Hostility and physiological responses to acute stress in people with type 2 diabetes

Significance of fostering the mental health of patients with diabetes through critical time intervention

BACKGROUND

Critical time intervention (CTI) is an evidence-based model of practice that is time-limited and aims to provide support for most susceptible individuals during a transition period.

AIM

To examine the significance of fostering the mental health of diabetes patients through CTI using the scoping review methodology.

METHODS

As part of the scoping review process, we followed the guidelines established by the Joanna Briggs Institute. The search databases were Google Scholar, PubMed, Scopus, PsycINFO, Reference Citation Analysis (https://www.referencecitationanalysis.com/), and Cochrane Library. From these databases, 77 articles were retrieved with the aid of carefully selected search terms. However, 19 studies were selected after two reviewers appraised the full texts to ensure that they are all eligible for inclusion, while 54 papers were excluded.

RESULTS

This study revealed that diabetic patients who had experienced homelessness were at higher risk of being diagnosed with mental illness and that social support services are impactful in the management of the comorbidity of diabetes and mental health problems. In addition, this review reveals that CTI is impactful in enhancing the mental health of homeless patients during the transitional period from the hospital through social support services.

CONCLUSION

CTI is a promising intervention for alleviating mental health symptoms in homeless patients. Empirical studies are needed across the globe, involving both hospitalized and community-based patients, to determine how clinically effectively CTI is in managing the mental health of diabetics.

Investigating the association between diabetes and mental health: A train-and-test approach

Diabetes is a chronic health condition that affects how the body turns food into energy. Research has demonstrated a relationship between diabetes and various mental health issues, which include psychiatric disorders and other problems that are specific for people living with diabetes. Although previous studies have shed light on the associations between diabetes and various types of mental health issues with a focus on depression and anxiety, much less is known about how diabetes is associated with other dimensions of mental health such as social dysfunction and anhedonia and loss of confidence in a large nationally representative survey from the United Kingdom. The aim of the current study is to replicate the factor structure of the GHQ-12 and investigate how diabetes is related to general mental health and dimensions of mental health. By adopting a train-and-test approach to data from the UKHLS including 2,255 diabetes patients and 14,585 age and sex-matched participants who indicated that they were not clinically diagnosed with diabetes, the current study found that hypotheses are well-supported by the results.

Acute Stress Disorder Among Frontline Health Professionals During the COVID-19 Outbreak: A Structural Equation Modeling Investigation

OBJECTIVE

The outbreak of COVID-19 that commenced in December 2019 in Wuhan, China, has caused extensive public health concerns and posed substantial challenges to health professionals, especially for those in the center of the epidemic. The current study aimed to assess the prevalence, related factors, and mechanism of acute stress disorder (ASD) among health professionals in Wuhan during this critical period.

METHODS

The study used a cross-sectional design. Self-administered questionnaires were distributed to the frontline health professionals in Wuhan hospitals from January 28 to February 1, 2020. Mental health-related measurements included ASD, depression, anxiety, conflict experiences, hostility, and psychosomatic symptoms. Structural equation modeling was used to analyze the factors associated with ASD among health professionals.

RESULTS

A total of 332 frontline health professionals were included in the analysis (mean [standard deviation] age = 32.21 [8.77] years; 78.0% women). ASD was a prominent mental health problem in the health professionals surveyed, with a prevalence of 38.3%. Anxiety (24.7%) and depression (20.2%) were also common. Structural equation modeling analyses revealed that emotional distress (i.e., anxiety and depressive symptoms) fully mediated the association between conflicts with ASD (the standardized indirect coefficient β = 0.47, p = .016). The most common reported symptom was chest pain (51.2%). ASD was significantly associated with psychosomatic symptoms. The majority (67.8%) reported being easily annoyed or irritated, and ASD was associated with hostility.

CONCLUSIONS

During the COVID-19 outbreak, a substantial number of health professionals in Wuhan suffered from ASD. Furthermore, ASD was found to be associated with psychosomatic symptoms as well as the hostility. The poor mental health of health professionals has detrimental impacts both on the well-being of staff in health care systems and may adversely affect the quality of patient care. We call for interventions that aim to relieve the psychological and occupational stress. Considering that most of our participants were young, female frontline health professionals, the results may not be generalized to more heterogenous samples.

Hostile personality as a risk factor for hyperglycemia and obesity in adult populations: a systematic review

Purpose

Several studies have already provided valuable insights into the physiological and genetic causes of hyperglycemia and obesity. Concurrently, personality traits, such as hostility, have been suggested to have an impact on health and illness (i.e., self-reported general health, coronary artery disease, and overall mortality). The present systematic review investigated possible effects of hostility upon metabolic markers, such as high plasma glucose level and obesity among adults. We also attempted to reveal current gaps in knowledge and provide insights for future directions.

Methods

This systematic review was performed following the PRISMA 2009 guidelines to examine current evidence arising from observational studies regarding the potential impact of hostile behavior on hyperglycemia and obesity among adults. Of the initial 139 articles, 13 studies were included.

Results

The evidence supports an association between pre-diabetes and obesity with a hostile temperament in certain populations. The relationship between hostility and hyperglycemia was most common in African American women, in women with a family history of diabetes, in unmarried individuals, in White men, as well as in middle-aged and older people. Regarding obesity, high body mass index (BMI) was associated with a hostile personality, particularly among men. However, the paths by which hostile temperament affects glucose levels and BMI, as well as potential mediating and moderating mechanisms, are not entirely understood.

Conclusions

There is a need for research to enhance the understanding of biological, psychological and social factors related to hostility with a view to prevention and effective intervention.

Diabetes-related distress and daily cortisol output in people with Type 2 diabetes

AIMS

Diabetes-related distress is common in Type 2 Diabetes and is linked with poor diabetes control. However, mechanisms underlying this association are unclear. One pathway that could be involved is neuroendocrine dysfunction, as Type 2 Diabetes is associated with altered diurnal cortisol output. This study investigated the link between diabetes-related distress and diurnal cortisol output.

METHODS

134 people with Type 2 Diabetes provided 5 cortisol samples over the course of a day. Multivariate linear regression models were used to assess whether overall and sub-domains of diabetes-related distress measured by the Diabetes Distress Scale, predicted cortisol parameters (waking cortisol, cortisol awakening response, cortisol slope and evening cortisol).

RESULTS

Physician-related distress was associated with greater waking (B = 2.747, p = .015) and evening cortisol (B = 1.375, p = .014), and a blunted cortisol awakening response (B = -3.472, p = .038) adjusting for age, sex, income, body mass index, smoking and time of awakening. No associations were detected for overall distress, emotional, interpersonal or regimen distress.

CONCLUSION

Physician-related distress was associated with alterations in daily cortisol output. Longitudinal research is required to understand how physician-related distress is associated with diurnal cortisol patterning over time.

Stress Reactivity as a Contributor to Racial and Socioeconomic Disparities: Rationale and Baseline Results From the Richmond Stress and Sugar Study

OBJECTIVE

There are pronounced racial and socioeconomic disparities in type 2 diabetes. Although "stress" as a general phenomenon is hypothesized to contribute to these disparities, few studies have objective measures of stress reactivity in diverse samples to test hypotheses about purported mechanisms. This study describes the rationale and baseline characteristics of a cohort designed to address the question: how does stress contribute to disparities in diabetes risk?

METHODS

The Richmond Stress and Sugar Study recruited 125 adults at elevated risk of type 2 diabetes using a two-by-two sampling frame wherein non-Hispanic whites and African Americans (AAs) were each recruited from neighborhoods of higher and lower socioeconomic status (SES). Stress reactivity was assessed using the Trier Social Stress Test (TSST) and salivary cortisol. Analyses of variance and multilevel modeling were used to examine how stress reactivity varied both within and across race and neighborhood SES.

RESULTS

The mean (SD) age was 57.4 (7.3) years, 49% were female, 54% were AA or another racial/ethnic minority, and mean hemoglobin A1c level was in the prediabetes range (5.8%; range, 5.50%-5.93%). Living in a lower-SES neighborhood was associated with 16% (95% confidence interval [CI] = -0.04 to 34) higher pre-TSST cortisol, 8.4% (95% CI = -14 to -3) shallower increase in response to the TSST, and 1% (95% CI = 0.3 to 1.7) steeper decline post-TSST than living in the higher neighborhood SES. Post-TSST cortisol decline was 3% greater among AA compared with non-Hispanic whites. Race-by-SES interaction terms were generally small and nonsignificant.

CONCLUSIONS

SES is associated with stress reactivity among adults at high risk of diabetes.

Personality traits and the risk of coronary heart disease or stroke in women with diabetes - an epidemiological study based on the Women's Health Initiative

OBJECTIVE

We studied the associations between personality traits and the risk of coronary heart disease (CHD) or stroke in women with diabetes.

METHODS

From the Women's Health Initiative, 15,029 women aged 50 to 79 years at enrollment and with self-reported treated diabetes at baseline or follow-up, were followed for a mean of 10 years. Personality traits measured from validated scales included hostility, optimism, ambivalence over emotional expressiveness, and negative emotional expressiveness. Multivariable Cox proportional-hazards regression models were used to examine associations between personality traits and the risk of adjudicated CHD (nonfatal myocardial infarction and CHD death) or stroke outcomes. Progressively adjusted regression approach was used in the multivariable models to adjust for demographics, depression, anthropometric variables, and lifestyle factors.

RESULTS

A total of 1,118 incident CHD and 710 incident stroke cases were observed. Women in the highest quartile of hostility had 22% (hazard ratio [HR] 1.22, 95% confidence interval [CI] 1.01-1.48) increased risk for CHD compared with women in the lowest quartile of hostility. P values for trend were greater than 0.05. Stratified analysis by prevalent or incident diabetes showed that the highest quartile of hostility had 34% increased risk for CHD (HR 1.34, 95% CI 1.03-1.74) among women with incident diabetes. Other personality traits were not significantly associated with stroke or CHD.

CONCLUSIONS

Hostility was associated with incidence of CHD among postmenopausal women with diabetes, especially among incident diabetes. These results provide a basis for targeted prevention programs for women with a high level of hostility and diabetes.

Loneliness and biological responses to acute stress in people with Type 2 diabetes

Loneliness is linked with all-cause mortality and coronary heart disease. Altered neuroendocrine and inflammatory responses to stress constitute potential pathways linking loneliness and ill-health. Stress responsivity is modified in people with Type 2 diabetes, but it is unclear whether loneliness influences biological stress responses in this population. We assessed interleukin-6 (IL-6), interleukin-1 receptor antagonist (IL-1RA), monocyte chemoattractant protein-1 (MCP-1), and cortisol responses to acute stress in 135 people with Type 2 diabetes. Loneliness was measured used the Revised UCLA Loneliness Scale. Loneliness was inversely associated with cortisol output poststress (B = -4.429, p = 0.019) independent of age, sex, education, marital status, body mass index, and smoking. Lonelier individuals had raised MCP-1 concentrations 75 min poststress independent of covariates (B = 0.713, p = 0.022). No associations between loneliness and IL-6 or IL-1RA concentrations were detected. These results suggest that loneliness is associated with disturbances in stress responsivity in people with diabetes, and the impact of loneliness on health in people with diabetes may be mediated in part through dysregulation of inflammatory and neuroendocrine systems. Future research is required to understand if such changes increase the risk of poorer outcomes in this population.

Sex differences in interleukin-6 stress responses in people with Type 2 diabetes

People with Type 2 diabetes (T2D) show dysregulated inflammatory responses to acute stress, but the effect of sex on inflammatory responses in T2D remains unclear. The purpose of this study was to investigate differences in interleukin (IL)-6 stress responses between older men and women with T2D. One hundred and twenty-one people (76 men; mean age = 64.09, SD = 7.35, 45 women; mean age = 63.20, SD = 6.70) with doctor-verified T2D took part in this laboratory-based stress testing study. Participants carried out acute mental stress tasks, and blood was sampled at baseline, immediately poststress, 45 min poststress, and 75 min poststress to detect plasma IL-6 concentrations. IL-6 change scores were computed as the difference between the baseline measurement and the three time points poststress. Main effects and interactions were tested using mixed model analysis of covariance. We found a significant main effect of time on IL-6 levels, and a significant Sex × Time interaction. In adjusted analyses including the three change scores and all the covariates, the significant Sex × Time interaction was maintained; IL-6 responses were greater in women at 45 and 75 min poststress compared with men, adjusting for age, body mass index, smoking, household income, glycated hemoglobin, oral antidiabetic medication, insulin/other injectable antidiabetic medication, depressive symptoms, and time of day of testing. Different inflammatory stress response pathways are present in men and women with T2D, with women producing larger IL-6 increases. The long-term implications of these differences need to be elucidated in future studies.

Controlling for caffeine in cardiovascular research: A critical review

Caffeine, the most widely consumed drug in the world, exerts numerous effects on cardiovascular activity. Thus, it is important and advisable to control for caffeine consumption in studies examining caffeine and/or cardiovascular activity and reactivity. This paper 1) reviews the literature concerning caffeine's effects on cardiovascular parameters; 2) summarizes the widely varying protocols used to control for the drug in extant cardiovascular literature, and 3) provide guidelines for caffeine control procedures to minimize potentially confounding acute and withdrawal effects of the drug. An abstention period equal to the average half-life of the drug is recommended for creation of methodological controls for caffeine. Additional methodological recommendations are described concerning factors that moderate the half-life of caffeine. When feasible, researchers should consider and aim to control for caffeine's acute and extended psychophysiological effects. This understudied issue has fundamental implications for caffeine-related investigations and research in psychophysiology and behavioral medicine.

Negative and positive affect as predictors of inflammation: Timing matters

Very little research has assessed how measures of negative and positive affect (NA and PA) derived from assessments at multiple time points per day (e.g., via ecological momentary assessment [EMA]), as opposed to questionnaires that rely on recall over a longer period, are related to levels of peripheral inflammation. We examined how different indicators of NA and PA predicted concentrations of C-reactive protein (CRP) and seven peripheral inflammatory cytokines (IL-1β, IL-6, TNF-α, IL-8, IL-4, IL-10, and IFN-γ) that were examined in the form of an inflammatory composite. A community-based sample of 220 adults (62% Black/African-American and 25% Hispanic/Latino; aged 25-65; 65% female) completed questionnaires at baseline (including recalled affect "over the past month") and then provided EMA reports 5x/day for 14 days. Blood was drawn from each participant after completion of EMA and used to determine plasma levels of CRP and cytokines. Analyses examined if indicators of affect predicted inflammation, controlling for age, gender, body mass index, education, health conditions, and statin use. Neither recalled NA or PA nor momentary NA or PA (aggregated across the 14 days of EMA) were significantly associated with the cytokine composite or CRP. Negative mood more proximal to the blood draw (i.e., aggregated momentary NA in week 2 of EMA) was associated with the cytokine composite but not CRP. Exploratory moderation analyses revealed that the cytokine composite was also associated with PA in week 2 for men only, and with recalled NA for those with lower education. Exploratory analyses around temporal dynamics suggested that the timing of NA measurement relative to the blood draw mattered: Specifically, there were stronger trends of association between momentary NA and inflammatory cytokines when NA was assessed closer in time to blood collection. Future investigation of the relevance of temporal proximity and other measurement details may improve understanding of how affect relates to inflammation.

The effect of beta-adrenergic blockade on inflammatory and cardiovascular responses to acute mental stress

Acute mental stress elicits increases in plasma cytokine concentrations in humans, but the underlying mechanisms remain poorly understood. We assessed the impact of beta-adrenergic blockade on plasma interleukin 6 (IL-6) and IL-1 receptor antagonist (IL-1Ra) responses in a parallel group, double-blind randomised placebo-controlled trial involving 64 healthy young adult volunteers. Participants were administered 80 mg slow-release propranolol or placebo daily for 7 days before the stress testing session in which responses to 3 behavioural challenges (public speaking, mirror tracing, mental arithmetic) were evaluated. Propranolol administration was associated with reduced baseline levels of heart rate and IL-1Ra, and systolic blood pressure (BP) in men. Tasks stimulated increased plasma IL-6 concentrations sampled 45 min and 75 min after challenge, but these responses were blocked by propranolol in men (p < 0.001). Propranolol did not influence IL-6 responses in women, or IL-1Ra in either sex. Blood pressure and heart rate increased markedly during the tasks, but there was no differential stress reactivity in propranolol and placebo conditions. The results of the study support a role of sympathetic nervous system activation in stimulating acute IL-6 responses to stress, but only in men. The reasons for the differences between men and women remain to be resolved.

The Role of Agonistic Striving in the Association Between Cortisol and High Blood Pressure

OBJECTIVE

A social action theory of chronic stress proposes that agonistic striving (seeking to influence or control others) impairs cardiovascular health by magnifying the impact of high adversity-induced cortisol levels on blood pressure. We tested three predictions of social action theory: (1) the social action theory taxonomy of regulatory strivings characterizes young adults from high-adversity neighborhoods; (2) high cortisol levels predict high blood pressure more reliably in the subgroup with the agonistic striving profile than in subgroups with other profiles; (3) the association of higher cortisol and higher blood pressure with agonistic striving is not explained by negative affect (depressive symptoms/dysphoria, anger, hostility).

METHODS

Participants were young adults (N = 198, mean [SD] age = 32 [3.4] years); 71% female; 65% black) from disadvantaged urban neighborhoods. Motive profiles (including agonistic strivings) were assessed using the Social Competence Interview. Cortisol levels were derived from saliva samples; blood pressure level was obtained during two days of ambulatory monitoring. Psychological measures of negative affect were assessed using questionnaires.

RESULTS

The predicted taxonomy of regulatory strivings was replicated in this sample; the interaction between cortisol and motive profile was significant (F(2, 91) = 6.72, p = .002); analyses of simple effects disclosed that higher cortisol levels predicted higher ambulatory blood pressure only in individuals who exhibited agonistic striving. Depressive symptoms/dysphoria, trait anger, and hostility were not correlated with agonistic striving, cortisol, or blood pressure.

CONCLUSIONS

Agonistic striving may represent a distinctive (and novel) social-cognitive mechanism of toxic stress and cardiovascular risk.

Trait hostility and cortisol sensitivity following a stressor: The moderating role of stress-induced heart rate variability

Hostility and adverse health outcomes are inconsistently associated in the literature. Self-regulation and cortisol secretion may play important roles in differentiating those hostile individuals who are at greater risk of negative health outcomes from those who are not. In the present study, we sought to examine if having high self-regulatory strength, as indexed by high stress-induced high-frequency heart rate variability (HF-HRV), buffered the effects of hostility on cortisol secretion. Participants (N=213) completed a self-report measure of hostility and measurement of HF-HRV at rest and during a social stress task. Saliva samples were collected immediately before (one sample), and over a 50min period after (six samples), the stress task to evaluate cortisol secretion over time. Hostile individuals were less likely to demonstrate cortisol sensitivity (i.e., high change in cortisol over time) when they had high stress-induced HF-HRV. Such findings are important given that cortisol sensitivity increases risk of metabolic and inflammatory disorders via glucocorticoid resistance and inflammation. Therefore, interventions that increase stress-induced HF-HRV may reduce the impact of hostility on health outcomes.

Psychosocial Factors in Diabetes and Cardiovascular Risk

Type 2 diabetes is a chronic disease that is increasing in prevalence globally. Cardiovascular disease is a major cause of mortality and morbidity in diabetes, and lifestyle and clinical risk factors do not fully account for the link between the conditions. This article provides an overview of the evidence concerning the role of psychosocial stress factors in diabetes risk, as well as in cardiovascular complications in people with existing diabetes. Several types of psychosocial factors are discussed including depression, other types of emotional distress, exposure to stressful conditions, and personality traits. The potential behavioral and biological pathways linking psychosocial factors to diabetes are presented and implications for patient care are highlighted.

Trait Hostility and Acute Inflammatory Responses to Stress in the Laboratory

Hostility has been associated with higher basal levels of inflammation. The present study evaluated the association of hostility with acute stress-induced changes in inflammatory activity. One hundred and ninety-nine healthy men and women, aged 19–64 years, were exposed to a stress protocol involving four interpersonal stressors. Participants completed the Cook-Medley Hostility questionnaire and provided two blood samples for the measurement of inflammatory biomarkers (CRP, Il-6, MPO, TNF-α, MCP-1, Il-8, Il-10, and Il-18), prior to and following exposure to a standardized stress protocol. In univariate analyses, hostility was associated with significantly higher TNF-α, but lower Il-8 and Il-18 values post-stress, though only Il-8 remained significant after controlling for baseline differences. In multivariate analyses, a significant Age by Hostility interaction emerged for Il-6, while sex moderated the relation between hostility and Il-10 reactivity. Following stress, hostility was associated with greater pro-inflammatory Il-6 activity among younger individuals and to decreased anti-inflammatory Il-10 activity in women. Future research is needed to replicate these findings and to evaluate their implication for disease.