Psychological Distress and All-Cause, Cardiovascular Disease, Cancer Mortality Among Adults with and without Diabetes

Figures & data

Table 1 Baseline Characteristics of the Study Population According to Psychological Distress Status

Baseline Characteristics	Psychological Distress Status
	No	Mild	Moderate	Severe
Sample size, n(%)	16,345 (42.3)	15,192 (38.6)	5278 (12.7)	2761 (6.5)
Mean age, (years)	60.95	59.27	57.81	55.97
Age (years)
18–64	8412 (56.7)	6740 (61.6)	5378 (65.9)	1991 (75.5)
≥65	7933 (43.3)	5155 (38.4)	3197 (34.1)	770 (24.5)
Sex, n(%)
Male	8393 (55.9)	4988 (47)	3153 (41.2)	980 (40.5)
Female	7952 (44.1)	6907 (53.1)	5422 (58.9)	1781 (59.5)
Race, n(%)
Hispanic	2701 (12.5)	1935 (12.3)	1688 (14.2)	731 (18.1)
Non-Hispanic White	9111 (64.7)	7178 (68.8)	4695 (65.6)	1441 (64.4)
Non-Hispanic Black	3664 (17.2)	2292 (14.5)	1836 (16)	489 (13.5)
Non-Hispanic Other	869 (5.6)	490 (4.4)	356 (4.2)	100 (3.9)
Education level, n(%)
Less than high school degree	4302 (22.5)	3153 (22.7)	3101 (32)	1187 (38.8)
High school degree	4851 (31.1)	3586 (30.9)	2564 (32)	804 (31.6)
More than high school degree	7065 (45.7)	5097 (46)	2846 (35.2)	751 (29)
Income, n(%)
Low	2573 (11.3)	2162 (13)	2441 (21.8)	1144 (34.3)
Middle	9093 (54.2)	6721 (55.8)	4915 (60)	1406 (55.7)
High	4679 (34.5)	3012 (31.2)	1219 (18.2)	211 (10)
BMI (kg/m2), n(%)
Normal weight/Underweight, <25 kg/m2	3037 (17.8)	2087 (16.9)	1391 (15.6)	438 (14.3)
Pre-obesity, 25–29.9 kg/m2	5569 (33.7)	3589 (30)	2422 (28)	706 (25.7)
Obesity, ≥30 kg/m2	7157 (44.8)	5806 (49.6)	4443 (52.7)	1527 (57)
Physical activity, n(%)
0 min/week	8229 (47.9)	5537 (43)	5081 (57.7)	1921 (68.3)
1–149 min/week	2916 (18.1)	2519 (22.1)	1580 (18.8)	407 (15.6)
≥150 min/week	4803 (31.3)	3532 (32)	1740 (21.1)	393 (14.5)
Smoking status, n(%)
Non-smoker	8542 (51.3)	5959 (49.2)	3967 (44.8)	1133 (38.9)
Former smoker	5579 (35.2)	4031 (34.9)	2759 (32.9)	815 (31.6)
Current smoker	2137 (13)	1838 (15.4)	1800 (21.7)	802 (29)
Alcohol intake status, n(%)
Lifetime abstainer	5289 (29.8)	3151 (23.9)	2499 (27.8)	829 (27.8)
Former drinker	4597 (27.3)	3615 (29.4)	2822 (32.7)	964 (36)
Light drinker	4670 (31.2)	3953 (36.4)	2504 (30.9)	938 (27.4)
Moderate drinker	1179 (7.8)	756 (6.8)	425 (5.5)	114 (4.2)
Heavy drinker	298 (2.0)	269 (2.3)	191 (2.1)	84 (2.8)
Hypertension, n(%)	10,757 (64.3)	8223 (67.5)	6296 (72.2)	2131 (76.3)
CVD, n(%)	4910 (29.7)	4077 (33.5)	3778 (44.1)	1405 (50.2)
Cancer, n(%)	2181 (13.3)	1295 (15.5)	410 (14.5)	410 (14.5)

Note: Values are n (percentage).

Abbreviations: BMI, body mass index; CVD, cardiovascular disease.

Figure 1 Psychological distress and the risk of mortality according to the presence of diabetes. The HRs (95% CI) are based on Cox regression models adjusted for age, sex, race/ethnicity, education, income, body mass index, smoking, alcohol intake, physical activity, history of CVD and cancer. The psychological distress score was measured by the Kessler 6 nonspecific distress scale.

Table 2 Joint Association of Diabetes and Psychological Distress Status with All-Cause, Cardiovascular Disease and Cancer Mortality

Psychological Distress Status	No. of Participants	No. of Deaths	Age-Standardized Mortality Rate per 10,000 (95% CI)	Model 1	Model 2	p for Multiplicative Interaction†
				HR (95% CI)	HR (95% CI)
All-cause mortality						0.02
Non-diabetes
No	216,538	24,576	94.5 (94.4,94.5)	1.00 (Reference)	1.00 (Reference)
Mild	145,548	15,632	105.3 (105.3,105.3)	1.11 (1.08,1.13)	1.07 (1.04,1.09)
Moderate	69,604	9041	154.1 (154.1,154.2)	1.61 (1.56,1.65)	1.26 (1.22,1.30)
Severe	14,598	2387	195.8 (195.7,195.9)	2.32 (2.19,2.46)	1.46 (1.38,1.55)
Diabetes
No	16,345	4581	173.8 (173.7,173.9)	1.59 (1.53,1.65)	1.39 (1.33,1.44)
Mild	11,895	3447	209.3 (209.2,209.4)	1.90 (1.83,1.98)	1.59 (1.53,1.66)
Moderate	8575	2808	269.0 (268.8,269.2)	2.72 (2.59,2.87)	1.90 (1.80,2.00)
Severe	2761	910	319.7 (319.3,320.0)	3.30 (3.02,3.61)	1.98 (1.82,2.17)
CVD mortality						0.70
Non-diabetes
No	216,538	5410	19.7 (19.7,19.7)	1.00 (Reference)	1.00 (Reference)
Mild	145,548	3425	23.2 (23.1,23.2)	1.15 (1.09,1.21)	1.09 (1.03,1.15)
Moderate	69,604	1975	31.3 (31.2,31.3)	1.67 (1.57,1.79)	1.25 (1.17,1.34)
Severe	14,598	485	41.4 (41.4,41.5)	2.34 (2.09,2.62)	1.39 (1.24,1.56)
Diabetes
No	16,345	1157	40.3 (40.2,40.3)	1.72 (1.60,1.86)	1.38 (1.27,1.49)
Mild	11,895	872	46.9 (46.8,46.9)	2.11 (1.93,2.30)	1.60 (1.46,1.75)
Moderate	8575	710	54.1 (54.1,54.2)	3.04 (2.74,3.38)	1.84 (1.65,2.04)
Severe	2761	226	73.4 (73.2,73.5)	3.86 (3.25,4.58)	1.96 (1.66,2.33)
Cancer mortality						0.94
Non-diabetes
No	216,538	6339	25.8 (25.8,25.8)	1.00 (Reference)	1.00 (Reference)
Mild	145,548	3976	27.2 (27.2,27.2)	1.07 (1.02,1.11)	1.02 (0.98,1.07)
Moderate	69,604	2168	36.0 (35.9,36.0)	1.39 (1.31,1.48)	1.12 (1.05,1.19)
Severe	14,598	546	42.9 (42.9,43.0)	1.91 (1.71,2.13)	1.26 (1.13,1.41)
Diabetes
No	16,345	935	36.8 (36.8,36.9)	1.34 (1.23,1.45)	1.22 (1.13,1.33)
Mild	11,895	643	40.5 (40.5,40.6)	1.41 (1.29,1.54)	1.25 (1.13,1.37)
Moderate	8575	462	46.0 (46.0,46.1)	1.76 (1.56,1.98)	1.38 (1.22,1.55)
Severe	2761	164	59.6 (59.5,59.8)	2.35 (1.93,2.86)	1.66 (1.37,2.02)

Notes: Model 1: adjusted for age and sex at baseline. Model 2: Model 1 plus additionally adjusted for race/ethnicity, education, income, body mass index, smoking, alcohol intake, physical activity, hypertension, CVD and cancer at baseline. †The p for multiplicative interaction between psychological distress and presence of diabetes were obtained using Wald testing.

Abbreviations: CI, confidence interval; HR, hazard ratio.

Figure 2 Joint association of diabetes and psychological distress with all-cause mortality. The HRs (95% CI) are based on Cox regression models adjusted for age, sex, race/ethnicity, education, income, body mass index, smoking, alcohol intake, physical activity, history of CVD and cancer. The psychological distress score was measured by the Kessler 6 nonspecific distress scale. The P for interaction between the presence of diabetes and psychological distress on mortality were obtained using Wald testing.

Table 3 Subgroup Analysis of the Association of Psychological Distress Status with All-Cause Mortality Among Participants with Diabetes

Subgroup	Psychological Distress Status				p for Multiplicative Interaction
	No	Mild	Moderate	Severe
Age					0.63
<65	1 (Reference)	1.14 (1.02,1.26)	1.32 (1.19,1.46)	1.34 (1.18,1.52)
≥65	1 (Reference)	1.10 (1.04,1.17)	1.32 (1.22,1.42)	1.35 (1.17,1.55)
Sex					0.004
Female	1 (Reference)	1.07 (0.99,1.15)	1.25 (1.15,1.35)	1.18 (1.04,1.34)
Male	1 (Reference)	1.16 (1.08,1.25)	1.41 (1.29,1.53)	1.62 (1.41,1.87)
Medication treatment status					0.02
No	1 (Reference)	1.00 (0.86,1.16)	1.23 (1.03,1.46)	1.02 (0.75,1.39)
Yes	1 (Reference)	1.14 (1.07,1.21)	1.34 (1.25,1.44)	1.48 (1.32,1.65)

Notes: Values are HR (95% CI). Adjusted for age, sex race/ethnicity, education, income, body mass index, smoking, alcohol intake, physical activity, hypertension, CVD and cancer at baseline. The p for interaction between psychological distress and age/sex/medication treatment status were obtained using Wald testing.

Abbreviations: CI, confidence interval; CVD, cardiovascular disease; HR, hazard ratio.