Potential Link Between T1D Self-stigma, HbA1c in Japanese Adults

There may be a strong link between diabetes-related self-stigma and glycated hemoglobin (HbA1c) in individuals with type 1 diabetes (T1D), according to a cross-sectional study published in the Journal of Diabetes Investigation.

“Addressing self-stigma might be as equally essential as measuring HbA1c in evaluating glycemic outcome among individuals with [T1D],” the authors said.

The study was conducted at a single clinic in Tokyo, Japan between August and November 2021. Final analyses included 109 eligible adults with T1D who had been treated with insulin after excluding participants with incomplete answers or missing laboratory data. The study did not include individuals experiencing serious mental conditions or individuals who underwent urgent medical treatment or hemodialysis.

Participants answered 9-item questionnaires that were scored using the Japanese version of the Self-Stigma Scale. HbA1c data were obtained from electronic health records, and average HbA1c—used to evaluate glycemic outcome—was calculated using HbA1c values measured in each participant’s last 3 clinical visits within 6 months of receiving the questionnaire. Adjusted linear regression analyses tested the association between scale scores and HbA1c.

The mean age was 58.3 years and mean body mass index was 22.9, with 43.1% of participants being women. Mean duration of T1D was 25.5 years, with 86.2% of participants having depleted insulin secretion.

When looking at employment status, about half were employed full-time and 13.7% were employed part-time. Additionally, median Self-Stigma Scale score was 11, and median scores of cognitive, affective and behavioral subscales were 5, 3, and 1, respectively. The mean HbA1c was 7.6%.

After adjusting for all of these factors, the authors found a significant positive association between diabetes self-stigma and HbA1c (β = 0.05; 95% CI, 0.01-0.08).

Unadjusted linear regression models still showed significant associations between HbA1c and all factors except for insulin depletion, which was not significantly associated with higher HbA1c in that case.

There was also a previous study looking at the association between diabetes self-stigma and type 2 diabetes (T2D) in Japanese adults. Interestingly, results differed between these 2 studies, with the previous study finding a statistically insignificant association between self-stigma and HbA1c, although that was not the primary endpoint of the study.

Other research has suggested individuals with T1D experience and perceive more stigma than individuals with T2D, which the current study authors say may be leading to these varying results. They also said this may be related to less public awareness of T1D than T2D, as well as misunderstandings that all types of diabetes arise the same way.

“Although it is evident that persons with [T2D] also perceive stigma that ‘they brought the condition on themselves,’ persons with [T1D] have a tendency to struggle with the diagnosis of ‘diabetes the lifestyle disease’, despite the different onset mechanisms, and think that [T1D] ruined their lives,” the study authors said. “These emotions might even relate to strong feelings of annoyance, anger and hatred against diabetes, and possibly interfere with development of self-stigma for diabetes.”

They also attributed increased stigma to the patient’s need for multiple daily insulin injection or pump therapy, as stigma has been shown to increase with the intensity of treatment.

“Insulin use is highly visible, and concerns about how insulin therapy is perceived in public are common among individuals with diabetes, leading to delayed or omitting insulin administration,” the authors said. “It is known that inappropriate timing of insulin administration is associated with poorer glycemic outcome, as measured by HbA1c.”

It is important to acknowledge the several limitations of this study, as it was single-centered, used a scale only generalizable to individuals with T1D, did not include assessments of total daily insulin dose or diabetes education, did not assess experienced or perceived stigma, and was conducted during COVID-19, which could impact glycemic levels.

The authors also emphasized this cross-sectional study does not prove a causal relationship between stigma and HbA1c.

Reference

Hamano S, Onishi Y, Yoshida Y, et al. Association of self-stigma with glycated hemoglobin: a single-center, cross-sectional study of adults with type 1 diabetes in Japan. J Diabetes Investig. Published online January 25, 2023. doi:10.1111/jdi.13963