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Stages of grief in diabetes and metabolic control

How to cite this article: Rodríguez-Moctezuma JR, López-Delgado ME, Ortiz-Aguirre AR, Jiménez-Luna J, López-Ocaña LR, Chacón-Sánchez J. Stages of grief in diabetes and metabolic control. Rev Med Inst Mex Seguro Soc. 2015;53(5):546-51.



Received: March 14th 2014

Accepted: April 28th 2015

Stages of grief in diabetes and metabolic control

José Raymundo Rodríguez-Moctezuma,a María Elisa López-Delgado,b Alma Rosa Ortiz-Aguirre,c Jorge Jiménez-Luna,d Luis Rafael López-Ocaña,d Jesús Chacón-Sáncheze

aCoordinación de Investigación en Salud

bCoordinación Clínica de Educación e Investigación, Unidad de Medicina Familiar 79

cMódulo de Investigación Hospital General Regional 72

dJefatura de Prestaciones Médicas

eCoordinación de Educación e Investigación, Hospital General de Zona 71

Instituto Mexicano del Seguro Social, Distrito Federal, México

Communication with: José Raymundo Rodríguez-Moctezuma

Telephone: (55) 5359 6354, extensión 28937


Background: To identify type 2 diabetic patients, the stages of grief and its association with metabolic control.

Methods: 186 patients both sexes, without recent loss of a loved one or a terminal illness. We applied a previously validated instrument, which explored the stages of grief (denial, anger/disbelief, bargaining, depression, and acceptance). There was measured BMI, waist circumference, and 6-month averages of glucose, cholesterol and triglycerides.

Results: The associations between the stages of grief and clinical variables showed that BMI is greater denial 33.1 ± 6.2 vs 28.9 ± 4.6 33.1 with p = 0.001, in disbelief stage glucose is greater 190 ± 67 vs 167 ± 51 with p < 0.05. The negotiation phase is associated with older age, 65.6 ± 10 vs 59.1 ± 11 years with p = 0.001 and higher cholesterol level against 229.4 ± 39.1 vs 206.6 ± 40 with p < 0.05. The stage of depression was associated with increased diagnostic time vs. 13.3 ± 8.9 vs 9.4 ± 7.1 years with p < 0.05 and the blood glucose level 198.9 ± 60, vs 164 ± 51 mg/dL p = 0.001

Conclusions: There are logical associations between clinical variables and stages of grief. Identify the stages of grief, as an additional element in the evaluation of patients with diabetes will develop strategies to improve adherence to medical management and metabolic control.

Keywords: Type 2 diabetes mellitus, Grief, Metabolic control

Some of the conditions occurring in women that result in the greatest loss of healthy years of life (DALYs) include diabetes and depression.1

In the Instituto Mexicano del Seguro Social (IMSS), diabetes is the second cause for consultation in primary care and the first in internal medical consultation.2,3 Multiple causes explain the low glycemic control in patients with diabetes, among them are those related to the disease, treatment regimens, the adherence to treatment regimens, lifestyle, personal factors, family and competence in self-care.4-7 Other factors attributed to the patient, such as compliance in long-term treatment, are determined by emotional states such as depression, stress, coping styles and are associated with "stages of grief due to loss".8

Grief is a normal emotional state of adaptation to the loss of a loved one, a job, a relationship, health, et cetera. It is related to a stressful life event of the highest magnitude faced by humans.

It is a unique and unrepeatable process, dynamic and changing, and each event varies between individuals, cultures and societies. This process is related to the onset of health problems such as depression, generalized anxiety, or panic attacks, which can increase the abuse of alcohol and drugs. Between 10 to 34% develop pathological grief that increases the risk of death from cardiac events and suicide.9-11

In the Kubler-Ross model, presented in the book On Death and Dying, there are five different stages to the process individuals go through when experience a loss: denial, anger/disbelief, bargaining, depression and acceptance.10 These steps were initially applied to people suffering from terminal illness and then later to any significant loss in life.

The stages do not necessarily occur in the order described, and not all are experienced by all patients, although a person will suffer at least two of these stages.10

In a recent study, the average annual rate of visits to a health center turned out to be 80% higher among patients undergoing grievance than in the rest of the population.11

We have studied the process of adaptation in the form of experiencing and feeling grief and loss in type 1 diabetes patients and families, as well as the impact of grief in pre-diabetic states.12,13

The aim of the study was to identify, through an instrument constructed expressly for the study, the five stages of grief for loss of health and to measure their association with the level of metabolic control in patients suffering from type 2 diabetes mellitus.


Overview of the study

A cross-sectional, descriptive and analytical study was conducted over a period of one year in a unit of Family Medicine in the Estado de México. A random probability sample of 186 subjects who came regularly to the outpatient unit was selected.

Subjects with a diagnosis of diabetes mellitus type 2 recorded in the electronic medical record, aged 18 to 65, who agreed to participate in the study after signing informed consent were included. Patients with end-stage disease were excluded, as well as those with consequences such as amputation, amaurosis, cerebral vascular disease with disabilities, cancer, and AIDS, and those with gestational diabetes, type 1 diabetics and subjects who had lost a family member in the last 6 months.

Glucose, cholesterol and triglycerides levels reported by the clinical laboratory unit during the past six months were obtained from medical records, and average values ​​were calculated; body mass index and waist circumference were calculated, and patients were questioned about clinical and demographic variables such as age, sex, duration of diabetes, treatment received at the time of the study and the presence of chronic complications. An instrument was applied to measure the stages of grief, which was completed by the subject in a period of time not exceeding 30 minutes. The sample size was calculated based on the prevalence reported in the literature, for the stage of depression 75%, for the denial stage 20%, and for the acceptance stage 25%, which were reported in studies of subjects with chronic diseases with an estimated average of 50% in the three steps mentioned with a significance value of 0.05 and a power of 80% for a confidence interval of 95%.

Construction and validation of the instrument applied

The IMEDD (instrument to measure diabetic stages of grief) is a questionnaire specifically designed to measure the stages of grief in subjects with type 2 diabetes. The instrument was composed of 31 items divided into five domains that explored the stages of grief according to model Kubler-Ross: denial, anger/disbelief, bargaining, depression and acceptance .10

The first draft of the instrument, which consisted of 45 items, was sent for review to a group of 12 thanatology professionals (composed of five doctors, four nurses, three psychologists and two doctors with high levels of mastery in clinical research, experts in the construction of instruments of measurement by means of the Delphi method modified by the following procedure.

Each professional was given the initial version of the instrument as well as a checklist to rate each of the items and the answer forms; for each item, they were questioned as to whether or not it actually measured the corresponding stage of grief and if the expert would include or exclude this item.

There was only one round of review with the thanatologists, since the agreement between them to include and exclude items was greater than 95%. Following this review, the preliminary instrument of 31 items was presented to the two doctors with experience in the construction of instruments for a review of its appearance; they exclusively reviewed the construction of the instrument in terms of drafting, qualifying scores, and for the possibility that different responses could be mutually exclusive.

The final questionnaire consisted of 31 items that are rated based on the Likert scale (with scores ranging from 0 to 3 points in each of the domains), with a maximum score of 10 for denial, 10 for disbelief/anger, 12 for bargaining, 23 for depression and 15 for acceptance.

The final instrument was applied to a group of five diabetic patients who were questioned as to whether it was understandable, if the questions made sense, and about possible answers. The agreement on the understanding of the language of the questions and possible answers of the pilot group was unanimous. It was felt that the instrument could be applied to the study sample.

The study was reviewed and accepted by the Local Research and Ethics Committee; statistical analysis was performed using descriptive statistics with measurements of central tendency and dispersion scored as median, mean, and standard deviation for quantitative variables, chi squared for the analysis of each qualitative variable with breakpoints set for the presence or absence of each stage of grief, Spearman's correlation analysis for the variables to assess the association between total scores obtained from the instrument and clinical variables with a significance level of 0.05 using SPSS version 20.


Performance of IMEDD

The instrument was validated in appearance and content, establishing a significant negative correlation between final stage of acceptance and the rest of the stages of grief, as shown in Table I.

Table I Spearman's correlation analysis, between the different domains of the instrument to measure the stages of grief in diabetes.
Acceptance Depression Bargaining Anger/disbelief Denial
Acceptance       1 -.252 ** -.328 **      -.263 **    -.199 **
Depression       - .252       1 .214 **      .393 **    -.030
Bargaining       -.328 **       .214 **        1      .221 **    .146 *
Anger/disbelief -.263 ** .393 ** .221 **      1    .074
Denial -.199 *       -.030 .146 *      .074    1
** Correlation with significance level of 0.01
* Correlation with 0.05 significance level of 0.05

To determine the rating for each of the stages of the instrument, whether each stage was present or not, cutoffs were established at each stage in accordance with the minimum and maximum scores as follows:

  • For the denial stage, the minimum score was 0 and the maximum was 10 with a cutoff of ≥ 6 (presence of denial).
  • For the disbelief/anger stage, the minimum score was 0 and the maximum was 10 with a cutoff of ≥ 6 (presence of disbelief/anger).
  • For the negotiation stage, the minimum score was 0 and the maximum was 12 with a cut-off of ≥ 7 (presence of bargaining).
  • For the stage of depression, the minimum score was 0 and the maximum was 23 with a cut-off of ≥ 12 (presence of depression).
  • For the acceptance stage, the minimum score was 5 and the maximum was 15 with a cutoff of ≥ 11 (presence of acceptance).
  • The cutoff points for the percentage of the presence of each of the stages of grief in the sample are shown in Table II.

Table II Percentage of the different stages of grief in the sample of study subjects (N = 186)
Stage of grief Percentage fo study population
Denial 8.1
Anger/disbelief 14
Negotiation 19.9
Depression 17.7
Acceptance 67.7

The sample

A total of 186 subjects were analyzed, 70.1% were women, and the average age was 60.5 years. The rest of the clinical and demographic data from the study sample is recorded in Table III.

Table III Clinical and demographic characteristics for the study sample (N = 186)
Variables de estudio
Age (years)            60.4 ±   11
Sex (%)
            Female            70.4
            Male            29.6
Time of diagnosis of diabetes (years)            10.1 ±     7.6
Waist circumference (centimeters)            94.4 ±   12
Body mass index            29.9 ±     4.9
Average glycemic level (mg/dL)          170.4 ±   54
Average cholesterol level (mg/dL)          210.5 ±   41
Average triglyceride level (mg/dL)          214.5 ± 124
Chronic complications (%)
            Nephropathy              2.2
            Neuropathy            11.6
            Ophthalmopathy              9.4
            Ischemic heart disease              3.3
            Cerebral vascular disease              1.7
Treatment (%)
            None              3.2
            Oral antidiabetic            81.7
            Insulin              6.5
            Combined (oral antidiabetic/insulin)              8.6

36.2% of the patients had glucose values ​​of up to 140 mg / dL, 36.8% with values ​​between 141-199 mg / dL and 27% with values between ≥ 200 mg / dL. 41.4% had cholesterol levels of ≤ 200 mg / dL, and 54.6% had figures of ≤ 180 mg / dL for triglycerides.

According to the cutoff points established for the presence of any of the stages of grief with clinical variables, the denial stage was present when BMI was higher than 33.1 ± 6.2 against 28.9 ± 4.6 with p = 0.001 (95% CI 1.65 to 6.7); this stage also occurred in older subjects 65.6 ± 10 verses 59.1 ± 11 years with P = 0.001 (95% CI 2.5 to 10.3%) and in those with higher cholesterol 229.4 ± 39.1 against 206.6 ± 40 p < 0.05 (95% CI 5.9-39.6%).

The stage of disbelief was present when glucose levels were greater than 190 ± 67 against 167 ± 51 p <0.05 (95% CI 2-60%).

The presence of the depression stage was most frequently diagnosed, 13.3 ± 8.9 against 9.4 ± 7.1 years with p <0.05 (95% CI 1 to 6.7%) and with glucose values ​​of 198.9 ± 60 vs. 164 ± mg / dL p = 0.001 (95% CI 14.5 to 54.7%).

Similarly, lower average glucose, cholesterol and triglycerides were observed in the acceptance stage, but with no statistically significant differences.

When different clinical variable cutoffs were analyzed with the presence or absence of the stages of grief, it was observed that the stage of depression was higher for women by 21% versus 7% in men with p = 0.45, with a level of greater than 200 mg / dL glucose with p = 0.029, with development time of up to 20 years with p = 0.021 and the presence of painful peripheral neuropathy 38% vs. 15% p = 0.012.

The presence of the rest of the stages of grief were not established, nor were the clinical and demographic variables analyzed with cutoff points; however an analysis was conducted of nonparametric correlation between the total scores of the different stages of grief and said clinical variables, which are shown in Table IV.

Table IV Spearman's correlation between the total scores for the qualification of the stages of grief and clinical variables
Clinical and demographic variables Acceptance Depression Negociation Anger/disbelief Denial
Age -.146 * -.011    .213 **    -.071 .094
Time of diagnosis of diabetes -.087 .226 **    .062    .068 .071
Waist circumference -.019 -.085    .098    -.015 -0.23
Body mass index .081 -.055    -.027    -.004 .032
Glycemia -.109 .184 *    .046    .092 .121
Cholesterol -.191 .084    .140    .157 * .047
Triglycerides -.055 .076    -.071    .122 .07
** Correlation with significance level of 0.01
* Correlation with 0.05 significance level of 0.05


Grief has been established as a normal adaptive reaction to loss, whether it be the loss of a loved one or any other situation that the subject perceives as significant, it is a stressful life event of great magnitude that an individual may face at any time his or her life.10,11

The state of mourning has also been linked to the loss of tangible property, romantic relationships, physical benefits and health status, particularly in chronic and serious illnesses such as cancer or AIDS.14 A patient with a chronic-degenerative disease like diabetes can be expected to experience the same stages of grief for losses resulting from the disease and its complications (such as impaired renal function, loss of vision, or even loss of a limb). It was observed that the most common stage of grief was acceptance (67%), which is inconsistent with the overall prevalence of chronic diseases in which depression is the most frequent stage (75%); this may be because most of the patients studied had an average of 10 years with diabetes, and probably would have already gone through the earlier stages of bereavement, and also because the instrument was not designed to be comprehensive in diagnosing depression, as it only provides for the possibility of its detection.

The stage of grief least frequently found was that of denial, as similarly reported in stages of grief in general, and the stage of denial has been frequently observed in the pre-diabetic state.15 The expected associations between the different stages of grief and clinical and demographic variables in subjects were those that can be considered as limiting the gaining of commitment to take control of the disease, such as the denial stage in subjects with higher body weight and elevated cholesterol levels, however, at the time of diagnosis that association was not made where it was expected. The stage of anger and disbelief, understood as a transition between negative stages and the more positive stage of acceptance, had a weak positive correlation with the level of cholesterol and with a poor glucose level. The stage of depression was where greater association with the time of diagnosis, poor glucose level, and the presence of painful peripheral neuropathy was observed. There were other logical associations that did not reach statistical significance, probably because the sample size was calculated as the average of the expected frequency in three stages for which the data was known, and in some of the steps we have probably made a beta type error due to lack of samples necessary in order to obtain better expected associations. On the other hand, linking metabolic control in patients with diabetes to a single cause produces variable results because there are multiple reasons why, regardless of the emotional state and, in this case the stage of grief, control targets are not reached, as has been reported in the Mexican population.16,17

Addressing diabetes, taking into consideration the state of grief, allows for the identification of different emotional stages that the patient goes through once diagnosed and that affect the achievement of treatment goals, as well as being related to degrees of compliance with medical directions and prescription.14,16

In the present study we used the Kubler-Ross model as the basis for the generation of our instrument because of its acceptance and also because each stage of this model differentiates between the various emotional states of grief for loss.

It is important to identify the stages of grief in patients with diabetes as an additional element in their assessment, and to establish strategies to improve adherence to medical management and metabolic control.

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Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.

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