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October, 2017 >>

Management of diabetes distress

Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital )

Komal Verma  ( Faculty, Amity Institute of Behavioural and Allied Sciences, Amity University Rajasthan New Delhi, India )

Yatan Pal Singh Balhara  ( Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India. )


This article discusses a comprehensive approach to the management of diabetes distress. It mentions the screening and diagnosis of diabetes distress, and discusses its etiopathogenesis, investigations and management strategies in detail. The management of diabetes distress, termed as diabetes therapy by the ear, is based upon four pillars: strengthening of self-care skills, optimization of coping skills, minimizing change-related discomfort, and utilization of external support. The article describes coping skills training and change-related discomfort mitigation in detail.

Keywords: Communication, diabetes distress, diabetes education, diabetes support, motivation, stress,


Stress is a common experience of daily living. However, it is our reaction to stress which defines our health and well-being. Living with diabetes, too, could be stress. Our coping mechanisms, honed by coping skills, help us deal with the demands and challenges of life with diabetes.1

Management of diabetes is multifaceted, and includes both non-pharmacological and pharmacological therapy. Non-pharmacological interventions include diet, physical activity and tobacco cessation.2 Following all this advice, and accepting all these prescriptions, too, entails a fair amount of stress.

Diabetes Distress

Emotions related to living with, and managing diabetes, are termed as diabetes distress. Diabetes distress is defined as an emotional response characterized by extreme apprehension, discomfort or dejection, due to perceived inability in coping with the challenges and demands of living with diabetes.
Approach to Management

By definition, diabetes distress is a self-perceived insufficiency of coping skills. To correct this, one may choose to:

1. Improve self-perception
2. Improve coping skills
3. Minimize the burden that needs to be coped with
4. Involve other partners in coping

The management of diabetes distress is non-pharmacological in nature. As in any other clinical situation, the process of management follows a set pattern: history taking, physical examination, investigations and treatment. This should be true for diabetes distress as well.


To diagnose diabetes distress, one can use validated tools such as the Diabetes Distress Scale (DDS). Specific versions are available for use in type 1 diabetes, type 2 diabetes, parents and caregivers. A two item DDS2 screening tool is also available. DDS has been translated into Urdu and Punjabi.3 Work is underway to validate a questionnaire (The GlucoCoper) which measures and pinpoints the source of diabetes distress in pregnancy complicated by hyperglycaemia (Kalra B et al, personal communication).

If significant stress is present, or anticipated, coping mechanisms need to be analyzed. The assessment of coping mechanisms may precede, accompany, or follow the measurement of diabetes distress. It is debatable as to what should be analyzed first. Diabetes distress is not considered a separate 'complication', and is thought to be part of living with diabetes. At the same time, coping mechanisms are an integral part of life, and exist in everyone. A psychometric assessment of coping skills may actually help predict diabetes distress in later life. Coping skills assessment, therefore, is suggested as a primary investigation for diabetes distress prevention and treatment.


Coping skills can be assessed by validated questionnaires, most of which are not made specifically for use in people with diabetes.4 The GlucoCoper is a 6- item instrument which analyses 6 coping styles (2 negative, 4 positive). These are negativity, blame, acceptance, optimize, planning and action. The respondent answers 6 questions on a 1-10 visual 'thermometer- look alike'  'cope meter' scale. The responses provide an idea of current coping styles, and help identify areas for improvement. The values obtained with the GlucoCoper can be charted on graphs, to allow a reader-friendly impression of changes in coping styles over time.

The Gluco Coper should ideally be administered at first contact, and at regular intervals thereafter. In addition, psychological assessment should be considered when major stress or change in life pattern, health status or therapeutic intervention is anticipated, suspected, observed or planned.5


We suggest four pillars of management of diabetes distress (Table-1).

These include strengthening of self-care skills, optimization of coping skills, minimizing the discomfort associated with change, and utilization of support from other stakeholders. All these interventions are non-pharmacological in nature, and are based on patient- provider conversation and communication. Hence, these can be clubbed as 'diabetes therapy by the ear'.6 In this article we focus on optimization of coping skills, and on reduction of change-linked discomfort.

Coping skills training (CST) seeks to improve coping skills, while various methods of minimizing the discomfort of change (MDC) are used to minimize, postpone or redistribute the burden of living with diabetes.

Coping Skills Enhancement

Once coping styles have been mapped, the diabetes care professional works to eliminate negative coping mechanisms, and incorporate positive coping skills (Table-2).7

This may be done by the primary diabetes care provider, or by a qualified mental health professional. This decision depends on the availability of mental health professional, and also on the competence and comfort level of the primary diabetes care provider.8

Referral is also decided by the degree of distress of a particular person. While the symptoms of diabetes distress are similar to those of depression, they are not severe enough to meet the diagnostic criteria for major depressive disorder (MDD). If these criteria are met, the patient should ideally be referred to a psychiatrist.

Elimination of negative coping styles is done through a process of therapeutic conversation, which encourages the person to explore his or her (unfounded) thoughts and beliefs. Simultaneously, the person's self-care skills are developed through simultaneous education, counseling and support.9,10

Improvement of coping styles is a dynamic, and life long process. One needs to observe the person with diabetes on a regular basis, offer constructive feedback, and assist in upgrading the coping strategies. Positive motivation can be taken from a number of sources, including spiritual texts.11,12 and self-help publications.

Minimizing Discomfort of Change

The process of diabetes care is marked by multiple changes. These changes impact virtually every facet of life, from sleep-wake cycle to diet, exercise, work and recreation. Each change is marked by discomfort.13 While these changes have to be instituted for optimal therapeutic outcomes, they themselves may cause stress and create new challenges. However the discomfort associated with them can easily be minimized. Table-1 suggests a few methods of minimizing the discomfort of dealing with change (MDC) caused by diabetes.


Diabetes distress is a common occurrence in persons living with diabetes. A proactive approach to its screening and diagnosis is not enough. Diabetes care professionals must work to identify the cause or etiopathogenesis of diabetes distress, and minimize its impact. At the same time, they must strengthen the affected person by utilizing all available resources, so as to better prepare them to face diabetes. Simultaneous focus on all these practical aspects helps manage diabetes distress, and contributes to overall health and wellbeing.


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3. Scales and measures. Available from URL:  http://behavioraldiabetes.org/scales-and-measures/#1448434304099-9078f27c-4106Cited on 14 May 2017

4. Sherwood A, Blumenthal JA, Koch GG, Hoffman BM, Watkins LL, Smith PJ, et al. Effects of Coping Skills Training on Quality of Life, Disease Biomarkers, and Clinical Outcomes in Patients With Heart Failure. Clinical perspective. Circulation: Heart Failure. 2017; 10:e003410.

5. Young-Hyman D, de Groot M, Hill-Briggs F, Gonzalez JS, Hood K, Peyrot M. Psychosocial care for people with diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2016 ; 39: 2126-40.

6. Kalra S, Baruah MP, Das AK. Diabetes therapy by the ear: A bi-directional process. Indian J Endocr Metab 2015; 19(Suppl 1):S4-S5.3.

7. Kalra S, Kalra B, Sharma A, Sirka M. Coping skills training: The AEIOU approach. Endocr J 2010; 57 Suppl 2:S391.

8. Kalra S, Sridhar GR, Balhara YP, Sahay RK, Bantwal G, Baruah MP, et al. National recommendations: Psychosocial management of diabetes in India. Indian J Endocr Metab. 2013; 17: 376-95.

9. Kalra S, Kalra B. Mishit copes with diabetes: A pragmatic approach to coping skills training. J Soc Health Diabetes. 2017; 5:1-2.

10. Kalra S, Kalra B, Agrawal N, Sahay R, Unnikrishnan A, Chawla R. Coping Strategies In Diabetes. The Internet Journal of Geriatrics and Gerontology. 2009; 5 .

11. Niazi AK, Kalra S. Patient centred care in diabetology: an Islamic perspective from South Asia. Journal of Diabetes & Metabolic Disorders. 2012; 11(1):30-34.

12. Priya G, Kalra S, Dardi IK, Saini S, Aggarwal S, Singh R, et al.. Diabetes care: Inspiration from Sikhism. Indian J Endocr Metab. 2017; 21:453-59.

13. Kalra S, Kumar S, Kalra B, Unnikrishnan A, Agrawal N, Sahay R. Patient-provider interaction in diabetes: Minimizing the discomfort of change:. The Internet Journal of Family Practice. 2009; 8:2. 



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