# Effects of Routine Checkups and Chronic Conditions on Middle-Aged Patients with Diabetes

Authors: America E. McGuffee; Kailyn Chillag; Amber Johnson; Regan Richardson; Hallie Williams; Jessica Hartos
Journal: Advances in Preventive Medicine
 (2020)

---

## Abstract

Purpose. Middle-aged males and females with diabetes are more likely to have poor physical (PH) and mental health (MH); however, there is limited research determining the relationship between MH and PH and routine check-up in diabetic middle-aged adults, especially by gender. The purpose of this study was to determine whether PH and MH status differ by routine check-up in middle-aged (age 45–64) adults with diabetes in the general population. Methods. This cross-sectional analysis used data from the 2017 BRFSS conducted by the CDC for adults aged 45–64 who reported having diabetes in Florida (N
=
1183), Kentucky (N
=
617), Maryland (N
=
731), New York (N
=
593), and Ohio (N
=
754). Multiple logistic regression by state and gender was used to determine the relationship between MH and PH status and routine check-up while controlling for health-related, socioeconomic, and demographic factors. Results. Across states, up to one-half reported good PH (32–50%), over one-half reported good MH (46–67%), and most reported having a routine check-up (87–93%). Adjusted analysis indicated that MH and PH were not significantly related to routine check-up, but both were inversely related to having diabetes plus two other health conditions. Conclusions. Overall, routine check-up was not related to good PH and MH in this target population; however, a number of health conditions were inversely related to good PH and MH status. In a primary care setting for this target population, there may be a low to moderate prevalence of good PH and MH and a high prevalence of having a routine check-up and having multiple health conditions. It is recommended to automatically screen this target population for PH, MH, other chronic conditions, and physical activity and treat concurrently.


---

## Body

## 1. Introduction

Through utilization of preventative health examinations and routine checkups, the most common chronic physical and mental health conditions can be prevented, delayed, or treated more effectively [6, 11]. Visits of this type are linked with improved physical and mental health outcomes [4, 5, 14] as well as to improvements in health-related quality of life (HRQoL) and control over diseases [10]. However, research indicates that both engagement in preventative health checks and overall perception of one’s health differ based on demographic factors, socioeconomic status, health insurance coverage, lifestyle factors, and disease burden [4, 5, 9, 10, 12–14].Diabetes is a significant component of the disease burden in the US as it affects up to 30 million adults, and of those, up to 7 million may be undiagnosed (not aware of or did not report having DM) [2]. Because this condition is chronic and progressive, it can lead to other physical and mental health complications over time [10–12, 14] . In addition, those with diabetes report lower HRQoL ratings than do individuals without chronic illnesses [10]. Thus, annual or more frequent checkups would be necessary for persons with diabetes as research indicates that preventative care decreases both the prevalence and progression of this condition [6].However, research for associations between routine checkups and physical or mental health tends to focus on older adults/Medicare users [4–6], with no studies assessing these relations for differences by gender [9, 12–14] or by diabetes status [4, 7, 8]. Therefore, the purpose of this study is to assess whether physical and mental health differ by receiving a routine checkup in middle-aged males and females with diabetes.


## 2. Methods

### 2.1. Design

This study is a cross-sectional analysis that used data from the 2017 Behavioral Risk Factor Surveillance System (BRFSS) conducted by the Centers for Disease Control and Prevention (CDC) [3]. BRFSS is an annual telephone survey system that uses random digit dialing techniques for both landlines and cell phones across all 50 states in the US and the District of Columbia. This survey gathers data about US adult residents’ health-related behaviors, chronic health conditions, and use of preventative services. The CDC compiles all BRFSS data and makes deidentified data available for secondary analysis by researchers. This study was given exempt status by the Institutional Review Board of The University of North Texas Health Science Center.


### 2.2. Sample

The samples in the study include males and females with diabetes between the ages of 45 and 64 in Florida (N
=
1183), Kentucky (N
=
617), Maryland (N
=
731), New York (N
=
593), and Ohio (N
=
754) that had data for mental health, physical health, and routine checkup.These states were chosen because they had a large diabetic population and higher rates of fair/poor health status when compared to the other states [1].


### 2.3. Data

The original BRFSS variables for mental and physical health were determined by asking participants to self-report the number of “poor health days” in the past 30 days separately for mental health and physical health. Because these responses were highly skewed toward 0 days in each state and because we wanted to predict “good” health, we reversed and dichotomized these values to represent “yes” (30 days of good health in the past 30 days) or “no” (fewer than 30 days of good health in the past 30 days) separately for “good mental health” and “good physical health.” The factor of interest, routine check-up, was measured as yes/no to having a checkup in the past year.All models controlled for physical activity, weight status, tobacco use, alcohol use, education level, income level, employment status, age, ethnicity/race, and marital status. Health conditions were measured as the number of “yes” responses to whether participants had any of the following: heart attack, coronary heart disease, stroke, asthma, skin cancer, cancer, COPD, arthritis, depression, kidney disease, and diabetes. The resulting numbers were then categorized as “diabetes only,” “diabetes plus one other chronic condition,” and “diabetes plus two other chronic conditions.” Alcohol use was measured in BRFSS as number of drinks per day and we categorized the numbers as “none,” “light” (<1), and “moderate or excessive” (1–4+ females, 1–5+ males). All variables and their categories are shown in Table1(a).


### 2.4. Analysis

Frequency distributions by state were used to describe the samples. Multiple logistic regression was conducted by state and gender to determine the relationship between mental and physical health status and routine check-up while controlling for health-related, socioeconomic, and demographic factors. The state and gender data were analyzed separately to determine the relationship between the variables across multiple similar samples within our population of interest. As such, similar results in three out of five states were considered reliable evidence for relations. Any observations with missing data for any variable were excluded from the adjusted analysis and all analyses were conducted in STATA Version 15.1 (Copyright 1985–2017 StataCorp LLC).


## 2.1. Design

This study is a cross-sectional analysis that used data from the 2017 Behavioral Risk Factor Surveillance System (BRFSS) conducted by the Centers for Disease Control and Prevention (CDC) [3]. BRFSS is an annual telephone survey system that uses random digit dialing techniques for both landlines and cell phones across all 50 states in the US and the District of Columbia. This survey gathers data about US adult residents’ health-related behaviors, chronic health conditions, and use of preventative services. The CDC compiles all BRFSS data and makes deidentified data available for secondary analysis by researchers. This study was given exempt status by the Institutional Review Board of The University of North Texas Health Science Center.


## 2.2. Sample

The samples in the study include males and females with diabetes between the ages of 45 and 64 in Florida (N
=
1183), Kentucky (N
=
617), Maryland (N
=
731), New York (N
=
593), and Ohio (N
=
754) that had data for mental health, physical health, and routine checkup.These states were chosen because they had a large diabetic population and higher rates of fair/poor health status when compared to the other states [1].


## 2.3. Data

The original BRFSS variables for mental and physical health were determined by asking participants to self-report the number of “poor health days” in the past 30 days separately for mental health and physical health. Because these responses were highly skewed toward 0 days in each state and because we wanted to predict “good” health, we reversed and dichotomized these values to represent “yes” (30 days of good health in the past 30 days) or “no” (fewer than 30 days of good health in the past 30 days) separately for “good mental health” and “good physical health.” The factor of interest, routine check-up, was measured as yes/no to having a checkup in the past year.All models controlled for physical activity, weight status, tobacco use, alcohol use, education level, income level, employment status, age, ethnicity/race, and marital status. Health conditions were measured as the number of “yes” responses to whether participants had any of the following: heart attack, coronary heart disease, stroke, asthma, skin cancer, cancer, COPD, arthritis, depression, kidney disease, and diabetes. The resulting numbers were then categorized as “diabetes only,” “diabetes plus one other chronic condition,” and “diabetes plus two other chronic conditions.” Alcohol use was measured in BRFSS as number of drinks per day and we categorized the numbers as “none,” “light” (<1), and “moderate or excessive” (1–4+ females, 1–5+ males). All variables and their categories are shown in Table1(a).


## 2.4. Analysis

Frequency distributions by state were used to describe the samples. Multiple logistic regression was conducted by state and gender to determine the relationship between mental and physical health status and routine check-up while controlling for health-related, socioeconomic, and demographic factors. The state and gender data were analyzed separately to determine the relationship between the variables across multiple similar samples within our population of interest. As such, similar results in three out of five states were considered reliable evidence for relations. Any observations with missing data for any variable were excluded from the adjusted analysis and all analyses were conducted in STATA Version 15.1 (Copyright 1985–2017 StataCorp LLC).


## 3. Results

### 3.1. Participant Characteristics: Males with Diabetes

Table1(b) lists participant characteristics for middle-aged males with diabetes. The majority of participants had attended a routine medical checkup within the past year (87–90%) and reported good mental health (56–67%), but less than half reported good physical health (37–50%). Regarding health conditions, most participants had diabetes plus two or more chronic illnesses (71–84%) and were obese (54–63%), yet less than half reported being inactive (33–47%). Regarding health behaviors, one-third to one-half of participants did not use tobacco products (34–55%) or alcohol (47–69%). For demographics, the majority of participants were married (48–60%) and reported their race as white (56–87%). As for socioeconomic status, the majority of respondents had not graduated from college or technical school (67–77%), approximately half were employed (40–59%), and up to two-thirds earned an income of $50,000 or more (40–69%).Table 1
(a)
Participant characteristics by state: diabetic males.
Variable
Florida (N
=
516)
Kentucky (N
=
236)
Maryland (N
=
311)
New York (N
=
300)
Ohio (N
=
323)
N
%
N
%
N
%
N
%
N
%
Good mental health
516
100
236
100
311
100
300
100
323
100
Yes
333
65
131
56
207
67
199
66
209
65
No
183
35
105
44
104
33
101
34
114
35
Good physical health
516
100
236
100
311
100
300
100
323
100
Yes
232
45
87
37
154
50
141
47
142
44
No
284
55
149
63
157
50
159
53
181
56
Routine checkup
516
100
236
100
311
100
300
100
323
100
Yes
451
87
213
90
280
90
268
89
292
90
No
65
13
23
10
31
10
32
11
31
10
Health conditions
475
92
218
92
296
95
286
95
302
93
0 or 1 other health condition
101
21
34
16
67
23
84
29
55
18
2 other health conditions
374
79
184
84
229
77
202
71
247
82
Physical activity
461
89
214
91
270
87
248
83
300
93
Inactive
195
42
101
47
90
33
95
38
126
42
Insufficiently active
90
20
48
22
60
22
52
21
62
21
Active/Highly active
176
38
65
30
120
44
101
41
112
37
Weight status
487
94
230
97
295
95
287
96
315
98
Underweight or normal
53
11
27
12
34
12
32
11
34
11
Overweight
149
31
64
28
83
28
99
34
83
26
Obese
285
59
139
60
178
60
156
54
198
63
Tobacco use
495
96
229
97
296
95
277
92
315
98
Never
221
45
78
34
149
50
151
55
154
49
Former
182
37
82
36
90
30
85
31
113
36
Current
92
19
69
30
57
19
41
15
48
15
Alcohol use
495
96
228
97
298
96
293
98
313
97
None
299
60
157
69
146
49
138
47
182
58
Light
57
12
27
12
42
14
46
16
42
13
Moderate or excessive
139
28
44
19
110
37
109
37
89
28
Age
516
100
236
100
311
100
300
100
323
100
45–54
176
34
76
32
107
34
103
34
83
26
55–64
340
66
160
68
204
66
197
66
240
74
Ethnicity/Race
506
98
234
99
304
98
288
96
313
97
White
328
65
186
79
191
63
162
56
272
87
Other
178
35
48
21
113
37
126
44
41
13
Marital status
511
99
235
99
310
100
299
100
321
99
Married
292
57
130
55
187
60
145
48
190
59
Not married
219
43
105
45
123
40
154
52
131
41
Education level
515
100
233
99
310
100
297
99
321
99
Graduated college
126
25
56
24
209
33
93
31
75
23
Did not graduate college
389
76
177
76
101
67
204
69
246
77
Income level
464
90
182
77
272
87
272
91
287
89
$50,000 or more
142
31
65
36
164
60
103
38
123
43
Less than $50,000
322
69
117
64
108
40
169
62
164
57
Employment status
512
99
235
99
309
99
291
97
322
99
Employed
217
42
94
40
181
59
147
51
154
48
Other
295
58
141
60
128
41
144
49
158
52
(b)
Participant characteristics by state: females with diabetes.
Variable
Florida (N
=
667)
Kentucky (N
=
381)
Maryland (N
=
420)
New York (N
=
293)
Ohio (N
=
431)
N
%
N
%
N
%
N
%
N
%
Good mental health
667
100
381
100
420
100
293
100
431
100
Yes
331
50
197
52
232
55
134
46
205
48
No
336
50
184
48
188
45
159
54
226
52
Good physical health
667
100
381
100
420
100
293
100
431
100
Yes
258
39
123
32
193
46
96
33
162
38
No
409
61
258
68
227
54
197
67
269
62
Routine checkup
667
100
381
100
420
100
293
100
431
100
Yes
580
87
353
93
372
89
267
91
391
91
No
87
13
28
7
48
11
26
9
40
9
Health conditions
605
91
355
90
398
95
274
94
395
92
0 or 1 other health condition
115
19
51
14
78
20
52
19
62
16
2 other health conditions
490
81
304
86
320
80
222
81
333
84
Physical activity
610
91
344
90
365
87
250
85
401
93
Inactive
294
48
189
55
150
41
107
43
198
49
Insufficiently active
116
19
872
21
74
20
5
22
83
21
Active/Highly active
200
33
83
24
141
39
88
35
120
30
Weight status
589
88
335
88
378
90
270
92
388
90
Underweight or normal
91
15
44
13
4343
11
41
15
31
8
Overweight
147
25
92
27
90
24
73
27
94
24
Obese
351
60
199
59
245
65
156
58
263
68
Tobacco use
643
96
375
98
398
95
275
94
422
98
Never
325
51
180
48
232
58
143
52
211
50
Former
166
26
108
29
105
26
78
28
111
26
Current
152
24$
87
23
61
15
54
20
100
24
Alcohol use
656
98
379
99
410
98
284
97
420
97
None
473
72
303
80
227
55
143
60
307
73
Light
68
10
35
9^
85
21
78
14
64
15
Moderate or excessive
115
18
41
11
98
24
54
26
49
12
Age
667
100
381
100
420
100
293
100
431
100
45–54
234
35
140
37
140
33
120
41
134
31
55–64
433
65
241
63
280
67
173
59
297
69
Ethnicity/Race
651
98
377
99
416
99
279
95
427
99
White
426
65
309
82
230
55
162
58
348
82
Other
225
35
68
18
186
44
117
42
79
19
Marital status
666
100
379
99
417
99
288
98
429
100
Married
300
45
196
52
200
48
118
41
205
48
Not married
366
55
183
48
217
52
170
59
224
52
Education level
667
100
380
100
420
100
291
99
429
100
Graduated college
137
21
83
22
142
34
92
32
95
22
Did not graduate college
530
79
297
78
278
66
199
68
334
78
Income level
544
82
268
70
357
85
256
86
372
86
$50,000 or more
130
24
94
35
179
50
86
34
117
31
Less than $50,000
414
76
174
65
178
50
170
66
255
69
Employment status
662
99
379
99
418
100
287
98
430
100
Employed
235
36
133
35
213
51
128
45
164
38
Other
427
65
246
65
205
49
159
55
266
62


### 3.2. Participant Characteristics: Females with Diabetes

Table1(a) lists participant characteristics for middle-aged females with diabetes. Most participants reported having a routine checkup within the past year (87–93%). About half of the participants reported good mental health (46–55%) and less than half reported good physical health (32–46%). Regarding health conditions, most participants had diabetes plus two or more chronic conditions (80–86%) and were obese (58–68%), and about one-third to one-half reported being inactive (41–55%). Regarding health behaviors, the majority of participants reported no tobacco (48–58%) or alcohol use (55–80%). For demographics, a range of participants reported their race as white (55–82%) and around one half were married (41–52%). As for socioeconomic status, the majority of respondents had not graduated from college or technical school (66–79%) and earned an income of less than $50,000 (50–76%), while one-third to one-half of participants were employed (35–51%).


### 3.3. Mental Health: Males

As shown in Table2(a), the results of multiple logistic regression analysis for middle-aged males with diabetes indicated that after controlling for all other variables in the model, good mental health was significantly related to having had routine checkups in only 1 out of 5 states, which was not considered a reliable finding across states as was defined in the methods section.Table 2
(a)
Results of multiple logistic regression analyses across states: males.
Predicting good mental health (yes vs. no)
Florida
Kentucky
Maryland
New York
Ohio
AOR
95% CI
AOR
95% CI
AOR
95% CI
AOR
95% CI
AOR
95% CI
Low
High
Low
High
Low
High
Low
High
Low
High
Routine check-up
No
Ref
—
—
Ref
—
—
Ref
—
—
Ref
—
—
ref
—
—
Yes
1.27
0.64
2.50
4.43
1.07
18.45
2.06
0.73
5.82
2.02
0.68
5.98
0.95
0.35
2.61
Health conditions
0 or 1 other health condition
Ref
—
—
Ref
—
—
Ref
—
—
Ref
—
—
Ref
—
—
2 other health conditions
0.24
0.10
0.54
1.04
0.25
4.25
0.51
0.20
1.28
0.23
0.92
0.55
0.78
0 .33
1.84
Predicting good physical health (yes vs. no)
Florida
Kentucky
Maryland
New York
Ohio
AOR
95% CI
AOR
95% CI
AOR
95% CI
AOR
95% CI
AOR
95% CI
Low
High
Low
High
Low
High
Low
High
Low
High
Routine check-up
No
Ref
—
—
Ref
—
—
Ref
Ref
—
—
ref
—
—
Yes
0.59
0.29
1.18
2.39
0.53
10.77
1.39
0.50
3.86
2.55
0.84
7.76
1.48
0.54
4.03
Health conditions
0 or 1 other health condition
Ref
—
—
Ref
—
—
Ref
—
—
Ref
—
—
Ref
—
—
2 other health conditions
0.18
0.09
0.37
0.08
0.01
0.48
0.41
0.18
0.96
0.39
0.18
0.88
0.95
0.42
2.11
Note.AOR = adjusted odds ratio; 95% CI = 95% confidence intervals; Ref = referent group; boldface indicates significance (AORs with 95% CI that do not include 1.00 are significant). All models controlled for physical activity, weight status, tobacco use, alcohol use, age, ethnicity/race, marital status, education level, income level and employment status.
(b)
Results of multiple logistic regression analyses across states: females.
Predicting good mental health (yes vs. no)
Florida
Kentucky
Maryland
New York
Ohio
AOR
95% CI
AOR
95% CI
AOR
95% CI
AOR
95% CI
AOR
95% CI
Low
High
Low
High
Low
High
Low
High
Low
High
Routine check-up
No
ref
—
—
ref
—
—
ref
—
—
ref
—
—
ref
—
—
Yes
1.39
0.71
2.73
1.05
0.31
3.61
0.56
0.22
1.41
4.58
1.24
16.91
0.85
0.34
2.10
Health conditions
0 or 1 other health condition
ref
—
—
ref
—
—
ref
—
—
ref
—
—
ref
—
—
2 other health conditions
0.27
0.14
0.52
0.26
0.09
0.76
0.35
0.16
0.77
0.51
0.21
1.29
0.30
0.13
0.67
Predicting good physical health (yes vs. no)
Florida
Kentucky
Maryland
New York
Ohio
AOR
95% CI
AOR
95% CI
AOR
95% CI
AOR
95% CI
AOR
95% CI
Low
High
Low
High
Low
High
Low
High
Low
High
Routine check-up
No
ref
—
—
ref
—
—
ref
—
—
ref
—
—
ref
—
—
Yes
1.36
0.65
2.87
2.16
0.55
8.49
0.77
0.33
1.80
0.54
0.17
1.71
1.06
0.40
2.77
Health conditions
0 or 1 other health condition
ref
—
—
ref
—
—
ref
—
—
ref
—
—
ref
—
—
2 other health conditions
0.33
0.18
0.61
0.11
0.04
0.33
0.59
0.30
1.17
0.14
0.05
0.39
0.35
0.16
0.78
Note.AOR = adjusted odds ratio; 95% CI = 95% confidence intervals; Ref = referent group; boldface indicates significance (AORs with 95% CI that do not include 1.00 are significant).


### 3.4. Physical Health: Males

Also shown in Table2(a), the results of multiple logistic regression analysis for middle-aged males with diabetes indicated that after controlling for all other variables in the model, good physical health was not significantly related to routine checkups across in any state. However, those who reported having diabetes plus two or more other chronic conditions were about 2.5–12.5 times less likely to report good physical health compared to those who reported diabetes only across states.


### 3.5. Mental Health: Females

As shown in Table2(b), the results of multiple logistic regression analysis for middle-aged females with diabetes indicated that after controlling for all other variables in the model, good mental health was significantly related to having routine checkups in only 1 out of the 5 states, which was not considered a reliable finding across similar samples. However, compared to those with only diabetes, those who reported having diabetes plus two or more other chronic conditions were approximately three to four times less likely to report good mental health compared to those who reported having diabetes only in a majority of the states.


### 3.6. Physical Health: Females

Also shown in Table2(b), the results of multiple logistic regression analysis for middle-aged females with diabetes indicated that after controlling for all other variables in the model, good physical health was not significantly related to routine checkup across states. However, those who reported having diabetes plus two or more other chronic conditions were about 3–9 times less likely to report good physical health compared to those who reported having diabetes only in the majority of the states.


## 3.1. Participant Characteristics: Males with Diabetes

Table1(b) lists participant characteristics for middle-aged males with diabetes. The majority of participants had attended a routine medical checkup within the past year (87–90%) and reported good mental health (56–67%), but less than half reported good physical health (37–50%). Regarding health conditions, most participants had diabetes plus two or more chronic illnesses (71–84%) and were obese (54–63%), yet less than half reported being inactive (33–47%). Regarding health behaviors, one-third to one-half of participants did not use tobacco products (34–55%) or alcohol (47–69%). For demographics, the majority of participants were married (48–60%) and reported their race as white (56–87%). As for socioeconomic status, the majority of respondents had not graduated from college or technical school (67–77%), approximately half were employed (40–59%), and up to two-thirds earned an income of $50,000 or more (40–69%).Table 1
(a)
Participant characteristics by state: diabetic males.
Variable
Florida (N
=
516)
Kentucky (N
=
236)
Maryland (N
=
311)
New York (N
=
300)
Ohio (N
=
323)
N
%
N
%
N
%
N
%
N
%
Good mental health
516
100
236
100
311
100
300
100
323
100
Yes
333
65
131
56
207
67
199
66
209
65
No
183
35
105
44
104
33
101
34
114
35
Good physical health
516
100
236
100
311
100
300
100
323
100
Yes
232
45
87
37
154
50
141
47
142
44
No
284
55
149
63
157
50
159
53
181
56
Routine checkup
516
100
236
100
311
100
300
100
323
100
Yes
451
87
213
90
280
90
268
89
292
90
No
65
13
23
10
31
10
32
11
31
10
Health conditions
475
92
218
92
296
95
286
95
302
93
0 or 1 other health condition
101
21
34
16
67
23
84
29
55
18
2 other health conditions
374
79
184
84
229
77
202
71
247
82
Physical activity
461
89
214
91
270
87
248
83
300
93
Inactive
195
42
101
47
90
33
95
38
126
42
Insufficiently active
90
20
48
22
60
22
52
21
62
21
Active/Highly active
176
38
65
30
120
44
101
41
112
37
Weight status
487
94
230
97
295
95
287
96
315
98
Underweight or normal
53
11
27
12
34
12
32
11
34
11
Overweight
149
31
64
28
83
28
99
34
83
26
Obese
285
59
139
60
178
60
156
54
198
63
Tobacco use
495
96
229
97
296
95
277
92
315
98
Never
221
45
78
34
149
50
151
55
154
49
Former
182
37
82
36
90
30
85
31
113
36
Current
92
19
69
30
57
19
41
15
48
15
Alcohol use
495
96
228
97
298
96
293
98
313
97
None
299
60
157
69
146
49
138
47
182
58
Light
57
12
27
12
42
14
46
16
42
13
Moderate or excessive
139
28
44
19
110
37
109
37
89
28
Age
516
100
236
100
311
100
300
100
323
100
45–54
176
34
76
32
107
34
103
34
83
26
55–64
340
66
160
68
204
66
197
66
240
74
Ethnicity/Race
506
98
234
99
304
98
288
96
313
97
White
328
65
186
79
191
63
162
56
272
87
Other
178
35
48
21
113
37
126
44
41
13
Marital status
511
99
235
99
310
100
299
100
321
99
Married
292
57
130
55
187
60
145
48
190
59
Not married
219
43
105
45
123
40
154
52
131
41
Education level
515
100
233
99
310
100
297
99
321
99
Graduated college
126
25
56
24
209
33
93
31
75
23
Did not graduate college
389
76
177
76
101
67
204
69
246
77
Income level
464
90
182
77
272
87
272
91
287
89
$50,000 or more
142
31
65
36
164
60
103
38
123
43
Less than $50,000
322
69
117
64
108
40
169
62
164
57
Employment status
512
99
235
99
309
99
291
97
322
99
Employed
217
42
94
40
181
59
147
51
154
48
Other
295
58
141
60
128
41
144
49
158
52
(b)
Participant characteristics by state: females with diabetes.
Variable
Florida (N
=
667)
Kentucky (N
=
381)
Maryland (N
=
420)
New York (N
=
293)
Ohio (N
=
431)
N
%
N
%
N
%
N
%
N
%
Good mental health
667
100
381
100
420
100
293
100
431
100
Yes
331
50
197
52
232
55
134
46
205
48
No
336
50
184
48
188
45
159
54
226
52
Good physical health
667
100
381
100
420
100
293
100
431
100
Yes
258
39
123
32
193
46
96
33
162
38
No
409
61
258
68
227
54
197
67
269
62
Routine checkup
667
100
381
100
420
100
293
100
431
100
Yes
580
87
353
93
372
89
267
91
391
91
No
87
13
28
7
48
11
26
9
40
9
Health conditions
605
91
355
90
398
95
274
94
395
92
0 or 1 other health condition
115
19
51
14
78
20
52
19
62
16
2 other health conditions
490
81
304
86
320
80
222
81
333
84
Physical activity
610
91
344
90
365
87
250
85
401
93
Inactive
294
48
189
55
150
41
107
43
198
49
Insufficiently active
116
19
872
21
74
20
5
22
83
21
Active/Highly active
200
33
83
24
141
39
88
35
120
30
Weight status
589
88
335
88
378
90
270
92
388
90
Underweight or normal
91
15
44
13
4343
11
41
15
31
8
Overweight
147
25
92
27
90
24
73
27
94
24
Obese
351
60
199
59
245
65
156
58
263
68
Tobacco use
643
96
375
98
398
95
275
94
422
98
Never
325
51
180
48
232
58
143
52
211
50
Former
166
26
108
29
105
26
78
28
111
26
Current
152
24$
87
23
61
15
54
20
100
24
Alcohol use
656
98
379
99
410
98
284
97
420
97
None
473
72
303
80
227
55
143
60
307
73
Light
68
10
35
9^
85
21
78
14
64
15
Moderate or excessive
115
18
41
11
98
24
54
26
49
12
Age
667
100
381
100
420
100
293
100
431
100
45–54
234
35
140
37
140
33
120
41
134
31
55–64
433
65
241
63
280
67
173
59
297
69
Ethnicity/Race
651
98
377
99
416
99
279
95
427
99
White
426
65
309
82
230
55
162
58
348
82
Other
225
35
68
18
186
44
117
42
79
19
Marital status
666
100
379
99
417
99
288
98
429
100
Married
300
45
196
52
200
48
118
41
205
48
Not married
366
55
183
48
217
52
170
59
224
52
Education level
667
100
380
100
420
100
291
99
429
100
Graduated college
137
21
83
22
142
34
92
32
95
22
Did not graduate college
530
79
297
78
278
66
199
68
334
78
Income level
544
82
268
70
357
85
256
86
372
86
$50,000 or more
130
24
94
35
179
50
86
34
117
31
Less than $50,000
414
76
174
65
178
50
170
66
255
69
Employment status
662
99
379
99
418
100
287
98
430
100
Employed
235
36
133
35
213
51
128
45
164
38
Other
427
65
246
65
205
49
159
55
266
62


## 3.2. Participant Characteristics: Females with Diabetes

Table1(a) lists participant characteristics for middle-aged females with diabetes. Most participants reported having a routine checkup within the past year (87–93%). About half of the participants reported good mental health (46–55%) and less than half reported good physical health (32–46%). Regarding health conditions, most participants had diabetes plus two or more chronic conditions (80–86%) and were obese (58–68%), and about one-third to one-half reported being inactive (41–55%). Regarding health behaviors, the majority of participants reported no tobacco (48–58%) or alcohol use (55–80%). For demographics, a range of participants reported their race as white (55–82%) and around one half were married (41–52%). As for socioeconomic status, the majority of respondents had not graduated from college or technical school (66–79%) and earned an income of less than $50,000 (50–76%), while one-third to one-half of participants were employed (35–51%).


## 3.3. Mental Health: Males

As shown in Table2(a), the results of multiple logistic regression analysis for middle-aged males with diabetes indicated that after controlling for all other variables in the model, good mental health was significantly related to having had routine checkups in only 1 out of 5 states, which was not considered a reliable finding across states as was defined in the methods section.Table 2
(a)
Results of multiple logistic regression analyses across states: males.
Predicting good mental health (yes vs. no)
Florida
Kentucky
Maryland
New York
Ohio
AOR
95% CI
AOR
95% CI
AOR
95% CI
AOR
95% CI
AOR
95% CI
Low
High
Low
High
Low
High
Low
High
Low
High
Routine check-up
No
Ref
—
—
Ref
—
—
Ref
—
—
Ref
—
—
ref
—
—
Yes
1.27
0.64
2.50
4.43
1.07
18.45
2.06
0.73
5.82
2.02
0.68
5.98
0.95
0.35
2.61
Health conditions
0 or 1 other health condition
Ref
—
—
Ref
—
—
Ref
—
—
Ref
—
—
Ref
—
—
2 other health conditions
0.24
0.10
0.54
1.04
0.25
4.25
0.51
0.20
1.28
0.23
0.92
0.55
0.78
0 .33
1.84
Predicting good physical health (yes vs. no)
Florida
Kentucky
Maryland
New York
Ohio
AOR
95% CI
AOR
95% CI
AOR
95% CI
AOR
95% CI
AOR
95% CI
Low
High
Low
High
Low
High
Low
High
Low
High
Routine check-up
No
Ref
—
—
Ref
—
—
Ref
Ref
—
—
ref
—
—
Yes
0.59
0.29
1.18
2.39
0.53
10.77
1.39
0.50
3.86
2.55
0.84
7.76
1.48
0.54
4.03
Health conditions
0 or 1 other health condition
Ref
—
—
Ref
—
—
Ref
—
—
Ref
—
—
Ref
—
—
2 other health conditions
0.18
0.09
0.37
0.08
0.01
0.48
0.41
0.18
0.96
0.39
0.18
0.88
0.95
0.42
2.11
Note.AOR = adjusted odds ratio; 95% CI = 95% confidence intervals; Ref = referent group; boldface indicates significance (AORs with 95% CI that do not include 1.00 are significant). All models controlled for physical activity, weight status, tobacco use, alcohol use, age, ethnicity/race, marital status, education level, income level and employment status.
(b)
Results of multiple logistic regression analyses across states: females.
Predicting good mental health (yes vs. no)
Florida
Kentucky
Maryland
New York
Ohio
AOR
95% CI
AOR
95% CI
AOR
95% CI
AOR
95% CI
AOR
95% CI
Low
High
Low
High
Low
High
Low
High
Low
High
Routine check-up
No
ref
—
—
ref
—
—
ref
—
—
ref
—
—
ref
—
—
Yes
1.39
0.71
2.73
1.05
0.31
3.61
0.56
0.22
1.41
4.58
1.24
16.91
0.85
0.34
2.10
Health conditions
0 or 1 other health condition
ref
—
—
ref
—
—
ref
—
—
ref
—
—
ref
—
—
2 other health conditions
0.27
0.14
0.52
0.26
0.09
0.76
0.35
0.16
0.77
0.51
0.21
1.29
0.30
0.13
0.67
Predicting good physical health (yes vs. no)
Florida
Kentucky
Maryland
New York
Ohio
AOR
95% CI
AOR
95% CI
AOR
95% CI
AOR
95% CI
AOR
95% CI
Low
High
Low
High
Low
High
Low
High
Low
High
Routine check-up
No
ref
—
—
ref
—
—
ref
—
—
ref
—
—
ref
—
—
Yes
1.36
0.65
2.87
2.16
0.55
8.49
0.77
0.33
1.80
0.54
0.17
1.71
1.06
0.40
2.77
Health conditions
0 or 1 other health condition
ref
—
—
ref
—
—
ref
—
—
ref
—
—
ref
—
—
2 other health conditions
0.33
0.18
0.61
0.11
0.04
0.33
0.59
0.30
1.17
0.14
0.05
0.39
0.35
0.16
0.78
Note.AOR = adjusted odds ratio; 95% CI = 95% confidence intervals; Ref = referent group; boldface indicates significance (AORs with 95% CI that do not include 1.00 are significant).


## 3.4. Physical Health: Males

Also shown in Table2(a), the results of multiple logistic regression analysis for middle-aged males with diabetes indicated that after controlling for all other variables in the model, good physical health was not significantly related to routine checkups across in any state. However, those who reported having diabetes plus two or more other chronic conditions were about 2.5–12.5 times less likely to report good physical health compared to those who reported diabetes only across states.


## 3.5. Mental Health: Females

As shown in Table2(b), the results of multiple logistic regression analysis for middle-aged females with diabetes indicated that after controlling for all other variables in the model, good mental health was significantly related to having routine checkups in only 1 out of the 5 states, which was not considered a reliable finding across similar samples. However, compared to those with only diabetes, those who reported having diabetes plus two or more other chronic conditions were approximately three to four times less likely to report good mental health compared to those who reported having diabetes only in a majority of the states.


## 3.6. Physical Health: Females

Also shown in Table2(b), the results of multiple logistic regression analysis for middle-aged females with diabetes indicated that after controlling for all other variables in the model, good physical health was not significantly related to routine checkup across states. However, those who reported having diabetes plus two or more other chronic conditions were about 3–9 times less likely to report good physical health compared to those who reported having diabetes only in the majority of the states.


## 4. Discussion

The purpose of this study was to determine whether physical and mental health status differ by routine checkup in middle-aged males and females with diabetes. For this target population, both good mental and physical health did not significantly differ related to having routine checkups across states. These results differ from prior research which showed that preventative care is related to both improved depressive symptoms and the perception of good overall health [4, 5, 11]. The differences in findings may be due to differing target populations. While our results focus on patients with diabetes, previous research focused on the general population as a whole. Therefore, it is possible that prevention efforts were in place as most of the patients were already under medical care. Thus, to our knowledge, our study is the first to focus only on middle-aged patients with diabetes as related to regular checkups.However, the results of this study did show that for middle-aged males and females with diabetes, good physical and mental health were inversely related to having diabetes plus two or more other health conditions. This is generally consistent with prior research that showed chronic illnesses to be related to lower overall health in the general population [12]. As prior research focused primarily on the general population, our study focuses solely on middle-aged people with diabetes. For this target population, the comanagement and treatment of multiple chronic conditions may have a significant impact on their mental and physical health, and the assessment of comorbid conditions should be a focus for their care.


### 4.1. Limitations

The use of BRFFS data provided large, multiple samples to evaluate both physical and mental health (instead of “general” health) and separately for males and females (instead of together), which allowed us to determine whether patterns in variable relations were similar for different facets of health and by gender. In addition, BRFSS also provided current information, given that our dependent variables (mental and physical health) were measured within the last 30 days. However, BRFSS did not include variables that provided information about (1) current treatment and management of any mental or physical health condition, (2) current treatment and management of diabetes specifically, or (3) current management and severity of the chronic illnesses in addition to diabetes, all of which could have an impact upon mental and physical health. Future studies should include information about the current management and treatment of any mental and physical health conditions and should consider the influence of specific disease management and medication use in relation to its impact on mental and physical health in diabetics.


## 4.1. Limitations

The use of BRFFS data provided large, multiple samples to evaluate both physical and mental health (instead of “general” health) and separately for males and females (instead of together), which allowed us to determine whether patterns in variable relations were similar for different facets of health and by gender. In addition, BRFSS also provided current information, given that our dependent variables (mental and physical health) were measured within the last 30 days. However, BRFSS did not include variables that provided information about (1) current treatment and management of any mental or physical health condition, (2) current treatment and management of diabetes specifically, or (3) current management and severity of the chronic illnesses in addition to diabetes, all of which could have an impact upon mental and physical health. Future studies should include information about the current management and treatment of any mental and physical health conditions and should consider the influence of specific disease management and medication use in relation to its impact on mental and physical health in diabetics.


## 5. Conclusions

Because this study used population-based data, the results may generalize to males and females aged 45–64 with diabetes. Regarding the optimization of patient’s mental and physical health, we recommend automatic mental and physical health screening for adults aged 45–64 with diabetes as well as screening for other chronic health conditions. General practitioners should assess comorbid conditions and treatments, refer to specialists as needed, and educate patients on the importance of proper management of diabetes in combination with any other chronic illnesses for maintaining good mental and physical health.



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*Source: 4043959-2020-02-26.xml*