Prediabetes, depressive and anxiety symptoms, and risk of type 2 diabetes: A community-based cohort study

doi:10.1016/j.jpsychores.2016.08.011

Journal of Psychosomatic Research

Volume 89, October 2016, Pages 85-90

https://doi.org/10.1016/j.jpsychores.2016.08.011 Get rights and content

Highlights

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Examined the joint effect of prediabetes and depression/anxiety on diabetes risk.
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Prediabetes and depression interacted synergistically to increase diabetes risk.
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Depression more than doubled the risk of progressing from prediabetes to diabetes.
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Anxiety approximately doubled the risk of progressing from prediabetes to diabetes.

Abstract

Objective

To examine the potential synergistic associations between prediabetes, depressive and anxiety symptoms, and the risk of incident type 2 diabetes.

Methods

Data were from the Emotional Well-Being, Metabolic Factors and Health Status (EMHS) study and included 2486 adults between 40 and 69 years without diabetes at baseline. Hemoglobin A1c levels and measures of depressive and anxiety symptoms were collected at baseline and mutually exclusive groups were formed based on the presence/absence of prediabetes and high/low depressive and anxiety symptoms. A follow-up telephone interview conducted approximately 4.6 years later inquired about new diabetes diagnoses.

Results

86 participants developed diabetes during the follow-up period. After accounting for sociodemographic, lifestyle, and metabolic characteristics, participants with prediabetes and elevated depressive symptoms had an increased risk of developing diabetes compared to those without prediabetes and with low depressive symptoms (OR = 10.65, 95% CI = 4.60, 24.66). The joint effect of prediabetes and depressive symptoms on diabetes risk was synergistic (Synergy Index = 2.57, 95% CI = 1.02, 6.49). Similar results were found for participants with prediabetes and high symptoms of anxiety (OR = 8.95, 95% CI = 3.54, 22.63), however the joint effect of prediabetes and anxiety symptoms did not significantly exceed additive risk after adjusting for covariates (Synergy Index = 2.39, 95% CI = 0.83, 6.87).

Conclusion

The combination of prediabetes and depressive or anxiety symptoms was associated with an increased risk of developing diabetes. This study underscores the importance of mental health in the progression from prediabetes to type 2 diabetes.

Introduction

Type 2 diabetes is a major public health concern as prevalence rates are rapidly rising [1], [2]. Prediabetes, a condition characterized by blood glucose levels that are above the normal range but that do not reach the threshold for a diagnosis of type 2 diabetes, is a well-established risk factor for type 2 diabetes [3] that is also increasing in prevalence [4]. Though not everyone with prediabetes will develop type 2 diabetes, reported rates of progression from prediabetes to type 2 diabetes are as high as 70% [5]. Identifying predictors of the progression from prediabetes to type 2 diabetes could have important implications for reducing the incidence of type 2 diabetes.

Among people with prediabetes, the likelihood of reverting to normal glucose levels can be increased with healthy lifestyle changes [6], [7], [8]. Lifestyle behaviours such as smoking, unhealthy eating habits, and physical inactivity are common in people with depressive and anxiety symptoms [9] and these symptoms might increase the risk of progressing from prediabetes to type 2 diabetes. Depressive and anxiety symptoms are also well-documented correlates of type 2 diabetes [10], [11], [12], [13], [14]. Though prediabetes and depressive and anxiety symptoms are uniquely associated with an increased risk of diabetes, the combination of prediabetes and depressive or anxiety symptoms might amplify this risk. Only one study to date, to our knowledge, directly examined the associations between prediabetes, depressive and anxiety symptoms, and the risk of incident diabetes [15]. This study found that high psychological distress, assessed with a measure that combined symptoms of depression and anxiety, was associated with approximately double the risk of incident diabetes among participants with advanced prediabetes compared to those with advanced prediabetes and low psychological distress. Psychological distress was not associated with the risk of incident diabetes among those without prediabetes and low metabolic risk. It is unclear, however, whether the joint effect of prediabetes and depressive or anxiety symptoms on the risk of diabetes is synergistic, that is, whether the combined risk exceeds additive risk, and whether the potential risk remains when accounting for other metabolic factors.

The relative roles of depressive and anxiety symptoms in increasing the risk of progressing from prediabetes to type 2 diabetes are also unclear. Many of the existing longitudinal studies on psychological distress and the risk of type 2 diabetes have focused on depressive symptoms [16]; fewer studies have examined the role of anxiety and the risk of type 2 diabetes. Though some studies have shown that anxiety symptoms specifically are associated with the risk of diabetes [13], it is unclear if depressive symptoms and anxiety symptoms have similar patterns of associations with diabetes. For instance, Meurs and colleagues [17] found different patterns of cross-sectional associations between depressive and anxiety symptoms with diagnosed versus undiagnosed diabetes. They reported that whereas both undiagnosed and diagnosed diabetes were associated with increased odds of concurrent depressive symptoms, only diagnosed diabetes was associated with increased odds of concurrent anxiety symptoms. Therefore, despite the high comorbidity between depressive and anxiety disorders [18], it is unclear whether the patterns of associations with prediabetes and the risk of diabetes are similar for depressive and anxiety symptoms.

We recently reported findings from the Emotional Well-Being, Metabolic Factors and Health Status (EMHS) study [19], a community-based cohort study that examines the interactions between mental health and metabolic dysregulations in the development of type 2 diabetes over approximately 4.6 years. This study demonstrated that depressive symptoms in combination with metabolic dysregulations amplified the risk of developing type 2 diabetes by approximately 6 times compared to having low depressive symptoms and good metabolic health. The goals of the present study were to conduct a secondary analysis of the EMHS study to examine the potential synergistic interactions between prediabetes status and depressive and anxiety symptoms with the risk of type 2 diabetes, accounting for traditional risk factors for type 2 diabetes including sociodemographic characteristics, lifestyle behaviours, and other metabolic risk factors. The joint effect of prediabetes and depressive symptoms was expected to be greater than the sum of the individual effects in increasing the risk of incident diabetes, which would indicate a synergistic interaction. Similar results were expected for prediabetes and anxiety symptoms. A sensitivity analysis was also carried-out to examine the potential synergistic interaction between prediabetes and comorbid depressive and anxiety symptoms with the risk of diabetes. A secondary goal of the present study was to estimate the extent to which depressive or anxiety symptoms increase the rate of progression from prediabetes to type 2 diabetes by comparing the risk of diabetes among those with prediabetes only based on the presence or absence of depressive or anxiety symptoms.

Section snippets

Study population

EMHS participants were recruited from the CARTaGENE baseline cohort, a population-based health study of men and women aged between 40 and 69 years without diabetes at baseline and residing in one of four metropolitan areas in the Canadian province of Québec [20]. Blood samples and questionnaire assessments of psychological characteristics were collected by the CARTaGENE research group from August 2009 to October 2010. A subset of participants between 40 and 69 years of age with complete baseline

Results

Of the 2486 participants included in the present study, 86 participants (3.5%) reported a diagnosis of diabetes at follow-up. Table 1 describes diabetes incidence and demographic, lifestyle, metabolic, and depressive and anxiety characteristics of study participants stratified by prediabetes status at baseline. The 43% (n = 1058) of participants with prediabetes at baseline tended to be older and were more likely to have high blood pressure, low high-density lipoprotein cholesterol, high

Discussion

With a prospective community cohort of adults without diabetes at baseline, the goal of the present study was to examine the extent to which the combination of prediabetes and depressive or anxiety symptoms increased the risk of incident diabetes over approximately 4.6 years. The study was a secondary data analysis of the EMHS cohort study, which previously demonstrated that the combination of metabolic dysregulations and depressive symptoms increases the risk of diabetes. The results of the

Conclusions

This study demonstrates that elevated depressive and anxiety symptoms are each associated with an increased risk of progressing from prediabetes to diabetes, independently of several traditional risk factors for diabetes. Depressive symptoms in combination with prediabetes synergistically increased the risk of diabetes. Similar associations might exist for anxiety symptoms, though this was less clear in the present study. Taken together, these results support the importance of mental health

Competing interest statement

The authors have no competing interests to report.

Acknowledgements

This work was supported by an Operating Grant from the Canadian Institutes of Health Research (MOP-130552). Sonya Deschênes is supported by a fellowship from the Fonds de recherche du Québec – Santé, Canada and Rachel Burns is supported by a fellowship from the Canadian Institutes of Health Research (201411MFE-338860 FRN-142923). The funding agencies had no role in the design and conduct of the study, the collection, analysis and interpretation of the data, in the writing of the report, or in

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Citation Excerpt :
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Prediabetes, depressive and anxiety symptoms, and risk of type 2 diabetes: A community-based cohort study

Highlights

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Study population

Results

Discussion

Conclusions

Competing interest statement

Acknowledgements

Diabetes Res. Clin. Pract.

Lancet

Gen. Hosp. Psychiatry

J. Psychosom. Res.

J. Clin. Epidemiol.

J. Psychosom. Res.

J. Psychosom. Res.

Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the global burden of disease study 2013

Lancet

High-normal HbA1c is a strong predictor of type 2 diabetes in the general population

Diabetes Care

Prevalence of prediabetes in England from 2003 to 2011: population-based, cross-sectional study

BMJ Open

Impaired fasting glucose and impaired glucose tolerance implications for care

Diabetes Care

10-year follow-up of diabetes incidence and weight loss in the diabetes prevention program outcomes study

Lancet

Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance

N. Engl. J. Med.

Depression and type 2 diabetes over the lifespan: a meta-analysis

Diabetes Care

Rates and risks for co-morbid depression in patients with type 2 diabetes mellitus: results from a community-based study

Diabetologia

Depression as a risk factor for the onset of type 2 diabetes mellitus. A meta-analysis

Diabetologia

Psychological distress and risk of pre-diabetes and type 2 diabetes in a prospective study of Swedish middle-aged men and women

Diabet. Med.

Psychological distress and incidence of type 2 diabetes in high-risk and low-risk populations: the Whitehall II cohort study

Diabetes Care

Does emotional stress cause type 2 diabetes mellitus? A review from the European depression in diabetes (EDID) research consortium

Discov. Med.

Association of depressive and anxiety disorders with diagnosed versus undiagnosed diabetes: An epidemiological study of 90,686 participants

Psychosom. Med.