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Psychosomatics 47:240-246, May-June
doi: 10.1176/appi.psy.47.3.240
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Prospective Study on Influence of Psychosocial Factors on Glycemic Control in Japanese Patients With Type 2 Diabetes

Rika Nakahara, M.D., Ph.D., Kazuhiro Yoshiuchi, M.D., Ph.D., Hiroaki Kumano, M.D., Ph.D., Yoko Hara, M.D., Hiroyuki Suematsu, M.D., Ph.D., and Tomifusa Kuboki, M.D., Ph.D.

Received January 18, 2005; revised June 30, 2005; accepted August 9, 2005. From the Dept. of Psychosomatic Medicine, Faculty of Medicine, The Univ. of Tokyo, Tokyo, Japan; the Dept. of Psychiatry, Teikyo Univ. Mizonokuchi Hospital, Kanagawa, Japan; the Institute for Diabetes Care and Research, Asahi Life Foundation, Tokyo; and the Kawamura Gakuen Woman's University, Chiba, Japan. Send correspondence and reprint requests to Dr. Nakahara, Dept. of Psychosomatic Medicine, Faculty of Medicine, the Univ. of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. e-mail: nrika-tky{at}umin.ac.jp


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
The authors prospectively assessed the causal relationship between psychosocial factors and glycemic control in 256 Japanese outpatients with Type 2 diabetes. Using structural-equation modeling, they first developed a causal model in which glycosylated hemoglobin (HbA1c) at 6 months after assessment was influenced by the baseline psychosocial factors. Then, the reliability of the causal model was investigated with measurement of HbA1c at 12 months after baseline. Self-efficacy directly reinforced adherence, and adherence had a direct association with future HbA1c. Other psychosocial factors, including social support, diabetes-related distress, daily burden, and emotion-focused coping prospectively influenced HbA1c indirectly through self-efficacy.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
The quality of life in patients with diabetes mellitus is mainly undermined by complications of the disease.1–5 Good glycemic control could delay the onset and progress of complications.6–8 Therefore, it is important to identify the factors that directly and indirectly influence glycemic control.

Previous studies have reported, cross-sectionally, that psychosocial factors are associated with glycemic control in Type 2 diabetes patients; for example, life events9,10 and daily "hassles" (burden)11 adversely affect glycemic control. In contrast, social support,12–15 problem-focused coping,16 and self-efficacy12,17–19 relate to good regimen-adherence and glycemic control. Significant association between mood states and glycemic control has been established: depression is present in 15%–20% of Type 1 and Type 2 diabetes patients20 and is associated with poor glycemic control.21 On the other hand, treatment for depression results in reduction of glycosylated hemoglobin (HbA1c).22 Moreover, some studies have focused on diabetes-specific distress that is especially affected by poor regimen-adherence and glycemic control.23,24 A causal model pointed to the significant effect of active coping on glycemic control, where self-efficacy and mood influenced active coping in diabetic patients.25 However, the causal relationship between these psychosocial factors and glycemic control has not been investigated prospectively in patients with Type 2 diabetes.

In this study, using structural-equation modeling, the direct and indirect influences of psychosocial factors on glycemic control were investigated prospectively in Japanese Type 2 diabetic patients. We first developed a causal model, in which HbA1c at 6 months after baseline assessment was influenced by the initial (baseline) psychosocial factors. Then, in order to investigate the reliability of the causal model at 6 month after baseline, the same model was tested at 12 months post-baseline, using HbA1c as the dependent variable.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
Subjects
Participants were consecutive outpatients with Type 2 diabetes at the Asahi Life Foundation Institute for Diabetes Care and Research. Diagnosis was made by highly-trained diabetologists according to the latest criteria of the Japan Diabetes Society: specifically, a fasting plasma glucose level of ≥126 mg/dl or an oral glucose-tolerance test with a 2-hour post-load plasma glucose level of ≥200 mg/dl. Casual plasma glucose >200 mg/dl was also regarded as diabetes.3 Patients were excluded if they had severe complications that drastically interfered with their self-care activities, such as a severe visual problem, end-stage renal disease, clinically significant peripheral neuropathy, or coronary heart disease. The study was approved by the Institutional Review Board of the Asahi Life Foundation Institute for Diabetes Care and Research. The aim of this study was explained by diabetologists to each of 300 patients, who also received a questionnaires booklet. Of the 300 eligible patients, 256 (85.5%) gave written informed consent and returned the questionnaire. Thus, 256 patients (193 men and 63 women), with a mean age of 62.3 (standard deviation [SD]: 8.8) years comprised the baseline group.

Baseline Data Collection
The questionnaire consisted of six parts. Part 1 included educational level, marital status, occupation, company position, family history of diabetes, participation in diabetes education programs and education during hospitalization, and type of treatment regimen. Data from medical records were used when answers to the questionnaire were unclear.

Part 2 was the Summary of Diabetes Self-Care Activities scale, which normally consists of 12 items, divided into 4 subscales. These subscales assess both adherence to, and level of self-care for, diabetes regimens during the past 7 days. It includes diet, exercise, blood-glucose testing, and medication adherence. Each item was standardized, and the average was determined for each subscale.26 In this study, the subscale of blood-glucose testing was not analyzed because 219 patients (85.5%) did not carry out self-monitoring of blood glucose. Also, the subscale of medication adherence was excluded because patients had a wide range of prescriptions, varying from a single hypoglycemic agent to combinations for several concurrent diseases, which made it difficult to compare adherence to the diabetes medication. Consequently, only the scales for diet and exercise were evaluated in this study. The authors translated the original scale into Japanese, which was checked and revised by diabetologists and a bilingual person. The Cronbach alpha coefficient of internal consistency was then calculated for each subscale (diet amount: 0.84; diet type: 0.53; exercise: 0.84).

Part 3 was the Problem Areas in Diabetes scale (PAID), which was developed by Welch et al.23,24 and translated into Japanese by Ishii et al.27 The scale consisted of 20 items about diabetes-specific emotional distress, including guilt, anger, depressed mood, worry, and fear. Subjects rated the degree to which each item was currently problematic for them, from 1 (no problem) to 5 (serious problem). A total score was computed by summing the total item responses; Cronbach alpha was 0.94.

Part 4 was the Multidimensional Diabetes Questionnaire, which consisted of 41 items and was divided into 3 sections.19 The Japanese version was developed by the same process used for the Summary of Diabetes Self-Care Activities items. The first section included three subscales related to perceptions of diabetes. Responses were recorded on 7-point rating scales (0: not at all – 6: extremely). Because the perceived interference and severity subscales assessed similar psychological aspects to the PAID, only the subscale of Perceived Diabetes-Related Social Support (4 items) was utilized in this study. Cronbach alpha for this subscale was 0.84. The second section assessed social incentives from family members related to patients' self-care activities. On the original questionnaire, the second section comprised two subscales: Positive Reinforcing Behaviors (8 items) and Misguided Support Behavior (4 items), rated on 7-point scales (0: not at all – 6: extremely). However, the second section was analyzed as one subscale because the correlation between these subscales was relatively high in this study (r=0.81; p<0.01). Cronbach alpha for the second section was 0.95. The third section comprised two subscales that assessed Diabetes-Related Self-Efficacy (7 items) and Outcome Expectancies (6 items). The former measured patients' confidence in performing self-care activities, rated from 0: not at all confident to 100: very confident. The latter measured patients' perceptions of the effects of self-care activities on metabolic control and prevention of complications. It was measured on rating scales of 0: not at all important to 100: very important. Cronbach alphas for the two subscales were 0.80 and 0.70, respectively.

Part 5 was the Life- and Health-Related Questionnaire, which consisted of four sections.28,29 Section 1, which was modified from the Holmes and Rahe Life-Event scale,30 consisted of questions about 28 possible major life events, such as marriage, bereavement, pregnancy, and dismissal from employment. Subjects were required to circle any event they had experienced in the previous 12 months and to rate the stressfulness of each circled event on a scale of 0 to 100. The sum of the scores of the circled events was calculated. Section 2 consisted of 20 items about daily hassles at home and at work that subjects rated on 4-point scales (0: do not feel anything; 3: feel very much). Cronbach alpha was 0.90. Section 3 consisted of 15 questions about general coping skills, rated on 3-point scales (0: no; 1: neither yes nor no; 2: yes). Three aspects of coping were assessed: 1) doing something to change the problem causing the distress (problem-focused coping); 2) waiting for distress to disappear spontaneously ("waiting-for-time-to-pass" coping); and 3) regulation of distressing emotions (emotion-focused coping). Cronbach alpha for each subscale was 0.75, 0.66, and 0.60, respectively. Section 4 consisted of 10 items about available general social support, rated on 3-point scales (0: no; 1: neither yes nor no; 2: yes). Cronbach alpha for these items was 0.86.

Part 6 was the Profile of Mood States (POMS).31,32 The questionnaire consisted of 65 items that assessed current mood states on a 5-point scale (0: not at all; 1: a little; 2: moderately; 3: quite a bit; 4: extremely) and had six subscales: Tension/Anxiety, Depression, Anger/Hostility, Vigor, Fatigue, and Confusion. Each subscale except Vigor represented negative mood states, and higher scores indicated more severe mood disturbance, whereas Vigor represented a positive mood state, and a lower score implied worse mood states.

Physical data, including HbA1c, body mass index (BMI), the onset and duration of diabetes, and complications, were collected from medical records on the date closest to the study. HbA1c was measured by use of high-performance liquid chromatography, with a normal reference range of 4.3%–5.8%. For diabetes-specific complications, retinopathy was diagnosed and assessed by ophthalmologists. Diagnosis of nephropathy was made on the basis of the presence of prolonged microalbuminuria. Neuropathy was defined by clinical symptoms such as numbness or by neurological examination.

Follow-Up HbA1c Data Collection
Of the 256 patients who completed the questionnaire at baseline, three men were excluded 6 months later (one died, one changed hospital, and one dropped out); the medical data of the remaining 253 patients were used. A further two men and one woman were excluded at 12 months after baseline (one died, one changed hospital, and one dropped out). Consequently, 250 patients were enrolled in the 12-month follow-up study.

Statistical Analysis
We used Pearson's correlation coefficients, with a significance level of 0.05, to assess the simple correlation between the subscales. A structural-equation modeling (SEM) procedure33 was then used to develop a model of causal relationship between psychosocial factors and glycemic control. The model was developed on the basis of a review of previous studies9–19,21,23,24 and the results of the correlation matrix of subscales in this study. The SEM consisted of two parts: the measurement model and the structural-equation model. The measurement model specified how well the observed variables measured each latent variable and described the measurement reliability and validity. The structural-equation model specified the direct and indirect relationships among latent variables. The fit of the model was evaluated by the goodness-of-fit index (GFI) and the adjusted GFI (AGFI). The GFI is an index of the relative amount of variance and covariance explained by a model. The AGFI adjusts the GFI for the degrees of freedom of the model relative to its variance. Models are considered acceptable when the GFI is over 0.90.33,34

We first developed the causal model, in which HbA1c at 6 months after baseline was influenced by the baseline psychosocial factors. Using HbA1c at 12 months after baseline, SEM was then carried out to test whether the causal model at 6 months after baseline. Statistical significance was set at p<0.05. SAS Version 6.12 software (SAS Institute Japan; Tokyo) was used for the structural-equation modeling with the CALIS procedure.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
Demographic and Clinical Characteristics
Table 1 shows the demographic and clinical characteristics of participants at baseline. Their mean duration of diabetes was 16.9 (SD: 8) years. The mean level of HbA1c was 6.7% (SD: 1.1), and the mean BMI was 22.5 kg/m2 (SD: 3.3). Of the 256 patients, 101 (39.5%) had retinopathy, 102 (39.8%) had neuropathy, and 87 (34.0%) had nephropathy. These complications were in their early stages and showed few clinical symptoms.


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TABLE 1. Clinical Characteristics of Subjects



Glycemic control remained good throughout the study; mean HbA1c and BMI at 6 months after the baseline study were 6.9% (SD: 1.0) and 22.5 kg/m2 (SD: 3.4); 12 months after baseline, they were 6.9% (SD: 1.1) and 22.3 kg/m2 (SD: 2.8).

Correlation Matrix of Subscales
HbA1c at 6 months after baseline showed a significant positive correlation with the baseline psychosocial scores for the PAID score (r=0.21; p<0.01), Life-Events Impact (r=0.19; p<0.01), and daily burden (r=0.12; p<0.05). In contrast, HbA1c at 6 months after baseline showed a significant negative correlation with the baseline psychosocial scores for Adherence (Diet Amount: r = –0.17; p<0.01; Exercise: r = –0.16; p<0.05) and Diabetes-Related Self-Efficacy (r = –0.26; p<0.01). Adherence correlated significantly with Diabetes-Related Self-Efficacy (Diet Amount: r=0.56, p<0.01; Diet Type: r=0.27, p<0.01; Exercise: r=0.47, p<0.01); Social Support (Diet Amount: r=0.24, p<0.01); PAID score (Diet Amount: r = –0.15, p<0.05); Life-Events Impact (Exercise: r = –0.19, p<0.01), and daily burden (diet amount: r = –0.16, p<0.05; Exercise: r = –0.26, p<0.01). Statistically significant positive correlations were found between Diabetes-Related Self-Efficacy and Social Support (perceived social support: r=0.34, p<0.01; social incentives: r=0.25, p<0.01), whereas significant negative correlations were found between Diabetes-Related Self-Efficacy and the PAID score (r = –0.34, p<0.01), daily burden (r = –0.29, p<0.01), and with HbA1c at baseline (r = –0.26, p<0.01). Also, Emotion-Focused Coping showed significant correlation with the PAID score (r=0.21, p<0.01) and with daily burden (r=0.20, p<0.01).

Causal Model
The causal model in which HbA1c at 6 months after baseline was influenced by baseline psychosocial factors was developed on the basis of previous studies9–19,21,23,24 and the results of the correlation matrix of subscales in this study (GFI=0.94; AGFI=0.89). As shown in Figure 1 [A], HbA1c at 6 months after baseline was directly and indirectly influenced by six latent variables: adherence, diabetes-related self-efficacy, social support, daily burden, diabetes-related distress, and emotion-focused coping. Also, HbA1c at baseline remained as a predictor of HbA1c at 6 months after baseline. Self-efficacy directly influenced adherence, and adherence directly influenced HbA1c at 6 months after baseline. Other factors influenced self-efficacy. Social support increased self-efficacy, whereas daily hassles (burden) and diabetes-related distress undermined self-efficacy. Emotion-focused coping aggravated daily hassles and diabetes-related distress. Besides the direct influence on HbA1c at 6-month follow-up, HbA1c at baseline aggravated diabetes-related distress and decreased self-efficacy. All of the causal coefficients in the causal model were statistically significant (p<0.05).


Figure 1
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FIGURE 1.  Final Causal Model Between Psychosocial Factors at Baseline and Glycemic Control at 6 Months in 253 Patients With Type 2 Diabetes [A] and Between Psychosocial Factors at Baseline and Glycemic Control at 12 Months in 250 Patients With Type 2 Diabetes [B]

In each model, circles indicate latent variables, and rectangles indicate observed variables. The numbers on the paths are causal coefficients indicating the strength of the influence. All of the coefficients are statistically significant (p<0.05).

HbA1c_1, HbA1c at baseline; HbA1c_2, HbA1c at 6 months after baseline; HbA1c_3, HbA1c at 12 months after baseline; x1, emotion-focused coping score in Life and Health-Related Questionnaire; x2, daily hassles score in Life and Health-Related Questionnaire; x3, perceived diabetes-related social support score in Multidimensional Diabetes Questionnaire; x4, social incentives related to self-care activities given by family members score in Multidimensional Diabetes Questionnaire; x5, PAID score; x6, diabetes-related self-efficacy score in Multidimensional Diabetes Questionnaire; x7, diet adherence score in Summary of Diabetes Self-Care Activities scale; x8, Exercise adherence score in Summary of Diabetes Self-Care Activities scale; GFI, the goodness-of-fit index, AGFI, the adjusted goodness-of-fit index.


As shown in Figure 1 [B], the same model was confirmed using the 12-month HbA1c level as the dependent variable (GFI=0.94; AGFI=0.89).


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
In this study, the causal relationship between psychosocial factors and glycemic control was investigated prospectively. Using baseline data for psychosocial factors, we developed a causal model in which HbA1c level at 6 months after baseline was the dependent variable. This model was confirmed when we included HbA1c level at 12 months after baseline as the dependent variable.

Diabetes-Related Self-Efficacy was the only factor that directly reinforced adherence. Adherence had a direct positive association with good glycemic control. Previous cross-sectional studies have suggested a positive relationship between self-efficacy and glycemic control;12,17–19 likewise, the present causal model indicated that self-efficacy had a consistent relationship with glycemic control and was one of the most important prospective factors in diabetes-treatment research.

In this model, other factors indirectly influenced adherence and glycemic control through diabetes-related self-efficacy. Social support increased self-efficacy, whereas daily burden and diabetes-related distress undermined self-efficacy. Emotion-focused coping influenced self-efficacy by aggravating daily hassles and diabetes-related distress. Glasgow et al.12 have reported that self-efficacy and social support were highly associated with adherence. The results of the present study suggest that social support plays an important role in reinforcing self-efficacy, rather than having a direct effect on adherence. Bandura35 showed that self-efficacy develops through physical and emotional states. Management of daily hassles and diabetes-related distress may also be important for reinforcing self-efficacy, which can indirectly improve adherence and glycemic control. Just as some studies have reported that emotion-focused coping increased distress,36,37 emotion-focused coping exacerbated daily hassles and diabetes-related distress in the present causal model. It may be necessary to develop other effective coping skills in order to reduce these two psychological stresses and enhance self-efficacy. Furthermore, baseline poor glycemic control was associated with aggravated diabetes-related distress and decreased self-efficacy in addition to having a direct effect on follow-up HbA1c. Therefore, prospective glycemic control was mainly determined by current glycemic control in patients with Type 2 diabetes. Also, current glycemic control was important for psychological well-being, and psychosocial factors influenced future glycemic control independently of current glycemic control in the causal models in this study.

Mood states assessed by the POMS did not have significant influence on glycemic control at follow-up. This might be because the POMS monitors mood states only during the previous 7 days.

There are some limitations to this study, and there is a need for further research. Participants in this study showed relatively good glycemic control and good weight control. They had only milder diabetes-related complications. The Asahi Life Foundation Institute for Diabetic Care and Research is a specialized institute for advanced diabetes treatment and research in the Tokyo metropolitan area. Most patients at this institute are working at or had retired from large companies with relatively high positions. Participants in this study might have been provided with more effective treatments and shown better adherence than those in other general hospitals. Although only 14.5% of the participants did self-monitoring of blood glucose (SMBG) at the baseline point in this study, most of the patients had experienced SMBG before. Glycemic control was carefully checked at regular hospital visits, and SMBG could be re-prescribed by diabetologists. Concerning good weight control, previous studies have reported that the prevalence of overweight (BMI≥25) in Japanese adults is generally lower than that of Western people.38,39 Therefore, the average BMI in Japanese patients with Type 2 diabetes may be lower than that reported in other studies. The mean age of the participants in this study was relatively greater than that of previous studies. Given that some studies have suggested that levels of negative mood states were lower in elderly than in middle-aged diabetic patients,40 the level of daily hassles or diabetes-related distress may be lower in the participants in this study than in middle-aged patients. The influences of these psychosocial and physical factors on glycemic control in this study may therefore be different from those in middle-aged patients or in patients with poor glycemic control. Finally, we need to carry out psychosocial intervention and assessment studies to confirm the causal relationship found in this observation because models developed by SEM do not always reveal true causality.

In conclusion, the results of this study suggested that psychosocial factors were directly and indirectly associated with regimen adherence and prospective glycemic control in Type 2 diabetic patients. Diabetes-Related Self-Efficacy was the only factor that directly reinforced adherence, which, in turn, had a positive direct association with good glycemic control. Other factors, such as social support, daily hassles, diabetes-related distress, and emotion-focused coping indirectly influenced adherence and glycemic control through self-efficacy. Psychosocial interventions, especially, reinforcing self-efficacy, may be useful for long-term good glycemic control in patients with Type 2 diabetes.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. The Expert Committee on Diagnosis and Classification of Diabetes Mellitus: Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997; 20:1183–1197[Medline]
  2. Alberti KGMM, Zimmet PZ, for the World Health Organization Consultation: Definition, diagnosis, and classification of diabetes mellitus and its complications, part 1: diagnosis and classification of diabetes mellitus. Provisional Report of the World Health Organization Consultation. Diab Med 1998; 15:539–553[CrossRef][Medline]
  3. Kuzuya T, Nakagawa S, Satoh J, et al, for the Committee of the Japan Diabetes Society for the Society for the Diagnosis Criteria of Diabetes Mellitus: Report of the Committee of Japanese Diabetes Society on the Classification and Diagnostic Criteria of Diabetes Mellitus (in Japanese). J Japan Diab Soc 1999; 42:385–404
  4. UK Prospective Diabetes Study Group: Quality of life in Type 2 diabetes patients is affected by complications but not by intensive policies to improve blood glucose or blood pressure control (UKPDS 37). Diabetes Care 1999; 22:1125–1136[Abstract/Free Full Text]
  5. Glasgow RE, Dryfoos J, Ruggiero L, et al: Quality of life and associated characteristics in a large national sample of adults with diabetes. Diabetes Care 1997; 20:562–567[Abstract]
  6. The Diabetes Control and Complications Trial Research Group (DCCT): The effect of intensive treatment of diabetes on the development and progression of long-term complication in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329:977–986[Abstract/Free Full Text]
  7. The UK Prospective Diabetes Study (UKPDS) Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with Type 2 diabetes (UKPDS 33). Lancet 1998; 352:837–853[CrossRef][Medline]
  8. Okubo Y, Kishikawa H, Araki E, et al: Intensive insulin therapy prevents the progression of diabetes microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: a randomized, prospective, 6-year study. Diabetes Res Clin Prac 1995; 28:103–117[CrossRef][Medline]
  9. Bradly C: Life events and the control of diabetes mellitus. J Psychosom Res 1979; 23:159–162[CrossRef][Medline]
  10. Mooy JM, Bouter LM, Varies HD, et al: Major stressful life events in relation to prevalance of undetected Type 2 diabetes. Diabetes Care 2000; 23:197–201[Abstract]
  11. Aikens JE, Mayes R: Elevated glycosylated albumin in NIDDM is a function of recent everyday environment stress. Diabetes Care 1997; 20:1111–1113[Abstract]
  12. Glasgow RE, Toobert DJ, Riddle M, et al: Diabetes-specific social learning variables and self-care behaviors among persons with Type 1 and Type 2 diabetes. Health Psychol 1989; 8:285–303[CrossRef][Medline]
  13. Garay-Sevilla ME, Nava LE, Malacara JM, et al: Adherence to treatment and social support in patients with non-insulin dependent diabetes mellitus. J Diabetes Complications 1995; 9:81–86[CrossRef][Medline]
  14. Tillotson LM, Smith MS: Locus of control, social support, and adherence to the diabetes regimen. Diabetes Education 1996; 22:133–139[Free Full Text]
  15. Fukunishi I, Horikawa N, Yamazaki T, et al: Perception and utilization of social support in diabetic control. Diabetes Res Clin Pract 1998; 41:207–211[CrossRef][Medline]
  16. Toobert DJ, Glasgow RE: Problem-solving and diabetes self-care. J Behav Med 1991; 14:71–86[CrossRef][Medline]
  17. Kavanagh DJ, Gooley S, Wilson PH: Prediction of adherence and control in diabetes. J Behav Med 1993; 16:509–522[CrossRef][Medline]
  18. Skelly AH, Marshall JR, Haughey BP, et al: Self-efficacy and confidence in outcomes as determinants of self-care practices in inner-city African American women with non-insulin dependent diabetes. Diabetes Education 1995; 21:38–46[Free Full Text]
  19. Talbot F, Nouwen A, Gingras J, et al: The assessment of diabetes-related cognitive and social factors: The Multi-Dimensional Diabetes Questionnaire (MDQ). J Behav Med 1997; 20:291–312[CrossRef][Medline]
  20. Gavard JA, Lustman PJ, Clouse RE: Prevalence of depression in adults with diabetes: epidemiological evaluation. Diabetes Care 1993; 16:1167–1178[Abstract]
  21. Van der Does FEE, De Neeling JND, Snoek FJ, et al: Symptoms and well-being in relation to glycemic control in Type 2 diabetes. Diabetes Care 1996; 19:204–210[Abstract]
  22. Lustman PJ, Griffith LS, Freedland KE, et al: Fluoxetine for depression in diabetes. Diabetes Care 2000; 23:618–623[Abstract/Free Full Text]
  23. Polonsky WH, Anderson BJ, Lohrer PA, et al: Assessment of diabetes-related distress. Diabetes Care 1995; 18:754–760[Abstract]
  24. Welch GW, Jacobson AM, Polnsky WH: The problem areas in diabetes. Diabetes Care 1997; 20:760–766[Abstract]
  25. Rose M, Schirop T, Fliege H, et al: The network of psychological variables in patients with diabetes and their importance for quality of life and metabolic control. Diabetes Care 2002; 25:35–42[Abstract/Free Full Text]
  26. Toobert DJ, Glasgow RE: Assessing diabetes self-management: The Summary of Diabetes Self-Care Activities Questionnaire, in Handbook of Psychology and Diabetes. Edited by Bradley C. Amsterdam, The Netherlands, Harwood Academic Press, 1994, pp 351-375
  27. Ishii H: Psycho-behavioral problems in diabetes treatment. J Japan Diab Soc 2000; 43:13–16 (Japanese)
  28. Nomura S, Akabayashi A, Kuboki T: Development, validation, and application of a new questionnaire (Stress Checklist: SCL-86) for stress management in occupational health, in Behavioral Medicine: An Integrated Biobehavioral Approach to Health and Illness. Edited by Araki S. Amsterdam, The Netherlands, Elsevier, 1992, pp 195-203
  29. Yoshiuchi K, Kumano H, Nomura S, et al: Stressful life events and smoking were associated with Graves' disease in women, but not in men. Psychosom Med 1998; 60:182–185[Abstract/Free Full Text]
  30. Holms TH, Rahe RH: The Social Readjustment Rating Scale. J Psychosom Res 1996; 11:213–218[CrossRef]
  31. McMair DM, Lorr M, Dropplemann LF: Manual for Profile of Mood States (POMS), Revised. San Diego, CA, Educational and Industrial Testing Service, 1992
  32. Yokoyama K, Araki S, Kawakami N: Reliability and validity of the Japanese version of the Profile Of Mood States. Japanese J Pub Health 1990; 37:913–917 (Japanese)
  33. Bollen KA: Structural Equations With Latent Variables. New York, Wiley, 1989
  34. Bentler PM, Bonett DG: Significance tests and goodness-of-fit in the analysis of covariance structures. Psychol Bull 1980; 88:588–606[CrossRef]
  35. Bandura A: Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev 1977; 84:191–215[CrossRef][Medline]
  36. Lazarus RS, Folkman S: Stress, Appraisal, and Coping. New York, Springer, 1984
  37. Soderstrom M, Dolbier C, Leiferman J, et al: The relationship of hardiness, coping strategies, and perceived stress to symptoms of illness. J Behav Med 2000; 23:311–328[CrossRef][Medline]
  38. Ministry of Health, Labor and Welfare of Japan: National Nutrition Survey, 2001
  39. Flegal KM, Carroll MD, Ogden CL, et al: Prevalence and trends in obesity among U.S. adults, 1999-2000. JAMA 2002; 288:1723–1727[Abstract/Free Full Text]
  40. Peyrot M, Rubbin RR: Levels and risks of depression and anxiety symptomatology among diabetic adults. Diabetes Care 1997; 20:585–590[Abstract]



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