Effects of depression, diabetes distress, diabetes self-efficacy, and diabetes self-management on glycemic control among Chinese population with type 2 diabetes mellitus
Introduction
China has the largest population of people with diabetes in the world. It is estimated that an approximately 109.6 million people aged 20–79 in China were diagnosed with diabetes by the end of 2016 [1]. Diabetes and its comorbidities have placed heavy economic burdens on Chinese families [2]. It has been well established [3], [4] that strict glycemic control leads to decreased risk of diabetes complications. However, large-scale studies [5], [6], [7], [8] have shown that glycemic control was suboptimal among Chinese patients with type 2 diabetes (T2DM). Only 26.21–39.7% of participants in those studies achieved optimal glycemic control and met the goal of an HbA1c < 7.0% (53 mmol/mol). Therefore, it is critically important to understand the factors influencing glycemic control to guide interventions for preventing diabetes related complications.
So far a number of studies have been conducted to investigate glycemic control and the psychological and behavioral factors influencing it. By using regression analyses, researchers have found diabetes distress [9], [10], [11], diabetes self-efficacy [12], [13], [14], [15], and diabetes self-management behaviors [13], [15], [16], [17], [18] were independent predictors of glycemic control. Structural equation modeling enables researchers to examine the direct and indirect effects of the aforementioned factors on glycemic control. For example, they found that diabetes distress [19], [20], and diabetes self-efficacy [20], [21] had direct impacts on glycemic control. Moreover, a few studies found that diabetes self-efficacy [22], [23] and diabetes distress [24], [25] may have indirect effects on glycemic control through diabetes self-management behaviors. Furthermore, diabetes distress [24], [25] also influenced glycemic control through diabetes self-efficacy. However, researchers [20] found that depression was not associated with self-efficacy nor with HbA1c among 615 T2DM patients in the US.
Based on the aforementioned literature review, the majority of the literature focused on bivariate relationships and used regression analyses to examine relationships, and ignored the interplay between factors. More importantly, there has been limited research in China investigating psychological and behavioral factors and their collective impacts on glycemic control in spite of the large amount of populations with diabetes. Given the complexity of glycemic control, it is speculated that there is a variety of interplay among these factors. Examining the mechanisms leading to inadequate glycemic control is beneficial for clinicians developing interventions targeting modifiable factors. The purpose of the study is to identify the direct and indirect effects of depression, diabetes distress, diabetes self-efficacy and diabetes self-management on glycemic control in a group of T2DM patients residing in China. A model was proposed based on the literature review to guide the analyses (Fig. 1). In this model, it is hypothesized that depression, diabetes distress, diabetes self-efficacy and diabetes self-management have direct impacts on glycemic control; and that depression and diabetes distress have indirect effects on glycemic control through diabetes self-efficacy and diabetes self-management. Additionally, it is expected that the effect of diabetes self-efficacy on glycemic control will be mediated by diabetes self-management.
Section snippets
Sample
This study employed a cross-sectional correlational design. A convenience sample of 254 participants were recruited into the study. According to G∗Power 3 [26], a total of 254 participants ensures the statistical power of 0.96, much higher than the acceptable power of 0.8 [27]. To be eligible, participants had to meet the following criteria: (1) diagnosed with type 2 diabetes for more than one year; (2) had a HbA1c value obtained in the past three months; (3) able to read and write Chinese; and
Demographic characteristics
Demographic data were listed for the aggregate sample and by optimal glycemic control (HbA1c < 7.0%, or 53 mmol/mol) and suboptimal glycemic control groups (HbA1c ≥ 7.0%, or 53 mmol/mol), respectively (Table 1). Only 91 (35.82%) participants achieved optimal glycemic control. The mean age for all participants was 55.26 ± 10.11 years, and for those who achieved optimal glycemic control and suboptimal glycemic control were 52.85 ± 10.90 years and 56.60 ± 9.41 years, respectively. The majority of the subjects
Discussion
HbA1c is recommended by ADA to measure glycemic control during the past three months [32]. In our study, 91 (35.82%) participants achieved the glycemic control target of an HbA1c less than 7.0% (53 mmol/mol). This result is consistent with the findings from large-scale studies in China [5], [6], [7], [8]. Patients in the urban site had worse glycemic control than those in the suburban sites. In China, people always favor using hospitals in urban areas, especially when they feel they are severely
Conclusions
Findings from this study add to the current literature about how depression, diabetes distress, diabetes self-efficacy, and diabetes self-management collectively impact glycemic control among Chinese T2DM patients. Our study highlights the importance of good diabetes self-management in achieving optimal glycemic control levels. Meanwhile, depression, diabetes distress, and diabetes self-efficacy impact glycemic control levels indirectly via diabetes self-management. Clinicians should target
Conflicts of interest
No potential conflicts of interest relevant to this article were reported.
Funding sources
This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.
Contributors
Conducted data analysis and drafted the manuscript (K. Lin); Analyzed and interpreted data (C. Park); Designed/supervised the study, interpreted data (M. Li), Collected Data (X. Wang, X. Li and W. Li), Interpreted data and revised the paper (L. Quinn). All authors have approved the final article.
Acknowledgement
We would like to thank physicians in the three data collection sites for their support when we recruited the participants. More importantly, we would specially thank all of the participants who devoted their time to finishing our questionnaires.
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2023, Journal of Taibah University Medical SciencesSelf-efficacy mediates the associations of diabetes distress and depressive symptoms with type 2 diabetes management and glycemic control
2022, General Hospital PsychiatryCitation Excerpt :A meta-analysis of 775 studies concluded that self-efficacy was the most consistent predictor of all adherence behaviors (e.g., dietary and physical activities), and adherence to a healthy diet was the most significant predictor of HbA1c [21]. Recent research has highlighted self-efficacy as a potential mediator of the link between depression or depressive symptoms and diabetes management [16,17,22]. One study with 371 T2D patients in Malaysia found that both diabetes distress and depressive symptoms indirectly associated with self-care activities via self-efficacy [23].