Factors contributing to elevated glycated hemoglobin (HbA1c)

levels among BPO shift workers in Taguig City

Group 2

Geraldine Aclan, Yang Cheng, Olivia Daluz, Rhianna Martinez, Michael Van Haute

22 March 2014

Background of the Research Question

Chronic non-communicable diseases are on the rise, especially with high-stress jobs (e.g., employment as BPO agents) promoting tobacco use, unhealthy diet, and inadequate physical activity.

Such unhealthy behaviors may be instrumental in adding to the amount of risk for development of a variety of non-communicable diseases.

Statement of the Problem

There are a set of psychophysiological factors inherent in a number of high-stress jobs that can lead workers to take up maladaptive lifestyles and behaviors that can lead to unhealthy anthropometric and blood chemistry profiles, which in turn can put them at substantial risk for non-communicable diseases (NCDs). Given the nature of working as a BPO agent, those in this line of employment are at particular risk for NCDs.

Statement of the Problem

One particular NCD of interest is type 2 diabetes mellitus, as more people in younger age groups are developing this disease. Glycated hemoglobin (HbA1c) is a measurable parameter that is useful as an early indicator of risk for diabetes mellitus.

General Objective

To determine the factors that are associated with HbA1c levels among business process outsourcing (BPO) rotating shift-workers in voice and non-voice accounts employed by major BPO companies in Taguig City.

Specific Objectives

To determine the association of stress levels, sleep deprivation, and dietary pattern with HbA1c levels among BPO rotating shift-workers.

To determine if the type of account of BPO rotating shift-workers is associated with stress levels, sleep quality, and dietary patterns.

Significance of the Study

Such factors contributing to elevated HbA1c levels (and thus increased risk for diabetes mellitus), once identified, can be timely addressed so that measures and programs (e.g., helping workers deal with work-related stress, promotion of healthier lifestyles at the work place) can be implemented to hopefully prevent development of type 2 diabetes mellitus among BPO shift workers.

Glycated Hemoglobin (HbA1c)

Proportion of total hemoglobin that has undergone irreversible glycation

Levels reflect the average amount of glucose hemoglobin is exposed to over a period of 3 months (the average life span of red blood cells)

Normal levels: 3.9% to 5.6%

Better represents longer-term glycemic exposure than fasting blood sugar (FBS)

Diabetes Care 2009; 32 (7): 1327-1334 Diabetes Care 2011; 34 (2): 518-523

Glycated Hemoglobin (HbA1c)

Diabetes Care 2011; 34 (2): 518-523

HbA1c and risk of developing DM

Increased risk for diabetes mellitus was noted among those with HbA1c values above 5.0%, with adjusted relative risks for incident diabetes increasing for every 0.5% increment above 5.0% (2.9 for HbA1c of 5.0%5.4%, 12.1 for 5.5%5.9%, 29.3 for 6.0%6.4%, 28.2 for 6.5%6.9%, and 81.2 for 70%).

Am J Med 2007; 120 (8): 720-727

HbA1c and risk of developing DM

N Engl J Med 2010; 362 (9): 800-811

The adjusted hazard ratios of diabetes mellitus among those with HbA1c values of

Factors that may influence HbA1c levels

Risk factors for diabetes mellitus

Impaired fasting glucose and impaired glucose tolerance

HbA1c levels across the range of 5% to 6.5%

Family history

Obesity

Lifestyle factors: lack of exercise, smoking, sleep duration

Dietary patterns

Medical conditions: CVD, PCOS, Hyperuricemia, Metabolic

syndrome

HbA1c Levels

BPO rotating shift-workers

Voice account

Non-voice account

Psychophysiologic and lifestyle factors of

interest

Levels of Stress

Sleep quality

Dietary Patterns

Anthropometric measures

Body-mass-index

Waist-to-hip ratio

Socio-demographic characteristics

Age

Sex

Health-related background

Family history of diabetes

Existing medical condition

Highest educational attainment

Miscellaneous lifestyle and behavioral factors

Smoking habit and status

Levels of physical activity

Variables

INDEPENDENT CONFOUNDING INTERMEDIATE DEPENDENT

Type of BPO account

Stress levels Sleep quality Dietary

patterns

Age Sex Highest

educational attainment

Family history of diabetes mellitus

Existing medical conditions

Smoking habit Smoking status Level of

physical activity

Body mass index (BMI)

Waist-to-hip ratio (WHR)

HbA1c

Study Design and Setting

Study Design

Prospective cohort

Observational

Follow-up period: 6 months

Study Setting

Taguig City

Fort Bonifacio (a.k.a. BGC, or The Fort) has become the preferred location of BPO firms or companies (better infrastructure development and quality of office space, lower tax rates compared to neighboring cities)

Study Population and Study Subjects

The target population will be BPO-employed rotating shift-workers involved in customer service/relations.

The study population will be in rotating shift-workers employed in major BPO companies/firms in Taguig City; the study groups will be the voice and non-voice account groups.

Sampling Technique

Probability sampling method cluster sampling

BPO companies (the clusters) will be randomly selected, and the voice and non-voice shift-workers will be selected.

Sampling frame list of BPO companies/firms in Taguig City

Sampling units individual BPO companies in the list

Elementary units BPO voice and non-voice employees.

Inclusion Criteria

1. Individuals employed in the client relations department, with either a voice or a non-voice-account, in major BPO companies located in Taguig City.

2. Having an employment duration no longer than 1 month at time of inclusion.

3. Having a baseline HbA1c level below 6.5%.

Exclusion Criteria

1. BPO employees having a fixed working schedule.

2. Having on-going, or have a prior history of, anemia (includes iron-deficiency)

3. A history of recent (i.e., within 3 months) clinically significant blood loss (described as having had signs and symptoms of hemodynamic instability, pallor, cyanosis, irritability, and fatigue, requiring hospitalization and blood transfusion).

4. Had blood transfusion(s) within 3 months of the start of the study.

Exclusion Criteria

5. Presence of chronic kidney disease or chronic liver

disease.

6. Carrying a diagnosis of any hemoglobinopathy.

7. A history of chronic Vitamin C, Vitamin E, or Aspirin

intake.

8. A history of chronic alcohol intake.

9. Having a baseline HbA1c level of 6.5% or greater.

10. Carrying a diagnosis of diabetes mellitus, or currently

being treated medically for diabetes mellitus.

Figure 1. Summary of the process of identifying and defining study groups

Figure 2. Flowchart summarizing the sampling procedure

Figure 3. Summary of the general flow of the research process.

Calculations for the minimum sample size requirement

Data used as basis for sample size derived from a Japanese 14-year (1991 to 2005) prospective cohort study (Suwazono Y, et al. Chronobiology International 2009; 26(5): 926-941), which compared % increases in HbA1c levels from baseline between day workers (n = 4219) and alternating shift-workers (n = 2885) employed in a Japanese steel company. In this study, the OR for having an HbA1c level increase of at least 10% from baseline is 1.35.

Calculations for the minimum sample size requirement

Calculation of sample size was carried out using OpenEpi. A sample size calculator for cohort/RCT was employed.

Using the settings of 90% CI and 1 of 80%, the OR for having an HbA1c level increase of at least 10% from baseline which is 1.35 was entered.

Data Collection

Data collection tool: questionnaire

GPAQ (Global Physical Activity Questionnaire) levels of

physical activity

PSS-10 (Perceived Stress Scale) stress levels

FFQ (Food Frequency Questionnaire) dietary patterns

PSQI (Pittsburgh Sleep Quality Index) sleep quality

Direct measurement

Height and weight for BMI

Waist and hip circumferences for WHR

HbA1c (laboratory)

Data Processing and Analysis

Multivariate ordinal logistic regression

Outcome variable (HbA1c) is ordinal

10%, 15%, 20% increase from baseline level

Residual analysis test for linearity, homoscedasticity

Test for normality and randomness

Ethical Considerations

Confidentiality agreement

Participant comprehension of research objectives

Informed consent

Contact information (tracking participants with

elevated HbA1c level)

Control numbers to access electronic questionnaire

Protection of participant information

Risks and benefits

Proper disposal of whole blood samples

Study Limitations

Intensity and pace of employee training may vary from one company to another

Possibility of dropouts

Is a 6-month follow-up period long enough?

Self report questionnaire shortcomings

Time Table

Time Table

Budget

ACTIVITY COST (PhP)

Staffs salary (15 persons) 450,000

Training research assistants (10 persons) 20,000

First HbA1c determination (5,316 participants) 2,658,000

Second HbA1c determination (5,316 participants) 2,658,000

Field work allowances (15 persons) 10,000

Materials (measuring tools, FFQ for each participant, token for participants)

120,000

Transportation expenses 50,000

TOTAL 5,966,000

References

Gillett MJ. International Expert Committee report on the role of the A1c assay in the diagnosis of diabetes. Diabetes Care 2009; 32(7): 1327-1334.

Sacks DB. A1C versus glucose testing: a comparison. Diabetes Care 2011; 34 (2): 518-523.

Pradhan AD, et al. Hemoglobin A1c predicts diabetes but not cardiovascular disease in nondiabetic women. Am J Med 2007; 120 (8): 720-727.

Selvin E, et al. Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. N Engl J Med 2010; 362 (9): 800-811.

Suwazono Y, et al. ShiftWork and Impaired Glucose Metabolism: A 14-Year Cohort Study on 7104 Male Workers. Chronobiology International 2009; 26(5): 926-941.

Why Bonifacio Global City is still top choice for BPOs (by JC Rodriguez). Accessed from http://www.abs-cbnnews.com/business/12/11/13/why-bonifacio- global-city-still-top-choice-bpos on 18 March 2014.

THANK YOU 22 March 2014