CWB and DM

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The relationship between well-being and HbA1c in adults with type 1 diabetes:
A systematic review
Article in Journal of Diabetes · February 2023

DOI: 10.1111/1753-0407.13357
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Received: 14 July 2022 Revised: 20 December 2022 Accepted: 26 December 2022
DOI: 10.1111/1753-0407.13357
ORIGINAL ARTICLE
The relationship between well-being and HbA1c in adults

with type 1 diabetes: A systematic review
Aida Pérez-Fernandez 1 ndez-Berrocal 1

| Pablo Ferna |
2
María José Gutiérrez-Cobo
1
Department of Basic Psychology, Faculty
of Psychology, University of Malaga, Abstract
Malaga, Spain Background: Diabetes has been associated with psychological problems,
2
Department of Developmental and which in turn have been related to poorer glycemic control (glycosylated
Educational Psychology, Faculty of
hemoglobin [HbA1c]). On the contrary, psychological well-being constructs
Psychology, University of Malaga, Malaga,
Spain have been associated with superior medical outcomes, including better HbA1c.
Aim: The main objective of this study was to systematically review the existing
Correspondence
Aida Pérez-Fernandez, Department of
literature about the relationships between subjective well-being (SWB) and
Basic Psychology, Faculty of Psychology, HbA1c in adults with type 1 diabetes (T1D).
University of Malaga, Malaga, Spain. Methods: Comprehensive searches were conducted in PubMed, Scopus, and Med-
Email: apf356@uma.es
line, time restricted to 2021, for studies examining the link between HbA1c and the
Funding information cognitive (CWB) and affective (AWB) components of SWB. A total of 16 eligible
Junta de Andalucía, Grant/Award
studies were selected according to the inclusion criteria, of which 15 measured
Number: UMA18- FEDERJA-114; The
Spanish Ministry of Economy, Industry, CWB and 1 AWB.
and Competitiveness, Grant/Award Results: Of the 15 studies included, 11 showed a relationship between CWB
Number: PSI2017-84170-R
and HbA1c, with a higher level of HbA1c being related to poorer CWB. The
other four studies did not find any significant association. Finally, the only
study examining the relationship between AWB and HbA1c found a margin-
ally association between these variables in the expected direction.
Conclusion: The overall data suggest that CWB is negatively related to HbA1c
in this population, but these results are inconclusive. This systematic review
offers clinical implications, such as the possible evaluation, prevention, and
treatment of the problems associated with diabetes through the study and
training of the psychosocial variables that may directly influence SWB. Limita-
tions and future lines of investigation are discussed.
KEYWORDS
affective well-being, cognitive well-being, HbA1c, systematic review, type 1 diabetes
Highlights
• Subjective well-being (SWB) is an important variable to consider, given its associ-
ation with positive outcomes in people with diabetes and the general population.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2023 The Authors. Journal of Diabetes published by Ruijin Hospital, Shanghai JiaoTong University School of Medicine and John Wiley & Sons Australia, Ltd.
152 wileyonlinelibrary.com/journal/jdb Journal of Diabetes. 2023;15:152–164.


PEREZ-FERN ÁNDEZ ET AL. 153
• The main aim of this study is to systematically review how SWB factors are
related to type 1 diabetes management through the glycosylated hemoglobin
(HbA1c) index in adults.
• The overall data suggested that the cognitive well-being is negatively related
to HbA1c in this population, but these results are inconclusive.
1 | INTRODUCTION and affective well-being (AWB). CWB refers to the cogni-

tive evaluation of a person's life satisfaction in general
Diabetes mellitus is a chronic disease associated with sig- and specific life domains (eg, health satisfaction, job satisfac-
nificant morbidity and mortality worldwide.1 The global tion).21 On the other hand, AWB represents both the pleas-
prevalence of diabetes in 2019 is estimated to be 9.3% ant and unpleasant affect that a person can experience. This
(463 million people).2 More specifically, the prevalence of concept, in turn, can be divided into mood and emotions22
diabetes mellitus type 1 (T1D) in the world ranges that act as a monitoring system in the progress and achieve-
between 0.8 and 4.6/1000 inhabitants.3 T1D, which gen- ment of people's goals and efforts.23 AWB and CWB differ in
erally begins in childhood, is a disease in which the their stability and variability24 and are related to other vari-
insulin-producing beta cells of the pancreas are ables.25,26 Therefore, it seems logical that various external life
destroyed.4 Therefore, the required treatment consists of events could have a differential impact on an individual's
daily administrations of exogenous insulin. However, the AWB or CWB.22
cause of this type of diabetes is still unknown.5 SWB is a crucial variable to consider, given its associ-
To check how patients control their blood glucose ation with positive outcomes in people with diabetes and
levels, the glycosylated hemoglobin (HbA1c) test is used, the general population. For instance, relevant concepts
which shows the accumulated glycemic history from the such as social support and self-care behaviors are posi-
previous 2 or 3 months.6 The HbA1c test result is given tively related to CWB.27,28 In addition, indicators of
in percentages and has become a reliable indicator for AWB, such as positive affect, self-efficacy, optimism, and
the diagnosis and prognosis of diabetes. According to the gratitude, have been associated with good health out-
American Diabetes Association (ADA), people with T1D comes in various medical conditions.29,30 For example, a
are recommended to have an HbA1c level <7%.7 In addi- systematic review has shown that people with T1D and
tion, several prospective studies such as the Diabetes depressive symptoms also had lower CWB,31 and similar
Control and Complications Trial (DCCT), The UK pro- results have also been found with anxiety.13
spective Diabetes Study Group (UKPDS), and the Epide- Considering the previous literature, the main aim of this
miology of Diabetes Interventions and Complications, study is to systematically review how SWB factors are
have directly linked long-term diabetic complications related to T1D management through the HbA1c index in
with the HbA1c index.8–10 adults. We hypothesize that higher levels of CWB and AWB
Problems with maintaining adequate glucose levels will be negatively related to diabetes control, as indicated
make diabetes a highly stressful disease. Therefore, sev- by favorable (lower) HbA1c levels. Conversely, we expect
eral studies have investigated the relationship between lower levels of SWB will be associated with poorer HbA1c.
T1D and psychological problems.11 Specifically, diabetes has
been linked to depression,12 anxiety,13,14 and stress.15 Fur-
thermore, it has been found that these psychological prob- 2 | METHOD
lems are closely related to HbA1c, so the higher the levels of
depression, anxiety, and stress, the higher the HbA1c level, 2.1 | Literature search
implying poorer glycemic control.11,13,15,16 In addition to
depression, anxiety, and stress, T1D control could affect the PubMed, Scopus, and Medline databases were searched
subjective well-being (SWB) of these patients.17,18 exhaustively, time restricted to 2021, for studies examin-
The concept of SWB described by Diener19 refers to ing the link between T1D and SWB. Searches were con-
how people think and feel about their lives. According to ducted using the following keywords in English: “type
the initial formulation of this author, the SWB was made 1 diabetes” and “HbA1c” combined with “quality of life,”
up of three elements: satisfaction with life, positive affect, “positive affect,” “negative affect,” “life satisfaction,”
and negative affect. In turn, this concept can be divided “happiness,” and “psychological well-being” as terms in
into two components19,20: cognitive well-being (CWB) the title or abstract. Searches were undertaken between
154
PEREZ-FERNÁNDEZ ET AL.
September and October 2022. The review was previously

PUBMED SCOPUS MEDLINE
registered on the International Prospective Register of 581 813 604
Systematic Reviews (PROSPERO) platform with the
following ID: CRD42021287996.
2.2 | Inclusion criteria 1998 studies
To be included in the review, papers had to meet the fol- Eliminated due to
lowing requirements: (a) report empirical research provid- title/abstract 1233
ing data on the relationship or predictive capacity of SWB
for glycemic control, measured through the glycated hemo- Eliminated due to
repetition 272
globin index (HbA1c); (b) adult sample with a diagnosis of
T1D; (c) use of a valid and reliable cognitive and affective
493 studies
well-being scale or subscale; (d) of any ethnicity and gender;
(e) written in Spanish or English; and (f) cross-sectional
Eliminated due to
and longitudinal. In addition, we excluded letters, theses, inclusion/exclusion
comments, editorials, book chapters on previously pub- criteria 477
lished studies, protocol interventions, qualitative studies,
16 studies
articles that do not distinguish between T1D or type
2 (T2D), child or adolescent samples, articles on T2D, and
non-English or non-Spanish language publications.
15 studies 1 studies measuring
measuring CWB AWB
2.3 | Data extraction
F I G U R E 1 PRISMA flow-diagram for determining the articles
The initial database search identified 1998 potentially eli- included in this study AWB, affective well-being; CWB, cognitive
gible studies: 581 from PubMed, 813 from Scopus, and well-being; PRISMA, Preferred Reporting Items for Systematic
604 from Medline. After two reviewers independently Reviews and Meta-Analyses
assessed the titles and abstracts of all identified reports
and duplicates, 1505 studies were eliminated. Only
493 were selected for full-text review based on the speci- the 15 selected articles. A total of 10 articles found associ-
fied inclusion/exclusion criteria. After this, 16 studies ations between the two variables, and four did not find
were finally included. These articles were divided into any relationship. We have divided the results into cross-
two sections: those measuring CWB (15 studies) and sectional (11 studies, see Table 1) and longitudinal
those measuring AWB (1 study). Disagreements were (4 studies, see Table 2).
resolved by consensus with the lead reviewer. The pro- Five of the 11 cross-sectional studies explored the
cess of searching and selecting articles is shown in association between HbA1c and the DQOL questionnaire
Figure 1. To analyze the quality of the studies, we have scores. First, Weinger and Jacobson33 measured CWB
included a quality assessment table using the Mixed and HbA1c before and after an intensive diabetes treat-
Methods Appraisal Tool32 (see Appendix A, Table A1). ment. They found a negative relationship between the
satisfaction subscale of CWB and the HbA1c at baseline.
This negative relationship was also achieved between
3 | R E SUL T changes in the same CWB subscale and those in HbA1c
through the intervention. Thus, higher levels of satisfac-
We found 16 studies that linked SWB to HbA1c in adults. tion were related to lower HbA1c.
More specifically, 15 measured CWB, and 1 measured AWB. Second, Reddy et al34 divided their sample into two
groups of patients according to the type of treatment:
those who used insulin or continuous subcutaneous insu-
3.1 | CWB and HbA1c lin infusion and those who used multiple daily injections
(MDI). They found no correlation between HbA1c and
This section describes the studies that measured CWB the total score of CWB in the general study population.
with nine different questionnaires (see Appendix B) over Nonetheless, in the subanalysis by gender, they found a

TABLE 1 Cross-sectional studies analyzing the relationship between CWB and HbA1c
Outcome
Study Sample Instruments measures Results
33
Weinger and Jacobson 55 patients with T1D. Mean age DQOL HbA1c A higher CWB measured
USA 34 ± 8 years. Female, n = 31 through the satisfaction
(56.36%) subscale was associated with
a lower level of HbA1c
(r = 0.30, p = .03). This
negative relationship was also
found between the changes in
the same CWB subscale and
the changes in HbA1c
through the intervention
(r = 0.34, p = .01).
Reddy et al34 57 patients with T1D. Mean DQOL HbA1c HbA1c did not correlate with
UK age = 31.4 ± 11.6 years. CWB in the overall study
Female, n = 49 (85.9%) population. On the other
hand, in the cohort of women
treated with multiple daily
injections, lower CWB
measured through the total
scale of DQOL was associated
with a higher level of HbA1c
(R2 = 0.55, p = .01).
Alvarado-Martel et al35 100 patients with T1D. Mean Es-DQoL HbA1c Lower CWB measured through
Spain age = 31.4 ± 11.6 years. the total scale (r = 0.29,
Female, n = 45 (45%) p < .001) and all subscales of
Es-DQoL (except for socio-
vocational concerns) was
related to a higher level of
HbA1c.
Satisfaction subscale (r = 0.30,
p < .001)
Impact subscale (r = 0.30,
p < .001)
Worries subscale (r = 0.23,
p < .05)
Santos et al36 50 patients with T1D. Mean age DQOL HbA1c CWB was not associated with
Brazil 36.8 ± 11.3 years. Female, HbA1c levels.
n = 25 (50%)
Castellano-Guerrero et al37 312 patients with T1D. Mean Es-DQoL HbA1c HbA1c was not a predictor of
Spain age = 38.2 ± 12.7 years. CWB.
Female, n = 45 (48.4%)
Thomakos et al38 80 patients with T1D 35.9 EuroQol: EQ- HbA1c Higher CWB measured through
Greece ± 11.4 years. Mean age 35.9 5D EQ-5D and EQ-VAS was
± 11.4 years. Female, n = 43 EQ-VAS associated with a lower
(53.75%) HbA1c level (r = 0.048,
p = .036).
Benioudakis et al39 100 patients with T1D. Mean DQoL-BCI HbA1c Higher CWB measured through
Greece age 38.5 ± 13.9 years. Female, the total score of DQoL-BCI
n = 81 (73.6%) (95% CI) 3.84 (0.8, 6.9) p < .05
and the satisfaction with the
treatment scale was related to
better HbA1c (95% CI) 2.63
(0.8, 4.4) p < .05.
(Continues)
156
TABLE 1 (Continued)
Outcome
40
Anderson et al 5887 patients with T1D. Three PedsQL HbA1c Higher CWB measured through
New Zealand predetermined age groups: 8– Diabetes the total score of PedsQL was
12, 13–18, and 19–25 years. Module 3.0 associated with a lower level
19–25 years n = 1326. Female of HbA1c in all three age
n = 649 (49%) groups. (95% CI) 3.2 ( 4.0,
2.4) p < .001.
Bott et al41 657 patients with T1D. Mean DSQOLS HbA1c Higher CWB measured through
Germany age = 36 ± 11 years. Female, the subscales of physical
n = 42 (6.39%) complaints (r = 0.24*),
concerns about the future
(r = 0.17*), and satisfaction
with treatment (r = 0.22*)
was associated with a lower
HbA1c level (*p < .001).
Wilmot et al42 Patient-reported outcomes in ADDQoL HbA1c Good glycemic control for
India, Japan, Thailand, adults with T1D in global HbA1c (<7%) was associated
Bulgaria, Croatia, Serbia, real-world clinical practice: with a greater CWB through
Ukraine, Argentina, Brazil, The SAGE study 1724 (44.7%) Item 1 (present quality of life)
Chile, Colombia, Iran, were aged 26 to 44 years, 1512 (95% CI) 1.13 (1.06, 1.21)
Saudi Arabia, France, (39.2%) were aged 45 to p < .001 and the total scores
Germany, Italy, and the UK 64 years, and 622 (16.1%) of ADDQoL (95% CI) 1.05
were aged 65 years or above. (1.01, 1.10) p = .020.
Mean age: 47.4 ± 14
Tabaei et al43 1522 patients (634 with T1D) QWB-SA HbA1c HbA1c was not significantly
USA mean age 33 (18–78). Female associated with CWB.
n = 342 (54%)
Abbreviations: ADDQoL, Audit of Diabetes-Dependent Quality of Life; CI, confidence interval; CWB, cognitive well-being; DQOL, Diabetes Quality of Life;
DQOL-BCI, DQOL brief clinical inventory; DSQOLS, Diabetes-Specific Quality of Life Scale; EQ-5D, EuroQuality of Life-5D; EQ-VAS, EQ-visual analog scale;
Es-DQOL, Diabetes Quality of Life Spanish version; HbA1C, glycosylated hemoglobin; PedsQL, Pediatric Quality of Life inventory; QWB-SA, Quality of Well-
Being Self-Administered; T1D, type 1 diabetes.
positive association between HbA1c and the total score of Quality of Life brief clinical inventory (DQoL-BCI), found
CWB in the cohort of women who had MDI; that is, the that the CWB total score and the treatment satisfaction sub-
higher the DQOL score (worst possible CWB), the higher scale are negatively associated with HbA1c. In the same
the HbA1c levels. direction, Anderson et al,40 using the Pediatric Quality of
Third, Alvarado-Martel et al35 found that the most Life (PedsQL) Diabetes Module 3.0, also found a negative
recent HbA1c measured in the participants was positively association between the CWB total score and the HbA1c.
related to the total CWB score and all subscales except Overall, lower HbA1c was related to better CWB.
for socio-vocational concerns. In other words, again, poor Bott et al,41 using Diabetes-Specific Quality of Life
CWB was related to a higher HbA1c level. Specifically, Scale (DSQOLS), showed that three subscales (physical
multiple regression analyses showed how higher levels of complaints, worries about the future, and treatment
HbA1c, being female, and the severity of the complica- satisfaction) were negatively associated with HbA1c.
tions explained 25.2% of the total variance of the CWB Moreover, Wilmot et al,42 using the Audit of Diabetes-
score. Finally, two studies using the same questionnaire Dependent Quality of Life (ADDQoL), found that an
did not find any relationship between the two target HbA1c <7% was associated with higher scores on the
variables.36,37 total and current CWB. Finally, Tabaei et al,43 using
On the other hand, Thomakos et al38 using the Euro- the Quality of Well-Being Self-Administered (QWB-
QoL EQ-5D, found a negative correlation between CWB SA), did not find any association between CWB and
and the HbA1c. Benioudakis et al,39 using the Diabetes HbA1C.

TABLE 2 Prospective cohort studies analyzing the relationship between CWB and HbA1c
Outcome
44
Hanna et al T1: 184 emerging adults with T1D. DQOL-Y HbA1c HbA1c was not independently
USA Mean age = 18.2 ± 0.44 years. associated with any aspect of
Female, n = 104 (56.5%). T2: 161 CWB.
emerging adults (88%)
Peasgood et al45 2469 adults. Mean age: 39.3 EuroQol: EQ-5D HbA1c Higher CWB measured through
UK ± 13.8 years. Female n = 1199 EQ-VAS EQ-5D and EQ-VAS was
(48.6%) associated with a lower HbA1c
level.
Random-effects models, coefficient
(SE).
EQ-5D: 0.0161 (0.003) p < .01
EQ-VAS: 0.0164 (0.002) p < .01
Stahl-Pehe et al46 560 patients. Female, n = 275 DISABKIDS diabetes HbA1c Higher CWB measured through
(49.1%). Subgroup age 11–13: 14– module (DM) two subscales of DM (impact,
17: 18–21 (n = 114. 20.4%) R2 = 0.58, p < .001 and
treatment R2 = 0.35, p < .001)
was associated with a lower level
of HbA1c at times 1 and 2
(Impact, R2 = 0.116, p < .001
and treatment R2 = 0.104,
p < .001). However, this latter
association disappeared when
controlling for the HbA1c at time
1. Finally, the associations
remained significant at time 2 for
the impact subscale in patients
with a deficient HbA1C at time 1
(R2 = 0.407, p = .004)
Cooke et al47 262 patients with T1D. Mean age DSQOLS HbA1c HbA1c was negatively associated
USA 40 ± 14 years. Female, n = 131 with CWB in bivariate analyses
(50%) at baseline (r = 0.013, p < .05)
but not in the following
measures over time (post
course), which was confirmed by
multivariate analyses.
Abbreviations: CWB, cognitive well-being; DQOL-Y, Diabetes-related Quality-of-Life Measure for Youths; DSQOLS, Diabetes Specific Quality of Life Scale;
EQ-5D, EuroQuality of Life-5D; EQ-VAS, EQ-visual analog scale; HbA1C, glycosylated hemoglobin; T1D, type 1 diabetes; T2, type 2 diabetes.
TABLE 3 A cross-sectional study analyzing the relationship between AWB and HbA1c
Outcome
Eiser 97 patients with T1D. Mean age = 47.81 Well-being HbA1c Higher levels of HbA1c were related to
et al48 ± 16.67 years. Female, n = 49 (50.51%) Questionnaire marginally lower levels of general AWB
UK (r = 0.20, p < .07).
Abbreviations: AWB, affective well-being; HbA1C, glycosylated hemoglobin; T1D, type 1 diabetes.
Regarding the longitudinal studies, Stahl-Pehe et al,46 significant at time 2 for the impact subscale in patients
measured CWB twice (at baseline and after 3 years) using with a deficient HbA1C at time 1. Moreover, Peasgood
the DM questionnaire. They found a negative correlation et al,45 using the EuroQoL EQ-5D, found a negative cor-
between CWB and HbA1c at times 1 and 2. However, this relation between CWB and the HbA1c. This relationship
latter association disappeared when controlling for the was found for the two parts of the questionnaire: the EQ-
HbA1c at time 1. Finally, the correlations remained VAS (EQ-visual analog scale) and the EQ-5D.
158
Cooke et al,47 using an adaptation of the DSQOLS, Furthermore, in the persons with diabetes population, it
analyzed predictive factors influencing HbA1c and qual- has been found that CWB intervention programs have
ity of life 1 year after structured education in flexible, been associated with better medical outcomes.49 The pro-
intensive insulin therapy. Significant negative correla- tective component of CWB has also been studied in other
tions were found only between the questionnaire and medical conditions.50,51
HbA1c in bivariate analyses at baseline (before the Interestingly, three of the studies analyzed showed
course). Nonetheless, these results were confirmed in gender differences in the relationship between HbA1c
multivariate analyses for none of the other measures over and CWB, as it appears to be stronger in women than in
time (post course). men.34,35,40 This result is supported by previous literature
Finally, the study by Hanna et al,44 did not find any that has shown gender differences in the CWB variable,
significant correlations between the variables studied. where women obtain worse scores than men.52,53
In summary, of the 15 articles analyzed, 11 found On the other hand, four studies did not find any rela-
associations between CWB and HbA1c, three of which tionship between the target variables. These results were
used a large sample of patients.40,42,45 Four articles did unexpected, given the previous literature. Various alter-
not find any association between the key variables. natives could explain this absence of significant effects.
For example, Reddy et al,34 and Santos et al36 refer to the
small number of evaluated T1D individuals. Other stud-
3.2 | AWB and HbA1c ies explain that the unexpected results may be because of
the use of well-controlled diabetes participants who could
We found only one article that relates both variables (see not be entirely representative of the general T1D.34,43 The
Table 3), measuring AWB with the well-being question- study by Hanna et al44 relied on an emerging adult sam-
naire. In this article, Eiser et al,48 found only a marginally ple that, although with poor diabetes control, showed
significant correlation was found between the general limited variability in their HbA1c, which may have
AWB score and the HbA1c. reduced the possibility of detecting an association
In summary, the results obtained in this section do between the target variables.
not allow us to draw conclusions or generalize, given the In the second section, we included those studies in
scarce literature. Nonetheless, as a starting point, it which the relationship between AWB and HbA1c was
appears that lower levels of AWB are marginally and neg- analyzed. However, we found only one study. Eiser
atively associated with HbA1c levels in T1D. et al,48 found that those participants with higher levels of
HbA1c showed lower levels of global AWB, although this
relationship was only marginally significant. These
4 | DISCUSSION results are inconclusive, given the insufficient number of
studies. Thus, future studies should focus on extending
The present systematic review has focused on analyzing this promising line of research. Previous studies with
how the two SWB factors (AWB and CWB) are related to T1D adolescents have confirmed our hypothesis regard-
HbA1c in adults with T1D. We hypothesized that higher ing AWB and HbA1c; that is, greater positive affect
levels of CWB and AWB will be negatively related to dia- appeared to be related to better HbA1c.54,55
betes control, as indicated by better (lower) HbA1c levels. The present systematic review suggests the potential
Therefore, we divided the results into two main sections: value of considering CWB as a critical component for
those comparing CWB with HbA1c (15 studies, of which good HbA1c. However, the studies of the current review
11 were cross-sectional and 4 longitudinal) and those are not exempt from limitations. First, some of the stud-
comparing AWB with HbA1c (1 cross-sectional study). ies use a sample with an extensive age range,42,43 which
In the first section, we included those studies in can affect the relationships found because HbA1c and
which the relationship between CWB and HbA1c was CWB can differ throughout various life stages. Second,
analyzed. A total of 11 of the selected 15 articles found nine different CWB questionnaires have been employed
significant associations between the two variables in the across the studies analyzed. This variability makes it diffi-
direction of the hypothesis proposed. Lower HbA1c was cult to group the results according to the type of measure
related to a higher level of CWB. Although one of the and allows us to present only descriptive results, despite
studies found the expected results only in a subsample of the meta-analysis carried out.
the participants,34 the overall results of these studies are Moreover, all except two questionnaires were specific
consistent with our expectations considering the previous to diabetes, and the others were related to health percep-
positive outcomes related to CWB found in the literature tion. CWB is a more extensive concept that could include
(eg, social support and self-care behaviors).27,28 a more general perspective on life. Third, we have found

only one article regarding AWB, making it difficult to 4. Epstein FH, Atkinson MA, Maclaren NK. The pathogenesis of
draw any generalizable conclusions and suggesting that insulin-dependent diabetes mellitus. N Engl J Med. 1994;
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used in this review includes only adults. Therefore, future
news-room/fact-sheets/detail/diabetes
investigations should attempt to evaluate the impact of 6. WHO. Use of glycated haemoglobin (HbA1c) in the diagnosis
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because the literature has shown that HbA1c levels are 2011. Available from: https://apps.who.int/iris/bitstream/
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vice versa.
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andez-Berrocal https://orcid.org/0000-0002-
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diabetes quality of life brief clinical inventory. Diabetes Res Clin Fernandez-Berrocal P, Gutiérrez-Cobo MJ. The
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162
A PP EN D IX A
TABLE A1 Mixed methods appraisal tool (MMAT)
(Weinger (Castellano- (Stahl- (Bott (Tabaei (Cooke (Eiser

Quantitative non-randomized & (Reddy (Santos Guerrero (Hanna (Thomakos (Peasgood (Benioudakis (Anderson Pehe (Wilmot et al, et al, et al, et al,
studies Jacobson33) et al,34) et al,36) et al,37) et al,44) et al38) et al,45) et al,39) et al,40) et al,46) et al42) 1998) 2004) 2015) 2007)
S1. Are there clear research Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
questions?
S2. Do the collected data allow to Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
address the research
questions?
1.1. Are the participants Yes Yes Yes Yes Yes Can't tell Yes Yes Yes Yes Yes Yes Yes Yes Yes
representative of the target
population?
1.2. Are measurements Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes yes Yes Yes Yes
appropriate regarding
outcome and intervention (or
exposure)?
3.3. Are there complete outcome Yes Yes Yes No Yes Yes Yes Yes Yes No Yes Yes Yes Yes No
data?
1.4. Are the confounders Can't tell Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Can't Yes Yes Yes
accounted for in the design tell
and analysis?
1.5. During the study period, is Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
the intervention administered
(or exposure occurred) as
intended?
Mixed methods Alvarado-Martel et al35
S1. Are there clear research Yes

questions?
S2. Do the collected data allow to Yes

address the research
questions?
2.1. Is there an adequate Yes

rationale for using a mixed-
methods design to address the
research question?
2.2. Are the different components Yes

of the study effectively
integrated to answer the

research question?
2.3. Are the outputs of Yes

integrating qualitative and
quantitative components
PEREZ-FERN
adequately interpreted?
ÁNDEZ ET AL.

A PP E ND IX B: Instruments
(Eiser
2007)
et al,
We next define the instruments used to measure cogni-

(Cooke
2015)
et al,
tive well-being (CWB) and affective well-being (AWB) in

the studies selected. Those subscales that measure anxi-
(Tabaei
ety or depression in both the cognitive and affective com-

2004)
et al,
ponents of well-being will not be taken into account,

because our objective is to evaluate subjective well-being
from a positive psychology approach.58 Many studies
(Bott
1998)
et al,
have linked this disease with negative factors, and from

this perspective we wish to evaluate the factors that posi-
(Wilmot
et al )
42
tively influence or improve the well-being of these

people.
et al, )
(Stahl-
46
Pehe
CWB Instruments
(Anderson
et al, )
40
I. The Diabetes Quality of Life (DQOL).59 This ques-

tionnaire consists of 46 items and provides a total
score of general well-being. In addition, it is
(Benioudakis
divided into the four subscales of satisfaction,

et al, )
39
impact, diabetes-related worries, and worries

about social and vocational aspects. A higher score
(Peasgood
indicates a lower CWB. Cronbach's alpha values

et al, )
45
for the internal consistency of the four subscales

ranged between 0.66 and 0.92, with a test–retest
reliability r = 0.78–0.92.
(Thomakos
II. Diabetes-related Quality-of-Life Measure for

et al )
38
Youths (DQOL-Y).60 This questionnaire is com-

posed of three intercorrelated subscales: A Disease
(Hanna
et al, )
44
Impact Scale (23 items), a Disease-Related Worries

Scale (11 items), and a Diabetes Life Satisfaction
Scale (17 items), plus one single item on health
(Castellano-
perception. Each item is scored on a scale ranging

Guerrero
et al, )
37
from 1 (never or very dissatisfied) to 5 (all the time

or very satisfied). For the 1-item rating of health,
participants were asked to rate their health as poor
(Santos
et al, )
36
(1), fair (2), good (3), or excellent (4). Lower scores

indicated a poorer CWB. Reliability for each of the
et al, )
(Reddy
34
three subscales, life satisfaction, the impact of dia-

betes, and worries about diabetes were denoted by
alpha values of 0.90, 0.85, and 0.84, respectively.44
Jacobson )
33
(Weinger
III. EuroQoL EQ-5D.61 This is a generic measure of

Yes
No
health-related quality of life, divided into two

&
(Continued)
parts: the EQ-5D and the EQ-VAS (visual analog

Quantitative non-randomized
results adequately addressed?
2.5 Do the different components
scale). The EQ-5D comprises five subscales: mobil-

quantitative and qualitative
of the study adhere to the
tradition of the methods

inconsistencies between
ity, self-care, habitual activities, pain/discomfort,

quality criteria of each
2.4. Are divergences and
and anxiety/depression. Each question is answered

TABLE A1
on a scale from 1 (no problem) to 3 (severe prob-

involved?
lem). The EQ-VAS is used to assess the current

studies
CWB of the respondent. The score ranges from

0 (worst possible health) to 10 (best imaginable
164
health). The reliability for EQ-VAS and EQ-5D (10 items); treatment satisfaction according to treat-
was α = 0.78 and α = 0.73, respectively. ment goals (10 items); physical complaints (10 items);
IV. Diabetes Quality of Life-Brief Clinical Inventory emotional burdens and concerns (8 items); social
(DQoL-BCI).62 This consists of 15 questions problems (9 items); daily functions (work, leisure,
divided into two subscales: negative impact and time requirements; 11 items); and dietary restrictions
satisfaction with treatment. This questionnaire (6 items). Factor analysis revealed six reliable compo-
estimates patient satisfaction, the level of disease nents (Cronbach's α): social relations (0.88), worries
monitoring, and self-care attitudes. Responses are about future (0.84), physical complaints (0.84), diet
rated on a 5-point Likert scale, ranging from 1 (very restrictions (0.71), leisure time flexibility (0.85), and
satisfied/never) to 5 (very dissatisfied/constantly). daily hassles (0.70).
This scale offers a total score ranging from 15 to VIII. Audit of Diabetes-Dependent Quality of Life
75, where higher scores reflect poorer CWB.63 The (ADDQoL) questionnaire. This questionnaire con-
internal consistency of the questionnaire was sists of 19 items that measure the impact of the dis-
shown by α = 0.95.62 ease in different areas of life and how these affect
V. The Pediatric Quality of Life Inventory 4.0 their CWB. In addition, two other general ele-
(PedsQLTM type 1 diabetes module).64 This is a ments measure current CWB (Item 1) and what
quality-of-life measure that evaluates young peo- CWB would be like without diabetes (Item 2).
ple's perceptions of their health. The questionnaire Higher scores on Item 1 indicate a higher CWB,
consists of 28 items, divided into five subscales: and lower scores on Item 2 indicate better poten-
diabetes symptoms (11 items), treatment barriers tial CWB without diabetes. The internal consis-
(four items), treatment adherence (seven items), tency of the questionnaire was α = 0.92.66
worry (three items), and communication problems IX. The Quality of Well-Being Self-Administered
(three3 items). In addition, it offers a total score (QWB-SA)67 consists of 71 items that assess symp-
that ranges from 0 to 100. Therefore, only the total toms and disease functioning across three
score was used in our review. A higher score domains: mobility, physical activities, and social
denotes a better CWB. The mean Internal consis- activities of symptoms/problems, to provide a
tency for the type 1 diabetes module was α = 0.71. score as a total measure of CWB. This scale allows
VI. DISABKIDS Diabetes Module (DM).65 In this the placement of each individual on a continuum
scale, CWB is measured through two subscales: of well-being ranging from 0 (zero well-being) to
the impact scale (six6 items) and the treatment 1.0 (asymptomatic and fully functional). The test–
scale (four4 items). The score of both scales ranges retest reliability was r = 0, 77.
from 0 to 100, with higher scores indicating a bet-
ter CWB. The internal consistency for the ques-
tionnaire was α = 0.76 for the impact scale and AWB Instruments
α = 0.84 for the treatment scale.46
VII. The Diabetes-Specific Quality-of-Life Scale Well-being Questionnaire68: This questionnaire consists
(DSQOLS).41 This questionnaire specifically assesses of 22 items that are divided into four subscales: depres-
the four main components of CWB in patients with sion (six6 items), anxiety (six items), energy (four4 items),
type 1 diabetes (physical, emotional, and social and positive well-being (six6 items). Each item is evaluated
burdens together with daily functioning). The instru- on a scale ranging from 0 to 3. A higher score indicates
ment consists of 64 items, and responses are scored greater general AWB. Reliability for each of the four sub-
on a six-point Likert scale. The questionnaire is scales was depression, α = 0.74, anxiety, α = 0.78, energy,
divided into the following subscales: treatment goals α = 0.77 and positive well-being, α = 0.86.48
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Article in Journal of Diabetes · February 2023

Aida Pérez Fernández Pablo Fernández-Berrocal

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María José Gutiérrez-Cobo

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The relationship between well-being and HbA1c in adults

Aida Pérez-Fernandez 1 ndez-Berrocal 1

152 wileyonlinelibrary.com/journal/jdb Journal of Diabetes. 2023;15:152–164.

1 | INTRODUCTION and affective well-being (AWB). CWB refers to the cogni-

September and October 2022. The review was previously

2.2 | Inclusion criteria 1998 studies

TABLE A1 Mixed methods appraisal tool (MMAT)

(Weinger (Castellano- (Stahl- (Bott (Tabaei (Cooke (Eiser

Mixed methods Alvarado-Martel et al35

S1. Are there clear research Yes

S2. Do the collected data allow to Yes

2.1. Is there an adequate Yes

2.2. Are the different components Yes

2.3. Are the outputs of Yes

We next define the instruments used to measure cogni-

tive well-being (CWB) and affective well-being (AWB) in

ety or depression in both the cognitive and affective com-

ponents of well-being will not be taken into account,

have linked this disease with negative factors, and from

tively influence or improve the well-being of these

I. The Diabetes Quality of Life (DQOL).59 This ques-

divided into the four subscales of satisfaction,

impact, diabetes-related worries, and worries

indicates a lower CWB. Cronbach's alpha values

for the internal consistency of the four subscales

II. Diabetes-related Quality-of-Life Measure for

Youths (DQOL-Y).60 This questionnaire is com-

Impact Scale (23 items), a Disease-Related Worries

perception. Each item is scored on a scale ranging

from 1 (never or very dissatisfied) to 5 (all the time

(1), fair (2), good (3), or excellent (4). Lower scores

three subscales, life satisfaction, the impact of dia-

III. EuroQoL EQ-5D.61 This is a generic measure of

health-related quality of life, divided into two

parts: the EQ-5D and the EQ-VAS (visual analog

results adequately addressed?

2.5 Do the different components

scale). The EQ-5D comprises five subscales: mobil-

of the study adhere to the

tradition of the methods

ity, self-care, habitual activities, pain/discomfort,

and anxiety/depression. Each question is answered

on a scale from 1 (no problem) to 3 (severe prob-

lem). The EQ-VAS is used to assess the current

CWB of the respondent. The score ranges from

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