Diabetes affects 463 million people aged 20 to 79 years worldwide, and this number is expected to rise to 700 million by the year 2045.1 Cardiovascular disease remains the major cause of morbidity and mortality in persons with diabetes.2 Landmark studies have demonstrated that improved glycemic control is associated with reduced cardiovascular disease rates,3-5 yet evidence identifies a major gap in achieving glycemic targets.6 Achievement of glycemic targets is primarily dependent on day-to-day self-management decisions by those living with diabetes. Education programs with a person-centered approach help empower individuals and provide the knowledge, skills, and abilities for effective self-care.7 Examples of such programs include those that incorporate the National Standards for Diabetes Self-Management Education and Support8 and provide linkages to community resources. However, because of the demands of managing a complex chronic condition, many people with diabetes experience significant distress, burnout, and lowered quality of life.8 To promote healthy self-management behavior and improve quality of life, attention to the psychological aspects of diabetes self-care and promotion of emotional well-being is essential.

Diabetes-related distress refers to the emotional burden derived from managing a complex condition. A study of 8596 adults with diabetes across 17 countries reported that high distress levels were reported by 44.6% of participants.9 Diabetes distress is distinct from depressed mood and has been linked with higher hemoglobin A_1C levels.10 Diabetes distress is associated with poor self-care behaviors such as dietary/medication noncompliance11,12 and physical inactivity.12 Sources of distress include feeling overwhelmed, worrying about obtaining sufficient healthcare and support, interpersonal distress, and concerns over own self-care abilities. Interventions using diabetes self-management education or in combination with psychological components have reported reductions in diabetes distress.13-16 Assessing for areas of concern is important because many people may be reluctant to share their feelings with healthcare providers. The American Diabetes Association Standards of Medical Care in Diabetes recommends monitoring for diabetes distress at each healthcare encounter.17

In addition to distress, depression also impacts self-management and is important to address. According to the American Diabetes Association, depressive symptoms affect 1 in 4 persons with diabetes.17 Assessment for depression is recommended on an annual basis for those at risk for depression, who have a history of depression, or who are currently being treated for depression.17

A third area that has an important impact on diabetes self-management and quality of life is fear of hypoglycemia (FOH). Fear of hypoglycemia arises from a previous experience with hypoglycemia.18 Hypoglycemia, defined as a blood glucose level less than 70 mg/dL,19 is an ever-present risk for those taking blood glucose-lowering medications. Fear of hypoglycemia is prevalent among those with type 1 diabetes (T1D) (up to 77%)18 but is also experienced by those with type 2 diabetes (T2D).20 It tends to be worse at night. Many routinely set times to awaken during the night to monitor blood glucose levels, whereas others maintain higher blood glucose levels to avoid hypoglycemia. Consequences of FOH may have serious effects on physical and psychological health. These include greater glucose variability, overeating, insulin restriction, avoidance of physical activity, and heightened levels of anxiety.18,20 It is important for nurses to assess their patients with diabetes for FOH and situations that provoke worry. Strategies to reduce FOH include acknowledging the problem and discussing it with the patient and healthcare team. Blood glucose awareness training is recommended for those with hypoglycemia unawareness, and referral to a qualified behavioral practitioner may also be sought to reduce anxiety.17

Taken together, emotional well-being is an important component in supporting good health and quality of life in persons with diabetes. Emotions have a strong influence on the willingness and motivation to respond to self-care needs. Stress is commonly experienced by persons with diabetes and their families. Nurses play a key role in assessing their patients for the emotional burdens associated with diabetes. Exploring and acknowledging the stressors experienced is an important first step in partnering with persons with diabetes to promote health and prevent cardiovascular complications. Strategies to address these stressors can first be incorporated into regular diabetes care by nurses in healthcare and community settings with referrals for additional support as needed.

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