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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

([email protected]).

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

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