Reduced heart rate variability in people with type 1 diabetes and elevated diabetes distress: Results from the longitudinal observational DIA-LINK1 study

Dominic Ehrmann, Hannah Chatwin, Andreas Schmitt, Uffe Soeholm, Bernhard Kulzer, Johanne Lundager Axelsen, Melanie Broadley, Thomas Haak, Frans Pouwer, Norbert Hermanns

Research output: Contribution to journalArticleAcademicpeer-review


Aims: People with type 1 diabetes have a higher risk for cardiovascular disease (CVD). Reduced heart rate variability (HRV) is a clinical marker for CVD. In this observational study using continuous HRV measurement across 26 days, we investigated whether psychological stressors (diabetes distress, depressive symptoms) and glycaemic parameters (hypo- and hyperglycaemic exposure, glycaemic variability and HbA1c) are associated with lower HRV in people with type 1 diabetes. Methods: Data from the non-interventional prospective DIA-LINK1 study were analysed. At baseline, depressive symptoms and diabetes distress were assessed. Glucose values and HRV were recorded daily for 26 days using continuous glucose monitoring (CGM) and a wrist-worn health tracker respectively. Multilevel modelling with participant as nesting factor was used to analyse associations between day-to-day HRV and diabetes distress, depressive symptoms and CGM-derived parameters. Results: Data from 149 participants were analysed (age: 38.3 ± 13.1 years, HbA1c: 8.6 ± 1.9%). Participants with elevated diabetes distress had a significantly lower HRV across the 26 days compared to participants without elevated distress (β = −0.28; p = 0.004). Elevated depressive symptoms were not significantly associated with HRV (β = −0.18; p = 0.074). Higher daily exposure to hyperglycaemia (β = −0.44; p = 0.044), higher average exposure to hypoglycaemia (β = −0.18; p = 0.042) and higher HbA1c (β = −0.20; p = 0.018) were associated with reduced HRV across the 26 days. Sensitivity analysis with HRV averaged across all days corroborated these results. Conclusions: Diabetes distress is a clinically meaningful psychosocial stressor that could play a role in the cardiovascular health of people with type 1 diabetes. These findings highlight the need for integrated psychosocial care in diabetes management.
Original languageEnglish
Article numbere15040
JournalDiabetic medicine
Issue number4
Early online date2023
Publication statusPublished - Apr 2023


  • cardiovascular health
  • depression
  • diabetes distress
  • heart rate variability
  • type 1 diabetes

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