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http://tde.sagepub.com/content/early/2014/06/17/0145721714538925The online version of this article can be found at:
DOI: 10.1177/0145721714538925
published online 17 June 2014The Diabetes EducatorCuevasisa L. Sumlin, Theresa J. Garcia, Sharon A. Brown, Mary A. Winter, Alexandra A. Garca, Adama Brown and Heath
Depression and Adherence to Lifestyle Changes in Type 2 Diabetes: A Systematic Review
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Depression and Adherence
Sumlin et al
1
Lisa L. Sumlin, MSN, RN, ACNS-BC
Theresa J. Garcia, PhD, RN
Sharon A. Brown, PhD, RN, FAAN
Mary A. Winter, MSN, RN
Alexandra A. Garca, PhD, RN, FAAN
Adama Brown, PhD
Heather E. Cuevas, PhD, RN, CDE
From the School of Nursing, The University of Texas at Austin, Austin,
Texas (Ms Sumlin, Dr S. Brown, Dr AA Garcia, Dr Cuevas, Ms Winter,
Dr A. Brown); and College of Nursing & Health Sciences, Texas A&MUniversityCorpus Christi, USA (Dr TJ Garcia).
Correspondence to Sharon A. Brown, PhD, RN, FAAN, Joseph H. Blades
Centennial Memorial Professor in Nursing, School of Nursing, The
University of Texas at Austin, 1710 Red River, Austin, TX 78701, USA
Funding:This publication was made possible by grant 5R01NR011450
from the National Institute of Nursing Research (NINR) at the National
Institutes of Health to Sharon A. Brown. Its contents are solely the
responsibility of the authors and do not necessarily represent the official
views of NINR.
DOI: 10.1177/0145721714538925
2014 The Author(s)
Purpose
Depression affects millions of people worldwide and is
prevalent among those with diabetes. The purpose of this
review was to synthesize recent research on depression
and adherence to dietary and physical activity recom-
mendations in persons with type 2 diabetes (T2DM).
Methods
This systematic review is a subanalysis of an NIH-
funded model-testing meta-analysis. Thirteen electronic
databases were searched using terms: depression, adher-
ence, T2DM, diabetes. Selected studies: were reported in
English between 2000 and 2012, focused on adults with
T2DM, and measured depression and dietary and/or
physical activity adherence.
Results
Twenty-seven studies involving 7266 participants were
selected; participants were 54% female and 62 years of
age, on average. When reported, depression prevalencein study samples ranged from 4.5% to 74%. Six interven-
tion studies targeted diabetes treatment, with or without
depression treatment; no studies focused solely on treat-
ing depression. Twenty-one descriptive studies examined
relationships between depression and diet/physical activ-
ity adherence, finding a negative association. Only 2 of
38925 TDEXXX 10.1177/0145721714538925Depression and AdherenceSumlin et alle2014
Depression and Adherence to
Lifestyle Changes in Type 2Diabetes
A Systematic Review
The Diabetes Educator OnlineFirst, published on June 17, 2014 as doi:10.1177/0145721714538925
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Volume XX, Number X, Month/Month 2014
The Diabetes EDUCATOR
2
the 6 intervention studies examined this relationship;
findings were inconsistent.
Conclusion
Depression was associated with lower adherence to dia-
betes self-care, as evidenced primarily by descriptive
studies; results of intervention studies were conflicting.
Future research should focus on the effects of treating
depression on diabetes health outcomes.
Depression affects 121 million people
worldwide and in 2002 was the leading
cause of disability, accounting for 4.5%
of the global burden of disease.1,2
Depression is an acute or chronic mental
disorder presenting as a depressed mood, loss of interest
or pleasure, feelings of guilt or low self-worth, disturbed
sleep or appetite, low energy, and poor concentration.2
Depression is more prevalent among people with dia-
betes than among the general population.3,4Diabetes is a
serious metabolic condition that affects more than 346
million adults worldwide, a number expected to double
by the year 2030. Type 2 diabetes (T2DM) is the most
common form of diabetes and arises due to obesity and
other conditions that cause insulin resistance.
Complications of diabetes resulted in 3.4 million deaths
in 2004, 80% of which occurred in low- to middle-
income countries.5 The reported global prevalence of
depression among diabetes cohorts comprised of differ-
ent ethnic groups has ranged from 11% to 71.8%.6 A
meta-analysis of 42 studies conducted in 2001 found that
adults with diabetes were twice as likely to have depres-
sion as those without diabetes, reporting an 11% preva-
lence of major depression and a 31% prevalence of major
and mild depression combined in those with diabetes.7
Fewer than 25% of those suffering from depression are
treated effectively.2
Depression can substantially inhibit peoples fulfill-
ment of their daily responsibilities.2Studies have shown
that people diagnosed with both diabetes and depression
are less likely to adhere to lifestyle changes, namely,
recommended diet and physical activity changes, result-
ing in poor glycemic control and increased diabetes-
related complications, such as retinopathy, nephropathy,
and cardiac dysfunction.8 Researchers have examined
the relationship among depression; diabetes self-care,
sometimes referred to as self-management behaviors
diet, physical activity, medication self-administration,
blood glucose monitoring, and/or foot care; and glyce-
mic control.9-13,14,15
Egede (2005) found that depressedmood inhibited adherence to self-care behaviors by
decreasing the desire to seek treatment, thus making the
behaviors key mediators of the link between depression
and poor diabetes outcomes.4Few studies have focused
on the effects that depression or depressive symptoms
have on 2 important lifestyle changes (diet and physical
activity [PA]). These 2 behaviors are the cornerstones of
the nonpharmacological approach to preventing16-18and
treating T2DM.19
The purpose of this systematic review was to explore
and synthesize recent research that examined the associa-
tion between depression and adherence to lifestylechanges (diet and PA) in people with T2DM, inform
future intervention development, identify gaps in the lit-
erature, and suggest recommendations for future research.
This review includes studies conducted from 2000 to the
present, seeking to update and narrow the focus of
Egedes previous review,4concentrating only on diet and
PA behaviors. The research questions for this systematic
review, focused on persons with T2DM, were:
Research Question 1:What are the characteristics of studies
conducted since 2000 that have focused on depression
and dietary and PA adherence?Research Question 2:What relationships have been reported
between the diagnosis and/or symptoms of depression
and adherence to diet and PA recommendations?
Recent emphasis on patient-centered diabetes care, or
empowerment, has challenged the concepts of adher-
ence and compliance.20 However, the majority of
studies conducted during the past decade used these
terms and thus, the term adherence was used when
searching for and referencing these studies.
MethodsThis systematic review is a subanalysis of a model-
testing meta-analysis involving the examination of vari-
ables predictive of diabetes outcomes. The set of models
that is being examined in the meta-analysis includes psy-
chological (eg, depression, stress, anxiety), motivational
(eg, self-efficacy, health beliefs), and diabetes-related
knowledge factors in predicting diabetes outcomes, such
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Depression and Adherence
Sumlin et al
3
as glycemic control and quality of life, with behavioral
lifestyle factors (eg, adherence to diet and physical activ-
ity) as mediating variables. Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA)
guidelines and other published protocols for systematicreviews were followed.21,22Both published journal arti-
cles and unpublished dissertation studies that examined
the relationship between depression and dietary and/or
physical activity adherence in T2DM were sought.
Studies were included if they: (1) were written in English
and reported between 2000 and 2012, (2) included a sam-
ple of adults diagnosed with T2DM, and (3) measured
depression and dietary and/or PA adherence. Studies
were excluded if the type of diabetes was not clearly
specified or the sample was mixed with regard to type of
diabetes.
Search Strategy
A total of 13 electronic databases were searched.
Primary sources included: PubMed, Cumulative Index to
Nursing and Allied Health Literature (CINAHL), Web of
Science, Education Resources Information Center
(ERIC), ProQuest Dissertations & Theses, and
PsychINFO. Search terms and their synonyms appropri-
ate for each database were depression, adherence, type 2
diabetes, and diabetes. Approximately 7.5% of included
studies were obtained from ancestry searches of the refer-
ence list from each article that met the inclusion criteria.
Data Extraction
The initial search resulted in 183 citations. The first
screening of titles and abstracts according to the inclu-
sion criteria resulted in a total of 46 studies. A secondary
screening of the full text of each study resulted in 27
studies in the sample, or 15% of the original number of
studies located in the search. (See the flow diagram in
Figure 1.) A data extraction table (Table 1) was devel-
oped to summarize information on each study.
The criteria developed for the parent meta-analysis
upon which this review is based were used to measuremethodological quality for this systematic review: study
design, attrition, sample selection, and instrument reli-
ability. Each criterion was measured on a 4-point scale
resulting in a maximum quality score of 13 and a mini-
mum score of 0. The minimum methodological score
accepted for this review was set at 3, a low number in
order to be purposely inclusive.
Results
Characteristics of the Studies
Samples and Settings of Primary Studies
Across the 27 studies, sample sizes ranged from 25 to
879, for a total of 7266 participants overall; 54% was
female. All study participants were diagnosed with
T2DM, and the weighted mean age across studies was 62
years. There were 22 studies9-13,23-26,28-30,32-35,37,38,40,41,43,44
that reported racial/ethnic backgrounds of study partici-
pants; 3 studies focused on a single racial/ethnic group (2
studies of Hispanics and 1 study of African
Americans).11,13,35 Caucasians made up the majority of
the samples, ranging from 42% to 100% across studies,
excluding the 3 studies that were focused solely onminority groups. Studies involving mixed ethnic samples
tended to have larger numbers of African Americans, fol-
lowed by smaller numbers of Hispanics, Asian Americans,
and Native Americans/American Indians. Classifications
such as non-white and non-Hispanic were also used.
Mean glycosylated hemoglobin levels (A1C) ranged
from 6.9% to 9.4% across the 15 studies in which this
Figure 1. Flow diagram of sample selection.
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5
Author/Date
Purpose
Sub
jects
Des
ign
/Sett
ing
Intervention(s)
Depress
ion
/Diet/
PAInstruments
Ma
jorF
ind
ings
Conclu
sions
Dalyetal,
200933
Identify
relationsh
ips
b/tbarrie
rsto
DM
self-m
gmt
behaviors
and
glycemic
control
253T2DM;57%
female;85%w
hite,
15%n
on-white;mean
age=60.2,DM
duration=10.1yrs,
A1C=7.1%
Cross-sectional;
medical
recordreview
andmailed
survey;
random
sample
Outpatient
clinics,
midwestern
medicalcenter
NA
PHQ-9
Self-Care
BehaviorsSurvey
forPatientsw/
Diabetes
Meandep,PHQ-9=7.97.0
Depcorrw/higherA1C(r=0.22,
P=
.001)
Depinterferedw/mealplan,corrw/
higherA1C(r=0.18,
P.
01)
Depinterferedw/PA,corrw/higher
A1C(r=0.11,NS).
Aftercontrollingforpredictors,A1C
0.04%h
igherforevery1-point
increaseindepscore
Mainb
arriersacross
most
self-mgmt
beha
viorswerecost
anddep
Ptadh
mayimprovew/
deptreatment
Fisheretal,
201023
Evaluate
relationsh
ips
b/tdepression,
DM
distre
ss
anddisea
se
mgmt
behaviors
,
glycemic
control
463T2DM;51.5%
female;28%
non-white;meanage
=58.8,A1C=8.1,
BMI=34.8
Descriptive
pre-interven-
tionsurvey
Primarycare
clinicsand
education
centers,
CA
NA
PHQ-8
Diet:Startingthe
Conversation
PA:Community
HealthyActivities
ModelProgram
forSeniors
15.3%w
/majordep;51.3%w
/DM
distress
HigherDM
distressassociatedw/
higherA1CandlowerPA
Depnotassociatedw/A1CorPAbut
negativelyassociatedw/dietadh
Depse
lectivelyreto
disea
semgmt
Depmeasuresmaybe
assessingother
aspectsofmood
besid
esdep
Recom
mendongoing
scree
ningforclinical
depandDM
distress
Fisher,200334
(dissertation)
Assess
relationsh
ip
b/tadjustment
distressliving
w/DM,dep,
andstagesof
chgfor
exercise(PA)
125T2DM;54%
female;96%w
hite,
2.4%A
sian
American,0.8%
AfricanAmerican;
meanage=62.3,
DM
duration=4.4
yrs,A1C=9.4
Cross-sectional,
mailsurvey
Diabetes
suburban
hospital
outpatient
clinics,MA
NA
ShortGeriatricDep
(SGD)Scale
Stagesof
Change-exercise
Processesof
Change
Scale-exercise
ConfidenceScale
DecisionalBalance
Scale
18.4%w
/dep;SGD=2.93.0.
Mostinadvancedstagesofchange
Sig(P