The Moderating Role of Social Support on the Predictive Relationship between Diabetes Distress and Fatigue among T2DM Patients

The Moderating Role of Social Support on the Predictive Relationship between Diabetes Distress and Fatigue among T2DM Patients

Abstract

The present study investigated the moderating role of social support on the predictive relationship between diabetes distress and fatigue among T2DM patients. A cross-sectional survey design was adopted for the study.

The findings from regression moderation model showed that diabetes distress (across dimensions) did not significantly predict fatigue.  Social support moderated the relationship between diabetes distress and fatigue in the regimen distress and interpersonal distress dimensions of diabetes distress. Social support did not however moderate the association between diabetes distress and fatigue in the emotional burden and physician distress dimensions.

In conclusion, social support was found to strengthen the interactive relationship between diabetes distress and fatigue among T2DM patients in the positive direction. Hence, as social support increases, fatigability and distress symptoms increase as well.

This signals the need for caution in administering social support as well as calls for more research to be done along this line in different populations in order to establish whether there could be a limit at which social support becomes detrimental and to equally ascertain at what exact level (low, moderate or high) that social support could be of optimal benefit to the health and well-being of T2DM patients when acting as a moderator.

The Moderating Role of Social Support on the Predictive Relationship between Diabetes Distress and Fatigue among T2DM Patients

CHAPTER ONE

Introduction

Diabetes mellitus (DM), commonly known as diabetes, is a group of metabolic disorders characterized by hyperglycemia or a high blood sugar level over a prolonged period of time (WHO, 2014). Symptoms often include frequent urination (polyuria), increased thirst, (polydipsia) and polyphagia or increased hunger (Kitabchi et al., 2009). If left untreated, diabetes can cause many complications (Kitabchi et al., 2009).

Acute complications may include diabetic ketoacidosis (a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones), hyperosmolar hyperglycemic state (a metabolic complication of diabetes mellitus characterized by severe hyperglycemia, extreme dehydration, hyperosmolar plasma, and altered level of consciousness), or death (Saedi et al., 2016). Serious long-term complications include cardiovascular disease, stroke, chronic kidney disease, foot ulcers, damage to the nerves, damage to the eyes, and cognitive impairment (Kitabchi et al, 2009; Saedi et al., 2016).

Diabetes is due to either the pancreas not producing enough insulin (type 1 diabetes), or the cells of the body not responding properly to the insulin produced thereby unable to use insulin effectively (type 2 diabetes) (Harris, & Zimmet, 1997; Shoback, & Gardner, 2011).

Insulin is a hormone produced in the pancreas that allows glucose from food to enter the body’s cells where it is converted into energy needed by muscles and tissues to function. A person with diabetes does not absorb glucose properly, and glucose remains circulating in the blood (a condition known as hyperglycaemia) damaging body tissues over time and this damage can lead to disabling and life-threatening health complications.

Diabetes is a serious and complex metabolic disorder with a geometric prevalent increase over the past few decades. According to the International Diabetes Federation (IDF, 2019), the global diabetes prevalence in 2019 is estimated to be 9.3% (463 million people), rising to 10.2% (578 million) by 2030 and 10.9% (700 million) by 2045. The prevalence is higher in urban (10.8%) than rural (7.2%) areas, and in high-income (10.4%) than low-income countries (4.0%).

One in two (50.1%) people living with diabetes do not know that they have diabetes (IDF, 2019). In Nigeria, a nationwide population estimate of DM undertaken during the 1992 Nigerian National Non-communicable Diseases (NCD) survey, reported a 2.2% occurrence of DM in Nigeria population (Akinkugbe, 1997). However, recent studies have shown that in Africa, Nigeria has the highest number of people living with DM with over 4 million cases of 19.8 million cases recorded in Africa, with annual death rate of 100, 000 (IDF, 2013; Fasanmade & Dagogo-Jack, 2015). Some studies have also shown an increasing burden of T2DM in Nigeria which is equally becoming a disturbing national health concern (Nwakobi, 2014; Adeloye et al., 2017).

The Moderating Role of Social Support on the Predictive Relationship between Diabetes Distress and Fatigue among T2DM Patients

Uloko et al. (2018) in their study on the prevalence and risk factors for Diabetes Mellitus (DM) in Nigeria using a systematic review and meta-analysis, observed the pooled DM prevalence of 5.77% which suggests that 11.2 million Nigerians are living with the disease. Regional differences were also indicated in the prevalence of DM, with the highest rate observed in the south – south zone and the lowest rate seen in the north – western zone (Uloko et al., 2018).

The International Diabetes Federation (IDF, 2013) identifies three main types of diabetes: gestational diabetes mellitus (GDM), type 1 diabetes mellitus (T1DM), and type 2 diabetes mellitus (T2DM). Gestational diabetes is a resistance to insulin and subsequent high blood glucose, that is, diabetes first diagnosed during pregnancy in women (Hunt, & Schuller, 2007; IDF, 2013). It tends to occur around the 24th week of pregnancy. The condition arises because the action of insulin is blocked, probably by hormones produced by the placenta.

Uncontrolled or poorly managed gestational diabetes can have serious consequences for both the mother and her baby. It can lead to a significantly larger than average baby (a condition known as fetal macrosomia), which makes a normal birth difficult and risky leading to prolonged obstructed labour in some cases. The newborn will be at risk for shoulder injury and breathing problems.

The Moderating Role of Social Support on the Predictive Relationship between Diabetes Distress and Fatigue among T2DM Patients

There also exists the risk of preeclampsia, a condition where sudden high blood pressure threatens the health (and in some cases the life) of the mother and her baby (IDF, 2013). Gestational diabetes in mothers normally disappears after birth. However, women who have had gestational diabetes are at a higher risk of developing gestational diabetes in subsequent pregnancies and of developing type 2 diabetes later in life. Babies born to mothers with gestational diabetes also have a high risk of developing type 2 diabetes in the future (Mayfield, 1998).

Type 1 diabetes mellitus (T1DM) is caused by an autoimmune reaction, where the body’s defense system attacks the insulin-producing beta cells in the pancreas. As a result, the body can no longer produce the insulin it needs usually leading to absolute insulin deficiency (ADA, 1997; Mayfield, 1998). The disease can affect people of any age, but usually occurs in children or young adults. People with this form of diabetes need insulin every day in order to control the levels of glucose in their blood.

Type 1 diabetes often develops suddenly and can produce symptoms such as: abnormal thirst and a dry mouth, frequent urination, lack of energy, extreme tiredness, constant hunger, sudden weight loss, slow-healing wounds, recurrent infections, and blurred vision (IDF, 2013). People with type 1 diabetes can lead a normal, healthy life through a combination of daily insulin therapy, close monitoring, a healthy diet, and regular physical exercise. While the reasons for the increasing number of people with type 1 diabetes remain unclear, changes in environmental risk factors, early events in the womb, diet early in life, or viral infections are among the contributing factors (IDF, 2013).

Type 2 diabetes mellitus (T2DM), which is the concern of the present study, is the most common type of diabetes, affecting approximately 90 – 95% of individuals with the disease (Centre for Disease Control and Prevention, 2012). It usually occurs in adults, which explains why it was previously referred to as “adult-onset diabetes” but is increasingly being seen in children and adolescents, (WHO, 2013).

The Moderating Role of Social Support on the Predictive Relationship between Diabetes Distress and Fatigue among T2DM Patients

There is a rising trend in cases of T2DM, and this has been attributed to ageing, a rapid increase in urbanization, and obesogenic environments (IDF, 2017). In type 2 diabetes, the body is able to produce insulin but either this is not sufficient or the body is unable to respond to its effects (also known as insulin resistance), leading to a build-up of glucose in the blood (Genuth et al., 1995). Some of the important risk factors for developing type 2 diabetes include: obesity, poor diet, physical inactivity, advancing age, family history of diabetes, and high blood glucose during pregnancy affecting the unborn child (IDF, 2013).

T2DM is linked to an increased prevalence of mental health problems, primarily depression and anxiety disorders (Collins et al., 2009; Grigsby et al., 2002; Khuwaja et al., 2010; Smith et al., 2013; & Thomas et al., 2003). In contrast to people with type 1 diabetes, the majority of those with T2DM usually do not require daily doses of insulin to survive which may explain why T2DM was also previously referred to as “non insulin-dependent diabetes mellitus” (NIDDM) (IDF, 2013). Many people with T2DM are able to manage their condition through a healthy diet and increased physical activity or oral medication. However, if they are unable to regulate their blood glucose levels, they may be prescribed insulin.

Among people living with T2DM, fatigue is a pervasive and distressing complaint (Fritschi & Quinn, 2010). Fatigue is considered to be one of the classical presenting symptoms of diabetes mellitus (DM). For example, in newly diagnosed T2DM, 61% of the patients were fatigued and fatigue was the second most frequently reported symptom (Drivsholm et al., 2005).

The Moderating Role of Social Support on the Predictive Relationship between Diabetes Distress and Fatigue among T2DM Patients

Though fatigue also occurs in other medical disorders, the significance of fatigue may be greater in individuals with diabetes. It has been identified among major indices of poor clinical outcome and high mortality rates among diabetic patients (Bossola et al., 2015; Chilcot, 2015). Fatigue has been defined as a ‘subjective perception of a decreased capacity to perform physical and/or mental tasks due to one or a combination of physiological, psychological or lifestyle phenomena, including altered glucose control, diabetes symptoms, diabetes emotional distress, depression, physical inactivity and Body Mass Index (BMI), (Fritschi & Quinn, 2010). Fatigue has to do with continued extreme mental and/or physical tiredness and weakness or exhaustion (David et al., 1990; Pawlikowska, et al., 1994).

It is easy to mistake feelings of fatigue for depression and vice-versa. Depression occurs when a person feels sad, anxious, or hopeless for an extended period of time. People who are depressed often have sleep problems. They may sleep too much or not sleep at all. Fatigue in diabetes patients is a condition that causes the person to have continuous or occasional feelings of extreme exhaustion (Nall, 2017). With both depression and fatigue, symptoms may include low energy and low motivation among others (Burry, 2020).

However, the main difference between fatigue and depression is that fatigue is primarily a physical disorder while depression is a mental health disorder. Another distinguishing factor can be the desire to engage in activities – people who have fatigue wish to do things, but lack energy, whereas people with depression often feel very tired and aren’t interested in doing any activity, regardless of the task or the required amount of effort (Nall, 2017; Burry, 2020).

Fatigue is generally acknowledged to be complex and/or multifaceted, encompassing physiological, psychological, and situational components, such as life or work events (Aistars, 1987). While fatigue is considered a normal occurrence in daily life, it is also a symptom associated with a variety of physiological and psychological conditions. Fatigue normally occurs after mental or physical exertion, inadequate sleep, or other temporary phenomena.

The Moderating Role of Social Support on the Predictive Relationship between Diabetes Distress and Fatigue among T2DM Patients

Sometimes called acute or healthy, such fatigue is usually temporary and is alleviated with rest. Acute fatigue serves as a protective mechanism by signaling the body’s need for rest. Chronic fatigue or chronic fatigue syndrome (CFS), defined as severe fatigue that persists for at least six months, leads to substantial impairments in patients’ daily functioning (Fukuda et al., 1994; Reeves et al., 2003). In contrast, acute fatigue can largely vary during the day, and generally does not cause functional impairments. Chronic or pathologic fatigue, however, occurs after modest effort and continues despite rest (Hart & Freel, 1982; Kant et al., 2003; Ream, & Richardson, 1997).

Terms such as “unrefreshed by sleep” or “unresponsive to rest” have been used by some authors to differentiate chronic fatigue from acute (Trendall, 2000; LeMone, 1996; Aaronson et al., 1999). Chronic fatigue is most notably associated with diseases such as cancer, chronic obstructive pulmonary disease, rheumatoid arthritis, depression, and fibromyalgia, but it may also play a significant role in diabetes. A study carried out by Singh and Kluding (2013), showed that people with type 2 diabetes appear to have higher fatigue levels when compared to controls without diabetes at a comparable age, and the number of the complications resulting from diabetes may be related to this tiredness.

While fatigue in diabetes may be associated with physiological phenomena, such as hypo or hyperglycemia or wide swings between the two, fatigue may also be related to psychological factors, such as depression or psychological or emotional distress related to the diagnosis or to the intensity of diabetes self-management regimens (Fritschi & Quinn, 2010; Fritschi et al., 2012). This phenomenon may also assume another dimension such that when such concerns about healthcare services, diet, routine medication, monthly (or periodic) blood sugar checks, interpersonal distress (family) and financial concern/burden imposed by the health condition on an individual overwhelms that individual, this may evoke diabetes distress also referred to as diabetes related distress or diabetes burnout.

Polonsky et al., (2005) corroborate this when they assert that living with diabetes can be characterized by a “complex, demanding, and often confusing set of self-care directives, patients may become frustrated, angry, overwhelmed, and/or discouraged” (p. 626). Furthermore, relationships with loved ones can become strained and interactions with health care providers may be challenging, which contributes to diabetes-related distress (Polonsky et al., 2005).

Diabetes distress therefore refers to difficulty in coping related to living with and managing diabetes, not attributable to other causes of overall emotional distress or mental health problems (Fisher et al., 2014 & Fisher et al., 2009). Many adults with diabetes and depressive symptoms experience high levels of emotional distress stemming from their concerns and worries about diabetes (Fisher et al., 2007). This is largely due to the fact that for people living with type 1 or type 2 diabetes, the high degree of self-care, the threat of complications and the social burden of the condition can be very demanding (Hinder & Greenhalgh, 2012), often resulting in an emotional burden known as ‘diabetes distress’ (Fisher et al., 2007).

The Moderating Role of Social Support on the Predictive Relationship between Diabetes Distress and Fatigue among T2DM Patients

Severe diabetes distress occurs in 18 – 35 percent of adults with diabetes, with variation dependent on diabetes type, treatment regimen and presence of complications (Fisher et al., 2007; Speight et al., 2011). Population-based surveys demonstrate that both depression and diabetes distress are prevalent among adults with type 2 diabetes (Halliday et al., 2017 & Fenwick et al., 2016). While depression has long been a worthy focus of research and clinical efforts (Egede et al., 2002), diabetes distress is gaining attention, as it has been shown to contribute as much as thirty five percent to the variance in depression (Gonzalez et al., 2008), suggesting that efforts to reduce diabetes distress may also reduce depression.

Diabetes distress (DD) therefore could be understood in terms of a psychological condition which overlaps with anxiety, stress and depression (Erika., 2013). Depression can cause depressed moods, difficulty concentrating, disordered eating (eating more or less than normal), headaches, fatigue and loss of sleep. While many diabetics do suffer depression, diabetes distress is separate from depression and is at the same time a common occurrence in patients with diabetes, affecting about forty six percent of patients with diabetes (Baldwin & Gordon, 2019).

Diabetes distress is a common, understandable response to living with a chronic medical condition that requires constant attention. It differs from depression in that diabetes distress relates quite specifically to the demands of living with diabetes, ranging from experiencing stigma, struggling with diet, testing and medication regimens or concerns about long term complications and other worries and burdens experienced by diabetics as they work to keep their glucose under control. Depression on the other hand is characterized by a more pervasive sense of failure and hopelessness across the full range of life domains and a more generalized loss of enjoyment and motivation (Baldwin & Gordon, 2019).

Three common themes found in focus group discussions regarding diabetes distress are worry, relationship stress and medications. Worry and stress over blood sugar readings is common, and always looking at that number can be discouraging, leading to stress. Medications are a costly challenge facing diabetic patients. Taking medications every day, the cost of medications, along with worrying if they will develop hypoglycemia can cause distress (Burant & Young, 2012). Some diabetic medications contribute to mild hypoglycemia which is also a concern. Hypoglycemia is when the blood sugar gets to be too low and the body does not have enough sugar to use as energy.

Diabetes distress themes as captured in the diabetes distress scale (DDS-17) can be categorized into four namely: regimen-related distress, emotional distress, interpersonal distress, and physician/provider-related distress (Aljuaid et al., 2018). Regimen-related distress focuses on the distress patients feel when overwhelmed by the day-to-day management of their diabetes (Giese, 2020). They have to manage their diet, exercise, medications and possibly insulin intake throughout the day which may cause higher levels of regimen-related distress for those patients.

Emotional distress refers to the personal worries and fears diabetic patients experience. Some patients experience fatalistic fear of diabetes, in which case they can begin to feel like diabetes is controlling their lives, and no matter what they do they will have complications (Giese, 2020). Interpersonal distress centers on the support the patient has from their friends, family and medical providers. Patients sometimes feel they are not getting the desired level of support they would like.

They feel like the people who surround them do not fully understand all of the difficulties they face (Giese, 2020). Physician/provider-related distress refers to the level of confidence the patient has in the diabetic knowledge of their health provider. Some patients feel they do not receive enough empathy from their health provider, which causes a lack of confidence in their provider’s knowledge of all the challenges being faced by the diabetic patients (Giese, 2020).

The Moderating Role of Social Support on the Predictive Relationship between Diabetes Distress and Fatigue among T2DM Patients

Hence, symptoms of distress, or what is often referred to as diabetes burnout, are linked to diabetes and management of this disease and some of these symptoms may include feeling overwhelmed by the demands of living with diabetes; often failure in following a prescribed diabetes routine; feeling unsupported by friends and family; feeling angry, scared, and/or depressed about living with diabetes; and feeling that long-term complications of diabetes are inevitable (Polonsky et al., 2005).

In some patients with type 2 diabetes, high levels of diabetes distress can lead to poor self-management, poor medication adherence, and poor quality of life while in others, poor diabetes control can lead to distress (Fisher et al., 2009a, 2009b, Gonzalez et al., 2008). In addition, studies suggest that diabetes distress (but not depression or depressive symptoms) is linked to poor hemoglobin A1C levels (poor glycaemic control) in adults with type 2 diabetes (Gonzalez et al., 2014; Joensen et al., 2013), illustrating the importance of early detection and intervention (Fisher et al., 2010).

American Diabetes Association (ADA) shares several coping strategies that have helped patients with diabetes distress. These strategies include: individuals with diabetes accepting that they cannot control everything (patients with diabetes cannot always control what happens to their body); looking for support from people who can relate (finding other patients who have the same fears and anxiety helps patients cope with day-to-day stress); tapping into faith and family – coping with diabetes and the effects diabetes has on their body can be discouraging, but reaching out for support through their own faith groups and family have helped patients go through different stages of diabetes (ADA, 2020).

Beyond investigating the predictive relationship between diabetes distress and fatigue among people with T2DM, the present study seeks to explore (social support as a) psychosocial resource(s) that may moderate or mitigate the impact of diabetes distress on fatigue as well as the impact of both diabetes distress and fatigue on health outcome of people with T2DM.

Social support consistently has been linked to better health outcomes among adults with chronic health conditions (Uchino, 2009; Cohen et al., 2000), including diabetes (Strom & Egede, 2012; Miller & DiMatteo, 2013). Theories such as the buffering model of social support have established a positive link between social support and health outcomes. This buffering model of social support holds that health-related stressors will have deleterious effects on the well-being of those with little or no social support, while these effects will be lessened or eliminated for those with stronger support (Cohen, & McKay, 1984). It is therefore thought by the current researcher that social support as a psychosocial resource may assuage the negative impacts of diabetes distress and fatigue among people with T2DM.

The Moderating Role of Social Support on the Predictive Relationship between Diabetes Distress and Fatigue among T2DM Patients

Moderator is defined as the qualitative (e.g., sex, race, class) or quantitative (e.g., level of reward) variable that affects the direction or strength of the relation between an independent or predictor variable and a dependent or criterion variable (Baron & Kenny, 1986). A moderator variable is one that influences the strength of the relationship between two other variables.

A moderator variable specifies when or under what conditions a predictor variable influences a dependent variable (Baron & Kenny, 1986; Holmbeck, 1997). A moderator variable may reduce or enhance the direction of the relationship between a predictor variable and a dependent variable, or it may even change the direction of the relationship between the two variables from positive to negative or vice versa (Lindley & Walker, 1993). A moderator variable can be considered when the relationship between a predictor variable and a dependent variable is strong, but most often it is considered when there is an unexpectedly weak or inconsistent relationship between a predictor and a dependent variable (Baron & Kenny, 1986; Holmbeck, 1997; Lindley & Walker, 1993). The moderating effect is typically expressed as an interaction between predictor and moderator variable (Aldwin, 1994; Baron & Kenny, 1986; Holmbeck, 1997).

Undoubtedly, adapting to the challenges of diabetes health condition, and coping with its attendant difficulties would require social support and the important question for this study remains: how would social support moderate the association between diabetes distress and fatigue among type 2 diabetes persons? Social support has been defined as an aid provided to the individual under stress or in difficult situations by the people around him/her; a support conveyed from his/her social connections with other people, groups, and community; and a special concept showing that he/she is loved and appreciated and is in communication based on mutual cooperation (Altintoprak et al., 2005).

Social support implies satisfying an individual’s basic needs such as belongingness, affection, appreciation, and self realization as a result of the interaction he/she establishes with other individuals such as friends, family, or professional advisors (Eker et al., 2001; Karakurt et al., 2013). Recent studies suggest that the term “social support” is divided into two groups: perceived social support and received social support. The former is support the individual believes is available to him/her in times of need; the latter is the support actually received by the individual in real life (Eker et al., 2001; Karakurt et al., 2013).

The Moderating Role of Social Support on the Predictive Relationship between Diabetes Distress and Fatigue among T2DM Patients

Social support has been demonstrated to be an important psychosocial factor linked to healthy diet behaviors, physical activity, and adherence to medication among those with T2DM (Boas et al., 2012; Brouwer et al., 2012; Schiøtz et al., 2012). The International Diabetes Federation confirms that poor social support is a predictor of poor adherence to prescribed therapy (IDF, 2005). Additionally, studies carried out among patients with T2DM show that as social support increases, patients feel better physically and psychologically, cope more easily with stress, (distress) and fatigue, and display improved diabetic self-management (Schiøtz et al., 2012; Tang et al., 2008).

Social support involves not only family support but also persons with whom the individual interacts outside the family (friends) and social facilities (e.g. financial support, services). Social support from family and friends has been demonstrated to reduce stress related to performing self-care behaviors, facilitate adjustment to and coping with a diabetes diagnosis, and provide resources for frequent engagement in self-care behaviors (Boas et al., 2012; Brouwer et al., 2012).

In patients with a chronic disease, as the level of social support increases, physical and psychological welfare as well as coping with stress (distress) and fatigue improve (Aylaz et al., 2015). It is the opinion of some researchers also that because fatigue occurs in association with psychophysiological reasons in patients with T2DM, the level of fatigue in patients may be affected positively as social support increases (Aylaz et al. 2015).

These therefore suggest that social support is likely to moderate the relationship between diabetes distress and fatigue in persons with type 2 diabetes. Assessing social support, diabetes distress and fatigue therefore becomes imperative in assisting health care providers plan appropriate interventions that can enhance diabetic person’s adaptation to their illness and, consequently, improve their treatment adherence and general well-being.

The Moderating Role of Social Support on the Predictive Relationship between Diabetes Distress and Fatigue among T2DM Patients

Statement of the Problem

Diabetes Mellitus is a serious, long-term health condition with a major negative impact on the lives and well-being of individuals, families, and societies worldwide and is being considered a global challenge today. It imposes a large economic burden on the global health-care system and the wider global economy. This burden can be measured through direct medical costs, indirect costs associated with productivity loss, premature mortality and the negative impact of diabetes on gross domestic product (GDP) of nations.

Diabetes is also recognized as a significant cause of premature death and disability having been identified as a major cause of blindness, kidney failure, heart attacks, stroke and amputations. World Health Organization (WHO) estimates that diabetes was the seventh leading cause of death in the year 2016 with an estimate of 1.6 million deaths being directly caused by diabetes. It is one of four priority non-communicable diseases (NCDs) targeted by world leaders in the 2011 Political Declaration on the Prevention and Control of NCDs (Resolution 66/2, 2011).

Type 2 diabetes (T2D) is one of the most serious health concerns worldwide (Spinaci et al., 2006) as it has become one of the major challenges to human health in the 21st century. Previously considered a disease of the affluent “Western” countries of Europe and North America, epidemiological evidences suggest that the incidence of T2D is increasing worldwide.

The Moderating Role of Social Support on the Predictive Relationship between Diabetes Distress and Fatigue among T2DM Patients

It is now believed that low and middle-income countries will face the greatest burden of diabetes (Azad et al., 2010). The International Diabetes Federation (IDF, 2015) affirms that there are now more people with diabetes residing in the “emerging” economies than in the industrialized nations. In developing nations, the prevalence of diabetes is undoubtedly higher among urban populations, although it is also rapidly increasing in rural areas (Zabetian et al., 2014).

At the more personal and individual level, Diabetes Mellitus (DM) is epidemic, chronic and life-threatening health condition impacting negatively on the physical, financial and the psychological life of its victims (International Diabetes Federation, 2009; Jain et al., 2015).

Among people with T2DM, fatigue is a pervasive and distressing complaint (Fritschi & Quinn, 2010), having been considered to be one of the classical presenting symptoms of diabetes mellitus (DM). It has been identified among major indices of poor clinical outcome and high mortality rates among patients (Bossola et al., 2015; Chilcot, 2015). Most diabetic patients therefore because of fatigue find it difficult to meet with the demands of activities of daily life and some even abandon their jobs or career, thus, becoming dependent on their families.

Fatigue may result from diabetes distress and psychological distress that are usually associated with diabetic health condition. Literature indicates a high level of diabetes distress and psychological distress among individuals with type 2 diabetes. Indices of this diabetes distress and psychological distress include depression, anxiety, and stress. However, very few studies have considered the relationship between diabetes distress and fatigue among type 2 diabetic patients. The present study tries to fill this gap by exploring the predictive role of diabetes distress on fatigue among persons with type 2 diabetes mellitus in the Nigerian population.

Furthermore, many people living with diabetes mellitus in Nigeria experience diabetes distress and fatigue which negatively affects their productivity level and total well-being in general since the demands of living with and managing diabetes could be overwhelming for most patients. However, it is equally obvious that not all persons with type 2 diabetes are significantly weighed down by diabetes distress and fatigue.

The Moderating Role of Social Support on the Predictive Relationship between Diabetes Distress and Fatigue among T2DM Patients

Hence, an important question arises: what are those psychological buffers that help some individuals with a chronic disease, such as diabetes, to adapt to the challenges of their illness even as they encounter myriads of dismal difficulties? Could social support be a factor? Having gone through literatures, the present researcher found that diabetes distress and fatigue among type 2 diabetes patients in Nigeria have not received much attention, especially considering the regimen-related, emotional, interpersonal and physician related domains of diabetes distress in predicting fatigue and the role social support can play in moderating this relationship.

To fill this gap in literature, the present study seeks to explore the moderating role of social support on the relationship between diabetes distress and fatigue among patients with type 2 diabetes. To the best of the researcher’s knowledge, no study has been carried out on this with Nigerian population. Also this study will further add to the literature on the predictive role of diabetes distress on fatigue among persons living with T2DM.

The researcher therefore tries to fill this gap and to also add to existing literature by answering the following research questions:

1. Will Diabetes distress (regimen related distress, emotional distress, interpersonal distress and physician related distress) significantly predict fatigue among patients with T2DM?
2. Will social support significantly predict fatigue among patients with T2DM?
3. Will social support moderate the relationship between diabetes distress (regimen related distress, emotional distress, interpersonal distress, physician related distress) and fatigue among patients with T2DM?

Purpose of the Study

The aim of the present study is to examine whether:

1. Diabetes distress (regimen related distress, emotional distress, interpersonal distress and physician related distress) will significantly predict fatigue among patients with T2DM.
2. Social support will significantly predict fatigue among patients with T2DM?
3. Social support will moderate the relationship between diabetes distress (regimen related distress, emotional distress, interpersonal distress, physician related distress) and fatigue among patients with T2DM?

Operational Definition of Terms

Diabetes Distress: In this study, diabetes distress (DD) refers to a sense of stress, anxiety, worries, and other emotional and behavioral challenges that may be generated by diabetes and its management in T2DM patients as measured by Diabetes Distress Scale developed by Polonsky et al. (2005).

Fatigue: This refers to an experience of extreme weakness, tiredness or exhaustion, which results in difficulty to initiate and sustain strenuous physical and/or mental tasks as measured by Fatigue Severity Scale (FSS) developed by Krupp et al. (1989).

Social Support: This refers to the aid provided to T2DM patients from their social network such as family and friends, and from other social connections or interactions with other people, groups, and community which gives the diabetes patient the feeling of being loved, cared for, and appreciated as measured by the brief Chronic Illness Resources Survey (CIRS) developed by Glasgow et al. (2005).