Poorly controlled T2D in Singaporeans: Who are at risk of diabetes-related distress?

One in six people with poorly controlled type 2 diabetes (T2D) in Singapore experiences diabetes distress, with the risk factors including younger age, previous tobacco use, kidney disease history, and depressive symptoms, as reported in a study.

In a cohort of 356 participants (mean age 58.6 years, 50.3 percent women, 62.1 percent Chinese) with HbA1c of at least 8 percent who were recruited from two public primary care centres in Singapore, the prevalence of diabetes-related distress (DRD) was 17.4 percent. [BMC Prim Care 2023;24:54]

Participants with DRD were more likely to be younger (55.2 vs 59.4 years; adjusted odds ratio [aOR], 0.93, 95 percent confidence interval [CI], 0.89–0.97; p=0.001), ex-smokers (aOR, 22.30, 95 percent CI, 2.43–204.71; p=0.006), have a history of kidney disease (aOR, 3.41, 95 percent confidence interval [CI], 1.39–8.35; p=0.007), and depression (PHQ-9; aOR, 4.98, 95 percent CI, 1.19–20.86; p=0.028).

The number of comorbidities or of medications did not factor in the odds of having DRD in the cohort. However, DRD was associated with lower health-related quality of life (EQ5D index score; aOR, 0.11, 95 percent CI, 0.01–0.97; p=0.047).

“Younger working people with diabetes face financial stressors, challenges at work, and family responsibilities which may increase their difficulties of living with T2DM. They may perceive their illness as a threat or a loss at a time in their lives when they expect themselves to be able-bodied to perform their role as providers or caregivers for their families, hence reacting more negatively to the stressor,” the investigators explained.

Meanwhile, “DRD, depression and anxiety are often viewed as overlapping concepts, or part of a continuum. However, depression is a separate entity from DRD. Any person with diabetes may have depression or DRD or both… Thus, psychotherapy and counselling strategies to alleviate DRD in people with diabetes may concurrently prevent and manage their depression and improve their quality of life,” they added.

Coping with diabetes distress

T2D is a challenging condition, according to the investigators, and managing it properly requires a huge commitment from the affected people. They have to keep their blood sugar levels as close to normal as possible, which means watching what they eat and engaging in physical activity safely, among other tasks. This burden, in turn, may induce frustration, burnout, and a feeling of being overwhelmed—a negative emotional state that is known as DRD. [Diabet Care 1995;18:754-760]

In Singapore, DRD is slowly gaining recognition among primary care physicians. The 2014 Ministry of Health clinical practice guidelines on T2DM acknowledge DRD as one of the psychosocial issues that affect self-management and health outcomes for people with diabetes. As a result, clinical psychologists have become part of the multidisciplinary team in the polyclinics to support the primary care physicians in managing the multifaceted issues faced by their patients, the investigators pointed out. [https://www.moh.gov.sg/docs/librariesprovider4/guidelines/cpg_diabetes-mellitus-booklet---jul-2014.pdf]

“In the holistic management of people with diabetes, healthcare professionals are encouraged to recognize the social aspect of living with diabetes, which affects the clinical and psychological outcomes of PWDs. Many of these social factors lie beyond the PWD and the healthcare worker’s control,” the investigators said.

The first step, they said, is to raise awareness and engage with the larger community that people with diabetes interact with the goal of helping others understand and empathize with the struggles of the affected people.

The investigators called for public education efforts with immediate family members and managers at the workplace as the target audience. Education should help dispel common misconceptions and provide tips to engage friends and family to support people with diabetes.

“The associated factors and patterns of DRD could also change with time as the healthcare system and societal pressures evolve. The tool for DRD assessment has to adapt to the changing healthcare eco-system and needs to be simplified for ease of implementation in routine clinical services,” they added.