Skip to main content

Advertisement

Log in

Stress and A1c Among People with Diabetes Across the Lifespan

  • Psychosocial Aspects (S Jaser and KK Hood, Section Editors)
  • Published:
Current Diabetes Reports Aims and scope Submit manuscript

Abstract

Stress is known to negatively affect health and is a potentially serious barrier to diabetes-related health outcomes. This paper synthesizes what is known about stress and glycemic control among people with type 1 and type 2 diabetes across the lifespan. Chronic stress—especially in relation to living with diabetes—was most strongly associated with A1c, particularly among subgroups that face disproportionate stress, such as minority groups or adolescents/young adults. Mechanisms of the stress-A1c association include physiological, psychological, behavioral, and environmental links. Understanding the dimensions of stress as they relate to health in diabetes can be of significant clinical importance, and interventions targeting mechanisms that either exacerbate or buffer stress have reported modest improvements in A1c.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Geiss LS, Wang J, Cheng YJ, et al. Prevalence and incidence trends for diagnosed diabetes among adults aged 20 to 79 years, United States, 1980-2012. JAMA. 2014;312:1218–26.

    Article  CAS  PubMed  Google Scholar 

  2. American Diabetes Association. Standards of medical care in diabetes—2016. Diabetes Care. 2016;39(1):S1–S112.

    Google Scholar 

  3. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977–86.

    Article  Google Scholar 

  4. Diabetes Control and Complications Trial Study Group. The relationship of glycemic exposure (HbA1c) to the risk of development and progression of retinopathy in the diabetes control and complications trial. Diabetes. 1995;44:968–83.

    Article  Google Scholar 

  5. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352:837–53.

    Article  Google Scholar 

  6. Shichiri M, Kishikawa H, Ohkubo Y, et al. Long-term results of the Kumamoto Study on optimal diabetes control in type 2 diabetic patients. Diabetes Care. 2000;23(Suppl2):B21–9.

    PubMed  Google Scholar 

  7. Stark Casagrande S, Fradkin JE, et al. The prevalence of meeting A1C, blood pressure, and LDL goals among people with diabetes, 1988-2010. Diabetes Care. 2013;36:2271–9.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Miller KM, Foster NC, Beck RW, et al. Current state of type 1 diabetes treatment in the US: updated data from the T1D Exchange clinic registry. Diabetes Care. 2015;38:971–8.

    Article  PubMed  Google Scholar 

  9. Sherr J, Tamborlane WV, Xing D, Tsalikian E, et al. Achievement of target A1C levels with negligible hypoglycemia and low glucose variability in youth with short-term type 1 diabetes and residual β-cell function. Diabetes Care. 2012;35:817–20.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. DeSalvo D, Buckingham B. Continuous glucose monitoring: current use and future directions. Curr Diab Rep. 2013;13:657–62.

    Article  CAS  PubMed  Google Scholar 

  11. Johnson SR, Cooper MN, Jones TW, et al. Long-term outcome of insulin pump therapy in children with type 1 diabetes assessed in a large population-based case-control study. Diabetologia. 2013;56:2392–400.

    Article  CAS  PubMed  Google Scholar 

  12. Hood KK, Peterson C, Rohan J, et al. Association between adherence and glycemic control in pediatric type 1 diabetes: a meta-analysis. Pediatrics. 2009;124(6):e1171–9.

    Article  PubMed  Google Scholar 

  13. McEwen BS. Protective and damaging effects of stress mediators. N Engl J Med. 1998;338:171–9.

    Article  CAS  PubMed  Google Scholar 

  14. Pouwer F, Kupper N, Adriaanse MC. Does emotional stress cause type 2 diabetes mellitus? A review from the European Depression in Diabetes (EDID) Research Consortium. Discov Med. 2010;9:112–8.

    PubMed  Google Scholar 

  15. Pizzagalli DA. Depression, stress, and anhedonia: toward a synthesis and integrated model. Annu Rev Clin Psychol. 2014;10:393–423.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Fisher L, Gonzalez JS, Polonsky WH. The confusing tale of depression and distress in patients with diabetes: a call for greater clarity and precision. Diabetic Med. 2014;31:764–72. This paper provides one of the first and clearest definitions of the construct of “diabetes distress” (or diabetes-related stress), which is important to differentiate from general stress especially when evaluating associations with glycemic control and in clinical practice.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Bonora E, Tuomilehto J. The pros and cons of diagnosing diabetes with A1c. Diabetes Care. 2011;34:S184–190.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Fisher L, Glasgow RE, Mullan JT, et al. Development of a brief diabetes distress screening instrument. Ann Fam Med. 2008;6:246–52.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Fisher L, Polonsky WH, Hessler DM, et al. Understanding the sources of diabetes distress in adults with type 1 diabetes. J Diabetes Complications. 2015;29:572–7.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Fisher L, Hessler DM, Polonsky WH, et al. Prevalence of depression in type 1 diabetes and the problem of over‐diagnosis. Diabetic Med. 2015. epub ahead of print.

  21. Sturt J, Dennick K, Due-Christensen M, et al. The detection and management of diabetes distress in people with type 1 diabetes. Curr Diab Rep. 2015;15:1–14.

    Article  CAS  Google Scholar 

  22. Hagger V, Hendrieckx C, Sturt J, et al. Diabetes distress among adolescents with type 1 diabetes: a systematic review. Curr Diab Rep. 2016;16:1–14. This recent review goes into detail about the experiences of diabetes distress in youth with T1D.

    Article  Google Scholar 

  23. Fisher L, Mullan JT, Skaff MM, et al. Predicting diabetes distress in patients with type 2 diabetes: a longitudinal study. Diabetic Med. 2009;26:622–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Weinger K, Jacobson AM. Psychosocial and quality of life correlates of glycemic control during intensive treatment of type 1 diabetes. Patient Educ Couns. 2001;42:123–31.

    Article  CAS  PubMed  Google Scholar 

  25. Fisher L, Mullan J, Arean P, et al. Diabetes distress but not clinical depression or depressive symptoms is associated with glycemic control in both cross-sectional and longitudinal analyses. Diabetes Care. 2010;33:28–8.

  26. Aikens JE. Prospective associations between emotional distress and poor outcomes in type 2 diabetes. Diabetes Care. 2012;35:2472–8.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Reddy J, Wilhelm K, Campbell L. Putting PAID to diabetes-related distress: the potential utility of the problem areas in diabetes (PAID) scale in patients with diabetes. Psychosomatics. 2013;54:44–51.

    Article  PubMed  Google Scholar 

  28. Strandberg RB, Graue M, Wentzel-Larsen T, et al. Relationships of diabetes-specific emotional distress, depression, anxiety, and overall well-being with HbA1c in adult persons with type 1 diabetes. J of Psychosom Res. 2014;77:174–9. This paper compares diabetes-related and general stress constructs in relation to glycemic control, which helps to clarify the relative importance of diabetes-related experiences for research and clinical care.

    Article  Google Scholar 

  29. Hessler DM, Fisher L, Mullan JT, et al. Patient age: a neglected factor when considering disease management in adults with type 2 diabetes. Patient Educ Couns. 2011;85:154–9.

    Article  PubMed  Google Scholar 

  30. Cummings DM, Lutes L, Littlewood K, et al. Regimen-related distress, medication adherence, and glycemic control in rural African American women with type 2 diabetes mellitus. Ann Pharmacother. 2014;48:970–7.

    Article  PubMed  Google Scholar 

  31. Tsiouli E, Alexopoulos EC, Stefanaki C, et al. Effects of diabetes-related family stress on glycemic control in young patients with type 1 diabetes systematic review. Can Fam Physician. 2013;59:143–9.

    PubMed  PubMed Central  Google Scholar 

  32. Hessler D, Fisher L, Glasgow RE, et al. Reductions in regimen distress are associated with improved management and glycemic control over time. Diabetes Care. 2014;37:617–24. This paper is one of several that demonstrates that diabetes-related stress is a potentially modifiable construct and that changes have the potential to impact self-management and diabetes outcomes in a meaningful way.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Zagarins SE, Allen NAG, Welch G. Improvement in glycemic control following a diabetes education intervention is associated with change in diabetes distress but not change in depressive symptoms. J Behav Med. 2012;35:299–304.

    Article  PubMed  Google Scholar 

  34. Viner R, McGrath M, Trudinger P. Family stress and metabolic control in diabetes. Arch Dis Child. 1996;74(5):418–21.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Lawes T, Franklin V, Farmer G. HbA1c tracking and bio-psychosocial determinants of glycaemic control in children and adolescents with type 1 diabetes: retrospective cohort study and multilevel analysis. Pediatr Diab. 2014;15(5):372–83.

    Article  CAS  Google Scholar 

  36. Helgeson VS, Escobar O, Siminerio L, et al. Relation of stressful life events to metabolic control among adolescents with diabetes: 5-year longitudinal study. Health Psychol. 2010;29(2):153–9.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Lloyd CE, Dyer PH, Lancashire RJ, et al. Association between stress and glycemic control in adults with type 1 (insulin-dependent) diabetes. Diabetes Care. 1999;22(8):1278–83.

    Article  CAS  PubMed  Google Scholar 

  38. Stenstrom U, Wikby A, Hornqvist JO, et al. Recent life events, gender differences, and the control of insulin-dependent diabetes mellitus. A 2-year follow-up study. Gen Hosp Psychiatr. 1995;17(6):433–9.

    Article  CAS  Google Scholar 

  39. Walders-Abramson N, Venditti EM, Ievers-Landis CE, et al. Relationships among stressful life events and physiological markers, treatment adherence, and psychosocial functioning among youth with type 2 diabetes. J Peds. 2014;165(3):504–508 e501. This study from the TODAY Trial is one of the few examinations of stress in the vulnerable population of youth with type 2 diabetes.

    Article  Google Scholar 

  40. Goldston DB, Kovacs M, Obrosky DS. A longitudinal study of life events and metabolic control among youths with insulin-dependent diabetes mellitus. Health Psychol. 1995;14:409–14.

    Article  CAS  PubMed  Google Scholar 

  41. Griffith LS, Field BJ, Lustman PJ. Life stress and social support in diabetes: association with glycemic control. Int J of Psychiat in Med. 1990;20:365–72.

    Article  CAS  Google Scholar 

  42. Kaur G, Tee GH, Ariaratnam S, et al. Depression, anxiety and stress symptoms among diabetics in Malaysia: a cross sectional study in an urban primary care setting. BMC Fam Pract. 2013;14:1.

    Article  Google Scholar 

  43. Laraia BA, Karter AJ, Warton EM, et al. Place matters: neighborhood deprivation and cardiometabolic risk factors in the Diabetes Study of Northern California (DISTANCE). Soc Sci Med. 2012;74:1082–90.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Piette JD, Bibbins-Domingo K, Schillinger D. Health care discrimination, processes of care, and diabetes patients’ health status. Patient Educ Couns. 2006;60:41–8.

    Article  PubMed  Google Scholar 

  45. Wagner JA, Tennen H, Finan PH, et al. Self‐reported racial discrimination and endothelial reactivity to acute stress in women. Stress Health. 2013;29:214–21.

    Article  PubMed  Google Scholar 

  46. Wagner JA, Tennen H, Feinn R, et al. Racial discrimination and metabolic control in women with type 2 diabetes. Ethn Dis. 2015;23:421–7. This paper addresses the important role of stress from perceived racial discrimination and its associations with health outcomes, highlighting the need for more research in this understudied area.

    Google Scholar 

  47. Hilliard ME, Harris MA, Weissberg-Benchell J. Diabetes resilience: a model of risk and protection in type 1 diabetes. Curr Diab Rep. 2012;12:739–48.

    Article  PubMed  Google Scholar 

  48. Juster RP, McEwen BS, Lupien SJ. Allostatic load biomarkers of chronic stress and impact on health and cognition. Neurosci Biobehav R. 2010;35:2–16.

    Article  Google Scholar 

  49. Glei DA, Goldman N, Chuang YL, et al. Do chronic stressors lead to physiological dysregulation? Testing the theory of allostatic load. Psychosom Med. 2007;69:769–76.

    Article  PubMed  Google Scholar 

  50. Abelson JL, Khan S, Liberzon I, et al. Effects of perceived control and cognitive coping on endocrine stress responses to pharmacological activation. Biol Psychiatry. 2008;64:701–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  51. Truninger R, Uthoff H, Capraro J, et al. Glucose control during a driving training in patients with type 1 and type 2 diabetes mellitus—a randomised, controlled trial. Exp Clin Endocr Diab. 2013;121:420–4.

    Article  CAS  Google Scholar 

  52. Wiesli P, Krayenbühl PA, Kerwer O, et al. Maintenance of glucose control in patients with type 1 diabetes during acute mental stress by riding high-speed rollercoasters. Diabetes Care. 2007;30:1599–601.

    Article  PubMed  Google Scholar 

  53. Wiesli P, Schmid C, Kerwer O, et al. Acute psychological stress affects glucose concentrations in patients with type 1 diabetes following food intake but not in the fasting state. Diabetes Care. 2005;28:1910–5.

    Article  PubMed  Google Scholar 

  54. Phan-Hug F, Thurneysen E, Theintz G, et al. Impact of videogame playing on glucose metabolism in children with type 1 diabetes. Pediatr Diabetes. 2011;12:713–7.

    Article  CAS  PubMed  Google Scholar 

  55. Cryer PE. Hypoglycemia in type 1 diabetes mellitus. Enodocrinol Metab Clin N Am. 2010;39:641–54.

    Article  CAS  Google Scholar 

  56. Cesana G, Panza G, Ferrario M, et al. Can glycosylated hemoglobin be a job stress parameter? J Occup Environ Med. 1985;27:357–60.

    Article  CAS  Google Scholar 

  57. Xu W, Hang J, Gao W, et al. Association between job stress and newly detected combined dyslipidemia among Chinese workers: findings from the SHISO study. J Occup Health. 2011;53:334–42.

    Article  PubMed  Google Scholar 

  58. Cutrona CE, Abraham WT, Russell DW, et al. Financial strain, inflammatory factors, and haemoglobin A1c levels in African American women. Brit J of Health Psychol. 2015;20:662–79.

    Article  Google Scholar 

  59. Baucom KJ, Queen TL, Wiebe DJ, et al. Depressive symptoms, daily stress, and adherence in late adolescents with type 1 diabetes. Health Psychol. 2015;34:522–30.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Gonzalez JS, Shreck E, Psaros C, et al. Distress and type 2 diabetes-treatment adherence: a mediating role for perceived control. Health Psychol. 2015;34:505–13.

    Article  PubMed  Google Scholar 

  61. Tran V, Wiebe DJ, Fortenberry KT, et al. Benefit finding, affective reactions to diabetes stress, and diabetes management among early adolescents. Health Psychol. 2011;30:212–9.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Yi JP, Vitaliano PP, Smith RE, et al. The role of resilience on psychological adjustment and physical health in patients with diabetes. Brit J of Health Psychol. 2008;13:311–25.

    Article  Google Scholar 

  63. Perfect MM, Elkins GR, Lyle‐Lahroud T, et al. Stress and quality of sleep among individuals diagnosed with diabetes. Stress Health. 2010;26:61–74.

    Article  Google Scholar 

  64. Knutson KL, Van Cauter E, Zee P, et al. Cross-sectional associations between measures of sleep and markers of glucose metabolism among subjects with and without diabetes the coronary artery risk development in young adults (CARDIA) sleep study. Diabetes Care. 2011;34:1171–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  65. Barone MT, Menna-Barreto L. Diabetes and sleep: a complex cause-and-effect relationship. Diabetes Res Clin Pract. 2011;91:129–37.

    Article  PubMed  Google Scholar 

  66. Hilliard ME, Holmes CS, Chen R, et al. Disentangling the roles of parental monitoring and family conflict in adolescents’ type 1 diabetes self-care. Health Psychol. 2013;32:388–96.

    Article  PubMed  Google Scholar 

  67. Davidson M, Penney EA, Muller B, et al. Stressors and self-care challenges faced by adolescents living with type 1 diabetes. Applied Nursing Research. 2004;17:72–80.

    Article  PubMed  Google Scholar 

  68. Berlin KS, Rabideau EM, Hains AA. Empirically derived patterns of perceived stress among youth with type 1 diabetes and relationships to metabolic control. J Pediatr Psychol. 2012;37:990–8.

    Article  PubMed  Google Scholar 

  69. Jaser SS, Grey M. A pilot study of observed parenting and adjustment in adolescents with type 1 diabetes and their mothers. J Pediatr Psychol. 2010;35:738–47.

    Article  PubMed  Google Scholar 

  70. Rintala TM, Jaatinen P, Paavilainen E, et al. Interrelation between adult persons with diabetes and their family a systematic review of the literature. J Fam Nurs. 2013;19:3–28.

    Article  PubMed  Google Scholar 

  71. Mayberry LS, Osborn CY. Family support, medication adherence, and glycemic control among adults with type 2 diabetes. Diabetes Care. 2012;35:1239–45.

    Article  PubMed  PubMed Central  Google Scholar 

  72. Surwit RS, van Tilburg MA, Zucker N, et al. Stress management improves long-term glycemic control in type 2 diabetes. Diabetes care. 2002;25(1):30–4.

    Article  PubMed  Google Scholar 

  73. Koloverou E, Tentolouris N, Bakoula C, et al. Implementation of a stress management program in outpatients with type 2 diabetes mellitus: a randomized controlled trial. Hormones. 2014;13(4):509–18.

    PubMed  Google Scholar 

  74. Tang TS, Funnell MM, Brown MB, et al. Self-management support in “real-world” settings: an empowerment-based intervention. Patient Educ Couns. 2010;79:178–84.

    Article  PubMed  Google Scholar 

  75. Fisher L, Hessler D, Glasgow RE, et al. REDEEM: a pragmatic trial to reduce diabetes distress. Diabetes Care. 2013;36:2551–8.

    Article  PubMed  PubMed Central  Google Scholar 

  76. Grey M, Boland EA, Davidson M, et al. Coping skills training for youth with diabetes mellitus has long-lasting effects on metabolic control and quality of life. J Pediatr. 2000;137(1):107–13.

    Article  CAS  PubMed  Google Scholar 

  77. Whittemore R, Jaser SS, Jeon S, et al. An internet coping skills training program for youth with type 1 diabetes: six-month outcomes. Nurs Res. 2012;61:395–404.

    Article  PubMed  PubMed Central  Google Scholar 

  78. Laffel LMB, Vangsness L, Connell A, et al. Impact of ambulatory, family-focused teamwork intervention on glycemic control in youth with type 1 diabetes. J Pediatr. 2003;142:409–16.

    Article  PubMed  Google Scholar 

  79. Katz ML, Volkening LK, Butler DA, et al. Family-based psychoeducation and care ambassador intervention to improve glycemic control in youth with type 1 diabetes: a randomized trial. Pediatr Diabetes. 2014;15:142–50.

    Article  PubMed  Google Scholar 

  80. 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 Nurs. 2015;2:40–55.

    Article  Google Scholar 

  81. Wysocki T, Harris MA, Buckloh LM, et al. Randomized trial of behavioral family systems therapy for diabetes: maintenance effects on diabetes outcomes in adolescents. Diabetes Care. 2007;30:555–60.

    Article  PubMed  Google Scholar 

  82. Van Houtum L, Rijken M, Heijmans M, Gorenewegen P. Patient-perceived self-management tasks and support needs of people with chronic illness: generic or disease specific? Ann Behav Med. 2015;49:221–9.

    Article  PubMed  Google Scholar 

  83. Rosenberg AR, Yi-Frazier JP, Eaton JP, et al. Promoting resilience in stress management: a pilot study of a novel resilience-promoting intervention for adolescents and young adults with serious illness. J Pediatr Psychol. 2015;40:992–9.

    Article  PubMed  Google Scholar 

  84. Fisher L, Hessler D, Masharani U, Strycker L. Impact of baseline patient characteristics on interventions to reduce diabetes distress: the role of personal conscientiousness and diabetes self-efficacy. Diabet Med. 2014;31:739–46.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  85. Mochari-Greenberger H, Lee V, Luka A, Peters A, Pande RL. A tele-behavioral health intervention to reduce depression, anxiety, and stress and improve diabetes self-management. Telemedicine e-Health 2016, ahead of print: doi:10.1089/tmj.2015.0231

  86. Herman WH, Cohen RM. Racial and ethnic differences in the relationship between HbA1c and blood glucose: implications for the diagnosis of diabetes. J Clin Endo Metabol. 2012;97:1067–72.

    Article  CAS  Google Scholar 

  87. Willi SM, Miller KM, DiMeglio LA, et al. Racial-ethnic disparities in management and outcomes among children with type 1 diabetes. Pediatrics. 2015;135:424–34.

    Article  PubMed  PubMed Central  Google Scholar 

  88. Naranjo D, Schwartz DD, Delamater A. Diabetes in ethnically diverse youth: disparate burden and intervention approaches. Curr Diab Rep. 2015;11:251–60.

    Article  Google Scholar 

Download references

Acknowledgments

Marisa E. Hilliard, Ashley M. Butler, and Barbara J. Anderson report grants from the National Institutes of Health (1K12 DK097696).

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Marisa E. Hilliard.

Ethics declarations

Conflict of Interest

Marisa E. Hilliard, Joyce P. Yi-Frazier, Danielle Hessler, Ashley M. Butler, Barbara J. Anderson, and Sarah Jaser declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Psychosocial Aspects

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hilliard, M.E., Yi-Frazier, J.P., Hessler, D. et al. Stress and A1c Among People with Diabetes Across the Lifespan. Curr Diab Rep 16, 67 (2016). https://doi.org/10.1007/s11892-016-0761-3

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11892-016-0761-3

Keywords

Navigation