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The Benefits of Cognitive Behavioral Therapy (CBT) on Diabetes Distress and

Glycemic Control in Type 2 Diabetes

Article · August 2015

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ORIGINAL PAPER

The Benefits of Cognitive Behavioral Therapy (CBT) on Diabetes

Distress and Glycemic Control in Type 2 Diabetes

Seyed-Reza A1, Norzarina MZ1, Kimura LW2

1
Universiti Sains Malaysia (USM), Penang Island, Malaysia
2
INTI International College Penang, Penang Island, Malaysia

Abstract

Introduction: This study was designed to determine the effectiveness of

combined group Cognitive-Behavioral Therapy (CBT) in improving diabetes
distress and glycemic control among 60 adults with type 2 diabetes. Methods:
Half the participants were the experimental group (n = 30), and the other
half was the control group (n = 30). Group therapy consisted of eight sessions
for three months. Measures obtained at pre-test and post-test included the
Diabetes Distress Scale (DDS-17) and blood examination to examine the level
of HbA1c. Result: The results indicated that group CBT had significant
effects on the amelioration of diabetes distress and level of HbA1c among the
participants of the experimental group. Conclusion: The effectiveness of
group CBT in the maintenance of good diabetic control in people who are
suffering from type 2 diabetes was successfully demonstrated.

Keywords: Glycemic Control, Diabetes Distress, Cognitive Behavioral

Therapy, Malaysia

Introduction sleeping, and physical activities. Another

The Malaysian Diabetes Registry Database
in 2008 announced that Malaysia would
have 2.48 million cases of diabetes by 2030,
with a prevalence of 10.8%, a 164%
increase from the recorded 0.94 million
cases in 20001. However, Malaysia had
already exceeded that level by 3.6 million
cases in 20132. Diabetes is difficult to
manage by sufferers for many reasons.
Major change of lifestyle and daily decision-
making impose a strict discipline on a
diabetes patient; they need to carefully
control their regimen and sometimes greatly
alter their daily activities such as eating,
less obvious reason is that diabetes is
related to stress and stress acts directly on
metabolic control and insulin metabolism3.
An indirect effect of this link is interference
with the diabetic patient's self-care tasks3,
which means that in order to control
diabetes; a patient must be able to reduce
stress.
Some research carried out on stress
reduction has indicated positive effects in
lowering levels of HbA1c, as well as in
handling depression and anxiety in patients
with Type 1 diabetes4. CBT approaches
have been found to have a significant effect
MJP Online Early MJP-02-08-15

in reducing blood sugar levels in patients
with Type 2 diabetes5, 6, yet others found no
significant change in the level of HbA1c
after CBT. However, improvements in well-
being, levels of distress and depression were
found to result from CBT approaches6, 7.
Overall, therefore, there are some
encouraging findings concerning the
usefullness of CBT in diabetic control and in
the reduction of stress.
Despite the urgency of tackling the surging
rate of diabetes 2 in Malaysia, to date there
has not been any intervention focusing on
the psychological complications of diabetes
targeting patient coping skills through
individual cognition and behavior8, 9, 10.
However, one study recognized the vital
importance of a diabetes strategy that relies
more on the psychological complications of
diabetes and the need to understand the
patient's knowledge about the disease in
order to affect self-management of
diabetes11.
  employed; 14 (23.3%) were unemployed
Methods
Design
The quasi-experimental research consisted
of a 2 × 2 (Therapy × Control) design. The
two experimental conditions were: (1) group
CBT and (2) control group. Assessments
took place at pre-treatment and post-
treatment sessions.
Subjects
The sample consisted 60 adults, (39 males,
21 females), aged from 30 to 65 years old,
and a majority were married (n=57; 95%).
Patients were referred to this research by the
Pusat Sejahtera (Universiti Sains Malaysia
Clinic), Penang, Malaysia, where they were
receiving treatment. Participants must have
been diagnosed with type 2 diabetes at least
one year prior to this research and were
excluded if there was a history of a
psychological problem (e.g. major
depression disorder, mania, etc.),
bereavement or grief reaction during the
prior three months. In terms of ethnicity,
more than half (n = 35) were Malay (58%),
eight were Chinese (13.3%), fifteen were
Indian (25%), and two were foreign
(3.3%). The participants were between 50 to
59 years (46.7%). About half of the
participants (n = 33, 55%) were currently
(e.g., housewives) and 13 (21.7%) were
pensioners. Participants were at the
following income levels: eight (13.3%) at
RM 400-999, 21 (35%) at RM 1,000 - 2,999,
twenty (33.3%) at RM 3,000-5,999, and 11
(18.3%) at RM 6,000 or more (Table 1).

Table 1. Demographic Variables of Participants

Variables Frequency Percentage

Age
30-39 2 3.3
40-49 11 18.3
50-59 28 46.7
≥ 60 19 31.7
Gender
Female 21 35
Male 39 65
Marital Status
Single 2 3.3
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Married 57 95
Divorced 1 1.7
Employment Status
Employed 33 55
Non-Employed 14 23.33
Pensioner 13 21.7
Ethnicity
Malay 35 58.3
Chinese 8 13.3
Indian 15 25
Others 2 3.3
Income Status*
Low Income (<= RM400 – RM999) 8 13.3
Low Mid Income (RM1000 – RM2999) 21 35
Up Mid Income (RM 3000 – RM 5999) 20 33.3
High Income (>= RM 6000) 11 18.3

The current study was comprised of 60 Assessment sequence

participants, the accepted standard for a
quasi-experimental study being a minimum
of 30 with 20-25 participants for each
independent variable12. Thirty were assigned
to the experimental group, and the other
thirty to the control group. The therapist
started the therapy with three experimental
groups of 10 participants each, but after
several sessions some participants quit
necessitating a call for more participants
form a fourth group.
Measures
Diabetic control was measured by level of
HbA1c. An HbA1c higher than seven means
that one has a greater chance of developing
complications associated with diabetes, and
conversely, a low level can improve one’s
chances of staying healthier13. The
recommended level of HbA1c by the
Ministry of Health in Malaysia (2010) for
type 2 diabetes is ≤ 6.5%14. The level of
diabetes distress was determined by
administering the Diabetes Distress Scale
(DDS-17)15.
  second group, 8 out of 10 participants
The process of data collection was divided
in two phases. Phase one involved
interviews to investigate inclusion and
exclusion criteria in adults with diabetes and
in the second phase, group CBT was applied
those willing to join the program for the
entire three months. Eight therapy sessions
were conducted for four experimental
groups. In the first month there were weekly
sessions and the rest were once every two
weeks. The level of HbA1c and DDS-17
were measured at two different times for all
participants: once before entering therapy
(pre-test) and once after finishing therapy
(post-test).
Therapy procedure
The entire intervention program consisted of
eight sessions: the first four were conducted
weekly and the subsequent four were
conducted fortnightly. In the experimental
groups, 10 participants were assigned to the
first group; of these six participants (three
females, three males; five Malay and one
Indian) completed the program. In the
completed the program (three Indians, one
MJP Online Early
Chinese and four Malays; 1 female, 7
males). In the third group, 8 out of 10
participants completed (four Malays, two
Indians and two Chinese; 2 females, 6
males). In the fourth group, 8 out of 10
participants completed the program (three
Malays, five Indians; 6 females, 2 males). In
the present study, 10 participants failed to
complete the group therapy. The Malaysian
Ethical Committee of the Malaysian
Ministry of Health approved procedures for
the study.
  research and 5 percent significance level
Group CBT
The favorable impact of group CBT was
evaluated in a quasi-experimental design
over a period of three months. Our CBT
approach, incorporated (i) effective
components of cognitive therapy (e.g.,
cognitive-restructuring technique, stress
management or problem-solving), (ii) blood
sugar and food monitoring, and (iii) patient
education supplements. The focus of the
researcher's intervention was to help
participants learn to pay attention to their
own dysfunctional cognitions and behavior
through stimulating the reaction of their
conscious awareness about their concepts,
beliefs, and thought processes and the
overall way they deal with diabetes. By
becoming fully aware of their dysfunctional
cognitions and behavior, they could then be
guided to gradually control and decrease
them, and this in turn would cause their
metabolic control, distress and active coping
to improve. A group setting was utilized to
encourage attendance and participation, give
mutual support, model successful examples,
Table 2. t-Test Results of the HbA1c in the Experimental and Control Groups at Pre-Test
n M
Experimental group 30 8.66
Control group 30 8.81
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and exchange experiences and opinions16.
Statistical analysis
The statistical model used to test the effect
of the intervention was a mixed between-
within ANOVA. The experimental and
control groups served as the between-group
factor, and diabetes distress and HbA1c
levels before and after therapy served as the
within-group factor. The statistical package
software SPSS version 20 was used to
analyze the distracted data from the current
was considered acceptable for evaluating
parameter impacts.
Results
Before analyzing the data the normality of
the sample was examined using the
Kolmogorov-Smirnov (K-S) test. The results
of the K-S test for the mean differences in
blood sugar level (HbA1c) scores were 0.09,
with a p value of 0.20, and the results of the
K-S test for the mean differences in the
Diabetes Distress Scale (DDS-17) scores
were 0.09, with a p value of 0.97. Hence the
results revealed that the sample of the
current study was distributed normally.
To rule out any pre-existing differences in
the blood sugar levels of experimental and
control groups prior to the intervention, an
independent sample t-Test was conducted to
examine the blood sugar levels (HbA1c) in
the experimental and control groups before
therapy. The means and standard deviations
of the HbA1c levels for the experimental
and control groups are shown in Table 2.
SD t(58) p
0.62
0.93 0.35
0.61
MJP Online Early
As can be seen, since there was no
significant difference between the scores of
the experimental and control groups (t(58)
= 0.93, p = 0.35 two-tailed), the participants
in the experimental and control groups had
similar blood sugar levels (HbA1c) before
therapy.
To examine whether the changes in blood
sugar levels over time (pre-test to post-test)
were different in the two groups
(experimental and control groups), the
researcher measured the interaction effect,
which is the effect of group therapy on
blood sugar level which depended on the
time and group. The mixed between-within
subjects ANOVA showed a significant
interaction between group (experimental and
control groups) and time (pre- and post-test)
that influenced blood sugar levels (Wilks’
Table 3. HbA1c Scores across Two Time Periods
Experimental group (n = 30)
M SD
Pre-test 8.66 0.62
Post-test 7.33 1.06
To rule out any pre-existing differences in
the level of diabetes distress between the
experimental and control groups, an
independent sample t-Test was conducted on
Table 4. t-Test Results of Diabetes Distress in the Experimental and Control Groups at Pre-Test
n M
Experimental group 30 2.96
Control group 30 2.75
The independent sample t-Test revealed that
there was no significant difference in
diabetes distress between the experimental
and control groups (t(58) = 0.94, p = 0.34
two-tailed), in other words, participants in
both groups showed the same level of
diabetes distress before therapy sessions.
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Lambda = 0.58, F(42, 48) = 41.89, p <
0.01). The obtained Partial Eta Squared
value (η2) was 0.41. According to the
commonly used guideline (small effect =
0.01, moderate effect = 0.06 and large effect
= 0.14) proposed by Cohen (1988) and
Pallant (2010), this result suggests a very
large effect size17, 18.
The means before and after therapy in the
experimental group showed a 1.33-unit
difference, from 8.66 before therapy to 7.33
after therapy, which means that the blood
sugar level decreased after therapy.
Similarly, the mean before and after therapy
in the control group showed a 0.04-unit
difference, from 8.81 before therapy to 8.77
after therapy, which indicated that it
remained almost the same over time (Table
3).
Control group (n = 30)
M SD
8.81 0.61
8.77 0.84
the pre-test diabetes distress scores. The
mean and standard deviation scores for
diabetes distress for the experimental and
control groups are shown in Table 4.
SD t(58) p
1.01
0.94 0.34
0.75
To find out whether the changes in the level
of diabetes distress over time were different
in the two groups (experimental and control
groups) due to the group therapy
intervention, the interaction effect between
time and group on the level of diabetes
distress was assessed. The mixed between-
MJP Online Early MJP-02-08-15

within subjects ANOVA showed a showed a 0.78-unit difference, from 2.96

significant interaction between group
(experimental and control) and time (pre-
and post-test) that influenced the level of
diabetes distress, (Wilks’ Lambda = 0.78,
F(16, 10) = 16.03, p < 0.01). The Partial Eta
Squared value (η2) was 0.21, which is
considered a very large effect size.
The level of diabetes distress in the
experimental group before and after therapy
before therapy to 2.18 after therapy, which
means that the level of diabetes distress
decreased after therapy. Similarly, the
means before and after the therapy in control
group showed a -0.11-unit difference, from
2.75 before therapy to 2.86 after therapy,
indicating that the level of diabetes distress
increased after the same duration of time
(Table 5).

Table 5. Diabetes Distress Scores across Two Time Periods

Experimental group (n = 30) Control group (n = 30)

M SD M SD
Pre-test 2.96 1.01 2.75 0.75
Post-test 2.18 1.10 2.86 0.70

The mixed between-within subjects of improvements among diabetes distress

ANOVA also tested the differences in subscales (emotional burden, physician-
diabetes distress subscales for the related distress, regimen-related distress and
experimental and control groups before and interpersonal distress) across time. The
after therapy. There were significant results are summarized in Table 6.

Table 6. Means and Standard Deviations for Emotional Burden, Physician-Related

Distress, Regimen-Related Distress, and Interpersonal Distress at Pre-Test and Post-Test
 
Experimental (n = 30) Control (n = 30)
Subscales M SD M SD
Pre-test
Emotional burden 3.25 1.12 3.00 0.96
Physician-related distress 3.20 1.45 3.01 0.85
Regimen-related distress 3.18 1.19 2.93 1.02
Interpersonal distress 2.69 1.14 2.47 0.89
Post-test
Emotional burden 2.50 1.17 2.88 0.79
Physician-related distress 1.88 1.21 3.40 0.82
Regimen-related distress 2.26 1.23 3.00 0.89
Interpersonal distress 2.09 1.14 2.73 0.76

Discussion among the participants in the experimental

group, but no statistical difference in post-
Our study showed a significant decrease in test blood sugar level (HbA1c) among the
blood sugar level (HbA1c) after therapy participants in the control group. The
MJP Online Early
decrease in blood sugar level following
therapy in the experimental group
demonstrated the effectiveness of group
CBT in the improvement of glycemic
control. This was consistent with the results
obtained by previous studies19, 6, 20.
Improvement of blood sugar level in
experimental group members could be due
several factors, one of which is the
important educational component in our
CBT intervention. There was a rapid
increase in knowledge about diabetes, as
experimental group members received
informative notes regarding different aspects
of diabetes in each session of therapy, which
they were expected to study and apply.
Another factor explaining the lowering of
blood sugar levels is likely to be the daily
monitoring of food by participants in the
experimental group, who had to monitor
their food and blood regularly as an assigned
"homework" or hands-on task. This practice
of giving attention to eating more
appropriate foods, linked to the knowledge
of its benefits, gave them clear reasons why
they should eat in more appropriate ways.
The positive social influence impact of
group CBT was a strong motivating factor
encouraging patients to strive to reach the
desired blood sugar level each day. The
opportunity to share with other CBT group
members gave support and also brought
admiration if any member had improved on
a particular day. Participants with lower
blood sugar level became well-known faces
and received more positive reinforcement in
therapy sessions from their peers.
Due to the homogeneity of participants in
group therapy sessions, participants felt less
inferior, which encouraged them to
participate more, and this in turn, also
played a role in increasing adherence,
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specifically in control of blood sugar level.
Overall, as explained by Yalom and Leszcz
(2005), being with others in a group
contributes to better therapeutic changes.
For example, members can share their
feelings (catharsis) and knowing others are
like them (universalization); participants can
assist others with their work and can be
made to feel useful (imparting information,
providing feedback, and altruism)21.
The present research showed that the level
of diabetes distress was significantly lower
among participants in the experimental
group after the 12 weeks program compared
to before treatment and to the control group.
Our findings were similar to those of Peyrot
and McMurry (1992) and Henry et al.
(1997) whose research revealed lower levels
of distress after CBT therapy22, 23. What can
account for this lowering of distress is first
of all, being aware of it via the CBT
homework assignments and "stress log
sheet", which allowed patients to note the
external causes of stress, the specific coping
mechanisms they used to deal with it, and to
evaluate whether their chosen way was the
best or not, all before a public audience,
their peers, which added the social
reinforcement dimension. It was clear that in
stressful situations where the stressor had
high personal relevance, individuals less
frequently perceived favorable coping
options and tended to overuse emotional
reserves (emotion-focused coping) rather
than focus on strategic plans geared towards
implementing a course of action to cope
effectively with the situation (problem-
focused coping).
Concerning the several determinants of
diabetes-related distress which are crucial in
managing diabetes (i.e. emotional burden,
physician-related distress, regimen-related
distress, and internal distress), the mean of
emotional burden subscale decreased in the
MJP Online Early MJP-02-08-15

experimental group after the 12 weeks connection between their dietary plan and its
program. This indicates that after therapy, impact on blood sugar level, and take
the participants in the experimental group responsibility for it. Thus participants could
were more satisfied and felt less reduce their regimen- related distress and
overwhelmed by their diabetes in were motivated to continue to manage their
comparison to before therapy. Since diabetes.
emotional burden is one of the strongest
factors in self-healthcare behavior24 for Interpersonal distress, as another subscale of
diabetic patients, reducing emotional burden diabetes distress, asked whether or not the
is vital to improving self-care behavior so patient received his/her desired emotional
important in diabetes management25. support from family and friends. The mean
scores of interpersonal diabetes distress for
In addition, the mean of physician (or participants in the experimental group
therapist)-related1 stress was also lower after reduced after therapy, supporting the
the CBT group therapy sessions. Lee and research about diabetes management on the
Lin (2009) reported that trust between beneficial effects of social support29, 30.
patient and physician was one of the most
important factors in successful control of In all therapy sessions in the present study,
sugar level, and the stronger the relationship, participants shared their experiences and
the greater the likelihood of high self- emotions, and clearly benefited from
confidence which is associated with self- sharing, learning, and showing empathy in a
supportive behavior and better treatment group setting. Although most of the
outcomes26. Hence, the reasons for lower participants of the study were employees of
levels of therapist-related stress after a Universiti Sains Malaysia, for many of
therapy program can be explained by the them, it was their first time to share their
strong and trusting relationships among experiences regarding diabetes. As a result,
group members and with the therapist many new relationships were built among
throughout the therapy sessions. Trust also the participants even beyond the therapy
helps reduce the chances of negative mood sessions, which is a good indication that
during therapy and early termination of such support will continue into the future.
therapy27, 28. This achievement can be explained by the
interpersonal principles of psychotherapy.
In the current study, regimen-related distress Yalom and Leszcz (2005) supported a group
as a subscale of diabetes distress also setting for therapy, because it gives
showed a dramatic change after therapy participants the opportunity to become
among participants of the experimental aware of their difficulties and to build
group in comparison to the control group. sustainable relationships22. Participants in
Evidence indicated that group CBT helped groups also have the chance to observe one
lower diabetes distress as a result of self- another's behavior and modify previously
monitoring behavior7, taking care of diet, learned dysfunctional interpersonal
and improved health behaviors29. Daily behavior.
recording of food and blood sugar enabled
patients to identify problematic points in The results of the present study revealed that
their meal patterns and make a better plan group CBT produces a reduction in diabetes
for next day. They could clearly see the distress level and improvement in blood

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  sugar level. Given the potential importance
MJP Online Early
of such findings, it is suggested a larger-
scale study be conducted, incorporating
further methodological refinements such as
expanding the locations of the sample
collection to have a larger sample with
diverse ethnic groups and inclusive of all
age groups and a lengthy follow-up
assessment.
1
 This term used to describe a person who is helping
people with diabetes during their treatment such as a
medical doctor, a psychologist or a nurse.
Acknowledgements
The present research was funded by Post
Graduate Research Scheme (PRGS) at
Universiti Sains Malaysia (Grant number:
NMRR-12-507-11455).
The present research approved by Medical
Research and Ethics Committee of the
Ministry Health Malaysia, and informed
consent was obtained from all patients
participated in the study.
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Corresponding Author
Seyed Reza Alvani
School of Social Sciences.
Universiti Sains Malaysia (USM),
Penang Island, Malaysia
Tel: 0060125998071
Email: sralvani79@yahoo.com
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