Prediabetes is a major risk factor for type 2 diabetes (T2D) and cardiovascular disease. Although prediabetes is associated with chronic stress-related behavioral and physiological maladaptation, few studies have focused on chronic psychological stress.
Purpose
This study aimed to examine the feasibility and preliminary outcomes of Emotional Awareness and Expression Treatment (EAET) adopted and implemented among adults with high risk for prediabetes.
Method
This study used a prospective, within-subjects, repeated measures, uncontrolled design with a 4-week virtual intervention period and three measurement points for all participants: baseline, 3 months from baseline, and 6 months from baseline. Forty individuals were screened for prediabetes, and sixteen were eligible to participate. Divided into three groups, participants received four weekly virtual sessions of EAET. Glycated hemoglobin (A1C) and insulin secretion (C-peptide) were measured at baseline, 3- and 6-month periods in addition to self-reported eating habits, physical activity, and perceived stress.
Results
Twelve participants completed all sessions and were fully engaged in the intervention sessions. Across the study period, participants’ perceived stress and unhealthy eating habits decreased significantly. Glycated hemoglobin (A1C) showed a non-significant drop at 6 months, but the average C-peptide concentration, exercise frequency, and exercise duration increased significantly.
Conclusions
The EAET stress reduction intervention is feasible and showed promising results in reducing stress and decreasing risk factors for T2D. EAET can be further developed to reduce the incidence and prevalence of T2D, which could lead to a significant decrease in the direct and indirect health and cost burdens of T2D.
AlipourA.NoorbalaA.YazdanfarM.Agah HerisM. (2022). The effectiveness of emotional disclosure intervention on declining stress and inhibition among psychosomatic patients. Journal of Jahrom University of Medical Sciences, 9(2), 41–47. http://doi.org/10.29252/jmj.9.2.41
2.
American Diabetes Association. (2024). 2. Classification and diagnosis of diabetes: Standards of medical care in diabetes-2024. Diabetes Care, 47(Supplement_1), S20–S42. http://doi.org/10.2337/dc24-S002
3.
AndreouE.AlexopoulosE. C.LionisC.VarvogliL.GnardellisC.ChrousosG. P.DarviriC. (2011). Perceived stress scale: Reliability and validity study in Greece. International Journal of Environmental Research and Public Health, 8(8), 3287–3298. http://doi.org/10.3390/ijerph8083287
4.
AntonS. D.MillerP. M. (2005). Do negative emotions predict alcohol consumption, saturated fat intake, and physical activity in older adults?Behavior Modification, 29(4), 677–688. https://doi.org/10.1177/0145445503261164
BlockG.AzarK. M. J.RomanelliR. J.BlockT. J.PalaniappanL. P.DolginskyM.BlockC. H. (2016). Improving diet, activity and wellness in adults at risk of diabetes: Randomized controlled trial. Nutrition & Diabetes, 6(9), e231–e231. http://doi.org/ 10.1038/nutd.2016.42
7.
BowenD. J.KreuterM.SpringB.Cofta-WoerpelL.LinnanL.WeinerD.BakkenS.KaplanC. P.SquiersL.FabrizioC.FernandezM. (2009). How we design feasibility studies. American Journal of Preventive Medicine, 36(5), 452–457. https://doi.org/10.1016/j.amepre.2009.02.002
8.
BrannickB.Dagogo-JackS. (2018). Prediabetes and cardiovascular disease: Pathophysiology and interventions for prevention and risk reduction. Endocrinology and Metabolism Clinics, 47(1), 33–50. http://doi.org/ 10.1016/j.ecl.2017.10.001
9.
BurgM. M.SchwartzJ. E.KronishI. M.DiazK. M.AlcantaraC.Duer-HefeleJ.DavidsonK. W. (2017). Does stress result in you exercising less? Or does exercising result in you being less stressed? Or is it both? Testing the bi-directional stress-exercise association at the group and person (N of 1) level. Annals of Behavioral Medicine, 51(6), 799–809. https://doi.org/10.1007/s12160-017-9902-4
10.
BurgerA. J.LumleyM. A.CartyJ. N.LatschD. V.ThakurE. R.Hyde-NolanM. E.HijaziA. M.SchubinerH. (2016). The effects of a novel psychological attribution and emotional awareness and expression therapy for chronic musculoskeletal pain: A preliminary, uncontrolled trial. Journal of Psychosomatic Research, 81, 1–8. https://doi.org/10.1016/j.jpsychores.2015.12.003
ChailurkitL. O.JongjaroenprasertW.ChanprasertyothinS.OngphiphadhanakulB. (2007). Insulin and C-peptide levels, pancreatic beta cell function, and insulin resistance across glucose tolerance status in Thais. Journal of Clinical Laboratory Analysis, 21(2), 85–90. https://doi.org/10.1002/jcla.20138
14.
CohenS.KamarckT.MermelsteinR. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24(4), 385–396. https://doi.org/10.2307/2136404
15.
De MatosM. A.de Oliveira OttoneV.DuarteT. C.da Matta SampaioP. F.CostaK. B.FonsecaC. A.NevesM. P. C.SchneiderS. M.MoseleyP.CoimbraC. C.de Castro MagalhãesF.AmorimF. T. (2014). Exercise reduces cellular stress related to skeletal muscle insulin resistance. Cell Stress and Chaperones, 19(2), 263–270. http://doi.org/10.1007/s12192-013-0453-8
FordE. S.ZhaoG.LiC. (2010). Pre-diabetes and the risk for cardiovascular disease: A systematic review of the evidence. Journal of the American College of Cardiology, 55(13), 1310–1317. https://doi.org/10.1016/j.jacc.2009.10.060
GrossJ. J.JazaieriH. (2014). Emotion, emotion regulation, and psychopathology: An affective science perspective. Clinical Psychological Science, 2(4), 387–401. https://doi.org/10.1177/2167702614536164
20.
HeD.QiaoY.XiongS.LiuS.KeC.ShenY. (2020). Association between dietary quality and prediabetes based on the diet balance index. Scientific Reports, 10(1), 3190. https://doi.org/10.1038/s41598-020-60153-9
21.
HegdeS. V.AdhikariP.ShettyS.ManjrekarP.D'SouzaV. (2013). Effect of community-based yoga intervention on oxidative stress and glycemic parameters in prediabetes: A randomized controlled trial. Complementary Therapies in Medicine, 21(6), 571–576. https://doi.org/10.1016/j.ctim.2013.08.013
22.
HsuM. C.SchubinerH.LumleyM. A.StracksJ. S.ClauwD. J.WilliamsD. A. (2010). Sustained pain reduction through affective self-awareness in fibromyalgia: A randomized controlled trial. Journal of General Internal Medicine, 25, 1064–1070. https://doi.org/10.1007/s11606-010-1418-6
23.
IghodaroO. M. (2018). Molecular pathways associated with oxidative stress in diabetes mellitus. Biomedicine & Pharmacotherapy, 108, 656–662. https://doi.org/10.1016/j.biopha.2018.09.058
24.
JadhavR. A.HazariA.MonterioA.KumarS.MaiyaA. G. (2017). Effect of physical activity intervention in prediabetes: A systematic review with meta-analysis. Journal of Physical Activity and Health, 14(9), 745–755. https://doi.org/10.1123/jpah.2016-0632
25.
JonesA. G.HattersleyA. T. (2013). The clinical utility of C-peptide measurement in the care of patients with diabetes. Diabetic Medicine, 30(7), 803–817. https://doi.org/10.1123/jpah.2016-0632
26.
LazarusR. S. (2006). Emotions and interpersonal relationships: Toward a person-centered conceptualization of emotions and coping. Journal of Personality, 74(1), 9–46. https://doi.org/10.1111/j.1467-6494.2005.00368.x
27.
LeeE. H. (2012). Review of the psychometric evidence of the perceived stress scale. Asian Nursing Research, 6(4), 121–127. https://doi.org/10.1016/j.anr.2012.08.004
28.
LiL.WanZ.GengT.LuQ.ZhuK.QiuZ.LiuG. (2023). Associations of healthy dietary patterns with mortality among people with prediabetes. European Journal of Nutrition, 62(3), 1377–1387. https://doi.org/10.1007/s00394-022-03078-5
29.
LindströmJ.PeltonenM.ErikssonJ. G.Ilanne-ParikkaP.AunolaS.Keinänen-KiukaanniemiS.UusitupaM.TuomilehtoJ., & Finnish Diabetes Prevention Study (DPS). (2013). Improved lifestyle and decreased diabetes risk over 13 years: Long-term follow-up of the randomised Finnish Diabetes Prevention Study (DPS). Diabetologia, 56(2), 284–293. https://doi.org/10.1007/s00125-012-2752-5
30.
LoerzC.MaserE. (2017). The cortisol-activating enzyme 11β-hydroxysteroid dehydrogenase type 1 in skeletal muscle in the pathogenesis of the metabolic syndrome. The Journal of Steroid Biochemistry and Molecular Biology, 174, 65–71. https://doi.org/10.1016/j.jsbmb.2017.07.030
31.
LucK.Schramm-LucA.GuzikT. J.MikolajczykT. P. (2019). Oxidative stress and inflammatory markers in prediabetes and diabetes. Journal of Physiology & Pharmacology, 70(6), 809–824. http://doi.org/10.26402/jpp.2019.6.01
32.
LumleyM. A.CohenJ. L.StoutR. L.NeelyL. C.SanderL. M.BurgerA. J. (2008). An emotional exposure-based treatment of traumatic stress for people with chronic pain: Preliminary results for fibromyalgia syndrome. Psychotherapy: Theory, Research, Practice, Training, 45(2), 165. https://doi.org/10.1037/0033-3204.45.2.165
33.
LumleyM. A.SchubinerH. (2019). Emotional awareness and expression therapy for chronic pain: Rationale, principles and techniques, evidence, and critical review. Current Rheumatology Reports, 21(7), 1–8. https://doi.org/10.1007/s11926-019-0829-6
34.
LumleyM. A.SchubinerH.LockhartN. A.KidwellK. M.HarteS.ClauwD. J.WilliamsD. A. (2017). Emotional awareness and expression therapy, cognitive-behavioral therapy, and education for fibromyalgia: A cluster-randomized controlled trial. PAIN, 158(12), 2354–2363. http://doi.org/10.1097/j.pain.0000000000001036
35.
MillerG. E.ChenE.ParkerK. J. (2011). Psychological stress in childhood and susceptibility to the chronic diseases of aging: Moving toward a model of behavioral and biological mechanisms. Psychological Bulletin, 137(6), 959–997. https://doi.org/10.1037/a0024768
36.
MonazamitabarF.Ahmadi Tahoor SoltaniM.Bagherian SararoodiR.BehboodiM. (2015). The effectiveness of writing emotional disclosure on the reduction of depression, anxiety, and stress among veterans with post-traumatic stress disorder. Ebnesina, 17(3), 54–58. http://ebnesina.ajaums.ac.ir/browse.php?a_code=A-10-137-1&slc_lang=en&sid=1
37.
MorrisT.MooreM.MorrisF. (2011). Stress and chronic illness: The case of diabetes. Journal of Adult Development, 18, 70–80. https://doi.org/10.1007/s10804-010-9118-3
OhK. J.HanH. S.KimM. J.KooS. H. (2013). Transcriptional regulators of hepatic gluconeogenesis. Archives of Pharmacal Research, 36, 189–200. https://doi.org/10.1007/s12272-013-0018-5
40.
OrtizR.KluweB.OdeiJ. B.TcheuguiJ. B. E.SimsM.KalyaniR. R.JosephJ. J. (2019). The association of morning serum cortisol with glucose metabolism and diabetes: The Jackson heart study. Psychoneuroendocrinology, 103, 25–32. https://doi.org/10.1016/j.psyneuen.2018.12.237
41.
PerreaultL.PanQ.MatherK. J.WatsonK. E.HammanR. F.KahnS. E., & Diabetes Prevention Program Research Group. (2012). Effect of regression from prediabetes to normal glucose regulation on long-term reduction in diabetes risk: Results from the Diabetes Prevention Program Outcomes Study. Lancet (London, England), 379(9833), 2243–2251. https://doi.org/10.1016/S0140-6736(12)60525-X
42.
RadenbachC.ReiterA. M.EngertV.SjoerdsZ.VillringerA.HeinzeH. J.DesernoL.SchlagenhaufF. (2015). The interaction of acute and chronic stress impairs model-based behavioral control. Psychoneuroendocrinology, 53, 268–280. https://doi.org/10.1016/j.psyneuen.2014.12.017
43.
RayS. A. (2024). The perceived stress scale (PSS) score assessment method for stress reduction: An overview. Compassionate AI Research, 3(9), 55–61.
44.
RosmondR. (2003). Stress induced disturbances of the HPA axis: A pathway to Type 2 diabetes?Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, 9(2), RA35–RA39. https://www.altmetric.com/details/1672809
45.
SiyuY.HongL.QunY.HuaQ.KangW.YibiaoD.WenpingW.QianS.BoF.XiaonanR. (2020). Effects of exercise training combined with psychological intervention compared to exercise training alone in prediabetes subjects. Journal of Public Health, 42(2), 388–394. https://doi.org/10.1093/pubmed/fdaa024
46.
TryonM. S.CarterC. S.DeCantR.LaugeroK. D. (2013a). Chronic stress exposure may affect the brain's response to high calorie food cues and predispose to obesogenic eating habits. Physiology & Behavior, 120, 233–242. https://doi.org/10.1016/j.physbeh.2013.08.010
47.
TryonM. S.DeCantR.LaugeroK. D. (2013b). Having your cake and eating it too: A habit of comfort food may link chronic social stress exposure and acute stress-induced cortisol hyporesponsiveness. Physiology & Behavior, 114, 32–37. http://doi.org/10.1016/j.physbeh.2013.02.018
WallaceD. D.BarringtonC.AlbrechtS.GottfredsonN.Carter-EdwardsL.LytleL. A. (2022). The role of stress responses on engagement in dietary and physical activity behaviors among Latino adults living with prediabetes. Ethnicity & Health, 27(6), 1395–1409. https://doi.org/10.1080/13557858.2021.1880549
50.
Woods-GiscombeC. L.GaylordS. A.LiY.BrintzC. E.BangdiwalaS. I.BuseJ. B.MannJ. D.LynchC.PhillipsP.SmithS.LeniekK.YoungL.Al-BarwaniS.YooJ.FaurotK. (2019). A mixed-methods, randomized clinical trial to examine feasibility of a mindfulness-based stress management and diabetes risk reduction intervention for African Americans with prediabetes. Evidence-Based Complementary and Alternative Medicine, 2019, 1–16. https://doi.org/10.1155/2019/3962623
51.
XiaT.LopesS.ChenL.RothR.ZinzowH.JonesK.ZhangL.ShiL.JindalM. (2022). A feasibility study on low-dose mindfulnessbased stress reduction intervention among prediabetes and diabetes patients. Complementary Therapies in Medicine, 65, 1–17. 102810. https://doi.org/10.1016/j.ctim.2022.102810
52.
YarnsB. C.LumleyM. A.CassidyJ. T.SteersW. N.OsatoS.SchubinerH.SultzerD. L. (2020). Emotional awareness and expression therapy achieves greater pain reduction than cognitive behavioral therapy in older adults with chronic musculoskeletal pain: A preliminary randomized comparison trial. Pain Medicine, 21(11), 2811–2822. https://doi.org/10.1093/pm/pnaa145
53.
YauJ. W.ThorS. M.RamadasA. (2020). Nutritional strategies in prediabetes: A scoping review of recent evidence. Nutrients, 12(10), 2990. https://doi.org/10.3390/nu12102990
54.
YinP.ShaoP.LiuH.LiW.WangL.WangJ.ZhangS.LengJ.LiN.TianH.YangX.YuZ.HuG. (2017). C-peptide levels and the risk of diabetes and pre-diabetes among Chinese women with gestational diabetes. Journal of Diabetes and its Complications, 31(12), 1658–1662. https://doi.org/10.1016/j.jdiacomp.2017.08.006
55.
ZaehringerJ.Jennen-SteinmetzC.SchmahlC.EndeG.ParetC. (2020). Psychophysiological effects of downregulating negative emotions: Insights from a meta-analysis of healthy adults. Frontiers in Psychology, 11, 470. https://doi.org/10.3389/fpsyg.2020.00470
56.
ZhangX.GreggE. W.WilliamsonD. F.BarkerL. E.ThomasW.BullardK. M.ImperatoreG.WilliamsD. E.AlbrightA. L. (2010). A1c level and future risk of diabetes: A systematic review. Diabetes Care, 33(7), 1665–1673. https://doi.org/10.2337/dc09-1939
