Mental health problems can make people with diabetes sicker. Countless studies have shown that depression raises the risk of all sorts of bad outcomes in diabetes—from foot numbness to premature death. A new study supported by NIMHD found that stress management classes given by community health workers helped low-income Latino people with diabetes feel better, with fewer symptoms of depression and anxiety. And it wasn’t just their feelings that improved: The approach also helped participants control their blood sugar.
There are two main ways that negative feelings can affect the physical health of people with diabetes. One is physiological: People who are depressed, stressed, or anxious have more stress hormones, which raise blood sugar levels. The other route is through their behavior: Depressed people may not be able to get themselves to exercise, take medication, or monitor their blood sugar levels. Having too much sugar in the blood for too long damages the tiniest blood vessels, leading to complications such as kidney damage and blindness.
But many people with diabetes do not have access to treatment for depression. In an earlier study of low-income Latino people with poorly controlled diabetes, NIMHD grantee and public health nutritionist Rafael Perez-Escamilla, Ph.D., from the Yale School of Public Health, found that more than half had symptoms of depression. In that study, community health workers visited people at home and helped them get their blood sugar under control.
“I wanted to look at what happened if we taught the same population of patients how to manage their stress,” Perez-Escamilla said. So he got in touch with Julie Wagner, Ph.D., a clinical psychologist at UConn Health who studies how psychological and social factors affect the bodies of people who either have or are at risk for developing diabetes.
In partnership with the Hispanic Health Council, the researchers worked with Latino residents of Hartford, Connecticut to design an eight-session, culturally relevant course that taught people how to manage stress. “It’s not just language translation,” Wagner says. “It speaks to the cultural context in which the people are living.”
Because most Latino residents of Hartford have Puerto Rican ancestry, a lot of the analogies used in the curriculum involved weather and fishing—things that are relevant to island life. The pressure cooker, associated with old-fashioned ways of cooking in Puerto Rico, served as a metaphor for personal stress. Stress in the low-income community members’ lives came from factors like not being sure they would be able to afford food or rent so those were the kinds of examples used.
For the study, 107 participants attended a 2.5-hour group session on diabetes education that covered nutrition, medication, exercise, and how to monitor your blood glucose. Then 61 of the participants were randomly assigned to take the stress management course. All sessions were in Spanish and taught by the same community health worker.
Even with transportation provided, participants only attended four or five of the eight stress management sessions, on average. But the response was positive. “Oh my goodness, they loved it,” Wagner says. “We got such good feedback.” Participants were particularly enthusiastic about learning relaxation techniques.
And the classes worked. The people who were randomly assigned to take the classes felt healthier, with fewer symptoms of depression and anxiety, than the people who only had the single diabetes education session. The researchers also measured the change in hemoglobin A1C (HbA1C), a measure of how well blood sugar is controlled. The more classes a participant attended, the lower their HbA1C, on average—although, as a group, their HbA1C was not significantly lower than that of the people who weren’t assigned to the classes.
The results also show how valuable community health workers are, Wagner and Perez-Escamilla say. Providing mental healthcare is expensive; the study shows community health workers could improve health by delivering programs like these at a relatively low cost, and in a culturally sensitive way, because the workers come from the community and understand their neighbors’ needs. Community health workers normally provide health information and education and help people navigate the health system, understand medication instructions, find transportation, and a whole range of services that address the social factors that influence health. Because of a provision in the Affordable Care Act, the number of community health workers is expected to increase in the coming years.
“Our results show that community health workers have a place at the table for management of stress and mental health,” Perez-Escamilla says. And mental health is important to physical health, particularly for the population participating in the classes. Although providing mental healthcare is expensive, Wagner and Perez-Escamilla’s study demonstrates that through programs such as this, community health workers can provide care to people in need at a relatively low cost and in a culturally sensitive way.