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High Diabetes Distress Among Ethnic Minorities

Aug 4, 2018

Unsuccessful diabetes management found to lead to more diabetes distress, worse patient outcomes.

The prevalence of diabetes distress along with type 2 diabetes is rising. Diabetes distress is the term used to describe the emotional burden, stress, and worry associated with the chronic disease of diabetes. It is often overlooked and forgotten about when patients are evaluated for the status of their diabetes. The prevalence of type 2 diabetes is high in minorities and therefore diabetes distress is thought to also be higher in this patient population. The Distress and Depression in Diabetes Study showed that about 40% of patients with type 2 diabetes experienced a moderate degree of diabetes distress and almost 30% of patients who have type 2 diabetes experienced severe distress (2). In the Dutch Diabetes Cohort study, conducted in the Netherlands, the association of diabetes distress and ethnicity was investigated.


The study also investigated whether the diabetes distress was due to other diabetes complications like cardiovascular risk factors, lifestyle factors, and metabolic control. The cohort study consisted of 6,666 patients with type 2 diabetes, with ethnicities such as Caucasian, Asian, Moroccan, African, Latin American, Turkish, and Hindustani-Surinamese. The Caucasian group was the reference group that all other ethnic groups were compared to. 3,684 of the participants were Caucasian, 83 were Asian, 51 were Moroccan, 92 were African, 134 were Latin American, 46 were Turkish, and 101 were Hindustani-Surinamese. Ethnicity information was collected with the Problem Areas in Diabetes (PAID) questionnaire and conversations between participants and study nurses. Diabetes distress was measured using the PAID questionnaire, which was a 20-question assessment that had a range from 0 to 5; 0 meaning “not a problem” and 5 meaning “serious problem.” The scores were summed and then multiplied by a factor of 1.25 to create a new score that ranged from 0 to 100. A higher score indicated higher distress.

Patients with scores of 40 or greater were deemed to have a high level of diabetes distress. Education levels were self-reported by patients, along with alcohol consumption and smoking history. Patients’ BMIs were calculated by dividing the patients’ weight (kg) by their heights (m) squared. The PAID questionnaire also collected information regarding past medical histories of CVD. Nephropathy was detected by assessing the albumin-to-creatinine ratio found in the morning samples of urine. Neuropathy was evaluated using a device called the Horwell neurothesiometer. This device detected vibration thresholds. Vibration perception thresholds of 25 V or higher indicated neuropathy.

Descriptive statistics were used to assess the characteristics of the participants of each ethnic group, and the association of diabetes distress and ethnicity was evaluated using the logistic regression model. The Caucasians and Asians had the highest mean age. The Moroccan, African, and Turkish participants had intermediate levels of education. The mean BMI’s of Latin Americans, Africans, and Turkish participants were higher than those of the Caucasian participants. The highest percentage of albuminuria was found in Turkish participants. The highest percentage of participants with neuropathy were the Moroccans, and the highest percentage of participants who had a history of CVD were the Asians. Compared to the Caucasian reference group, participants of Moroccan, Latin American, African, Hindustani-Surinamese, and Turkish ethnicities had higher rates of diabetes distress by 4 to 7.5 times greater. The Asian participants did not differ much from the Caucasians in terms of diabetes distress. These results were independent of age, gender, education level, HbA1c, lifestyle factors, and CVD risk factors. Unmeasured factors such as language barriers, migration-related stress, literacy and comprehensive issues, and culture differences all may be contributing factors to diabetes distress. Some religions, for example, may alter the coping behaviors of some patients, making it difficult for these patients to seek professional or social help. Some view seeking for help with distress and depression as a weakness.

Diabetes self-management often leads to distress because many patients’ primary concerns are the use of their medications and how to properly care for their chronic disease. When diabetes management is unsuccessful it ultimately leads to more distress and worse patient outcomes. Although this study suggests that ethnic minorities have higher levels of diabetes distress, all patients, ethnic minorities and Caucasians, should be evaluated on their skills on self-management and knowledge of the disease state and should also be screened for distress according to the 2018 ADA guidelines (3).

Practice Pearls:

  • Diabetes distress is often overlooked when managing patients with diabetes.
  • Due to many factors, such as lifestyle factors, religion, socioeconomic status, and other comorbidities, ethnic minorities tend to have higher levels of diabetes distress compared to Caucasians with diabetes.
  • All patients with diabetes should be screened for diabetes distress as part of their routine diabetes management.
  • Providing social support and professional medical attention for depression and distress can lead to better diabetes management thus better patient outcomes.


Özcan, Behiye, et al. “High Diabetes Distress Among Ethnic Minorities Is Not Explained by Metabolic, Cardiovascular, or Lifestyle Factors: Findings From the Dutch Diabetes Pearl Cohort.” Diabetes Care, 2018, p. dc172181., doi:10.2337/dc17-2181.

Snoek FJ, Pouwer F, Welch GW, Polonsky WH. Diabetes-related emotional distress in Dutch and U.S. diabetic patients: cross-cultural validity of the problem areas in diabetes scale. Diabetes Care 2000;23:1305–130

“Professional Practice Committee:Standards of Medical Care in Diabetes—2018.” Diabetes Care, vol. 41, no. Supplement 1, Aug. 2017, doi:10.2337/dc18-sppc01.