Document Type : Original Article


Department of Community Medicine, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India


BACKGROUND: “Stress” acts as both etiological link and also as an outcome in the case of diabetes
mellitus. There is a paucity of literature regarding stress levels and also factors associated with it
among diabetic patients in India.
OBJECTIVE: To assess the perceived stress levels and their associated factors among diabetic
inpatients in a rural tertiary health care center, South India.
MATERIALS AND METHODS: Afacility‑based cross‑sectional analytical study was conducted among
inpatient diabetics seeking care at a rural tertiary care center in Kolar district of Karnataka. Apre‑tested
semi‑structured questionnaire was used to capture the sociodemographic, disease‑related,
treatment‑related and behavior‑related characteristics of the inpatients. The outcome of “perceived
stress” was captured using a standard questionnaire of Cohen Perceived Stress Scale–10. Poisson
regression was used for multivariable analysis, and the association was expressed as prevalence
ratio with 95% confidence intervals (CI).
RESULTS: Out of the 247 study participants analysed, “perceived stress” was seen among 97 (39.3%)
of the participants (95% CI: 33.3%–45.5%). Multivariable analysis showed that factors like younger
age, lesser duration of diabetes, presence of any comorbidity, being underweight, having conflicts
at work place/home in the last 1 month, and not having enough money for treatment had shown
higher levels of “perceived stress.”
CONCLUSION: About two out of five inpatient diabetics seeking care from rural tertiary health centres
had shown to have “perceived stress.” There is a need for the inclusion of stress management
techniques in the diabetes education program at all levels of health‑care systems.


1. Mendis S, Davis S, Norrving B. Organizational update: The world
health organization global status report on noncommunicable
diseases 2014; one more landmark step in the combat against
stroke and vascular disease. Stroke 2015;46:e121‑2.
2. International Diabetes Federation. International Diabetes
Federation Diabetes Atlas. 8th ed. Brussels, Belgium: International
Diabetes Federation; 2017. p. 106.
3. World Economic Forum, Harvard School of Public Health.
The Global Economic Burden of Non‑communicable Diseases.
Geneva, Switzerland: World Economic Forum; 2011. p. 45.
4. Peyrot M, Rubin RR, Lauritzen T, Snoek FJ, Matthews DR,
Skovlund SE. Psychosocial problems and barriers to improved
diabetes management: Results of the Cross‑National Diabetes
Attitudes, Wishes and Needs (DAWN) Study. Diabet Med
5. Burkhart PV, Sabaté E. Adherence to long‑term therapies:
Evidence for action. J Nurs Scholarsh 2003;35:207.
6. Pellmar TC, Brandt EN Jr., Baird MA. Health and behavior:
The interplay of biological, behavioral, and social influences:
Summary of an Institute of Medicine report. Am J Health Promot
7. Tol A, Mohebbi B, Sadeghi R. Evaluation of dietary habits and
related factors among type 2 diabetic patients: An innovative
study in Iran. J Educ Health Promot 2014;3:4.
8. Falco G, Pirro PS, Castellano E, Anfossi M, Borretta G, Gianotti L.
The Relationship between Stress and Diabetes Mellitus. J Neurol
Psychol April 2015;3:7.
9. Surwit RS, Schneider MS. Role of stress in the etiology and
treatment of diabetes mellitus. Psychosom Med 1993;55:380‑93.
10. Lloyd C, Smith J, Weinger K. Stress and diabetes: A review of the
links. Diabetes Spectr 2005;18:121‑7.
11. Viner R, McGrath M, Trudinger P. Family stress and metabolic
control in diabetes. Arch Dis Child 1996;74:418‑21.
12. Surwit RS, van Tilburg MA, Zucker N, McCaskill CC, Parekh P,
Feinglos MN, et al. Stress management improves long‑term
glycemic control in type 2 diabetes. Diabetes Care 2002;25:30‑4.
13. Rod NH, Grønbaek M, Schnohr P, Prescott E, Kristensen TS.
Perceived stress as a risk factor for changes in health behaviour
and cardiac risk profile: A longitudinal study. J Intern Med
14. Whitebird RR, Kreitzer MJ, O’Connor PJ. Mindfulness‑Based
Stress Reduction and Diabetes. Diabetes Spectr 2009;22:226‑30.
15. van Son J, Nyklíček I, Pop VJ, Pouwer F. Testing the effectiveness of a mindfulness‑based intervention to reduce emotional distress
in outpatients with diabetes (DiaMind): Design of a randomized
controlled trial. BMC Public Health 2011;11:131.
16. Niazi AK, Niazi SK. Mindfulness‑based stress reduction:
A non‑pharmacological approach for chronic illnesses. N Am J
Med Sci 2011;3:20‑3.
17. Carlson LE. Mindfulness‑based interventions for physical
conditions: A narrative review evaluating levels of evidence.
ISRN Psychiatry 2012;2012:651583.
18. van SonJ, Nyklícek I, PopVJ, BlonkMC, ErdtsieckRJ, SpoorenPF, et al.
The effects of a mindfulness‑based intervention on emotional distress,
quality of life, and HbA (1c) in outpatients with diabetes (DiaMind):
A randomized controlled trial. Diabetes Care 2013;36:823‑30.
19. Bhandary B, Rao S, Sanal TS. The effect of perceived stress and
family functioning on people with type 2 diabetes mellitus. J Clin
Diagn Res 2013;7:2929‑31.
20. Cohen S, Kamarck T, Mermelstein R. A global measure of
perceived stress. J Health Soc Behav 1983;24:385‑96.
21. Lee EH. Review of the psychometric evidence of the perceived
stress scale. Asian Nurs Res (Korean Soc Nurs Sci) 2012;6:121‑7.
22. Rosengren A, Teo K, Rangarajan S, Kabali C, Khumalo I,
Kutty VR, et al. Psychosocial factors and obesity in 17 high‑,
middle‑ and low‑income countries: The Prospective Urban Rural
Epidemiologic study. Int J Obes (Lond) 2015;39:1217‑23.
23. Bralić Lang V, Bergman Marković B, Vrdoljak D. The association
of lifestyle and stress with poor glycemic control in patients with
diabetes mellitus type 2: A Croatian nationwide primary care
cross‑sectional study. Croat Med J 2015;56:357‑65.
24. Kaur G, Tee GH, Ariaratnam S, Krishnapillai AS, China K.
Depression, anxiety and stress symptoms among diabetics in
Malaysia: A cross sectional study in an urban primary care setting.
BMC Fam Pract 2013;14:69.
25. Zhao FF, Suhonen R, Katajisto J, Leino‑Kilpi H. The association of
diabetes‑related self‑care activities with perceived stress, anxiety,
and fatigue: A cross‑sectional study. Patient Prefer Adherence
26. Sendhilkumar M, Tripathy JP, Harries AD, Dongre AR, Deepa M,
Vidyulatha A, et al. Factors associated with high stress levels in
adults with diabetes mellitus attending a tertiary diabetes care
center, Chennai, Tamil Nadu, India. Indian J Endocrinol Metab
27. Hara Y, Hisatomi M, Ito H, Nakao M, Tsuboi K, Ishihara Y. Effects
of gender, age, family support, and treatment on perceived stress
and coping of patients with type 2 diabetes mellitus. Biopsychosoc
Med 2014;8:16.
28. Harding JL, Backholer K, Williams ED, Peeters A, Cameron AJ,
Hare MJ, et al. Psychosocial stress is positively associated with
body mass index gain over 5 years: Evidence from the longitudinal
AusDiab study. Obesity (Silver Spring) 2014;22:277‑86.
29. Yamamoto K, Okazaki A, Ohmori S. The relationship between
psychosocial stress, age, BMI, CRP, lifestyle, and the metabolic
syndrome in apparently healthy subjects. J Physiol Anthropol
30. Abdel Sadek HA, Abu‑Nazel MW, Shata ZN, Abd El‑Fatah NK.
The relationship between the BMI and the emotional status of
Alexandria University students, Egypt. J Egypt Public Health
Assoc 2016;91:101‑8.
31. Vasanth R, Ganesh A, Shanker R. Impact of stress on type 2
diabetes mellitus management. Psychiatr Danub 2017;29:416‑21.
32. Mendenhall E, Shivashankar R, Tandon N, Ali MK,
Narayan KM, Prabhakaran D. Stress and diabetes in
socioeconomic context: A qualitative study of urban Indians.
Soc Sci Med 2012;75:2522‑9.
33. Rad GS, Bakht LA, Feizi A, Mohebi S. Importance of social support
in diabetes care. J Educ Health Promot 2013;2:62.
34. Thompson ML, Myers JE, Kriebel D. Prevalence odds ratio or
prevalence ratio in the analysis of cross sectional data: What is
to be done? Occup Environ Med 1998;55:272‑7.
35. Sengupta P. Health impacts of yoga and pranayama:
A state‑of‑the‑art review. Int J Prev Med 2012;3:444‑58.