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International Journal of Caring Sciences January-April 2018 Volume 11 | Issue 1| Page 502
www.internationaljournalofcaringsciences.org
Original Article
The Relation between Anger Level and Metabolic Control Variables in
Type 2 Diabetes
Feride Taskin Yilmaz, PhD, RN
Assistant Professor, Cumhuriyet University, Health High School of Susehri, Department of Internal
Disease Nursing, Sivas, Turkey
Azime Karakoc Kumsar, PhD. RN
Assistant Professor, Biruni University, Faculty of Health Sciences, Department of Internal Disease
Nursing Nursing, Istanbul, Turkey
Birnur Yesildag
Lecturer, Cumhuriyet University, School of Susehri Health High, Department of Nursing, Sivas, Turkey
Correspondence:
Feride Taskin Yilmaz, Assistant Prof. PhD. RN, Cumhuriyet University, School of
Susehri Health High, Department of Internal Disease Nursing, 58140 Sivas, Turkey
E-mail: feride_taskin@hotmail.com
Abstract
Objective: The study has been conducted to determine the relation between anger level, manners of expressing
anger and the metabolic control variables in type 2 diabetes.
Methods: This descriptive and cross-sectional study was conducted in 177 patients with type 2 diabetes
presenting at the endocrinology and metabolic diseases clinic of of Cumhuriyet University Health Services
Application and Research Hospital in Turkey between February and June 2017. Data is acquired through Patient
Identification Form and Constant Anger and Manner of Expressing Anger Scale.
Results: The mean duration of disease among individuals was 12.41 ± 10.56 years and 57.1% had another
chronic disease. 46.4% of the individuals developed diabetic complications; average rate of total cholesterol is
above the limit, fasting glucose level, HbA1C, triglyceride and LDL cholesterol levels are above the target value.
The constant anger and anger control of the individuals are at medium level while intrinsic anger and extrinsic
anger levels are below the average. It is determined that there is a significant low degree positive relation
between individuals’ constant anger and intrinsic anger score averages, and the disease period, HbA
1
C, LDL
cholesterol and HDL cholesterol levels (p<0.05).
Conclusion: In this study, it was determined that type 2 diabetic individuals obtain a medium-level anger; the
more the anger levels rise, the more HbA
1
C and LDL cholesterol rates increase. Therefore health professionals
can support individuals risky in sense of constant anger and anger control.
Key Words: Diabetes, anger, manners of expressing anger, metabolic control.
Introduction
As an important health problem, type 2
diabetes is a chronic metabolism disease
requiring life-long treatment (Sonmez &
Kasim, 2013). Changes in life style including
diet, physical activity, drug use and blood
sugar evaluation are necessary in type 2
diabetic individuals (Karlsen, Oftedal, &
Bru, 2012). In addition to this, the distress,
come up with disease symptoms,
complications and the treatments applied,
concern for the future, the belief of losing
self-sufficiency, the anxiety of being
dependent to others and the fears about the
body image may affect individuals’ lives
negatively. That’s why diabetic patient may
come up against a range of problems and
struggles physically, emotionally and socially
(Tav et al., 2010). This situation causes
psychological problems in diabetic
individuals (Yi et al., 2008; Sonmez &
Kasim, 2013; Kucuk, 2015). In literature,
compared to the general population, it is
stated that psychological problems are seen
more in diabetics (Whittemore, Melkus, &
Grey, 2005).
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Psychological concerns by affecting both
neuroendocrine and hormonal manners and,
indirectly, the treatment and tracking of type
2 diabetes lead to blood sugar irregularity (Yi
et al., 2008; Abraham et al., 2015). On the
other hand, reactions such as anger, temper,
and psychological defense make the curation
and adaptation of the disease harder.
Distempered patient struggles in following
the rules regarding diet, treatment
management and physical activities (Kucuk,
2015). This condition may cause a vicious
circle by affecting the diabetic management
and metabolic control negatively (Karlsen,
Oftedal, & Bru, 2012).
Anger, as an extremely natural, universal,
understandable, restrainable emotion given to
unsatisfied wishes, unwanted outcomes and
unexpected expectations is a regenerative
feeling between individuals if expressed
right. But, it also has the potential to turn into
an aggressive and extremely devastating
reaction reflected on behaviors destructively
and out of control (Bodur, Infal, & Kurt,
2010). In literature, it is stated that constant
anger leads to a decrease in number and
sensibility of beta adrenergic receptor;
accordingly resulting in sympathetic
activation, while constant anger level creates
a risk factor for hypertension, ischemic heart
disease, and atrial ventricular arrhythmias
(Golden et al., 2006; Celik et al., 2009).
Besides, the exasperation individual has been
through may cause conflicts in interpersonal
relations and other health problems
(Andersson, Jansson, & Archer, 2008).
Considered as a risk factor for cardiovascular
diseases, anger control in type 2 diabetics
gains importance (Golden et al., 2006). On
the other hand, the connection between high
anger level and the risk of type 2 diabetes as
well as poor glycemic control are presented
in international studies (Yi et al, 2008;
Abraham et al., 2015).
Nevertheless, limited researches has been
done on subjects like regular anger level,
manners of expressing anger or temper
control in type 2 diabetic individuals
(Penckofer et al., 2007; Yi et al, 2008; Celik
et al., 2009).
The study has been conducted to determine
the relation between anger degree, manners
of expressing anger and metabolic control
variables in type 2 diabetic patients.
Methods
Study Design and Sample
It is a descriptive and cross-sectional
research. The population of the research is
composed of 283 individuals diagnosed as
type 2 diabetics applied to endocrinology and
metabolic diseases clinic of Cumhuriyet
University Health Services Application and
Research Hospital between the dates 1
February – 1 June 2017. Also, calculated
according to the population number unknown
paradigm calculation formula, with 95%
confidence interval and 0.05 margin of error,
the population size has been detected as 158
people. In this regard, 177 individuals at a
sufficient cognitive level, without any verbal
communication problem or diagnosis of a
psychiatric disease, diagnosed as type 2
diabetic for at least 6 months agreed on
participating in the research and are included
in the study.
Data Collection Tools
The data is acquired through patient
identification form, constant anger and
manner of expressing anger scale, and
metabolic control variables form.
Patient Identification Form; This form is
composed of 20 questions researchers
prepared in accordance with literature
analysis examining sociodemographic
characteristics (age, gender, marital status,
training, occupation) and disease data (name
and period of the disease, drug use, presence
of complication etc.) (Yi et al., 2008; Kara &
Cinar, 2011; Sonmez & Kasim, 2013).
Constant Anger and Manner of Expressing
Anger Scale: Developed by Spielberger
(1983), its availability and reliability in our
country has been established by Özer (1994).
Dealing with the feeling and expression of
temper in terms of state and durability, this
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scale is made up of 4 sub-dimensions;
constant anger (10 items), intrinsic anger (8
items), extrinsic anger (8 items), temper
control (8 items), and 34 subjects. In the
evaluation, “Never defines” is 1 point,
“Slightly defines” 2 points, “Fairly defines” 3
points, and “Thoroughly defines” is 4 points.
Constant anger subscale minimum point is
10, maximum point is 40, while intrinsic and
extrinsic anger and temper control
subdimensions minimum point is 8 and
maximum point is 32. Without a general total
point of the scale, the items of 4
subdimensions compose the total score of
that subdimension. The high scores got from
constant anger subscale show the extent of
temper level, high scores obtained from
intrinsic anger subscale show the repressed
anger, high scores received from extrinsic
anger subscale mean anger is repressed easily
and high scores got from temper control
subscale mean the anger is controlled. High
scores obtained from constant anger, intrinsic
and extrinsic anger subdimensions are
interpreted as negative while high scores got
from temper control subdimensions are
interpreted positive (Ozer, 1994). The
Cronbach alpha rates of constant anger,
intrinsic and extrinsic anger and temper
control subdimensions found in the study are
respectively 0.85, 0.72, 0.83 and 0.85.
Metabolic Control Variables Form: In the
form organized to evaluate the metabolic
control variables of diabetic individuals the
rates of fasting blood glucose, total
cholesterol, triglyceride, LDL Cholesterol,
HDL Cholesterol, HbA
1
C, and blood
pressure are included. The blood pressure of
individuals is determined by the researches
via measurement. For other parameters,
evaluation of the medical attendant is asked
for while attending the clinic. The data of
these parameters are obtained from
laboratory result paper.
Data Collection
Data is collected by the researchers by
talking face to face in a room suitable for
discussion. Data, regarding to the metabolic
parameters of patients, are acquired from
patient file. Filling up the data forms and
measuring blood pressure lasted
approximately 25-30 minutes.
Ethical Approval
Before collecting data, a written permission
is received from the ethical committee of a
university (Decision no: 2016-12/17).
Moreover, each attendant joining the study is
informed about the content and voluntary
participation and their verbal consent is
taken.
Data Analysis
Data is interpreted in SPSS (Statistical
Package for the Social Sciences) version 17.0
software. Sociodemographic and disorder
traits of diabetic individuals are evaluated
with percentage and average test while the
relation between disease period and
metabolic parameters and constant anger and
manner of expressing anger score averages
are evaluated through Pearson correlation
analysis. Relevance in statistical assessment
is regarded as p<0.05.
Results
The mean age of the participants was
56.64±11.56 years; 57.6% are women, 78.5%
are married, 13.6% are illiterate, 49.2% are
housewives, 72.9% are financially average,
3.4% do not have any health insurance, and
19.2% live alone.
One third of the diabetic individuals are
obese and 26% still smoke while 11.3% use
alcohol. 35.6% of the participants with
average disease period of 12.41±10.56 years
use insulin while 19.2% do not implement
the treatment regularly. 57.1% of diabetics
have another chronic disease, 46.9% have
hypertension and 31.2% have chronic
coronary failure.
A 49.2% of diabetic individuals pay attention
to their diets and 29.9% do regular exercise.
46.4% of diabetics possess diabetic
complications; 35.5% retinopathy and 23.1%
neuropathy. 67.2% of the participants have
been hospitalized due to diabetes or its
complications for at least once within a
year’s time. 84.2% of diabetic individuals
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indicated that they are informed about their
disease by a doctor or a nurse while 26% judge their general health state as poor.
(Table 1).
Table 1. Some Sociodemographic Characteristics of Diabetic Individuals
Characteristics
n
%
Age (year) (M±SD) 56.64±11.56 (min=21, max=74)
Duration of disease
(year
)
(M
±SD)
12.41±10.56
(min=1, max=36)
Body Mass Index (kg/m
2
)
<18.5 7 4.0
18.5 - 24.9 46 26.0
25 - 29.9 57 32.2
≥30 67 37.8
Smoking status
Current smoker 46 26.0
Never smoker 103 58.2
Ex-smoker 28 15.8
Using alcohol
Current user 20 11.3
Never user 152 85.9
Ex-user 5 2.9
Treatment type
Oral antidiabetic treatment 51 28.8
Oral antidiabetic and insulin therapy treatment 63 35.6
Insulin treatment 63 35.6
Implement of treatment regularly
Yes 143 80.8
No 34 19.2
Other chronic disease
Yes 101 57.1
No 76 42.9
Attention to diet
Yes 87 49.2
Partially 69 39.0
No 21 11.8
Doing regular exercise (at least 20 minutes’ walk every day, etc.)
Yes 53 29.9
Partially 71 40.2
No 53 29.9
Diabetes
-
related chronic complication
*Yes 82 46.4
Retinopathy 29 35.5
Neuropathy 19 23.1
Nephropathy 10 12.3
Diabetic foot / Amputation 13 15.8
Myocardial infarction 9 10.9
Stroke 2 2.4
No 95 53.6
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The frequency of hospitalized due to diabetes or its complications for at least once
within a year’s time
Never 58 32.8
One time 49 17.7
Two time 39 22.0
Three times and over 31 17.5
Informed status about the disease by the doctor or nurse
Yes 149 84.2
No 28 15.8
General health state
Good 38 21.5
Moderate 93 52.5
Poor 46 26.0
* n is variable
Table 2. Distribution of Metabolic Parameters in Diabetic Individuals
Metabolic Parameters Min-Max M ± SD
Fasting blood glucose (mg/dl) 60-453 167.92±72.62
HbA
1
C (%) 5.40-14.70 8.77±2.60
Systolic Blood Pressure (mmHg) 90-150 120.45±13.89
Diastolic Blood Pressure (mmHg) 50-100 75.39±10.06
Total Cholesterol (mg/dl) 75-500 202.31±77.67
Triglyceride (mg/dl) 63-610 182.13±105.78
LDL Cholesterol (mg/dl) 51-260 133.02±40.19
HDL Cholesterol (mg/dl) 20-72 41.98±10.97
Table 3. Distribution and Correlation of Constant Anger and Manner of Expressing
Anger Scale Score Averages in Diabetic Individuals
Constant Anger and
Manner of Expressing
Anger Scale
Range of
obtainable scores
(min-max)
Range of scores
obtained (min-max)
M±SD
Constant Anger 10-40 10-40 24.70±7.04
Intrinsic anger 8-32 9-30 17.53±4.78
Extrinsic anger 8-32 8-32 17.44±6.09
Temper control 8-32 8-32 20.10±4.87
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Table 4. The Relation Between Constant Anger and Manner of Expressing Anger Scale
Score Averages and Period of Disease and Metabolic Parameters in Diabetic Patients
Parameters Constant
Anger Intrinsic
anger Extrinsic
anger Temper
control
Duration of disease r=.223,
p=0.003** r=.301,
p=0.000** r=.243,
p=0.001** r=-.089,
p=0.241
Fasting blood glucose r=.043,
p=0.566 r=.141,
p=0.062 r=.291,
p=0.000** r=-.120,
p=0.110
HbA
1
C r=.297,
p=0.002** r=.237,
p=0.014* r=-.164,
p=0.092 r=.130,
p=0.183
Systolic Blood Pressure r=-.024,
p=0.755 r=.036,
p=0.637 r=.014,
p=0.856 r=-.111,
p=0.140
Diastolic Blood Pressure
r=.005,
p=0.946 r=.056,
p=0.461 r=.073,
p=0.331 r=-.124,
p=0.087
Total Cholesterol r=.126,
p=0.127 r=.259,
p=0.001** r=.252,
p=0.002** r=-.099,
p=0.232
Triglyceride r=.036,
p=0.654 r=.150,
p=0.060 r=.205,
p=0.010* r=-.150,
p=0.060
LDL Cholesterol r=.209,
p=0.008** r=.292,
p=0.000** r=.271,
p=0.001** r=.098,
p=0.217
HDL Cholesterol r=-.368,
p=0.001** r=-.226,
p=0.045* r=-.075,
p=0.514 r=.017,
p=0.882
r: Pearson correlation analysis; * P <0.05; ** p <0.01
Data related to metabolic parameters of
diabetic patients are given in Table 2.
Accordingly, the average value of systolic
and diastolic blood pressure and HDL
cholesterol is close to the target value while
average rate of total cholesterol is above the
limit and fasting glucose level, HbA
1
C,
triglyceride and LDL cholesterol levels are
above the target value.
The distribution of score averages of constant
anger and manner of expressing anger scale
in diabetic patients is given in Table 3.
Hence, it is determined that anger level
(24.70±7.04) and temper control
(20.10±4.87) are at average while intrinsic
(17.53±4.78) and extrinsic (17.44±6.09)
anger levels are low.
It is stated that statistically there is a
significant low degree relation between
individual’s constant anger and intrinsic
anger score averages and period of disease,
HbA
1
C, LDL cholesterol and HDL
cholesterol rates, extrinsic anger score
averages and disease period, fasting glucose,
total cholesterol, triglyceride and LDL
cholesterol rates (p<0.05). it is clarified that
temper control level has no connection with
disease period and metabolic parameters
(p>0.05) (Table 4).
Discussion
The evidence of the research conducted to
determine the relation between anger level
and manners of expressing anger and
metabolic control variables in type 2 diabetic
individuals is discussed comparatively in
accordance with literature knowledge.
Ensuring control in type 2 patients is
essential in prevention of unwanted side-
effects of the treatment and complications
developed with diabetes (Kara & Cinar,
2011). The target values to obtain metabolic
control in diabetic individuals are submitted
with American Diabetes Association report
(2011) and Turkey Endocrinology and
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Metabolism Organization Guideline
(2013)
as; LDL cholesterol <100 mg/dl (in diabetics
been through a primary cardiovascular
incident <70 mg/dl), triglyceride <150 mg/dl,
HDL cholesterol in male >40 mg/dl, in
female >50 mg/dl, total cholesterol <200
mg/dl, systolic and diastolic blood pressure
≤140/80 mmHg and HbA
1
C ≤%6.5. It is
determined that systolic and diastolic blood
pressure and HDL cholesterol rates are close
to the target value while total cholesterol rate
is above the limit, and fasting blood glucose,
HbA
1
C, triglyceride and LDL cholesterol
rates are above the target value. In the study
of Kara and Cinar (2011) it is identified that
average body mass index, fasting blood
sugar, triglyceride and HDL cholesterol
levels of diabetic patients are at poor control
degree, average HbA1c and total cholesterol
rates are at limit while average blood
pressure levels are at good control limit. In
another study, it is confirmed that metabolic
controls of 54.9% of diabetic individuals are
poor, 29.3% are at limit and 24.8% are good
(Citik, Ozturk, & Gunay, 2010). In a study
examining five observational researches
including 6.442 type 2 diabetics, it is seen
that HbA
1
C rate of two thirds of the
participants is above >6.5% and systolic
blood pressure rate is high at limit (Vazquez
et al., 2014). These results proved that
metabolic control of diabetic patients is not
enough and the training and counselling
practice aiming diabetic management needs
to be carried out in defiance of personal risk
factors and individual life style.
Living with type 2 diabetes is considered as a
tough period. Especially, it is known that
poor glycemic control and intense treatment
bring along psychological problems in
diabetic individuals (Karlsen, Oftedal, &
Bru, 2012). Also, it is stated that insufficient
control of blood glucose level cause
disappointment and anger (Penckofer et al.,
2007). Research has shown that type 2
diabetic individuals obtain a medium level
anger, they neither suppress nor express their
temper easily. In a study conducted on type 1
diabetics, it is indicated that the temper level
of the participants are at normal limits
(Muscatello et al., 2017). In other studies,
however, it is proved that diabetic patients
have a higher level of anger compared to
healthy individuals (Kolbasovsky, 2004;
Kiziltas et al., 2016). In a qualitative study
conducted with type 2 diabetic women, it is
seen that most of the women experienced
anger and this affected their life quality
negatively (Penckofer et al., 2007). In a
research done comparatively with healthy
individuals, it is decided that individuals with
a physical disease has a more intense anger
level, still, the intrinsic anger level of
diabetic patients are lower than individuals
with cardiovascular, gastro-intestinal and
skin diseases (Batigun, Sahin, & Demirel,
2011).
Examining similar studies, the results of the
research show that constant anger level in
diabetics is low compared to the study of
Savasan (2009) with hypertension patients, is
high compared to the study of Gülec et al.
(2004) made with women with fibromyalgia
syndrome, and is similar to the study of
Engin et al. (2006) conducted on alcohol and
drug addicted individuals. In contrast to these
results, in a study comparing diabetic,
migraine and cardiac patients with healthy
individuals, it is seen that temper, extrinsic
anger level and anger reaction in diabetic
patients have similarities with healthy
individuals, and the temper level of diabetics
is lower than migraine patients. In the same
study, it is determined that intrinsic anger
level of diabetics is lower than individuals
with other diseases (Hamedi & Azamameri,
2013). In another study aiming to diagnose
the chronic disease (diabetes, leukemia and
chronic kidney failure) of the participants
including teenagers half of whom are
diabetic with a chronic disease, it is seen that
there is not a difference between constant,
intrinsic and extrinsic anger and temper
control levels (Bodur, Infal, & Kurt, 2007).
According to the research finding, it is
obvious that temper level in diabetic
individuals show distinction when compared
to literature; temper level can be defined as
normal or high. This situation proves that
more long term studies should be carried out
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with a similar practice group. Our research
result, however, shows the fact that temper
level in disease management period in
diabetic individuals also needs to take place
between parameters tracked. By this way, we
believe that strategies can be fostered for
individuals in need of support for temper
control.
Recently, in literature studies examining the
relation between anger, anger expression and
diabetic progress are also found. But, the
results obtained from these studies are
inconsistent. In a longitudinal study aiming
to determine the effect of anger on diabetic
progress, it is confirmed that there is not a
significant difference between temper levels
(low, average, high) of individuals and
fasting blood glucose rates while high anger
level increases the risk of diabetes 34%
(Golden et al., 2006). In another prospective
study, it is determined that intense anger is
related to type 2 diabetes development and
17.2% of the individuals with high level
anger developed diabetes (Abraham et al.,
2015).
Chronic diseases like diabetes damage
mental and psychological well-being and
affect coping skills with anger negatively (Yi
et al., 2008). It is stated in the study that the
anger control of diabetic individuals are on
average. Besides, it is seen that anger control
level of diabetics is low compared to
hypertension patients (Çelik et al., 2009;
Savasan, 2009), is similar to fibromyalgia
patients (Gulec et al., 2004) and alcohol and
drug addicted individuals (Engin et al.,
2006). The result of the research proves that
improvements in effective temper control and
awareness are necessary for diabetic patients.
Throughout the study, it is seen that constant
and intrinsic anger levels of diabetic
individuals increase when the period of the
disease, HbA
1
C and LDL cholesterol rates
rise, however, anger control is not affected
by disease period and metabolic parameters.
Another study showed that the anger level of
individuals with an HbA
1
C rate over %6.5 is
higher (Kiziltas et al., 2016).
In a research conducted with 100 diabetic
patients, it is seen that high coping skills with
temper is effective in ensuring low HbA
1
C
rate (Yi et al., 2008). In the study of
Tsenkova et al. (2014) it is also determined
that low temper control is connected with
high glucose rates. In contrast to these
studies, in another research, it is identified
that HbA
1
C rates of individuals with low
temper level (8.98±0.65) are higher
compared to individuals with high temper
level (7.71±0.35), yet this circumstance is
detected as unreasonable (Altekin et al.,
2006). In a study examining psychological
conditions related to diabetes like anger,
disappointment and fear, it is seen that there
is no difference between HbA
1
C rates and
psychological conditions of type 2 diabetic
women (Whittemore, Melkus, & Grey,
2005). However, in a study conducted with
11.614 healthy individuals, it is determined
that there is a statistically significant
advanced relation between anger level,
triglyceride and HDL cholesterol values,
there is no connection with systolic blood
pressure levels while triglyceride and HDL
cholesterol rates of individuals with intense
temper level is high (Golden et al., 2006).
The result of the research shows the necessity
of the discussion of psychological aspects
like anger while sustaining the target
metabolic control in diabetic individuals.
Especially, drawing attention on the presence
of anger and anger control as a distinct topic
will create positive outcomes in terms of
giving utterance to existing anger and asking
for help. Also, experimentally controlled
studies on this subject will provide clearer
results for the evaluation of the effectiveness
of anger on metabolic parameters.
Study Limitations
As it is conducted in a single university with
diabetic patients applied and agreed
participation at a specific time zone,
generalization to its own population is the
study’s essential limitation. Also, the input
acquired about anger level and temper
control is based upon self-statements of the
individual.
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Conclusions
In accordance with the results obtained from
the study, it is determined that metabolic
control parameters of diabetic individuals are
not at the recommended level, their anger
levels are on average, they do not suppress
their anger, but cannot express it easily, and
HbA
1
C and LDL cholesterol rates rise
parallel to anger level. Regarding these
results, in order to provide target metabolic
control parameters counselling on training
individuals about diabetes and management
knowledge as well as anger expression and
control, adapting patients to the treatments
such as diet, exercise and glucose tracking,
examining psychological matters like
experiencing temper periodically, and
supporting individuals risky in sense of
constant anger and anger control are
suggested. Moreover, it is clear that similar
researches with a large practice group
including healthy individuals will be
beneficial.
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