Skip to main content Skip to main navigation menu Skip to site footer

The relationship between diabetes distress and HbA1C level in type 2 diabetes mellitus therapy patients: a systematic review

  • Zefo Kiyosi Wibowo ,
  • Sony Wibisono Mudjanarko ,
  • Khairina Khairina ,


Introduction: The success of therapy did not follow the increasing number of type 2 diabetes mellitus patients. This systematic review aimed to evaluate the relationship between diabetes distress and HbA1c in type 2 diabetes mellitus patients during therapy.

Methods: The authors systematically searched databases (PubMed, Cochrane library, and ScienceDirect) up to January 2021. Articles were screened according to PRISMA 2020 statements. The selection criteria of this study were patients’ characteristics, type of therapy, and outcomes.

Results: The search started from 1.303 articles to 17 eligible articles. Furthermore, seventeen studies included 11,976 patients. The mean HbA1c level was around 6.4% to 9.9%. The result of diabetes distress scores were five studies with low scores, eight moderate scores, and two high scores. Emotional burden and regimen-related distress were the highest domain score. Age, health facilities, and type of therapy affected diabetes distress. The correlation between diabetes distress and HbA1c was dominant in the range of 0.15 to 0.26.

Conclusion: Diabetes distress had a low-moderate correlation with HbA1c. The dominant domains were emotional burden and regiment-related distress. There were two mechanisms of effect, direct by hormones and indirect through medication adherence, self-management, and 12 months of quality of life.


  1. Ehrenthal JC, Düx A, Baie L, Burgmer M. Levels of personality functioning and not depression predict decline of plasma glucose concentration in patients with type 2 diabetes mellitus. Diabetes Res Clin Pract. 2019;151:106–13.
  2. Chen SY, Hsu HC, Wang RH, Lee YJ, Hsieh CH. Glycemic Control in Insulin-Treated Patients With Type 2 Diabetes: Empowerment Perceptions and Diabetes Distress as Important Determinants. Biol Res Nurs. 2019;21(2):182–9.
  3. Choi WH, Seo YM, Ha Y. Evaluation of factors related to glycaemic control among South Korean patients with type 2 diabetes. Int J Nurs Pract. 2018;24(1):1–8.
  4. Cholil AR, Lindarto D, Pemayun TGD, Wisnu W, Kumala P, Puteri HHS. DiabCare Asia 2012: Diabetes management, control, and complications in patients with type 2 diabetes in Indonesia. Med J Indones. 2019;28(1):47–56.
  5. Reach G, Pechtner V, Gentilella R, Corcos A, Ceriello A. Clinical inertia and its impact on treatment intensification in people with type 2 diabetes mellitus. Diabetes Metab [Internet]. 2017;43(6):501–11. Available from:
  6. Stankovic, Z., Jasovic-Gasic, M., & Lecic-Tosevski D. Psychological problems in patients with type 2 diabetes - clinical considerations. Mil Med Pharm J Serbia. 2013;70(12).
  7. Onyenekwe BM, Young EE, Nwatu CB, Okafor CI, Ugwueze CV. Diabetes Distress and Associated Factors in Patients with Diabetes Mellitus in South East Nigeria. Dubai Diabetes Endocrinol J. 2020;26(1):31–7.
  8. Farm BAS, Perwitasari DA, Thobari JA, Cao Q, Krabbe PFM, Postma MJ. Translation, Revision, and Validation of the Diabetes Distress Scale for Indonesian Type 2 Diabetic Outpatients with Various Types of Complications. Value Heal Reg Issues [Internet]. 2017;12(April 2018):63–73. Available from:
  9. Fisher, L., Mullan, J. T., Skaff, M. M., Glasgow, R. E., Arean, P., & Hessler D. Predicting diabetes distress in patients with Type 2 diabetes: a longitudinal study. Diabet Med. 2009;26(6):622–7.
  10. Perrin NE, Davies MJ, Robertson N, Snoek FJ, Khunti K. The prevalence of diabetes-specific emotional distress in people with Type 2 diabetes: a systematic review and meta-analysis. Diabet Med. 2017;34(11):1508–20.
  11. Wong EM, Afshar R, Qian H, Zhang M, Elliott TG, Tang TS. Diabetes Distress, Depression and Glycemic Control in a Canadian-Based Specialty Care Setting. Can J Diabetes [Internet]. 2017;41(4):362–5. Available from:
  12. Gonzalez, J.S., Shreck, E., Psaros, C., & Safren SA. Distress and type 2 diabetes-treatment adherence: A mediating role for perceived control. Heal Psychol Off J Div Heal Psychol Am Psychol Assoc. 2015;34(5):505–13.
  13. Linetzky B, Jiang D, Funnell MM, Curtis BH, Polonsky WH. Exploring the role of the patient–physician relationship on insulin adherence and clinical outcomes in type 2 diabetes: Insights from the MOSAIc study. J Diabetes. 2017;9(6):596–605.
  14. Lin K, Park C, Li M, Wang X, Li X, Li W, et al. Effects of depression, diabetes distress, diabetes self-efficacy, and diabetes self-management on glycemic control among Chinese population with type 2 diabetes mellitus. Diabetes Res Clin Pract [Internet]. 2017;131:179–86. Available from:
  15. Chew BH, Vos RC, Pouwer F, Rutten GEHM. The associations between diabetes distress and self-efficacy, medication adherence, self-care activities and disease control depend on the way diabetes distress is measured: Comparing the DDS-17, DDS-2 and the PAID-5. Diabetes Res Clin Pract [Internet]. 2018;142:74–84. Available from:
  16. Aghili R, Polonsky WH, Valojerdi AE, Malek M, Keshtkar AA, Esteghamati A, et al. Type 2 Diabetes: Model of Factors Associated with Glycemic Control. Can J Diabetes [Internet]. 2016;40(5):424–30. Available from:
  17. Asuzu CC, Walker RJ, Williams JS, Egede LE. Pathways for the relationship between diabetes distress, depression, fatalism and glycemic control in adults with type 2 diabetes. J Diabetes Complications [Internet]. 2017;31(1):169–74. Available from:
  18. Darawad MW, Hammad S, Samarkandi OA, Hamdan-Mansour AM, Khalil AA. Evaluating the psychometric properties of the arabic version of the diabetes distress scale. J Psychosoc Nurs Ment Health Serv. 2017;55(9):43–51.
  19. Hsu HC, Lee YJ, Wang RH. Influencing Pathways to Quality of Life and HbA1c in Patients With Diabetes: A Longitudinal Study That Inform Evidence-Based Practice. Worldviews Evidence-Based Nurs. 2018;15(2):104–12.
  20. Kuniss N, Rechtacek T, Kloos C, Müller UA, Roth J, Burghardt K, et al. Diabetes-related burden and distress in people with diabetes mellitus at primary care level in Germany. Acta Diabetol. 2017;54(5):471–8.
  21. Lum ZK, Tsou KYK, Lee JYC. Mediators of medication adherence and glycaemic control and their implications for direct outpatient medical costs: a cross-sectional study. Diabet Med. 2018;35(6):807–15.
  22. Mirghani HO. Distress and psychopathology among Sudanese patients with type 2 diabetes mellitus and its relation to glycaemic control. J Taibah Univ Med Sci [Internet]. 2017;12(4):298–303. Available from:
  23. Nanayakkara N, Pease A, Ranasinha S, Wischer N, Andrikopoulos S, Speight J, et al. Depression and diabetes distress in adults with type 2 diabetes: Results from the Australian National Diabetes Audit (ANDA) 2016. Sci Rep [Internet]. 2018;8(1):1–10. Available from:
  24. Sukkarieh-Haraty O, Egede LE, Abi Kharma J, Bassil M. Diabetes fatalism and its emotional distress subscale are independent predictors of glycemic control among Lebanese patients with type 2 diabetes. Ethn Heal [Internet]. 2019;24(7):767–78. Available from:
  25. Walker RJ, Campbell JA, Egede LE. Differential Impact of Food Insecurity, Distress, and Stress on Self-care Behaviors and Glycemic Control Using Path Analysis. J Gen Intern Med [Internet]. 2019;34(12):2779–85. Available from:
  26. Wardian JL, Tate J, Folaron I, Graybill S, True M, Sauerwein T. Who’s distressed? A comparison of diabetes-related distress by type of diabetes and medication. Patient Educ Couns [Internet]. 2018;101(8):1490–5. Available from:
  27. Winchester RJ, Williams JS, Wolfman TE, Egede LE. Depressive symptoms, serious psychological distress, diabetes distress and cardiovascular risk factor control in patients with type 2 diabetes. J Diabetes Complications [Internet]. 2016;30(2):312–7. Available from:
  28. Lee AA, Piette JD, Heisler M, Rosland AM. Diabetes distress and glycemic control: The buffering effect of autonomy support from important family members and friends. Diabetes Care. 2018;41(6):1157–63.
  29. Ji M, Ren D, Dunbar-Jacob J, Gary-Webb TL, Erlen JA. Self-Management Behaviors, Glycemic Control, and Metabolic Syndrome in Type 2 Diabetes. Vol. 69, Nursing research. 2020. 9–17 p.

How to Cite

Wibowo, Z. K., Mudjanarko, S. W., & Khairina, K. (2022). The relationship between diabetes distress and HbA1C level in type 2 diabetes mellitus therapy patients: a systematic review. Bali Medical Journal, 11(1), 476–484.




Search Panel

Zefo Kiyosi Wibowo
Google Scholar
BMJ Journal

Sony Wibisono Mudjanarko
Google Scholar
BMJ Journal

Khairina Khairina
Google Scholar
BMJ Journal