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Abstract

Positive humor and laughter have long been associated with health and well-being. Although evidence exists that positive humor can be strengthened, there is no evidence that these findings can be generalized to people living with diabetes. This study used a pre-posttest design to examine the effects of a humor training program on four styles of humor. The sample consisted of 30 participants with type 1 diabetes, 76.6% female (n = 23), 90% Caucasian (n = 27), and 76.6% college educated (n = 23). Participants completed the Humor Styles Questionnaire prior to and after completing The 7 Humor Habits Program. Participants demonstrated an increase in both types of positive humor, affiliative humor (P < .05) (P-value = .036), and self-enhancing humor (P < .01) (P-value = .006). There was no significant difference on either type of negative humor, aggressive humor (P > .05) (P-value = .8), or self-defeating humor (P > .05) (P-value = .975). Results suggest that people with type 1 diabetes can strengthen their positive sense of humor (affiliative, self-enhancing) while not impacting negative sense of humor (aggressive, self-defeating). Results are discussed relative to strengthening positive styles of humor without increasing styles of humor not associated with effective diabetes management.

Keywords

diabetes humor type 1 humor training

“D.G. wrote the manuscript and researched data. N.K. conducted all statistical analyses and reviewed the results and discussion sections.”

Introduction

Diabetes can take a tremendous toll on both physical and psychological health. People with diabetes are 2-3 times more likely than the general population to die of heart disease or suffer a stroke^1,2 and diabetes is the leading cause of kidney disease.³ People with diabetes are 40% more likely to develop glaucoma, 60% more likely to develop cataracts, and are at significant risk of retinopathy.^1,2 Over half have peripheral neuropathy, are at greater risk of peripheral arterial disease, and experience higher rates of lower limb amputation.^1,2 Psychologically, people with diabetes experience rates of depression 1 ½ to 3 times higher than the general population,^4,5 twice the rate of anxiety,^6,7 2 to 2 ½ times the rate of eating disorders,^8,9 and a greater risk of dementia and cognitive decline.^10,11

On the other hand, research suggests that laughter and a positive sense of humor may have positive effects particularly for people with diabetes. Humor has been found to boost the immune system,^12,13 reduce the risk of heart disease,¹⁴ lower blood pressure,^15,16 decrease stress,^12,13 combat depression,^17-21 reduce pain,^12,22,23 and aid with sleep.^16,24 Research specifically with diabetes populations has suggested that laughter and humor may decrease levels of prorenin²⁵, improve immune responses,²⁶ reduce inflammatory response²⁷ lower blood glucose levels,^28,29 and improve the ability to learn and sustain memory.³⁰ (Table 1)

Table 1.

Humor Research.

Humor Type	Population	Design	Results	Reference
Positive	General	Randomized Pre-post	Increased NK cell Activity Reduced stress and stress related arousal Reduced pain	12
Positive and Negative	General	Pre-post	Moderating effect on the immunosuppressive effects of stress	13
Positive	General	Correlational	Inverse relationship between sense of humor And coronary heart disease	14
Positive	Chronic renal Failure patients	Experimental	Reduced blood pressure	15
Positive	Geriatrics	Pre-post	Reduced blood pressure Improved mood and happiness Improved sleep	16
Positive	Depressed adults	Pre-post	Reduced depressive symptomology	17
Positive	General	Pre-post control group	Reduced depression, anxiety and Increased sense of well-being	18
Positive	General	Randomized, placebo-Controlled	Short-term reduction in depression	19
Positive	General	Experimental	Lowered levels of depression and anxiety	20
Positive	General	Pre-post, nonequivalent Control group	Significant effect on serotonin activation lessoning depression	21
Positive	General	Pre-post	Induced endogenous opioid release and Increased pain threshold	22
Positive	Geriatric	Experimental	Decrease in pain and perceived loneliness	23
Positive	General	Correlational	Decreased sleep disturbance	24
Positive	type 2	Experimental	Modulates prorenin and improves cognitive activity	25
Positive	type 2	Pre-post	Increased NK cell activity	26
Positive	high-risk diabetes	Experimental	Lowered Inflammatory Cytokines, increased HDL Cholesterol	27
Positive	type 2	Experimental	Inhibitory effect on increase in post-prandial blood glucose	28
Positive	type 2	Pre-post	Suppressed post-prandial blood glucose level increase	29
Positive	type 2	Randomized Controlled trial	Improved learning, delayed recall, and visual recognition. Decreases in salivary cortisol	30

Despite the potential benefits of humor on physical and psychological health, there remains a limited understanding of the overall association between diabetes and humor. Greene et al³¹ reported that people with type 1 diabetes did not differ in overall levels of positive humor from a non-diabetes norm group. Given the stress of living with a life altering chronic illness, this was noted as a surprising and optimistic finding. Greene and King³² found that that those with good control of their diabetes (A1C ≤6.99%) had higher levels of positive humor (affiliative humor and self-enhancing humor) as compared with those with A1C ≥7.0%. Left unexplored was if people with diabetes could build on and strengthen their positive sense of humor, and what effect that might have on A1C.

There is general evidence that humor can be developed and strengthened.^17-19,33-39 McGhee³⁵ is noted as the first researcher to decompose sense of humor into a set of habits that could be learned and strengthened.³⁴ This was developed into the 7 Humor Habits Program (7HHP).^35-37 The effectiveness of his training program has been demonstrated across a series of studies.^17-19,34 Falkenberg et al¹⁷ conducted a small pre/postintervention pilot study using the humor training program with depressed clients. They reported enhanced humor abilities and motivation and reduced depressive symptoms. Crawford and Caltabiano¹⁸ conducted a pre/postintervention control group study implementing the humor training program. In addition to noting improvements in sense of humor, the authors reported decreases in depression, anxiety, and stress and an overall increase in emotional well-being. In a randomized, placebo-controlled trial, Wellenzohn et al¹⁹ studied the effects of five humor-based activities. All of the interventions resulted in significant improvements in happiness and short-term reductions in depression. Most recently Ruch et al³⁴ found that groups using the 7HHP increased their humor levels, malleability of humor, and life satisfaction when compared to a placebo humor group and a control group.

Others have successfully developed their own individualized humor protocols (e.g., 15, 22, 23, 27, 30, 40). Several diabetes educators have reported that humor in diabetes education programs can promote connections, encourage and support diabetes management, galvanize effectiveness and increase the audience’s attention during education programs.^38,39 Still the 7HHP remains the most widely researched and effective humor training program available^17-19,34

Despite the benefits of a positive sense of humor, and that humor can be strengthened, little is known about the effectiveness of humor training on people with diabetes. This study was designed to examine the effects of humor training on four dimensions of humor; affiliative, self-enhancing, aggressive, and self-defeating, specifically with subjects diagnosed with type 1 diabetes.

Methods

Sense of Humor

Sense of humor is a global concept that not only includes laughter, but also cognitive, emotional, and social components.^41,42 In response to concerns that the concept of humor is not only multi-dimensional, but includes both positive and negative components, Martin et al⁴² developed the Humor Styles Questionnaire (HSQ). The HSQ posits four dimensions of humor; affiliative, self-enhancing, aggressive, and self-defeating. Two positive dimensions, affiliative and self-enhancing, involve humor that enhances oneself and relationships with others. Two negative dimensions, aggressive and self-defeating, involve humor that enhances self at the expense of others, and enhances others at the expense of self.

The HSQ is a 32-item survey using a 1 to 7 Likert scale. Item anchors are totally disagree(1) and totally agree.(7) Each of the four humor subscales are comprised of 8 items. Eleven items are reverse scored. After reversing the appropriate items, scoring consists of adding the 8 item scores per subscale. Scores range from 8 to 56 per subscale. Higher scores reflect increased demonstration of that type of humor.⁴²

Reliability of the four scales has been demonstrated by internal consistencies of .77 to .81 and test-retest reliabilities of .80 to .85.⁴⁹ Evidence of construct validity includes theoretically meaningful differential correlations with other measures of sense of humor and associated traits (e.g., self-esteem, psychological well-being, coping).⁴²

Sense of Humor Training

The 7 Humor Habits Program (7HHP) focuses on key humor habits and skills.^35-37 The 7 habits are ordered hierarchically, with increasing difficulty. The habits are listed as (a) surround yourself with humor, (b) cultivate a playful attitude, (c) laugh more often and heartily, (d) create your own verbal humor, (e) look for humor in everyday life, (f) take yourself lightly and laugh at yourself, and (g) find humor in the midst of stress. Each habit includes background information regarding that topic, self-assessments, humorous anecdotes, suggestions for practice, ways to use the recommended “humor log,” and “home play.” Home play are suggestions for applying and practicing the skills discussed in that habit. The 7HHP is a standardized training, which can be completed individually or guided by an instructor in a group. Due to the COVID pandemic the training was delivered individually and remotely. Participants were provided Humor as Survival Training for a Stressed-Out World: The 7 Humor Habits Program³⁷ that guided them through the training at their own pace. Introductory 10-minute videos were provided on Flipgrid, a video discussion and sharing app.⁴³ This platform allowed the PI to introduce information about each habit and maintain semi-personalized contact. Participants were encouraged to stay in contact with the PI by phone, email, and/or text. Periodic emails were sent to participants to encourage questions, concerns, and serve as a reminder to continue moving through the habits.

McGhee³⁷ recommends participants take 1-2 weeks for each habit. Participants were reminded of this throughout the study. The training completion ranged from 8–40 weeks (mean 23.1 weeks). (Table 2)

Table 2.

Study Demographics.

Variables	Participants
n (%)
Sex
Female	23 (76.6)
Male	7 (23.4)
Total	30 (100%)
Educational level
High school / GED	6 (20.0)
Associate degree	1 (3.4)
Bachelor’s degree	8 (26.6)
Master’s degree	12 (40.0)
Doctoral degree	3 (10.0)
Total	30 (100%)
Race
White/Caucasian	27 (90.0)
Other	3 (10.0)
Total	30 (100%)
Age (y)*
18-29	5 (16.7)
30-39	3 (10.0)
40-49	8 (26.7)
50-59	5 (16.7)
60-69	6 (20.0)
> 69	3 (10.0)
Total	30 (100%)
Training time (weeks)^**
<10	2 (6.7)
10-19	10 (33.4)
20-29	11 (36.7)
30-39	5 (16.7)
>39	2 (6.7)

Mean age 48.23 y.

Mean time 23.1 weeks.

Data Collection

Participants were solicited using postings on both local and national type 1 diabetes blog sites, LinkedIn, announcements distributed by regional Diabetes Educators, presentations at several type 1 diabetes support networks, and several Listservs associated with the University of Northern Colorado, Greeley, CO. The announcements included a brief description of the study, the inclusion criteria (must be at least 18 years of age and have an existing medical diagnosis of type 1 diabetes) and assurance that data was confidential and would only be used in aggregate form. Interested people were directed to contact the principal investigator. Potential participants received an email detailing the methodology and participant expectations. Those who met the inclusion criteria and confirmed they were interested in participating were enrolled in the study, mailed a copy of Humor as Survival Training for a Stressed-Out World: The 7 Humor Habits Program³⁷ and directed to the Flipgrid platform.

Participants completed a questionnaire that included a formal informed consent, the HSQ, and entry points for general demographic information. The questionnaire was created in Qualtrics,⁴⁴ an on-line software survey tool. The University of Northern Colorado Institutional Review Board approved the study.

Sample

Thirty-six people originally agreed to participate, filled out the pre-training questionnaire, and received a copy of Humor as Survival Training for a Stressed-Out World. Four formally withdrew from the study primarily due to time issues or changing life circumstances. Two withdrew for unknown reasons and failed to respond to follow up emails. A total of 30 participants were included in the final sample. Respondents were 76.6% female (n = 23) and 23.4% male (n = 7); 90% White/Caucasian (n = 27) and 10% other (n = 3); and 20% held high school diplomas (n = 6), 3.4% associate degrees (n = 1), 26.6% bachelor’s degrees (n = 8), 40% master’s degrees (n = 12) and 10% doctoral degrees (n = 3). The mean age of the sample was 48.23 years (Table 2). No incentives were offered. Participants were recruited and data collected from July 1, 2021, through May 1, 2022.

Results

Two-tailed repeated Student’s t-tests, P < .05, were conducted to compare pre-training and post-training scores on four types of humor (affiliative, self-enhancing, aggressive, and self-defeating). There was a significant difference on both affiliative humor, P < .05, df = 29, t = 2.05 (P-value = .036) and self-enhancing humor, P < .05, df = 29, t = 2.05 (P-value = .006). The post-training scores were significantly higher on both styles of positive humor. There was no difference on either aggressive humor, P > .05, df = 29, t = 2.05(P-value = .8), or self-defeating humor, P > .05, df = 29, t = 2.05 (P-value = .975). The training did not impact either type of negative humor. (Table 3)

Table 3.

Statistical Analysis.

	n	Mean	Standard Deviation	t-value	Degrees of freedom	P-value
Affiliative humor
Pre-test	30	46.43	5.22	2.05	29	.036
Post-test	30	49.00	5.16
Self-enhancing humor
Pre-test	30	41.27	8.49	2.05	29	.006
Post-test	30	45.73	5.54
Aggressive humor
Pre-test	30	25.07	8.82	2.05	29	.80
Post-test	30	24.6	8.03
Self-defeating humor
Pre-test	30	30.77	10.71	2.05	29	.975
Post-test	30	30.67	11.3
A1C
Pre-test	30	7.12	1.36	2.05	29	0.14
Post-test	30	6.75	0.79

A two-tailed repeated Student’s t test was also conducted to compare pre- and post-training A1C scores. Although the mean A1C dropped from 7.12% (SD = 1.36) to 6.75% (SD = .79), no statistical significance was found, P > .05, df = 29, t = 2.05. (Table 3)

Discussion

People with diabetes face a myriad of medical and emotional risks and complications all while dealing with a complicated and challenging chronic disease.^1-3 Interestingly, a positive sense of humor has long been associated with buffering many of the risk factors and complications associated with diabetes.^12-30 Although a growing body of evidence suggests that positive humor can be developed and strengthened,^17-19,33-39 there is no empirical evidence with any population of people with diabetes, specifically type 1. Greene et al³¹ did find people with type 1 diabetes were able to maintain a positive sense of humor compatible with a non-diabetes norm group suggesting that it is possible to live with type 1 diabetes without impairing one’s sense of humor. It was therefore hypothesized that people with type 1 diabetes, starting at a comparable level of humor with a non-diabetes norm group, would benefit from a humor training program (i.e., demonstrate an increase in levels of humor from baseline).

This hypothesis was supported for both styles of positive humor. The post-training scores were significantly higher than the pre-training scores for affiliative humor, P < .05, df = 29, t = 2.05, and self-enhancing humor, P < .05, df = 29, t = 2.05. Affiliative humor is positively correlated with self-esteem, psychological well-being, social intimacy, and emotional stability and negatively correlated with depression, and anxiety.⁴² Self-enhancing humor involves the ability to maintain a humorous outlook on life and using humor in emotion regulation and coping. Like affiliative humor, it is correlated with cheerfulness, self-esteem, optimism, psychological well-being, and life satisfaction, and negatively related to depression and anxiety.⁴² Studies using the 7HHP found confirming evidence. Falkenberg et al¹⁷ reported enhanced humor abilities, increased motivation, and reduced depressive symptoms. Crawford and Caltabiano¹⁸ reported an overall increase in emotional well-being, self-efficacy, positive thinking, optimism, and perceptions of control, while decreasing negative thinking, depression, anxiety, and stress. Wellenzohn et al¹⁹ reported significant improvements in well-being, happiness and short-term reductions in depression. Ruch et al³³ found an increase in the participants’ ability to shape and adapt their humor, increases in cheerfulness and life satisfaction. It is primarily affiliative humor and self-enhancing humor that are associated with the reported physical and emotional benefits associated with humor.

The training did not impact either type of negative humor, as pre- and post-training scores on aggressive humor P > .05, df = 29, t = 2.05, and self-defeating humor, P > .05, df = 29, t = 2.05 remained unchanged. This finding suggests that the training did not inadvertently increase aggressive or self-defeating styles of humor. Aggressive humor is most associated with the use of sarcasm, teasing, and using humor to criticize. Related to hostility and aggression, this type of humor is negatively associated with health and well-being.⁴² An increase in aggressive humor would be contraindicated for people with type 1 diabetes who already experience a significant risk of physical complications.^1-3 Self-defeating humor involves excessive self-disparaging and ingratiating humor. It is positively correlated with depression, anxiety, hostility, aggression, psychiatric symptoms, and negatively related to self-esteem, psychological well-being, intimacy, and satisfaction with social supports.⁴² An increase in self-defeating humor would be contraindicated for people with type 1 diabetes who already experience a significant risk of depression, anxiety, and other psychiatric symptoms.^12,13,17-21

As noted, the participants in this study were volunteers, self-motivated to participate in a humor training, and with good control of their diabetes (pre-study A1C 7.12%). It is unlikely that these types of participants will be in the greatest need of humor training. Studies using humor training programs, however, have been successful with people experiencing depression,^17,20,21 chronic renal failure,¹⁵ high stress,¹³ high-risk diabetes,²⁷ sleep disturbance,²⁴ and pain and loneliness associated with aging.^16,23

Pre- and post-training A1C scores were also collected. Based on recent findings that people with good control of their diabetes (A1C ≤6.99%) had higher levels of positive humor (affiliative humor and self-enhancing humor) as compared with those with A1C ≥7.0%,³² it was hypothesized that an increase in positive humor scores may result in reduced A1C scores. This was not supported. While the mean A1C score did drop (pre-training 7.12%, SD = 1.36 to post-training 6.75%, SD = .79), it did not reach statistical significance, P > .05, df = 29, t = 2.05. The discussion of this finding needs to be reviewed relative to diabetes control. A1C is the gold standard for measuring diabetes control⁴⁵ and is routinely used in diabetes research.^46-52 While the ADA⁵³ generally recommends an A1C <7% (with adaptations based on factors such as age and complications), it is recognized that many individuals are not able to achieve such tight control. The mean A1C in the DCCT⁴⁶ conventional group (M = 9.0%), DCCT intensive group (M = 7.0%), the EDIC⁴⁹ conventional group (M = 8.0%), and the EDIC intensive group (M = 8.0%), are examples. And although Ali et al⁵² reported an increase in glycemic control from 1999-2010 (66.6% achieved A1C levels equal to or below 7.0%), the mean A1C was still 7.2%. This study’s pre-training mean A1C (7.12%, SD = 1.36) suggested a well-controlled type 1 diabetes sample prior to the training leaving little room (statistically) to reduce the A1C. While not reaching statistical significance, a reduction from 7.12% to 6.75% may very well indicate practical and psychological significance.

Implications

To the best of our understanding, this is the first study to examine the effect between humor training and type 1 diabetes. As such, it provides preliminary support that humor training can strengthen levels of positive humor while not inadvertently increasing unwanted levels of negative humor in type 1 diabetes populations. Given the extensive list of physical and emotional benefits of positive humor for people with diabetes, this suggests that humor training may be a viable, potent, and holistic adjunct to traditional treatment. Humor training programs are easily accessible, low to no cost, and easy to implement. Furthermore, once trained, access to ongoing humor is free, readily available, and fun. Prior work suggests that it is possible to live with type 1 diabetes, a life altering, chronic illness while maintaining a positive sense of humor and not manifesting it in aggressive humor.³¹ This study adds that it is possible to strengthen the existing level of positive humor and enhance quality of life.

Limitations and Future Directions

As with any study involving volunteers, the ability to secure a representative sample is challenging. This study was no exception. The sample was skewed toward female, Caucasian, college educated participants under good glycemic control. Given the use of various social media blogs, university listservs, and personal announcements, a final sample of 30 represents a low response rate. Reasons for low response rates are multifaceted. It is impossible to know how many non-responses were simply because the recipient did not meet the inclusion criteria. In addition, requests to participate in research overload, personal time restraints, lack of personal incentives to complete, and study fatigue likely contributed to non-response of those who actually read the announcement and met the inclusion criteria. Finally, no financial incentive was offered, a rarity with this type of time commitment.

All participants were self-selected. It is suspected that people who were interested in and believed they had a good sense of humor may have been more willing to participate. Future research should attempt to control for these factors. A more normative sample regarding A1C scores should be included. This will involve identifying groups not normally associated with diabetes associations or having an interest in participating in research on humor. More rigorous outreach and the use of incentives are suggested. It is suspected that further research may identify at least a correlational if not a causal relationship between positive humor and reduced A1C.

Finally, there is limited research on humor differences in type 1 and type 2 populations. In a preliminary study, Greene et al³¹ found that people with diabetes did not differ in overall levels of positive humor (affiliative and self-enhancing) from a non-diabetes norm group. However, when separating type 1 and type 2, the type 2 group was significantly lower than the norm on affiliative humor. This suggests that more research is warranted before generalizing results between types.

Conclusion

There is increasing evidence of the medical and psychological benefits associated with positive humor within diabetes populations. This study used a pre-posttest design to examine the effects of a humor training program on four disparate styles of humor. Results indicated that people with type 1 diabetes were able to significantly increase both their affiliative and self-enhancing styles of humor while not inadvertently increasing either their aggressive or self-defeating styles of humor. Furthermore, humor training can be effective in group, individual, other-directed, or self-directed formats^37,54 and positive humor poses no identifiable risks.^41,55,56 Results should be interpreted understanding that this study involved volunteers and was skewed toward female, Caucasian, college educated participants under good glycemic control and more research is warranted before generalizing results between type 1 and type 2. However, given the extensive list of physical and emotional benefits of positive humor for people with diabetes, this suggests that humor training may be a viable, potent, and holistic adjunct to traditional treatment.

Footnotes

Author Contributions

D.G. wrote the manuscript and researched data. N.K. conducted all statistical analyses and reviewed the results and discussion sections.

Conflict of Interest

There are no conflicts of interest relevant to this manuscript for any author.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Guarantor Statement

Dr. Greene is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

ORCID iD

David S Greene

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Humor Training and Diabetes: An Adjunct to Treatment

Abstract

Keywords

Introduction

Methods

Sense of Humor

Sense of Humor Training

Data Collection

Sample

Results

Discussion

Implications

Limitations and Future Directions

Conclusion

Footnotes

Author Contributions

Conflict of Interest

Funding

Guarantor Statement

ORCID iD

References