Introduction
Diabetes is a major health problem worldwide due to its rapidly growing prevalence and high disease burden. It is a major cause of blindness, renal failure, cardiovascular disease and lower limb amputation.1 The prevalence of diabetes is predicted to grow to 642 million by 2040, and it is anticipated to be the seventh leading cause of death by 2030.2 Diabetes costs exceeded US$727 billion in 2017, and contributes to approximately 12% of the total medical expenses for adults worldwide.3 Research has shown that living with diabetes is challenging. In the face of the complex and demanding daily self-management, adults with diabetes may become frustrated, angry, overwhelmed, and/or discouraged .4 5 Psychological comorbidity is high in people with diabetes, with extensive research demonstrating that approximately 30% of adults experience depressive symptoms.6 Diabetes distress is another psychological disorder among adults with diabetes, with a slightly higher prevalence compared with depressive symptoms in one study (36% vs 30%).7
Diabetes distress refers to negative emotions in response to living with diabetes (eg, feeling frustrated, hopeless, angry, guilty, fearful), which has been reported to occur in 18%–45% of adults with diabetes.8–10 Diabetes distress is exacerbated by lack of understanding of diabetes self-management, unhelpful interactions with family, friends and health professionals, and feeling overwhelmed by the demands of managing the condition .5 11 Diabetes distress has been associated with less self-management, poor glycemic control12 and low health-related quality of life.13–15 Diabetes distress is not associated with clinical depression or anxiety,16 17 and is less recognized and treated in clinical care compared with anxiety and depression.18
There are several interventions aimed to reduce psychological comorbidity, such as diabetes distress in adults with diabetes, including cognitive–behavioral therapy, problem-solving therapy, network-based cognitive–behavioral therapy, and mindfulness therapy.19 Overall, compared with conventional diabetes education, these interventions can effectively relieve diabetes distress and show moderate beneficial effects on depression, anxiety, and general psychological distress.20 Mindfulness-based interventions (MBI) have been increasingly used to alleviate negative emotions such as stress, anxiety, depression, and diabetes distress among adults with diabetes.21 22 MBIs can not only help adults with diabetes learn to cope with distress without escaping the stressful emotion, thus preventing or delaying physiological complications.23–25 MBIs can also contribute to better self-care and self-management behaviors.21
MBIs are derived and adapted from Buddhist practices to help individuals relax their minds and achieve a state of calmness, peace, and happiness. Breathing techniques and meditation exercises are used, aiming to channel non-judgmental attention into the present moment.26 Research on the effect of MBIs on health has exponentially increased in the past decade.27 There are several different principles of mindfulness therapies, which include mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), acceptance and commitment therapy, dialectical behavior therapy (DBT), and mindfulness-based self-compassion. The different approaches of these mindfulness therapies are displayed in online supplementary Appendix 1. MBIs that have been evaluated in adults with diabetes have focused on MBSR and MBCT.
Recently, a systematic review and meta-analysis was conducted on the effect of MBIs on quality of life, diabetes distress, and glycemic control in adults with diabetes.21 MBIs demonstrated a small-to-moderate effect size for pretreatment to post-treatment changes in diabetes distress and metabolic control among treatment group participants. However, in the eight studies included in this systematic review, there were clinical and methodological heterogeneity in baseline diabetes distress levels of adults, the principles of MBIs, the intervention delivery (group vs individual), the use of home practice, and length of follow-up. The purpose of this systematic review was to explore the influence of these factors on the effect of MBIs on diabetes distress using subgroup analysis. The evidence synthesized can then be used to help guide future research and clinical practice in the use of MBIs for adults with diabetes.