Self-Stigma Could Contribute to Worsening Glucose Control in Type 1 Diabetes

Yukiko Onishi MD, PhD

Few, outside of the person with diabetes and their care team, can understand the burden a diagnosis of diabetes places on the physical and mental health of people with type 1 diabetes. Now, a new study from investigators in Japan is shedding new light on the effects of self-stigma on glucose control among people with type 1 diabetes.

A single-center, cross-sectional study, which estimated associations between 9-item Self-Stigma Scale scores and HbA1c, results of the research endeavor provide insight into the mean self-stigma scores among people with type 1 diabetes and point to a positive association between self-stigma and HbA1c that remained significant after multivariable adjustment.

“We focused on this issue through clinical experiences with people with type 1 diabetes, whose glycemic management improved markedly by social supports of eliminating diabetes-related stigma. Although the finding of an association between self-stigma and HbA1c is significant, further longitudinal research is required to determine whether self-stigma leads to sub-optimal HbA1c,” said corresponding author Yukiko Onishi MD, PhD, of the Institute of Medical Science, Asahi Life Foundation, in Tokyo, in a statement. “This research does support and highlight the importance of eliminating self-stigma when treating people with type 1 diabetes.”

People with diabetes face a unique challenge not posed by many other chronic illnesses: stigma. Thankfully, not many people afflicted with disease are made to bear the disease burden and blame of diagnosis the way the general public has demonized the presence of diabetes. Although this more often pertains to stigma towards type 2 diabetes, particularly with weight stigma towards people with obesity, the mental hurdles of diabetes management are not unique to type 2 diabetes. In a recent episode of Diabetes Dialogue, Jill Weissberg-Benchell, PhD, a pediatric psychologist at the Ann & Robert H. Lurie Children’s Hospital of Chicago, sat down with hosts to discuss the importance of mental health and describe the challenges faced by people with diabetes in their daily lives.

Citing previous research linking perceived stigma with psychological and clinical outcomes in people with type 1 diabetes, Onishi and a team of collaborators sought to describe the impact of self-stigma on glucose control among adults with type 1 diabetes. With this in mind, investigators launched a single-center, cross-sectional study at the Institute of Medical Science, Asahi Life Foundation in Tokyo from August-November 2021. Limiting their study to those aged 18 years or older with a doctor-reported diagnosis of type 1 diabetes being treated with insulin injections and without serious mental health disorders, investigators identified a cohort of 166 for potential inclusion in their study.

The Self-Stigma Scale used in the study asked participants to provide scores using a 4-point Likert scale of agreement. The total scores possible with the scale ranged from 0 to 27, with higher scores indicating a greater level of self-stigma. For the purpose of analysis, mean HbA1c levels were calculated using HbA1c measurements from the last 3 clinical visits within 6 months, starting from the day the questionnaire was distributed.

After distributing questionnaires, which included the 9-item Self-Stigma Scale, to these patients, investigators collected responses from 140 participants. After excluding those not providing answers pertaining to self-stigma, those with missing data on insulin use, and those with a falsely low value of HbA1c due to anemia, investigators identified 109 people with type 1 diabetes for inclusion in the study. This cohort had a mean age of 58.3 years, 43.1% were women, a mean duration of diabetes was 25.5 years, a mean BMI of 22.9, and a mean BMI of 7.6%.

Upon analysis, the median of the total scores of the 9-item Self-Stigma scale was 11. For the cognitive, affective, and behavioral subscales, the median scores were 5, 3, and 1, respectively. In analyses adjusted for age, sex, employment status, BMI, duration of diabetes, and insulin secretion, there was a significant positive association between self-stigma and HbA1c (β=.05; 95% CI, 0.01-0.08).

“The present cross-sectional study showed an important finding that self-stigma is associated with HbA1c among adults with type 1 diabetes. Our study suggests that treatment of diabetes should be provided to persons with type 1 diabetes with considerations that HbA1c is associated with self-stigma,” wrote investigators.

This study, “Association of self-stigma with glycated hemoglobin: A single-center, cross-sectional study of adults with type 1 diabetes in Japan,” was published in the Journal of Diabetes Investigation.