Diabetes-specific Stress Research Articles

Pressure pain sensitivity: A new stress measure in children and adolescents with type 1 diabetes?

Type 1 diabetes (T1D) is associated with general- and diabetes-specific stress which has multiple adverse effects. Hence measuring stress is of great importance. An algometer measuring pressure pain sensitivity (PPS) has been shown to correlate to certain stress measures in adults. However, it has never been investigated in children and adolescents. The aim of our study was to examine associations between PPS and glycated hemoglobin (HbA1c), salivary cortisol and two questionnaires as well as to identify whether the algometer can be used as a clinical tool among children and adolescents with T1D. Eighty-three participants aged 6-18 years and diagnosed with T1D were included in this study with data from two study visits. Salivary cortisol, PPS and questionnaires were collected, measured, and answered on site. HbA1c was collected from medical files. We found correlations between PPS and HbA1c (rho = 0.35, P = 0.046), cortisol (rho = -0.25, P = 0.02) and Perceived Stress Scale (rho = -0.44, P = 0.02) in different subgroups based on age. Males scored higher in PPS than females (P < 0.001). We found PPS to be correlated to HbA1c but otherwise inconsistent in results. High PPS values indicated either measurement difficulties or hypersensibility towards pain.

Within-person relationships of sleep duration with next-day stress and affect in the daily life of adults with Type-1 diabetes

ObjectiveThe objective of this study is to examine the within-person relationships between sleep duration and next-day stress and affect in the daily life of individuals with T1D. MethodsStudy participants were recruited in the Function and Emotion in Everyday Life with Type 1 Diabetes (FEEL-T1D) study. Sleep duration was derived by synthesizing objective (actigraphy) and self-report measures. General and diabetes-specific stress and positive and negative affect were measured using ecological momentary assessment. Multilevel regression was used to examine the within-person relationships between sleep duration and next-day stress and affect. Cross-level interactions were used to explore whether gender and baseline depression and anxiety moderated these within-person relationships. ResultsAdults with T1D (n = 166) completed measurements for 14 days. The average age was 41.0 years, and 91 participants (54.8%) were female. The average sleep duration was 7.3 h (SD = 1.2 h). Longer sleep was significantly associated with lower general stress (p < 0.001) but not diabetes-specific stress (p = 0.18) on the next day. There were significant within-person associations of longer sleep with lower levels on next-day negative affect (overall, p = 0.002, disappoint, p = 0.05; sad, p = 0.05; tense, p < 0.001; upset, p = 0.008; anxious, p = 0.04). There were no significant associations with positive affect. Examination of the interaction effects did not reveal significant differential relationships for men and women and for individuals with and without depression or anxiety at baseline. ConclusionFindings from this study suggest optimizing sleep duration as an important interventional target for better managing general stress and improving daily emotional wellbeing of individuals with T1D.

HUMANISTIC BURDEN OF INFORMAL CAREGIVERS OF CHILDREN AND YOUNG ADULTS WITH NEWLY DIAGNOSED TYPE 1 DIABETES (T1D): A SYSTEMATIC LITERATURE REVIEW (SLR)

OBJECTIVES: To describe the humanistic and economic burden of informal caregivers of children, adolescents, and young adults newly diagnosed with T1D.&#x0D; METHODS: An SLR was conducted in MEDLINE®, Embase®, and PsycInfo® (search date: December 7, 2021) to identify clinical and observational studies assessing the humanistic burden experienced by informal caregivers (i.e., persons who provide unpaid care) of children, adolescents, and young adults aged 6 to 21 who were diagnosed with T1D within three months.&#x0D; RESULTS: Four prospective cohort studies and one randomized controlled trial (RCT) were included. Caregiver sample size ranged from 59 to 191. Duration of T1D was 2 to 6 weeks. Among parents of children aged ≤11 years, mothers had a moderate posttraumatic stress disorder symptom severity (mean score: 11.9; standard deviation [SD]: 7.4), while fathers experienced mild severity (8.4; SD: 6.2; p &lt; 0.001; Posttraumatic Diagnostic Scale). Mothers experienced clinically significant symptoms (defined as score &gt;5) of anxiety (mean score: 7.5), social dysfunction (7.5), and somatic symptoms (5.1; General Health Questionnaire [GHQ]-28). Fathers showed clinically significant anxiety (5.5) and social dysfunction (7.7; GHQ-28) only. Results from the RCT indicated a mean hypoglycemia fear score of 46.6 out of 108 at diagnosis and 34.9 after 14 weeks, with a higher score indicating greater fear (Hypoglycemia Fear Survey-Parents). Parents of children aged &gt;11 years experienced clinically significant social dysfunction (mean score for mothers/fathers: 7.6/7.1) and anxiety (mothers: 5.4; GHQ-28). Parents experienced moderate to extreme diabetes-specific stress (defined as score ≥5; mean score: 6.3; SD: 1.9) at diagnosis, and no to moderate stress (4.5; SD: 2.1) at 3 months. None of the included studies reported on economic burden.&#x0D; CONCLUSIONS: This SLR highlights parents of children and young adults with newly diagnosed T1D experience caregiver burden, with a greater burden among mothers than fathers. Due to the paucity of evidence, further studies are warranted to better understand the humanistic burden among this group of informal caregivers.

708-P: Within-Person Relationships of Sleep Duration with Next-Day Stress and Affect in the Daily Life of Adults with Type 1 Diabetes

Introduction: Daily short sleep duration may negatively impact individuals with type 1 diabetes’ (T1D) ability to manage emotional well-being and to cope with daily stressors. Nevertheless, existing research is limited and mostly focused on between-person differences rather than impact of fluctuations in sleep duration on individuals. Methods: Participants in the Function and Emotion in Everyday Life with Type 1 Diabetes (FEEL-T1D) study completed 14 days of intensive longitudinal data collection. Sleep duration was derived by synthesizing objective (actigraphy) and self-report measures. General and diabetes-specific stress, positive affect (PA), and negative affect (NA) were measured via ecological momentary assessment (5-6 times per day at 3-hr intervals). Multilevel regression was used to examine within-person relationships between sleep duration and next-day stress and affect. Cross-level interactions were used to explore whether gender and baseline depression and anxiety moderated these relationships. Results: Adults with T1D (N=166) with at least 7 days of complete data were analyzed. Participants were 41.0 years, and 54.8% female. Average sleep duration was 7.3 hours (SD=1.2). Longer sleep was significantly associated with lower general stress (p&amp;lt;0.001) but not diabetes-specific stress (p=0.18) on the next day. Longer sleep was related to lower levels on all next-day NA (overall, p=0.002; disappointed, p=0.05; sad, p=0.05; tense, p&amp;lt;0.001; upset, p=0.008; anxious, p=0.04). There were no significant associations with PA (all p&amp;gt;0.05). Examination of interaction effects did not reveal significant differential relationships by gender, depression or anxiety. Conclusion: Findings from this study suggest optimizing sleep duration as an important intervention target for better managing stress and improving daily emotional wellbeing of individuals with T1D. Disclosure H.Jin: None. J.S.Gonzalez: Consultant; Virta Health Corp. E.Pyatak: Research Support; Abbott Diabetes. S.Schneider: None. C.J.Hoogendoorn: None. R.Hernandez: None. P.Lee: None. D.Spruijt-metz: None. Funding National Institutes of Health (1R01DK121298)

654-P: Characterizing Mental Health Status and Service Utilization in Chinese Americans with Type 2 Diabetes

Objectives: Mental health issues are common in people with type 2 diabetes (T2D). Yet, the mental health burden of Chinese immigrants with T2D remains unknown. This study examined mental health status, mental health-seeking behaviors, and service utilization among Chinese immigrants with T2D. Methods: We conducted a telephone-based cross-sectional survey among 66 Chinese immigrants with T2D recruited from the diabetes registry in NYC. Participants’ mental health status including anxiety, depressive symptoms, general stress, and diabetes-specific distress were measured using the Hospital Anxiety and Depression Scale-Anxiety subscale, Patient Health Questionnaire-9, Perceived Stress Scale, and Diabetes Distress Scale, respectively. Information related to mental health-seeking behaviors and service utilization was also collected. Descriptive statistics were used. Results: Most participants (mean age 56.1±10.5 years) were female (57.6%), currently married (80.3%), foreign born (100%), high school graduate or less (77.3%), with annual household income &amp;lt; $25,000 (50.8%), and limited English proficiency (95.5%). About 9%, 25.7%, and 23.7% reported moderate or higher depressive symptoms, general stress, and diabetes-specific distress, respectively. Only 11.5% with elevated symptoms have ever seen a mental health professional and 3.8% were currently seeking mental health services. Not seeking mental health services was attributed to no need (92.4%), not knowing where to find Chinese-speaking providers (4.5%), cost (1.5%), and time (1.5%). Conclusions: Mental health issues, especially general stress and diabetes-specific stress were high among Chinese immigrants with T2D. However, very few of them have ever sought or are currently seeking mental health services. Future research needs to gain a better understanding of the barriers and design culturally tailored programs to serve the needs of this minority group. Disclosure Y.Shi: None. B.Wu: None. N.Islam: None. M.Sevick: None. A.Shallcross: None. H.Bao: None. X.Xu: None. Y.Jiang: None. L.Hu: None. Funding National Institutes of Health (P50MD017356)

Sweet as Sugar-How Shared Social Identities Help Patients in Coping with Diabetes Mellitus.

Social identification is health-beneficial as social groups provide social support (i.e., the social cure effect). We study this social cure effect in diabetes patients by focusing on two relevant sources of social support, namely medical practitioners (MP) and fellow patients. As both groups have diabetes-specific knowledge, we predict that sharing an identity with them provides access to specific support, which, in turn, optimizes individuals’ diabetes management and reduces diabetes-related stress. We further predict that identifying with their MP or fellow patients will be more strongly related to perceived social support among individuals with lower diabetes-specific resilience because they pay more attention to supportive cues. We tested this moderated mediation model in a two-wave study with n = 200 diabetes patients. Identification with the MP related to more support, which, in turn, was related to better diabetes management and less diabetes-specific stress. Identification with fellow patients related to more support; however, social support was unrelated to diabetes management and stress. Resilience only moderated the relationship between MP identification and support, as people with lower resilience levels reported more support from their MP. This study shows the importance of social identification with the MP and other diabetes patients, especially for people with lower resilience levels.

Trait Mindfulness and Mindfulness Practices in Adolescents with Type 1 Diabetes: Descriptive and Comparative Study.

Study describes mindfulness (trait and practices) and compares levels of trait mindfulness (low/high) and practices (yes/no) on demographic, clinical characteristics, and diabetes-related outcomes among adolescents with type 1 diabetes (T1D). Adolescents completed a survey on demographics, clinical data, trait mindfulness/practices, diabetes-specific stress, and diabetes self-management (DSM). Glycemic control (A1c) obtained from medical records. T and χ2 tests were applied for comparative analyses. 129 adolescents (12-18 years) reported moderately high levels of mindfulness (31 ± 8; range, 10-40). One-third (30%) reported having experience with mindfulness practices (formal, informal, and religious). Adolescents who reported higher levels of trait mindfulness had higher insulin pump usage (p =.005), less diabetes-specific stress (p <.001), greater DSM (p =.006), and less A1c (p =.013). Adolescents who reported more types of mindfulness practices had greater DSM scores. Adolescents with higher levels of trait mindfulness and with more types of mindfulness practices had better diabetes-related outcomes. Introducing mindfulness training tailored to adolescents with T1D should be examined.

Validity, Reliability, and Measurement Invariance of the Diabetes Stress Questionnaire-Short Form.

The purpose of this study was to develop a short form of the Diabetes Stress Questionnaire (DSQ) with adequate psychometric properties (i.e., internal consistency, convergent, criterion, discriminant validity, construct validity, and measurement invariance). In total, 181 youth with type 1 diabetes (T1D) completed the 65-item DSQ, and archival data were obtained from 142 youth with T1D to serve as an independent cross-validation sample. Twenty-four items were chosen to retain the original eight scales of the DSQ and to maximize internal consistency and correlations to full subscales. Confirmatory factor analyses were used to evaluate the proposed factor structure of the Diabetes Stress Questionnaire-Short Form (DSQ-SF) and to assess invariance of the DSQ-SF across sex, race, grade level, glycemic control, illness duration, and annual income categories. The 24-item DSQ-SF was found to have good internal consistency, factor structure and fit, correlated highly to the full scale (r = .98), and was invariant across sex, race, grade level (<9th grade or >9th grade), glycemic control, illness duration, and annual income. The DSQ-SF appears to be a psychometrically robust measure of diabetes-specific stress in youth with T1D. Present findings suggest that the DSQ-SF has the potential to be a useful, quick, cost-effective, and comprehensive screening tool for identifying youth with T1D who may benefit from T1D-specific stress reduction interventions as a way to improve health behaviors, psychosocial well-being, and glycemic control.

Psychological Distress Predicts HbA1c Trajectories among Type 1 Diabetic Adolescents

Diabetic adolescents have poor metabolic control. We aimed to characterize the longitudinal association between the stress-related domains of emotional burden (EB), physician related-distress (PD), regimen-related distress (RD), diabetes-related interpersonal distress (ID), and hemoglobin glycosylated (HbA1c) trajectories among Type 1 diabetics Chilean adolescents.&#x0D; Thirty-two Type 1 diabetic adolescents (Mage=15.97; SD=3.45) were followed for one year. HbA1c was assessed at three time points, and a stress measure was obtained. Using a longitudinal growth curve modeling, a marginal overall negative linear trend was found in HbA1c (b = -0.23, p = 0.096). There was an interaction between time and PD (b = -0.33, p &lt; 0.05), and a main effect of EB, RD, and ID on HbA1c. Psychological stress domains predict metabolic control trajectories. Monitoring diabetes specific stress may be a useful tool to identify adolescents at risk for poor control, and interventions that reduce such stress might lead to better management of diabetes in adolescents.

Trajectories of Acute Diabetes-Specific Stress in Adolescents With Type 1 Diabetes and Their Caregivers Within the First Year of Diagnosis.

Our aims were to describe stress trajectories for newly diagnosed type 1 diabetes (T1D) in adolescents and their parents, explore whether resilience is associated with stress trajectories, and to examine the effects of stress trajectories on diabetes-specific outcomes. Fifty-nine youth aged 10-18 years with newly diagnosed T1D and a primary caregiver were followed for 12 months. Stress and resilience were assessed using questionnaires every 3 months, and diabetes-specific outcomes (self-care, quality of life, and hemoglobin A1C) at 6 and 12 months. Parent and adolescent stress trajectories were identified using semiparametric group-based modeling. Four stress trajectories emerged for parents and three emerged for adolescents. Adolescent trajectories were stable throughout the 12 months, and those with stable low stress had the highest levels of resilience. Further, the stable low stress group had higher quality of life scores at 12-month postdiagnosis. In contrast, stress for parents changed considerably over the 12-month period, and trajectory groups did not associate with 12-month outcomes. Distinct patterns of stress emerged for both the adolescent and parent cohorts. Resilience at the time of diagnosis was particularly protective for adolescents. These results suggest that stress-reducing and resilience-promoting interventions for newly diagnosed adolescents with T1D may have potential to improve longer-term outcomes.

Diabetes-Specific and General Life Stress and Glycemic Outcomes in Emerging Adults With Type 1 Diabetes: Is Race/Ethnicity a Moderator?

This study examines whether race/ethnicity moderates relationships of (a) diabetes stress and general life stressors with (b) diabetes outcomes of glycemic control and diabetic ketoacidosis (DKA) among emerging adults (aged 18-25 years) with type 1 diabetes (T1D). Using a T1D Exchange Registry sample of non-Hispanic White, African American, and Hispanic emerging adults (N = 3,440), multiple group analyses were used to determine whether race/ethnicity moderates the relationships between stress and diabetes outcomes. The relationships between the two stress types and glycemic control did not differ between African American and non-Hispanic Whites. However, as compared with non-Hispanic Whites, the association between higher diabetes-specific stress and poorer glycemic control was significantly stronger for Hispanics, and Hispanics had poorer glycemic control when they experienced a relatively fewer number of general life stressors than non-Hispanic Whites. The relationships between the type of stress (diabetes-specific and general stress) and DKA did not differ across racial/ethnic groups. Future research should evaluate possible mechanisms that contribute to the different relationships of stress with glycemic control among Hispanics compared with non-Hispanic Whites.

General and diabetes-specific stress in adolescents with type 1 diabetes.

Type 1 diabetes (T1D) is one of the most common chronic health conditions in adolescents in the United States. Adherence to the recommended treatment regimen has been reported as a source of stress for adolescents. The purpose of this study was to examine the associations among general and diabetes-specific stress and glycemic control (HbA1c), self-management, and diabetes-specific quality of life (QOL) in adolescents with T1D. A secondary analysis of baseline data (N=320) from a randomized controlled trial was conducted. Adolescents completed validated measures of general and diabetes-specific stress, self-management, and diabetes-specific QOL. HbA1c levels were obtained from medical records. Over 50% of the sample scored at or above criteria for high general and diabetes-specific stress. Higher general and diabetes-specific stress was significantly associated with higher HbA1c, poorer self-management activities, and lower diabetes-specific QOL. Diabetes-specific stress accounted for a significant proportion of the variance in HbA1c, while general stress did not. General and diabetes-specific stress accounted for 40% of the variance in diabetes-specific QOL. General and diabetes-specific stress are common in adolescents with T1D. Healthcare providers must be mindful of the sources of stress that adolescents with T1D face on a daily basis. General stress and diabetes-specific stress should be differentiated and may require different interventions to improve coping and outcomes.

A dyadic multiple mediation model of patient and spouse stressors predicting patient dietary and exercise adherence via depression symptoms and diabetes self-efficacy.

Using dyadic data from 117 married couples in which one partner was diagnosed with Type 2 diabetes, the purpose of this study was to determine whether a number of specific patient and spouse stressors (chronic life stress, diabetes-specific stress, and physical health stress in the form of the number of comorbidities) were associated with Type 2 diabetes patients' dietary and exercise adherence through two potentially modifiable patient and spouse factors-depression symptoms and diabetes self-efficacy. We found that patient and spouse stressors, particularly patient and spouse diabetes stress and the number of patient comorbidities, were related to patient dietary and exercise adherence through patient depression symptoms and both patient and spouse diabetes self-efficacy. These conclusions were strengthened by incorporating a number of relevant control variables in our models and by testing four alternative models which supported our proposed model. These results are important because they provide further evidence of the significant role spouses' play in managing diabetes and they provide diabetes educators and clinicians with specific targets for intervention programming.

Assessing measurement invariance of the diabetes stress questionnaire in youth with type 1 diabetes.

To evaluate the factor structure and measurement invariance of the Diabetes Stress Questionnaire (DSQ), a measure of diabetes-specific stress, across sex, age (<9th grade vs. ≥9th grade), and glycemic control (optimal vs. suboptimal). Data from 318 adolescent participants were pooled from four archival data sets and the ongoing Predicting Resiliency in Youth with Type 1 Diabetes study in which the DSQ was completed. Confirmatory factor and measurement invariance analyses were conducted to confirm the proposed factor structure and measurement invariance across sex, age, and glycemic control. The DSQ factor structure was found to have an acceptable fit, which was invariant across sex, age, and glycemic control. When using the DSQ, differences in diabetes-related stress with respect to sex, age, or glycemic control can be considered meaningful. This study supports the DSQ as an evidence-based and well-established assessment of perceived diabetes stress in youth with type 1 diabetes.

Measurement of diabetes stress in older children and adolescents with type 1 diabetes mellitus

Studies indicate general psychological stress plays a role in the glycemic control of individuals with type 1 diabetes mellitus (T1DM). Disease-specific rather than general measures may be more closely related to measures of health outcomes. Therefore, measurement of diabetes-related stress is needed to advance knowledge of significant relationships between stress and glycemic control. The objective of this study was to evaluate the psychometric properties of a measure of diabetes-related stress for youth with T1DM. A 65-item diabetes stress questionnaire for youths (DSQY) was previously developed for use with older children and adolescents. The DSQY was completed by 417 youths with T1DM and the results were analyzed to determine the factor structure and psychometric properties of the questionnaire, as well as relationships of diabetes stress with demographic and clinical variables. A factor analysis of the DSQY yielded an eight-factor solution with acceptable internal consistencies. Significant relationships were observed between glycemic control and stress related to parents and dietary issues. While age and socioeconomic status were unrelated with DSQY scores, higher stress was associated with longer diabetes duration, female gender, and racial/ethnic minority status. The DSQY is a reliable and valid measure for assessment of diabetes-specific stress in youths with T1DM.

Families With Children With Diabetes: Implications of Parent Stress for Parent and Child Health

To examine the relation of parent stress to parent mental health and child mental and physical health. We interviewed children with type 1 diabetes (n = 132; mean age 12 years) annually for 5 years and had one parent complete a questionnaire at each assessment. Parents completed measures of general life stress, stress related to caring for a child with diabetes, benefit finding, and mental health. Child outcomes were depressive symptoms, self-care behavior, and glycemic control. Multilevel modeling was used to examine concurrent and longitudinal relations. Greater parent general stress and greater parent diabetes-specific stress were associated with poorer parent mental health. Overall, greater parent general stress was associated with poorer child outcomes, whereas greater parent diabetes-specific stress was associated with better child outcomes. Families with high levels of general life stress should be identified as they are at risk for both poor parent and child health outcomes.

Development of a Group Intervention for Teens With Type 1 Diabetes

Adolescents with Type 1 diabetes (DM1) are at significant risk for depression compared to their non-diabetic counterparts and frequently demonstrate poor glycemic control. Comorbid depression may further exacerbate inadequate metabolic control by creating emotional barriers to effective adherence. Caregiver response to the diagnosis and management of DM1 also has implications for diabetic teens' psychological and physical health. This article describes the development and implementation of a group intervention for adolescents with DM1 and a parallel caregiver support group. The group intervention is designed to improve psychosocial functioning and medical adherence in teen participants and to reduce diabetes-specific stress in caregivers.

The impact of cognitive distortions, stress, and adherence on metabolic control in youths with type 1 diabetes

Purpose To investigate the role of cognitive distortions in the relationship between adherence behavior, diabetes-specific stress, general stress, and metabolic control. Methods Obtained questionnaire data, glucometer readings, and glycosylated hemoglobin (HbgA 1c) assays from 143 youths (11–18 years old) with type 1 diabetes. Examined path model of relationships between cognitive distortions, stress, adherence behavior, and metabolic control. Data were analyzed using path analysis. Results Higher levels of negative cognitive distortions were associated with more stress (both diabetes-specific and general). Higher levels of general stress then led to less adherent behavior and subsequently poorer metabolic control (higher HbgA 1c). More diabetes-specific stress also led to poorer metabolic control, as well as general stress. Conclusions The findings indicate an indirect role of negative cognitive distortions in metabolic control. The current findings suggest that instead of the proposed direct link between cognitive distortions and adherence behavior, an indirect relationship may exist through stress.

A Cognitive Behavioral Adherence Intervention for Adolescents with Type 1 Diabetes

This study examined the impact of a cognitive behavioral intervention for nonadherent adolescents with type 1 diabetes. Six youths having problems following the diabetes regimen received training in cognitive restructuring and problem solving during individual sessions. A multiple baseline design across participants was used. Treatment effectiveness was assessed through 24-hr recall adherence interviews with adolescents and frequency of testing data was downloaded from glucose meters. Data was also collected for diabetes-specific stress. Five youths displayed improvement on at least one self-care behavior. Furthermore, the results suggest that the cognitive behavioral intervention was effective in diminishing diabetes-related stress in two participants. Cognitive behavioral interventions show promise for increasing self-care behaviors among nonadherent youths with type 1 diabetes. However, individual youths varied in their response to treatment. Further research is needed in developing procedures to better meet the needs of youths, improve youth participation, and enhance treatment effectiveness.

Dimensions of quality of life in people with non-insulin-dependent diabetes.

The purpose of the study was to find out which of five Quality of life (QoL) questionnaires are reliable and valid for evaluating the QoL in German patients with type 2 diabetes: the Diabetes Treatment Satisfaction Questionnaire (DTSQ), the Well-Being Questionnaire (WBQ), the Short Form SF36 of the Medical Outcome Study (SF36), the Diabetes39 and the Quality of Life with Diabetes (LQD) questionnaire. A stratified sample of 144 patients who were attending one of nine special hospitals for people with diabetes at the time of the study were given the questionnaires twice. Most of the scales of the questionnaires had internal consistencies (alpha) of above 0.80 as recommended; the retest reliabilities were lower, especially for scales evaluating satisfaction with levels of blood sugar and treatment in general. A factor analysis of all scale scores yielded four factors: (1) physical aspects, (2) well-being and satisfaction, (3) diabetes-specific stress, and (4) treatment satisfaction. Construct validity showed frequency of hypoglycemias, neuropathies, treatment with insulin and number of late complications to have a negative impact on QoL scores. No single questionnaire covered all relevant aspects of the QoL of subjects with type 2 diabetes. Thus, quality of life in diabetic people should be evaluated with scales representing the cognitive dimensions found in this study so as not to miss significant aspects.