Exploring correlates of diabetes-related stress among adults with Type 1 diabetes in the T1D exchange clinic registry

Published:October 28, 2017DOI:


      • We explored diabetes stress in a large, diverse sample of adults with Type 1 Diabetes (T1D).
      • Higher diabetes stress was reported by female, non-white, younger participants, and those with a shorter disease duration.
      • Diabetes stress was robustly associated with higher HbA1c.
      • Diabetes stress was robustly associated with multiple other health- and treatment-related variables.
      • This cross-sectional study replicates and extends a burgeoning research literature on diabetes stress/distress.



      To explore relations between diabetes-related stress and multiple sociodemographic, diabetes health, other health, and treatment-related variables among a large sample of adults with Type 1 Diabetes (T1D).


      The sample consisted of 10,821 adults (over 18 years old) enrolled in the T1D Exchange Clinic Registry. The T1D Exchange clinic network consists of 67 diabetes clinical centers throughout the United States selected to broadly represent pediatric and adult patients with T1D. Variables were assessed through participant self-report and extraction of clinic chart data. Univariate and multiple linear regression (with simultaneous entry of all predictors) analyses were conducted.


      Robustly associated with increased diabetes-related stress across analyses were multiple sociodemographic (female [vs. male], native Hawaiian/other Pacific islander [vs. white/Caucasian], decreased age and diabetes duration), diabetes health (higher HbA1c), other health (lower general health, presence of major life stress and depression, less physical activity), and treatment related variables (use of injections/pen or combination injection/pen/pump [vs. pump], use of CGM, increased frequency of missing insulin doses and BG checking, decreased frequency of BG checking prior to bolus, receipt of mental health treatment).


      We replicated and extended research demonstrating that diabetes-related stress among people with T1D occurs at higher levels among those with particular sociodemographic characteristics and is associated with a range poorer diabetes health and other health variables, and multiple treatment-related variables. The strong incremental prediction of diabetes-related stress by multiple variables in our study suggests that a multi-variable, personalized approach may increase the effectiveness of treatments for diabetes-related stress.


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        • Young-Hyman D.
        • de Groot M.
        • Hill-Briggs F.
        • Gonzalez J.S.
        • Hood K.
        • Peyrot M.
        Psychosocial care for people with diabetes: a position statement of the American Diabetes Association.
        Diabetes Care. 2016; 39: 2126-2140
        • Aikens J.E.
        Prospective associations between emotional distress and poor outcomes in type 2 diabetes.
        Diabetes Care. 2012; 35: 2472-2478
        • Fisher L.
        • Hessler D.
        • Polonsky W.
        • Strycker L.
        • Masharani U.
        • Peters A.
        Diabetes distress in adults with type 1 diabetes: prevalence, incidence and change over time.
        J Diabetes Complications. 2016; 30: 1123-1128
        • Nicolucci A.
        • Kovacs Burns K.
        • Holt R.I.
        • Comaschi M.
        • Hermanns N.
        • Ishii H.
        • et al.
        Diabetes attitudes, wishes and needs second study (DAWN2™): cross-national benchmarking of diabetes-related psychosocial outcomes for people with diabetes.
        Diabet Med. 2013; 30: 767-777
        • Rees W.L.
        Stress, distress and disease. The Presidential Address at the annual meeting of the Royal College of Psychiatrists, held in London, 9th July, 1975.
        British J Psych. 1976; 128: 3-18
        • Watson D.
        • Pennebaker J.W.
        Health complaints, stress, and distress: exploring the central role of negative affectivity.
        Psychol Rev. 1989; 96: 234-254
        • Aikens J.E.
        • Wallander J.L.
        • Bell D.S.
        • Cole J.A.
        Daily stress variability, learned resourcefulness, regimen adherence, and metabolic control in type I diabetes mellitus: evaluation of a path model.
        J Consult Clin Psychol. 1992; 60: 113-118
        • Cox D.J.
        • Taylor A.G.
        • Nowacek G.
        • Holley-Wilcox P.
        • Pohl S.L.
        • Guthrow E.
        The relationship between psychological stress and insulin-dependent diabetic blood glucose control: preliminary investigations.
        Health Psychol. 1994; 3: 63-75
        • Kemmer F.W.
        • Bisping R.
        • Steingrüber H.J.
        • Baar H.
        • Hardtmann F.
        • Schlaghecke R.
        • et al.
        Psychological stress and metabolic control in patients with type I diabetes mellitus.
        N Engl J Med. 1986; 314: 1078-1084
        • Riazi A.
        • Pickup J.
        • Bradley C.
        Daily stress and glycaemic control in Type 1 diabetes: individual differences in magnitude, direction, and timing of stress-reactivity.
        Diabetes Res Clin Pract. 2006; 66: 237-244
        • Polonsky W.H.
        • Fisher L.
        • Earles J.
        • Dudl R.J.
        • Lees J.
        • Mullan J.
        • et al.
        Assessing psychosocial distress in diabetes.
        Diabetes Care. 2005; 28: 626-631
        • Sturt J.
        • Dennick K.
        • Due-Christensen M.
        • McCarthy K.
        The detection and management of diabetes distress in people with type 1 diabetes.
        Curr Diab Rep. 2015; 15: 101
        • Fisher L.
        • Mullan J.T.
        • Arean P.
        • Glasgow R.E.
        • Hessler D.
        • Masharani U.
        Diabetes distress but not clinical depression or depressive symptoms is associated with glycemic control in both cross-sectional and longitudinal analyses.
        Diabetes Care. 2010; 33: 23-28
        • Fisher L.
        • Skaff M.M.
        • Mullan J.T.
        • Arean P.
        • Mohr D.
        • Masharani U.
        • et al.
        Clinical depression versus distress among patients with type 2 diabetes.
        Diabetes Care. 2007; 30: 542-548
        • Farrell S.P.
        • Hains A.A.
        • Davies W.H.
        • Smith P.
        • Parton E.
        The impact of cognitive distortions, stress, and adherence on metabolic control in youths with type 1 diabetes.
        J Adolesc Health. 2004; 34: 461-467
        • Hermanns N.
        • Kulzer B.
        • Gulde C.
        • Eberle H.
        • Pradler E.
        • Patzelt-Bath A.
        • et al.
        Short-term effects on patient satisfaction of continuous glucose monitoring with the GlucoDay with real-time and retrospective access to glucose values: a crossover study.
        Diabetes Technol Therap. 2009; 11: 275-281
        • Iturralde E.
        • Weissberg-Benchell J.
        • Hood K.K.
        Avoidant coping and diabetes-related distress: pathways to adolescents’ Type 1 diabetes outcomes.
        Health Psychol. 2017; 36: 236
        • Lloyd C.E.
        • Pambianco G.
        • Orchard T.J.
        Does diabetes-related distress explain the presence of depressive symptoms and/or poor self-care in individuals with type 1 diabetes?.
        Diabet Med. 2010; 27: 234-237
        • Peyrot M.
        • McMurry Jr., J.F.
        • Kruger D.F.
        A biopsychosocial model of glycemic control in diabetes: stress, coping and regimen adherence.
        J Health Soc Behav. 1999; 40: 141-158
        • Zoffmann V.
        • Vistisen D.
        • Due-Christensen M.
        A cross-sectional study of glycaemic control, complications and psychosocial functioning among 18-to 35-year-old adults with Type 1 diabetes.
        Diabet Med. 2014; 31: 493-499
        • Jamieson S.
        Likert scales: how to (ab) use them.
        Med Educ. 2004; 38: 1217-1218
        • Norman G.
        Likert scales, levels of measurement and the “laws” of statistics.
        Adv Health Sci Educ. 2010; 15: 625-632
        • Cohen J.
        • Cohen P.
        • West S.G.
        • Aiken L.S.
        Applied multiple regression/correlation analysis for the behavioral sciences.
        Routledge, 2013
        • Peña E.A.
        • Slate E.H.
        Global validation of linear model assumptions.
        J Am Stat Assoc. 2006; 101: 341-354
      1. R Core Team. R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing; 2013. URL <>.

        • Durbin J.
        • Watson G.S.
        Testing for serial correlation in least squares regression III.
        Biometrika. 1971; 58: 1-19
      2. Eicker F. Limit theorems for regression with unequal and dependent errors. In: Proceedings of the Fifth Berkeley symposium on mathematical statistics and probability; 1967. p. 59–82.

      3. Huber PJ. The behavior of maximum likelihood estimates under nonstandard conditions. Proceedings of the Fifth Berkeley Symposium on Mathematical Statistics and Probability. 1967:221–233.

        • White H.
        A heteroskedasticity-consistent covariance matrix estimator and a direct test for heteroskedasticity.
        Econometrica. 1980; 48: 817-838
        • Strandberg R.B.
        • Graue M.
        • Wentzel-Larsen T.
        • Peyrot M.
        • Thordarson H.B.
        • Rokne B.
        Longitudinal relationship between diabetes-specific emotional distress and follow-up HbA1c in adults with Type 1 diabetes mellitus.
        Diabet Med. 2015; 32: 1304-1310
        • Weinger K.
        • Jacobson A.M.
        Psychosocial and quality of life correlates of glycemic control during intensive treatment of type 1 diabetes.
        Patient Educ Couns. 2001; 42: 123-131
        • Dollinger S.J.
        • Malmquist D.
        Reliability and validity of single-item self-reports: with special relevance to college students' alcohol use, religiosity, study, and social life.
        J Gen Psychol. 2009; 136: 231-242
        • Zimmerman M.
        • Ruggero C.J.
        • Chelminski I.
        • Young D.
        • Posternak M.A.
        • Friedman M.
        • et al.
        Developing brief scales for use in clinical practice: the reliability and validity of single-item self-report measures of depression symptom severity, psychosocial impairment due to depression, and quality of life.
        J Clin Psych. 2006; 67: 1536-1541
        • Li C.
        • Balluz L.S.
        • Ford E.S.
        • Okoro C.A.
        • Zhao G.
        • Pierannunzi C.
        A comparison of prevalence estimates for selected health indicators and chronic diseases or conditions from the behavioral risk factor surveillance system, the National Health Interview Survey, and the National Health and Nutrition Examination Survey, 2007–2008.
        Prev Med. 2012; 54: 381-387
        • Nelson D.E.
        • Powell-Griner E.
        • Town M.
        • Kovar M.G.
        A comparison of national estimates from the National Health Interview Survey and the Behavioral Risk Factor Surveillance System.
        Am J Public Health. 2003; 93: 1335-1341
        • McGuire B.E.
        • Morrison T.G.
        • Hermanns N.
        • Skovlund S.
        • Eldrup E.
        • Gagliardino J.
        • et al.
        Short-form measures of diabetes-related emotional distress: the Problem Areas in Diabetes Scale (PAID)-5 and PAID-1.
        Diabetologia. 2010; 53: 66-69
        • Welch G.W.
        • Jacobson A.M.
        • Polonsky W.H.
        The Problem Areas in Diabetes Scale: an evaluation of its clinical utility.
        Diabetes Care. 1997; 20: 760-766
        • Mauss I.B.
        • Levenson R.W.
        • McCarter L.
        • Wilhelm F.H.
        • Gross J.J.
        The tie that binds? Coherence among emotion experience, behavior, and physiology.
        Emotion. 2005; 5: 175-190
        • Lynam D.R.
        • Hoyle R.H.
        • Newman J.P.
        The perils of partialling: Cautionary tales from aggression and psychopathy.
        Assessment. 2006; 13: 328-341
        • Sturt J.
        • Dennick K.
        • Hessler D.
        • Hunter B.
        • Oliver J.
        • Fisher L.
        Effective interventions for reducing diabetes distress: systematic review and meta-analysis.
        Int Diabetes Nursing. 2015; 12: 40-45