL),
instrumental activities of daily living (IADL), and the Summary of Diabetes Self-care Activities
(SDSA). There was a negative correlation between HRQOL and Short Geriatric Depression
Scale (SGDS). Lower SGDS scores, higher SDSA scores, and being male were associated with
higher HRQOL, with these variables explaining 57.5% of the variance in participants’ HRQOL.
2)Regarding reference #7, I did not see any support for the one-way arrow of the structural model
of the effect of quality of life on self-care. Below is a summary of  Egede et al.'s article:
Egede LE, Zheng D, Simpson K. Comorbid depression is associated with increased health care
use
and expenditures in individuals with diabetes. Diabetes care. 2002;25(3):464-70.
Abstract:
Objective: This study ascertained the odds of diagnosed depression in individuals with diabetes
and the relation between depression and health care use and expenditures.
Research design and methods: First, we compared data from 825 adults with diabetes with that
from 20,688 adults without diabetes using the 1996 Medical Expenditure Panel Survey (MEPS).
Second, in patients with diabetes, we compared depressed and nondepressed individuals to
identify differences in health care use and expenditures. Third, we adjusted use and expenditure
estimates for differences in age, sex, race/ethnicity, health insurance, and comorbidity with
analysis of covariance. Finally, we used the Consumer Price Index to adjust expenditures for
inflation and used SAS and SUDAAN software for statistical analyses.
Results: Individuals with diabetes were twice as likely as a comparable sample from the
general U.S. population to have diagnosed depression (odds ratio 1.9, 95% CI 1.5-2.5). Younger
adults (<65 years), women, and unmarried individuals with diabetes were more likely to have
depression. Patients with diabetes and depression had higher ambulatory care use (12 vs. 7,
P < 0.0001) and filled more prescriptions (43 vs. 21, P < 0.0001) than their counterparts
without depression. Finally, among individuals with diabetes, total health care expenditures for
individuals with depression was 4.5 times higher than that for individuals without depression
($247,000,000 vs. $55,000,000, P < 0.0001).
Conclusions: The odds of depression are higher in individuals with diabetes than in those without
diabetes. Depression in individuals with diabetes is associated with increased health care use and
expenditures, even after adjusting for differences in age, sex, race/ethnicity, health insurance,
and comorbidity.
3) My concerns about the overlap of the questionnaires have remained.