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Journal of Diabetes 8 (2016) 269 – 278

O R I G I N A L A RT I C L E

Gender differences in the association between lifestyle

behaviors and diabetes distress in a community sample of
adults with type 2 diabetes
Carla LIPSCOMBE,1,2 Kimberley J. SMITH,3,4 Geneviève GARIEPY1,2 and Norbert SCHMITZ1,2,5,6
Departments of 1Epidemiology and Biostatistics and 5Psychiatry, McGill University, 2Douglas Mental Health University Institute and
6
Montréal Diabetes Research Centre, Montreal, Quebec, Canada, 3Department of Life Sciences and 4Institute of Environment Health and
Societies, Healthy Ageing, Brunel University, Uxbridge, UK

Correspondence
Norbert Schmitz, Douglas Mental Health
University Institute, McGill University,
6875 LaSalle Boulevard, Montréal,
Québec, Canada H4H 1R3.
Tel: +1514 761 6131 extn 3379
Fax: +1514 888 4064
Email: norbert.schmitz@douglas.mcgill.ca
Received: 28 November 2014; revised 13
March 2015; accepted 30 March 2015.
doi: 10.1111/1753-0407.12298
Abstract
Background: The present study examined the association between moderate
and severe diabetes distress (DD) and lifestyle behaviors (physical activity,
smoking, alcohol consumption) in a community sample of adults with type 2
diabetes mellitus (T2DM).
Methods: A total of 1971 adults with T2DM were recruited using mixed
methods sampling. Participants were considered eligible if they had a doctor
diagnosis of T2DM (≤10 years), were insulin naïve, aged 40–75 years, and
were from Quebec, Canada. Participants provided information on DD, life-
style behaviors, sociodemographic, and diabetes-related factors. Multinomial
logistic regressions examined the association between moderate and severe
DD and each lifestyle behavior, according to gender. Effect estimates can be
interpreted as probability ratios (PR).
Results: In females, physical inactivity was associated with an increased
likelihood of moderate distress (PR 2.2; 95% confidence interval [CI] 1.49–
3.24) and severe distress (PR 1.80; 95% CI 1.00–3.24). In males, only severe
distress was associated with physical inactivity (PR 1.92; 95% CI 1.00–3.66).
Current smoking was associated with a greater probability of severe distress in
males (PR 3.0; 95% CI 1.54–5.84) and females (PR 1.32; 95% CI 0.67–2.60);
however this effect was stronger in males. No association was found between
alcohol consumption and DD in females. In males, frequent alcohol con-
sumption was associated with a reduced probability of moderate (PR 0.56;
95% CI 0.34–0.91) and severe distress (PR 0.47; 95% CI 0.21–1.06).
Conclusions: The findings of this study suggest important gender differences
in the association between DD and lifestyle behaviors.
Keywords: alcohol drinking, exercise, mental health, smoking, type 2 diabetes
mellitus.

Significant findings of the study: In females, physical inactivity was associated with a greater probability of
moderate and severe DD. In males, smoking was associated with greater probability of severe DD. In males only,
alcohol consumption was associated with a reduced probability of moderate and severe distress.
What this study adds: This is the first study to investigate the association between smoking, alcohol consumption,
and DD in a community sample of adults with T2DM. The findings highlight the role of gender in the relationship
between DD and diabetes-related health behaviors.

© 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd 269
Lifestyle behaviors and diabetes distress
Introduction
Type 2 diabetes mellitus (T2DM) is a progressive and
chronic metabolic disorder affecting roughly 6% of
Canadians.1 Standard treatment for T2DM is focused
on glucose regulation and includes a combination
of pharmacological (e.g. insulin therapy) and non-
pharmacological approaches.2 Daily self-care and life-
style modifications are important components of the
T2DM treatment regimen and have been shown to delay
the progression of diabetes complications and improve
diabetes-related health outcomes.3 The Canadian Diabe-
tes Association (CDA) recommends that people with
T2DM engage in regular physical activity, limit their
alcohol consumption, and quit smoking.2
Poor mental health is a common comorbidity among
people with T2DM, and has been shown to interfere with
regimen compliance and is associated with poorer
diabetes-related health outcomes.4–6 Most studies on
mental health in people with diabetes examine depres-
sion; however, researchers are increasingly interested in a
form of distress specific to living with diabetes called
“diabetes distress” (DD). Diabetes distress is a multidi-
mensional construct characterized by negative emotions,
worries, and fears relating to four major diabetes-related
problem areas. Subdomains of DD include: (i) emotional
distress, characterized by feelings of anger, frustration,
and worry regarding living with the demands of diabetes
or future diabetes-related complications; (ii) physician
distress, relating to the quality of care provided by
healthcare professionals; (iii) regimen-related distress,
pertaining to fears and concerns regarding diabetes treat-
ment regimens; and (iv) interpersonal distress, relating to
the level of social support received from family members
and friends.7 In people with diabetes, DD appears to be
more common than major depression (MD). Recent
point estimates in community samples have found the
prevalence of moderate to severe DD to be as high as
18%.8 In addition, DD appears to be more strongly asso-
ciated with poorer glycemic control than MD,6,9–11 and is
associated with poorer disease management, including
worse medication adherence,6,10,12 poor dietary
habits,6,10,12,13 and lower levels of physical activity.6,10,12,13
Despite considerable symptom overlap between DD and
MD, particularly with regard to somatic symptoms (e.g.
feeling tired, having low energy), evidence suggests that
DD is a separate and distinct condition from MD.9,14
Lifestyle behaviors such as smoking, excessive alcohol
consumption, and physical inactivity are associated with
a wide range of physical and mental health consequences
in people with T2DM.2,15–18 However, little is known
about the relationship between smoking, alcohol con-
sumption, and DD in this population. Several studies
270 © 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
C. LIPSCOMBE et al.
have examined the relationship between physical activity
levels and DD;6–8,10,12,13 however, the large majority of
these studies have used clinical samples or samples iden-
tified through medical groups or diabetes education
centers, rendering conclusions about how this relation-
ship may manifest in the general population difficult to
make.
The relationship between lifestyle behaviors and DD is
also likely to vary by sex. Females tend to evidence
higher average levels of DD than males,12,19,20 and this
pattern appears to hold cross-culturally.21,22 In addition,
longitudinal studies find females have a greater odds of
developing DD13 and experience greater persistence of
DD symptoms over time.11 Similarly, lifestyle behaviors
such as smoking, physical activity, and alcohol consump-
tion tend to differ according to gender.1,23
To date, few studies have examined how smoking,
physical activity, and alcohol consumption relate to total
DD, and the multiple dimensions of DD in a represen-
tative sample of adults living with T2DM. As such, the
main objectives of the present study were to describe and
examine the association between physical activity,
smoking, and alcohol consumption according to indi-
vidual DD subscales and total DD. In addition, given the
existence of gender differences in the development, sever-
ity, and persistence of DD, as well as in the prevalence
and performance of these lifestyle behaviors, all analyses
were stratified by gender.
Methods
Subjects
Data for the present study were derived from the Evalu-
ation of Diabetes Treatment study (EDIT), a longitudi-
nal community-based survey of adults with T2DM (for
more information, see Smith et al.24). Participant recruit-
ment involved mixed method sampling techniques
including random digit dialing and mail-out surveys. Eli-
gibility criteria included being a resident of Quebec
(Canada), aged 40–75 years, having a doctor diagnosis of
T2DM within the previous 10 years, and being insulin
naïve. A total of 2028 subjects met the inclusion criteria
and underwent the interview process. Participants who
did not provide information on questions relating to
DD, smoking levels, alcohol consumption, or physical
activity levels were excluded from the analyses. In all,
1971 participants were included in the final sample. The
present study uses baseline data collected in 2011. The
study protocol was reviewed and approved by the
Research Ethics Committee of the Douglas Mental
Health University Institute. All participants provided
informed consent.
C. LIPSCOMBE et al.
Diabetes distress
Diabetes distress was assessed with the 17-item Diabetes
Distress Scale (DDS-17).7 The DDS-17 measures distress
associated with four major areas that are pertinent to
living with diabetes. Participants are asked to rate the
degree to which various problem areas have caused them
distress during the previous month using a six-point
Likert-scale (1 = no problem; 6 = very serious problem).
Subdomains of DD include: (i) emotional distress (ED;
five items); (ii) physician-related distress (PD; four
items); (iii) interpersonal distress (ID; three items); and
(iv) regimen-related distress (RD; five items). The
DDS-17 allows for the calculation of a global composite
DD score and a score for each subscale. A recent valida-
tion study provided evidence supporting the use of three
categories of distress to more accurately depict sub-
groups of DD.8 As such, participants’ global DD scores
were categorized to reflect three levels of distress: (i) little
to no DD (0.0–1.0); (ii) moderate DD (2.0–2.9); and (iii)
severe DD (≥3.0). Given that there is no evidence to
support a similar categorization scheme for DD sub-
scales, scores on each of the four DD subdomains were
tabulated and are presented as the mean ± SD.
Physical inactivity
Physical inactivity was determined by asking partici-
pants to report the amount of days over the past month
spent engaged in sports or exercise for at least 15 min.
Participants were classified according to two categories
reflecting either low activity levels (“inactive”) if they
reported 0–11 days of physical activity a month (this
would roughly translate into being active less than three
times a week) or high activity levels (“active”) if they
reported at least 12 days of physical activity a month
(this would roughly translate into at least 3 days of physi-
cal activity a week). This particular categorization
scheme was selected based on its approximation to
weekly physical activity guidelines recommended by the
CDA.2
Drinking patterns
Alcohol consumption was assessed with the three-item
Alcohol Use and Disorders Identification Test (AUDIT-
C).25 To determine past year drinking patterns, we used
the first two questions of the AUDIT-C and adapted a
classification scheme used in the Canadian Alcohol and
Drug Use Monitoring Survey.23 Participants were classi-
fied according to the following three categories: (i) non-
drinkers: participants who reported, at the time of the
interview, abstention from alcohol during the previous
12 months; (ii) infrequent drinkers: participants report-
© 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
Lifestyle behaviors and diabetes distress
ing drinking less often than once a week; and (iii) fre-
quent drinkers: participants reporting drinking once a
week or more.
Smoking
Questions pertaining to smoking status and frequency
were derived from the Canadian Community Health
Survey (CCHS) Cycle 1.2.26 Participants were catego-
rized according to the following scheme: (i) non-smokers
included participants who reported smoking less than
100 total cigarettes in their lifetime (i.e. never smokers)
or participants who reported smoking more than 100
total cigarettes in their lifetime but who, at the time of
the interview, did not smoke (i.e. former smokers); and
(ii) current smokers, consisting of participants reporting
being a current smoker. This classification scheme was
selected for consistency with the Canadian Tobacco Use
Monitoring Survey.27
Covariates
Participants provided information on characteristics
including age, gender, education (less than secondary
school, secondary school, post-secondary school),
marital status (married or partnered; widowed, sepa-
rated, or divorced; never married), and major depression
(MD) (assessed with the nine-item Patient Health Ques-
tionnaire28). Diabetes complications were assessed with
the 17-item Diabetes Complications Index (DCI).29 The
DCI assesses past diagnoses and current symptoms of six
of the most common complications of T2DM, namely
coronary artery disease, cerebrovascular disease, periph-
eral vascular disease, neuropathy, foot problems, and eye
problems. Scores on the DCI can range from 0 to 6, with
higher scores indicating the presence of more diabetes
complications. We cross-tabulated DD and MD to
assess the degree of overlap between these two conditions
and found a small degree of comorbidity (25% of those
with moderate–severe distress had comorbid MD).
Based on this finding and evidence from the literature
suggesting that DD and MD are likely separate con-
structs describing largely distinct mental health states,9,14
the role of MD in the relationship between DD and
lifestyle was not considered further.
Data analysis
Chi-squared analyses (for categorical data), one-way
ANOVA’s or t-tests (for continuous data) were used to
test for differences between lifestyle factors according
to DD, DD subscales, and gender. When more than
two group means were being compared (i.e. subscale
scores according to alcohol consumption), significant
271
Lifestyle behaviors and diabetes distress
ANOVAs were followed up with Bonferroni post hoc
analyses. To further examine the association between
each lifestyle factor (smoking status, alcohol consump-
tion, physical activity level) and DD, three separate
multinomial logistic regression models were developed.
In all three regression models, a stepwise approach was
applied. Step 1 assessed the unadjusted association
between the exposure variable and the outcome. In Step
2, sociodemographic factors were entered into the model
(age, education, marital status). Step 3 further adjusted
for diabetes complications and physical activity and/or
smoking and/or alcohol consumption. All analyses were
conducted separately for males and females. Given the
use of a multinomial logistic regression, effect measures
should be interpreted as a ratio of probability ratios (PR)
comparing (i) the respective level of distress (moderate or
severe) to the reference level of distress (little to no dis-
tress) given a particular level of the lifestyle behavior in
question with (ii) the respective level of distress (moder-
ate or severe) to the reference level of distress (little to no
distress) given the reference level of the lifestyle behavior
in question. Data were analyzed using Stata version 12.0
software (Stata Corp., College Station, TX, USA).
Sensitivity analyses
Sensitivity analyses were performed to verify the robust-
ness of the observed effects. Participants physical activity
scores were re-classified into: (i) physically inactive,
reflecting 0 days of physical activity in the previous
month; and (ii) some physical activity, reflecting “1” day
or more of physical activity in the previous month. Using
the total AUDIT-C score (range 0–12), alcohol con-
sumption was recategorized to reflect: (i) non-drinkers
(AUDIT score of 0); (ii) moderate drinkers (AUDIT-C
score of >0 to <4.0 for women or >0 to <5.0 for men); and
(iii) heavy drinkers (AUDIT-C score of ≥4.0 for women
or ≥5.0 for men). The AUDIT-C has been found to have
good sensitivity and specificity when using a cut-off score
of 4 in women and a score of 5 in men to denote harmful
or hazardous drinking behaviors.30 Finally, the main
analysis was repeated with DD as a continuous outcome
variable (log transformed) and a log linear regression
performed.
Results
Sample descriptive statistics
The prevalence of moderate to severe distress in the
sample was 23% (this is comparable to estimates derived
from other community samples11). Table 1 lists sample
characteristics and lifestyle behaviors according to
272 © 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
C. LIPSCOMBE et al.
gender. Significance tests revealed differences in physical
activity level, DD, and alcohol consumption between
males and females. Females evidenced a higher mean
DD score, a lower number of physical activity days, and
were more likely to be non-drinkers and infrequent
drinkers than males. The association between lifestyle
factors and DD categories is given in Table 2. Significant
differences were found between smoking, physical activ-
ity, and DD in females. In males, significant differences
were found between smoking, alcohol consumption, and
DD. Tables S1–S3, available as Supplementary Material
to this paper, list mean ± SD scores for lifestyle behav-
iors according to DD subscales and stratified based on
gender.
Multinomial logistic regression analyses
Stepwise, multinomial logistic regression models further
examined the association between lifestyle behaviors
and DD.
In females, physical inactivity was associated with a
greater probability of moderate distress. Notably, this
effect was of large magnitude and remained significant
even after controlling for sociodemographic, lifestyle,
and diabetes-related factors. Inactivity was also associ-
ated with a greater likelihood of severe distress in unad-
justed (Step 1) and partially adjusted models (Step 2);
however, this result was no longer significant once life-
style and diabetes-related factors were entered into the
model (Step 3), although point estimates for this com-
parison remained >1, indicating a consistent effect across
steps (PRStep3 1.35; 95% CI 0.71–2.56; Table 3). In males,
physical inactivity was associated with a greater prob-
ability of severe distress in unadjusted (Step 1) and par-
tially adjusted models (Step 2). In fully adjusted models
(Step 3), the association was no longer significant;
however, the point estimate remained >1, indicating a
consistent effect across steps (PRStep3 1.51; 95% CI 0.75–
3.01; Table 4).
Compared with non-smokers, current smoking was
associated with an increased probability of severe dis-
tress for both males and females. In males, this effect was
of large magnitude and was significant even after con-
trolling for sociodemographic, lifestyle, and diabetes-
related factors (Table 4). In females, the association
between smoking and severe DD was no longer signifi-
cant once lifestyle and diabetes-related factors were
entered into the model; however, it should be noted that
the point estimate for this comparison remained >1, indi-
cating a consistent effect across steps of the analysis
(PRStep3 1.32; 95% CI 0.67–2.60; Table 3).
Alcohol consumption was not associated with DD in
females (Table 3). However, in males alcohol consump-
C. LIPSCOMBE et al. Lifestyle behaviors and diabetes distress

Table 1 Sample characteristics and lifestyle behaviors according to gender

Female Male

No. subjects 987 984

Age (years; n = 1971) 61 ± 8 59.8 ± 8.3
Highest level of education (n = 1945)
Less than secondary school graduation 45.23% 35.88%
Secondary school graduation 29.44% 32.37%
Post-secondary school 25.33% 31.75%
Marital status (n = 1965)
Married or partnered 60.14% 71.04%
Widowed, separated, or divorced 29.46% 15.65%
Never married 10.40% 13.31%
Mean no. diabetes complications (n = 1865) 0.95 ± 0.83 0.92 ± 0.82
DD summary score* (n = 1971) 1.64 ± 0.71 1.54 ± 0.64
DD categories (n = 1971)
Little to no distress 75.38% 78.96%
Moderate distress 18.54% 16.16%
Severe distress 6.08% 4.88%
Physical activity* (days; n = 1971) 11.0 ± 0.36 12.2 ± 0.36
Physical activity (n = 1971)
Inactive 59.88% 55.28%
Active 40.12% 44.72%
Smoking (n = 1971)
Non-smokers 79.64% 79.07%
Current smokers 20.36% 20.93%
Alcohol consumption* (n = 1971)
Non-drinkers 45.39% 23.78%
Infrequent 40.83% 38.41%
Frequent 13.78% 37.80%

The percentage of participants within each categorical variable according to gender is shown. Continuous variables are given as the mean ± SD.
Asterisks indicate lifestyle behaviors that had a significant association with gender using either Chi-squared analyses (categorical variables) or
t-tests (continuous variables).
DD, diabetes distress.

tion was associated with a reduced likelihood of moder-
ate and severe distress. More specifically, compared with
non-drinkers, male frequent drinkers were less likely to
report moderate distress. This effect was of large magni-
tude (nearly 50% less likely) and remained stable across
steps of the analysis. Similarly, infrequent and frequent
drinking were associated with a reduced likelihood of
severe distress. Although this association was no longer
significant in fully adjusted models, point estimates for
infrequent drinking (PRStep3 0.47; 95% CI 0.21–1.03) and
frequent drinking (PRStep3 0.47; 95% CI 0.21–1.06)
remained highly stable, changing minimally across steps
of the analysis (Table 4).
Sensitivity analyses
Changes to the parameters used to describe physical
activity level and alcohol consumption did not alter the
pattern of observed effects. The results of a series of
linear regressions with DD as a continuous variable (log
transformed) supported the pattern of results in Tables 3
and 4 (data not shown).
Discussion
The main finding of the present study is an association
between three lifestyle behaviors (physical activity,
smoking, alcohol consumption) and moderate and
severe DD in a community sample of people with
T2DM. In addition, separate analyses for males and
females revealed important gender differences in the rela-
tionship between lifestyle and DD. This study contrib-
utes to the literature by being the first to investigate
smoking and alcohol consumption as additional factors
associated with DD. Furthermore, this is the first study
to identify associations between lifestyle factors accord-
ing to DD categories and DD subscales, specifically by
gender.

© 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd 273
Lifestyle behaviors and diabetes distress C. LIPSCOMBE et al.

Table 2 Sample characteristics and lifestyle behaviors according to diabetes distress categories, separated by gender

Little to no distress Moderate distress Severe distress P-value

Female
No. subjects 744 183 60
Age (years; n = 986) 61.58 ± 8.24 59.10 ± 8.74 57 ± 8
Education
Less than secondary school (n = 441) 46% 41.90% 45.76%
Secondary school (n = 287) 28.90% 32.40% 27.12%
Post-secondary school (n = 247) 25.10% 25.70% 27.12%
Marital status
Married or partnered (n = 590) 62.89% 55% 41.67%
Widowed, separated, or divorced (n = 289) 28.34% 32.22% 35%
Never married (n = 102) 8.77% 12.78% 23.33%
Diabetes complications (n = 934) 0.997 ± 1.090 1.44 ± 1.24 1.82 ± 1.37
Physical activity* 0.000
Inactive (n = 591) 55.91% 72.68% 70.00%
Active (n = 396) 44.09% 27.32% 30.00%
Smoking* 0.016
Non-smokers (n = 786) 81.32% 77.05% 66.67%
Current smokers (n = 201) 18.68% 22.95% 33.33%
Alcohol consumption 0.488
Non-drinkers (n = 448) 44.22% 49.73% 46.67%
Infrequent (n = 403) 42.20% 37.16% 35.00%
Frequent (n = 136) 13.58% 13.11% 18.33%
Male
No. subjects 777 159 48
Age (years; n = 983) 60.4 ± 8.2 58.08 ± 8.68 55.88 ± 7.38
Education
Less than secondary school (n = 348) 37.12% 31.85% 29.17%
Secondary school (n = 314) 31.90% 33.76% 35.42%
Post-secondary school (n = 308) 30.98% 34.39% 35.42%
Marital status
Married or partner (n = 699) 72.72% 64.78% 64.58%
Widowed, separated, or divorced (n = 154) 15.44% 15.72% 18.75%
Never married (n = 131) 11.84% 19.50% 16.67%
Diabetes complications (n = 929) 0.96 ± 1.05 1.60 ± 1.39 1.53 ± 1.35
Physical activity 0.078
Inactive (n = 544) 54.18% 55.97% 70.83%
Active (n = 440) 45.82% 44.03% 29.17%
Smoking* 0.000
Non-smokers (n = 778) 80.57% 79.87% 52.08%
Current smokers (n = 206) 19.43% 20.13% 47.92%
Alcohol consumption* 0.017
Non-drinkers (n = 234) 21.75% 29.56% 37.50%
Infrequent (n = 378) 38.61% 40.25% 29.17%
Frequent (n = 372) 39.54% 30.19% 33.33%

The percentage of participants within each categorical variable according to gender is shown. Continuous variables are given as the mean ± SD.
Asterisks indicate lifestyle behaviors that had a significant association with gender using either Chi-squared analyses (categorical variables) or
one-way ANOVA (continuous variables). P-values indicating the results of significance tests are presented in the final column.

Our findings for physical activity parallel previous
results in the literature6–8,10,12,13 of a negative association
between activity levels and DD. However, the results
from the present study suggest that this association may
differ depending on the level of DD examined and
according to gender. For example, although a strong
association between physical activity and moderate and
severe DD was found for females, no association was
found for males and moderate DD. Although there was
some evidence of an association between physical activ-
ity and distress in males, this association was restricted to
the severe distress category. One implication of these
results is that the relationship between distress and physi-
cal activity may be stronger for females than for males.

274 © 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
C. LIPSCOMBE et al. Lifestyle behaviors and diabetes distress

Table 3 Multinomial logistic regression predicting the probability of moderate and severe diabetes distress from lifestyle behaviors in females

Step 1: Unadjusted Step 2: Adjusted Step 3: Fully adjusted

PR (95% CI) PR (95% CI) PR (95% CI)

Model 1: Physical activity

Moderate distress
Inactive versus active 2.10 (1.47–2.99)*** 2.14 (1.48–3.08)*** 2.20 (1.49–3.24)***
Severe distress
Inactive versus active 1.84 (1.04–3.26)* 1.80 (1.00–3.24)* 1.35 (0.71–2.56)
Model 2: Smoking
Moderate distress
Current versus non-smoker 1.30 (0.88–1.92) 1.20 (0.80–1.79) 0.90 (0.58–1.41)
Severe distress
Current versus non-smoker 2.18 (1.23–3.84)** 1.83 (1.01–3.29)* 1.32 (0.67–2.60)
Model 3: Alcohol consumption
Moderate distress
Infrequent versus non-drinker 0.78 (0.55–1.11) 0.77 (0.54–1.11) 0.89 (0.61–1.31)
Frequent versus non-drinker 0.86 (0.52–1.42) 0.86 (0.51–1.45) 0.97 (0.56–1.67)
Severe distress
Infrequent versus non-drinker 0.79 (0.44–1.41) 0.71 (0.39–1.31) 1.04 (0.53–2.07)
Frequent versus non-drinker 1.28 (0.62–2.66) 1.43 (0.66–3.06) 1.92 (0.85–4.36)

Diabetes distress reference category: little to no distress.

Step 1, unadjusted association; Step 2, adjusted for age, marital status, and education; Step 3, further adjusted for diabetes complications and
lifestyle behaviors (smoking and/or alcohol consumption and/or physical activity). Missing due to incomplete datasets: n = 57 (0.03% of
dataset).
*P < 0.05, **P < 0.01, ***P < 0.001.
PR, probability ratio; CI, confidence interval.

Table 4 Multinomial logistic regression predicting the probability of moderate and severe diabetes distress from lifestyle behaviors in males

Step 1: Unadjusted Step 2: Adjusted Step 3: Fully adjusted

PR (95% CI) PR (95% CI) PR (95% CI)

Model 1: Physical activity

Moderate distress
Inactive versus active 1.08 (0.76–1.52) 1.03 (0.72–1.46) 0.96 (0.66–1.40)
Severe distress
Inactive versus active 2.05 (1.08–3.89) * 1.92 (1.00–3.66)* 1.51 (0.75–3.01)
Model 2: Smoking
Moderate distress
Current versus non-smoker 1.04 (0.68–1.60) 0.88 (0.56–1.37) 0.84 (0.53–1.33)
Severe distress
Current versus non-smoker 3.81 (2.10–6.90)*** 3.30 (1.77–6.11)*** 3.00 (1.54–5.84)**
Model 3: Alcohol consumption
Moderate distress
Infrequent versus non-drinker 0.77 (0.50–1.17) 0.71 (0.46–1.10) 0.73 (0.46–1.15)
Frequent versus non-drinker 0.56 (0.36–0.87)* 0.54 (0.34–0.86)** 0.56 (0.34–0.91)*
Severe distress
Infrequent versus non-drinker 0.44 (0.21–0.90)* 0.39 (0.18–0.83)* 0.47 (0.21–1.03)
Frequent versus non-drinker 0.49 (0.24–0.98)* 0.47 (0.23–0.98)* 0.47 (0.21–1.06)

Diabetes distress reference category: little to no distress.

Step 1, unadjusted association; Step 2, adjusted for age, marital status, and education; Step 3, further adjusted for diabetes complications and
lifestyle behaviors (smoking and/or alcohol consumption and/or physical activity). Missing due to incomplete datasets: n = 57 (0.03% of
dataset).
*P < 0.05, **P < 0.01, ***P < 0.001.
PR, probability ratio; CI, confidence interval.

© 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd 275
Lifestyle behaviors and diabetes distress
For example, females may be more susceptible to the
presence of moderate amounts of distress than males, or
inactivity may lead to measurably greater amounts of
distress in females than in males. Given the cross-
sectional nature of the present study, the direction of
causality between these variables cannot be determined.
It is also possible that the shape of the relationship
between DD and physical activity differs depending on
gender and the level of DD experienced (i.e. curvilinear
in females, threshold or straight line relationship in
males). Partial support for a non-linear relationship
between these variables is provided by the recent work of
Fisher et al.8 Alternatively, the types of physical activity
that men and women engage in may be qualitatively
different and, as a result, associate differently with DD
(i.e. physical labor versus leisure-type physical activities).
Current smoking was associated with a greater prob-
ability of severe distress; however, this association
appeared to be stronger in male than female smokers.
Although this result supports evidence from the litera-
ture of an association between smoking and mental
health comorbidities in adults with T2DM,31–33 it also
highlights a potentially important role of DD severity
and gender in this relationship. Interestingly, this finding
is somewhat at odds with the results of a large, nationally
representative study that found a stronger association
between smoking and general psychological distress in
females compared with males.34 One possible explana-
tion for this discrepancy is that the association between
smoking, gender, and distress may manifest differently
depending on the subpopulation under investigation and
the measure of psychological distress used. The findings
from the present study suggest that, among adults with
T2DM, smoking may be a better indicator of diabetes-
specific distress in males than in females. This result may
also reflect true differences in coping styles between the
sexes. For example, it has been suggested that males are
more likely than females to turn to alcohol and other
drugs as a coping mechanism when faced with difficult
life situations.35 Given the strong medical evidence sup-
porting the importance of smoking cessation in people
with T2DM,36,37 future studies may consider examining
the role of DD in smoking cessation attempts or the
propensity for relapse in this population. Although it
cannot be determined from the present study whether
smokers are more likely to develop severe distress or
whether severe distress leads to more frequent smoking,
this finding does highlight a potentially critical role for
severe distress in the performance of an unhealthy life-
style behavior, particularly in men.
In females, there was little statistical support for an
association between alcohol consumption and DD.
However, in males, alcohol consumption was associ-
276 © 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
C. LIPSCOMBE et al.
ated with a reduced likelihood of moderate and severe
distress. Although several lines of evidence in the litera-
ture point to a beneficial effect of moderate alcohol
consumption on diabetes health outcomes,38–41 including
a reduced likelihood of anxiety and depression symp-
toms,42 this finding should be interpreted with some
caution. Non-drinkers (the reference category) may be
a group comprised of both healthy individuals choosing
not to drink out of personal preference and individuals
in poorer health who do not drink as a result of their
health status or contraindication with certain medica-
tions. Comparatively, the group of infrequent and/or
frequent drinkers may be comprised of people who are
well enough to be able to drink in the first place. In the
present study, male non-drinkers tended to have more
overall distress than both infrequent and frequent male
drinkers. As such, the relationship between lower DD
and alcohol consumption seen in the present study may
be explained by a third factor, such as “general health”,
and not alcohol consumption per se. However, one pos-
sible implication of this result is that men in this sample
that drink are using alcohol as a means by which to
dampen or quell feelings of distress. Thus, the relative
reduction in distress seen among drinkers may reflect a
form of self-medication on the part of males. It has
been shown that males are more likely than females to
engage in problem drinking,23 and may be more likely
than females to use alcohol as a coping mechanism35 or
as self-medication.43 Although it cannot be determined
from the present study whether frequent drinking leads
to a reduced likelihood of being distressed or whether
the contrary is true, the possibility of abuse or misuse
of alcohol in males with moderate or severe DD should
be considered in future studies.
Limitations
Because of the cross-sectional nature of the present study
and the a posteriori decision to use subgroup analyses,
interpretation of the data must be done with care. For
example, it is not possible to comment on the direction of
causality between the lifestyle behaviors examined and
DD. In addition, despite efforts to control for possible
confounds, alternative explanations for the observed
relationships are possible (e.g. Hba1c levels, diet). We
excluded household income as a potential covariate due
to a high level of missing data on this variable (15%).
However, it should be noted that sensitivity analyses
with income included as a covariate revealed no differ-
ences in the pattern of results. Physical activity was mea-
sured using a single question that assessed frequency of
activity during the previous month. As a result, we were
unable to examine the association between duration,
C. LIPSCOMBE et al.
intensity, or type of physical activity performed and DD.
Finally, given the possibility for misclassification of DD
and MD cases, further research is needed to better
understand the role of depression in the association
between DD and lifestyle behaviors.
Conclusion
The findings of the present study add to the growing body
of evidence suggesting an important role for DD in
diabetes-related health behaviors. In addition, this study
highlights the need to consider DD as an important com-
ponent of diabetes disease management in people with
T2DM. From a clinical standpoint, this study provides
support for DD screening by health professionals during
routine medical visits in patients presenting with T2DM
and a history of unhealthy lifestyle behaviors. For
example, smoking may be a good proxy for distress in
males, whereas inactivity a good proxy for distress in
females. Future studies are needed to delineate the direc-
tion of causality between DD and these lifestyle factors.
An understanding of the causal relationship could benefit
interventional studies aimed at eliminating unhealthy life-
style habits or reducing DD. As an example, it may be
important to screen for and treat DD symptoms prior to
interventions designed to encourage smoking cessation or
increase physical activity levels in people with T2DM.
Finally, the evidence from the present study suggests that
future research examining the role of DD in diabetes
health may consider the role of severe distress and gender
more closely.
Acknowledgements
Funding for this study was provided by an operating
grant from the Canadian Institutes of Health Research.
Disclosure
None declared.
References
1. Pelletier C, Dai S, Roberts KC, Bienek A, Onysko J,
Pelletier L. Report summary. Diabetes in Canada: Facts
and figures from a public health perspective. Chronic Dis
Inj Can. 2012; 33: 53–4.
2. Cheng AY. Canadian Diabetes Association 2013 clinical
practice guidelines for the prevention and management of
diabetes in Canada. Introduction. Can J Diabetes. 2013;
37 (Suppl. 1): S1–3.
3. Gonder-Frederick LA, Cox DJ, Ritterband LM. Diabe-
tes and behavioral medicine: The second decade. J
Consult Clin Psychol. 2002; 70: 611–25.
© 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
Lifestyle behaviors and diabetes distress
4. de Groot M, Anderson R, Freedland KE, Clouse RE,
Lustman PJ. Association of depression and diabetes com-
plications: A meta-analysis. Psychosom Med. 2001; 63:
619–30.
5. Katon W, Lin EH, Kroenke K. The association of
depression and anxiety with medical symptom burden in
patients with chronic medical illness. Gen Hosp Psychia-
try. 2007; 29: 147–55.
6. Aikens JE. Prospective associations between emotional
distress and poor outcomes in type 2 diabetes. Diabetes
Care. 2012; 35: 2472–8.
7. Polonsky WH, Fisher L, Earles J et al. Assessing psycho-
social distress in diabetes: Development of the diabetes
distress scale. Diabetes Care. 2005; 28: 626–31.
8. Fisher L, Hessler DM, Polonsky WH, Mullan J. When is
diabetes distress clinically meaningful? Establishing cut
points for the Diabetes Distress Scale. Diabetes Care.
2012; 35: 259–64.
9. Fisher L, Mullan JT, Arean P, Glasgow RE, Hessler D,
Masharani U. Diabetes distress but not clinical depres-
sion or depressive symptoms is associated with glycemic
control in both cross-sectional and longitudinal analyses.
Diabetes Care. 2010; 33: 23–8.
10. Fisher L, Glasgow RE, Strycker LA. The relationship
between diabetes distress and clinical depression with gly-
cemic control among patients with type 2 diabetes. Dia-
betes Care. 2010; 33: 1034–6.
11. Fisher L, Skaff MM, Mullan JT, Arean P, Glasgow R,
Masharani U. A longitudinal study of affective and
anxiety disorders, depressive affect and diabetes distress
in adults with Type 2 diabetes. Diabet Med. 2008; 25:
1096–101.
12. Delahanty LM, Grant RW, Wittenberg E et al. Associa-
tion of diabetes-related emotional distress with diabetes
treatment in primary care patients with Type 2 diabetes.
Diabet Med. 2007; 24: 48–54.
13. Fisher L, Mullan JT, Skaff MM, Glasgow RE, Arean P,
Hessler D. Predicting diabetes distress in patients with
Type 2 diabetes: A longitudinal study. Diabet Med. 2009;
26: 622–7.
14. Fisher L, Skaff MM, Mullan JT et al. Clinical depression
versus distress among patients with type 2 diabetes: Not
just a question of semantics. Diabetes Care. 2007; 30:
542–8.
15. Tonstad S. Cigarette smoking, smoking cessation, and
diabetes. Diabetes Res Clin Pract. 2009; 85: 4–13.
16. Sluik D, Buijsse B, Muckelbauer R et al. Physical activity
and mortality in individuals with diabetes mellitus: A
prospective study and meta-analysis. Arch Intern Med.
2012; 172: 1285–95.
17. Engler PA, Ramsey SE, Smith RJ. Alcohol use of diabe-
tes patients: The need for assessment and intervention.
Acta Diabetol. 2013; 50: 93–9.
18. Lysy Z, Da Costa D, Dasgupta K. The association of
physical activity and depression in Type 2 diabetes.
Diabet Med. 2008; 25: 1133–41.
19. 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: 1305–9.
277
Lifestyle behaviors and diabetes distress
20. Pandit AU, Bailey SC, Curtis LM et al. Disease-related
distress, self-care and clinical outcomes among low-
income patients with diabetes. J Epidemiol Community
Health. 2014; 68: 557–64.
21. Spencer MS, Kieffer EC, Sinco BR et al. Diabetes-
specific emotional distress among African Americans and
Hispanics with type 2 diabetes. J Health Care Poor
Underserved. 2006; 17 (Suppl): 88–105.
22. Tsujii S, Hayashino Y, Ishii H, Diabetes Distress
andCare Registry at Tenri Study Group. Diabetes dis-
tress, but not depressive symptoms, is associated with
glycaemic control among Japanese patients with type 2
diabetes: Diabetes Distress and Care Registry at Tenri
(DDCRT 1). Diabet Med. 2012; 29: 1451–5.
23. Health Canada. Canadian Alcohol and Drug Use Moni-
toring Survey (CADUMS). Ottawa, Ontario, 2011. Avail-
able from: http://www.hc-sc.gc.ca/hc-ps/drugs-drogues/
stat/_2011/summary-sommaire-eng.php (accessed 1
September 2014).
24. Smith KJ, Gariepy G, Pedneault M, Beland M, Clyde M,
Schmitz N. Exploring the association of psychological
status with self-rated diabetes control: Results from the
Montreal evaluation of diabetes treatment study. Psycho-
somatics. 2013; 54: 35–43.
25. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley
KA. The AUDIT alcohol consumption questions
(AUDIT-C): An effective brief screening test for problem
drinking. Ambulatory Care Quality Improvement Project
(ACQUIP). Alcohol Use Disorders Identification Test.
Arch Intern Med. 1998; 158: 1789–95.
26. Statistics Canada. Canadian Community Health Survey
Mental Health and Well Being Cycle 1.2. Statistics
Canada, Ottawa, 2003.
27. Health Canada. Canadian Tobacco Use Monitoring
Survey (CTUMS). 2012. Available from: http://www.hc-
sc.gc.ca/hc-ps/tobac-tabac/research-recherche/stat/
ctums-esutc_term-eng.php (accessed 1 September 2014).
28. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Valid-
ity of a brief depression severity measure. J Gen Intern
Med. 2001; 16: 606–13.
29. Fincke BG, Clark JA, Linzer M et al. Assessment of long-
term complications due to type 2 diabetes using patient
self-report: The diabetes complications index. J Ambul
Care Manage. 2005; 28: 262–73.
30. Dawson DA, Grant BF, Stinson FS, Zhou Y. Effective-
ness of the derived Alcohol Use Disorders Identification
Test (AUDIT-C) in screening for alcohol use disorders
and risk drinking in the US general population. Alcohol
Clin Exp Res. 2005; 29: 844–54.
31. Shin JK, Chiu YL, Choi S, Cho S, Bang H. Serious
psychological distress, health risk behaviors, and diabetes
care among adults with type 2 diabetes: The California
Health Interview Survey 2007. Diabetes Res Clin Pract.
2012; 95: 406–14.
32. Katon W, von Korff M, Ciechanowski P et al. Behavioral
and clinical factors associated with depression among
278 © 2015 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and Wiley Publishing Asia Pty Ltd
C. LIPSCOMBE et al.
individuals with diabetes. Diabetes Care. 2004; 27: 914–
20.
33. Solberg LI, Desai JR, O’Connor PJ, Bishop DB, Devlin
HM. Diabetic patients who smoke: Are they different?
Ann Fam Med. 2004; 2: 26–32.
34. Hrywna M, Bover Manderski MT, Delnevo CD. Sex
differences in the association of psychological distress
and tobacco use. Am J Health Behav. 2014; 38: 570–6.
35. Nolen-Hoeksema S. Sex differences in unipola depres-
sion: Evidence and theory. Psychol Bull. 1987; 101: 259–
82.
36. Al-Delaimy WK, Willett WC, Manson JE, Speizer FE,
Hu FB. Smoking and mortality among women with type
2 diabetes: The Nurses’ Health Study cohort. Diabetes
Care. 2001; 24: 2043–8.
37. Al-Delaimy WK, Manson JE, Solomon CG et al.
Smoking and risk of coronary heart disease among
women with type 2 diabetes mellitus. Arch Intern Med.
2002; 162: 273–9.
38. Ahmed AT, Karter AJ, Warton EM, Doan JU, Weisner
CM. The relationship between alcohol consumption and
glycemic control among patients with diabetes: The
Kaiser Permanente Northern California Diabetes Regis-
try. J Gen Intern Med. 2008; 23: 275–82.
39. Shai I, Wainstein J, Harman-Boehm I et al. Glycemic
effects of moderate alcohol intake among patients with
type 2 diabetes: A multicenter, randomized, clinical inter-
vention trial. Diabetes Care. 2007; 30: 3011–16.
40. Carlsson S, Hammar N, Grill V. Alcohol consumption
and type 2 diabetes meta-analysis of epidemiological
studies indicates a U-shaped relationship. Diabetologia.
2005; 48: 1051–4.
41. Howard AA, Arnsten JH, Gourevitch MN. Effect of
alcohol consumption on diabetes mellitus: A systematic
review. Ann Intern Med. 2004; 140: 211–19.
42. Collins MM, Corcoran P, Perry IJ. Anxiety and depres-
sion symptoms in patients with diabetes. Diabet Med.
2009; 26: 153–61.
43. Khantzian EJ. The self-medication hypothesis of sub-
stance use disorders: A reconsideration and recent appli-
cations. Harv Rev Psychiatry. 1997; 4: 231–44.
Supporting Information
Additional Supporting Information may be found in the
online version of this article at the publisher’s web-site:
Table S1 Association between diabetes distress sub-
scales, total distress, and physical activity status in males
and females.
Table S2 Association between diabetes distress sub-
scales, total distress, and smoking in males and females.
Table S3 Association between diabetes distress subscale,
total distress, and alcohol consumption in males and
females.
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