Diabetes distress is associated with neuropathic pain but not diabetic peripheral neuropathy
Aims: Diabetes distress is increasingly recognised as an important component of diabetes care, yet its relationship with diabetic peripheral neuropathy (DPN) and painful-DPN remains inadequately explored. This study investigated this association in a cross-sectional analysis of 1,418 participants with type 2 diabetes from The Maastricht Study.
Methods: Diabetes distress was assessed using the Problem Areas in Diabetes (PAID-20) questionnaire and categorised as low, moderate or high. DPN was defined using vibration perception threshold (VPT) measured with a neurothesiometer, while neuropathic pain was identified using the DN4 questionnaire. Participants were classified as having DPN alone, neuropathic pain alone, or both DPN and neuropathic pain. Multivariable logistic regression models adjusted for sociodemographic characteristics, glycaemic control, insulin use and depression.
Results: Among the 1,418 people included within the analysis with PAID-20 data, moderate and high diabetes distress were present in 22.5% and 4.8% of participants, respectively. Individuals with greater diabetes distress were younger, had higher HbA1c, greater insulin use, higher rates of depression and previous foot ulceration, and were more likely to report neuropathic pain. The prevalence of moderate and high diabetes distress was highest in participants with neuropathic pain, irrespective of whether abnormal vibration perception was present.
After adjustment for potential confounders, moderate and high diabetes distress remained independently associated with neuropathic pain, with approximately two-fold and four-fold higher odds, respectively, compared with participants reporting low diabetes distress. In contrast, diabetes distress was not independently associated with painless DPN, and the association with combined painful-DPN was attenuated after adjustment.
Conclusions: These findings suggest that diabetes distress is more closely associated with the experience of neuropathic pain than with large-fibre neuropathy itself.
Comments: Diabetes distress is increasingly recognised in routine clinical practice, reflecting the emotional and practical challenges of living with diabetes. This study provides further evidence that neuropathic pain, rather than the presence of large-fibre neuropathy alone, is associated with greater diabetes-specific distress. These findings highlight the need to consider psychosocial wellbeing as part of a routine assessment in individuals with painful-DPN.
The study has several strengths, including its large, well-characterised cohort, adjustment for important confounding factors, and use of validated questionnaires to assess both diabetes distress and neuropathic pain. However, the cross-sectional design precludes conclusions regarding causality, as it remains unclear whether diabetes distress contributes to the development of neuropathic pain, whether chronic pain increases diabetes distress, or whether both influence one another in a bidirectional manner. In addition, defining DPN solely by vibration perception threshold predominantly identifies large-fibre dysfunction and may fail to detect early small-fibre neuropathy, particularly when fixed cut-off values are used. This therefore may potentially explain the substantial number of participants reporting neuropathic pain in the absence of abnormal vibration perception. Overall, this study supports a more holistic approach to the management of painful-DPN, emphasising that effective care should extend beyond pain relief to include recognition and management of diabetes distress.
Gordon Sloan
Reference. Cardon A, Cleal B, Due-Christensen M, Dukers-Muijrers N, Kirketerp-Møller K, Rasmussen A, Ahluwalia TS, Hansen CS, Schram MT, Koster A. Associations Between Diabetes Distress, Diabetic Peripheral Neuropathy and Neuropathic Pain in People With Type 2 Diabetes-The Maastricht Study. J Peripher Nerv Syst. 2026 Jun;31(2):e70130. doi: 10.1111/jns.70130. PMID: 42167749.
