Identifying Factors Associated with Functional Limitation Among Diabetic Patients in Northwest of Iran: Application of the Generalized Additive Model.

Background: Functional limitation is one of the most important health - related concerns of diabetic patients. This study aimed to identify the factors associated with functional limitation among diabetic patients using generalized additive model (GAM) as a flexible technique to reveal the non - linear and non - monotonic association between the response and a set of independent variables.

Methods: The source data belonged to two cross - sectional studies conducted in 2014. A total of 694 people with type 2 diabetes in the age range of 31 - 70 years were selected via convenience sampling from diabetes clinics in Ardabil and Tabriz. The data were collected by interviewers using structured questionnaires and checklists. The functional capacity was measured using the physical functioning subscale of the Medical Outcomes Study Short Form 36 - Item Health Survey (SF36). Participants with a total functional capacity of less than 90 were considered to have "moderate or high level of functional limitation." To identify the factors associated with functional limitation and reveal the shape of associations, the GAM procedure with "logit" link function was applied to the dataset of 378 diabetic patients without any missing data by smoothening of the effect of underlying factors. The Akaike information criterion (AIC) as the relative quality of the model's criterion was computed for GAM and compared with AIC of the simple logistic regression.

Results: Sex (P = 0.029), age (P < 0.001), BMI (P = 0.029), and SBP (P = 0.04) were significant in the GAM. Moreover, age with a linear function (df = 0.98), BMI with quadratic function (df = 1.75), and SBP with the degree 1.33 were significantly related to functional capacity. AIC of the GAM was lower than that of the logistic model.

Conclusions: In our sample, GAM could identify some linear and nonlinear associations between underlying factors and functional limitation in diabetic patients. These complex associations could relatively increase the fit quality of the GAM when compared to logistic regression.