Body Fat, Fat Distribution, and Psychosocial Factors Among Patients With Type 2 Diabetes Mellitus
Ronny A. Bell
Diabetes, a risk factor for cardiovascular disease, requires lifestyle modifications (diet, exercise, weight loss). The relations between body mass index, waist-hip ratio (WHR), and psychosocial indicators, such as affect and stress, among 302 diabetic patients from a clinic and a neighborhood health center were analyzed. Data included stress and mood scale responses, body size (height, weight, and WHR) and potential confounders (physical activity, energy intake, and diabetes duration). In univariate analyses, body mass index was positively associated with stress and inversely associated with positive affect only in women. Multiple regression analyses indicated that stress was associated with body mass index and negative mood was associated with the WHR. The findings suggested that stress and affect may be important correlates of body fat among women with Type 2 diabetes, leading to more complications. Healthcare providers can help women with Type 2 diabetes lose weight and lower the risk of cardiovascular disease by recognizing and helping them deal with these psychosocial issues.
Index Terms: ABS scale, BEPSI scale, body mass index, non-insulin-dependent diabetes mellitus, waist-hip ratio
Diabetes mellitus is a disease of tremendous public health impact. Approximately 8 million Americans in the United States have been diagnosed with diabetes. Diabetes is a strong risk factor for a number of other conditions, such as lower limb amputation, cardiovascular disease, kidney failure, and blindness. Successful management of diabetes has been shown to delay or prevent the onset of some of these conditions. Dietary modification, glucose monitoring, exercise, and weight loss play a major role in diabetes management, but implementation of these behaviors is predicated on many factors, including the psychosocial orientation of the patient.
In the general population, body composition has been shown to be associated with factors such as depression and anxiety, although this relation has been shown primarily among women.[3-6] Among persons with diabetes, research findings have demonstrated a connection between depression, stress, and anxiety and control of diabetes.[7,8] In the only study of its kind to date, Lloyd and colleagues showed that, among persons with Type 1 diabetes, waist-hip ratio (WHR) was associated with stress, depression, social support, Type A personality, and anxiety. However, this association has not been demonstrated in an older population with Type 2 diabetes.
Type 2 non-insulin-dependent diabetes (NIDDM) is more prevalent than Type 1. In addition, the risk of cardiovascular disease is greater for patients with Type 2 diabetes than for those with Type 1 diabetes. That risk is enhanced by obesity and central adiposity. Understanding the relation between body composition and psychosocial factors is therefore important to the management of diabetes and to the well-being of persons with this disease.
In this study, we examined the associations of body fat (body mass index) and body fat distribution (WHR) with psychosocial factors, such as stress and affect, in a patient population with Type 2 diabetes. Knowing whether such a relation between body fat and psychosocial factors exists in a condition as common as Type 2 diabetes may be helpful in developing strategies to reduce the complications of the disease.
We identified participants from a computerized patient list from the Wake Forest University Family Practice Center (n = 433) and the Reynolds Health Center (n = 613), a community health clinic. Recruitment to participate in the screening occurred through a mailing to the patients’ homes. During a 1-year period, we screened 324 patients who met World Health Organization criteria for Type 2 diabetes (fasting plasma blood glucose [is greater than or equal to] 200 mg/dL) to determine risk factors for future cardiovascular and renal diseases.
Response rates and severity of diabetes (as measured by diabetes duration and glycemic control) from Black and White patients from the two clinics were similar. In this report, we include data from patients about whom complete psychosocial assessments were available (n = 302; 93.2% of total study sample).
We measured height and weight during physical examinations and derived a body mass index (BMI) for each patient from this information (BMI = weight in kilograms divided by height in meters, squared). To measure body fat distribution, we calculated WHR, measuring waist and hip circumferences using a single cloth tape measure. The waist circumference was measured at the level of the umbilicus; hip circumference was defined as the greatest measurement around the hips and buttocks.
The measure of energy intake we used was based on a 3-day food intake diary that had been mailed to patients with instructions for completion. Patients recorded food intake for 2 weekdays and 1 weekend day during the same week. A registered dietitian reviewed the completed food records and used the Nutritionist III software program ([N.sup.2] Computing, Salem, OR) to analyze all diet records.
To estimate weekly exercise energy expenditure, we held face-to-face interviews and recorded the type, frequency, and duration of patients’ self-reported usual physical activity. We used the definitions of exercise and physical activity developed by Caspersen et al and restricted data collection to leisure time physical activity. Patients’ smoking status was determined by self-reports. Classifications were never (not smoked 100 cigarettes in lifetime), former (smoked 100 cigarettes in lifetime and currently not smoking), and current. After patients fasted for 12 hours, a clinician drew venous blood from each patient to measure hemoglobin [A.sub.1c] ([HbA.sub.1c]).
We used two psychosocial measures for the present report. The Brief Encounter Psychosocial Instrument (BEPSI) was used to measure perceived stress and coping. On this instrument, higher scores indicate greater levels of perceived stress and coping.
As an indicator of the magnitude and balance between affective dimensions and to reflect responses to stress, we used the Affect Balance Scale (ABS). The raw scores for the ABS were divided into two major categories that were denoted as ABS-Ill (including items regarding depression, anxiety, guilt, and hostility) and ABS-Well (including items regarding joy, contentment, vigor, and affection). High scores of ABS-Ill and ABS-Well denote high levels of each mood, and vice versa (see Table 1 for more information on these instruments). Cronbach’s alphas for both scales were high and were similar for men and women (BEPSI: women .90, men .87; ABS-Ill: women .87; men .88; ABS-Well: women .87; men .85).
Demographic, Health, and Psychosocial Characteristics of
302 Patients With Type 2 Diabetes, by Gender
Men (N= 127) Women (N= 175)
M 60.0 56.8
SD 11.0 12.6
African American (%) 34.0 43.1
Duration of diabetes
M 8.3 8.0
SD 8.4 7.3
Hemoglobin [A.sub.1c] (%)
M 7.2 7.3
SD 2.2 2.2
Body mass index
M 30.4 31.9
SD 6.2 6.7
M .96 .90
SD .06 .08
Leisure time physical
M 276 220
SD 731 457
Caloric intake (kcal/day)
M 1,698 1,336
SD 642 525
Current smoker (%) 20.0 20.1
M 17.6 22.8
SD 11.0 14.0
M 44.5 36.8
SD 24.0 24.0
M 29.0 28.0
SD 23.0 23.0
Note. BEPSI = Brief Encounter Psychosocial Instrument: ABS = Affect Balance Scale; ABS-Ill indicates feelings of anxiety and guilt: ABS-Well indicates feelings of joy: high scores indicate high levels of each emotion.
([dagger]) Range = 0-54 (high stress = 30-50 +).
([double dagger]) Range = 0-100.
See Table 1 for the demographic characteristics of the study participants, by sex. The mean age for all study patients was 58 years, and the mean duration of diabetes was 8.1 years. Slightly more than half of the participants were women, and slightly less than half were African Americans. The study sample as a whole was relatively obese (mean BMI = 31.3 kg/[m.sup.2]).
The correlation analyses of each psychosocial variable with BMI and WHR for men and women are shown in Table 2. Among the women, BMI was inversely associated with age (-.320, p [is less than] .001) and positively associated with energy intake (.254, p [is less than] .001). Between the BEPSI and BMI, we found a significant positive correlation (-.320, p [is less than] .001); comparison of the ABS-Well and BMI revealed a significant negative correlation (.308, p [is less than] .001). For men, only age was significantly associated with BMI and WHR (-.312, p [is less than] .001; -.256, p [is less than] .01, respectively).
TABLE 2 Pearson Correlation Coefficients for Association Between Psychosocial Factors and Body Mass Index (BMI) and Waist-Hip Ratio (WHR) for 302 Patients With Type 2 Diabetes, by Gender
Age -.320(**) -.016
Duration of diabetes -.129 .005
Hemoglobin [A.sub.1c] (%) .111 -.035
Leisure-time physical activity -.100 -.040
Caloric intake .254(**) -.056
BEPSI .308(**) -.080
ABS-Ill -.155 .163
ABS-Well -.183(*) .013
Age -.312(**) -.256(*)
Duration of diabetes .083 -.055
Hemoglobin [A.sub.1c] (%) -.201 -.103
Leisure-time physical activity -.106 -.055
Caloric intake -.146 .104
BEPSI .132 -.011
ABS-Ill .029 .090
ABS-Well -.088 .065
Note. BEPSI = Brief Encounter Psychosocial Instrument; ABS = Affect Balance Scale; Abs-Well reflects feelings of joy; ABS-Ill reflects feelings of anxiety.
(*) p [is less than] .01;
(**) p [is less than] .001.
Regression coefficients for various factors potentially associated with BMI and WHR among women are shown in Table 3. Among the psychosocial variables, BEPSI was found to be a significant independent predictor of BMI (beta = .182, p = .037). For WHR, ABS-Ill was found to be a significant, independent predictor (beta = .179, p = .046).
TABLE 3 Regression Coefficients for Predictors of Body Mass Index (BMI) and Waist-Hip Ratio (WHR) for Women With Type 2 Diabetes, With BEPSI and ABS-Well as Independent Variables
Body mass index
BEPSI .182 .037
ABS-Well -.090 .239
ABS-Ill .022 .791
Age -.198 .020
Race .088 .229
Duration of diabetes -.132 .086
Glycosylated hemoglobin .073 .535
Exercise(a) .001 .986
Energy intake -.061 .424
Smoking status -.035 .636[R.sup.2] .190 [is less than] .0001
BEPSI -.060 .527
ABS-Well -.049 .565
ABS-Ill .179 .046
Age -.037 .688
Race .075 .338
Duration of diabetes .118 .151
Glycosylated hemoglobin .084 .370
Exercise(a) -.023 .770
Energy intake -.082 .315
Smoking status .011 .888[R.sup.2] .080 .178
Note. BEPSI = Brief Encounter Psychosocial Instrument; ABS = Affect Balance Scale; ABS-Well reflects feelings of joy; ABS-Ill reflects feelings of anxiety.
(a) Log values for exercise kilocalories were used.
To determine a potential “dose-response” effect, we calculated BMI means for women by tertiles of BEPSI scale scores (data not shown). BMI values differed significantly between the highest tertile and the lowest and middle tertiles. The mean BMI for the upper tertile of BEPSI was 34.65, compared with 29.50 for the lowest tertile, and 31.24 for the middle tertile (p [is less than] .001). We conducted a similar analysis for tertiles of ABS-Ill and WHR, and observed a nonsignificant difference in WHR between the upper tertile of ABS-Ill scores (0.91) and the lower and middle tertiles (.89 for both, p = .31).
Diabetes is a disease that increases risks for a number of serious medical conditions. Through lifestyle modification, including dietary changes, weight control, exercise, and glucose monitoring, the patient may reduce or delay the negative effects of diabetes to some extent. The degree to which patients participate in personal or provider-motivated lifestyle modification may be determined by a number of factors, including psychosocial factors.
In the present study, we found that women, but not men, with the higher levels of perceived stress and moods characterized by less joy, contentment, vigor, and affection and by higher levels of depression, anxiety, guilt, and hostility were more overweight (eg, had higher BMIs and WHRs). In other populations, psychosocial factors have been linked to obesity and central adiposity[3-6,14] and to cardiovascular disease risk.[15,16] This study, to the best of our knowledge, however, is the first to report links among these psychosocial factors and measures of body size and central adiposity in a population of patients with Type 2 diabetes.
Such a link is important in the care of persons with diabetes, which is a major risk factor for coronary artery, renal, and peripheral vascular disease, as well as for stroke and blindness. Through dietary modification, weight control, and maintenance of euglycemia, the negative effects of diabetes mellitus may be reduced or delayed, but patients must be both willing and able to make these changes. To help patients with diabetes make such changes, physicians and other healthcare providers must be aware of the barriers their patients face, including such psychological barriers as stress, depression, and anxiety.
Men and women appear to be different in this relation. We found no associations between body fat and body composition and psychosocial factors for men. Lloyd and colleagues found differences between men and women in the psychosocial factors that correlated with WHR; for men, WHR was associated with depression, anxiety, social support, and Type A personality, whereas WHR was associated with depression and stress among women. Although it is difficult to substantiate, the differences we report in this study may be attributable to gender differences in willingness to report psychosocial measures. However, the Cronbach alpha scores for the psychosocial measures in the present study did not vary substantially by sex.
Our findings are limited in that the data are cross-sectional. We cannot answer the question of whether the psychosocial factors preceded or were the result of the patients’ body composition and fat distribution profiles. Furthermore, the relation between diabetes mellitus and depression, stress, and other psychological factors cannot be fully evaluated.
Although it is possible that our findings in this investigation were the result of chance, this is somewhat mitigated in that our observations are in the anticipated direction (increased stress/depression, increased adiposity), and that our findings agree to some degree with those of Lloyd and colleagues. We also observed a dose-response effect in the relation between BMI and BEPSI scale scores.
Nonetheless, these findings suggest that primary care providers may need to be more aware of psychological factors among their patients, particularly among the women with Type 2 diabetes. To be effective in helping patients achieve goals, such as weight loss, the physician should recognize that treating patients’ anxiety, stress, or depression may be a crucial first step in helping certain individuals with Type 2 diabetes decrease their risk for cardiovascular and other diseases.
This study was funded by Grant U32CCU-403318 from the Centers of Disease Control and Prevention, Atlanta, Georgia.
For further information, please address correspondence to Dr Ronny A. Bell, Department of Public Health Services, Bowman-Gray School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157.
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Dr Bell is a research assistant professor with the Department of Public Health Sciences at Bowman Gray School of Medicine in Winston-Salem, North Carolina, where Mr Summerson is a research specialist with the Department of Family and Community Medicine and Dr Spangler is an assistant professor. Dr Konen is chair of the Department of Family Medicine at the Carolina Medical Center in Charlotte, North Carolina.
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