Microaggressions, diabetes distress, and self-care behaviors in a sample of American Indian adults with type 2 diabetes

Abstract

American Indian/Alaska Native people experience the highest age-adjusted prevalence of type 2 diabetes of any racial group in the United States, as well as high rates of related health problems. Chronic stressors such as perceived discrimination are important contributors to these persistent health disparities. The current study used structural equation modeling to examine the relationships between racial microaggressions, diabetes distress, and self-care behaviors (diet and exercise) in a sample of 192 American Indians with type 2 diabetes from the northern United States. We found that microaggressions was positively associated with diabetes distress and that microaggressions had an indirect link to self-care via diabetes distress. Diabetes distress is an important mechanism linking microaggressions to self-care behaviors, which are critical to successful disease management and the reduction of complications. The amelioration of diabetes distress could improve self-care even in the presence of pervasive, chronic social stressors such as microaggressions.

This is a preview of subscription content, access via your institution.

Fig. 1

References

  1. Aikens, J. E., & Mayes, R. (1997). Elevated glycosylated albumin in NIDDM is a function of recent everyday environmental stress. Diabetes Care, 20(7), 1111–1113. https://doi.org/10.2337/diacare.20.7.1111

    CAS  Article  PubMed  Google Scholar 

  2. Anderson, R. J., Freedland, K. E., Clouse, R. E., & Lustman, P. J. (2001). The prevalence of comorbid depression in adults with diabetes: A meta-analysis. Diabetes Care, 24(6), 1069–1078. https://doi.org/10.2337/diacare.24.6.1069

    CAS  Article  PubMed  Google Scholar 

  3. Blackwell, D. L., Lucas, J. S., & Clarke, T. C. (2014). Summary health statistics for U.S. adults: National health interview survey, 2012. Vital Health Statistics, 10(260), 1–161.

    Google Scholar 

  4. Brondolo, E., Love, E. E., Pencille, M., Schoenthaler, A., & Ogedegbe, G. (2011). Racism and hypertension: A review of the empirical evidence and implications for clinical practice. American Journal of Hypertension, 24(5), 518–529. https://doi.org/10.1038/ajh.2011.9

    Article  PubMed  Google Scholar 

  5. Chae, D. H., & Walters, K. L. (2009). Racial discrimination and racial identity attitudes in relation to self-rated health and physical pain and impairment among two-spirit American Indians/Alaska Natives. American Journal of Public Health, 99, S144–S151. https://doi.org/10.2105/AJPH.2007.126003

    Article  PubMed  PubMed Central  Google Scholar 

  6. Dawson, A. Z., Walker, R. J., Campbell, J. A., & Egede, L. E. (2015). Effect of perceived racial discrimination on self-care behaviors, glycemic control, and quality of life in adults with type 2 diabetes. Endocrine, 49(2), 422–428.

    CAS  Article  PubMed  Google Scholar 

  7. Dolezsar, C. M., McGrath, J. J., Herzig, A. J. M., & Miller, S. B. (2014). Perceived racial discrimination and hypertension: A comprehensive systematic review. Health Psychology, 33(1), 20–34. https://doi.org/10.1037/a0033718

    Article  PubMed  PubMed Central  Google Scholar 

  8. Fisher, L., Gonzalez, J. S., & Polonsky, W. H. (2014). The confusing tale of depression and distress in patients with diabetes: A call for greater clarity and precision. Diabetic Medicine, 31(7), 764–772. https://doi.org/10.1111/dme.12428

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  9. Fisher, L., Hessler, D. M., Polonsky, W. H., & Mullan, J. (2012). When is diabetes distress clinically meaningful? Establishing cut points for the Diabetes Distress Scale. Diabetes Care, 35(2), 259–264. https://doi.org/10.2337/dc11-1572

    Article  PubMed  PubMed Central  Google Scholar 

  10. Fisher, L., Mullan, J. T., Arean, P., Glasgow, R. E., Hessler, D., & Masharani, U. (2010). Diabetes distress but not clinical depression or depressive symptoms is associated with glycemic control in both cross-sectional and longitudinal analyses. Diabetes Care, 33(1), 23–28.

    Article  PubMed  Google Scholar 

  11. Fisher, L., Mullan, J. T., Skaff, M. M., Glasgow, R. E., Arean, P., & Hessler, D. (2009). Predicting diabetes distress in patients with type 2 diabetes: A longitudinal study. Diabetic Medicine, 26(6), 622–627. https://doi.org/10.1111/j.1464-5491.2009.02730.x

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  12. Fisher, L., Skaff, M. M., Mullan, J. T., Arean, P., Glasgow, R., & Masharani, U. (2008). A longitudinal study of affective and anxiety disorders, depressive affect and diabetes distress in adults with type 2 diabetes. Diabetic Medicine, 25(9), 1096–1101. https://doi.org/10.1111/j.1464-5491.2008.02533.x

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  13. Fisher, L., Skaff, M. M., Mullan, J. T., Arean, P., Mohr, D., Masharani, U., et al. (2007). Clinical depression versus distress among patients with Type 2 diabetes. Diabetes Care, 30(3), 542–548. https://doi.org/10.2337/dc06-1614

    Article  PubMed  Google Scholar 

  14. Gonzales, L., Davidoff, K. C., Nadal, K. L., & Yanos, P. T. (2015). Microaggressions experienced by persons with mental illnesses: An exploratory study. Psychiatric Rehabilitation Journal, 38(3), 234. https://doi.org/10.1037/prj0000096

    Article  PubMed  Google Scholar 

  15. Gonzales, K. L., Lambert, W. E., Fu, R., Jacob, M., & Harding, A. K. (2014). Perceived racial discrimination in health care, completion of standard diabetes services, and diabetes control among a sample of American Indian women. The Diabetes Educator, 40(6), 747–755. https://doi.org/10.1177/0145721714551422

    Article  PubMed  Google Scholar 

  16. Gonzalez, J. S., Fisher, L., & Polonsky, W. H. (2011). Depression in diabetes: Have we been missing something important? Diabetes Care, 34(1), 236–239.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Indian Health Service. (2016). Indian Health Disparities. Rockville, MD: Indian Health Service. Retrieved from https://www.ihs.gov/newsroom/factsheets/disparities/

  18. Iwasaki, Y., Bartlett, J., & O’Neil, J. (2005). Coping with stress among Aboriginal women and men with diabetes in Winnipeg, Canada. Social Science and Medicine, 60(5), 977–988. https://doi.org/10.1016/j.socscimed.2004.06.032

    Article  PubMed  Google Scholar 

  19. Jiang, L., Beals, J., Whitesell, N. R., Roubideaux, Y., Manson, S. M., Team, A.-S., et al. (2008). Stress burden and diabetes in two American Indian reservation communities. Diabetes Care, 31(3), 427–429. https://doi.org/10.2337/dc07-2044

    Article  PubMed  Google Scholar 

  20. Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9. Journal of General Internal Medicine, 16(9), 606–613.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  21. Lewis, T. T., Cogburn, C. D., & Williams, D. R. (2015). Self-reported experiences of discrimination and health: Scientific advances, ongoing controversies, and emerging issues. Annual Review of Clinical Psychology, 11, 407–440. https://doi.org/10.1146/annurev-clinpsy-032814-112728

    Article  PubMed  PubMed Central  Google Scholar 

  22. McQuaid, R. J., Bombay, A., McInnis, O. A., Matheson, K., & Anisman, H. (2015). Childhood adversity, perceived discrimination, and coping strategies in relation to depressive symptoms among First Nations adults in Canada: The moderating role of unsupportive social interactions from ingroup and outgroup members. Cultural Diversity and Ethnic Minority Psychology, 21(3), 326–336. https://doi.org/10.1037/a0037541

    Article  PubMed  Google Scholar 

  23. Muthén, L. K., & Muthén, B. O. (2007). Mplus User’s guide (5th ed.). Los Angeles: Muthen & Muthen.

    Google Scholar 

  24. National Center for Health Statistics. (2016). Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities. Hyattsville, MD: U.S. Department of Health and Human Services. Retrieved from http://www.cdc.gov/nchs/data/hus/hus15.pdf#specialfeature

  25. Paradies, Y. (2006). A systematic review of empirical research on self-reported racism and health. International Journal of Epidemiology, 35(4), 888–901. https://doi.org/10.1093/ije/dyl056

    Article  PubMed  Google Scholar 

  26. Pascoe, E. A., & Smart Richman, L. (2009). Perceived discrimination and health: A meta-analytic review. Psychological Bulletin, 135(4), 531–554. https://doi.org/10.1037/a0016059

    Article  PubMed  PubMed Central  Google Scholar 

  27. Pearlin, L. I., Menaghan, E. G., Lieberman, M. A., & Mullan, J. T. (1981). The stress process. Journal of Health and Social Behavior, 337–356.

  28. Pearlin, L. I., Schieman, S., Fazio, E. M., & Meersman, S. C. (2005). Stress, health, and the life course: Some conceptual perspectives. Journal of Health and Social Behavior, 46(2), 205–219. https://doi.org/10.1177/002214650504600206

    Article  PubMed  Google Scholar 

  29. Schmitt, A., Reimer, A., Kulzer, B., Haak, T., Gahr, A., & Hermanns, N. (2015). Negative association between depression and diabetes control only when accompanied by diabetes-specific distress. Journal of Behavioral Medicine, 38(3), 556–564. https://doi.org/10.1007/s10865-014-9604-3

    Article  PubMed  Google Scholar 

  30. Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A., Nadal, K. L., et al. (2007). Racial microaggressions in everyday life: implications for clinical practice. American Psychologist, 62(4), 271. https://doi.org/10.1037/0003-066X.62.4.271

    Article  PubMed  Google Scholar 

  31. Toobert, D. J., Hampson, S. E., & Glasgow, R. E. (2000). The summary of diabetes self-care activities measure: Results from 7 studies and a revised scale. Diabetes Care, 23(7), 943–950.

    CAS  Article  PubMed  Google Scholar 

  32. Turner, R. J., Wheaton, B., & Lloyd, D. A. (1995). The epidemiology of social stress. American Sociological Review, 104–125.

  33. Wagner, J. A., Tennen, H., Finan, P. H., Ghuman, N., & Burg, M. M. (2013). Self-reported racial discrimination and endothelial reactivity to acute stress in women. Stress and Health, 29(3), 214–221. https://doi.org/10.1002/smi.2449

    Article  PubMed  Google Scholar 

  34. Walls, M. L., Chapple, C. L., & Johnson, K. D. (2007). Strain, emotion, and suicide among American Indian youth. Deviant Behavior, 28(3), 219–246. https://doi.org/10.1080/01639620701233100

    Article  Google Scholar 

  35. Walls, M. L., Gonzalez, J., Gladney, T., & Onello, E. (2015). Unconscious biases: Racial microaggressions in American Indian health care. The Journal of the American Board of Family Medicine, 28(2), 231–239. https://doi.org/10.3122/jabfm.2015.02.140194

    Article  PubMed  Google Scholar 

  36. Walters, K. L., & Simoni, J. M. (2002). Reconceptualizing Native women’s health: An “indigenist” stress-coping model. American Journal of Public Health, 92(4), 520–524. https://doi.org/10.2105/AJPH.92.4.520

    Article  PubMed  PubMed Central  Google Scholar 

  37. Williams, D. R., Haile, R., Mohammed, S. A., Herman, A., Sonnega, J., Jackson, J. S., et al. (2012). Perceived discrimination and psychological well-being in the USA and South Africa. Ethnicity and Health, 17(1–2), 111–133.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Williams, D. R., & Mohammed, S. A. (2009). Discrimination and racial disparities in health: Evidence and needed research. Journal of Behavioral Medicine, 32(1), 20–47. https://doi.org/10.1007/s10865-008-9185-0

    Article  PubMed  Google Scholar 

  39. Zagarins, S. E., Allen, N. A., Garb, J. L., & Welch, G. (2012). Improvement in glycemic control following a diabetes education intervention is associated with change in diabetes distress but not change in depressive symptoms. Journal of Behavioral Medicine, 35(3), 299–304. https://doi.org/10.1007/s10865-011-9359-z

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

Research reported in this manuscript was supported by the National Institute on Diabetes, Digestive and Kidney Diseases #DK091250 (M. Walls, PI). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors thank the project’s community members: Sidnee Kellar, Rose Barber, Robert Miller, Tweed Shuman, Lorraine Smith, Sandy Zeznanski, Patty Subera, Tracy Martin, Geraldine Whiteman, Lisa Perry, Trisha Prentice, Alexis Mason, Charity Prentice-Pemberton, Kathy Dudley, Mona Nelson, Eileen Miller, Geraldine Brun, Murphy Thomas, Hope Williams, Betty Jo Graveen, Daniel Chapman, Jr., Mary Sikora-Petersen, Tina Handeland, Phillip Chapman, Sr., GayeAnn Allen, Frances Whitfield, Doris Isham, Stan Day, Jane Villebrun, Beverly Steel, Muriel Deegan, Peggy Connor, Michael Connor, Ray E. Villebrun, Sr., Pam Hughes, Cindy McDougall, Melanie McMichael, Robert Thompson, Sandra Kier.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Kelley J. Sittner.

Ethics declarations

Conflict of interest

Kelley J. Sittner, Brenna L. Greenfield, and Melissa L. Walls declare that they have no conflicts of interest

Human and animal rights and Informed consent

All procedures performed in studies 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. Informed consent was obtained from all patients for being included in the study.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Sittner, K.J., Greenfield, B.L. & Walls, M.L. Microaggressions, diabetes distress, and self-care behaviors in a sample of American Indian adults with type 2 diabetes. J Behav Med 41, 122–129 (2018). https://doi.org/10.1007/s10865-017-9898-z

Download citation

Keywords

  • Diabetes
  • Microaggressions
  • Diabetes distress
  • Stress
  • American Indian