Effects of perceived competence, negative appraisal, and motivation orientation on glycemic stability in individuals with type 2 diabetes :A prospective cohort study

Open AccessPublished:October 09, 2020DOI:https://doi.org/10.1016/j.pcd.2020.09.008

      Highlights

      • Glycemic variability is targeted as a central risk factor for adverse outcomes in type 2 diabetes.
      • Patient competence, adjustment, and motivation may impact glycemic control.
      • The experience of diabetes as stressful affects levels of variability in HbA1c.
      • Greater perceived competence may predict a more stable glycemic control.

      Abstract

      Aims

      HbA1c variability is targeted as a part of clinical risk assessment in type 2 diabetes. Psychological factors such as patient competence, adjustment to diabetes, and motivation, may influence glycemic control. The objective of the present study was to determine if perceived competence, diabetes appraisal, and motivation predicted HbA1c variability, and to examine differences regarding these factors in relation to diabetes duration, in individuals with type 2 diabetes.

      Methods

      Data on perceived competence, appraisal of diabetes, and motivation orientation from 158 individuals with type 2 diabetes were analyzed as potential predictors of HbA1c at five measurement points over a time period of 24 months. Associations between psychological factors and HbA1c variability were examined through multiple linear regression analyses, and differences in psychological measures between groups with different diabetes duration were examined using ANOVA.

      Results

      Negative appraisal of diabetes predicted higher HbA1c variability and was associated with higher baseline HbA1c, and greater perceived competence predicted lower HbA1c variability.

      Conclusions

      The results indicate that lower levels of diabetes distress, as well as confidence in one’s ability to manage diabetes, could potentially predict better glycemic control.

      Keywords

      1. Introduction

      Perceived competence to manage diabetes, diabetes appraisal, and motivation are psychological factors that target three important domains of diabetes self-care: patient competence, adjustment to diabetes, and patient autonomy (Table 1) [
      • Norris S.L.
      • Engelgau M.M.
      • Narayan K.V.
      Effectiveness of self-management training in type 2 diabetes a systematic review of randomized controlled trials.
      ,
      • Lorig K.R.
      • Holman H.R.
      Self-management education: history, definition, outcomes, and mechanisms.
      ,
      • Williams Gc
      • McGregor H.
      • Zeldman A.
      • et al.
      Promoting glycemic control through diabetes self-management: evaluating a patient activation intervention.
      ]. Perceived competence contributes to goal pursuit and attainment, by promoting behavioral engagement, learning and skill acquisition. Williams et al. found that change in perceived competence predicted diabetes self-care behaviors (diet, exercise, and glucose monitoring) and sustained glycemic change, concluding that enhanced patient competence could benefit chronic disease management [
      • Williams G.C.
      • McGregor H.A.
      • Zeldman A.
      • et al.
      Testing a self-determination theory process model for promoting glycemic control through diabetes self-management.
      ]. The appraisal of diabetes as uncontrollable or threatening can have serious impact on diabetes management, as well as on overall psychological adjustment to the disease [
      • Macrodimitris S.D.
      • Endler N.S.
      Coping, control, and adjustment in type 2 diabetes.
      ]. Assessing diabetes distress, the negative emotional experiences of living with diabetes, is increasingly recognized as a part of diabetes management [
      • Fisher L.
      • Polonsky W.H.
      • Hessler D.
      Addressing diabetes distress in clinical care: a practical guide.
      ,
      • Skinner T.C.
      • Joensen L.
      • Parkin T.
      Twenty-five years of diabetes distress research.
      ,
      • Snoek F.J.
      • Bremmer M.A.
      • Hermanns N.
      Constructs of depression and distress in diabetes: time for an appraisal.
      ]. Higher levels of distress is associated with poor glycemic control, and may be influenced by the indivdual’s appraisal of diabetes [
      • Martinez K.
      • Lockhart S.
      • Davies M.
      • et al.
      Diabetes distress, illness perceptions and glycaemic control in adults with type 2 diabetes.
      ]. According to self-determination theory, motivation can be categorized as predominantly autonomous or controlled [
      • Deci E.L.
      • Ryan R.M.
      Self-determination theory: a macrotheory of human motivation, development, and health.
      ]. Autonomy support, i.e. support to act volitionally/with a sense of choice, that a patient receives from a healthcare provider, has in previous research been shown to increase patient motivation and ability to regulate glucose levels, and is considered to be related to internalization and long-term change of behavior [
      • Macrodimitris S.D.
      • Endler N.S.
      Coping, control, and adjustment in type 2 diabetes.
      ,
      • Williams G.C.
      • Freedman Z.R.
      • Deci E.L.
      Supporting autonomy to motivate patients with diabetes for glucose control.
      ,
      • Teixeira P.J.
      • Carraça E.V.
      • Markland D.
      • et al.
      Exercise, physical activity, and self-determination theory: a systematic review.
      ]. Perceived competence, appraisal of diabetes, and motivation may reflect to what degree the individual is successful when it comes to diabetes self-care behaviors. Both perceived competence and autonomous motivation may be improved with interventions, but it is not clear whether these factors are subject to change over time, i.e. as a result of diabetes duration [
      • Trouilloud D.
      • Regnier J.
      Therapeutic education among adults with type 2 diabetes: effects of a three-day intervention on perceived competence, self-management behaviours and glycaemic control.
      ]. Previous studies have found that changes in autonomous motivation and perceived competence are associated with improved glycemic control, and that greater autonomous motivation is associated with following recommended diet and physical activity recommendations [
      • Trouilloud D.
      • Regnier J.
      Therapeutic education among adults with type 2 diabetes: effects of a three-day intervention on perceived competence, self-management behaviours and glycaemic control.
      ,
      • Juul L.
      • Rowlands G.
      • Maindal H.T.
      Relationships between health literacy, motivation and diet and physical activity in people with type 2 diabetes participating in peer-led support groups.
      ]. However, there are to date no studies on the relationship between these psychological factors associated with glycemic control, and HbA1c variability.
      Table 1Psychological factors of importance to diabetes management.
      Definition
      Perceived competenceThe individual’s perceived capability to master personally challenging tasks, encompassing both the ability to perform and the consideration of personal importance of the task [
      • Halvari H.
      • Healey J.
      • Olafsen A.H.
      • et al.
      Physical activity and motivational predictors of changes in health behavior and health among DM2 and CAD patients.
      ].
      AppraisalThe process of interpreting and assessing a situation, in order to manage it. Appraisal influences an event’s emotional impact on the individual, leading to the utilization of a response (e.g. avoidance, problem-solving) [
      • Siemer M.
      • Mauss I.
      • Gross J.J.
      Same situation-different emotions: how appraisals shape our emotions.
      ,
      • Jamieson J.P.
      • Nock M.K.
      • Mendes W.B.
      Mind over matter: reappraising arousal improves cardiovascular and cognitive responses to stress.
      ].
      Controlled motivationMotivation driven by coercion or pressure, dependent upon external contingencies, external or internal pressure (“If I don’t exercise, my physician will be less accepting of me”) [
      • Deci E.L.
      • Ryan R.M.
      Self-determination theory: a macrotheory of human motivation, development, and health.
      ].
      Autonomous motivationMotivation driven by volition, i.e. valued and endorsed by the individual (“I feel free to exercise in my own way”) [
      • Williams G.C.
      • Freedman Z.R.
      • Deci E.L.
      Supporting autonomy to motivate patients with diabetes for glucose control.
      ,
      • Teixeira P.J.
      • Carraça E.V.
      • Markland D.
      • et al.
      Exercise, physical activity, and self-determination theory: a systematic review.
      ].
      The benefits and risks of glycemic thresholds are still unclear, since previous research have shown that not only high HbA1c, but also low HbA1c, is associated with mortality risk [
      • Currie C.J.
      • Peters J.R.
      • Tynan A.
      • et al.
      Survival as a function of HbA1c in people with type 2 diabetes: a retrospective cohort study.
      ,
      • Huang E.S.
      • Davis A.M.
      Glycemic control in older adults with diabetes mellitus.
      ]. Glycemic variability has in recent years been targeted as a central factor in clinical risk assessment in type 2 diabetes, alongside the two other components of the so-called “glucose triumvirate”: chronic hyperglycemia and hypoglycemic episodes [
      • Gorst C.
      • Kwok C.S.
      • Aslam S.
      • et al.
      Long-term glycemic variability and risk of adverse outcomes: a systematic review and meta-analysis.
      ,
      • Cardoso C.R.L.
      • Leite N.C.
      • Moram C.B.M.
      • Salles G.F.
      Long-term visit-to-visit glycemic variability as predictor of micro- and macrovascular complications in patients with type 2 diabetes: the Rio de Janeiro Type 2 Diabetes Cohort Study.
      ,
      • Forbes A.
      • Murrells T.
      • Mulnier H.
      • Sinclair A.J.
      Mean HbA1c, HbA1c variability, and mortality in people with diabetes aged 70 years and older: a retrospective cohort study.
      ,
      • Orsi E.
      • Solini A.
      • Bonora E.
      • et al.
      Haemoglobin A1c variability is a strong, independent predictor of all-cause mortality in patients with type 2 diabetes.
      ,
      • Prentice J.C.
      • Pizer S.D.
      • Conlin P.R.
      Identifying the independent effect of HbA1c variability on adverse health outcomes in patients with type 2 diabetes.
      ]. Long-term glycemic variability usually refers to fluctuations in HbA1c, which reflects the variability over several weeks or months. Although HbA1c variability has not yet been definitively confirmed as an independent risk factor for diabetes complications, it indicates the presence of glycemic excursions, and may as such represent the risk of hyperglycemia or hypoglycemia [
      • Ceriello A.
      • Monnier L.
      • Owens D.
      Glycaemic variability in diabetes: clinical and therapeutic implications.
      ]. Unstable HbA1c could be a sign of treatment difficulties, and evaluating HbA1c variability in relation to patient level factors could help identify key characteristics of individuals at risk of diabetes complications [
      • Mehring M.
      • Donnachie E.
      • Schneider A.
      HbA1c variability and cardiovascular events.
      ].
      The objective of the present study was to examine if the psychological factors perceived competence, appraisal of diabetes, and motivation, are associated with HbA1c baseline levels or HbA1c variability in individuals with type 2 diabetes. A main aim was to determine if these psychological factors predicted HbA1c variability over a time period of 24 months. The study further aimed to examine differences regarding perceived competence, appraisal, and motivation in relation to diabetes duration.

      2. Subjects, materials and methods

      2.1 Study setting

      The present study is part of the study “Detailed Assessment of Type 2 diabetes” (DIACT). The main objective of the DIACT study is to map different pathophysiological components relevant for type 2 diabetes progression, and to examine psychological factors’ association with disease management over time. The present study analyzed baseline data on perceived competence, appraisal of diabetes, and motivation orientation as potential predictors of HbA1c at five measurement points over a time period of 24 months.

      2.2 Study sample and selection

      Type 2 diabetes patients were contacted through the patient registry “All New Diabetics in Scania” (ANDIS), which is a combined research and quality assurance project that collects information about all new cases of diabetes in the region. Inclusion criteria were type 2 diabetes diagnosis and age (35–75 years), and participants were continuously enrolled in the study. Exclusion criteria were pregnancy, GAD-antibodies, other endocrine disorders, ongoing medication (e.g. cortisone) that could affect blood glucose levels, injury or disease that could affect measurement accuracy or challenge the individual’s health upon participation, inability to comprehend the implications of participation in the study, or participation in any other, ongoing study that could affect or be affected by the present study. Starting May 2013, 1398 individuals (812 men and 549 women) were contacted for participation in the study. A screening of eligibility was made over the phone by research staff, and those eligible for participation met a medical doctor for further screening. In the end, a total of 198 participants were included. The present study reports the results from participants enrolled in the study between May 2013 and March 2016, which accounts for 195 individuals. Of these, three participants were excluded due to medical reasons, two participants were diseased before follow-up, 19 participants had less than five measurements of HbA1c, and 13 participants dropped out before follow-up. Hence, the final sample for the present study consisted of 158 individuals.

      2.3 Material and methods

      Participants were assessed at a diabetes daycare clinic at Skåne university hospital, and each individual had a baseline assessment and repeated measures every six months. HbA1c was repeatedly measured at each visit. In the present study, HbA1c measurements from the first five visits (i.e. from the first two years) are analyzed. Laboratory analyses of HbA1c were carried out at local laboratories. The questionnaire data, assessing patient competence, adjustment to diabetes, and patient autonomy, was attained at each visit. Questionnaire data from the first visit only is analyzed in the present study.

      2.3.1 Psychological factors

      Patient competence was measured with the Perceived Competence for Diabetes Scale (PCDS), which measures the individual’s perception of how capable he or she is in managing daily aspects of diabetes care [
      • Williams G.C.
      • Freedman Z.R.
      • Deci E.L.
      Supporting autonomy to motivate patients with diabetes for glucose control.
      ]. The PCDS includes four items, and contains statements such as “I am capable of managing my diabetes” and “I feel confident in my ability to manage diabetes”. Each item is scored on a range from 1 (not at all true) to 7 (very true), and the items are averaged to form a perceived competence score. Higher scores indicate a greater level of perceived competence in the ability to manage diabetes. The original version of the PCDS has been validated in previous studies [
      • Williams G.C.
      • Freedman Z.R.
      • Deci E.L.
      Supporting autonomy to motivate patients with diabetes for glucose control.
      ]. In the present study, PCDS had an internal consistency reliability of Cronbach’s α = .93. Adjustment to diabetes was evaluated using the Appraisal of Diabetes Scale (ADS) [
      • Carey M.P.
      • Jorgensen R.S.
      • Weinstock R.S.
      • et al.
      Reliability and validity of the appraisal of diabetes scale.
      ]. The questionnaire includes seven items, designed to assess the perceived stressful impact of diabetes, and contains questions such as “Do you believe that achieving good diabetic control is due to your efforts as compared to factors which are beyond your control?”, and “How much uncertainty do you currently experience in your life as a result of having diabetes?”. All items are scored on a range from 1 to 5, and are summarized into a total score, with higher scores indicating greater level of stressful impact of diabetes. ADS has been shown to be an internally consistent and stable measure of diabetes-related distress [
      • Carey M.P.
      • Jorgensen R.S.
      • Weinstock R.S.
      • et al.
      Reliability and validity of the appraisal of diabetes scale.
      ]. The translated version of ADS used in the present study had an internal consistency reliability of Cronbach’s α = .74. Patient autonomy was measured with a modified version of the Treatment Self-Regulation Questionnaire (TSRQ). TSRQ measures different forms of behavioral regulation in terms of the degree to which motivation for health-related behaviors represent autonomous or self-determined/controlled functioning. All items are scored on a range from 1 (not at all true) to 7 (very true). Each item represents a reason for engaging in lifestyle changes, e.g. “Because it is important to me personally” (autonomous representation) or “Because others would be upset if I didn’t do it” (controlled representation). The questionnaire used in the study included eight items, focused on reasons for changing to a more healthy lifestyle (or continuing an already healthy lifestyle) and responses were categorized into the subscales Autonomous (four items) and Controlled (four items) regulation. Scores were averaged to form each subscale. Higher scores on the Autonomous subscale represent greater level of internal motivation, and higher scores on the Controlled subscale represent higher levels of external motivation. The TSRQ has in previous studies shown adequate psychometric properties [
      • Levesque C.S.
      • Williams G.C.
      • Elliot D.
      • et al.
      Validating the theoretical structure of the Treatment Self-Regulation Questionnaire (TSRQ) across three different health behaviors.
      ]. In the present study, the subscales Autonomous regulation and Controlled regulation had internal consistency reliabilities of Cronbach’s α = 0.91 and α = 0.78, respectively.

      2.3.2 Glycemic control

      HbA1c (mmol/mol, %) was assessed as a measurement of glycemic control and measured every sixth month in each participant. HbA1c variability was defined as the standard deviation (SD) as well as the coefficient of variation (CV) over the five measure points. CV was calculated as (SD/mean HbA1c) *100.

      2.3.3 Diabetes duration

      Diabetes duration was assessed at the first study visit, and measured as years since date of diabetes diagnosis.

      2.4 Statistical analysis

      All statistical analyses were performed using IBM SPSS Statistics for Macintosh, Version 26.0. Descriptive statistics, percentage or means and SD, were computed for all variables. Multiple linear regression analyses were conducted to determine if the psychological factors predicted HbA1c variability over the course of 24 months. Each analysis was stepwise adjusted for the potential confounders sex, age, diabetes duration, metformin treatment, and baseline HbA1c, using backwards elimination in order to only include control variables that significantly contributed to the variance of the dependent variable. Initially, four separate crude models were built with each of the psychological factors as main independent variable. A final analysis included all psychological factors in the same, adjusted model, in order to examine the mutually adjusted effect of the psychological factors on HbA1c variability, while controlling for additional potential confounders (sex, age, diabetes duration, metformin treatment, and baseline HbA1c), according to previously described backwards elimination. Multiple linear regression analyses were also used to examine baseline cross sectional associations between baseline HbA1c and psychological factors perceived competence, appraisal of diabetes, autonomous motivation, and controlled motivation. Sex, age, diabetes duration, and metformin treatment were included as potential confounders, and stepwise eliminated. Univariate analyses of variance (ANOVA) were performed to examine differences regarding psychological factors perceived competence, appraisal of diabetes, autonomous motivation, and controlled motivation, between groups based on time since diabetes diagnosis. Time since diabetes diagnosis was categorized as ≤2 years and >2 years, based on a median split.The analyses were adjusted for age, sex, baseline HbA1c and metformin treatment, using backwards elimination. Standardized effect sizes (Cohen’s d.) of pair wise comparisons were calculated according to formula d=(mean1-mean2)/SDpooled, where SDpooled=(SD12+SD22)/2 [
      • Durlak J.A.
      How to select, calculate, and interpret effect sizes.
      ].

      3. Results

      Table 2 describes sample characteristics. The distribution of men and women in the sample was 65.8% men (n = 104), and 34.2% women (n = 54). Among the participants, 53.8% had been diagnosed with type 2 diabetes for two years or less. A large part (71.8%) of participants were prescribed metformin treatment, and the mean HbA1c at baseline was 46.9 mmol/mol (6.4%). Participants reported higher mean autonomous motivation than controlled motivation (Table 2).
      Table 2Sample characteristics (N = 158).
      Sex
       Women34.2 (54)
       Men65.8 (104)
      Age (years)
       Mean (SD)67.5 (7.0)
       Range44−78
      Years since diagnosis
       Median3.5
       q11.0
       q36.0
       Range0−20
      Baseline HbA1c, mean (SD)
       %6.4 (0.7)
       mmol/mol46.9 (7.5)
      Prescribed metformin71.5 (113)
      Prescribed insulin (n = 156)7.1 (11)
      Other antidiabetic drugs (sulfonylureas, glitazones, DPP IV inhibitors, GLP-1 agonists)10.8 (17)
      Negative appraisal of diabetes, mean (SD) (n = 135)15.0 (3.1)
      Total score range 7–35.
      Perceived competence, mean (SD) (n = 143)5.4 (1.3)
      Total score range 1–7.
      Motivation orientation, mean (SD)
       Autonomous (n = 141)5.8 (1.2)
      Total score range 1–7.
       Controlled (n = 140)3.7 (1.5)
      Total score range 1–7.
      Note. Data are presented as percentage (n) unless otherwise indicated.
      a Total score range 7–35.
      b Total score range 1–7.
      Both perceived competence and negative appraisal of diabetes significantly predicted HbA1c variability (SD, CV); greater perceived competence significantly predicted lower HbA1c variability, and greater negative appraisal of diabetes was a significant predictor of higher HbA1c variability, in the crude models (p ≤ 0.01). In the adjusted model, only the association between negative appraisal and HbA1c variability (CV) remained significant (p = 0.03) (Table 3).
      Table 3Multiple linear regression analysis between psychological factors and HbA1c variability (SD, CV) during a 24-month follow up period.
      Crude modelsAdjusted model
      B95 % CIβpB95 % CIβp
      Negative appraisal of diabetes
       SD0.200.07, 0.330.220.0030.15−0.01, 0.310.170.05
       CV0.340.11, 0.570.240.0040.310.04, 0.570.210.03
      Perceived competence
       SD−0.42−0.73, −0.12−0.200.01−0.31−0.71, 0.09−0.140.13
       CV−0.79−1.31, −0.26−0.230.004−0.53−1.22, 0.16−0.150.13
      Autonomous motivation
       SD−0.16−0.47, 0.16−0.070.330.11−0.27, 0.500.050.57
       CV−0.34−0.88, 0.20−0.100.220.17−0.49, 0.830.050.61
      Controlled motivation
       SD−0.05−0.31, 0.21−0.030.72−0.13−0.41, 0.15−0.070.35
       CV−0.15−0.60, 0.30−0.050.52−0.30−0.79, 0.18−0.100.22
      Note. CI = confidence interval.
      Greater negative appraisal of diabetes was further significantly associated with higher baseline HbA1c, and greater perceived competence was significantly associated with lower baseline HbA1c, in the crude models (p ≤ 0.03). No significant relationship between autonomous or controlled motivation and baseline HbA1c were found. In the adjusted model, the significant association between negative appraisal of diabetes and baseline HbA1c remained, and significant associations between controlled motivation and baseline HbA1c, and between autonomous motivation and baseline HbA1c were found (p ≤ .04). Greater autonomous motivation was associated with higher HbA1c, and greater controlled motivation was associated with lower HbA1c in this model (Table 4).
      Table 4Multiple linear regression analysis between psychological factors and baseline HbA1c (mmol/mol) in independent and mutually adjusted model.
      Crude modelsAdjusted model
      B95 % CIβpB95 % CIβp
      Negative appraisal of diabetes0.700.30, 1.110.290.0010.640.17, 1.100.260.01
      Perceived competence−1.10−2.06, −0.14−0.190.03−1.07−2.29, 0.15−0.180.09
      Autonomous motivation0.46−0.53, 1.450.080.361.590.44, 2.750.270.01
      Controlled motivation−0.60−1.41, 0.22−0.120.15−0.91−1.77, −0.06−0.190.04
      Note. CI = confidence interval.
      There were no statistically significant differences between individuals with different diabetes duration regarding negative appraisal, perceived competence, autonomous motivation, or controlled motivation (Table 5).
      Table 5Psychological factors (negative appraisal of diabetes, perceived competence, autonomous motivation, and controlled motivation), in groups with different diabetes duration.
      Diabetes durationDiabetes duration
      ≤2 years (n = 85)>2 years (n = 73)
      Mean (95% CI)Mean (95% CI)Mean difference (95% CI)pd
      Negative appraisal of diabetes (n = 135)14.83 (14.16, 15.49)15.32 (14.57, 16.06)−0.49 (−1.49, 0.52)0.340.19
      Perceived competence (n = 143)5.47 (5.19, 5.75)5.28 (4.97, 5.58)0.19 (−0.22, 0.61)0.360.20
      Autonomous motivation (n = 138)5.88 (5.60, 6.16)5.63 (5.33, 5.94)0.24 (−0.17, 0.66)0.250.20
      Controlled motivation (n = 138)3.76 (3.42, 4.11)3.60 (3.22, 3.97)0.17 (−0.34, 0.68)0.520.11
      Note. CI = confidence interval, d = Cohen’s d.

      4. Discussion

      The aims of the present study were to examine associations between psychological factors and HbA1c at baseline, determine if these factors predict HbA1c variability, and to examine differences in these factors in relation to diabetes duration. The main results show that negative appraisal of diabetes is associated with higher baseline HbA1c and may predict greater HbA1c variability, while no significant differences in negative appraisal of diabetes, perceived competence, or motivation were found between those who have had diabetes for less than two years, compared to those who have had diabetes for more than two years.
      Studying multiple psychological factors concurrently allows an understanding of how these different factors relate to each other, as well as to the outcome of interest [
      • Walker R.J.
      • Gebregziabher M.
      • Martin-Harris B.
      • Egede L.E.
      Independent effects of socioeconomic and psychological social determinants of health on self-care and outcomes in type 2 diabetes.
      ]. Negative appraisal of diabetes was in the present study associated with both higher baseline HbA1c and HbA1c variability, indicating a less stable long-term glycemic control in individuals who perceive diabetes as stressful and difficult to manage. These results are in line with previous findings on the association between HbA1c and diabetes distress [
      • Skinner T.C.
      • Joensen L.
      • Parkin T.
      Twenty-five years of diabetes distress research.
      ]. The present study adds to this by employing a longitudinal study design in order to address the direction of this relationship. As a chronic condition, diabetes not only temporarily threatens the individual’s way of life, but continually demands adjustments of everyday life in order to keep glycemic control within a healthy range. The emotional response to this ongoing stress was in the present study shown to predict HbA1c variability, implicating that the subjective, emotional response to the ongoing stress of having type 2 diabetes, affects long-term glycemic stability. Patients that perceive themselves as in control of their condition may feel less threatened by it [
      • Sagui S.J.
      • Levens S.M.
      Cognitive reappraisal ability buffers against the indirect effects of perceived stress reactivity on type 2 diabetes.
      ,
      • Rodgers W.M.
      • Markland D.
      • Selzler A.M.
      • et al.
      Distinguishing perceived competence and self-efficacy: an example from exercise.
      ,
      • Halvari H.
      • Healey J.
      • Olafsen A.H.
      • et al.
      Physical activity and motivational predictors of changes in health behavior and health among DM2 and CAD patients.
      , ,
      • John O.P.
      • Gross J.J.
      Healthy and unhealthy emotion regulation: personality processes, individual differences, and life span development.
      ,
      • Siemer M.
      • Mauss I.
      • Gross J.J.
      Same situation-different emotions: how appraisals shape our emotions.
      ,
      • Jamieson J.P.
      • Nock M.K.
      • Mendes W.B.
      Mind over matter: reappraising arousal improves cardiovascular and cognitive responses to stress.
      ]. This underlines the importance of assessing the emotional aspects of living with type 2 diabetes, since insufficient support to deal with diabetes-related distress may have a direct impact on the individual’s HbA1c.
      Effective self-management may be enhanced when people perceive themselves as having the skills necessary to affect their HbA1c levels, i.e. a sense of competence may engage the individual in health behaviors beneficial to diabetes management [
      • Halvari H.
      • Healey J.
      • Olafsen A.H.
      • et al.
      Physical activity and motivational predictors of changes in health behavior and health among DM2 and CAD patients.
      ]. Perceived competence has in previous studies been found to be a motivational variable associated with diabetes self-care behaviors, and as such a psychological mechanism through which HbA1c levels indirectly can be decreased [
      • Williams G.C.
      • McGregor H.A.
      • Zeldman A.
      • et al.
      Testing a self-determination theory process model for promoting glycemic control through diabetes self-management.
      ,]. The present study did not find a significant association between perceived competence and HbA1c in the adjusted model, although the difference in effect sizes were minimal between significant and non-significant psychological factors included in the model. A larger sample size may improve the precision of the results. Since the association between health behaviors of diabetes and perceived competence was not a focus of the present study, this relationship was not examined. However, the effect of perceived competence on glycemic control may be mediated by health behaviors [
      • Williams G.C.
      • McGregor H.A.
      • Zeldman A.
      • et al.
      Testing a self-determination theory process model for promoting glycemic control through diabetes self-management.
      ]. Further research on the associations between perceived competence and health behaviors could help focus educational efforts aimed at diabetes management. To understand and support the individual’s personally meaningful efforts related to diabetes management could be one way to promote perceived competence and endorse effective self-management of diabetes.
      Both autonomous and controlled motivation were associated with baseline HbA1c, emphasizing motivation as an important part of glycemic control. In the present study, greater autonomous motivation was associated with higher HbA1c, while previous studies have shown that autonomous motivation is indirectly associated with reductions in HbA1c [
      • Williams G.C.
      • Freedman Z.R.
      • Deci E.L.
      Supporting autonomy to motivate patients with diabetes for glucose control.
      ]. This result requires further examination, but may reflect a gap between intent and implementation of relevant health behaviors in these patients.
      The reliability of the findings from the present study may be restricted by the somewhat small sample size, as well as the use of translated questionnaires that have not yet been validated. Additionally, the mean duration of diabetes was relatively short, a predominant part of participants were only prescribed metformin, and the mean HbA1c at baseline in the sample was in the lower end of recommended target levels, indicating a sample with a relatively healthy glycemic control, which may limit the generalizability of the study’s results [
      • John O.P.
      • Gross J.J.
      Healthy and unhealthy emotion regulation: personality processes, individual differences, and life span development.
      ]. Future studies should examine whether these findings are valid for individuals with less well-regulated HbA1c. Although significant, differences in HbA1c are comparatively small, which may limit the clinical application of the results. Being a measure of glycemic control over the past few months, HbA1c levels are likely to be the result of a complex set of factors, not limited to the factors examined in the present study.
      The present study found that individuals who perceive diabetes as stressful and difficult to manage experience a less stable long-term glycemic control, reflected as both higher levels of HbA1c and greater variability in HbA1c. These results indicate that diabetes appraisal may influence the degree of glycemic stability that the individual experiences, which constitutes a risk factor for future diabetic complications. Assessing patients’ appraisal of diabetes could help identify individuals in need of additional support in their diabetes management, since they may be at risk of diabetic complications due to increased HbA1c variability.

      Informed consent

      Informed consent was obtained from all individual participants included in the study.

      Funding

      This work was supported by the Ragnar Söderberg Foundation , the Swedish Foundation for Strategic Research and ALF .

      Ethical approval

      All procedures performed involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The present study was approved by the research ethics committee at Lund University (Date 2014-11-07, No. 2013/84).

      Conflict of interest

      None.

      Acknowledgements

      The authors would like to thank Anders Rosengren (PI, DIACT study), Maria Fälemark (research nurse, DIACT study), Helene Ferm (research nurse, DIACT study) and Hannah Nenonen (research coordinator, DIACT study), Gothenburg University, for access to data from the DIACT study and for helpful comments.

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