Relationships of Depression, Anxiety, and Stress with Adherence to Self-Management Behaviors and Diabetes Measures in African American Adults with Type 2 Diabetes

  • Diane Orr ChlebowyEmail author
  • Catherine Batscha
  • Nancy Kubiak
  • Timothy Crawford


This study examines the relationships of depression, anxiety, and stress with adherence to self-management behaviors and diabetes measures in 42 African American adults with type 2 diabetes (T2D). Participants were recruited from an outpatient clinic located in an urban area of a midsized city in the southeastern USA. The mean age of the sample was 54.9 years (SD = 9.9) and the majority of the participants were female (73.2%), high school graduates (55.3%), unemployed (70.7%), and publicly insured (77.8%). Each participant completed a demographic survey and the Depression, Anxiety and Stress Scale 21. Adherence to self-management behaviors (physical activity, diet, and medication use) was assessed using surveys and self-reports. Glycated hemoglobin (A1c) and body mass index (BMI) were obtained from participants’ medical records at the time of the participants’ clinic visits. Depression, anxiety, and stress were not significantly correlated with self-management behaviors. Depression (r = 0.38, p = 0.03), anxiety (r = 0.56, p = 0.001), and stress (r = 0.36, p = 0.04) were positively correlated with A1c. The greater the dietary risk assessment score, the higher the A1c (r = 0.34, p = 0.05). Anxiety was the strongest correlate of A1c followed by depression, stress, and dietary risk assessment. Future studies to confirm this study’s findings in a larger sample are warranted. Interventions to mitigate the effects of these correlates should be designed and tested to improve health outcomes in African American adults with T2D.


Depression Anxiety Stress African Americans Self-management Diabetes biomarkers 

Diabetes is the seventh leading cause of death in the USA [1]. In 2015, an estimated 30.3 million persons in the USA had diabetes [1] and 90 to 95% of them had type 2 diabetes (T2D) [2]. T2D is associated with an insulin deficiency and/or insulin resistance rather than a total deficit of insulin [3]. T2D is a significant chronic health problem among African Americans in the USA [2]. Non-Hispanic blacks in the USA have a higher prevalence of diabetes (12.7%) as compared with non-Hispanic whites (7.4%) [1]. African American adults with T2D experience higher rates of diabetes-related complications than other ethnic groups [2]. Heredity, limited access to health care services, and economic status are possible factors that contribute to the increased rates of complications among African Americans with T2D [4].

Moreover, there is growing concern among health care providers about the rising incidence of diabetes and diabetes-related complications among African Americans. It is essential to better understand the underlying mechanisms for the existing health disparity and how to help this vulnerable population with effective diabetes self-management strategies. Daily diabetes self-management is vital to effectively manage blood glucose levels and avoid and/or reduce diabetes-related complications [5]. Successful diabetes self-management is the product of therapeutic adherence to diet, medications, and physical activity regimens and often requires major lifestyle changes [5].

Depression is common and characterized by persistent sadness, loss of interest in former pleasurable activities, and decreased ability to function in daily life [6]. The relationship between depression and diabetes is complex with some supporting evidence that inflammation may contribute to the development of both disorders [7]. Depressive symptoms are common in diabetes and persistent depressive symptoms are associated with deficits in self-management of diabetes [8]. Although African Americans have lower rates of major depressive disorder than whites, the disorder may be more persistent in African Americans [9] and 1 year prevalence rates in older adults are not significantly different [10]. Differences in treatment beliefs and preferences in African Americans may contribute to the persistence of depression [11]. African Americans who have both diabetes and depression have significantly higher rates of functional disability than African Americans with either of these illnesses [12]. In African Americans with diabetes, presence of depressive symptoms interferes with self-care behaviors including diet, physical activity and, glucose self-monitoring [13]. However, when depressive symptoms are reduced, it may not result in more effective self-management of diabetes [14]. A lack of precision in discriminating clinical depression that may have preceded diabetes from distress related to a diagnosis has interfered with identification of effective interventions [15]. Thus, it is important to further examine the relationships of depression and other common comorbidities with adherence in self-management behaviors in African American adults with diabetes. Few published studies have examined these relationships in the African American population.

Anxiety and depression are common comorbidities in people with diabetes, but the relationship of anxiety to diabetes is less clearly defined than that of depression. Anxiety occurs as a normal reaction to stressful events or anticipated events. If levels of anxiety are out of proportion to a stressor or if anxiety interferes with functional ability, the person meets criteria for diagnosis with an anxiety disorder [16]. Rates of anxiety disorders in people with diabetes have been found to be higher than those of the general public [17, 18, 19], although the prevalence of anxiety in people with T2D may decrease with age [20]. Presence of depression and anxiety may affect self-management of diabetes [21]. Bystritsky, Danial, and Kronemyer [22] proposed that anxiety is related to diabetes in one of two ways: (1) anxiety disorders may lead to maladaptive coping strategies that may promote development of diabetes; or (2) a diagnosis of diabetes may lead to anxiety symptoms or anxiety disorders. Anxiety may also contribute to development of diabetes through activation of the hypothalamic-pituitary-adrenal (HPA) axis [23]. While both depressive and anxious temperaments were common comorbidities in Portuguese people with diabetes, anxious temperament was not independently associated with adverse diabetes outcomes [24, 25]. Presence of an anxiety disorder (rather than anxiety symptoms) was not associated with development or outcome of diabetes; the presence of anxiety was thought to actually increase diabetes management behaviors [26]. Hall, Rodin, Vallis, and Perkins [27] found that although presence of an anxiety disorder might facilitate earlier diagnosis of diabetes, anxiety did not positively affect management of the disease. Some anxiety in people with diabetes may more precisely be conceptualized as distress related to concerns about the diabetes itself [15].

The role of stress in both development and management of T2D is complex. The presence of chronic or excessive stressors can lead to adverse physical outcomes including T2D [28]. Chronic stress is associated with decreased glycemic control in people with T2D [29]. Stressors activate the HPA axis increasing cortisol, blood glucose [30], and abdominal adiposity [31]. In addition, multiple stressors decrease medication adherence behaviors in people with T2D and reduce dietary adherence in those who were previously adherent to diet [32].

Study Purpose

The purpose of this study was to examine the relationships of depression, anxiety, and stress with adherence to self-management behaviors (physical activity, diet, and medication use) and diabetes measures (glycated hemoglobin [A1c] and body mass index [BMI]) in African American adults with T2D.

Research Design and Methods

Sample and Setting

The convenience sample consisted of 42 participants receiving medical care at an outpatient internal medicine clinic in an urban area of a midsized city in the southeastern USA. Inclusion criteria for participation were (1) self-reporting African American ethnicity, (2) 18 years of age or older, (3) English speaking, and (4) diagnosis of T2D which was treated by prescribed oral anti-hyperglycemic agents and/or insulin. Exclusion criteria included (1) inability to understand study purpose and procedures, (2) inability to engage in moderate physical activity, and (3) receiving current treatment from a mental health provider. As shown in Table 1, the mean age of the sample was 54.9 years (SD = 9.9) and the majority of the participants were female (73.2%), high school graduates (55.3%), unemployed (70.7%), and publicly insured (77.8%). Approximately 42% of the participants used an oral medication to manage T2D. Additional demographic data and health history information specific to study participants are displayed in Table 1. The study sample was representative of the African American adult population with T2D who receive care at the clinic recruitment site.
Table 1

Sociodemographic characteristics of African American adults living with T2D (N = 42)


n (%)

Age, mean (std)

54.9 (9.9)


30 (73.2)

Marital status


7 (16.7)


5 (11.9)

 Living with someone

3 (7.1)


9 (21.4)


18 (42.9)

Living arrangements


10 (45.5)


9 (40.9)


2 (9.1)

Education level

 ≤ High school

5 (13.2)

 High school graduate

21 (55.3)

 College +

12 (31.6)

Employment status


29 (70.7)


12 (29.3)

Monthly income


10 (27.8)


15 (41.7)


11 (30.6)

Insurance type


21 (77.8)


4 (14.8)


1 (3.7)


1 (3.7)



14 (33.3)


28 (66.7)



15 (41.7)


13 (36.1)


8 (22.2)

Proportions are based on n responding to each question. The amount of missing data varied slightly across each question


After receiving Institutional Review Board approval, study personnel recruited participants at the ambulatory internal medicine clinic at the time of their clinic visits. Written informed consent was obtained from eligible, interested participants. Study participants completed a demographic questionnaire and the Depression, Anxiety, and Stress Scale 21 (DASS 21) [33] at the time of their clinic visits. In addition, study participants completed questionnaires to measure adherence to self-management behaviors: (1) physical activity was assessed using the Seven-Day Physical Activity Recall (PAR) [34], (2) diet was assessed using the Ammerman et al. questionnaire [35], and (3) medication use was assessed with the use of a self-report instrument created for use in this study. All paper questionnaires were administered by a member of the research team. Since an 80% cutoff point is traditionally used in similar clinical trials, adherence to prescribed treatment regimens was defined as (1) following recommended diet at least 80% of the time, (2) taking at least 80% of prescribed diabetes medication, and (3) participating in the recommended level of physical activity at least 80% of the time. Diabetes measures (A1c and BMI) were obtained from the participants’ medical records; these measures were obtained at the time of the participants’ clinic visits. Each participant received a $10 non-monetary gift for participation in the study.

Surveys and Self-Report Measures

A demographic survey was created for use in this study to obtain demographic and medical history information. The DASS 21, a self-report measure, assessed the negative emotional states of depression, anxiety, and stress, and consisted of three different seven-question scales. Scores on the DASS 21 can range from 0 to 42 to determine the level of these three emotional states [33] and it differentiates depression (low self-esteem and low incentive with decreased perceived inability to attain life goals), anxiety (enduring anxiety and specific fears), and stress (persistent arousal, tension, and reduced tolerance for becoming upset or frustrated) [36]. The DASS 21 showed internal consistency (p = 0.94) and discrimination of depression, anxiety, and stress in an older primary care population [37] as well as a lack of divergence among scores of four racial groups [38]. Physical activity was assessed by the Seven-Day PAR that provides details regarding the duration, intensity, and volume of physical activity; data from the PAR is considered representative of typical activity patterns [34]. Diet adherence was measured using the Ammerman et al. 31-item dietary questionnaire that targets the frequency of foods eaten in various categories [35]. Medication usage was obtained by self-report reflecting the date and time of medication administration.


Descriptive statistics were calculated to describe the study population with means and standard deviations calculated for all continuous variables; frequencies and percentages were calculated for all categorical variables. Pearson’s product moment and point biserial correlations were conducted to assess the relationship among the three predictors (depression, anxiety, and stress), self-management behaviors (physical activity, diet, and medication use), and diabetes measures (A1C and BMI). To determine differences among the outcomes and demographic characteristics, independent sample t tests and analysis of variance were conducted. Data were analyzed using SAS version 9.4 (Cary, NC) and all p values < 0.05 were regarded as statistically significant.


In this study, approximately 48% of participants were adherent to physical activity and the mean dietary risk assessment score was 31.5 (9.3). The average A1c among the participants was 8.4 (SD = 2.5) and the average BMI was 37.8 (SD = 9.1). Participants with a monthly income > $1000 had significantly higher mean dietary risk assessment scores compared to those with incomes between $0–$500 and $501–$1000 (37.3 versus 30.7 and 27.9, p = 0.04), and participants who used both insulin and oral medications had higher BMIs compared to those using only oral medications or insulin (45.6 versus 37.8 and 34.3, p = 0.04). In addition, participants who used both insulin and oral medications had higher mean depression (25.4 versus 9.8 and 17.2, p = 0.03) and anxiety scores (29.7 versus 10.7 and 16.3, p = 0.003) compared to those using only oral medications or insulin, respectively. Table 2 provides the correlations among the predictors (e.g., depression, anxiety, and stress scores), diabetes measures, and self-management behaviors. There were significant correlations among the DASS 21 scores and A1c. A1c was positively correlated with depression (r = 0.381, p = 0.03), anxiety (r = 0.562, p = 0.001), and stress (r = 0.363, p = 0.041). The positive correlations suggest that higher levels of depression, anxiety, and stress are associated with higher A1C levels. There was also a significant positive correlation between the dietary risk assessment and A1c (r = 0.342, p = 0.047).
Table 2

Correlations among diabetes measures, self-management behaviors, and DASS 21 scores





Physical adherence

Medication adherence








− 0.05





− 0.13



Physical adherence


− 0.12

− 0.03



Medication adherence




− 0.015





− 0.134


− 0.043

− 0.151





− 0.001


− 0.033

− 0.045






− 0.125



− 0.051




*p < 0.05

**p < 0.01

***p < 0.001


This study examined the relationships of depression, anxiety, and stress with adherence to self-management behaviors and diabetes measures in an urban African American adult population receiving care at an outpatient clinic. In this study, depression, anxiety, and stress were not correlated with the self-management behaviors studied. This may support emerging hypotheses that the association of the mood disorders and stress with diabetes outcomes is more than just the behaviors of the mood disorders (e.g., overeating or inactivity) that contribute to poor glycemic control. Our study examined general perceptions of stress experienced by the participants. Other studies [39] have found that persons with more stressors had lower adherence to their diet and medication regimens than persons with fewer stressors, and these stressors, independent of depressive symptoms, predicted poorer adherence. In our study, stress was not significantly correlated with dietary behaviors and medication use. Thus, it may be that coping with diabetes can contribute to anxiety and depression, as suggested by Kok, Williams, and Zhao [40]. Others have proposed that ineffective management of stress can lead to anxiety [41] and may contribute to depression [42]. The chronic stress of diabetes could contribute to anxiety and depression, and some behaviors of the mood disorders can exacerbate control of diabetes by engaging in behaviors such as overeating [22]. The research of others, along with the correlation of stress with poor glycemic control in our study population, suggests the need to consider stress when developing programs and future studies to improve glycemic control or adherence to diet and medication regimens in persons with diabetes.

A complex interaction exists among stress, anxiety, depression, and diabetes. Anxiety [23] and depression [7] are associated with poor diabetes outcomes and complications in persons with T2D. The two mood disorders frequently coexist and share vulnerability factors [43], and depression impacts the course and therapeutic outcomes of anxiety [44]. Researchers have postulated that a bi-directional association occurs between diabetes and anxiety or depression; therefore, diabetes can contribute to the development or worsening of anxiety or depression, and vice versa [22]. Even medications for mood disorders may affect diabetes by inducing or worsening diabetes control, interfering with the metabolism of some oral hypoglycemic drugs, or inducing weight gain or appetite change [7]. Thus, the interplay of stress, anxiety, and depression and their therapies have a potential impact in glycemic control in persons. Our study highlights the coexistence of these factors in a sample of African American adults with T2D.

Our study revealed that depression, anxiety, and stress were positively correlated with A1c, while anxiety emerged as the strongest predictor of an elevated A1c. A number of approaches to improve depression in persons with diabetes showed contradictory or few benefits in diabetes outcomes [7, 45]. Katon et al. [8] suggested that a collaborative care model may improve depression management in persons with chronic diseases, including diabetes. However, anxiety was not specifically addressed in this model [8]. Collaborative care has also been shown to improve anxiety outcomes in persons in the primary care setting, but no published study has specifically addressed anxiety in persons with diabetes in order to improve glycemic control [23]. In addition to targeting depression and stress, building collaborative approaches that also address anxiety may further improve outcomes, given the stronger correlation of anxiety with A1c in our study. Further research is needed to test this hypothesis; such collaborations would likely target dietary choices, another variable examined in our study.

This study has several limitations. A number of self-report measures were used in this study. The convenience sample excluded those in psychiatric care; thus, the study results cannot be generalized to this population. In addition, participants were generally of a lower socioeconomic class; thus, these findings may not be generalizable to other classes of African American adults. The duration of diabetes and its impact on depression, anxiety, and stress was not examined in this study. It was difficult to describe the sociodemographic characteristics of the sample due to the large amount of missing data on the demographic surveys. The sample size was small and participants were recruited from a single clinic. A study with a larger sample size would allow for a regression analysis to determine if anxiety, stress, and depression are independent variables affecting diabetes control.


Our findings may be useful in designing future collaborative care models that address the variety of mood disorders, stress, and self-management behaviors influencing glycemic control in African American adults with T2D. Future studies to confirm this study’s findings in a larger sample are warranted. If these findings are supported in future studies, this information may be helpful in the design and testing of interventions to mitigate the effects of stress, anxiety, and depression on diabetes outcomes in African American adults with T2D.


Funding information

The authors acknowledge the University of Louisville School of Nursing for funding of this study. The authors also thank the staff at the clinic who supported the implementation of this study.


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Copyright information

© W. Montague Cobb-NMA Health Institute 2018

Authors and Affiliations

  • Diane Orr Chlebowy
    • 1
    Email author
  • Catherine Batscha
    • 1
  • Nancy Kubiak
    • 2
  • Timothy Crawford
    • 3
  1. 1.University of Louisville School of NursingLouisvilleUSA
  2. 2.University of Louisville School of MedicineLouisvilleUSA
  3. 3.Wright State University Departments of Population and Public Health Sciences and Family MedicineDaytonUSA

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