Diabetes distress is linked with worsening diabetes management over time in adults with type 1 diabetes
Open accessAbstract
Abstract Aim To determine the cross‐sectional and longitudinal associations between diabetes distress and diabetes management. Methods In a non‐interventional study, 224 adults with Type 1 diabetes were assessed for diabetes distress, missed insulin boluses, hypoglycaemic episodes, and HbA1c at baseline and 9 months. Results At baseline, greater distress was associated with higher HbA1c and a greater percentage of missed insulin boluses. Longitudinally, elevated baseline distress was related to increased missed insulin boluses, and decreases in distress were associated with decreases in HbA1c. In supplementary analyses, neither depression symptoms nor a diagnosis of major depressive disorder was associated with missed insulin boluses, HbA1c or hypoglycaemic episodes in cross‐sectional or longitudinal analyses. Conclusions Significant cross‐sectional and longitudinal associations were found between diabetes distress and management; in contrast, no parallel associations were found for major depressive disorder or depression symptoms. Findings suggest that elevated distress may lead to more missed insulin boluses over time, suggesting a potential intervention target. The covarying association between distress and HbA1c points to the complex and likely interactive associations between these constructs. Findings highlight the need to address distress as an integral part of diabetes management in routine care.
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Claims the paper makes
0 of 10 cited sources checked · 0 supported · 0 flagged
- Findingown data
In adults with Type 1 diabetes, higher baseline diabetes distress predicts an increase in the percentage of missed insulin boluses over 9 months, controlling for baseline missed boluses.
“Longitudinally, elevated baseline distress was related to increased missed insulin boluses”
- Also stated in: § Prospective analyses · plain
“baseline diabetes distress significantly predicted change in percent of missed boluses (β = 0.05, P = 0.006) over time”
- Also stated in: § Conclusion · hedged
“individuals with elevated baseline distress are more likely to miss more insulin boluses at 9-month follow-up, even after controlling for baseline levels of missed insulin boluses.”
Quote in the paperSubstantial claim- Rests on an assumption: Missing data are missing completely at random and listwise deletion does not bias the results.
- Rests on an assumption: Self-reported missed insulin boluses and hypoglycaemic episodes accurately reflect actual diabetes management behaviours.
- Also stated in: § Prospective analyses · plain
- Findingown data
In adults with Type 1 diabetes, baseline diabetes distress does not predict change in HbA1c over 9 months.
“Baseline distress was not predictive of change in HbA1c or number of hypoglycaemic episodes over time.”
Quote in the paperNot a substantial claim- Rests on an assumption: Missing data are missing completely at random and listwise deletion does not bias the results.
- Findingown data
In adults with Type 1 diabetes, decreases in diabetes distress over 9 months are associated with decreases in HbA1c.
“decreases in distress were associated with decreases in HbA1c”
- Also stated in: § Time-varying analyses · plain
“Reductions in diabetes distress over the 9 months were significantly related to improvement in HbA1c (β = 0.34, P < 0.01).”
- Also stated in: § Conclusion · plain
“increases in distress are significantly associated with increases in HbA1c and vice versa.”
Quote in the paperSubstantial claim- Rests on an assumption: Missing data are missing completely at random and listwise deletion does not bias the results.
- Also stated in: § Time-varying analyses · plain
- Findingown data
In adults with Type 1 diabetes, higher diabetes distress is cross-sectionally associated with a greater percentage of missed insulin boluses at baseline.
“At baseline, greater distress was associated with higher HbA1c and a greater percentage of missed insulin boluses.”
- Also stated in: § Baseline cross-sectional analyses · plain
“percent of missed insulin boluses (β = 0.04, P = 0.02)”
- Also stated in: § Conclusion · plain
“elevated distress associated with higher HbA1c and a greater percentage of missed insulin boluses.”
Quote in the paperSubstantial claim- Rests on an assumption: Missing data are missing completely at random and listwise deletion does not bias the results.
- Rests on an assumption: Self-reported missed insulin boluses and hypoglycaemic episodes accurately reflect actual diabetes management behaviours.
- Also stated in: § Baseline cross-sectional analyses · plain
- Findingown data
In adults with Type 1 diabetes, baseline levels of diabetes management variables (missed insulin boluses, HbA1c, and hypoglycaemic episodes) do not predict change in diabetes distress over 9 months.
“models that tested baseline levels of management variables (i.e. missed insulin boluses, HbA1c and number of hypoglycaemic episodes) as predictors of change in distress failed to reach significance.”
Quote in the paperSubstantial claim- Rests on an assumption: Missing data are missing completely at random and listwise deletion does not bias the results.
- Rests on an assumption: Self-reported missed insulin boluses and hypoglycaemic episodes accurately reflect actual diabetes management behaviours.
- Findingown data
In adults with Type 1 diabetes, baseline diabetes distress does not predict change in the number of hypoglycaemic episodes over 9 months.
“Baseline distress was not predictive of change in HbA1c or number of hypoglycaemic episodes over time.”
Quote in the paperNot a substantial claim- Rests on an assumption: Missing data are missing completely at random and listwise deletion does not bias the results.
- Rests on an assumption: Self-reported missed insulin boluses and hypoglycaemic episodes accurately reflect actual diabetes management behaviours.
- Findingown data
In adults with Type 1 diabetes, the association between change in diabetes distress and change in HbA1c remains significant after controlling for change in self-management behaviour.
“the association between change in distress and HbA1c remained significant even after controlling for change in self-management behaviour (β = 0.36, P < 0.01).”
Quote in the paperSubstantial claim- Rests on an assumption: Missing data are missing completely at random and listwise deletion does not bias the results.
- Rests on an assumption: Self-reported missed insulin boluses and hypoglycaemic episodes accurately reflect actual diabetes management behaviours.
- Findingown data
In adults with Type 1 diabetes, depression symptoms are not associated with any diabetes management variable in cross-sectional, prospective, or time-varying analyses.
“neither depression symptoms nor a diagnosis of major depressive disorder was associated with missed insulin boluses, HbA1c or hypoglycaemic episodes in cross-sectional or longitudinal analyses.”
- Also stated in: § Supplementary analyses · plain
“no PHQ8 measure of depressive symptoms, nor current or past year measures of MDD, was significantly associated with any measure of diabetes self-management.”
- Also stated in: § Supplementary analyses · plain
“no measure of depression symptoms or diagnosis of MDD was significantly linked with any diabetes management variable in any cross-sectional, prospective or time-varying analysis.”
Quote in the paperSubstantial claim- Rests on an assumption: Missing data are missing completely at random and listwise deletion does not bias the results.
- Rests on an assumption: Self-reported missed insulin boluses and hypoglycaemic episodes accurately reflect actual diabetes management behaviours.
- Also stated in: § Supplementary analyses · plain
- Findingown data
In adults with Type 1 diabetes, higher diabetes distress is cross-sectionally associated with higher HbA1c at baseline.
“At baseline, greater distress was associated with higher HbA1c and a greater percentage of missed insulin boluses.”
- Also stated in: § Baseline cross-sectional analyses · plain
“diabetes distress was associated with baseline HbA1c (β = 0.28, P = 0.03)”
- Also stated in: § Conclusion · plain
“elevated distress associated with higher HbA1c and a greater percentage of missed insulin boluses.”
Quote in the paperSubstantial claim- Rests on an assumption: Missing data are missing completely at random and listwise deletion does not bias the results.
- Also stated in: § Baseline cross-sectional analyses · plain
- Findingown data
In adults with Type 1 diabetes, a diagnosis of major depressive disorder is not associated with any diabetes management variable in cross-sectional, prospective, or time-varying analyses.
“neither depression symptoms nor a diagnosis of major depressive disorder was associated with missed insulin boluses, HbA1c or hypoglycaemic episodes in cross-sectional or longitudinal analyses.”
- Also stated in: § Supplementary analyses · plain
“no PHQ8 measure of depressive symptoms, nor current or past year measures of MDD, was significantly associated with any measure of diabetes self-management.”
- Also stated in: § Supplementary analyses · plain
“no measure of depression symptoms or diagnosis of MDD was significantly linked with any diabetes management variable in any cross-sectional, prospective or time-varying analysis.”
Quote in the paperSubstantial claim- Rests on an assumption: Missing data are missing completely at random and listwise deletion does not bias the results.
- Rests on an assumption: Self-reported missed insulin boluses and hypoglycaemic episodes accurately reflect actual diabetes management behaviours.
- Also stated in: § Supplementary analyses · plain
- Findingown data
In adults with Type 1 diabetes, reductions in diabetes distress over 9 months are not related to change in behavioural self-management.
“Reductions in distress, however, was unrelated to change in hypoglycaemic episodes or behavioural self-management”
Quote in the paperSubstantial claim- Rests on an assumption: Missing data are missing completely at random and listwise deletion does not bias the results.
- Rests on an assumption: Self-reported missed insulin boluses and hypoglycaemic episodes accurately reflect actual diabetes management behaviours.
- Findingown data
In adults with Type 1 diabetes, reductions in diabetes distress over 9 months are not related to change in hypoglycaemic episodes.
“Reductions in distress, however, was unrelated to change in hypoglycaemic episodes or behavioural self-management”
Quote in the paperNot a substantial claim- Rests on an assumption: Missing data are missing completely at random and listwise deletion does not bias the results.
- Rests on an assumption: Self-reported missed insulin boluses and hypoglycaemic episodes accurately reflect actual diabetes management behaviours.
- Study design and conductown data
There were no significant differences between participants who completed the SCID or 9-month assessment and those who did not on any demographic or diabetes-related variable tested.
“There were no significant differences between participants who completed the SCID or 9-month assessment and those who did not on any demographic or diabetes-related variable tested.”
Quote in the paperNot a substantial claim - Premisecitation
Prior studies in Type 1 and Type 2 diabetes have found that baseline diabetes distress is significantly associated with diabetes management at follow-up.
“studies in both Type 1 and Type 2 diabetes have noted that baseline levels of distress are significantly associated with diabetes management at follow-up [9,10].”
Quote in the paperSubstantial claim0 of 2 sources checked - Interpretationown data
Diabetes distress and HbA1c have a covarying, likely bidirectional relationship over time in adults with Type 1 diabetes.
“The covarying association between distress and HbA1c points to the complex and likely interactive associations between these constructs.”
- Also stated in: § Conclusion · plain
“the longitudinal effect between diabetes distress and HbA1c is a significant covarying association, in which increases in distress are significantly associated with increases in HbA1c and vice versa.”
- Also stated in: § Conclusion · hedged
“each construct likely influences the other cyclically over time.”
Quote in the paperSubstantial claim - Also stated in: § Conclusion · plain
- Interpretationown data
Elevated diabetes distress may lead to more missed insulin boluses over time in adults with Type 1 diabetes.
“Findings suggest that elevated distress may lead to more missed insulin boluses over time, suggesting a potential intervention target.”
- Also stated in: § Conclusion · hedged
“offering cautionary support for a possible causative linkage.”
Quote in the paperSubstantial claim - Also stated in: § Conclusion · hedged
- Interpretationnone given
This is the first prospective longitudinal finding of its kind.
“To our knowledge, this is the first prospective longitudinal finding of its kind and has important implications for intervention.”
Quote in the paperNot a substantial claim - Interpretationown data
Diabetes distress may have important consequences for Type 1 diabetes management.
“The current findings suggest that diabetes distress may have important consequences for Type 1 diabetes management and highlight the need to address distress in programmes of care.”
Quote in the paperSubstantial claim - Premisereasoning
None of the prior studies reported significant prospective findings suggesting that diabetes distress directly affects or influences diabetes management over time.
“None of these studies, however, has reported significant prospective findings to suggest that distress directly affects or influences management over time.”
Quote in the paperSubstantial claim
- Classified as probably not a substantial claim. 11
- May combine two claims. 8
Classified as probably not a substantial claim.
Study design and conductcitationMultiple comparisons were adjusted using the Benjamini-Hochberg procedure with a false discovery rate of 0.05.
“we adjusted for multiple comparisons using the Benjamini–Hochberg procedure [18] utilizing a false discovery rate of 0.05; adjusted significance values are reported in addition to unadjusted values.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [18] source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationSeveral prior studies have found significant bidirectional associations between diabetes distress and glycaemic control over time.
“In a second pattern of findings, several studies have pointed to significant bidirectional associations among diabetes distress and glycaemic control over time.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).
Study design and conductnone givenThe study could have been strengthened by a more comprehensive and less subjective measurement of missed insulin boluses and low blood sugars.
“First, the study could have been strengthened by a comprehensive and less-subjective measurement of missed insulin boluses and low blood sugars.”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationIn a study by Weinger and Jacobson, baseline distress did not predict change in HbA1c, but change in distress was associated with change in HbA1c over 5 months.
“a notable exception is a study by Weinger and Jacobson [13], who found that baseline distress did not predict change in HbA1c, but that change in distress was associated with change in HbA1c over the 5-month study.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [13] source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductnone givenThe study sample was relatively well-educated and had high rates of healthcare accessibility and computer access.
“Second, the study sample was relatively well-educated individuals having a high rate of healthcare accessibility and computer access.”
Quote in the paperNot a substantial claimMay combine two claims.
InterpretationcitationChanges in missed insulin boluses do not explain the association between diabetes distress and HbA1c, suggesting multiple mechanisms.
“changes in missed insulin boluses did not explain the association between diabetes distress and HbA1c, supporting the view that there are likely multiple mechanisms at work that may differ for subgroups of participants [2].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [2] source
Not checked in the free run.
May combine two claims.
PremisecitationThose prior studies did not find that baseline distress predicted changes in management outcomes over time or management at follow-up after controlling for baseline levels.
“However, neither of these studies found prospective associations where baseline distress predicted changes in management outcomes over time, or predicted management at follow-up after controlling for baseline levels.”
Quote in the paperSubstantial claim0 of 2 sources checkedClassified as probably not a substantial claim. May combine two claims.
Study design and conductreasoningThe study design only allowed SCID diagnostic interview assessment at baseline, not time-varying models to assess MDD.
“Third, the study design only allowed for SCID diagnostic interview assessment at baseline, thus not allowing for time-varying models to assess MDD.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationIn adults with Type 2 diabetes, decreases in diabetes distress were bidirectionally associated with decreases in HbA1c, without support for one construct exclusively influencing the other.
“In both observational and intervention contexts with adults with Type 2 diabetes, we found that decreases in distress were bidirectionally associated with decreases in HbA1c, without support for one construct exclusively influencing the other [2,12].”
Quote in the paperNot a substantial claim0 of 2 sources checkedProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductreasoningThe study was limited to two assessments over 9 months, which did not permit a more comprehensive analysis of long-term change.
“Fourth, the study was limited to two assessments over 9 months, which did not permit a more comprehensive analysis of long-term change.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataOf the baseline participants, 73% (n = 224) completed the 9-month assessment.
“Of 348 eligible U.S. participants identified, 305 completed the baseline survey (88%); 73% (n = 224) of whom completed the 9-month assessment.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductcitationThe sample size was determined by the aims of the larger study and allowed for detecting moderate effects (d = 0.35) at 0.80 or greater power (two-sided α = 0.05).
“The sample size was determined by the aims of the larger study [15] and allowed for detecting moderate effects (e.g. d = 0.35) at 0.80 or greater power (two-sided α = 0.05).”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [15] source
Not checked in the free run.
Probably not a substantial claim: may not pass S2 (checkable).
PremisereasoningRelatively little prior work has examined the association between diabetes distress and diabetes management over time.
“Relatively little work has examined the association between diabetes distress and diabetes management over time.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductown dataThree SCID interviewers were trained until acceptable inter-rater reliability was reached, and all three rated every tenth interview to monitor reliability, with all Kappa values ≥ 0.90.
“Three interviewers were trained by a master SCID trainer until acceptable inter-rater reliability was reached. All three interviewers then rated every tenth interview to monitor ongoing reliability and to prevent inter-rater drift over time (all Kappa values ≥ 0.90).”
Quote in the paperNot a substantial claim
The paper relies on this without support.
Missing data are missing completely at random and listwise deletion does not bias the results.
“Missing data were not imputed, and cases were excluded list wise.”
The paper relies on this without support.
Self-reported missed insulin boluses and hypoglycaemic episodes accurately reflect actual diabetes management behaviours.
“Numbers of hypoglycaemic episodes (defined as blood glucose < 70 mg/dl) in the past 7 days were self-reported. The per cent of missed insulin boluses was calculated from self-reported total number of boluses and boluses skipped during the past 2 weeks.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Diabetes distress is prevalent among adults with type 1 diabetes and is associated with poor clinical outcomes.
“Diabetes distress (DD) is a prevalent concern among people with type 1 diabetes (T1D) and is linked to poor clinical outcomes.”
From Addressing emotional distress to improve outcomes in adults with type 1 diabetes: Protocol for ACT1VATE randomized controlled trial (2024) · cites this paper as [3]
The Results (Abstract; page not provided) link greater diabetes distress in adults with type 1 diabetes to higher HbA1c and more missed insulin boluses. The passages establish an association with poorer outcomes but do not establish that diabetes distress is prevalent among this population; a search for prevalence found no supporting statement. (LLM, conf=0.82)
Experimental — accuracy not yet measuredProlonged significant diabetes distress is associated with depressed mood and elevated HbA1c levels.
“Prolonged significant diabetes distress is associated with depressed mood and elevated HbA 1c levels (169).”
From The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) (2021) · cites this paper as [169]
The Results report that greater diabetes distress was associated with higher HbA1c at baseline, and that changes in the two covaried over nine months in adults with type 1 diabetes (Abstract, Results; Results, Time-varying analyses; no page given). The paper does not report that prolonged distress was associated with depressed mood; it examines depressive symptoms separately and emphasizes distinguishing them from diabetes distress (Conclusion; no page given). (LLM, conf=0.86)
Experimental — accuracy not yet measuredDiabetes distress has stronger and more consistent associations with sub-optimal diabetes self-management and HbA1c than other broader forms of emotional distress.
“While related to other, broader forms of emotional distress, DD has stronger and more consistent associations with sub-optimal diabetes self-management and HbA1c (1–3).”
From Addressing emotional distress to improve outcomes in adults with type 1 diabetes: Protocol for ACT1VATE randomized controlled trial (2024) · cites this paper as [3]
Diabetes distress has been linked to worse glycemic control and problematic self-care in both cross-sectional and longitudinal studies.
“Diabetes distress is a significant clinical problem; it has been associated with poor glycemic control and problematic self-care behavior in both cross-sectional and longitudinal studies.5–9”
From Economic costs of implementing group interventions to reduce diabetes distress in adults with type 1 diabetes mellitus in the T1-REDEEM trial (2019) · cites this paper as [9]
Diabetes-related distress may be more closely linked to glycaemic control than depression.
“Indeed, evidence now suggests that diabetes‐related distress may be more closely linked to glycaemic control than depression. 18 , 19 , 20”
Currently, no available interventions have been shown to significantly reduce both diabetes distress and HbA1c.
“Although DD is highly prevalent (4) and consistently related to self-management behavior and glycemic outcomes among people with diabetes (1–3), currently, no available interventions have been shown to significantly reduce both DD and HbA1c.”
From Addressing emotional distress to improve outcomes in adults with type 1 diabetes: Protocol for ACT1VATE randomized controlled trial (2024) · cites this paper as [3]
The Conclusion reports behavioural programmes that reduced diabetes distress and says decreases in distress were associated with improved glycaemic control. It does not say whether any intervention significantly reduced both distress and HbA1c, so it cannot establish the claim that none had done so. The paper’s own Results describe associations over time, not an intervention test; the citation in the printed sentence appears beside the association claim rather than the intervention claim. No page number is available in our copy. (LLM, conf=0.76)
Experimental — accuracy not yet measured
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Conclusion reverses the direction of missed-bolus change
MinorThe conclusion describes high baseline distress as leading to fewer missed boluses, whereas the prospective results say it predicts more missed boluses over time.
“The effect of high baseline distress on subsequent reductions in missed boluses is prospective and unidirectional, offering cautionary support for a possible causative linkage.”
“In prospective analyses, baseline diabetes distress significantly predicted change in percent of missed boluses (β = 0.05, P = 0.006) over time: those with higher initial diabetes distress displayed more missed insulin boluses over 9 months than those with lower initial diabetes distress.”
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- Authors
- Hessler, D. M., Fisher, L., Polonsky, W. H., Masharani, U., Strycker, L. A., Peters, A. L., Blumer, I., & Bowyer, V.
- Affiliations
- Department of Family & Community Medicine San Francisco USA
- Behavioral Diabetes Institute San Francisco USA
- University of California, San Francisco (US)
- Oregon Research Institute (US)
- University of Southern California (US)
- Charles H. Best Diabetes Centre Ontario Canada
- Corresponding author
- Hessler, D. M.
- ORCID
- Venue
- Diabetic Medicine
- Publisher
- Wiley
- Published
- 2017-06-18
- Volume
- 34
- Issue
- 9
- Pages
- 1228-1234
- ISSN
- 0742-3071 (ISSN-L)
- 1464-5491
- PMC
- PMC5561505
- OpenAlex
- W2612875258
- Cited by
- 155
- References
- 24
- Citations by year
- 2026: 16 · 2025: 18 · 2024: 23 · 2023: 15 · 2022: 19 · 2021: 24 · 2020: 13 · 2019: 14 · 2018: 10 · 2017: 2 · 2014: 1
- FWCI
- 8.43
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Locations
- Diabetic Medicine (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health (DK094863)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
- Keywords
- diabetes distress, type 1 diabetes, diabetes self-management, hypoglycemia, HbA1c, glycemic control, major depressive disorder, depressive symptoms, longitudinal change
- MeSH terms
- Adolescent, Adult, Blood Glucose, Child, Cross-Sectional Studies, Diabetes Mellitus, Type 1, Female, Glycated Hemoglobin, Humans, Hypoglycemia, Longitudinal Studies, Male, Middle Aged, Stress, Psychological, Time Factors, Disease Progression, Diabetes Complications, Young Adult
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Claims read under definition version 3 (extract-v3) on 2026-09-28.
Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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