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Self-Management Behavior and Retinal Microvascular Status: The Indirect Role of HbA1c in Type 2 Diabetes

Qi An ORCID
Faculty of Medicine, Universiti Sultan Zainal Abidin (UniSZA), Medical Campus, Jalan Sultan Mahmud, 20400 Kuala Terengganu, Terengganu Darul Iman, Malaysia
Mohammad Hudzaifah Bin Nordin ORCID
Faculty of Medicine, Universiti Sultan Zainal Abidin (UniSZA), Medical Campus, Jalan Sultan Mahmud, 20400 Kuala Terengganu, Terengganu Darul Iman, Malaysia
Swee Leong Ong ORCID
Faculty of Medicine, Universiti Sultan Zainal Abidin (UniSZA), Medical Campus, Jalan Sultan Mahmud, 20400 Kuala Terengganu, Terengganu Darul Iman, Malaysia
Qi An ORCID
Faculty of Medicine, Medical Campus, Universiti Sultan Zainal Abidin (UniSZA), Kuala Terengganu 20400, Malaysia
Mohammad Hudzaifah Bin Nordin ORCID
Faculty of Medicine, Medical Campus, Universiti Sultan Zainal Abidin (UniSZA), Kuala Terengganu 20400, Malaysia
Swee Leong Ong ORCID
Faculty of Medicine, Medical Campus, Universiti Sultan Zainal Abidin (UniSZA), Kuala Terengganu 20400, Malaysia

Received: 27 March 2026; Revised: 6 April 2026; Accepted: 28 April 2026; Published: 12 May 2026

Abstract

The study evaluates the relationship with diabetes self-management behavior and retinal microvascular status and hypothesizes whether HbA1c has an indirect statistically significant association between diabetes self-management behavior and retinal microvascular status in individuals with type 2 diabetes. The second view is to determine whether the involvement of continuous glucose monitoring is a moderator of the relationship between the self-management behavior and the HbA1c. An empirical cross-sectional study involved 328 adults with type 2 diabetes. The model combined six indicators of self-management, three of the HbA1c indicators, four indicators of the Optical Coherence Tomography Angiography (OCTA)-based retinal microvascular indicators, and four indicators of the continuous glucose monitor activity. A Partial Least Squares Structural Equation Modeling (PLS-SEM) model was developed in Python and evaluated based on reliability, convergent and discriminant validity, bootstrapped path estimation, indirect effect test, moderation analysis, and predictive analysis. Better self-management behavior is related to lower HbA1c (β = −0.496, p = 0.001) and more desirable retinal microvascular situation (β = −0.144, p = 0.002). Worse retinal microvascular status was linked with higher levels of HbA1c (β = 0.584, p < 0.001). The self-management behavior indirectly related to retinal microvascular status via HbA1c was significant (β = −0.290, p < 0.001), and this could be attributed to partial mediation. The constant glucose monitoring involvement had a significant moderate effect on the association between self-management behavior and HbA1c (β = −0.120, p = 0.004). The results substantiate a composite behavioral, metabolic, and retinal imaging model with self-management behavior, HbA1c, and OCTA-generated retinal radiations being strongly correlated.

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