Diabetes Distress and Glycemic Control in Type 2 Diabetes: Mediator and Moderator Analysis of a Peer Support Intervention

Abstract

Background High levels of psychosocial distress are correlated with worse glycemic control as measured by glycosylated hemoglobin levels (HbA1c). Some interventions specifically targeting diabetes distress have been shown to lead to lower HbA1c values, but the underlying mechanisms mediating this improvement are unknown. In addition, while type 2 diabetes mellitus (T2D) disproportionately affects low-income racial and ethnic minority populations, it is unclear whether interventions targeting distress are differentially effective depending on participants’ baseline characteristics. Objective Our objective was to evaluate the mediators and moderators that would inform interventions for improvements in both glycemic control and diabetes distress. Methods Our target population included 290 Veterans Affairs patients with T2D enrolled in a comparative effectiveness trial of peer support alone versus technology-enhanced peer support with primary and secondary outcomes including HbA1c and diabetes distress at 6 months. Participants in both arms had significant improvements in both HbA1c and diabetes distress at 6 months, so the arms were pooled for all analyses. Goal setting, perceived competence, intrinsic motivation, and decisional conflict were evaluated as possible mediators of improvements in both diabetes distress and HbA1c. Baseline patient characteristics evaluated as potential moderators included age, race, highest level of education attained, employment status, income, health literacy, duration of diabetes, insulin use, baseline HbA1c, diabetes-specific social support, and depression. Results Among the primarily African American male veterans with T2D, the median age was 63 (SD 10.2) years with a baseline mean HbA1c of 9.1% (SD 1.7%). Improvements in diabetes distress were correlated with improvements in HbA1c in both bivariate and multivariable models adjusted for age, race, health literacy, duration of diabetes, and baseline HbA1c. Improved goal setting and perceived competence were found to mediate both the improvements in diabetes distress and in HbA1c, together accounting for 20% of the effect of diabetes distress on change in HbA1c. Race and insulin use were found to be significant moderators of improvements in diabetes distress and improved HbA1c. Conclusions Prior studies have demonstrated that some but not all interventions that improve diabetes distress can lead to improved glycemic control. This study found that both improved goal setting and perceived competence over the course of the peer support intervention mediated both improved diabetes distress and improved HbA1c. This suggests that future interventions targeting diabetes distress should also incorporate elements to increase goal setting and perceived competence. The intervention effect of improvements in diabetes distress on glycemic control in peer support may be more pronounced among White and insulin-dependent veterans. Additional research is needed to understand how to better target diabetes distress and glycemic control in other vulnerable populations.

Resilience, self‐efficacy and diabetes distress on self‐management behaviours in patients newly diagnosed with type 2 diabetes: A moderated mediation analysis

“…Having diabetes distress seemed to be a detriment to the positive effect of positive psychological characteristics on self‐management behaviours in such patients; nevertheless, further studies are needed to confirm this suggestion. Compared with previous studies supporting that positive psychological characteristics could moderate the effect of negative psychological characteristics on health outcomes in patients with diabetes (Holmes‐Truscott et al, 2020; Mizokami‐Stout et al, 2021), the role of interacting between positive and negative psychological characteristics on health in patients with T2DM requires further study for elucidation.…”

“…For example, self-esteem was found to moderate the relationship between depressive symptoms and diabetes distress in insulin-treated T2DM patients (Holmes-Truscott et al, 2020). Race was found to be a significant moderator between diabetes distress and HbA1c levels (Mizokami-Stout et al, 2021).…”

“…For example, self‐esteem was found to moderate the relationship between depressive symptoms and diabetes distress in insulin‐treated T2DM patients (Holmes‐Truscott et al, 2020). Race was found to be a significant moderator between diabetes distress and HbA1c levels (Mizokami‐Stout et al, 2021). As is understood, no studies have examined the moderating role of diabetes distress on self‐management behaviours in patients with diabetes, nor in studies of patients newly diagnosed with T2DM, although a previous study has supported that diabetes distress could moderate the spousal influence on diabetes self‐care behaviours in patients with T2DM (Soriano et al, 2021).…”

Olfaction disorders in patients with pituitary adenoma after endoscopic transsphenoidal surgery: a qualitative study

“…Doctors and nurses can teach self-regulation and self-control methods of negative emotions, educate family members on communicating and giving emotional support. For some patients, complaining about reducing social activities and inclusion of peer support intervention should be encouraged (25,26). The use of online peer education breaks the limitation of time and geography and provides emotional support and information for users through communication and sharing common experiences, which may help alleviate negative emotions.…”

Effects of the Norfolk diabetes prevention lifestyle intervention (NDPS) on glycaemic control in screen-detected type 2 diabetes: a randomised controlled trial

“…The effect size in mean HbA1c in this trial was significantly greater in those < 65 years old compared to those > 65 years old, and a similar age effect is apparent in meta-analysis of lifestyle and behavioural programmes in type 2 diabetes [ 52 ]. A greater glycaemic benefit for peer intervention in type 2 diabetes has been described when the peers are older than the participants and in younger participants [ 75 – 77 ].…”