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Table of Contents
Year : 2021  |  Volume : 9  |  Issue : 3  |  Page : 176-179

A study to assess diabetic distress and other factors which affect glycemic control in patients with type 2 diabetes mellitus

Department of General Medicine, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

Date of Submission24-Jan-2021
Date of Decision07-Mar-2021
Date of Acceptance19-Apr-2021
Date of Web Publication16-Jul-2021

Correspondence Address:
Dr. Amruthavarshini Nagabhushana
70/Y, 14th Main, 3rd Block, Rajajinagar, Bengaluru - 560 010, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajim.ajim_8_21

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Objective: The objective of the study was to assess diabetes distress and other factors, which affect glycemic control in patients with type 2 diabetes mellitus (T2DM) and to assess the relation between hemoglobin A1c (HbA1c) and diabetes distress, duration of illness, educational status and treatment modalities, and body mass index (BMI). Methodology: A cross-sectional study conducted at Bangalore Medical College and Research Institute included T2DM patients attending outpatient departments between November 2018 and February 2019, 280 patients were screened for diabetic-related distress using Diabetes Distress Screening Scale (DDS), the patients with diabetes distress were subjected to DDS 17 Questionnaire to determine the type of diabetes distress, and based on score divided into (0–2) little/no distress, (2–2.9) moderate distress, and (3 and more) severe distress. Results: Among 280 patients, 184 patients had diabetic distress and among them, 58.2% had severe distress, 7.5% had moderate distress, 34.3% had little/no distress, 83.1% had emotional burden, 59.2% had physician-related distress, 60.4 had regimen-related distress, and 83% had interpersonal distress. The diabetes distress was significantly associated with age (P = 0.032) and medication adherence (P = 0.00) with educational status. 51.4% had poor glycemic control with HbA1c of >7. The factors significantly associated with poor glycemic control included duration of diabetes with P = 0.008, diabetic distress with P = 0.00, and no significant association with educational status, age, BMI, and treatment modalities. Conclusion: Among type 2 diabetes patients, diabetic distress is a serious problem and needs to be addressed for better glycemic outcome.

Keywords: Body mass index, diabetes distress, diabetes mellitus, hemoglobin A1c

How to cite this article:
Nagabhushana A, Ramaiah M, Khan MA, Nijaguna S. A study to assess diabetic distress and other factors which affect glycemic control in patients with type 2 diabetes mellitus. APIK J Int Med 2021;9:176-9

How to cite this URL:
Nagabhushana A, Ramaiah M, Khan MA, Nijaguna S. A study to assess diabetic distress and other factors which affect glycemic control in patients with type 2 diabetes mellitus. APIK J Int Med [serial online] 2021 [cited 2021 Jul 29];9:176-9. Available from: https://www.ajim.in/text.asp?2021/9/3/176/321664

  Introduction Top

The WHO report says, globally, that an estimated 463 million adults were living with diabetes in 2019, compared to 422 million in 2014. The prevalence of diabetes in Indian population is 8.9% according to the International Diabetes Federation.[1]

The chronicity of the condition poses a significant physical and psychological burden on the patient.[2] Diabetes-related distress is defined as “patient concerns about disease management, support, emotional burden, and access to care.”[3] Diabetes distress can be measured across 4 domains which include physician-related distress, emotional burden, interpersonal distress, and regimen distress.[3]

The study was conducted to explore the association between diabetes distress and other factors affecting glycemic control.

  Methodology Top

A cross-sectional study was conducted in hospitals attached to Bangalore Medical College and Research Institute over 1.5 years from November 2018 to May 2020 with sample size of 280 patients. Patients included in the study were those living with Type 2 diabetes of more than 1 year of duration, between age group 18 and 70 years who were willing to participate in study.

Patient with type 1 diabetes, pregnant women, alcohol or drug dependence (CAGE Criteria), chronic medical or surgical illness other than diabetes, diabetic <1 year, patient with psychiatric illness, on antidepressant and other antipsychotic drugs, thyroid disease, corticosteroid use, and terminally ill patients were excluded from this study. Sample size was estimated to be 280 using study by Islam et al.[4] The protocol was approved by the Ethical review Committee, and informed written consent was obtained from each individual of total 280 patients included in this study before data collection. Diabetes Distress Scale English version was translated into Kannada and Hindi and was used to measure diabetes distress.

Diabetes Distress Scale-17 (DDS-17)[5] is a validated tool for measuring diabetes distress. At first, DDS2 was used for screening purpose, and patients with average score of >3 or sum of the tool >6 were screened positive for Diabetes Distress and subjected to DDS17, second questionnaire to help define the content of the distress.

A patient's diabetes distress was measured by DDS 17 scale with subscales reflecting four domains including emotional burden (5 items), physician distress (4 items), regimen distress (5 items), and interpersonal distress (3 items) considering a mean item score as a level of distress and graded as little/no distress: <2, moderate distress: 2–2.9, and high distress: ≥3. Each questionnaire took approximately 20–25 min to fill up.

The results obtained after subjecting the study population to Diabetes Distress Scale were compared with clinical variables – age of the patient, body mass index (BMI), duration of type 2 DM (T2DM), medication history, and glycemic control (hemoglobin A1c [HbA1c]). To determine glycemic status, HbA1c level was categorized as HbA1c level ≤7% as good glycemic control and >7% considered as poor glycemic control.

Statistical analysis

Statistical analysis comparisons between different groups were made using independent samples t-test and Chi-square test for level of diabetes distress. Bivariate correlations were done to find the associations between diabetes distress score and duration of diabetes mellitus (DM), age of the patient, BMI, medication history, and glycemic status. All the tests were two tailed, and P < 0.05 was considered as statistically significant. Logistic regression analysis applied to study correlation.

  Results Top

Among 280 type 2 diabetic patients included in the study, 42.5% were female and 57.5% were males. The mean age of study population was 55.85 years (SD = 9.562 years). Among 35–45 years age group, 16.3% had diabetes distress; between 46 and 55 years, 31.5% had distress; and between 56 and 65 years, 37.5% had diabetic distress, and a positive correlation was found between age and diabetes distress.

Of total 280 diabetic patients, 186 (67%) were positive for screening in DDS 2 and were further subjected to DDS-17; mild distress was found in 34.3%, moderate distress in 7.5%, and severe distress in 58.2%. Across the 4 domains of diabetes distress, 83.1% had emotional burden, 59.2% had physician-related distress, 60.4% had regimen-related distress, and 83% had interpersonal distress. A score more than 3 suggestive of severe distress was found in 55.3% in patients with emotional burden, 59.2% with physician-related distress, 27.2% with regimen-related distress, and 50% with interpersonal distress [Figure 1].
Figure 1: Percentage of 4 domains of diabetes distress in the study

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Of the total study population, 35.4% on insulin, 64.6% on oral hypoglycemic agents (OHAs), and of which 51.1% of total insulin population and 48.9% of total OHAs population had diabetic distress. Of patients with HbA1c ≤7 (good glycemic control), 22.8% had diabetic distress and more than 7% (poor glycemic control) and 72.8% had distress [Table 1]. Age and duration of diabetes did not show any significant association with glycemic control.
Table 1: Association between diabetes distress and hemoglobin A1c

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A significant association was found between HbA1c and diabetes distress (P = 0.008) [Table 2], diabetic distress and BMI (P = 0.024), and diabetic distress and age (P = 0.032). Using logistic regression analysis, positive correlation was found between age and diabetes distress scores (odds ratio = 42.09), between BMI and diabetes distress a positive correlation found (odds ratio = 32.78), and positive correlation found between HbA1c and diabetes distress scores (odds ratio = 2.43) [Table 2]. There is no significant association found between diabetes distress and education, diabetes distress and gender, and diabetes distress and duration of diabetes.
Table 2: Factors affecting diabetic distress

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  Discussion Top

Diabetic distress is a significant health problem among patients with T2DM. Once diagnosed with diabetes, the patient has to bring about a drastic change in his/her lifestyle to achieve favorable metabolic control and to avoid complications.[3] This process is complex which involves a multitude of self-care activities ranging from strict adherence to medication, diet, physical activity, and frequent blood glucose monitoring. On a longer run, the disease can create an emotional burden among patients which might affect the activities related to diabetes self-care.[6]

Fisher et al. created a brief diabetes distress screening instrument that can be used to diagnose diabetic distress clinically. This scale builds upon a 17-item Diabetes Distress Scale that had been develop by Dr. William Polonsky and Dr. Fischer in 2007 (DDS 17). Dr. Fischer created a 2-item diabetes distress screening instrument (DS2) that asks patients to rate on 6 point scale. If a patient answers affirmatively to DDS2 questions, DDS17 can be administered to help define the content of distress.[7]

Diabetes distress brings about unfavorable attitudes among patients toward tackling the disease such as poor compliance to medication, poor diet control, disinterest in exercises, irregular follow-up visits, and poor self-care. There is a higher incidence of complications associated with diabetes associated with among patients having diabetes distress.[8] Addressing the distress improves both self-care and glycemic control. Fortunately for both patients and clinicians, new tools are now available to help diagnose diabetes distress.

Lowering the HbA1C level to <7% has proved to reduce the microvascular complications if it was implemented immediately after the diagnosis of diabetes and thereby reduces the long-term macrovascular disease.[9] Glycemic control remains the major therapeutic objective for the prevention of target organ damage and other complications which arise due to diabetes.[10] Hence, it is necessary to assess the factors which affect glycemic control in diabetic patients. A limited literature is available regarding the diabetes distress in diabetic patients.

Of total 280 diabetic patients, 186 (67%) were positive for screening in DDS 2, 34.3% of them had mild distress, 7.5% had moderate distress, and 58.2% had severe distress. Islam et al.[4] estimated that among the adult T2DM patients, 51.5% had little or no distress, 26.1% had moderate distress, and 22.4% had high distress. This proportion of diabetes distress in this study was consistent with the study findings of Fisher et al. where they found that the prevalence of diabetes distress was high among T2DM.[5],[11]

Across the 4 domains of diabetes distress, 83.1% had emotional burden, 59.2% had physician-related distress, 60.4% had regimen-related distress, and 83% had interpersonal distress. Major domain involved was emotional burden, and it is considered the most important domain in diabetes distress. Our findings are consistent with the study conducted by Islam et al.[4] and Shojaeezadeh et al.[12]

Significant association was found between glycemic control and age, BMI, and diabetes distress in our study. Islam et al.[4] showed that the influence of glycemic status on the level of diabetes distress was statistically significant. A study by Hemavathi et al.[13] showed a positive correlation between both diabetes distress total score and emotional distress with the glycemic control. It was noted that those who had high levels had poor glycemic control. Similar finding was also observed in diabetic populations by Kuniss et al.[14] and Gonzalez et al.[15]

It was observed in the current study that as the age increased, the diabetes distress levels decreased. This finding is consistent with the earlier study conducted by Fisher et al.[10],[11] which documented the positive association of DD with age.

Limitations of the study

It is a cross-sectional study, and there is a lack of long-term conclusions. The total DSS score was not compared with diabetic vascular complications. The study was conducted in tertiary care center which limits the generalization of results.

  Conclusion Top

This study helps us to understand the factors that could predict the glycemic control in the diabetic patients. It addresses the question of possible relationship between diabetes distress and glycemic control in patients suffering from DM attending our diabetes clinic. Among type 2 diabetes patients, diabetic distress is a serious problem which affects their living. It is necessary as clinicians to address diabetic distress in the patients for better glycemic outcome. The factors associated with diabetes distress need to be further evaluated in depth to formulate an effective intervention program and rehabilitation. Measures need to be taken for effective management like lifestyle modifications as well as ways to deal with their stress and diabetes.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

International Diabetes Federation Diabetes Atlas. 9th ed. International Diabetes Federation, Belgium 2019.  Back to cited text no. 1
Harris MA, Lustman PJ. The psychologist in diabetes care. Clin Diabetes 1998;16:91.  Back to cited text no. 2
Fisher L, Glasgow RE, Mullan JT, Skaff MM, Polonsky WH. Development of a brief diabetes distress screening instrument. Ann Fam Med 2008;6:246-52.  Back to cited text no. 3
Islam MR, Karim MR, Habib SH, Yesmin K. Diabetes distress among type 2 diabetic patients. Int J Med Biomed Res 2013;2:113-24.  Back to cited text no. 4
Polonsky WH, Fisher L, Earles J, Dudl RJ, Lees J, Mullan J, et al. Assessing psychosocial distress in diabetes: Development of the diabetes distress scale. Diabetes Care 2005;28:626-31.  Back to cited text no. 5
Aikens JE. Prospective associations between emotional distress and poor outcomes in type 2 diabetes. Diabetes Care 2012;35:2472-8.  Back to cited text no. 6
Fisher L, Mullan JT, Skaff MM, Glasgow RE, Arean P, Hessler D. Predicting diabetes distress in patients with type 2 diabetes: A longitudinal study. Diabet Med 2009;26:622-7.  Back to cited text no. 7
Ascher SH, Zagar A, Jiang D, Schuster D, Schmitt H, Dennehy EB, et al. Associations between glycemic control, depressed mood , clinical depression, and diabetes distress before and after insulin initiation. Ann Fam Med 2008;6:246-52.  Back to cited text no. 8
Position statement, standards of medical care in diabetes–2012. Diabetes Care 2012;35:S11-63. doi.org/10.2337/dc12-s011.  Back to cited text no. 9
Koro CE, Bowlin SJ, Bourgeois N, Fedder DO. Glycemic control from 1988 to 2000 among U.S. adults diagnosed with type 2 diabetes: A preliminary report. Diabetes Care 2004;27:17-20.  Back to cited text no. 10
Fisher L, Hessler DM, Polonsky WH, Mullan J. When is diabetes distress clinically meaningful? Establishing cut points for the diabetes distress scale. Diabetes Care 2012;35:259-64.  Back to cited text no. 11
Shojaeezadeh D, Tol A, Sharifirad G, Eslami A. Is assessing diabetic distress an efficient pathway to tailor more effective intervention programs? Geneva Health Forum; 2012.  Back to cited text no. 12
Hemavathi P, Satyavani K, Smina TP, Vijay V. Assessment of diabetes related distress among subjects with type 2 diabetes in South India. Int J Psychol Couns 2019;11:1-5.  Back to cited text no. 13
Kuniss N, Rechtacek T, Kloos C, Müller UA, Roth J, Burghardt K, et al. Diabetes-related burden and distress in people with diabetes mellitus at primary care level in Germany. Acta Diabetol 2017;54:471-8.  Back to cited text no. 14
Gonzalez JS, Fisher L, Polonsky WH. Depression in diabetes: Have we been missing something important? Diabetes Care 2011;34:236-9.  Back to cited text no. 15


  [Figure 1]

  [Table 1], [Table 2]


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