Depression, Distress, and Diabetes
Emerging Evidence and New Directions
September 2012
Volume 3, Issue 3

When Is Diabetes Distress Clinically Meaningful?

Establishing cut points for the Diabetes Distress Scale

Diabetes Care. 2012;35(2):259-64

Introduction:  The Diabetes Distress Scale (DDS17) has 17 items.  In this study, researchers looked for the pattern of relationships between those items and diabetes variables.  The goal was to establish cut points for high diabetes distress in patients with type 2 diabetes.

Methods:  Type 2 diabetes patients were included in the study; there were 506 participants from study 1 (primary sample—used baseline data from the Distress and Depression in Diabetes Study) and 392 participants from study 2 (used baseline, pre-intervention data from the Reducing Distresses and Enhancing Effective Management study).

The DDS17 was associated with A1c, diabetes self-efficacy, diet, and physical activity by using multiple regression equations (control variables, linear, and quadratic).

The 2-item DDS screener (DDS2) was also studied and associations noted.

Results:  Between DDS17 and each diabetes variable, there were significant quadratic effects.

In study 1, an increase in diabetes distress was associated with:

  • Higher A1c (p < 0.02)
  • Lower self-efficacy (p < 0.001)
  • Worse diet (p < 0.001)
  • Less physical activity (p < 0.04)

In study 2, an increase in diabetes distress was association with:

  • Higher Q1c (p < 0.03)
  • Lower self-efficacy (p < 0.004)
  • Worse diet (p < 0.04)
  • Less physical activity (p = ns)

In both studies, substantive curvilinear associations for all 4 variables were seen at low levels of DDS17.  The slope, which increased linearly between scores 1 and 2, was muted between 2 and 3, and peaked between 3 and 4, suggest 3 patient subgroups for the DDS17:

  • Little or no distress <2.0
  • Moderate distress 2.0-2.9
  • High distress ≥ 3.0

The DDS2 had similar results.

Conclusions:  There was a consistent pattern of curvilinear relationship between the DDS and A1c, diabetes self-efficacy, diet, and physical activity; this was seen in 2 samples of type 2 diabetes patients.  Three cut points are suggested for the Diabetes Distress Scale:  little or no distress, moderate distress, and high distress.


This article advances research on the role of emotional distress in diabetes by attempting to determine a reasonable cut-point for emotional distress in diabetes using the diabetes distress scale. The authors tested several cut-points and concluded that three cut-points were reasonable: little or no distress, moderate distress and high distress. This is very helpful because it will assist clinicians in determining when to be concerned when patients present with emotional distress. Nevertheless, there is still a lot of work that needs to be done to determine if these cut-points are reasonable. First, the studies need to be replicated in diverse racial/ethnic groups. Second, it will be important to determine how well the measure responds to treatment. Finally, studies are needed that test different strategies to determine which psychosocial interventions are effective for reducing symptoms of distress and whether these results are sustained.

Next Article:
Depression in Diabetes: Have We Been Missing Something Important?
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